Nutrition
Medical Food Coverage
(e.g., Ensure, Boost, medical infant formula)
Sections:
SNAP
WIC
Medicare
MassHealth
Pharmaceutical Company Programs
Advocacy tip: Carnation Instant Breakfast is less expensive than Ensure and Boost. Before substituting, patients should ask their medical provider if it would be an acceptable substitute for them. (Thanks to Barbara Maxam for this tip!)
SNAP
When considering the eligibility of vitamins and supplements, power bars, energy drinks and other branded products, the primary determinant is the type of product label chosen by the manufacturer to conform to Food and Drug Administration (FDA) guidelines:
- Items that carry a nutrition facts label are eligible foods (most Ensure and Boost-type products carry this type of label)
- Items that carry a supplement facts label are classified by the FDA as supplements, and are therefore not eligible.
-Source and for more information: http://www.fns.usda.gov/sites/default/files/eligibility.pdf
The nutrition supplements must be available for purchase by the general public, without a physician's prescription, but the patient must be purchasing the supplement because a doctor recommended it. (Source: http://www.mitoaction.org/red-tape/%22thinking-outside-can%22-part-2)
Learn more about SNAP
WIC
WIC serves low-income pregnant or post-partum women, infants, & children up to age 5 who are at nutritional risk.
Enfamil Infant and Enfamil ProSobee (soy) are WIC's standard infant formulas.
WIC Formula List: https://www.mass.gov/files/2017-08/formula-list.pdf.
Special and Metabolic Formulas for WIC participants NOT Enrolled in MassHealth
WIC also provides special and metabolic formulas for participants with special medical needs who do NOT have MassHealth. A completed WIC Request for Special Formula and Food form requesting a special or metabolic formula with a nutrition-related ICD code must be provided outlining the patient’s qualifying medical condition(s) warranting need prior to issuance.
MassHealth members requiring Enfamil Gentlease and Enfamil A.R. will receive these formulas through WIC without needing to pursue prior authorization from MassHealth.
A Request for Special Formula and Food form is required for Enfamil A.R. before issuance will be approved.
WIC Formula List: https://www.mass.gov/files/2017-08/formula-list.pdf.
Special and Metabolic Formulas for WIC participants enrolled in MassHealth
MassHealth is the payer of first choice for special medical formulas for WIC participants who are MassHealth members. While waiting for MassHealth approval, WIC will provide one month of benefits for the prescribed formula from WIC (after the medical provider has completed the WIC Request for Special Formula and Food form) and will act as a safety net for families should the process take longer. WIC staff can guide WIC participants and medical providers through the process of receiving special or prescription formulas through MassHealth insurance.
-Source and for more information: http://www.mass.gov/eohhs/consumer/basic-needs/food/wic/providers/special-formula.html
Learn more about WIC
Medicare
Nutritional products taken ORALLY
- Are covered when a hospital inpatient or during a covered SNF stay (under Medicare A).
- Are NOT covered in the outpatient or homecare setting.
Nutritional products taken via FEEDING TUBE
- Medicare Part B covers under the prosthetic device benefit.
- Requirements
- The beneficiary must have a permanent functional impairment* of the gastrointestinal tract.
- Enteral nutrition Treatment (ENT) must be reasonable and necessary for the beneficiary.
- The beneficiary must require tube feeding to maintain weight and strength commensurate with his or her overall health status.
- If these coverage requirements for ENT are satisfied, the related enteral equipment, supplies and nutrients may be covered under Medicare Part B
*Permanent Functional Impairment: "...enteral and parenteral nutritional therapy are not covered under Part B in situations involving temporary impairments. Coverage of such therapy, however, does not require a medical judgment that the impairment...will persist throughout the patient’s remaining years. If the medical record, including the judgment of the attending physician, indicates that the impairment will be of long and indefinite duration, the test of permanence is considered met."
MassHealth
Medicaid coverage varies by state, the information here applies to MassHealth.
Adults
Infant Formula
Due to supply chain issues, MassHealth is TEMPORARILY Covering Pediatric Enteral Special Formula and Thickening Agents Dispensed at Pharmacies
(4/22) More Information.
MassHealth is the payor of last resort for certain infant formulae. The WIC Program has primary responsibility for the provision of “standard infant formula” to WIC-eligible MassHealth members. MassHealth does not consider formula to be medically necessary under the following circumstances:
- the member is WIC-eligible;
- the enteral nutrition product being requested is listed as a “standard infant formula” on the current list of formulas covered by WIC; and
- the formula is available in adequate amounts to the member through the WIC program.
WIC Formula List: https://www.mass.gov/files/2017-08/formula-list.pdf
MassHealth is the payer of first choice for special medical formulas for WIC participants who are MassHealth members. While waiting for MassHealth approval, WIC will provide one month of benefits for the prescribed formula from WIC (after the medical provider has completed the WIC Request for Special Formula and Food form) and will act as a safety net for families should the process take longer. WIC staff can guide WIC participants and medical providers through the process of receiving special or prescription formulas through MassHealth insurance. More under WIC above.
Learn more about MassHealth
Pharmaceutical Company Programs
