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WAC 182-554-500 Covered enteral nutrition products, equipment and related supplies - Orally administered - Clients twenty years of age and younger only.
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WAC 182-554-500 Covered orally administered enteral nutrition products, equipment and related supplies - Clients age twenty and younger only.
Effective May 1, 2017
- Subject to the prior authorization requirements and limitations in this section, and in the Enteral Nutrition Program Billing Guide, the agency covers orally administered enteral nutrition products for clients age twenty and younger.
- The agency's enteral nutrition program is not a food benefit. All clients under age five who qualify for supplemental nutrition from the women, infants, and children (WIC) nutrition program must receive products and formulas directly from that program. The agency may cover orally administered enteral nutrition products for a client under age five if the client has a WIC information form that verifies:
- The client is not eligible for the WIC program;
- The client is eligible for the WIC program, but the client's need for an oral enteral nutrition product or formula exceeds the amount allowed by WIC rules; or
- The client is eligible for the WIC program, but a medically necessary product or formula is not available through the WIC program.
- With expedited prior authorization, the agency covers orally administered enteral nutrition products for a one-time, initial one-month supply if the client:
- Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula; and
- Has completed the agency's enteral nutrition products prescription form (HCA 13-961).
- With prior authorization (PA), the agency covers a monthly supply of orally administered enteral nutrition products if the client:
- Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula;
- Has a valid prescription that states the product is medically necessary as defined in WAC 182-500-0070; and
- Has a nutrition assessment from a registered dietitian (RD) that includes all of the following:
- Evaluation of the client's nutritional status, including growth and nutrient analysis;
- An explanation about why the product is medically necessary as defined in WAC 182-500-0070;
- A nutrition care plan that monitors the client's nutrition status, and includes plans for transitioning the client to food or food products, if possible; and
- Recommendations, as necessary, for the primary care provider to refer the client to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) who will address the client's growth or nutrient deficits as described in (a) of this subsection, and facilitate the client's transition to food or food products.
- If a client requires orally administered enteral nutrition products for longer than one month, the client must continue to meet criteria in subsection (4) of this section and receive periodic reevaluations from an RD. Periodic reevaluations:
- Must be performed at least three times a year for a client age three or younger;
- Must be performed at least two times a year for a client older than age three; and
- May be performed face-to-face, or by medical record and growth data review and phone contact with the client or the client's caregiver.
- If a client requires orally administered enteral nutrition products for longer than one month, the DME or pharmacy provider must obtain PA from the agency. The request for PA must include all of the following:
- Documentation of the client's diagnosis that supports the client's need for the orally administered enteral nutrition product;
- The client's nutrition care plan, which must monitor the client's nutrition status, and transition the client to food or food products, if possible, or document why the client cannot transition to food or food products;
- Updates to the client's nutrition care plan resulting from subsequent reevaluations;
- Updates to the client's growth chart;
- Documentation that shows through regular follow up and weight checks how the prescribed product is treating the client's growth or nutrient deficits, or is necessary to maintain the client's growth or nutrient status;
- Referrals, if necessary, to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) and show communication of recommendations and treatment plans for the client; and
- Documentation of any communication the treating provider has had with other providers, such as those in subsection (4)(c)(iv) of this section, directly or indirectly treating the client's growth or nutrient deficits while the client is receiving orally administered enteral nutrition products.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
PEBB Continuation Coverage
PEBB Continuation Coverage
Your PEBB Continuation Coverage benefits include medical, dental, and vision coverage. You may be able to continue your life and long-term disability insurance, depending on the type of continuation coverage you enroll in. If you choose to continue your PEBB benefits, you must pay all the premiums.
Washington Prescription Drug Program (WPDP)
We ensure the value of prescription drug purchasing by the state.
The Washington Prescription Drug Program provides evidence-based prescription drug guidance to state agencies that purchase drugs on behalf of Washington residents.
Goals
Our goal is to make sure Washington prescription drug consumers get safe medications with proven results at lower prices. We do this through the following methods:
- Our evidence-based preferred drug selection process for the Washington Preferred Drug List (WA PDL).
- ArrayRx Solutions multistate partnership pools prescription drug purchasing power.
- ArrayRx prescription drug discount card available to all Washingtonians.
Making informed health care decisions
Health care can be complicated. But as the consumer, you can be an active participant in your health. This page includes resources and tools to help you take charge of your health care.
The Washington State Health Care Authority (HCA) seeks to help residents in improving their health and well-being. These resources can assist you in exploring your health care options.
Choosing a primary care doctor
It's important to have a primary care doctor you know and trust.
- Read five tips for choosing a provider
- Is your doctor right for you?
- Find a provider for public employee benefits (PEBB)
- Find a for school employee benefits (SEBB)
Choosing procedures wisely
Some of the most common medical procedures may be overused. The Washington Health Alliance's Choosing Wisely campaign focuses on cervical cancer screening, antibiotics, cardiac and other imaging, and early elective births.
Understanding health insurance coverage
- Our partners at the Health Benefit Exchange offer easy-to-understand information about health insurance on their Know Your Plan page. From shopping for a plan to understanding your bill, this information is helpful for anyone who has basic questions about health insurance.
- The federal HeathCare.gov website includes a section on using health coverage to stay healthy and get the care you need . This section includes videos and a user-friendly publication, From Coverage to Care: A Roadmap to Better Care and a Healthier You.
- The Henry J. Kaiser Family Foundation offers resources in English and Spanish to help anyone shopping or helping someone shop for health coverage within the health insurance marketplaces.
Owning your health
As health care consumers, we have a big role in making sure we get the right care. The Washington Health Alliance's Own Your Health campaign offers tools and resources to help make sure you are getting high quality care, and a good experience at a fair price.
