POLICY INFORMATION
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Medicare is funded by the Federal Government and does not have individual financial requirements for access to the program. It was established in 1965 and is a health insurance program for:
  • people age 65 or older,
  • people under age 65 with certain disabilities,
  • people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Four Parts of Medicare:

Medicare Part A: Also known as Hospital Insurance, Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals, hospice and skilled nursing facilities (up to 100 days) and some home health care.

Medicare Part B: Also known as Medical Insurance, Medicare Part B is optional and must be purchased to access. In addition to other products and services,  Medicare Part B helps cover doctors' services, outpatient care, some services provided by physical and occupational therapists and some preventive care services like medical nutrition therapy. Medicare Part B provides coverage for enteral nutrition when administered through a feeding tube in the homecare setting. Tube-fed residents of Skilled Nursing Facilities may have enteral nutrition covered by Medicare Part B after the Medicare Part A benefit limit has been reached. 

*Medicare does not provide coverage for nutritional products when orally consumed in the outpatient or homecare setting.

Medicare Part C (Medicare Advantage): Formerly known as Medicare + Choice, Medicare Advantage is a group of Medicare Managed Care Plans offered through commercial insurance companies that are contracted by Medicare. They offer the same benefits provided by traditional Medicare and depending on the plan, may provide expanded benefits.

Medicare Part D: Also known as Prescription Drug Coverage, beneficiaries can choose a drug plan and pay a monthly premium. Enteral nutrition is not covered under Medicare Part D.




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Medicaid is America's health care program for low-income citizens of all ages. If patients are eligible to receive Medicaid, their benefits may be managed directly through the state program or through a commercial managed care plan that is contracted by the state.

Each state and each managed care plan establishes its own criteria regarding coverage of nutritional products in the outpatient or homecare setting. Most states and plans will provide coverage for enteral nutrition when there is medical necessity for a feeding tube. Some states and plans will provide coverage for nutritional products when consumed orally in specific medically necessary situations. Payer policies can change and will vary by plan.




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Some private/commercially available insurance plans provide coverage for medical foods. Individual plans have specific coverage guidelines and criteria that must be met. More often coverage exists in situations where there is medical necessity for a feeding tube, when medical foods are needed for inborn errors of metabolism or when a specialty product is needed for an infant or a child.

Abbott Nutrition's PATHWAY Reimbursement HelpLine is a resource to help you understand potential eligibility coverage and insurance benefits. It can provide information about the following services:

  • General Payer Policy Research – Research conducted at a non-patient specific level to determine coverage guidelines for a specific AN product.
  • Benefit Verification – Completed at a patient-specific level and includes outbound calls to payers to research eligibility, product coverage, benefit details (including copays, deductibles, coinsurance, etc.), prior authorization requirements and claims submission process.
  • Coding and Billing Information – Can include information about claims filing/billing, including outreach to the payer to determine specific billing requirements and guidelines, and the provision of publicized codes for billing purposes.
  • Prior Authorization Support - Research into the process for obtaining the Prior Authorization, including criteria, submission process, turn-around times, notification of results, and regular follow-up with the Payer and provider until a decision has been made. Can also include provision of sample medical necessity template letters to the provider for completion.
  • Appeal Process Information – Researching the process for obtaining the appeal (including criteria, submission requirements, turn-around times, notification of results, etc.), providing template letters to the provider for completion, and regular follow-up with the Payer and provider until a decision has been made.
Private Insurance Medical Necessity Template letters can be accessed at our Private Insurance Medical Necessity Template Letter section.


The letters outline medical benefits and features of Abbott Nutrition products and serve as a template to be customized by the physician for each patient. The payer will ultimately determine if reimbursement for a product is available.

NOTE:
These letters are to be used as templates and customized by the physician for each patient. The list of diagnoses and ICD-9 codes contained in the letters are not all-inclusive. It is ultimately the responsibility of the health care professional/persons associated with the patient's care to determine and document the appropriate diagnosis(es) and code(s) for the patient's condition. Abbott Nutrition does not guarantee that the use of any information provided in these letters will result in coverage or payment by any third-party payer.




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Additional sources for coverage or procurement of medical nutritional products may exist through other federal and state-funded programs. Eligibility, terms and conditions vary by state and by program. Contact your state's program directly for specific details.

Examples of additional programs include but are not limited to:

  • ADAP (AIDS Drug Assistance Programs)
  • BCMH (Bureau for Children with Medical Handicaps)
  • SCHIP (State Children's Health Insurance Programs)
  • WIC (Women, Infants and Children)
  • SNAP (Supplemental Nutrition Assistance Program)

NOTE:
Information contained in this section is taken from a variety of sources including, but not limited to, official government documents. Such information is provided for our customers from information correct at the time of publication. Abbott Nutrition and Abbott Laboratories assume no responsibility for omissions, errors, or policy changes contained therein. Additionally, the information provided is meant to be a guide for your information only. Each health care provider office is ultimately responsible for verifying codes, coverage, and payment policies used for individual patients to ensure that they are accurate and appropriate for the services and items provided.

© Abbott Nutrition 2012