The Medicaid content provided on this web page is designed to assist RDNs with understanding Medicaid coverage for Medical Nutrition Therapy (MNT) services. Learn more about traditional fee for service Medicaid programs and Medicaid Managed Care programs, as well as an introduction to eligibility, funding, and coverage for programs. Topics covered on this page:
- Exploring Medicaid Coverage for Medical Nutrition Therapy
- Introduction to the Medicaid Program
- Traditional Fee for Service Medicaid Programs
- Medicaid Managed Care Programs
- Program Eligibility
- Program Funding and Cost
- Program Design and Coverage
- Medicaid Program Coverage of Obesity Prevention and Treatment
- Medicaid Benefits
- Understanding Medicaid and Medicare Dual Eligible Coverage
- Medicaid, Telemedicine and Telehealth
Note: Information contained on this website is made available to provide basic information to assist RDNs in identifying Medicaid coverage in a given state and is not a guarantee by the Academy of Nutrition and Dietetics as to the current accuracy of the information contained herein. For example, coverage information, reimbursement rates, and links may not be accurate given ongoing updates to state programs.
Exploring Medicaid Coverage for Medical Nutrition Therapy
The Medicaid content provided on this web page is designed to assist RDNs with understanding Medicaid coverage for Medical Nutrition Therapy (MNT) services. Although Medicaid programs will vary greatly as they are designed and managed at the state level, the Patient Protection and Affordable Care Act (ACA), has created expanded opportunities for RDNs to provide MNT under the essential health benefit category of "Preventive and Wellness Services."
Under the ACA, preventive care services related to MNT provided by RDNs include:
- Dietary counseling for adults at higher risk for chronic disease
- Obesity screening and counseling for all age groups
Individual state Medicaid plans are offered in a variety of delivery models which could include a traditional fee-for-service plan or Managed Medicaid plan. Within a particular state, and even between different delivery models of Medicaid plans in that particular state, Medicaid coverage for MNT can vary in how the plans cover MNT benefits including the specifics on the who, what, when, where and how the MNT benefit is defined. The Academy is working with Affiliate and DPG Nutrition Services Payment Specialists and other RDNs who bill Medicaid to define Medicaid coverage by state and to make this information available on the Academy's Medicaid MNT web page. More information will be uploaded by state as reliable MNT coverage information is available.
Introduction to the Medicaid Program
Medicaid is our nation's largest health care plan and covers one in five Americans. Enacted in 1965 under Social Security Act Title 19, Medicaid is a public health insurance program for low-income children, adults, seniors, and people with disabilities. The Children's Health Insurance Program (CHIP), Social Security Act Title 21, was established 32 years later in 1997 to provide new coverage opportunities for children in families with incomes too high to qualify for Medicaid, but who could not afford private insurance coverage. In 2010 under the Patient Protection and Affordable Care Act (ACA), states were granted the option to voluntarily expand Medicaid coverage to include low income adults. One of the primary goals of the ACA was to expand national access to health insurance.
The details of coverage varies by state as each program is designed and implemented at the state level using broad federal guidelines. RDNs can locate specific information on Medicaid and CHIP programs and coverage in their state by visiting their state-specific Medicaid program website.
Traditional Fee for Service Medicaid Programs
- Medicaid provides health coverage to low-income adults, children, pregnant women, elderly adults and people with disabilities. It is jointly funded by the Federal Government and States.
- The federal government does not require states to provide any benefits for Medical Nutrition Therapy (MNT) through Medicaid or the Children's Health Insurance Program (CHIP); however, about half of states have elected to add some benefits for nutrition.
- The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is the child health component of Medicaid. The federal government does not require states to provide nutrition counseling services, but states are allowed to determine what other services are "medically necessary" as part of program. Some states include nutrition counseling as a medically necessary service. How these services can be provided also varies by state.
- Some states that have added MNT benefits under Medicaid, CHIP or EPSDT credential RDNs, and others do not.
