This filing was published in the 02/01/2008, issue, Vol. 2008, No. 171, of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
R414-71
Medical Supplies - Parenteral, Enteral, and IV Therapy
DAR File No.: 30378
Filed: 01/10/2008, 08:10
Received by: NL
Medicaid, based on a public hearing and other comments, proposes to amend its original rule filing and put the rule back out for additional comments. The proposed amendments to the original filing clarify Medicaid policy regarding program access and service coverage for nutritional supplements and oral nutrition.
This change clarifies Medicaid policy regarding program access and service coverage for nutritional supplements and oral nutrition. It also makes other minor clarifications. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed amendment that was published in the September 15, 2007, issue of the Utah State Bulletin, on page 40. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike out indicates text that has been deleted. You must view the change in proposed rule and the proposed amendment together to understand all of the changes that will be enforceable should the agency make this rule effective.)
Sections 26-18-3 and 26-1-5, and 42 CFR 440.70 and 441.15
The original filing estimated an annual cost of $52,255 to the General Fund and $122,745 in federal funds to pay for the expansion of nutritional services. There is no anticipated change in that budget impact based on the further amendments proposed by this filing.
There is no budget impact because local governments do fund or provide oral nutrition for Medicaid clients.
The original filing estimated that businesses that provide nutritional supplies will experience approximately $175,000 in additional sales. Qualifying Medicaid clients will receive an additional $175,000 in nutritional services. There is no anticipated change in that budget impact based on the further amendments proposed by this filing.
There are no compliance costs because this change only clarifies Medicaid policy regarding nutritional supplements and oral nutrition for Medicaid clients.
No unacceptable fiscal impact is expected on businesses impacted by this rule change. This will be evaluated after the public has an opportunity to comment. David N. Sundwall, MD, Executive Director
Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov
03/03/2008
03/10/2008
David N. Sundwall, Executive Director
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-71. Medical Supplies -- Parenteral, Enteral, and IV Therapy.
. . . . . . .
R414-71-4. Program Access Requirements.
(1) TPN and total EN is available to individuals with a:
(a) missing digestive organ;
(b) long term or permanently non-functioning gastrointestinal tract; or
(c) short term non-functioning gastrointestinal tract which may occur following a surgical procedure.
(2) IV therapy requires a physician's order or prescription and prior authorization.
(3) TPN, EN or other related nutritional products require a physician's order or prescription which must specify the kilo calories necessary per day. Parenteral infusion is identified and reimbursed per daily kilocalorie requirements.
[(4) EN products must be given by gastrostomy,
jejunostomy or nasogastric tube to qualify for coverage under the EN Program.
(5)](4)
Total oral nutrition and supplemental oral or by tube nutrition is
available for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
eligible children if it is an integral part of another EPDST service or has a
curative or healing effect on the recipient beyond that which would be provided
by ordinary food. All total oral
nutrition or supplemental nutrition must be a medical food for reimbursement by
Medicaid.
R414-71-5. Service Coverage.
(1) TPN and EN systems, related supplies, equipment, and nutrients are covered as prosthetic devices if they replace normal nutritional function of the esophagus, stomach or bowel.
(2) TPN or EN therapy is a covered benefit for clients residing at home or in a long term care facility.
(3) The following services are allowed for clients residing at home or in a long term care facility:
(a) parenteral solutions;
(b) a monthly parenteral nutrition administration kit which includes all catheters, pump filters, tubing, connectors, and syringes relating to the parenteral infusions;
(c) [enteral solutions for total enteral
therapy;]IV medications, blood factors, and solutions;
(d) [IV medications, blood factors, and
solutions;]heparin flush and heparin;
(e) [enteral administration kits; and]enteral
solutions for total enteral therapy through a tube; and
(f) [heparin flush and heparin.]enteral
administration kits.
(4) Nutritional supplements are covered for
infants and children ages 0 through 5 who live at home and are in the WIC
program, for quantities [which exceed 8 ounces per day and time which
exceeds 60 days if the]beyond what WIC allows if:
(a) the target weight of a child cannot be attained with expected oral feedings;
(b) the oral feedings are present but [too
extended ]due to weakness, illness, or disease [to ]the [infant]child's
nutritional level is difficult to maintain; or
(c) the child is concurrently using a ventilator or oxygen, or has a tracheostomy.
(5) IV Therapy and treatment which may include injections or infusions are a covered service. IV therapy may include:
(a) pain medication therapy;
(b) antibiotics and antimicrobials;
(c) fluids such as glucose and fluid replacement;
(d) electrolytes;
(e) blood products;
(f) IV supply kit for recipients residing at home;
(g) extension tubing set for peripheral or midline catheter; or
(h) solutions used to cleanse or irrigate the catheter for which a national drug code (NDC) code exists.
(6) Administration supplies, syringes, bags, pumps, tubes, and administration kits for providing TPN, EN and IV therapies are covered with reasonable limitations as to amounts and length of administration as medically indicated and according to current standard medical practices.
(7) Total nutrition without a feeding tube and
supplemental nutrition with a feeding tube are covered for children 0 through
20 years of age if the requirements of subsections (a) through ([e]c)
are met. Nutritional supplements are
covered for children 5 through 20 years of age if the requirements of
subsections (a) through ([e]c) are met.
