Medicare covers enteral nutrition therapy, commonly called tube feeding, under the Medicare Part B prosthetic device benefit for beneficiaries residing at home or in a skilled nursing facility (SNF) or nursing facility (NF) when the stay is not covered by Medicare Part A. Enteral equipment and supplies are used to provide enteral nutrients through a tube into the stomach or small intestine.
Enteral nutrition is a product category in Round 2021 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. With the exception of SNFs and NFs that become specialty suppliers, contract suppliers for the enteral nutrition product category must furnish services to beneficiaries throughout the competitive bidding area (CBA), regardless of whether a beneficiary lives in a private residence or institutional setting.
Payment for Enteral Nutrition under the Medicare DMEPOS Competitive Bidding Program
Medicare makes payments for nutrients for a 30-day supply based on the “from” date on the claim. If the "from" date on the claim is prior to the implementation date of Round 2021, any Medicare enrolled supplier can bill for the 30-day supply and be paid the adjusted fee schedule amount for the 30-day supply. If the "from" date on the claim is on or after the date of implementation of Round 2021, only a Round 2021 contract supplier may bill Medicare for these services, and Medicare will pay the Round 2021 single payment amount (SPA) for the 30-day supply.
Maintenance and servicing (MS) payments for enteral pumps will be paid to the contract supplier using the existing guidelines found in the Centers for Medicare & Medicaid Services Manual System Pub.100-04, Medicare Claims Processing, Chapter 20, §40.3, with the exception that the payment methodology will be one-half of the Medicare DMEPOS Competitive Bidding Program SPA for one month’s rental rather than one-half of the fee schedule amount for one month’s rental.
Rented Enteral Equipment
Under the Medicare DMEPOS Competitive Bidding Program laws and regulations, enteral nutrition cannot be grandfathered. Only oxygen and oxygen equipment and rented durable medical equipment (DME) including rented walkers
and non-invasive ventilators can be grandfathered. On April 9, 2020, the non-invasive ventilators product category was removed from Round 2021 due to the novel COVID-19 pandemic. A Medicare beneficiary must obtain related enteral accessories, nutrition, and supplies from a contract supplier. Below are some scenarios that discuss supplier responsibilities for enteral nutrition equipment or supplies that were rented prior to the implementation of Round 2021 of the Medicare DMEPOS Competitive Bidding Program.
Scenario 1: The enteral nutrition pump has been rented for less than 15 months at the time of Round 2021 implementation.
If the enteral nutrition pump was rented for less than 15 months at the time of the implementation of Round 2021, the rental of the pump must transition to a contract supplier. The contract supplier will be paid the remainder of the rental months and subsequent maintenance and service until a determination is made by the beneficiary's physician that the equipment is no longer medically necessary. The contract supplier will be paid the new SPA and required to accept assignment on the claims. The pickup of the existing pump and delivery of the new pump should occur on the anniversary date on which the pump was first rented to the beneficiary. For example, if the equipment was rented on August 15th, the anniversary would be September 15th, October 15th, and on the 15th of each following month. A contract supplier may not refuse to furnish items to a beneficiary based on the number of rental months remaining in the 15-month rental period. Suppliers should consider this fact when developing their bids.
Scenario 2: The enteral nutrition pump has been rented for at least 15 months at the time of Round 2021 implementation.
If the enteral nutrition pump was rented for at least 15 months at the time of implementation of Round 2021, the supplier (contract or non-contract supplier) that provided the item in the 15th month of the rental period is responsible for furnishing, maintaining, and servicing the enteral equipment as long as it is medically necessary. However, the beneficiary must obtain related enteral accessories, nutrients, and supplies from a contract supplier.