- In some of the states that have added MNT benefits, RDNs are recognized as independent billing providers under Medicaid. In other states that have MNT benefits, the RDN can provide the service, but only the physicians or primary care providers is the recognized billing provider.
- States that expanded their Medicaid programs under the Affordable Care Act are required to include preventive health screening and counseling services that are Grade A or B recommendations from the US Preventive Services Task Force. In some states, RDNs may be able to provide the dietary and behavior change counseling services associated with these recommendations.
- Many state affiliates of the Academy of Nutrition and Dietetics have member leaders to help members understand Medicaid in their state. To locate the Nutrition Services Payment Specialist and/or your State Regulatory Specialist visit the Academy's Leadership Directory.
Medicaid Managed Care Programs
The majority of Medicaid beneficiaries nationwide receive Medicaid program health care services through Medicaid Managed Care Programs as states can significantly reduce state Medicaid program costs and better manage utilization of health services by contracting with various types of Managed Care Organizations (MCOs) to deliver services to their beneficiaries. These MCOs accept a set per member per month (capitation) payment for providing health care services to the state Medicaid beneficiaries.
Some states are implementing a range of initiatives to coordinate and integrate care beyond traditional Medicaid Managed Care. These initiatives focus on improving care for populations with chronic and complex conditions, aligning payment incentives with performance goals, and building in accountability for high quality care.
Click on the link below to view a recorded presentation on Medicaid Managed Care Programs. Highlights of the information are included as bullet points below the link.
(Length: 19 minutes)
Presentation Main Points:
- Managed care is the dominant delivery system for Medicaid and the Children's Health Insurance Plan (CHIP).
- The federal government does not require state Medicaid agencies to provide nutrition counseling benefits, but Managed Care Organizations (MCOs) can elect to provide nutrition counseling benefits for their members.
- There are multiple ways RDNs might be able to provide Medical Nutrition Therapy associated with preventive services benefits to populations enrolled in Medicaid and the Children's Health Insurance Program (CHIP) through Managed Care Organizations (MCOs).
- Each state Medicaid program is different, and all MCOs are different.
- RDNs can explore whether their state uses MCOs and then identify Medicaid/CHIP MCOs at the local level.
- The credentialing and contracting process with MCOs is likely to be similar to the process used by private payers.
- Payments from MCOs for services provided by RDNs may be different than payments from state Medicaid agencies.
Most Medicaid eligibility and all CHIP eligibility is based on modified adjusted gross income (MAGI). Income eligibility levels are tied to the federal poverty level (FPL).
Adults may apply for Medicaid for the following reasons:
- They are terminally ill and want hospice services.
- Eligible for Medicare and have low income and limited resources.
- Are 65 years old or older, blind, or disabled and have low income and few resources.
- Live in a nursing home.
- Need nursing home care but can stay at home with special community care services.
The Children's Health Insurance Program (CHIP) serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. States have broad discretion in setting their income eligibility standards, and eligibility varies across states.
The Affordable Care Act (ACA) expanded Medicaid to reach low-income adults previously excluded from the program and provided federal funding to states for the vast majority of the cost of newly eligible adults. Under the ACA, states have the flexibility to expand the Medicaid program to reach individuals who earn up to 133% of the Federal Poverty Level. The link below identifies states with expanded adult coverage.
Program Funding and Cost
Medicaid is a complex joint federal-state program which is financed jointly by both the federal government and the individual states. The federal government matches state Medicaid spending. The federal match rate varies by the poverty level of the state based on a federal formula and ranges from a minimum of 50% to nearly 75% in the poorest state. Under the ACA, the federal match rate for adults newly eligible was 100% for 2014-2016, phasing down gradually to 90% in 2020 and thereafter.
In 2016, Medicaid was the second-largest item in state budgets, after elementary and secondary education, accounting for 15.6% of state funds (general and other funds). Federal Medicaid matching funds are the largest source of federal revenue (57.7%) in state budgets. Accounting for state and federal funds, Medicaid accounts for 28.7% of total state spending.