(a) The prescribed nutritional product is a medical food.
(b) Current disease or dysfunction of the digestive tract, including dysphagia, causes nutritional deficiency with insufficient nutrients to maintain body weight by impaired delivery of nutrients to the small bowel or due to impaired digestion and absorption by the small bowel, or both.
(c) The client's physician provides documentation to the Department:
(i) that the
client has been unable to reach or maintain weight in the 10th percentile for
the client's age and sex by taking food orally for the [three]two
months prior to the request;
(ii) that the client's specific diagnosis and current condition require medical food supplementation; and
(iii) by peer review medical literature that the prescribed medical food will improve body weight, the clinical outcome, and limit disease progression for the client's specific diagnosis and current condition when compared to nonmedical food.
(8) Oral
supplemental nutrition is covered for adults and children to treat inborn
errors of metabolism subject to all criteria listed in Sub[S]section
R414-71-5(7).
(9) To reauthorize ongoing care the following is waived:
(a) The need to document the recipient's weight under the 10th percentile;
(b) If the client's medical diagnosis has not materially changed, the need to resubmit peer review medical literature if it has been previously submitted.
R414-71-6. Limitations[ for TPN or EN Therapy].
The specific limitations for TPN, [or]
EN, or IV therapy are as follows:
(1) Cassettes shall be supplied with the parenteral administration kits and not as separate items.
(2) Enteral nutrients, IV diluents, injectable medications, and solutions are available as allowed in the pharmacy program with the limitations stipulated therein.
(3) [Baby
foods such as Similac, Enfamil, Mull-Soy or other foods generally used as
breast milk substitutes are not medical foods, and are not covered by Medicaid.]A
monthly supply and administration kit containing all supplies except the
catheter is a Medicaid benefit only for recipients residing at home. Bags can not be reimbursed separately if a
kit is supplied.
(4) [Kits,
bags and pumps are not covered benefits with nutritional supplements unless
administered by a tube.]Equipment such as IV poles, disposable swabs,
antiseptic solutions and dressings for the catheter are not reimbursable by
Medicaid for nursing home patients, but are provided by the nursing home under
a per diem rate.
(5) [A
monthly supply and administration kit containing all supplies except the
catheter is a Medicaid benefit only for recipients residing at home. Bags can not be reimbursed separately if a
kit is supplied.]To begin an infusion, an intravenous catheter may be
placed by a home health agency nurse who has been trained for IV catheter
placement, a physician, or a physician's assistant whose training and protocols
allow for this service.
(6) [Total
and supplemental nutrition are not available for persons with nutritional need
resulting from psychological problems or a failure to thrive.]Breast
milk from breast milk banks and infant formulas such as Similac, Enfamil, or
other foods generally used as breast milk substitutes are not medical foods,
and are not covered by Medicaid unless formulated for use through a feeding
tube.
(7) [Equipment
such as IV poles, disposable swabs, antiseptic solutions and dressings for the
catheter are not reimbursable by Medicaid for nursing home patients, but are
provided by the nursing home under a per diem rate.]Kits, bags and pumps
are not covered benefits with nutritional supplements unless administered by a
tube.
(8) [General
nutrition is included in the per diem rate paid by Medicaid under a contract
with a long term care facility and is not separately reimbursable for its
patients.]Total and supplemental nutrition are not available for persons
with an organic nutritional need resulting from psychological problems or a
failure to thrive.
(9) [Nutritional
supplements are not covered for adults residing at home or in a long term care
facility. Total nutrition for children
age 0 through 5 is covered under the WIC program, as stated in Subsection
R414-71-5(4).]General nutrition is included in the per diem rate paid by
Medicaid under a contract with a long term care facility and is not separately
reimbursable for its patients.
(10) [A
pharmacy provider may be reimbursed for TPN or EN supplies, nutrients and
medications. There is no additional
reimbursement to the pharmacist for preparing the medication, such as filling
syringes, mixing solutions, or adding drugs to an infusion solution. Pharmacists bill Medicaid using National
Drug Codes. Heparin for flushing the
infusion catheter is billed through the pharmacy point of sale system using the
NDC for heparin.]Nutritional supplements are not covered for adults
residing at home or in a long term care facility. Total nutrition for children ages 0 through 5 is covered under
the WIC program as stated in Subsection R414-71-5(4).
(11) [To
begin an infusion, an intravenous catheter may be placed by a home health
agency nurse who has been trained for IV catheter placement, a physician, or a
physician's assistant whose training and protocols allow for this service.]A
pharmacy provider may be reimbursed for TPN or EN supplies, nutrients and
medications. There is no additional
reimbursement to the pharmacist for preparing the medication, such as filling
syringes, mixing solutions, or adding drugs to an infusion solution. Pharmacists bill Medicaid using National
Drug Codes. Heparin for flushing the
infusion catheter is billed through the pharmacy point of sale system using the
NDC for heparin.
. . . . . . .
KEY: Medicaid
Date of Enactment or
Last Substantive Amendment: [2007]2008
Authorizing, and Implemented or Interpreted Law: 26-18-3; 26-1-5
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764).
Last modified: 01/30/2008 6:40 PM