The complexity of the health care system can overwhelm even the savviest patient and/or clinical professional. That is why Compassion Works Medical was created to hold hands with patients and alleviate the clinics time through the difficult process of medical food insurance coverage.
 
Compassion Works Medical is founded by Raenette Franco, CEO and Certified Billing and Insurance Specialist. Raenette has been inspired to share her hands-on experience with medical foods insurance coverage specialized in all types of inherited metabolic diseases and rare genetic disorders. Compassion Works Medical works with you and for you, providing guidance and supporting you with compassion and integrity.  Ms. Franco specializes only in medical food coverage and has been battling insurance coverage for medical foods for over a few years in addition to fighting for the Medical Nutrition Equity Act on Washington’s’ DC Capitol Hill. Compassion Works Medical collaborates with patients’ current insurance policies, and fights for state mandated coverage.
 
Every case is unique and different.  Understanding your options and insurance terminology is essential to obtaining the coverage that you deserve!
 
Let’s start with the basics………….
 
What is a Medical Food? You may hear these words often and could be confusing to the words “formula” or “dietary supplements”.

• Medical foods are foods that are specially formulated and processed (as opposed to a naturally occurring foodstuff used in a natural state) for a patient who requires use of the product as a major component of a disease or condition’s specific dietary management (i.e. designed for a certain disease) and intended to be used under medical supervision.

• Formula is basically the same thing as a medical food as they are made from the building blocks of foods.

• Dietary supplements are not generally designed for a certain disease, but are used in contribution to maintain a disease such as added vitamins. Dietary supplements are sometimes added to patient’s dietary management.

• What is Enteral? Enteral is a medical term used for a feeding method either oral or tube feeding; Hence Enteral formula.

 
Overall Medical foods, dietary supplements and enteral formula are common words uses for insurance coverage.
 
Coverage for medical foods and dietary supplements are generally covered under medical benefits and supplied by a durable medical equipment (DME) distributor by using the description of coverage. However, medical foods are also covered under pharmacy benefits by product only, just a little tougher to maneuver insurance coverage.
 
Coverage for special injectable vitamins: Are you or your family member on injection vitamins such as cyanocobalamin/hydroxocobalamin ML (B-12)? If yes, coverage for this special vitamin could be challenging. This special injectable vitamin may or may not be covered under pharmacy benefits. Some pharmacy benefits does not cover these products and considered over the counter. To obtain coverage, it requires jumping through loop holes.  However, the health insurance benefits for cyanocobalamin/hydroxocobalamin ML could be covered under your medical benefits.  Since the skin is pinched or broken such as with an injection and the place of service is at your clinic. If your clinic could administer the vitamin and bill your insurance company, it would be the best affordable route.
 
The insurance language under medical benefits for Hydroxocobalamin ML use HCPCS code J3420 and for Pharmacy benefits it is under an NDC number (i.e. 00591-2888-30). The place of service is at the office – Usually injected at the physician’s office under medical benefits.
 
Insurance coverage tips…………………
 
To start investigating coverage for your dietary management, it is recommended to start with your medical benefits first. Sometimes when we get a prescription we automatically think it’s a pharmacy benefit and that’s natural, however, if you have a prescription for medical foods or dietary supplements it’s best to check with your medical benefits first.
 
Here are eight tips below to better understand your medical food and dietary supplement insurance coverage:
 
Rule No. 1: Never take NO for an answer!

1. Insurance Terminology                                               
2. Difference between Medical and Pharmacy coverage 
3. Reimbursement issues between insurance company and supplier    
4. Verifying Insurance Benefits before placing an order
5. Medical Food Exclusion Removal
6. Gap Exceptions for policies with no out-of-network benefits
7. Be prepared for a prior authorization before covered services                                   
8. Got Medicare or Medicaid? Best Avenue for medical food coverage.

 
It’s important to understand your health plan’s guidelines for medical food coverage by thoroughly reading through your health plans summary of benefits to find out if your medical foods and dietary supplements are covered. Start by looking under durable medical equipment benefits (DME) and non- covered services including exclusions. Key words: ENTERAL, MEDICAL FOODS, NUTRITION, FORMULA, SUPPLEMENTS.

