No. 27231 (New Rule): R414-71. Medical Supplies -- Parenteral, Enteral, and IV Therapy

DAR File No.: 27231
Filed: 06/14/2004, 01:42
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to comply with H.B. 126, 2003 General Session, which requires that previously implemented policy and reimbursement methodologies be put into rule. (DAR NOTE: H.B. 126 is found under UT L 2003 Ch 324, and was effective 05/05/2004.)

 

Summary of the rule or change:

This is a new rule for Parenteral, Enteral, and IV Therapy Supplies which was previously implemented by policy.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3; and 42 CFR 440.70 and 42 CFR 441.15

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the program was previously implemented by policy and now needs to be implemented by rule pursuant to recent changes in the State Medicaid statute.

 

local governments:

There is no budget impact to local governments as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented by rule pursuant to recent changes in the State Medicaid statute.

 

other persons:

There is no budget impact to other persons as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented by rule pursuant to recent changes in the State Medicaid statute.

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because the program was previously implemented by policy and now needs to be implemented by rule pursuant to recent changes in the State Medicaid statute.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This is a new rule for Parenteral, Enteral, and IV Therapy Supplies which was previously set forth by policy. There will be no new fiscal impact on businesses. Scott D. Williams, MD

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/02/2004

 

This rule may become effective on:

08/03/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-71. Medical Supplies -- Parenteral, Enteral, and IV Therapy.

R414-71-1. Introduction and Authority.

(1) Eligible Medicaid recipients with chronic physical illnesses, trauma, or terminal disease, who are able to live at home or in a long term care facility but who cannot be sustained with oral feeding, and, therefore rely on total parenteral nutrition (TPN) or enteral nutrition (EN) to sustain life, are covered under this program.

(2) The IV therapy program provides medications, solutions, blood factors, chemicals, or nutrients by injection or infusion for eligible Medicaid recipients who reside at home or in a nursing facility.

(3) The provision of services and supplies is under the authority of 42 CFR 440.70 and 42 CFR 441.15, Oct. 2003 ed.

 

R414-71-2. Definitions.

(1) Total Parenteral Nutrition (TPN) means total nutrition administered by intravenous, subcutaneous or mucosal infusion.

(2) Enteral Nutrition (EN) means by nasogastric, jejunostomy or gastrostomy tube into

the stomach or intestines to supply nutrition when a non-functioning gastrointestinal tract is present due to pathology or structure.

(3) Nutrients means those products with specific formulas used to supply the total

nutritional intake of the patient by gastrostomy, jejunostomy or nasogastric tube.

(4) Nutritional Supplements means products, such as Ensure, that are used

occasionally to supplement a regular but possibly inadequate diet.

(5) Cassettes mean prepackaged containers or envelopes of semi-disposable

needles and tubing which provide a pathway for the TPN or IV medication to pass from container to vein.

(6) WIC is the federal nutritional program for women, infants and children.

 

R414-71-3. Client Eligibility Requirements.

TPN, EN and IV services are provided to categorically and medically needy eligible individuals.

 

R414-71-4. Program Access Requirements.

(1) TPN and 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 therapies require a physician's order or prescription and require 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 infusions are identified and reimbursed per daily Kcal requirements.

(4) EN products must be given by gastrostomy, jejunostomy or nasogastric tube to qualify for coverage under the EN Program.

 

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) Parenteral solutions and IV therapy provided by infusion or enteral therapy are

benefits for clients residing in a long term care facility.

(4) 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;

(d) IV medications, blood factors, and solutions;

(e) enteral administration kits; and

(f) heparin flush and heparin.

(5) Medicaid may approve nutritional supplements for covered infants and children ages 0 to 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:

(a) target weight of a child cannot be attained with expected oral feedings;

(b) oral feedings are present but too extended due to weakness, illness, or disease to the infant; or

(c) child is concurrently using a ventilator or oxygen, or has a

tracheostomy.

(6) 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 patients 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.

(7) 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.

(8) All TPN and EN solutions, equipment, and nutritional products and most IV supplies require prior authorization. There must be a reasonable medical expectation that an improved quality of life will result from the TPN, EN, or IV therapy. A copy of the physician's prescription must be on file with the provider as part of the prior authorization request.

(a) The attending physician must justify through diagnosis and applicable history the need for a pump for metered dosage, continuous infusion, extremely small doses which cannot be measured accurately without a pump for metered dosage, continuous infusion, extremely small doses which cannot be measured accurately without a pump, or other special medical needs requiring a pump. For nutritional pumps, the medical need determination must establish that syringe feeding or gravity feeding is not satisfactory due to aspiration, diarrhea, or dumping syndrome, or other unique medical manifestations. The simplest form of feeding by syringe must be ruled out prior to authorizing a nutritional pump.

(b) For TPN or EN a new prior authorization shall be obtained every two months to renew the type of feeding or therapy in use for home health patients. Extended use of TPN or EN without home health intervention may be approved for a longer period of time.

(c) The home health agency and the pharmacy shall make separate prior authorization requests for their respective services and supplies.

(d) IV products, including IV catheters, require prior authorization. Gravity flow supplies and equipment do not require prior authorization.

(e) Nutritional supplements require prior authorization. Documentation must include:

(i) medical condition of the patient;

(ii) weight loss or expected gain to a specific level;

(iii) expected duration of supplementation, including quantity and frequency of administration.

 

R414-71-6. Limitations for TPN or EN Therapy.

The specific limitations for TPN or EN 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 and Mull-Soy are breast milk substitutes and are not covered by Medicaid.

(4) Kits, bags and pumps are not covered benefits with nutritional supplements.

(5) A monthly supply and administration kit containing all supplies except the catheter is a Medicaid benefit only for patients residing at home. Bags can not be reimbursed separately if a kit is supplied.

(6) Total nutrition is not available for persons with nutritional need resulting from psychological problems or a failure to thrive.

(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.

(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.

(9) Nutritional supplements are not covered for patients residing at home or in a long term care facility. Only total nutrition for patients residing at home is covered with the exception of children who are covered under the WIC program, as stated in R414-71-5(5).

(10) Pharmacy providers 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.

(11) To begin an infusion, intravenous catheters 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.

 

R414-71-7. Reimbursement.

(1) HCPCs coding is used for reimbursement. Reimbursement fees are established by discounting historical charges, by discounting Medicare fees for HCPCs codes for the geographic region, and by professional judgment to encourage efficient, effective and economical services. Adjustments to the fee schedule are made in accordance with appropriations and to produce efficient and effective services to be in accordance with the provisions of 4.19-B of the State Plan.

(2) The Department pays the lower of the amount billed and the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.

(3) Providers must accept the Medicare assignment for clients eligible for both Medicare and Medicaid benefits. All third party payors, including Medicare, must be billed prior to billing Medicaid.

 

KEY: Medicaid

2004

26-18-3

26-1-5