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KMAP BULLETIN: Medicaid as Primary Payor of Exempt Formulas

Date: 08/07/25

KMAP GENERAL BULLETIN 25047 (PDF)

Effective with dates of service on or after May 1, 2025, the Kansas Medical Assistance Program (KMAP) will cover normal daily oral nutrition for members aged 0 through 4 years with an inherited error of metabolism (IEM), specified gastrointestinal disorders, or specified malabsorption disorders. Refer to below list of diagnosis codes that are covered without prior authorization.

KMAP will become the primary and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) will become the secondary payor for exempt formula, for normal daily oral nutrition for these members.

Note: The Durable Medical Equipment (DME) provider must submit the enteral product supplemental billing form in addition to the product invoice.

Providers are to use the following modifier, which is informational, when applicable:

  • Modifier “BO” to be used for oral nutrition in eligible members.

Codes will continue to be manually priced based on the submitted invoice at provider cost plus 35%. 

Codes:

  • B4153
  • B4157
  • B4161
  • B4162

Covered Diagnosis Codes for Exempt Formula/Medical Foods:

 E70.0  E70.1 E70.20 E70.21 E70.29 E7030
 E70.310 E70.311  E70.318  E70.319  E70.320  E70.321 
 E70.328 E70.329  E70.330  E70.331  E70.338  E70.339
 E70.39 E70.40 E70.41 E70.49 E70.5 E70.8
 E70.81 E70.89 E70.9 E71.0 E71.110 E71.111
 E71.118 E71.120 E71.121 E71.128 E71.19 E71.2
 E71.30 E71.310 E71.311 E71.312 E71.313 E71.314
 E71.318 E71.32 E71.39 E71.40 E71.41 E71.42
 E71.43 E71.440 E71.448 E71.50 E71.510 E71.511
 E71.518 E71.520 E71.521 E71.522  E71.528 E71.529
 E71.53 E71.540 E71.541 E71.542 E71.548 E72.00
 E72.01 E72.02 E72.03 E72.04 E72.09 E72.10
 E72.11 E72.12 E72.19 E72.20 E72.21 E72.22
 E72.23 E72.29 E72.3 E72.4 E72.50 E72.51
 E72.52 E72.53 E72.59 E72.8 E72.81 E72.89
 E72.9 K20.0 K52.2 K52.21 K52.22 K52.81
 K52.82 K90.0 K90.49  K90.82  K90.821  K90.822 
 K90.829  K90.83     

 

Note: The effective date of the policy is May 1, 2025. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.

For changes resulting from this bulletin, view the updated General TPL Fee-for-Service Manual, page 3-1; DME Fee-for-Service Manual, pages 8-86 to 8-88 8-87 to 8-89; and Coding Modifiers Table, page 9 – Modifier BO.