overview
A study recently published in JAMA estimated that more than 6 million people in the United States suffer from dietary and activity restrictions and could benefit from medically tailored meals, or medically assisted food and nutrition (MSF&N) services. The estimate also suggests that providing such meals to these people could avert 1.6 million hospitalizations and save $13.6 billion annually. In recent years, growing evidence of the positive effects of nutrition assistance on health outcomes and costs has prompted policy changes at both the federal and state levels, resulting in new opportunities for medical and nutrition service organizations to collaborate to improve health through MSF&N services. This discussion will highlight some of these opportunities.
What are MSF&N Services?
MSF&N services represent a continuum of services that recognizes and responds to the critical link between nutrition and health. These include medically tailored meals and groceries, medically supported meals and groceries, produce prescriptions, and food pharmacies. The Food is Medicine Coalition, a national group of nonprofit MSF&N providers, represents these services as a continuum of services that respond to the severity of an individual’s 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 a patient-centered model of care for the prevention, management, and treatment of chronic diseases and health conditions 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 supporting MSF&N services
As evidence accumulates supporting the value of MSF&N services on health outcomes and costs, new avenues of authority, funding, and integration in health care delivery systems are emerging.
Medicaid and Children’s Health Insurance Program (CHIP): Historically, certain MSF&N services were typically provided 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 were the first states to use Medicaid Section 1115 demonstration waivers to pay for MSF&N for individuals with certain complex chronic illnesses and other health conditions. Since then, several other states have funded MSF&N services in their Medicaid programs using 1115 waivers or under Medicaid’s managed care “in lieu of service” (ILOS) authority. 1
In 2022, the Centers for Medicare & Medicaid Services (CMS) began formalizing its policy on MSF&N, alongside its policy on housing, with a November 2023 “Information Bulletin” and accompanying framework listing the following approvable services related to food and nutrition:
Nutrition/food access case management services, nutrition counseling and instruction, home-delivered meals or pantry stocking, 2 nutritional formulas (e.g., fruit and vegetable formulas or protein boxes), and provision of groceries.
Beyond the Section 1115 waiver, CMS guidance outlines other options for Medicaid coverage of MSF&N, including options to cover such services through managed care plans (under ILOS authority), for people who need 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 the CHIP Health Services Initiative).
Medicare: In 2020, CMS issued guidance to further define and expand the Special Supplemental Benefits for the Chronically Ill (SSBCI) that Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs), can offer to improve the health outcomes of enrollees with chronic conditions. Medicare Advantage plans can use SSBCI to provide meals, food, produce, and transportation for grocery shopping. According to Milliman’s analysis, 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 reimburse for home-delivered meals and other MSF&N services.
Commercial and Marketplace Programs: The Biden Administration has sought to prioritize integrating nutrition into health care delivery across all payers. Commercial or Marketplace plans offer medically tailored meal or grocery delivery nationwide for enrollees with certain diet-related health conditions. For example, Geisinger Health’s Fresh Food Farmacy provides fresh, healthy food to enrollees and their families weekly if their A1C levels are above 8.0 and food is insufficient. Since its launch in 2016, enrollees participating in the Fresh Food Farmacy program have seen an average of two-point reduction in HbA1c levels, lower weight, blood pressure, triglycerides, and cholesterol, and reduced health care costs by $16,000 to $24,000 per participating enrollee.
Expanding opportunities for MSF&N services
States: Recent guidance from CMS provides a roadmap for states seeking to authorize, design, and launch MSF&N programs in their Medicaid systems. In several states that have implemented MSF&N services, the Medicaid program is already one of the largest funders of these services. States play a key role in defining which MSF&N services will be covered, who is eligible to receive them, what standards providers must meet, and what data must be collected to evaluate outcomes. As more states roll out MSF&N services through Medicaid and document outcomes and lessons learned, other states will likely follow suit.
Health Insurance 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 improve outcomes, reduce utilization, and enhance enrollee experience. As more states add MSF&N coverage to their Medicaid programs, many are incorporating the cost of services into plan fees and delegating management of the services to plans. This includes identifying and engaging eligible individuals, contracting with and overseeing MSF&N provider organizations, and tracking enrollee utilization and health outcomes. Although adoption in the commercial market is still in its early stages, a robust and thoughtful MSF&N program could give commercial plans a competitive advantage and help reduce costs.
Healthcare providers: As MSF&N coverage expands, many health care providers are partnering with local food and nutrition organizations to screen, identify, and refer patients with diet-related chronic conditions who are food insecure and could benefit from MSF&N services. As value-based payment systems become increasingly prevalent, health care providers who bear financial risk on behalf of their patients may see the integration of cost-effective interventions like MSF&N services as an attractive service that supports patients and reduces costs and utilization.
MSF&N Organizations: As MSF&N services become more integrated into health care delivery, new opportunities arise for nutrition organizations to sustain and expand their activities. For example, the Food is Medicine Coalition has developed a voluntary national certification program for MSF&N providers. Grants and technical assistance (available through state Medicaid programs, health plans, and charitable organizations) can help organizations set up new systems and enhancements, such as contracting, management, data, and billing capabilities, needed to support the delivery of MSF&N services. Larger, more experienced MSF&N organizations can have new opportunities under such programs to train other organizations and be compensated for their role. Organizations can also form so-called “community care hubs,” which share administrative capabilities and operational infrastructure and band together to serve more diverse populations. States vary in the extent to which they encourage the formation of such hubs.
Issues we are tracking
State Medicaid programs are working to: Do they authorize funding for MSF&N services (e.g., through Section 1115 waivers, ILOS, HCBS waivers)? Do they financially incentivize Medicaid plans and/or providers to invest in MSF&N services (e.g., reinvestment requirements, quality measures, incentive contracts)? Do they incorporate the cost of MSF&N services into Medicaid managed care fees? How are federal and state policymakers incentivizing Medicare Advantage plans and D-SNPs to provide MSF&N services through SSBCI? What support do health plans and 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 to bill and exchange data with providers?And how are states, plans, and providers helping to address these challenges? What provider eligibility criteria and oversight processes have states and plans adopted for MSF&N services? How do states and other payers evaluate the effectiveness of MSF&N services? Conclusion
MSF&N’s services help improve the lives and health of millions of Americans with diet-related health issues. MSF&N’s expanding scope of services and growing recognition that food and nutrition are upstream drivers of health status reflect an encouraging focus on “whole person” care.
1 As of April 2024, state Medicaid programs with payment authority for MSF&N services for certain populations include Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.
2 Of note, the CMS framework provides that section 1115-authorized nutrition support programs that provide enrollees with three meals per day are limited to six months and may be extended for an additional six months if enrollees continue to meet the eligibility criteria. This limit does not apply to programs that provide fewer than three meals per day.