Making shared decisions with your provider
Shared decision making is a process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.
Patient decision aids are tools that can help people engage in shared health decisions with their health care provider. Research shows that use of patient decision aids leads to increased knowledge, more accurate risk perception, and fewer patients remaining passive or undecided about their care.
- Learn more about shared decision making
- Learn more about patient decision aids
- See a list of state-certified aids
Finding support during serious illness or end of life
Know what your options are when you or a loved one are recovering from a serious illness or entering the end stages of life.
Medicaid Transformation Project (MTP)
MTP is Washington State's Section 1115 Medicaid demonstration waiver between the Health Care Authority (HCA) and Centers for Medicare & Medicaid Services (CMS). MTP allows our state to create and continue to develop projects, activities, and services that improve Washington’s health care system.
On June 30, 2023, CMS approved MTP to continue for five more years. Our state's MTP renewal, called MTP 2.0, will help widen our reach to provide more programs, services, and supports to our most vulnerable populations.
An overview of MTP 2.0
To read complete details about the following graphic, read the long description.
- MTP 2.0 infographic: long description
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The graphic above illustrates the various programs under the Medicaid Transformation Project (MTP) renewal, called MTP 2.0.
On the left side of the graphic
We provide this language about MTP 2.0:
“The Medicaid Transformation Project (MTP) is Washington State’s Section 1115 Medicaid demonstration waiver. MTP allows our state to create and continue to develop projects, activities, and services that improve Washington’s health care system. All MTP programs support Apple Health (Medicaid) enrollees. In June 2023, the federal government approved MTP to continue for an additional five years. We call the MTP renewal ‘MTP 2.0,’ which will help widen our reach to provide more programs, services, and supports to our most vulnerable populations.”
On the bottom left corner
A legend describes how to view the illustration part of the graphic. Each MTP program is designed as a hexagon-shaped tile (with six sides), which connects to a topic (also designed as a hexagon-shaped tile). The topic and program(s) create an individual cluster, and all clusters connect together. Each cluster has a specific color—and depending on if a program is new or continuing—the shade of the cluster will vary. New programs are a darker shade; programs continuing from the initial MTP waiver period have a lighter shade.
The clusters are as follows:
Behavioral health—colored purple—has three programs:
- Both the mental health IMD and substance use disorder (SUD) IMD programs are continuing from the initial MTP waiver period
- Contingency management for SUD treatment is a new MTP 2.0 program
Older and aging adults and family caregivers—colored blue—has two programs:
- Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) are continuing
- Presumptive Eligibility is new
Housing and employment—colored green—has one program:
- Foundational Community Supports is continuing
Health-related social needs (HRSN)—colored gold—has three programs:
- Native Hub, other HRSN services, and Community Hubs are new
HRSN system—colored orange—has one program:
- HRSN infrastructure is new
Reentry from a carceral setting—colored grey blue—has one program:
- Reentry services for individuals leaving a prison, jail, or youth correctional facility is new
Continuous enrollment—colored red—has two programs:
- Continuous Apple Health enrollment for children, ages 0–5 and Apple Health postpartum coverage expansion are new
On the bottom of the graphic
We provide this definition:
“IMD stands for ‘institution for mental diseases.’ IMDs are hospitals, nursing facilities, or other institutions of more than 16 beds that are primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, which includes SUD. We acknowledge the term ‘mental disease’ may be harmful or stigmatizing. We use it in this context only to reflect the legal terminology used in statute."
Clinical collaboration and initiatives
The Clinical Quality and Care Transformation (CQCT) Division improves health care access, quality, and cost for Washingtonians using evidence to make clear and consistent coverage decisions.
Our division works with providers and manufacturers to stay informed of industry standards and trends. We conduct provider outreach and advise on health care policy.
Our mission is to make clinical policy decisions that guide medical coverage, maintain quality standards, and ensure providers have access to evidence-based practices for medical care.
What we're working on
Clinical program staff work to improve outcomes for issues related to substance use disorders (SUD), primary care in Washington, pharmacy policy and costs, reproductive health, and more.
Substance use disorder treatment
- ScalaNW
- Opioids
Primary care transformation
Pharmacy programs
Eliminating hepatitis C
Reproductive health
Quality program and initiatives
- Value-based purchasing
- Washington State Common Measure Set
- Apple Health managed care reports
- Data and reports
Other clinical programs and initiatives
- Community Health Workers
- Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
- Prior authorization
Partnerships and collaborations
- The Bree Collaborative
- ER is for Emergencies
- OB outcomes
- Shared decision making
- Performance Measures Coordinating Committee
- Partnership Access Line
- Suicide prevention resources
- Workforce Innovation & Alignment
- Academic Learning Collaborative
Contact us
Chief Medical Officer
Email: Judy Zerzan-Thul
Chief Pharmacy Officer
Email: Donna Sullivan
Washington State Opioid Authority
Email: Jessica Blose
I need medical, dental, or vision care
I need medical, dental, or vision care
You or your family may qualify for free or low-cost Apple Health coverage. Coverage includes primary care, emergency visits, maternity services, pediatric care, dental services, vision care, prescription medications and more. Explore our resources to learn about covered benefits and services, and how to apply for, use, or manage your coverage.
Retirees
Retirees
As a retiree, your PEBB benefits include medical, dental, and vision coverage. You may also have term life insurance. Explore the benefits available to you and learn how to enroll and manage your coverage.
Are you preparing to retire? We offer monthly retirement webinars that walk through eligibility, the enrollment process, and explain what benefits are available.
Programs and initiatives
Program information for providers
Program information for providers
Listed below are many of the programs we offer our Apple Health (Medicaid) clients. If you are looking for information on a program not listed, visit our Provider billing guides and fee schedules page.
