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The Healthcare Nutrition Council (HNC) works to ensure patients have access
to the enteral and parenteral nutrition products they need. HNC continues
to educate and collaborate with legislative and regulatory representatives,
patient and consumer advocacy groups, academia, industry, and other
stakeholders to promote awareness of the impact of nutrition on health and
ensure people have access to enteral and parenteral nutrition products.
Enteral Nutrition: Access and Coverage
Specialized nutrition is either taken by mouth and/or given via a feeding tube.
Specialized Nutrition
• The term, enteral, refers to nutrition Nasal feeding tube
administered via the gastrointestinal terminates at, either:
tract. It may be administered orally • Stomach (Nasogastric)
or via tube feeding. Further, enteral • Duodenum (Nasoduodenal)
nutrition (EN) may be defined as, • Jejunum (Nasojejunal)
“A system of providing nutrition
directly into the gastrointestinal Oral Nutritional
tract via a tube, catheter, or stoma Supplements (ONS)
that bypasses the oral cavity.”
• Enteral products, administered both Feeding tube that
orally and via a feeding tube, are leads though an
often medically necessary as a sole or artificial external
complementary source of nutrition opening into
in order to maintain health, quality Stomach the stomach
of life, prevent malnutrition, and (Gastrostomy)
address specific nutritional needs of
people in various disease states. Feeding tube that
leads through an
Varying Coverage Policies artificial external
Duodenum opening into the
• Medicare covers EN (when small intestine
administered via a feeding tube) (Jejunostomy)
under the Medicare Part B prosthetic Jejunum
device benefit for beneficiaries at
home or in a skilled nursing facility
and for nursing facilities when the that the beneficiaries cannot be coverage policies (Medicare only
stay is not covered by Medicare maintained with oral feeding. covers EN as a prosthetic benefit),
Part A. Under Medicare Part B, EN • Orally administered enteral this can limit access to enteral
is eligible for coverage when there supplements are not covered products that are not required as
is a permanent impairment that under Medicare Part B, but may a result of permanent impairment
requires feeding via tube. Typical be covered under some state or administered orally.
examples provided by the Centers Medicaid programs and some • Enteral coverage policies vary across
for Medicare and Medicaid Services commercial insurance programs. payers and plans leading to additional
(CMS) are head and neck cancer with • However, because some Medicaid complexity. The uncertainty and
reconstructive surgery and central and commercial payers use Medicare complexity of a beneficiary’s coverage
nervous system disease leading coverage policy to set their own can negatively impact access to
to problems with severe ingestion
HEALTHCARENUTRITION.ORG PUBLISHED 2019 1
necessary nutrition products. To Access Challenges necessity by the ordering physician
help solve for this, HNC advocates • Patients may have a difficult time is essential to secure coverage.
for a simplified, uniform claims finding providers to supply the Coverage guidelines differ from plan
adjudication for enteral products enteral products they need, due to to plan. As a result, there can be
to improve patient access. coverage and reimbursement issues. challenges to patients in securing
coverage and receiving the nutrition
Limited Reimbursement • Enteral products, administered both therapies they need. In many cases,
Rates orally and via a feeding tube, are denials of coverage result from a
• EN (administered via a feeding tube) accessible and often provided in non-transparent and complicated
inpatient settings and are covered claims adjudication system.
and related supplies is a product under the overall daily hospital
category of the CMS Medicare Durable reimbursement rate. However, Why Protect Access to
Medical Equipment, Prosthetics, access to enteral products can Enteral Nutrition?
Orthotics and Supplies (DMEPOS) become especially limited when
competitive bidding program. patients leave hospitals or healthcare • Providing appropriate enteral
Medicare’s competitive bidding centers. For example, EN may be products to critically ill hospitalized
fee schedules may influence other self-administered in the patient’s patients can significantly improve
payers’ reimbursement rates. home or by a nonprofessional (who patient survival, improve outcomes,
• Recent reports from both private and has had specialized training), but reduce length of hospital stay,
public institutions have shown that the EN and nonprofessional service and reduce total costs of care.
Medicare’s Part B competitive bidding provider may not be covered. • Providing enteral products to
fee schedules and governance, often • Like other specialized products, patients in the community can
the status quo for reimbursement of claims for enteral products under reduce hospitalizations and
home medical equipment (HME), can all health insurance plans must be help meet their nutrition needs
jeopardize access to care in the home. approved on an individual, case-by- to prevent malnutrition.
case basis. Documentation of medical
References
1 American Society for Parenteral and Enteral Nutrition. What Is Nutrition Support Therapy. (2019).
2 American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in
ASPEN. (2018).
3 Medicare.gov. Enteral Nutrition Supplies and Equipment. (2019).
4 Newtown, Alyce; and Gisela Barnadas. Understanding Medicare Coverage for Home Enteral Nutrition: A Case-Based
Approach. Practical Gastroenterology. (May 2013).
5 Department of Health and Human Services. Office of Inspector General. Coverage of Enteral Nutrition Therapy: Medicare
and Other Payers. (May 1995).
6 Cigna. Medical Coverage Policy: Nutrition Support. (2019).
7 Department of Health and Human Services. Office of Inspector General. Coverage of Enteral Nutrition Therapy: Medicare
and Other Payers. (May 1995).
8 Centers for Medicare & Medicaid Services. Durable Medical Equipment (DME) Center. (2019).
HEALTHCARENUTRITION.ORG PUBLISHED 2019 2
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