Dear Mr. Greer:

On behalf of Mom's Meals, thank you for the opportunity to provide comments on the Virginia Department of Medical Assistance Services' (DMAS) proposed amendments to the Commonwealth Coordinated Care Plus (CCC+), Community Living (CL), and Family and Individual Supports (FIS) 1915(c) Home and Community-Based Services (HCBS) Waivers, with a proposed effective date of January 1, 2027. We commend DMAS for its continued efforts to strengthen home and community-based services and support individuals with disabilities and complex care needs in remaining safely and independently in their communities.

Since 1999, Mom’s Meals has helped improve health through better nutrition at home. We provide fully prepared, refrigerated, medically tailored home-delivered meals and related nutrition supports, including supplements, produce and pantry boxes, education, counseling, and personalized engagement. With more than 20 years of Medicaid and Medicare experience, we offer scalable nationwide infrastructure, including the ability to reach rural and underserved populations. Our registered dietitian-designed, condition-specific menus support members with chronic conditions, post-discharge needs, and functional limitations, while evidence from pilots shows reductions in hospitalizations, emergency department visits, and total healthcare costs.

As Virginia considers changes to personal assistance services and its broader HCBS delivery framework, we encourage DMAS to consider expanding access to home-delivered meals (HDMs), including medically tailored meals (MTMs) when clinically appropriate, as an additional service option across all three waivers.

Our primary recommendations are:

• Add HDMs as a covered service under the CCC+, CL, and FIS Waivers for participants whose assessed functional or health-related needs limit their ability to obtain or prepare nutritious meals.
• Allow medically tailored meal options when participants have chronic conditions or other clinical needs requiring dietary modifications, with the appropriate level of nutritional assessment and oversight.
• Recognize HDMs as a complement to personal assistance services, providing another means of addressing meal-related needs while preserving access to necessary hands-on care and individualized service planning.

Expanding HCBS Coverage to Address Nutritional Needs

Virginia's existing HCBS waiver services recognize the importance of assistance with activities of daily living, including eating and meal preparation. However, the current covered-service frameworks for the CCC+, CL, and FIS Waivers do not identify home-delivered meals as a distinct waiver service. Although personal assistance and other community-based supports may help individuals prepare meals, these services do not necessarily ensure access to prepared, nutritionally appropriate meals. For individuals with physical disabilities, cognitive impairments, chronic health conditions, or limited informal caregiver support, meal preparation can remain a significant barrier to maintaining health and independence in the community.[i]

Adding HDMs as an optional waiver service would allow DMAS to address these needs more directly. Eligibility could be based on an individualized assessment demonstrating that a participant cannot consistently obtain or prepare adequate meals due to functional limitations, medical conditions, or insufficient available supports. Meal frequency and duration could then be established through the participant's person-centered service plan.

For participants managing conditions such as diabetes, cardiovascular disease, or chronic kidney disease, medically tailored options could provide additional nutritional support aligned with clinical needs. This approach would help ensure that nutrition services are available based on individual circumstances rather than requiring all participants to receive the same level or type of intervention.

Supporting Participants Under the Proposed Personal Assistance Limits

The proposed amendments to the CL and FIS Waivers would establish a 56-hour weekly soft cap on personal assistance services, with exceptions available for individuals requiring additional hours. We recognize the importance of maintaining an individualized exceptions process to ensure participants continue receiving the level of assistance necessary for their health and safety.

These proposed changes also present an opportunity to evaluate additional HCBS options that can help meet participants' daily needs. Home-delivered meals could complement personal assistance by reducing the amount of staff time needed for meal preparation when a prepared meal would adequately meet the participant's needs.

For example, participants who require assistance with shopping, food preparation, or managing complex dietary needs may benefit from scheduled home meal deliveries. This could allow direct support professionals and caregivers to devote more of their available time to other essential activities, including bathing, dressing, mobility, medication assistance, and supervision.

Importantly, HDMs should not be used as a substitute for personal assistance when participants require help with eating, feeding, or other medically necessary services. Rather, incorporating HDMs as an additional waiver option would provide greater flexibility in developing person-centered service plans and matching available supports to individual needs. This flexibility may also be beneficial in areas experiencing direct care workforce shortages, including rural communities where arranging consistent in-home assistance can be challenging.

Evidence Supporting Home-Delivered Nutrition Services

A growing body of research demonstrates that home-delivered nutrition services can improve health outcomes, reduce avoidable health care utilization, and support independence among individuals with chronic conditions and functional limitations.

