Medicaid Redesign Team Change Effective
June 7, 2013

Date Issued: 6/7/2013

Enteral Nutritional Formula

On June 7, 2013, Medicaid managed care, fee-for-service and Managed Long Term Care plans began covering orally administered enteral nutritional formula for adults with a diagnosis of HIV infection, AIDS or HIV-related illness, or other disease or condition, who need oral feeding or meet these additional requirements:

  • Supplemental nutrition of up to 1,000 calories per day, 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 and Prevention (CDC); or
  • Supplemental nutrition of up to 1,000 calories per day, demonstrate documented compliance with an appropriate medical and nutritional plan of care, have a BMI under 22 as defined by the CDC, and a documented, unintentional weight loss of 5 percent or more within the previous six-month period; or
  • Total oral nutritional support, have a permanent structural limitation that prevents the chewing of food or the placement of a feeding tube is medically contraindicated.