1. Insurance Terminology: Medical food and dietary supplements coverage is a complete foreign language to the health insurance industry. There are certain terminologies used to help obtain the most accurate coverage details with your health plan’s benefit specialist such as;
   1. Service codes (also known as HCPCS codes) used to describe the medical foods, enteral formula, dietary supplements and vitamins (i.e. B4155, B4157, B4162, B9998, S9435, S9435, J3420). These codes could be administered orally, tube feeding or vitamin injection. Injections are usually done at the clinic and not at home for proper coverage.
   2. In-network and out-of-network to help determine the most affordable way to obtain your dietary needs. Also known as participating or non-participating.
   3. Know the difference between prior authorization and predetermination. Prior authorization is required before coverage and predetermination is not required before coverage, but helps avoid any future denials.
   4. Diagnosis driven plan: This is a plan that will only cover if the diagnosis code such as your medical condition(s) matches the description of service. Your diagnosis codes starts with a letter (i.e. ICD-10: E71.121). If it matches then you are covered. Diagnosis driven plans are easily mistaken as not covered, so if your benefit specialist mentions that it’s not covered ask if your plan is diagnosis driven.
   5. Other words are exclusions, out-of-pocket, state mandated plans, deductibles, fully insured, self-funded, allowed amounts, suppliers, gap exceptions.
2. Difference between Medical and Pharmacy coverage: Typically medical foods and dietary supplements are generally covered under your medical benefits and provided by a DME distributor. The medical benefits cover by using the service codes and the diagnosis code. Pharmacy benefits cover by the product alone and not the service. Medical foods and dietary supplements could be challenging for coverage under pharmacy benefits, if the product is not listed in their system and considered over the counter it’s not covered. If you pharmacy plan does not cover your product, then use you medical benefits or file for an appeal.
3. Reimbursement-Billing issues between insurance company and supplier: Receiving bills from your providers could be scary. Don’t panic! First make-sure you if you’ve received a bill from your provider or is it an Explanation of Benefits- EOB statement (not a bill) from your insurance company. Check your EOB and match it with your invoice to determine if the bill is for your deductible or co-insurance. If not, contact your provider immediately and go over your invoices. Look out for any unnecessary charges.
4. Verifying Insurance Benefits before placing an order: The best way to avoid delays with your medical food orders are to try to verify your benefits and coverage “first” with your insurance carrier before placing an order. Contact your insurance carrier and ask for benefit coverage for Medical Food/Enteral Formula or nutritional supplements. Include diagnosis code (ICD-10). Mention it’s “usually covered under DME”. Remember to ask if the plan is diagnosis driven to avoid any misunderstandings.
5. Ask for any exclusion on your policy for medical foods; if there are any exclusions that does not cover your medical foods, it is not the insurance company that you would fight with. This is out of their hands. You will have to go to you employers HR department and ask for a medical food exclusion removal and present your letter of medical necessity explaining your rare genetic disease. Medical food removal template letters can be found at Compassion Works Medical. To make a request, email raenettef@compassionworksmrs.com.
6. What is a Gap Exception?  A coverage gap exception is a waiver from a healthcare insurance company that allows a customer to receive medical services from an out of network provider at an in network rate. Usually HMO or EPO plans do not have out-of-network benefits, but if you can’t find an in-network provider to supply your medical foods, you could ask your insurance carrier for a gap exception. Also, your out-of-network supplier could request a Gap exception to your insurance company directly. This way is easier!
7. One of the best reasons for your waiver is that there aren’t any other in-network providers within 100 miles of your residence that can supply your medical foods. Another is that you prefer to use the out-of-network provider because of a strong long-lasting and trusting previous relationship.
8. Any request is worth a shot! This also saves time for your out-of-network supplier as well as providing faster medical food service.
9. Be prepared for a prior authorization that is required by your insurance carrier: some policies require prior authorizations from your insurance company before they will cover. Prior authorizations need to be identified as “medical necessary”. This is usually provided by your clinic or medical food supplier. Make sure your clinic provides you a letter of medical necessity (LMN) with a prescription and recent progress notes (A.K.A. clinical notes). Your provider usually makes these requests.
10. Stay on top of your prior authorization approvals. When they expire, you or your provider will have to request a renewal. This depends on your policy; i.e. month to month, every 3 months, yearly, etc.
11. Do you have a government plan such as Medicaid or Medicare? As most of you already know, Medicaid usually follows all of the state mandated laws and covers 100% for in-network providers and may require a prior authorization. Medicare straight from your state does not cover medical foods “UNLESS fed by a feeding tube and is the sole source of nutrition”.
12. Want Medicare Coverage?: If you have already have Medicare you can switch to a Managed Medicare Plan in your state such as AARP, UHC, BCBS, Humana, etc. and they could provide your medical food coverage. You may not have to pay any extra premiums. Many patients are able to be covered through their managed Medicare plans.  This is NOT a Supplement Plan; it is a Managed plan that has leniency for medical food coverage. Supplement plans only follow the Medicare straight state plans. Supplement plans will have the word “supplement” on your card or “Complete” .Make sure that your plan is not a supplement as they follow Medicare guidelines. To find a managed Medicare plan in your state by visiting https://www.medicare.gov/find-a-plan/questions/home.aspx. Or simply call member services listed on the back of your Medicare card for assistance.

 
An extra bonus tip ***: From my experience if you are looking for a reliable dietary supplement, medical food and vitamin supplier for all types of rare genetic disorders, I suggest checking out Solace Nutrition, LLC. https://www.solacenutrition.com/ . They are very unique and provide most dietary supplements that you cannot find anywhere else. Ask your provider to search their website for the most appropriate supplement that could help you and your family member’s dietary management. Also, most of their products are covered by some insurance companies.
 
In addition: If you or a family member has an inborn error of metabolism disease such as PKU, TYR, HCU MSUD, I suggest checking out this unique European company POA Pharma North America http://www.poapharma.com/en/ .Their products are also very distinctive comparing to other markets in the USA. Also, most of their products are covered by some insurance companies.
 
I have experienced success with patients affording products from Solace Nutrition, LLC and POA Pharma North America.
 
The tips above are based on actual experiences. I believe there are no true experts with all of the answers.
 
So let’s face the facts, patients NEED an Advocate, preferably someone with a medical food-insurance background.  Patients need champions who can: (1) TRANSLATE what’s being told (2) ASK THE RIGHT QUESTIONS that patients ‘don’t know to ask’ (3) COMMUNICATE upwards, downwards and sideways.
 
For support and questions on medical food insurance coverage for all types of Inherited Metabolic Diseases and rare genetic diseases, please contact Compassion Works Medical at
(973) 832-4736; email raenettef@compassionworksmrs.com.