Medically tailored meals (Wisconsin Medicaid in lieu of service)
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Defines coverage, provider enrollment, billing, and member eligibility for medically tailored meals offered as an in lieu of service by participating BadgerCare Plus and Wisconsin Medicaid SSI HMOs; affects Food Is Medicine providers, HMOs, and referring/network providers in Wisconsin.
Effective January 1, 2025, HMOs can reimburse Medicaid-enrolled Food Is Medicine providers for medically tailored meal services to eligible members.
Reimbursement covers preparation (and delivery if applicable) of up to two meals per day for up to 12 weeks, with HMO reauthorization every 12 weeks up to one year from initial authorization.
Establishes a new Food Is Medicine provider type that must enroll with Wisconsin Medicaid before contracting with HMOs.
Specifies billing codes and U1/U2/U3 modifiers mapping to clinical populations (high-risk pregnancy/postpartum, diabetes post-discharge, cardiovascular disease post-discharge).
Coverage Criteria for Medically Tailored Meals
Member Eligibility
Covered when ANY of the following clinical criteria are met and the member is enrolled in a participating HMO:
Members must be enrolled in an HMO that contracts with Food Is Medicine providers.
Authorization duration and reauthorization
Coverage and authorization duration rules:
HMOs may set additional service authorization requirements in contracts.
Medically tailored meals are available only through participating BadgerCare Plus or Wisconsin Medicaid SSI HMOs. Effective January 1, 2025, HMOs may choose to reimburse Medicaid‑enrolled Food Is Medicine providers for this in‑lieu‑of service, but the benefit is not available to members enrolled in Wisconsin fee‑for‑service Medicaid or to members enrolled in other excluded Wisconsin Medicaid programs such as Family Care, Family Care Partnership, IRIS, PACE, or the Children’s Long‑Term Support (CLTS) Program.
To receive reimbursement from an HMO for medically tailored meal services, a Food Is Medicine provider must be contracted with or have an agreement in place with at least one participating HMO. Providers should confirm HMO contracting status and billing agreements before delivering services to HMO members.
Services are not covered for members who have Wisconsin fee‑for‑service Medicaid or who are enrolled in excluded Medicaid programs. Specifically, medically tailored meals are not covered under Family Care, Family Care Partnership, IRIS, PACE, or the Children’s Long‑Term Support (CLTS) Program. Because this benefit is an HMO optional in‑lieu‑of service, members must be enrolled in a participating HMO to be eligible.
Billing and Coding Guidance
| 97802 | Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. |
| 97803 | Medical nutrition therapy; reassessment and intervention, individual, face-to-face with the patient, each 15 minutes. |
| 97804 | Medical nutrition therapy; group (2 or more individuals), each 30 minutes. |
| S9470 | Nutritional counseling, dietitian visit (use for real-time, interactive audio-only telehealth). |
| U1 | Modifier: high-risk pregnancy or postpartum population. |
| U2 | Modifier: member with diabetes after a hospital discharge. |
| U3 | Modifier: member with cardiovascular disease after a hospital discharge. |
Provider Responsibilities and Authorization Workflow
Prior authorization and billing using specified codes and modifiers
HMOs review referrals and member requests and must determine both eligibility and service authorization before authorizing medically tailored meal services. Providers must bill HMOs using the designated meal and dietitian procedure codes and appropriate U1/U2/U3 modifiers as required by the HMO.
Must hold an HMO contract or agreement to be reimbursed
Food Is Medicine providers must be contracted with—or have a written agreement with—at least one BadgerCare Plus or Medicaid SSI HMO to receive reimbursement for services provided to members in those HMOs.
- Providers without an HMO contract/ agreement are not eligible for reimbursement for HMO-enrolled members.
HMO clinical review required prior to authorization
HMO licensed clinical staff must review referrals or member requests and determine medical appropriateness and whether the member meets eligibility criteria before authorizing services; the HMO must document those findings in the member's record.
- Clinical determination is required whether the referral comes from a network provider, HMO identification, or member request.
Maintain complete service documentation including meals and delivery/visit mode
Providers must prepare and maintain truthful, accurate, complete, legible, and concise service and medical/financial records that include specific meal and visit details.
- Document meals provided.
- Document mode of meal delivery (delivery or pick‑up).
- Document mode of dietitian visit (in‑person, audio‑visual telehealth, or audio‑only telehealth).
- Produce or submit documentation to HMOs or DHS upon request.
Retain and produce documentation per DHS retention rules
Follow Wis. Admin. Code § DHS 106.02(9) for retention of service records and be prepared to produce or submit documentation to DHS upon request to verify claims for reimbursement.
- Per Wis. Stat. § 49.45(3)(f), maintain records required by DHS for verification of provider claims.
- DHS may audit records to verify provision of services and claim accuracy.
Complete enrollment within 10 days or restart; ForwardHealth denial process
Providers starting the Medicaid enrollment application have 10 days to complete it; if not completed within 10 days, the provider must restart the application process. After completion, ForwardHealth will approve or deny the application and send a denial letter stating reasons if denied.
- ForwardHealth usually notifies providers of enrollment status within 10 business days and will notify within 60 days.
- Approved applicants receive enrollment, a welcome letter, provider agreement, and an attachment with effective dates and assigned provider type.
Refusing to produce documentation can lead to denials, recoupment, or sanctions
Refusal to produce required documentation when requested by DHS may result in denial of submitted claims, recoupment of paid claims, application of intermediate sanctions, or termination from the Medicaid program.
- DHS may audit records to verify service provision and claim appropriateness; non‑production risks financial and programmatic penalties.
Definitions
Background
Medically tailored meals are prepared meals customized by a registered dietitian to meet a member’s unique clinical needs with the goal of helping manage medical conditions and preventing more complex or costly care such as hospital readmission. Meals must accommodate allergies, preferences, and cultural or religious dietary restrictions and are provided under the supervision of an RD licensed in Wisconsin. As an in‑lieu‑of service, medically tailored meals serve as a medically appropriate, cost‑effective substitute for other covered services when offered by an HMO.
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