PM 11-01-01-a.
Send Request for Therapeutic Diet Allowance (Form 146) to the client's doctor.
Completion of the form by the doctor, or a letter containing information regarding diagnosis and the type of diet, meets the requirement for a prescribed diet.
Unless the doctor indicates a shorter timeframe, allow 12 months. If prescribed by a doctor, all diabetic diets may be used for longer periods.
Except for the diabetic diet allowance, a diet allowance must be renewed yearly or as indicated by the doctor. The Family Community Resource Center is responsible for initiating the renewal and maintaining necessary controls.
Request for dietary supplements are to be made by the provider in accord with WAG 20-18-02.
Monthly Allowances for Therapeutic Diets
| TYPE OF DIET |
AMOUNT |
CODE |
| Ulcer (and other chronic conditions requiring a bland low-residue diet) |
$ 5.95 |
364 TD U |
| Diabetic - less than 1700 calories - adult |
$ 7.92 |
365 TD D1 |
| Diabetic - 1700 calories or more - adult |
$17.82 |
366 TD D2 |
| Diabetic - all children |
$17.82 |
367 TD D3 |
| High-protein, High-caloric, High-vitamin for clients 13 years of age or older |
$12.85 |
368 TD H1 |
| High-protein, High-caloric, High-vitamin for children 6 through 12 years of age |
$ 7.91 |
369 TD H2 |
| High-protein, High-caloric, High-vitamin for children 3 through 5 years of age |
$ 9.02 |
370 TD H3 |
Home-Delivered Meals
| NUMBER EATING TOGETHER |
TOTAL MONTHLY FOOD ALLOWANCE |
AMOUNT ALLOWED FOR DELIVERED MEALS |
ALLOWANCE FOR OTHER MEALS |
| 1 |
$61.52 |
Meal (Dinner) 5 Days Per Week $36.66 |
$24.86 |
| 2 |
$59.46 |
Meal (Dinner) 5 Days Per Week $36.66 |
$22.81 |
| 1 |
$70.67 |
1 Meal (Dinner) 7 Days Per Week $51.33 |
$19.33 |
| 2 |
$69.06 |
1 Meal (Dinner) 7 Days Per Week $51.33 |
$17.72 |
| 1 |
$52.38 |
1 Meal (Lunch) 5 Days Per Week $22.00 |
$30.39 |
| 2 |
$49.86 |
1 Meal (Lunch) 5 Days Per Week $22.00 |
$27.87 |
| 1 |
$57.89 |
1 Meal (Lunch) 7 Days Per Week $30.81 |
$27.08 |
| 2 |
$55.64 |
1 Meal (Lunch) 7 Days Per Week $30.81 |
$24.83 |
| 1 |
$53.30 |
2 Meals (Lunch-Dinner) 2 Days Per Week $23.47 |
$29.83 |
| 2 |
$50.84 |
2 Meals (Lunch-Dinner) 2 Days Per Week $23.47 |
$27.37 |
| 1 |
$75.22 |
2 Meals (Lunch-Dinner) 5 Days Per Week $58.65 |
$16.57 |
| 2 |
$73.86 |
2 Meals (Lunch-Dinner) 5 Days Per Week $58.65 |
$15.20 |
| 1 |
$89.84 |
2 Meals (Lunch-Dinner) 7 Days Per Week $82.11 |
$ 7.73 |
| 2 |
$89.21 |
2 Meals (Lunch-Dinner) 7 Days Per Week $82.11 |
$ 7.10 |
| 1 |
$84.36 |
3 Meals 5 Days Per Week $73.30 |
$11.06 |
| 2 |
$83.42 |
3 Meals 5 Days Per Week $73.30 |
$10.12 |
| 1 |
$102.63 |
3 Meals 7 Days Per Week $102.63 |
-- |
| 2 |
$102.63 |
3 Meals 7 Days Per Week $102.63 |
-- |
|
TOTAL |
CODE 105 |
CODE 101 |
