Santa Clara Family Health Plan (SCFHP) offers a Value-Based Insurance Design (VBID) model that provides members with benefits such as grocery allowances.
Type: Medicaid - Social Determinant of Health
Program Goal: Meaningful reduction in food insecurity, reduce chronic conditions
Target Population: Health plan MediCal / Medicare and D-SNP members
States Served: CA
RD Requirements:
Health Plan Credentialing | State Medicaid Enrollment | Foodsmart Credentialing Requirements |
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| Medallion Credentialing Application |
Benefits Overview:
Video Required | # of Allowed Visits | # of Allowed Units per Visit | Schedule Cadence | Billing Codes | Foodsmart Program Features |
No | Tier 1 - Low Risk- NO MNT VISITS
Tier 2 - Moderate Risk up to 3 visits- then can reassess for additional visits of MNT and food
Tier 3 - High Risk up to 3 visits- then can reassess for additional visits of MNT and food | Initial: 4 units Follow up: 4 units
| Aim to schedule follow-ups 3 to 4 weeks apart and must be clinically necessary | S9470 | Foodsmart app, Telenutrition |
Low Risk Members
Overview:
Due to recent updates to DHCS requirements, SCFHP will no longer cover MNT as a standalone service (i.e., not paired with MTM) under the Community Supports program effective July 1st.
What this means for RD’s:
Starting July 1st, we will no longer be able to provide Medical Nutrition Therapy (MNT) services to low-risk patients. This means that once a member completes their Risk Assessment within the Initial Appointment and is classified as “low risk,” we will need to inform them that, due to updated state and plan guidelines, Foodsmart can no longer offer MNT services to this group. High / Medium risk patients are not affected by the changes.
Script For RD’s whose members are low risk:
I wanted to share that based on your Risk Assessment results, you are not eligible for our services (medically tailored meals or medical nutrition therapy).
If you have questions or want to explore other options or resources, please don’t hesitate to reach out to your SantaClara Community Supports team — CS@scfhp.com or 408-874-1929
*RDs should never directly reach out to Santa Clara for member updates. Always reach out to Foodsmart and we can help advocate for your member.
RD Assessments:
Nutriquiz | SNAP Required | Risk Assessment Required |
Recommended at first visit and every 3 months | SNAP eligibility should be checked frequently |
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Low risk (as identified by Risk Assessment): NO MNT VISITS or FOOD as of 7/1/25
Medium risk (as identified by Risk Assessment): 3 visits and can qualify for additional visits after reassessment (and will qualify for at least 12 weeks of meals)
High risk (as identified by Risk Assessment): 3 visits and can qualify for additional visits after reassessment (and will quality for at least 12 weeks of meals)
Visit 1: Initial assessment + initial risk assessment (REQUIRED)
Visit 2: MNT
Visit 3: MNT + risk assessment (for possible additional MNT and food- REQUIRED)
Visits 1-3= 12 weeks of MTM (food)
Visit 4: MNT (if eligible)
Visit 5: MNT (if eligible)
Visit 6: MNT + risk assessment (for possible additional MNT and food- REQUIRED)
Visits 4-6= 12 weeks of MTM (food)
Visit 7: MNT (if eligible)
Visit 8: MNT (if eligible)
Visit 9: MNT + risk assessment (for possible additional MNT and food- REQUIRED
Visits 7-9= 12 weeks of MTM (food)
Food Benefits:
Foodsmart Bucks | Foodboxes/MTM | Food Selection Instructions |
NONE | Yes
Tier 1 - Low Risk- None Tier 2 - 12 weeks + possible extension of additional 12 weeks Tier 3 - 12 weeks + possible Extension of additional 12 weeks | See below
There is no maximum food benefit
Estimated turnaround time after the RA is submitted is 1-2 weeks |
Food Support is intended to cover approximately two (2) meals per day, seven (7) days per week, for twelve (12) weeks, or longer if medically necessary or otherwise indicated.
(i) Food Support(s) that are eligible for or reimbursed by alternate programs are not eligible.
(ii) Food Support(s) are not covered to respond solely to food insecurities.
Important Food Benefit Reminders:
Initial talking point with your member:
Before taking the risk assessment, it is the RD’s responsibility to assess factors (current medical conditions, access to food support) that your member may or may not be eligible to receive MNT visits and/or food benefits.
Please do not use the word “denial” when discussing your member's food support. We are not their health plan.
RDs should not tell members they are “low, medium or high risk." Instead say whether they are or are not eligible for services.
Use the word “recommend” when discussing the results of our risk assessment (i.e., “I recommend 12 weeks of food be provided based on this assessment. Ultimately, your health plan will review this recommendation for final approval.”
RDs should never directly reach out to Santa Clara for member updates. Always submit a Food Support ticket and we can help advocate for your member.
Authorized Representative Form (ARF) – SCFHP Overview
The ARF allows Santa Clara Family Health Plan (SCFHP) members to designate someone (e.g., family, caregiver, legal rep) to act on their behalf for health-related matters—this includes accessing health info, discussing benefits, and filing grievances or appeals.
