State Identified Request Form for In Lieu of Services for Medically Tailored Meals (MTM)

Cost-Effective Alternative Services (In Lieu of)

Revised 4.21.22

  • Form is also available in Portable Document Format (PDF)

Effective July 6, 2016, federal regulations allowed and clarified the use of cost-effective alternative services that are approved by the State to be offered by Medicaid Managed Care Organizations (MMCOs). These regulations encourage innovation and promote efficiency and quality by enabling MMCOs to offer their enrollees physical and behavioral health services that are not covered under the Medicaid State Plan.

MMCOs may, as a cost-effective alternative to Medicaid State Plan services and settings, provide Medicaid Managed Care enrollees with alternative services and settings as permitted by 42 CFR 438.3(e)(2) and approved by the State. These cost-effective alternative services are often referred to as "in lieu of services" (ILS). The cost of such services must be included in the development of the MMCO rates.

ILS are defined as alternative services or settings that are not included in the State Plan but are medically appropriate, cost-effective substitutes for covered services or settings.1 "State Approved ILS" means ILS proposed by an MMCO that has been approved by the State. "State Identified ILS" means ILS that has been identified by the State as appropriate ILS for the Medicaid Managed Care program. Both State Approved and State Identified ILS will be posted on State agency websites.

  • MMCOs may not provide ILS pursuant to 42 CFR 438.3(e)(2) without first applying to the State, obtaining State approval to offer the ILS, demonstrating all of the following requirements will be met. Pursuant to 42 CFR 438.3(e)(1), MMCOs may voluntarily agree to provide any service to an enrollee outside of an approved ILS construct, however the cost of such voluntary services may not be included in determining State premium rates.
    • Voluntary for Enrollee: A MMCO cannot require an enrollee to use an ILS instead of a State Plan-covered service or setting but can offer enrollees the option of such services when doing so would be medically appropriate and cost-effective.
    • Voluntary for MMCO: It is a MMCO´s option to offer ILS. A MMCO may apply to the State for approval if it chooses to provide an ILS.
    • Proposals for ILS must demonstrate that the alternate services are medically appropriate and cost-effective.
    • Proposal must define population and criteria for the alternate service(s). The plan is responsible to calculate the cost-benefit analysis.
    • ILS may not include expenditures that are prohibited by CMS, such as training or equipment for law enforcement and room and board.
  • Once the State approves an ILS application for an MMCO:
    • The ILS must be added to the MMCO´s Medicaid Managed Care contract (amendment to Appendix M).
    • The ILS will be posted on State agency websites as a State Approved ILS.
    • The cost and utilization of ILS will be factored into the medical portion of the MMCO´s rates.
    • MMCO must inform enrollees of new ILS benefits and must post approved ILS publicly, including on MMCO website and in an updated member handbook or member handbook insert.
    • The MMCO will be responsible for offering the ILS to all enrollees that meet the defined population and criteria for the alternate service. Enrollees have the right to request appeal, external appeal, and fair hearing regarding the denial of a State approved ILS being offered by the MMCO.
    • Encounter data tracking: Plans must use rate codes that have been approved by the State to track the claiming and provision of ILS.
    • Cost reports: Plans must have mechanisms to track and report ILS expenditures in a manner and format established by the State.
  • Termination of ILS:
    • State-initiated termination: State may terminate ILS if it is determined to be harmful to the enrollee or is not cost effective.
    • MMCO-initiated termination: MMCO may terminate ILS upon notice to NYS. The MMCO must publicize a termination date and provide 90 days´ notice to enrollees. The MMCO must create and implement a plan for continuity of care for member(s) who are in receipt of ILS.
    • Termination date must occur at the end of the fiscal quarter, except in the case ILS is terminated due to a threat against the health, safety or welfare of the plan´s enrollees.

MMCOs must complete the In Lieu of Request Form attached to this guidance and submit for review and approval to NYS Department of Health at: ILS@health.ny.gov.

MMCOs may apply to the State for approval to:

  1. provide State Identified ILS completing only Section One below;
  2. provide a State Approved ILS previously developed by another MMCO as posted on State agency websites by completing only Section One below; and/or
  3. Initiate a new ILS by completing the full application.

The State will use the information provided by the MMCO via this Request Form to approve or deny the request, and to serve as documentation for the State´s actuary and/or the Centers for Medicare and Medicaid Services (CMS) regarding the cost-effectiveness of the service. The Office of Mental Health and the Office of Alcohol and Substance Abuse Services, in consultation with the Department of Health, will determine the clinical appropriateness of the proposed ILS intended for HARP enrollees and for Behavioral Health ILS.

MMCOs may submit requests for approval of ILS to the State at any time. The State will review requests upon receipt. Upon approval, plans may begin providing the ILS only at the beginning of a state fiscal quarter.


