Coverage for Home Enteral Nutrition

Enteral nutrition costs for qualified Medicare beneficiaries may be reimbursed under Medicare Part B. This pays 80% of allowable charges, which are billed through payors that have contracts with the Centers for Medicare and Medicaid Services (CMS). Physician services, outpatient care, lab and other services as well as some medications are processed by various carriers, and equipment is processed by Durable Medical Equipment Medicare Administrative Contractors or “DME MACs”, and the benefits vary based on the patient’s state of residence.[7]

If a patient does not have coverage under Medicare Part B, they may be covered under the state Medicaid program, if eligible, for a daily rate. The policies and rates vary by state.

Third party insurance payments will vary according to policy and some may include Medigap coverage for coinsurance and deductible expenses not covered by Medicare.

A contract may be negotiated between a facility or home care agency and a managed care organization, HMO, of the VA system. In some cases the contract will include enteral nutrition, and in others the provider may bill the managed care, HMO, or VA organization, though coverage policies may vary.

There are several resources available for clinicians, patients, and caregivers to learn more about, and manage, home tube feeding. Two organizations are in the forefront, having been involved in the development of guidelines and strategies to assist in successful home nutrition support, and the transition from acute to longer-term care. The websites contain quite a lot of information for health care professionals and patients and their caregivers. In addition to these, telephone and support group help can be found at local hospitals, clinics, through medical equipment and supply companies and elsewhere to assist patients and their caregivers in adjusting to longer-term home enteral nutrition so that they can achieve an optimal quality of life.

ASPEN - www.oley.org ASPEN (American Society for Parenteral and Enteral Nutrition) - www.nutritioncare.org

[7] Medicare Part B: Enteral Nutrition Reimbursement Manual. Abbott Laboratories (2010-2011). Available at:  http://abbottnutrition.com/Downloads/9th%20Edition%20Reimbursement%20Manual%20-%20Interactive%20PDF.pdf