Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Durable Medical Equipment Bulletin 16 January 2010 TO: Durable Medical Equipment (DME) Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Clarification of Coverage of Formulas (Enteral-Nutrition Products) Background This bulletin clarifies the coverage of certain enteral-nutrition products for MassHealth members who may also be eligible for these products (also referred to as regular and special formulas) when provided by the Department of Public Health’s (MDPH’s) Women, Infants and Children (WIC) Nutrition Program. Members who may qualify for the WIC Program include pregnant, postpartum, and breastfeeding women; infants; and children under the age of five. Coverage by WIC The WIC program has primary responsibility for the provision of regular formulas to WIC-eligible MassHealth members. MassHealth is the payer of last resort for regular formulas. Because these products and their names change frequently, providers should visit the WIC Web site at www.mass.gov/wic to obtain a current list of formulas covered by the WIC program and information on WIC eligible products. Coverage by MassHealth MassHealth (including its contracted managed care organizations (MCOs)) will pay for enteral products if the request meets the MassHealth Guidelines for Medical Necessity Determination of Enteral Nutrition Products (see below). In addition, all enteral products require prior authorization, and the member must meet one of the following: • the member requires a special or prescription formula that is not on the WIC list; • the member does not receive adequate amounts of regular formula from WIC to meet the member’s medical needs; or • the member is not eligible for WIC. MassHealth Durable Medical Equipment Bulletin 16 January 2010 Page 2 Prior-Authorization The supplier of enteral nutrition products—that is, a MassHealth durable Documentation medical equipment (DME) provider; a MassHealth oxygen and respiratory therapy equipment provider with a specialty of DME; or a pharmacy provider with a specialty of DME—must submit the PA request to MassHealth for enteral-nutrition products with supporting medical documentation. MassHealth has published Guidelines for Medical Necessity Determination for Enteral Nutrition Products, which can be viewed on MassHealth’s Web site at: http://www.mass.gov/Eeohhs2/docs/masshealth/guidelines/mg- enteralnutrition.pdf MassHealth has also published the Medical Necessity Review Form for Enteral Nutrition Products, which can be viewed at: http://www.mass.gov/Eeohhs2/docs/masshealth/guidelines/mnr_enteraln utrition.pdf Providers may download and use this form when submitting PA requests for enteral products or may request products in accordance with the MassHealth DME regulation prescription and PA requirements at 130 CMR 409.407 and 409.408. For a MassHealth MCO member, the supplying provider must submit the combined MassHealth Managed Care Organization (MCO) Medical Necessity Review Form for Enteral Nutrition (Special Formula) to the MCO where the member is enrolled. For additional information, the provider should contact the appropriate MCO provider customer service number provided below or access the form online at the MCO’s Web site in the provider section. Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. For MassHealth MCO members, providers must contact the appropriate MCO customer service center listed below. o Boston Medical Center HealthNet Plan: 1-888-566-0008 or 1-800-900-1451 o Fallon Community Health Plan: 1-866-275-3247 o Network Health: 1-888-257-1985 o Neighborhood Health Plan: 1-800-462-5449