Becky Boley, R.N., is an intake specialist with CarePro Home Infusion. With nearly 30 years of nursing experience, she knows that understanding insurance coverage can be a challenge. This month, she offers us answers to the frequently asked questions about one of the more complicated home infusion services: tube-feeding, also known as enteral feeding.
Is tube-feeding covered by my insurance?
Every insurance policy is different, so unfortunately there’s no blanket answer to this question. Some companies don’t cover tube-feedings. Medicare has four main requirements when it comes to tube-feeding:
- The tube-feeding must be sustained for 90 days or more
- The patient must have a feeding tube in order for the feedings to be covered.
- The patient must have a functional impairment that prevents them from being able to eat, such as a tumor, difficulty swallowing due to a stroke, etc. Medicare won’t cover tube-feedings if the patient simply refuses to eat.
- The patient must be getting most of their calories from tube-feeding. If a patient is able to consume most of their food by mouth, Medicare won’t cover the tube-feedings.
These four criteria must be met, otherwise Medicare won’t cover the tube-feeding costs.
Is tube-feeding formula covered by my insurance?
Think about when you go down the cereal aisle in the grocery store. There are so many different types of cereal, it can almost be overwhelming! That’s about what it’s like with formulas. There are at least 40 to 50 different types of formulas. Some of these formulas have been created to be specialized; for instance, there are special kinds of formula created especially for patients with pulmonary and renal diseases. Medicare won’t cover specialized formulas like this unless a general formula has been proven not to work for the patient.
What will I be expected to pay out-of-pocket?
Medicare will only cover 80 percent of tube-feeding costs, so patients will be expected to pay for 20 percent, unless they have a secondary or supplemental insurance.
Why can’t I have a pump?
A pump most likely will not be covered if the tube goes into the stomach (G-tube). Medicare requires that patients try bolus or gravity feedings first, as these are more similar to the way we would normally eat. When a person is healthy, the stomach is used to feeding intermittently, not continuously. If the physician can document failed bolus or gravity feeding trials, it may be possible to get the pump covered. Pumps are often used in the hospital settings, as they are convenient for the staff. Unfortunately they are often not covered when the patient transitions to homecare.
The most important thing to remember is that coverage is different for home care services than it is for a patient who is hospitalized. Because patients won’t be under the constant supervision of doctors and nurses like they are when they are in the hospital, teaching visits are required, so that patients and their caregivers can learn how to properly administer the feedings. While the coverage is different, we know that living at home is much more preferable to staying in the hospital, and we’re ready to help you every step of the way.