Program Design and Coverage
The rules governing Medicaid programs vary from state to state. Medicaid is structured as a federal-state partnership program. Although subject to federal standards, it is the states that administer both the Medicaid and CHIP programs and states have the authority and flexibility to determine covered populations, covered services, health care delivery models, and methods for paying providers and hospitals. Because of this flexibility at the state level, there is tremendous variation across state Medicaid programs. In addition, states can also obtain Section 1115 waivers to test and implement program approaches that diverge from federal Medicaid rules if the Secretary of Health and Human Services (HHS) determines these will advance Medicaid program objectives.
RDNs need to explore Medicaid and CHIP program nutrition coverage details specific for their individual state given the broad discretion each state has in designing key aspects of their Medicaid program. Medical nutrition therapy (MNT) or nutrition counseling benefits may be included in a state Medicaid or CHIP plan, however RDNs will need to refer to each state Medicaid plan details to identify important coverage information including the who, what, when, where, and how to provide and bill for nutrition services. States may offer nutrition benefits but not recognize RDNs as providers. In these cases, RDNs may be able to provide and bill MNT services "incident to" a physician.
Medicaid Program Coverage of Obesity Prevention and Treatment
A. Under Preventive and Wellness Service Coverage of the Affordable Care Act
On Jan. 1, 2014, the Affordable Care Act (ACA) greatly expanded the health care benefits being offered to millions of Americans with no health coverage, as well as millions more who are underinsured. The law sets certain standards that all state Health Insurance Marketplace plans and many other insurers must meet, and mandates that all health plans offered to those who buy health insurance on their own or in small groups include a set of "essential health benefits" at no additional cost to the insured- even if they have not yet met their deductible.
Although health insurance provided through large employers is not required to feature these essential benefits, Medicaid Benchmark or Benchmark Equivalent Plans, now called Alternative Benefit Plans (ABPs), must cover the 10 Essential Health Benefits (EHB) as described in section 1302(b) of the Affordable Care Act, whether the state uses an ABP for Medicaid expansion or coverage of any other groups of individuals. MNT services provided by an RDN in an ambulatory care setting would fall under the essential health benefit category "Preventive and Wellness Services."
B. Under ACA's Federal Medicaid Funding Matches to Certain States
Provisions under the Affordable Care Act also include an enhanced Medicaid federal match for states that cover all U.S. Preventive Services Task Force (USPSTF) grade A and B recommended preventive services and the Advisory Committee on Immunization Practices (ACIP) recommended vaccines and their administration with no cost-sharing. Obesity screening and counseling for children, adolescents and adults are USPSTF recommended services with Grade B ratings as noted below:
- Effective 2012, the USPSTF recommended screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
- Effective 2017, the USPSTF recommended that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
C. Guaranteed Obesity Coverage for Children and Adolescents
Effective 2017, the USPSTF recommended that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
Through Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, Medicaid-eligible children under the age of 21 are provided coverage for preventive and comprehensive health services. This benefit entitles Medicaid-eligible children to regular checkups and all medically necessary health services in order to ensure that their health and developmental needs are met. The EPSDT benefit includes screening, vision services, dental services, hearing services, and other services necessary to correct or improve health conditions discovered through screenings.
Under the screening component of EPSDT, State Medicaid programs are responsible for assuring that children receive periodic physical examinations, complete health and developmental histories, and health education. The health education component provides an opportunity for the provider to discuss health concerns such as healthy weight or nutrition with the child and/or child's parent or guardian. Any medical service or treatment determined to be medically necessary for the child that can be covered under Medicaid such as additional nutritional assessments, counseling, or surgery, would be available through the EPSDT benefit. Thus the EPSDT benefit requires States to include services necessary to prevent and treat obesity. Each individual state Medicaid plan will determine if these services can be provided and billed by an RDN.
