Overview
A recent study published in JAMA estimated that more than six million people in the United States have dietary sensitivities and activity restrictions who could benefit from medically adapted meals, a type of Medical Supplementary Food and Nutrition (MSF&N) service. These estimates also show that providing these types of meals to these individuals could prevent 1.6 million hospitalizations and save $13.6 billion annually. In recent years, increasing evidence of the positive effects of nutrition assistance on health outcomes and costs has contributed to policy change at both the federal and state levels; This creates new opportunities for health and nutrition services organizations to work together to improve health through MSF&N services. This discussion highlights some of these opportunities.
What are MSF&N Services?
MSF&N services represent a spectrum of services that recognize and respond to the critical link between nutrition and health; they include medically tailored meals and groceries, medically supportive meals and groceries, prescription products, and food pharmacies. The Food is Medicine Coalition, a national group of nonprofit MSF&N providers, outlines these services along a spectrum that corresponds to the severity of individual needs. (See Figure 1.)
Figure 1. Range of Food and Nutrition Interventions to Improve Health
Source: Food is Medicine Coalition: Our Model
MSF&N services are, by definition, integrated into patient-centered models of care for the prevention, management, and treatment of chronic diseases and health problems and are distinct from the broader hunger safety net (e.g., the Supplemental Nutrition Assistance Program or the National School Lunch Program).
Recent Health Policy Changes in Support of MSF&N Services
As evidence supporting the value of MSF&N services in terms of health outcomes and costs has grown, new avenues for authorization, financing and integration into the health care delivery system have emerged.
Medicaid and the Children’s Health Insurance Program (CHIP): In the past, certain MSF&N services were generally available only as part of Medicaid Home and Community-Based Services (HCBS) programs for individuals receiving long-term support services. In the 2010s, California, Massachusetts, and North Carolina became the first states to use Medicaid Section 1115 introductory waivers to cover MSF&N costs for individuals with certain complex chronic diseases and other health conditions. Since then, many other states have followed suit, using 1115 waivers to fund MSF&N services in their Medicaid programs or under Medicaid managed care “in lieu of service” (ILOS) authorities.one
In 2022, the Centers for Medicare and Medicaid Services (CMS) began formalizing its MSF&N-related policies alongside housing-related policies, listing the following certifiable services related to food and nutrition in its November 2023 Information Bulletin and accompanying framework:
- Case management services for nutrition/food access;
- Nutrition counseling and education;
- Home-delivered meals or pantry stocks;2
- Nutritional recipes (for example, fruit and vegetable recipes or protein boxes); and
- Grocery supply.
CMS’s guidance extends beyond Section 1115 waivers to outline other options for MSF&N’s Medicaid coverage, including options for coverage of such services through managed care plans (under ILOS authority), for populations requiring long-term services and supports (through HCBS waivers), as part of the regular Medicaid benefits package (through state plan amendments), and for children (through CHIP Health Care Initiatives).
Health insurance: In 2020, CMS issued guidance that further defines and expands the Chronically Ill Special Supplemental Benefits (SSBCI) that Medicare Advantage plans can offer to improve health outcomes for chronically ill enrollees, including Dual Eligible Special Needs Plans (D-SNPs). Medicare Advantage plans can offer transportation for meals, groceries, produce, and groceries using SSBCI. Food, produce and meal subsidies were among the most common SSBCI benefits offered by Medicare Advantage plans in 2023, according to an analysis by Milliman. Medicare Part A (traditional fee-for-service Medicare) does not currently reimburse home-delivered meals or other MSF&N services.
Commercial and Market Programs: The Biden Administration has sought to prioritize the integration of nutrition into the delivery of health care across all payers. Commercial or marketplace plans provide medically tailored meals and/or grocery delivery for enrollees with specific diet-related health issues nationwide. For example, Geisinger Health’s Fresh Food Farmacy provides weekly fresh, healthy meals to enrollees and their families when enrollees have A1C levels higher than 8.0 and are food insecure. Since its launch in 2016, enrollees participating in the Fresh Food Farmacy program have shown an average 2-point reduction in HbA1c levels, lower weight, blood pressure, triglycerides, and cholesterol, and the plan has found that medical costs have decreased by $16,000 to $24,000 per participant.