The MMCO should answer each question as comprehensively as practical. Questions should be directed to ILS@health.ny.gov at the New York State Department of Health

MMCO INFORMATION
Date:
MMCO Plan Name:
Contact Person: Title:
Phone: Email:
SECTION ONE:

Complete only this section to provide State Approved or State Identified ILS. Add additional lines if necessary. If the MCO is modifying any portion of the State Approved or State Identified ILS, describe the change by completing the appropriate section(s) in Section Two of this form.

1.

ILS to be Provided NYS Authorization Number Expected start date for provision of service Target area for availability of service Related to DSRIP/VBP?
A. Medically Tailored Meals(MTM) Leave Blank     No
B.        
C.        

2. MCO Monitoring Activities - Describe activities, reports, and/or analyses your MCO will use to monitor the provision, utilization, quality, cost-benefit and/or outcomes of the in lieu of service. MUST be completed for State Identified ILS.

 
 
 
 
 
SECTION TWO:

Complete this section if the plan is initiating a new ILS. Complete appropriate areas as necessary if the MMCO is modifying a State Approved or State Identified ILS.

  1. In Lieu Of Service Name and Description - Describe the proposed in lieu of service with sufficient detail so that the State can evaluate and assess the nature of this request. (One service per request form)
    Proposed In Lieu of Service
    A. Service name Medically Tailored Meals (MTM)
    B. Description of service, including which State Plan service this may be offered as a substitute for Home delivered MTMs will be available to individuals 18yrs or older, living with severe illness through a referral from a medical professional or healthcare plan. Meal plans will be tailored to the medical needs of the recipient by a Registered Dietitian Nutritionist (RDN), and designed to improve health outcomes, lower cost of care, and increase patient satisfaction. MTM services will include an initial intake with an RDN and nutritional therapy to discuss meal composition. Medically Tailored Meals will substitute for one of the following:
    1. Personal Care Aide (PCA) service – PCA hours allotted for meal preparation and food shopping may be substituted for delivery of Medically Tailored Meals (MTM). Members who opt in to receive MTM in lieu of meal preparation and food shopping hours will incur a reduction in the number of PCA hours they receive. The hours reduced will depend on the number of meals the individual receives.
    2. Hospital Inpatient stays and/or Emergency Department visits – high- volume service utilizers with hospital inpatient stays and emergency department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS. High-volume service utilization being defined as:
      • Two or more Hospital Inpatient stays related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
      • Five or more Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months; or
      • One Hospital Inpatient stay AND four Emergency Department visits related to cancer, diabetes, heart failure, and/or HIV/AIDS within the last 12 months.
    C. Proposed procedure code(s) defining service HCPCS Code S5170 SE - home delivered meal, including preparation, per meal
    D. Is this ILS related to a DSRIP project or VBP contract  No. This ILS is being issued as part of MRTII SDH pilot program. The purpose is to promote social determinant of health interventions.
    E. Expected start date for provision of service  
    F. Target area for availability of service, or indicate ILS will be offered in full MMCP service area. ILS may be offered in full Medicaid Managed Care Plan (MMCP) service area. MMCOs must contract with an eligible provider for MTM services. Identified MTM providers include:
    • God´s Love We Deliver
    • The Food Pantries for the Capital District
    • FeedMore of Western New York.
    • Mom´s Meals
    G. Assessment of capacity to provide this service within each target area MMCOs must partner with an organization that has the capacity to prepare and deliver meals according to Food is Medicine Coalition (FIMC) MTM nutritional standards, to individuals in their homes under the supervision of a Registered Dietitian Nutritionist (RDN). The provider must have experience providing Medically Tailored Meals; infrastructure to perform necessary tasks and services, including tracking service delivery and data collection.
  1. Information about the Population(s) that may receive the In Lieu Of Service - Describe the anticipated enrolled managed care population that will use/receive the proposed in lieu of service.2
    Population Age
    Range
    Approximate
    Number of
    Expected Users
    over 12-Month
    Period
    Characteristics of the Population
    (e.g., acuity level, gender, family
    status, placement setting, other)
    Adults 18+   Eligible individuals must meet the following criteria:
    • High-volume service utilizer (as defined above) with at least one of the following diagnoses: cancer, diabetes, heart failure, and/or HIV/AIDS
    • Limited in ability to perform ADLs
    • Recommended for MTM by a healthcare provider or MCO
    • Must have a secure place to store and heat meals
    • Must be able to benefit from the MTM intervention to improve overall health
  1. Goals and Objectives- Describe the rationale for providing this service.
    Maintaining proper nutrition is essential for all individuals and is particularly important for those experiencing serious or chronic illness. Poor nutrition is associated with reduced control of chronic conditions. Providing MTM will reduce food insecurity and prevent malnutrition by providing healthy, balanced meals. Providing MTM as a partial substitute for PCA services with allotted meal preparation and food shopping duties can reduce Medicaid spend since the PCA hours will not be needed for these tasks. MTM can also reduce costs by decreasing monthly healthcare costs and reducing inpatient hospital stays and ED utilization. In addition, the meals will be prepared for the individual based on their specific medical needs, ensuring that they are eating a proper diet to improve their overall health and symptoms of chronic disease.
