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"Ensure" and Enteral Nutritional Supplements - When does Medicaid Pay for it? 2013 Changes for Adults

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Posted: 18 Jul, 2013
by Valerie Bogart (New York Legal Assistance Group)
Updated: 29 Jul, 2013
by Valerie Bogart (New York Legal Assistance Group)

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 ยง 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

The new standards are also available in the State Medicaid Provider Manual for Durable Medical Equipment --  see pp 30-31

The State Dept. of Health's Power Point presentation for the Enteral Nutritional Formula webinar held on July 25, 2013 is now available at MRT 5901-Coverage for Enteral Formula.

NEW GUIDELINES  in regulations--

Enteral nutrition is limited to Medicaid coverage for --

  1. Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube.

  2. Beneficiaries with inborn metabolic disorders

  3. 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.

  4. 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.

Procedures --

According to eMedNY, the changes to the fee for service automated enteral formula telephone prior authorization system supporting the new benefit were expected to be completed by July 1, 2013. These changes have been delayed and are now expected to be completed by July 15, 2013.

In the interim, practitioners treating an adult patient with an urgent medical need who now qualifies under the new benefit<https://www.emedny.org/ProviderManuals/DME/PDFS/DME_Procedure_Codes.pdf> may request coverage through prior approval.

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<https://www.emedny.org/ProviderManuals/DME/PDFS/DME_PA_Guidelines.pdf>.

Questions may be directed to the Division of OHIP Operations, Medical Prior Approval, at ohipmedpa@health.state.ny.us   or 1 800 342-3005, option 1.  If you have any questions, please contact Andreas Christodoulou at 518-257-4505.

Also read
item Medicaid Reimbursement of Home Care and other Medical Expenses
item The Medicaid Pharmacy Benefit
item Court Orders Lifting Restrictions in Medicaid Coverage for Compression Stockings and Orthopedic Footwear

Also listed in
folder Medicaid -> Other Services
folder Medicaid -> Medicaid Managed Care

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