Change in Benefits for WA Medicaid Program
OLYMPIA – In order to meet budget targets for the coming biennium, the Department of Social and Health Services will no longer cover oral enteral nutrition for adult Medicaid clients who are not using the liquid nutrition in tube feeding. The new policy is effective for dates of service on or after July 1, 2009.
“We understand that reductions to health-care coverage are difficult for our clients, and we are trying to make these necessary changes in a way that minimizes any hardship,” said Doug Porter, Assistant Secretary of the Health and Recovery Services Administration within DSHS. “Clients and their doctors will have the opportunity to request higher levels of service through an exception process.”
Porter noted that the changes in nutrition and other medical supplies – from diapers for incontinence and sterile gloves to some diabetic supplies — are being forced by the state’s severe economic squeeze. These optional benefits were available when funding was more readily available. He said the nutrition change is part of $13 million in medical supply savings assigned to DSHS under the upcoming biennial budget. The nutrition change alone will save the state an estimated $3.2 million a year
“We also have determined that Medicaid was one of a few health-care payers nationally that were covering adult nutrition or incontinent supplies at these levels,” he said. “Medicare and most commercial insurance companies do not cover these items and have already implemented these limitations. Obviously, Washington taxpayers deserve to know in these economic times that we are matching industry benchmarks.”
“We are working to communicate as much information as possible to our clients to help with this transition,” he added. “We realize that sometimes exceptions are necessary, so we do have a process that allows special treatment when it is appropriate.”
Porter also noted:
There is no change in the current Medicaid enteral nutrition benefit for children
Clients who were given prior authorization to receive oral enteral nutrition will continue to receive it through the authorized period
Clients and their providers may seek authorization for an exception under the Washington Administrative Code (WAC 388-501-0160). Called “exception-to-rule,” the process basically lets the state allow coverage in cases where a client’s clinical needs are significantly different that the rest of the population.
The nutrition change is one of several benefit changes for durable medical equipment and medical supplies. All the changes below are effective for dates of service on or after August 1, 2009.
Bath or shower items, stockings and auto blood pressure cuffs are no longer a covered benefit for adults. These clients also will have the exception-to-rule option under WAC 388-501-0160. There is also no change in current policy on covering these supplies for children.
Incontinent supplies for adults and children will be limited to 200 per client per month, instead of the current limit of 240 per month for adults and 300 per month for children. This includes briefs only, or a combination of briefs and pull-ups.
Non-sterile gloves for adults and children will be limited to 200 per client per month instead of the current limit of 900 per month. Sterile gloves will be limited to 30 per month.
Diabetic supplies (lancets and test strips) for adults and children will be limited to 100 a month for clients on insulin, or 100 every three months for clients who are not on insulin.
Clients or their providers can request authorization to exceed these limits under a “limitation extension” option in the Washington Administrative Code (WAC 388-501-0169). This option allows Medicaid to authorize more supplies for a specific client when his or her health-care needs would not be met under the limit.
DSHS does not discriminate and provides equal access to its programs and services for all persons without regard to race, color, gender, religion, creed, marital status, national origin, sexual orientation, age, veteran’s status or the presence of any physical, sensory or mental disability.
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