Dual-Eligible Beneficiaries’ Grocery Supplemental Benefit Use and Health Care Utilization

ABSTRACT

Objective: To examine the association between the use of the grocery card supplemental benefit offered by Medicare Advantage (MA) plans and health care utilization.

Study Design: Observational study utilizing 2021-2022 MA claims data.

Methods: This observational cohort study examined eligible adults who were continuously enrolled between January 1, 2021, and December 31, 2022, in MA dual-eligible special needs plans that offered a grocery card benefit from January 1, 2022, through December 31, 2022. We performed difference-in-differences analyses comparing health care utilization among dual-eligible members who opted to use grocery card supplemental benefits vs those who did not, before and after the benefit’s introduction.

Results: Grocery card use was associated with an increase in the likelihood of annual wellness, primary care provider (PCP), and specialist visits (6.6%, 4.9%, and 6.6%, respectively) and increased number of office and specialist visits (2.3% and 2.8%, respectively). Frequent use (more than half of the available grocery card dollars) was analyzed separately and was associated with slightly greater increases in the likelihood and number of visits (all P < .05).

Conclusions: This observational study of dual-eligible beneficiaries found a modest relative increase in office visits, including annual wellness, PCP, and specialist visits, among beneficiaries who opted to use the grocery card supplemental benefits after they were offered compared with beneficiaries who did not. These findings suggest that policy changes that allow for nonmedical supplemental benefits have had favorable results, especially for dual-eligible beneficiaries.

Am J Manag Care. 2026;32(2):In Press

Takeaway Points

We evaluated the association between the use of grocery dollars offered through Medicare Advantage supplemental benefits and health care utilization among dual-eligible beneficiaries enrolled in Medicare Advantage plans that offered grocery supplemental benefits.

• Compared with dual-eligible beneficiaries who did not opt to use grocery dollars, dual-eligible beneficiaries who opted to use grocery dollars were more likely to have annual wellness, primary care provider, and specialist visits (6.6%, 4.9%, and 6.6%, respectively) and increased number of office and specialist visits (2.3% and 2.8%, respectively).
• These findings suggest that the 2019 and 2020 policy changes allowing Medicare Advantage plans to offer nonmedical supplemental benefits, such as grocery cards, have had encouraging results for Medicare Advantage members—particularly for dual-eligible members, who may have greater needs than their non–dual-eligible counterparts.

Medicare Advantage (MA) plans, covering more than half of eligible Medicare beneficiaries, can offer supplemental benefits not included under traditional fee-for-service Medicare. Regulatory and legislative changes effective in 2019 and 2020 expanded the scope of allowed supplemental benefits to address health-related social needs (HRSNs),^1,2 including newly permitted nonmedical services, such as grocery cards, which can help address food insecurity. Dual-eligible members, who are eligible for both Medicare and Medicaid, often have access to a wider array of these nonmedical supplemental benefits through specialized plans such as dual-eligible special needs plans (D-SNPs) and plans participating in the MA value-based insurance design model.

Since these benefits were implemented, there has been interest in understanding the extent to which individuals are using the benefits and how they impact health and well-being. Previous analysis has shown that most MA members are using at least 1 supplemental benefit and that beneficiaries in underserved areas are more likely to use these benefits.³ Although there is evidence that supplemental benefit use is associated with improved health care utilization,⁴ evidence on the value of specific services such as grocery cards and their relationship to the health care of individuals is limited.^5,6

Food insecurity can play a large role in a person’s health. It is associated with more health conditions^7-11 and costly health care utilization patterns, including increased emergency department (ED) visits, hospitalizations, and nursing home stays.^12,13 At the same time, individuals who experience food insecurity are less likely to have a usual source of health care and more likely to have fewer office visits.^14,15 This potential delayed care, in turn, can exacerbate the individual’s health conditions and continue their reliance on higher-cost health care.^16,17

Furthermore, food insecurity coupled with low income is an even greater burden on the individual. They are closely linked; low income, like food insecurity, is associated with increased barriers to preventive health care.^18,19 Delaying needed health care can have downstream effects on individuals’ risk for more expensive conditions and health care needs, which can affect their budget for other items, including nutritious food.

The implementation of nutritional support systems and cash transfers has been associated with improvements in food insecurity.^20,21 Food assistance programs can help reduce the need for high-cost health care, such as hospitalizations and nursing home admissions.^22,23 Additionally, cash transfers, particularly those intended to support individuals with low incomes, have demonstrated improved health care utilization.^24,25

Elevance Health, a large national insurer, administers MA plans that offer grocery cards as a supplemental benefit. This benefit is primarily offered to and widely used by members with low incomes and/or with certain chronic conditions. The aim of our study was to assess the relationship between the use of the grocery card supplemental benefits and health care utilization outcomes within a population dually eligible for Medicare and Medicaid. We chose to focus on the dual-eligible population because low income and limited access to nutritious food are more common among these beneficiaries,^26-28 and, therefore, alleviating financial stress through grocery card benefits may have the largest impact on this population.