D. Variable Obesity Coverage for Adults Depending on State Medicaid Type
Coverage for adult obesity in traditional fee for service Medicaid plans varies as states must cover preventive services for adults newly eligible for Medicaid under the ACA, but this is not required for the group of adults enrolled in or eligible for traditional Medicaid prior to the ACA's expansion of the program. Managed Medicaid plans are required to include benefits but may not recognize RDNs as approved providers. RDNs can identify adult obesity coverage details for their specific state by visiting their state Medicaid website.
The following resources provide useful state-by-state information on obesity coverage.
- Henry J. Kaiser Family Foundation November 2014 Issue Brief: Coverage of Preventive Services for Adults in Medicaid
- 2016 50 State and District of Columbia Survey- Medicaid Fee-for-Service Treatment of Obesity Interventions
Enrolling as a Medicaid Provider
RDNs seeking to enroll to provide MNT services to Medicaid or Children's Health Insurance Program (CHIP) beneficiaries will need to enroll as a Medicaid Provider in the particular state they would like to provide services, as these programs are administered by individual states. Eligibility requirements to become a provider vary by state and some states do not recognize RDNs as Medicaid providers.
Medicaid is a decentralized program that is managed at the state level. To locate instructions for how to enroll in a specific state's Medicaid Program or CHIP, RDNs can conduct a web search using the terms:
"state" + "Medicaid provider enrollment" (NOTE: Replace "state" with the name of the state where you seek to enroll)
Federal law requires states to provide certain "mandatory" Medicaid benefits and allows states the choice of covering other "optional" benefits. Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy. Nutritional coverage details are not outlined specifically by Medicaid in the list of optional benefits however MNT could fall under "Other diagnostic, screening, preventive and rehabilitative services." Healthy diet counseling and obesity counseling are two services covered by many states. For any Medicaid benefits, the individual state determines the type, amount, duration, and scope of services within these broad federal guidelines.
Understanding Medicaid and Medicare Dual Eligible Coverage
Dual Eligible Beneficiaries are those individuals enrolled in both Medicare and Medicaid, including individuals enrolled in Medicare Part A, Medicare Part B, or both who receive full Medicaid benefits, assistance with Medicare premiums, cost sharing benefits, or any combination of those.
Medicare-covered services also covered by Medicaid are paid first by Medicare because Medicaid is generally the payer of last resort.
The options for dual eligible individuals to receive their Medicare and Medicaid benefits vary by state. In some states, dual eligible individuals receive Medicaid through Medicaid Managed Care plans, and in other states, Medicaid coverage may be Fee-For-Service.
In some states, certain dual eligible individuals can join plans that include all Medicare and Medicaid benefits.
For more information on dual eligibility, refer to the following resources:
Medicaid, Telemedicine and Telehealth
The federal Medicaid statute does not recognize telemedicine as a distinct service however individual states can elect to cover telemedicine. State Medicaid plans may or may not cover services provided under telehealth which is not the same as telemedicine under Medicaid. Medicaid defines Telemedicine and Telehealth as:
Telemedicine can be defined as using telecommunications technologies to support the delivery of all kinds of medical, diagnostic and treatment-related services usually by doctors.
Telehealth is similar to telemedicine but includes a wider variety of remote healthcare services beyond the doctor-patient relationship including services provided by other members of the healthcare team who help with patient health education, social support and medication adherence, and troubleshooting health issues for patients and their caregivers.
Overall, individual states decide whether or not to cover telemedicine, determine what types of telemedicine to cover; where in the state it can be covered; how it is covered; what types of telemedicine providers may be reimbursed, as long as such providers are "recognized" and qualified according to Medicaid regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed Federal Upper Limits.
Medicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states require providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. All telemedicine requirements or restrictions placed by the state are binding under current Medicaid rules.
RDNs can learn more about telemedicine coverage in their state by visiting the Academy's Telehealth Resource Center to locate a 50 state telehealth guide for Medicaid coverage.
Email your question to the Academy's Nutrition Services Coverage Team at firstname.lastname@example.org