Most recently, a 2026 study published in Nature Medicine evaluated medically tailored meals (MTMs) provided through Massachusetts' Medicaid Section 1115 demonstration. Among 1,866 MTM recipients compared with 1,372 eligible nonrecipients, researchers found that MTM participation was associated with 31% fewer hospitalizations, 20% fewer emergency department visits, and $3,433 in lower health care costs per participant during enrollment. Importantly, these savings offset approximately 98% of the program's costs, with net savings observed among participants with cardiovascular disease, chronic kidney disease, diabetes, and other complex health conditions.[ii] These findings offer particularly relevant evidence for states considering the incorporation of nutrition services into Medicaid-funded care delivery.

Additional research reinforces these findings. A 2023 study published in JAMA Health Forum examined a home-delivered meal benefit among older Medicare Advantage members following hospitalization. Among patients hospitalized for heart failure, the combined 30-day rate of rehospitalization or death was 23.3% among meal recipients, compared with 38.5% among a concurrent group that did not receive meals. Among patients hospitalized for other acute conditions, the corresponding rates were 16.5% and 32.9%, respectively.[iii] Although observational, these findings demonstrate the potential value of meal delivery during periods of heightened medical vulnerability.

Similarly, a 2019 study published in JAMA Internal Medicine found that participation in a medically tailored meal program was associated with approximately 16% lower monthly health care expenditures, representing an estimated $753 in savings per participant per month, inclusive of program costs. Participants also experienced fewer hospitalizations and skilled nursing facility admissions, suggesting that nutrition interventions may help reduce reliance on higher-cost institutional care.[iv]

Beyond health care utilization, home-delivered meals provide important benefits for individuals receiving long-term services and supports. A 2025 study published in JAMA Network Open found that older adults receiving home-delivered nutrition services through the Older Americans Act reported improvements in nutritional well-being, greater independence, and reduced reliance on caregivers for meal preparation. Participants also described improvements in caregiver well-being, including reduced stress and additional time for other responsibilities.[v] These findings are particularly relevant to HCBS populations, where preserving independence and supporting informal caregivers are central objectives of community-based care.

Individuals with intellectual and developmental disabilities (I/DD) may face additional nutritional challenges related to swallowing difficulties, physical limitations, and the need for specialized meal preparation. A 2024 study published in the Journal of Applied Research in Intellectual Disabilities found that 43.8% of older adults with intellectual disabilities experienced swallowing difficulties, with 83.3% of identified cases not documented in participants' medical records.[vi] Although conducted among older adults receiving intellectual disability services in the Netherlands, these findings highlight the potential for substantial and underrecognized nutritional needs within this population. Swallowing disorders can contribute to malnutrition, dehydration, choking, and aspiration, underscoring the importance of access to meals appropriate for an individual's functional and clinical needs.[vii]

For participants in Virginia's Community Living and Family and Individual Supports Waivers, access to home-delivered meals could help address these challenges through flexible meal options, including pureed and other texture-modified meals when clinically indicated. Such options would help accommodate participants who have difficulty chewing or swallowing while reducing the burden of preparing specialized meals on family caregivers and direct support professionals. Incorporating these options into a covered HDM benefit would help ensure that participants with complex nutritional needs can receive meals aligned with their individualized assessments and person-centered service plans.

Together, this evidence supports incorporating HDMs, including medically tailored and texture-modified options when clinically appropriate, as an additional HCBS service. For Virginia's CCC+, Community Living, and Family and Individual Supports Waivers, access to prepared, nutritionally appropriate meals could help address unmet nutritional needs, support chronic disease management, reduce caregiver burden, and complement existing personal assistance services while helping participants remain safely in their homes and communities.

Conclusion

We appreciate Virginia's continued efforts to maintain and strengthen home and community-based services for individuals with disabilities, older adults, and others requiring long-term supports. As DMAS considers the proposed amendments, we encourage the Commonwealth to recognize home-delivered meals as an additional tool for addressing nutritional needs, supporting caregivers, and helping participants remain safely in their homes and communities.

Including HDMs, with medically tailored options when clinically appropriate, across the CCC+, CL, and FIS Waivers would strengthen the range of services available to meet individualized needs and complement Virginia's existing HCBS infrastructure. Thank you for your consideration of these recommendations. We welcome the opportunity to provide additional information or discuss how home-delivered nutrition services could support Virginia's HCBS participants.

Sincerely,

Paula L. Hopper
Senior Director of Government Affairs & Advocacy
paula.hopper@momsmeals.com