Overview
A recent study published in JAMA estimated that more than 6 million people in the U.S. have diet-sensitive conditions and exercise limitations who could benefit from medically tailored meals, a type of Medically Supportive Food and Nutrition (MSF&N) service. These estimates also suggest that providing such meals to these individuals could prevent 1.6 million hospitalizations and save $13.6 billion annually. In recent years, mounting evidence of the positive effects of nutrition assistance on health outcomes and costs has contributed to policy changes at both the federal and state levels, which in turn has created new opportunities for health and nutrition service organizations to collaborate 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, which may include medically tailored meals and groceries, medically assisted meals and groceries, product prescriptions, and food pharmacies. The Food is Medicine Coalition, a national group of nonprofit MSF&N providers, depicts these services along a spectrum that corresponds to the severity of the individual’s need. (See Figure 1.)
Figure 1. Spectrum 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 care models for the prevention, management, and treatment of chronic diseases and conditions. They are distinct from the broader safety net against hunger (e.g., the Supplemental Nutrition Assistance Program or the National School Lunch Program).
Recent changes in health policy to support MSF&N services
As more evidence became available supporting the value of MSF&N services on health outcomes and costs, new opportunities for authority, financing and integration into the health system emerged.
Medicaid and the Children’s Health Insurance Program (CHIP): Historically, certain MSF&N services were typically available only as part of Medicaid Home and Community Based Services (HCBS) programs for individuals receiving long-term supportive services. In the 2010s, California, Massachusetts, and North Carolina became the first states to use Medicaid Section 1115 demonstration waivers to pay for MSF&N for individuals with certain complex chronic diseases and other health conditions. Since then, several other states have followed suit by using 1115 waivers or Medicaid managed care “in lieu of services” (ILOS) authorities to pay for MSF&N services in their Medicaid programs.1
In 2022, the Centers for Medicare and Medicaid Services (CMS) began formalizing its policy on MSF&N, in addition to housing. This resulted in a November 2023 information bulletin and accompanying framework, which lists the following approvable food and nutrition-related services:
- Case management services for access to nutrition/food;
- Nutritional advice and instruction;
- Home delivered meals or inventory management;2
- Dietary guidelines (e.g. fruit and vegetable recipes or protein boxes); and
- Food supply.
CMS’s guidance goes beyond the Section 1115 waivers and summarizes other options for MSF&N’s Medicaid coverage, including options for covering such services through managed care plans (under the authority of ILOS), for populations in need of long-term services and supports (through HCBS waivers), as part of the regular package of Medicaid benefits (through state plan amendments), and for children (through CHIP Health Services Initiatives).
Medicare: In 2020, CMS issued guidance that further defines and expands Special Supplemental Benefits for the Chronically Ill (SSBCI) that Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs), can offer to improve health outcomes for chronically ill enrollees. Medicare Advantage plans can use SSBCI to provide meals, food, produce, and grocery transportation. According to an analysis by Milliman, food, produce, and meal assistance were among the most common SSBCI benefits offered by Medicare Advantage plans in 2023. Medicare Part A (traditional fee-for-service Medicare) does not currently cover home-delivered meals or other MSF&N services.
Commercial and Marketplace Programs: The Biden administration has sought to prioritize the integration of nutrition into health care delivery across all payers. Commercial or marketplace plans are making medically tailored meals and/or grocery delivery available to enrollees with specific diet-related health conditions across the country. For example, Geisinger Health’s Fresh Food Farmacy provides fresh, healthy food to enrollees and their families weekly when enrollees have an A1C level above 8.0 and are food insecure. Since its launch in 2016, enrollees participating in the Fresh Food Farmacy program have seen an average 2-point reduction in HbA1c, weight, blood pressure, triglycerides and cholesterol, and the plan found that medical costs decreased by between $16,000 and $24,000 per participating enrollee.
Extensive options for MSF&N services
States: CMS’s recent guidance provides a roadmap for states seeking to authorize, design, and launch MSF&N programs in their Medicaid systems. In the several states that have implemented MSF&N services, the Medicaid program has already become one of the largest funders of such services. States play a critical role in defining what MSF&N services are covered, who is eligible to receive them, 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 outcomes and lessons learned, other states are likely to follow.
Health insurance plans (Medicaid Managed Care Plans, Medicare Advantage, private insurers): Expanded reimbursement for MSF&N services enables plans to invest in popular, cost-effective interventions that can improve outcomes, reduce utilization, and enhance the enrollee experience. As more states choose to add MSF&N coverage to their Medicaid programs, many states are rolling the cost of services into plan fees and delegating management of services to plans, including identifying and engaging eligible individuals, contracting with and overseeing MSF&N provider organizations, and tracking enrollees’ utilization and health outcomes. While commercial market adoption is still in its infancy, robust and well-designed MSF&N programs can give commercial plans a competitive edge and help keep costs down.
Healthcare providers: With the expansion of MSF&N coverage, many providers are partnering with local food and nutrition organizations to screen, identify, and refer patients with diet-related chronic diseases and food insecurity who could benefit from MSF&N services. As value-based payment arrangements continue to expand, providers who take financial risk for their patients may see the integration of cost-effective interventions such as MSF&N services as an attractive offering to support their patients and reduce costs and utilization.
MSF&N organizations: As MSF&N services become more integrated into health care delivery, food organizations have a new opportunity to sustain and scale their work. For example, the Food is Medicine Coalition has developed a voluntary national accreditation program for MSF&N providers. Grants and technical assistance (available 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, needed to support the delivery of MSF&N services. Larger and more experienced MSF&N organizations may have new opportunities under such programs to train other organizations and be reimbursed for that role. Organizations can also form so-called “Community Care Hubs” that work together to share administrative functions and operational infrastructure and serve a more diverse set of populations. States vary in the extent to which they encourage such hub formation.
Issues we track
- What are the states’ Medicaid programs like:
- Authorizing the financing of MSF&N services (e.g., through Section 1115, ILOS, HCBS waivers)?
- Financial incentives for Medicaid plan and/or provider investments in MSF&N services (e.g., reinvestment requirements, quality measures, incentive schemes)?
- Can we include the costs of MSF&N services in 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 insurers and healthcare providers need to effectively integrate MSF&N services into healthcare?
- What infrastructure and capacity challenges do MSF&N providers face as they begin to bill and exchange data with healthcare organizations? And how do states, health plans, and providers help address these challenges?
- What provider qualification standards and oversight processes do states and plans use for MSF&N services?
- How do states and other payers evaluate the effectiveness of MSF&N services?
Conclusion
MSF&N services can help improve the lives and health outcomes of millions of Americans with diet-related health conditions. The increasing coverage of MSF&N services, coupled with the growing recognition of food and nutrition as upstream drivers of health outcomes, reflect an encouraging focus on whole-person care.
1 Beginning in April 2024, the following state Medicaid programs will be authorized to pay for MSF&N services for specific populations: Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.
2 Notably, CMS’s framework provides that Section 1115-authorized nutrition assistance programs that provide participants with three meals per day are limited to six months, renewable for additional six-month periods if the participant continues to meet eligibility criteria. This limitation does not apply to programs that provide fewer than three meals per day.