Medicare Coverage for Enteral Nutrition
Medicare covers enteral nutrition therapy and supplies at home for beneficiaries with permanent impairments. Feeding tubes, pumps and other supplies must be considered medically necessary and ordered by your doctor. You will pay 20 percent of the cost for these products.
Medicare Coverage for Enteral Nutrition Supplements
Medicare Part B covers enteral nutrition when it is administered to patients via a feeding tube in the home. Medicare Part A covers enteral nutrition therapy administered in an inpatient hospital or skilled nursing facility.
To qualify for Medicare coverage, your need for enteral nutrition must result from a permanent injury or disability. Your medical record should indicate that your impairment is expected to last indefinitely.
Enteral and parenteral nutritional therapy at home isn’t usually covered in situations involving temporary impairments.
Each claim for enteral nutrition must include a written order or prescription from your doctor. There must also be sufficient medical documentation — such as hospital records and clinical findings from your doctor — to prove that your need for enteral nutrition is medically necessary.
- Head and neck cancer with reconstructive surgery
- Central nervous system diseases that lead to problems with ingestion, such as amyotrophic lateral sclerosis (ALS) or stroke
- Nonfunction or disease of the structures that normally permit food to reach the small bowel
- Disease of the small bowel that impairs digestion and absorption of an oral diet
The order from your doctor will indicate the type of feeding formula, strength, delivery method and feeding frequency you need.
When properly coded and ordered by your doctor, Medicare will pay for various accessories you may need.
- Catheter/tube anchoring device
- Feeding bag or container
- Flushing solution bag or container
- Extension tubing
- Feeding/flushing syringes
- Dressings used for gastrostomy tube site
- Gastric pressure relief valve
Medicare Part B also covers IV poles used to deliver nutrients.
Enteral therapy may be given by nasogastric, jejunostomy or gastrostomy tubes and can be provided in the home by specially trained nonprofessionals.
If the claim involves a pump, sufficient medical documentation must be provided. Pump-assisted feeding uses an electric device to better control the rate of nutrition delivery in patients who are at a higher risk of complications.
Medicare will pay for the simplest pump model that meets your medical needs.
You can choose to either buy or rent the appropriate pump from your durable medical equipment supplier.
If you choose to rent, you will be given the option to purchase the pump during the 10th rental month. If you decide to buy it, Medicare will pay for all necessary maintenance and servicing of the pump.
If you choose not to buy it, your supplier must continue to provide the pump to you even after rental payments end after the 15th month. However, you’ll be responsible for any maintenance or servicing fees for the pump.
Medicare considers enteral formulas consisting of semi-synthetic intact protein or protein isolates appropriate for most beneficiaries. If a special enteral nutrition formula is provided and the medical record does not document why that item is medically necessary, Medicare won’t pay for it.
Enteral Supplements and Supplies Not Covered by Medicare
Orally administered enteral supplements are not covered by Medicare Part B. But according to the Healthcare Nutrition Council, some state Medicaid programs and commercial insurance programs may cover these supplements.
Nutritional supplements are often given as medicine between meals to patients receiving enteral therapy. However, nutritional supplementation is not covered under Medicare Part B.
Finally, food thickeners, baby food and other over-the-counter products that can be used with the enteral system aren’t covered by Medicare. Self-blended formulas aren’t covered either.
Medicare Guidelines for Enteral Nutrition Reimbursement
Enteral nutrition therapy given at home is covered by Medicare Part B. You will owe 20 percent of the cost for these products and supplies. Medicare pays the other 80 percent.
You may owe less if you have supplement insurance, such as Medicaid or a Medigap policy.
Medicare Part A pays for enteral nutrition therapy in a hospital or skilled nursing facility. These products are included in your overall inpatient care, so you won’t owe any additional money after meeting your Part A deductible.
Medicare pays for no more than one month’s supply of enteral nutrients at a time.
Claims for enteral products must be approved on an individual, case-by-case basis.
What Is Enteral Nutrition?
Enteral nutrition — also known as tube feeding — is a system of delivering nutrition directly to the stomach or small intestine.
Your doctor may recommend tube feeding if you can’t receive the nutrients you need from oral feeding due to an illness or injury, but your digestive system works normally.
Feeding tubes deliver liquid nutrition directly to your stomach or small intestine. Tubes can run through your nose, mouth or the skin on your stomach.
Enteral liquid food supplements contain protein, carbohydrates, fats, vitamins and minerals.
5 Cited Research Articles
- United Healthcare. (2021, April 19). Enteral and Parenteral Nutritional Therapy (NCD 180.2). Retrieved from https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-guidelines/e/enteral-parenteral-nutrition-therapy.pdf
- Mayo Clinic. (2019, December 12). Home enteral nutrition. Retrieved from https://www.mayoclinic.org/tests-procedures/home-enteral-nutrition/about/pac-20384955
- Healthcare Nutrition Council. (2019). Enteral Nutrition: Access and Coverage. Retrieved from https://healthcarenutrition.org/wp-content/uploads/2020/02/EN-Fact-Sheet-Feb-2020.pdf
- American College of Gastroenterology. (n.d.). Enteral and Parenteral Nutrition. Retrieved from https://gi.org/topics/enteral-and-parenteral-nutrition/
- Medicare.gov. (n.d.). Enteral nutrition supplies & equipment. Retrieved from https://www.medicare.gov/coverage/enteral-nutrition-supplies-equipment