MRT Initiative 5901

Phase 2 - Coverage for Enteral Formula

  • MRT 5901 also available in Portable Document Format (PDF, 381KB)

JULY 25, 2013
DIVISION OF OHIP OPERATIONS
OFFICE OF HEALTH INSURANCE PROGRAMS

Division of OHIP Operations

  • Deborah Henderson - Director, Bureau Medical Prior Approval
  • Kevin Hepp - Manager, Medical Prior Approval for DME, Vision, and Physician services

Webinar Objectives

  • New Benefit limits
  • Overview of Utilization Management procedures
  • Stakeholder feedback

Previous Enteral Benefit

Prior to June 7, 2013, Enteral Benefit applied to:

  • Beneficiaries who are fed via nasogastric, gastrostomy or jejunostomy tube.
  • Beneficiaries with inborn metabolic disorders.
  • Children up to 21 years of age, who require liquid oral nutritional therapy when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized.
  • Or, subject to standards established by the commissioner, for persons with a diagnosis of HIV infection, AIDS or HIV-related illness or other diseases and conditions.

New Benefit limit

Effective June 7, 2013, the following three coverage criteria are added to the benefit limit.

  • Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who;
    • require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, and have a body mass index (BMI) under 18.5 as defined by the Centers for Disease Control, up to 1,000 calories per day; or
  • Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who;
    • require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, have a body mass index (BMI) under 22 as defined by the Centers for Disease Control, and a documented, unintentional weight loss of 5 percent or more within the previous 6 month period, up to 1,000 calories per day; or
  • Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who;
    • require total oral nutritional support, have a permanent structural limitation that prevents the chewing of food, and placement of a feeding tube is medically contraindicated. (These individuals are not subject to a 1,000 calorie limit)

Utilization Management

Why additional prior approval requirements?

  • New benefit expands coverage and spending
  • No specific funding allocated
  • Global spending cap

New Utilization Management (UM)

Paper Prior Approval required for:

  • Oral fed adults with a BMI between 18.5 and 21.9 who have demonstrated at least a 5% weight loss over previous 6 months.
  • Oral fed adults with a BMI under 18.5 requiring more than 2-three month authorizations within a 365 day period.
  • Oral fed adult with a permanent structural limitation (tube feeding contraindicated)
  • Oral fed children (under 21) requiring more than 1,000 calories per day
  • Oral fed children (under 21) with a BMI of 18.5 or higher

Existing UM

Paper Prior Approval required for:

  • All individuals requiring more than 2,000 calories per day
  • Individuals who must change dispensing providers while refills remain on the prescription. Acceptable reasons are current provider is no longer able to fill the order or the individual moves and does not have reasonable access to that provider.

Goals Achieved

  • Expanded coverage for the most medically fragile beneficiaries
  • Avoided unnecessary increase in expenditures

Questions/Comments

Provide written questions or comments to: OHIPMedPA@health.ny.gov

MRT: Additional Information