If a member says they have an ARF on file, or if someone on the phone states they are an authorized representative through an ARF, we must honor it. Please make a note in the chart.
What is DualConnect?
SCFHP DualConnect is a Dual-Eligible Special Needs Plan (HMO D-SNP) for people who are eligible for both Medicare and Medi-Cal
DualConnect members with diabetes or chronic heart failure are notified by mail that they may be eligible for a Food Benefit Card.
They are then sent over to FoodSmart and assessed by our RD, provided nutrition education and offered the most appropriate meal benefit.
At the time they are recommended for the grocery benefit, eligible members are referred to Nations to receive a $75 monthly benefit card.
The benefit card can be used at a grocery store or groceries can be ordered through Nation's website
Who qualifies for VBID?
Be a DualConnect member, AND
Have a diagnosis or Diabetes or Congestive Heart Failure, AND
Cannot be receiving Medically Tailored Meals (MTMs) or Medically-Supportive Food (MSF)
Must receive MNT while receiving VBID.
In essence, the only way they qualify for VBID is if they score LOW risk on the Foodsmart Assessment.
At the time they are recommended for the grocery benefit, eligible members are referred to Nations by the Health plan to receive a $75 monthly benefit card.
Where to send members for VBID Support and Questions?
VBID inquiries should go back to the Santa Clara Health Plan ContactDualConnect@scfhp.com
For members who call Foodsmart to inquire about VBID eligibility and they do not have any authorizations for Nutritional Counseling with Foodsmart, Foodsmart instructs the members to call or email SCFHP’s Customer Service department at 1-800-260-2055 or ContactDualConnect@scfhp.com.
For members who are speaking with Foodsmart and they state they only want VBID and not the recommended services (MTM or MSF), Foodsmart instructs the members to call or email SCFHP’s Customer Service department at 1-800-260-2055 or ContactDualConnect@scfhp.com.
For the reassessment of members who already received NC and MTM or MSF and are in Foodsmart’s system, Foodsmart will incorporate the VBID eligibility screening into their standard reassessment process for members who were not previously eligible for VBID.
Food Vendors
Loaves and Fishes
Medically Tailored Food and Nutrition services are provided to Medi-Cal clients with chronic health conditions or who have recently been discharged from the hospital. Santa Clara
Family Health Plan refers clients for a variety of services, including Medically Tailored Meals, Medically Tailored Groceries, or Nutrition Education.
Grocery Box or Delivered Meals (frozen & hot daily MTMs + Grocery (protein+produce+shelf-stable)
Mom’s Meals
With nine condition-specific menus and 60+ meal options, there are numerous tasty choices to make. Designed by professional chefs and registered dietitians in USDA-approved kitchens, all our medically tailored meals are made with high-quality ingredients. Providing nutrition support for leading chronic health conditions to improve outcomes and reduce the total cost of health care.
Delivered Meals (only (refrigerated MTMs)
Roots Food Group
Our recipes have been specifically designed by our chef & registered dietitians to meet nutritional guidelines for the following chronic illnesses: Diabetes, Heart Disease, Hypertension, High Cholesterol, and Kidney Disease. Prepared by our team under rigorous nutritional guidelines of the ADA, AHA and more, each Roots Food Group meal plan includes nutrient-rich breakfast and dinner entrées that are ready to heat and delicious to eat.
Delivered Meals Only (Frozen and Refrigerated)
SunTerra
SunTerra Produce is a Grower, Packer, and Shipper of a diverse range of fresh fruits and vegetables headquartered in Newport Beach, CA. SunTerra partners with the best growers in the U.S. and Mexico to provide the most delicious, healthy and safe fruits and vegetables direct to homes. The new Medically Tailored Meal benefit program recently launched in 2022 by the CalAIM initiative.
Grocery Box or Delivered Meals (frozen, pre-prepared daily MTMs + Grocery boxes (produce only)
Food Health Collective
We offer medically tailored food via Instacart (We find this is the preferred fit for those wanting more autonomy and choice with the weekly food. For those that are less-tech-savvy, we have "assisted-Instacart" which facilitates the food choice and ordering process for the participant.
Grocery Box or Delivered Meals (frozen, pre-prepared daily MTMs + Grocery boxes (protein+produce+shelf-stable)
GA Foods
Provides either medically tailored meals or weekly grocery boxes, based on members' health conditions, personal preferences, and living situation. The program is designed for individuals with chronic conditions, those recently discharged, at high risk of hospitalization, or those with significant care coordination needs.
Grocery Box or Delivered Meals (frozen, pre-prepared daily MTMs + Grocery boxes (protein+produce+shelf-stable)
Performance Kitchen
Performance Kitchen provides the next generation of chronic disease management through healthy Medically Tailored Meals, paid for by insurance and delivered directly to your home.
Grocery Box or Delivered Meals (frozen and refrigerated, pre-prepared daily MTMs + Grocery boxes (protein+produce+shelf-stable)
HomeStyle Direct
Crafted by registered dietitians, our meals support better health for members with diabetes, heart disease, kidney disease, and other long-term conditions.
Delivered Meals (Frozen)
Visit Anatomy:
Please see the following link of Overview of Health Plans for info on all health plans.