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Food for Thought: Expanded Opportunities for Nutrition as Medicine | Manatt, Phelps & Phillips, LLP

Food for Thought: Expanded Opportunities for Nutrition as Medicine | Manatt, Phelps & Phillips, LLP


Overview

A recent study published in JAMA estimated that more than six million people in the U.S. have diet-sensitive conditions and activity limitations that could benefit from medically tailored meals, a type of Medically Supportive Food and Nutrition (MSF&N) service. These estimations also suggest that providing such meals to these individuals 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 contributed to policy change at both the federal and state levels—which, in turn, is creating 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, which can include medically tailored meals and groceries, medically supportive meals and groceries, produce 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 with the acuity of individual need. (See Figure 1.)

Figure 1. Spectrum of Food and Nutrition Interventions to Improve Health

 

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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 illnesses 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 in Support of MSF&N Services

As the evidence base has grown supporting the value of MSF&N services to health outcomes and costs, new pathways for authority, funding, and integration in the health care delivery system have emerged.

Medicaid and Children’s Health Insurance Program (CHIP): Historically, certain MSF&N services have typically been available only as part of Medicaid Home and Community Based Services (HCBS) programs for individuals receiving long-term supports services. In the 2010’s, 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 illnesses and other health conditions. Since then, multiple other states have followed suit using 1115 waivers or under Medicaid managed care “in lieu of services” (ILOS) authorities to fund MSF&N services in their Medicaid programs.1

In 2022, the Centers for Medicare and Medicaid Services (CMS) began formalizing its policies regarding MSF&N, alongside those on housing, culminating in a November 2023 Informational Bulletin and accompanying framework, which lists the following approvable services relating to food and nutrition:

  • Case management services for access to nutrition/food;
  • Nutrition counseling and instruction;
  • Home-delivered meals or pantry stocking;2
  • Nutrition prescriptions (e.g., fruit and vegetable prescriptions or protein boxes); and
  • Grocery provision.

CMS’s guidance extends beyond Section 1115 waivers to summarize other options for Medicaid coverage of MSF&N, including options for covering such services through managed care plans (under ILOS authority), for populations in needs 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 further defining and expanding 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 are able to use SSBCI to offer meals, food, produce, and transportation for grocery shopping. According to an analysis by Milliman, food, produce, and meals supports were among the most common SSBCI benefits offered by Medicare Advantage plans in 2023. Medicare Part A (traditional fee-for-service Medicare) does not reimburse home-delivered meals or other MSF&N services at this time.

Commercial and Marketplace 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 are making medically tailored meals and/or grocery delivery available for enrollees with specific diet-related health conditions across the country. For example, Geisinger Health’s Fresh Food Farmacy provides fresh, healthy food weekly to enrollees and their families when enrollees have A1C levels greater 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 drop in HbA1c level, lower weight, blood pressure, triglycerides, and cholesterol, and the plan found that medical expenses fell between $16,000 and $24,000 per participating enrollee.

Expanded Opportunities 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 biggest funders of such services. States play a critical role in defining which 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 deploy MSF&N services through Medicaid and document outcomes 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 enables plans to invest in popular, cost-effective interventions that can improve outcomes, reduce utilization, and enhance enrollee experience. As more states opt to add coverage for MSF&N in their Medicaid programs, many states are building the service cost into plan rates and delegating administration of the services to plans, including identifying and engaging eligible individuals, contracting with and overseeing MSF&N provider organizations, and tracking enrollee utilization and health outcomes. Though commercial market adoption is still nascent, robust and thoughtful MSF&N programs may give commercial plans a competitive advantage and help keep costs down.

Health Care Providers: With the expansion MSF&N coverage, many health care providers are establishing partnerships with local food and nutrition organizations to screen, identify and refer patients who have diet-related chronic diseases and are food insecure and could benefit from MSF&N services. As value-based payment arrangements continue to proliferate, providers that take on financial risk for their patients may view the integration of cost-effective interventions like MSF&N services as an attractive offering to support their patients and drive down costs and utilization.

MSF&N Organizations: As MSF&N services become more integrated into health care delivery, nutrition 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 via state Medicaid programs, health plans, and/or philanthropy) can help organizations set up 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 under such programs to train other organizations and be reimbursed for that role. Organizations may also form so-called “Community Care Hubs” that band together to share administrative functions and operational infrastructure and serve a more diverse array of populations. States differ in the extent to which they encourage such hub formation.

Issues That We Are Tracking

  • How are state Medicaid programs:
    • Authorizing the funding of MSF&N services (e.g., through Section 1115 waivers, ILOS, HCBS waivers)?
    • Financially incentivizing Medicaid plan and/or provider investment in MSF&N services (e.g., reinvestment requirements, quality measures, incentive arrangements)?
    • Building the costs of MSF&N services into Medicaid managed care rates?
  • How are federal and state policymakers encouraging Medicare Advantage plans and D-SNPs to provide MSF&N services via 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 are MSF&N providers encountering as they begin to bill and exchange data with health care organizations, and how are states, plans, and providers helping to address these challenges?
  • What provider qualification standards and oversight processes are states and plans adopting for MSF&N services?
  • How are states and other payers evaluating 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 expanding coverage of MSF&N services, along with the growing recognition of food and nutrition as upstream drivers of health outcomes, reflect an encouraging focus on “whole-person” care.


1 As of April 2024, State Medicaid programs with authority to pay for MSF&N services for specific populations include: Oregon, Washington, New Jersey, North Carolina, Massachusetts, New York, and California.

2 Of note, CMS’s framework stipulates that Section 1115-authorized nutrition support programs that provide enrollees with three meals per day are limited to six months, renewable for additional six-month periods if the enrollee continues to meet eligibility criteria. This limitation does not apply to programs that provide less than three meals a day.



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