Type: Medicaid
Program Goal: A food as medicine program as part of the 1115 MLTSS waiver in New Jersey.
Target Population: Adults who will be transitioning out of an inpatient setting and likely have trouble with activities of daily living and may also have a caregiver who helps them at home.
What is MLTSS?
New Jersey Medicaid’s MLTSS program supports individuals who require a nursing facility level of care, enabling them to receive comprehensive support in their homes and remain within their communities. This in-home care is suitable for various conditions, including:
Inability to complete Activities of Daily Living (ADLs)
Medical conditions necessitating injections, catheter care, and/or IVs
Cognitive impairment
Behavioral issues
State(s): New Jersey (non-licensure state)
RD Requirements:
Health Plan Credentialing | State Medicaid Enrollment | Foodsmart Credentialing Requirements |
No | Yes | Medallion Credentialing Application, Copies of CDR, CV |
Benefits Overview:
Video Required
| # of Allowed Visits
| # of Allowed Units per Visit
| Schedule Cadence
| Billing Codes |
No. A large majority of these visits will be done via audio only. | 6 | 4 | Once per month or sooner if clinically necessary | Initial: 97802 Follow Up: 97803
|
Nutriquiz | SNAP Required | Find Help Required | Risk Assessment |
Required at two visits. MUST screen for food insecurity. | SNAP visit is recommended if the patient does not have SNAP. | Find Help available if needed | No |
Food Benefits:
Foodsmart Bucks | Foodboxes/MTM | Food Selection Instructions |
No | Yes
| *See Below
|
*NOTE: At the time of scheduling, our member support team will collect food preferences from the member via google form so that the member can receive food within 48 hours of their discharge. The member will most likely already be receiving food at the time of the MNT visit. Please refer to this google sheet to confirm if food preferences have been submitted. If the member's preferences are not on this google sheet please use this order form and collect the preferences so the member can receive food support in a timely manner.
The patient's Care Manager referral will indicate which of the following grocery provisions the patient gets.
Transitional Pantry Stocking (TPS)
Transitional Pantry Stocking is for patients transitioning from an institutional or congregate setting (such as a hospital, nursing facility, or carceral setting, etc.) to a community residence.
One instance of pantry-stocking for up to 30 days of shelf-stable food items AND/OR
Up to six monthly instances of medically tailored meals (MTM), and/or medically tailored groceries (MTG) either limited to a 30-day supply per monthly occurrence.
Members can only receive this Transitional Pantry Stocking benefit once per their lifetime.
Grocery Provisions will be delivered on a weekly or bi-weekly cadence based on patient preference.
Members will receive 3 meals per day for up to 6 months.
The member will select what type of grocery provision they prefer (MTM or MTG) each month. Transitional pantry stocking may also include housing supplies such as cleaner and paper products.
Short-Term Grocery Provision
Short-Term Grocery Provision is for members experiencing a disruption in ability to get adequate food (e.g., due to recent hospitalization, loss of caregiver, or other sudden event).
Provisions are delivered at least every other week.
Only one 30-day supply may be provided per year.
Members can only receive Short Term Grocery Provisions OR Transitional Pantry Stocking not both.
Many members face difficulties with Activities of Daily Living (ADLs), which are essential for independent living. These activities are categorized into five key areas:
Mobility: Moving from bed or a chair, and navigating between rooms.
Bathing: Personal hygiene, including grooming like brushing teeth and hair, and nail care.
Dressing: Putting on and taking off clothes.
Eating: Consuming food and drink.
Toileting: Using the restroom independently.
You likely will speak to the caregiver of these patients. Please obtain consent verbally from the patient that you are permitted to speak to their caregiver and document verbal consent granted in FFD.
Sample Visit Topics:
This gives you an idea of what topics may be of interest to your patient and what to cover in each visit and what items you must complete and in what visit.
Visit Number | Sample Topics | Must Complete |
1 | Get to Know, NutriQuiz (baseline measurements + reminder to get lab work done), Food Insecurity Screening, Introduction to Foodsmart Program | NutriQuiz and collect food preferences if not on SHEET |
2 | SNAP application (if applicable), Connection to Community Resources, Food access, budget, and meal preparation support
| SNAP (if applicable) and 1 Find Help Referral and Selection of Grocery Provision |
3 |
Affordable sources of nutrient needed for older adults (calcium, fiber, omega-3, etc) | NutriQuiz and Screening for Food Insecurity) Updated biometrics Selection of Grocery Provision
|
4 | Quick easy recipes < 20 minutes or recipes (sitting down recipes, no cook recipes, freeze and eat, slow cooker, etc) | Selection of Grocery Provision
|
5 | Weight management and muscle preservation (importance of protein, etc) | Selection of Grocery Provision |
6 | Hydration and fluid intake needs, overcoming obstacles and upcoming barriers, planning for the future. | NutriQuiz and Screening for Food Insecurity (update labs if pt has) and Selection of Grocery Provision |
Please see the following link of Overview of Health Plans for info on all health plans.