  1. Expected Outcomes - Describe the expected outcomes resulting from the provision of this in lieu of service on member´s health status, utilization of services, cost of care, functional status and/or community integration. If your MMCO has provided this service in other programs or states, please describe the outcomes observed. The purpose of this question is to inform how the service will provide the same or better quality of care as the State Plan service for which it is being substituted.2
    Increasing research indicates that MTM is an effective strategy for achieving the "triple aim" – better quality care, more cost-effective care, and improved patient satisfaction. MTM can improve care quality by providing meals prepared for each individual's specific health and dietary needs. MTM can ensure that highly specific dietary needs of those with cancer, HIV/AIDS, heart failure, and diabetes are consuming the nutrients that their bodies need to become and remain healthy. MTM is a low-cost, high-impact intervention that can reduce overall Medicaid spend, inpatient hospitalizations, and ED utilization. Finally, MTM can improve patient satisfaction by providing a diet that will reduce side effects of chronic conditions and prevent malnutrition. MTM deliveries can also provide social interaction for those who are generally isolated from their communities.
  1. Staffing Qualifications, Credentialing Process, and Levels of Supervision, Administrative, and Clinical Required - Describe the provider´s licensure or certification (if required), staffing patterns, and clinician oversight (if required) over unlicensed practitioners. Describe how your MMCO will enroll/screen qualified providers that meet the requirements to deliver the service with the quality outlined in #4 above.
    Medically tailored meal providers must have the capacity to prepare and deliver meals to individuals at their homes. Eligible Medicaid members will be assessed, and all meal plans must be approved by a RDN. Medicaid members must be referred to the program by a healthcare provider or health plan. In addition, providers must offer nutrition education and counseling to Medicaid members served. Special diets, including diabetic and heart healthy, must be available. All individuals who work with food must receive food safety training and providers must consistently receive passing grades on all safety inspections by the local department of health.
  1. Unit of Service - For each proposed procedure code listed in question #1, what is the unit of service that defines this alternative in lieu of service (e.g., 1 hour, 1 day, a visit, 15 minutes)? If different units of service apply to different procedure codes, delineate in the following table as applicable. Add more rows as needed.
    Procedure Code Unit of Service
    Definition
    Other Information (optional)
    HCPCS Code S5170 SE - home delivered meal, including preparation; per meal Per meal Costs of intake, screening, nutrition assessment and education, meal preparation, and delivery are included in the unit cost of each medically tailored meal.
  1. Anticipated Units of Service per User - For each proposed procedure code listed in question #1, what is the anticipated average number of expected users and average number of units per expected user over a 12- month period? (Time frame, LOS, expected units) If this metric varies by population, delineate by population type.2
    Population Age
    Range
    Approximate Number
    of Expected Users
    over 12-Month Period
    Procedure
    Code
    (must
    indicate
    unique
    identifier
    to track
    service)
    Approximate
    Number of Units of
    Service Per User
    Per 12-Month
    Period
    Adults 18+   HCPCS Code S5170 SE - home delivered meal, including preparation; per meal The total number of units per user (1 unit = 1 meal) for a 12 month period would be 1092 meals (up to 21meals/ week for 52 weeks) For this ILS, MMCOs will utilize a 6-month authorization period. The total number of units per user will be 546 meals (up to 21 meals/ week for 26 weeks)
  1. Targeted Duration of Service - For the service, describe the expected average duration of the service to achieve the desired outcomes. This could be the average length of treatment/care (e.g., 6 weeks, 6 months) or, if the service is not directly tied to a course of treatment, it could be the frequency at which the service is expected to be delivered to each user (e.g., weekly, monthly, as needed).
    MMCOs will utilize a 6-month authorization period for MTM services. MTM recipients will participate in the program for a minimum 6-months, with the potential to extend MTM services if the need persists. Members will receive up to 3 meals/day through the program.
  1. Cost-Effectiveness - For the population intended to receive the in lieu of service, provide information on the cost-effectiveness of the in lieu of service versus the State Plan service(s) available. The State is requesting this information to determine if the requested in lieu of service is cost-effective, consistent with the provisions of 42 CFR 438.3(e)(2).2

    This question requires the MMCO to complete two Parts: Part 1 requests information on expenditures on the State Plan service(s) that the in lieu of service would be offered to replace, and Part 2 requests information on anticipated expenditures on the in lieu of service.**

    For the in lieu of service to be considered cost-effective, the total expected expenditure on the in lieu of service must be less than or equal to the total expected cost of comparable State Plan service(s).

