5101:3-10-26 Enteral nutritional products.

(A) Definition

"Enteral nutrition" is defined as oral or tube-delivered caloric sustenance products for those medicaid consumers demonstrating a disability or life-threatening disease with significant nutritional problems that cannot be managed by ordinary or blenderized foods.

(B) Coverage determination

(1) For an enteral nutritional product to be considered for coverage, one of the following criteria must be met:

(a) The consumer is unable to swallow food due to a damaged or diseased (non-functioning) oral pathway and must be tube-fed, as determined and documented by a licensed prescriber.

(b) The consumer has the ability to swallow, but is unable to meet caloric and nutritional requirements from ordinary foods, including pureed or blenderized foods, to maintain life-sustaining functions, as determined and documented by a licensed prescriber.

(2) Consumers with infants and children age five or younger whose children require enteral nutrition products, breast-feeding consumers with an infant one year of age or younger, or post-partum mothers with a child six months of age or younger, must apply to their county women, infant and children (WIC) program for an eligibility evaluation before coverage by the Ohio department of job and family services (ODJFS) will be considered.

(C) Non-covered products

(1) Enteral nutrition products that are designed to provide meal replacements, or snack alternatives to be eaten within the context of a consumer's individualized meal plan, are not covered. These products include, but are not limited to:

(a) Shakes;

(b) Meal bars;

(c) Snack bars;

(d) Supplement thickeners;

(e) Cereals;

(f) Puddings;

(g) Vitamins/ minerals; and

(h) Blenderized or pureed foods prepared in a personal residence or long term care facility (LTCF).

(2) Enteral nutrition products that are designed as meal replacements, or to be eaten within the context of a consumer's prescribed reduced calorie diet for consumers with diabetes, obesity issues, pre- or post-gastric bypass, or bariatric surgery, are not covered.

(3) Enteral nutrition products that are administered in an outpatient provider setting (i.e., a dialysis outpatient clinic or a facility receiving per diem payments from the department) are not separately reimbursable.

(4) Adult and pediatric electrolyte replacement is covered under the pharmacy benefit program as described in Chapter 5101:3-9 of the Administrative Code.

(5) Any facility receiving per diem reimbursement from the Ohio medicaid program for a consumer's care cannot submit claims to ODJFS for separate reimbursement for enteral nutritional products.

(D) Prior authorization

(1) The following documentation must be submitted for prior authorization (PA) before reimbursement for enteral nutrition products will be considered:

(a) A fully completed form JFS 01907 , "Certificate of Medical Necessity for Enteral Nutrition Services/ Prescription" (CMN) (appendix to this rule) that is signed and dated no more than thirty days prior to the first date of service.

(2) Prior authorization requests for medicaid consumers who cannot maintain weight must include a current weight history. Providers requesting for a consumer a daily caloric intake of greater than two thousand calories must have "section 9" of form JFS 01907 completed prior to requesting a prior authorization.

(3) Initial prior authorization requests for enteral nutrition products may be approved for a maximum of twelve months. Subsequent PAs for the same consumer for the same disease state may be approved for a maximum of twelve months.

(4) Consumers having a change in their treatment plan that requires the use of an enteral product that is different than a previously authorized enteral product will require a new certificate of medical necessity before a new enteral product will be authorized.

(E) Dispensing

(1) Enteral nutrition products shall be dispensed in no greater quantity than one month's supply.

(2) Providers may dispense enteral nutrition products' generic equivalents (e.g., vendor branded or private label equivalent) if available, as long as the substituted product is correctly formulated to meet the needs of the consumer and the consumer's prescriber is notified in advance of dispensing.

(3) Medicaid providers may not provide a re-supply of enteral nutrition products sooner than one week before a consumer's next scheduled supply dispense date.

(4) No dispensing, mailing, or delivery fees are separately reimbursable by the Ohio medicaid program.

(5) The consumer will be supplied with the ordered enteral product that is in the most cost effective formulation that the consumer can tolerate.

(F) Reimbursement

(1) Unless otherwise specified, enteral nutrition products are reimbursed by the Ohio medicaid program consistent with paragraph (F) of rule 5101:3-10-05 of the Administrative Code.

(2) For enteral nutrition products that do not have a predesignated medicaid maximum allowable on the Ohio medicaid fee schedule as listed in appendix DD to rule 5101:3-1-60 of the Administrative Code, the Ohio medicaid program will reimburse the supplier's average wholesale price (AWP) minus twenty-three per cent.

(3) No more than one month's supply of enteral nutrition products is allowed for one month's prospective billing.

(4) For enteral nutrition that is administered orally, the modifier BO must be utilized in conjunction with the appropriate "Healthcare Common Procedure Coding System" (HCPCS) code . This modifier will be authorized for use by the PA department during the initial PA review and documented on the provider's PA letter.

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Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , Section 309.30.75 of Am. Sub. H.B. 1, 128th G.A
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.75 of Am. Sub. H.B. 1, 128th G.A
Prior Effective Dates: 1/1/06, 8/18/08, 1/1/10