Managed care organizations (MCOs) have traditionally focused on providing medical benefits such as doctor’s visits, hospitalizations, and prescription medications to care for members facing illness or injury. But as research grows on how social determinants of health (SDOH) impact health and well-being, MCOs including managed Medicaid, as well as states administering Medicaid programs, are looking for ways to implement innovative, new benefits to help their members proactively address SDOH.
Now the Centers for Medicare and Medicaid Services (CMS) is supporting some of those efforts by state Medicaid programs. Recently, CMS approved a proposal by California’s Medicaid plan, called Medi-Cal, to use Community Supports (California’s nomenclature for the proposed list of state-approved In Lieu of Services/ILOS) to offer a set of 14 health-related, non-medical services to members. With CMS approval, ILOS allows plans to substitute services or settings covered in a state Medicaid plan because they are medically appropriate and cost-effective alternatives to traditional benefits.
California is a vanguard when it comes to ILOS, but awareness and interest in the option is growing. New York is now piloting SDOH interventions including medically tailored meals delivered to high-need individuals in certain counties.
14 approved Community Supports in California
- Housing Transition Navigation Services
- Housing Deposits
- Housing Tenancy and Sustaining Services
- Short-Term Post-Hospitalization Housing
- Recuperative Care (Medical Respite)
- Day Habilitation Programs
- Caregiver Respite Services
- Nursing Facility Transition/Diversion to Assisted Living Facility
- Community Transition Services/Nursing Facility Transition to a Home
- Personal Care and Homemaker Services
- Environmental Accessibility Adaptations (Home Modifications)
- Asthma Remediation
- Medically Tailored Meals
- Sobering Centers
ILOS benefit to members
Members benefit from ILOS because they can have access to helpful services that address needs and improve health, such as nutritious home-delivered meals, asthma remediation, and home modifications. Under CMS rules, health plans can offer innovative services that help meet a person’s unique needs, particularly related to SDOH and health equity concerns.
ILOS benefit to health plans
CMS’ support of approved ILOS benefits is good news for managed care plans too. This benefit flexibility allows plans to focus on preventative solutions to keep members healthy and out of the hospital which could improve outcomes and reduce costs. ILOS expenditures qualify as covered services for rate-setting, meaning their claims count toward the capitation rate.
How do ILOS work?
There is no set list of ILOS benefits states can offer. Rather, it’s up to a state to seek CMS approval for services it proposes that are medically appropriate and cost-effective substitutes for Medicaid services. CMS approved a range of ILOS in California including nutritious meals, caregiver respite, home modifications, sobering centers, and more.
A recent pilot program between Inland Empire Health Plan (IEHP) in California and Mom’s Meals® demonstrates how a preventative program leveraging a service that addresses both a clinical need and a social need can work effectively to improve the health and lives of members.
The pilot's goal was to improve IEHP members' health through better access to nutritious food, nutritional education, and improved monitoring. Dually-eligible Cal MediConnect members with congestive heart failure and a minimum of two previous hospital stays within the prior 12 months in certain counties received home delivered meals from Mom’s Meals for 24 weeks. They also received nutrition counseling, support from community health workers and nurse case managers, exterior safety checks of their homes, and in-person health wellness surveys, as well as produce and pantry boxes from Mom’s Meals for 12 weeks. The pilot was a success and achieved:
- 50% reduction in hospitalizations
- $1,613 per member per month savings on health care costs
- 5.8-pound average weight loss per participant
- 95% overall program satisfaction from participants
Mom’s Meals – your ILOS partner
As the leading national provider of home-delivered, medically tailored meals, Mom’s Meals is a valuable resource when it comes to developing strategies to promote ILOS. Rely on our expertise in partnering with managed care organizations and State Departments of Health in California and New York to help inform your program.
How Mom’s Meals helps
- Laying groundwork for an ILOS program that includes medically tailored meals
Pilot Program Reporting
- Preparing data for internal and external stakeholders including state Medicaid directors and state departments of health
Pilot Program Development
- Identifying targeted members
- Developing protocols
- Measuring outcomes
ILOS Program Definition
- Eligible populations
- Billing requirements
Considering ILOS for your plan but need support? The Mom’s Meals team can help. Contact John Phillips, Vice President of National Program Development at firstname.lastname@example.org or 888-343-8020.