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Insurance

Kate Farms medical nutrition* is broadly eligible for insurance coverage through major public and private insurance plans. Exact coverage depends on whether you or your loved one will be using the product for tube feeding or drinking, the diagnosis on the prescription, how many calories will come from formula each day, and the insurance plan’s formula benefits.**  

Exploring insurance coverage can seem daunting, and we want to make it as easy as possible. Read on for information about coverage for select major insurance types, how to check your coverage, and what to do about denials. Contact us anytime with any questions. We’re here to help! 

*Kate Farms Nutrition Shake is not eligible for insurance coverage.  
**As the manufacturer, Kate Farms cannot bill insurance directly. 

Quick Links to Resources 

Coverage by major insurance types

We have helped walk thousands of patients through the process of checking insurance coverage and have learned the following about formula coverage for the major insurance types listed below.  

Medicare

Medicare covers formula for those who are exclusively tube-fed, but unfortunately does not cover formula for drinking.  

The best option for a someone who will be drinking Kate Farms with Medicare-only (no secondary insurance) is to purchase their formula supply online. Please contact us if you are having trouble affording your formula, we may be able to help. 

Medicaid

Medicaid covers Kate Farms in most states for both tube feeding and drinking, whether it’s the primary or secondary insurance plan. To find out which Kate Farms product are eligible for Medicaid coverage in your state, please contact us

We work closely with Medicaid in all 50 states to ensure coverage is available for those who qualify. If you are having trouble accessing Kate Farms through Medicaid, please contact us. We’d be happy to help.  

Medi-Cal and California Children’s Services (CCS) 

Medi-Cal is California’s Medicaid program. Most Kate Farms formulas are covered for both tube feeding and drinking through Medi-Cal. CCS is a state program for children up to 21 years of age with certain diseases and health complications. Most Kate Farms formulas are covered for both tube feeding and drinking for CCS beneficiaries that have a CCS-qualifying condition. To find out which Kate Farms products are currently eligible for Medi-Cal and CCS coverage, please contact us

We work closely with Medi-Cal to ensure coverage is available for those who qualify. If you are having trouble accessing Kate Farms through Medi-Cal or CCS, please contact us. We’d be happy to help as best we can.

Kaiser

All Kate Farms formulas are available in Kaiser hospitals and through Kaiser home medical services. Kaiser follows Medicare guidelines, meaning they typically cover medical nutrition for tube feeding, but not for drinking. If you are a Kaiser member, ask your Kaiser healthcare team about writing you a prescription for Kate Farms. 

United Healthcare, Anthem, Blue Cross Blue Shield, Cigna and Aetna

The insurance providers listed above are large companies that offer private insurance plans (often through an employer or purchased on the open marketplace), but some also manage select public insurance plans like Medicare and Medicaid. Because their offerings vary so widely, the best way to determine your plan type and coverage eligibility for formula is to contact them by following the steps below under How to find out your coverage

Other private insurance companies

Most private insurers do consider coverage for medical nutrition. Coverage eligibility for formula for drinking and tube feeding will vary depending on the type of insurance (e.g., Commercial, Medicare, Medicaid). The best way to determine your plan’s coverage is to contact the insurance company by follow the steps below under How to find out your coverage. 

How to find out your coverage

If you’d like to find out if you are covered for Kate Farms before asking your doctor to write a prescription, call the member services phone number listed on the back of your insurance card. 

When you call, tell the representative how you will use Kate Farms, either for tube feeding or drinking, and provide the billable insurance code, also known as the HCPCS code, for the Kate Farms formula you’re considering. 

  • Kate Farms Pediatric Peptide 1.0 – HCPCS B4161 
  • Kate Farms Pediatric Peptide 1.5 – HCPCS B4161 
  • Kate Farms Pediatric Standard 1.2 – HCPCS B4160 
  • Kate Farms Peptide 1.0 – HCPCS B4153 
  • Kate Farms Peptide 1.5 – HCPCS B4153 
  • Kate Farms Standard 1.0 – HCPCS B4150 
  • Kate Farms Standard 1.4 – HCPCS B4150 
  • Kate Farms Glucose Support 1.2 – HCPCS B4154 
  • Kate Farms Renal Support 1.8 – HCPCS B4154 

Questions to ask your insurance provider

Here are a few questions to ask to help you understand your coverage. Note: insurance companies will refer to formula by the term enteral nutrition, meaning nutrition that goes through the GI tract and is taken by mouth or feeding tube. This will help them differentiate from a benefit you may have for total parenteral nutrition, which is the term for nutrition that bypasses the GI tract completely and is administered by an IV. We recommend using the term enteral nutrition to help keep you and the representative on the same page. 

Does my policy cover nutrition?

Why this matters: Unfortunately, some insurance policies and companies do not cover nutrition at all. If this is the case, and you will have difficulty affording our formula, contact us and we may be able to help. 

If formula will make up part, but not all of your diet, ask… does my policy cover enteral nutrition for supplemental nutrition? 

Why this matters: Some plans provide coverage when a formula is your only source of nutrition, or sole-source nutrition, but will not cover if it’s going to be a supplement to solid food. Ask your insurance company if your policy will provide coverage if formula will make up less than 100% of your daily calories. 

If you will be drinking formula, ask…does my policy cover enteral nutrition if I’m drinking it? 

Why this matters: Some plans only cover formula that is used for tube feeding but not if you are drinking it. Medicare is one example of an insurance payor that may cover formula for tube feeding, but not for drinking.

What percent of the total prescribed enteral nutrition cost will my policy cover?

Why this matters: Some health insurance policies cover the majority, but not all, of the cost of tube feeding supplies and formula. For example, they may cover 50% of your formula needs, but you will be responsible for the remaining 50%. It’s important to learn what percentage your plan will cover so you are aware of any potential out-of-pocket expenses. 

Do I need prior authorization and how do I get it?

Why this matters: Prior authorization, also known as a pre-authorization, is a process of obtaining approval for coverage of a prescribed product from your health insurance plan. Enteral nutrition formula oftentimes requires prior authorization to ensure a prescribed product is medically necessary. Your healthcare provider, or in some cases home medical supplier, will complete this process on your behalf. If your insurance requires it, make sure to mention to your healthcare provider or medical supply company to remind them of this step. 

Do I need a Letter of Medical Necessity from my doctor?

Why this matters: Your insurance policy will provide guidelines that you must meet for them to cover nutrition. To determine if you meet those guidelines, they may require additional clinical notes and medical documentation to be submitted along with the prescription. Ask your insurance company what those documentation requirements are and let your doctor know. A common requirement is a Letter of Medical Necessity. To make things easier, we have created templates of Letters of Medical Necessity for each Kate Farms formula. Send your doctor the one for the formula he or she is prescribing and ask them to fill it out and send it along to your home medical supplier along with the prescription. 

Denials

There are a number of reasons why you might receive a denial for insurance coverage, but many of those reasons could be corrected with an additional clinical note from your doctor or clarification on your paperwork. Let us help navigate your denial and see if it is truly a “no”. We recommend working closely with your healthcare and home medical providers to learn if there is an opportunity to appeal the decision. 

Contact a Patient Advocate

Free, personal support to help you talk to your doctor, home medical supplier, or insurance provider, or for more information on getting started with Kate Farms.