Children under 21 are entitled to obtain "Ensure" or other nutritional supplements when medically necessary. However, the State has enacted laws in the last few years that restrict eligibility for nutritional supplements for adults age 21+. In 2011, the state budget law limited these "enteral supplements" to only those adults who can only be tube-fed. This change was Medicaid Redesign Team MRT 5901 Bowing to pressure to reinstate broader access to these supplements, in 2012, the state amended Social Services Law § 365-a(2)(g) to direct the State Department of Health to develop standards so that adults diagnosed with an HIV-related condition and other illness and conditions may qualify for Medicaid to pay for these supplements, including those who do not have to be tube-fed. The State Department of Health delayed in issuing the new standards for adults until finally issuing them in June 2013.
18 NYCRR 505.5(g)(3) was amended by an emergency regulation dated June 6, 2013 and published on June 26, 2013 -- located at page 17-18 of this link. Final rule is unchanged, available here.
The new standards are also available in the State Medicaid Provider Manual for Durable Medical Equipment -- see pp 29-32
The State Dept. of Health's Power Point presentation for the Enteral Nutritional Formula webinar held on July 25, 2013 is available at MRT 5901: Coverage for Enteral Formula
NEW GUIDELINES in regulations--
Enteral nutrition is limited to Medicaid coverage for --
Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube.
Beneficiaries with inborn metabolic disorders
Children up to 21 years of age,who require liquid oral nutritional therapy when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized.
Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who
- require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, and have a body mass index (BMI) under 18.5 as defined by the Centers for Disease Control, up to 1,000 calories per day;
- require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, have a body mass index (BMI) under 22 as defined by the Centers for Disease Control, and a documented, unintentional weight loss of 5 percent or more within the previous 6 month period, up to 1,000 calories per day;
- require total oral nutritional support, have a permanent structural limitation that prevents the chewing of food, and placement of a feeding tube is medically contraindicated.
- The therapy must be an integral component of a documented medical treatment plan and ordered in writing by an authorized practitioner. It is the responsibility of the practitioner to maintain documentation in the member’s record regarding the medical necessity for enteral nutritional formula.
Documentation Requirements - From State Medicaid Provider Manual for Durable Medical Equipment
The physician or other appropriate health care practitioner has documented the member's nutritional depletion.
Medical necessity for enteral nutritional formula must be substantiated by documented physical findings and/or laboratory data (e.g., changes in skin or bones, significant loss of lean body mass, abnormal serum/urine albumin, protein, iron or calcium levels, or physiological disorders resulting from surgery, etc.)
Documentation for beneficiaries who qualify for enteral formula benefit must include an established diagnostic condition and the pathological process causing malnutrition and one or more of the following items:
(a)Clinical findings related to the malnutrition such as a recent involuntary weight loss or a child with no weight or height increase for six months.
(b)Laboratory evidence of low serum proteins (i.e., serum albumin less than 3 gms/dl; anemia or leukopenia less than 1200/cmm);
(c)Failure to increase body weight with usual solid or oral liquid food intake.
Enteral formula requires voice interactive prior authorization, as indicated by the “*” next to the code description. The prescriber must write the prior authorization number on the fiscal order and the dispenser completes the authorization
process by calling (866) 211-1736. For requests that exceed 2,000 calories per day for qualifying beneficiaries, a prior approval request may be submitted with medical justification.
Prior approval requests must be submitted by a qualified enrolled Medicaid pharmacy or DME provider and include the valid order and supporting medical documentation from the enrolled practitioner. For information on how to submit a prior approval refer to the Prior Approval Guidelines Prior Approval Guidelines
Questions may be directed to the Division of OHIP Operations, Medical Prior Approval, at email@example.com or 1 800 342-3005, option 1. If you have any questions, please contact Andreas Christodoulou at 518-257-4505.