Part 1: Computation of Comparable State Plan Service(s) Cost (include type, amount, frequency, etc.)

State Plan Service
Name/Description
State Plan
Service
Identifying
Code(s)
Unit of
Service
Definition
Average
Number of
Expected
Users over
12-Month
Period
Average
Number of
Units of
Service Per
User Per
12-Month
Period
Average Unit
Cost
Personal Care Assistant (PCA) with meal prep S5130,
T1019,
T1020
Per hour   7.00 – 8.75hrs of PCA meal prep per week. At 7.00hrs/per week, the average number of service unit for 12month period, will be 364hrs of PCA with meal prep. At 8.75hrs/per week, the average number of service unit for 12month period, will be 455hrs of PCA with meal prep. Average unit cost is $18.83 - $29.64 per hour
Emergency Department Professional-CPT
99281
99282
99283
99284
99285
Ambulatory Payment Classification (APC)
5021
5022
5023
5024
5025
Per visit     Average cost per visit: $278
Hospital Inpatient Stays Professional - CPT
99221
99222
99223
99231
99232
99233
Per day     Average cost per stay: $12,234

Part 2: Computation of In Lieu Of Services Cost (include type, amount, frequency, etc.)

In Lieu Of
Services Name/Description
In Lieu Of
Services Identifying Code(s)
Unit of
Service Definition
Average
Number of
Expected
Users over
12-Month
Period
Average
Number of
Units of
Service Per
User Per
12-Month
Period
Average Unit
Cost
Medically Tailored Meals S5170 SE Per meal For a 6-month intervention, each user will receive 546 meals total (3 meals/day) $9.50/meal

** MCOs may propose a different cost analysis approach that includes comparison of state plans services vs ILS to demonstrate projected cost with and without ILS.

  1. Encounter Data Reporting - Describe the process by which your MMCO will submit valid and complete encounter data applicable to the in lieu of service. If possible, include descriptions of record/claim type(s), provider codes/taxonomies, and other data elements so that the State and its actuary will have the ability to locate and analyze actual encounter data for the requested in lieu of service.
    All Medically Tailored Home-Delivered meal encounters will be submitted to the NYS All Payer Database (APD), consistent with the requirement of all other MMCO encounters. Procedure code: S5170 SE. NYS will track this service using encounter data reported.

    Additionally, MMCO will be required to submit patient level information using attached MTM Reporting Template on a quarterly basis, to track utilization and ILS service evaluation.
  1. Financial Statement Reporting - Please explain your MMCO´s ability to track in lieu of service expenditure. These expenditures will be required to be reported in the plans Operating Reports (i.e., MMCOR). The information will inform the State and its actuary the amount of in lieu of expenditure for the development of prospective managed care capitation rates.
    Cost and Utilization for this MTM ILS should be reported on Medicaid Tables 21 and 21A and HARP Tables 21 and 21A (Tables 23 and 23A for SNPOR).
  1. MMCO Monitoring Activities - Describe activities, reports, and/or analyses your MMCO will use to monitor the provision, utilization, quality, cost-benefit and/or outcomes of the in lieu of service. This MUST be completed for state identified ILS.
    Must be completed by the MMCO in Section 1, question 2 of the application.
  1. Other Information - Provide any other relevant information for the State´s consideration of this request. This could include, if the MMCO wishes to submit it, information like references to medical and scientific evidence in support of the proposed ILS, provider- and/or enrollee-facing information regarding of the purpose of the ILS, authorization requirements for ILS, or other operational considerations.
    N/A for State Identified ILS.

______________________________________

1. 42 CFR 438.3(e)(2).  1
2. MMCO´s should utilize experience and knowledge of their enrolled populations and any research/findings available regarding the proposed ILS to best estimate or approximate the information requested. The State will use this information in its assessment of the MMCO´s application, however will not consider the estimates or approximations as binding for actual service delivery or outcomes.  2


References

iBerkowitz SA, Terranova J, Randall L, Cranston K, Waters DB, Hsu J. Association between rec


Medically tailored meals are:
  • Delivered to individuals living with severe illness through a referral from a medical professional or healthcare plan;
  • Meal plans are tailored to the medical needs of the recipient by a Registered Dietitian Nutritionist (RDN) and designed to improve health outcomes, lower cost of care and increase patient satisfaction; and
  • Delivered in accordance with the FIMC MTM Nutrition Standards.
Chart of Medically Tailored Meals Nutritional Standards

Courtesy of: www.fimcoalition.org

MMCOs will utilize the attached template to collect and report member level information on a quarterly basis, for the purpose for tracking MTM utilization and evaluation.