Expanded Opportunities for MSF&N Services
States: CMS’s latest guidance provides a roadmap for states seeking to authorize, design, and launch MSF&N programs in their Medicaid systems. In many states that implement MSF&N services, the Medicaid program has already become one of the largest funders of such services. States play a critical role in determining which MSF&N services are covered, who is eligible to receive those services, what standards providers must meet, and what data must be collected to evaluate outcomes. As more states implement MSF&N services through Medicaid and document results and lessons learned, other states are likely to follow suit.
Health Plans (Medicaid Managed Care Plans, Medicare Advantage, Private Insurers): Expanded reimbursement for MSF&N services allows plans to invest in popular, cost-effective interventions that can improve outcomes, reduce utilization, and improve enrollees’ experience. As more states choose to add MSF&N coverage to their Medicaid programs, many states are incorporating the cost of services into plan rates and delegating management of services to plans, including identifying and engaging eligible individuals, contracting with and supervising and monitoring MSF&N provider organizations. enrollee use and health outcomes. Although commercial market adoption is still new, solid and thoughtful MSF&N programs can give commercial plans a competitive advantage and help keep costs low.
Healthcare Providers: With the expansion of MSF&N coverage, many healthcare providers are forming partnerships with local food and nutrition organizations to screen, identify, and refer patients with diet-related chronic diseases who are food insecure and who may benefit from MSF&N services. As value-based payment arrangements continue to proliferate, providers who assume financial risk for their patients may find the integration of cost-effective interventions, such as MSF&N services, an attractive proposition to support their patients and reduce costs and utilization.
MSF&N Organizations: As MSF&N services become more integrated into healthcare delivery, nutrition organizations have a new opportunity to sustain and scale their work. For example, the Food is Medicine Coalition developed a voluntary national accreditation program for MSF&N providers. Grants and technical assistance (provided through state Medicaid programs, health plans, and/or philanthropy) can help organizations establish new systems and expanded capabilities, such as contracting, administrative, data, and billing functions, necessary to support the delivery of MSF&N services. . Larger and more experienced MSF&N organizations may have new opportunities to train other organizations under such programs and receive reimbursement for this role. Organizations may also be referred to as “Community Care Centers” that come together to share administrative functions and operational infrastructure and serve more diverse populations. States vary in the degree to which they encourage such center formation.
Issues We Track
- What are state Medicaid programs like:
- Is funding of MSF&N services allowed (e.g., through Section 1115 exemptions, ILOS, HCBS exemptions)?
- Financially incentivize Medicaid plans and/or providers to invest in MSF&N services (e.g., reinvestment requirements, quality measures, incentive arrangements)?
- Want to include the costs of MSF&N services in your Medicaid managed care rates?
- How do federal and state policymakers encourage Medicare Advantage plans and D-SNPs to offer MSF&N services through SSBCI?
- What support do health plans and health care providers need to effectively integrate MSF&N services into health care delivery?
- What infrastructure and capacity challenges do MSF&N providers face as they begin billing and exchanging data with healthcare organizations, and how are states, plans, and providers helping to address these challenges?
- What provider qualification standards and oversight processes do states and plans adopt for MSF&N services?
- How do governments and other payers evaluate the effectiveness of MSF&N services?
Solution
MSF&N services can help improve the lives and health outcomes of millions of Americans with nutrition-related health challenges. The expanding scope of MSF&N services and the increasing recognition of food and nutrition as determinants of health outcomes reflect an encouraging focus on “whole-person” care.
one As of April 2024, State Medicaid programs authorized to pay for MSF&N services for certain populations include: Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.
2 Notably, CMS’s framework stipulates that Section 1115-authorized nutrition support programs that provide enrollees with three meals per day are limited to six months and may be renewed for additional six-month periods if the enrollee continues to meet eligibility criteria. This limitation does not apply to programs that provide fewer than three meals per day.