METHODS

Data Source

We used administrative medical claims data from the Healthcare Integrated Research Database (HIRD), a proprietary repository of fully adjudicated claims data for members enrolled in Elevance Health’s affiliated health plans.²⁹ The HIRD provides member enrollment and health care utilization data. We derived the Robert Graham Center’s Social Deprivation Index (SDI) from the American Community Survey.³⁰ We used data from the US Department of Agriculture’s Food Access Research Atlas to identify members residing in a food desert³¹ and data from the National Center for Health Statistics Urban-Rural Classification Scheme for Counties to identify members residing in urban areas.³² The vendor responsible for managing the supplemental benefit provided data on individual-level spending of the grocery card allowance in dollars for 2022.

Study Population

Our sample included adults aged 18 to 89 years from 19 states who were continuously enrolled from January 1, 2021, to December 31, 2022, in 1 of 55 Elevance Health–affiliated MA D-SNPs that offered a new grocery card benefit from January 1, 2022, through December 31, 2022. Overall, 85% of participants were enrolled in 10 D-SNPs across 10 states. The grocery card supplemental benefit provided members with an allowed amount per month toward grocery purchases; more than 99% of the sample population received $50 per month. Grocery dollars could be used starting on the first day of the month. The study population excluded members if they entered hospice, had end-stage renal disease, or resided in long-term institutions.

Exposure

Members were grouped based on whether they used the grocery card benefit in 2022. This included groups of members who used any level of grocery card allowed dollars (any use) and members who did not use the grocery card benefit (nonuse). Members who used more than half of the allowed grocery card dollars in 2022 (frequent use) were included in a subanalysis of the any-use group.

Outcomes

The primary outcomes of interest were annual presence of an all-cause inpatient admission, ED visit, and office visit, as well as number of visits of each. Secondary outcomes of interest included emergent vs nonemergent ED visits, office visits with a primary care provider (PCP) vs a specialist, and the presence of an annual wellness visit. ED visits were classified as either emergent or nonemergent based on the primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code and whether it was most likely associated with emergent or nonemergent ED visit diagnosis codes.³³ Office visits included face-to-face and telehealth PCP and specialty care visits.

Outcomes for presence of a visit were measured as binary based on whether a member had at least 1 claim for each type of health care utilization during each calendar year. Outcomes for number of visits were measured as counts of distinct visits within each calendar year for all visit types except annual wellness visits, which are, at most, associated with a single visit annually.

Statistical Analysis

We used an observational cohort design with adjusted difference-in-differences (DID) analysis to examine the relationship between voluntary grocery card use and health care utilization. The design analyzed changes in health care utilization from 2021 to 2022 among beneficiaries who opted to use grocery card benefits offered in 2022 compared with those who did not. We used logistic regression models for binary outcomes and Poisson regression models for count outcomes. All models included 2 binary indicators: any use of the grocery card benefit (intervention; any use) vs no use of the grocery card benefit (control; nonuse), and pre–grocery card benefit vs post grocery card benefit. The interaction term between these 2 variables yielded our DID estimates. This allowed us to evaluate the change in health care utilization prior to and after the introduction of the grocery card benefit. Similar regression models evaluated differences between the frequent-use and nonuse groups. The models were adjusted for sex, age group, race and ethnicity, and urbanicity of residence. We chose to use state-of-residence fixed effects rather than county-of-residence fixed effects due to limited sample sizes in many counties. SEs were clustered at the state level. Relative changes for outcomes of interest were based on the exponentiated coefficients derived from the nonlinear regression models, and absolute differences were based on marginal effects.

All individuals in each regression had both a pre- and post data point in the model, allowing us to evaluate the change over time within an individual. This method reduces selection bias, as both observed and unobserved characteristics that may lead a member to choose to use grocery card benefits in 2021, if available, would likely persist in 2022 and affect health care utilization similarly in both periods.

A full description of the regression models is included in eAppendix A (eAppendices available at ajmc.com). We used a subset of the study population that had 5 years of continuous enrollment between January 1, 2018, and December 31, 2022, to test the parallel trend assumption required for internal validity of DID estimates (eAppendix B). This subset includes the maximum number of individuals with 5 years of continuous enrollment in Elevance Health–affiliated plans, as we have utilization data from 2018 through 2022 only for those continuously enrolled with these plans through the entire period. Sensitivity tests addressed whether the results of the subset of the study population used to test the parallel trends assumption were similar to the main study results (eAppendix C). Additional sensitivity tests addressed the possibility that changes in health status were correlated with both use of the grocery card benefit and changes in health care utilization by restricting the sample to individuals whose health status remained consistent prior to and after the introduction of the grocery card benefits (eAppendix D). Health status was defined as the Charlson Comorbidity Index (CCI) score calculated between January 1 and December 31 of the year prior to (2021) and after (2022) the benefit’s introduction. Finally, sensitivity analyses of the full study population included an adjustment at the plan level to address potential variation by D-SNP benefit package (eAppendix E). All sensitivity analyses are based on the main study’s adjusted regression models in eAppendix A, unless otherwise noted.

RESULTS

The study sample characteristics for each of the 3 groups used in this analysis (any-use, frequent-use, and nonuse groups) are presented in Table 1.³⁴ The analysis included 60,697 members in the any-use group, 49,645 members in the frequent-use group, and 19,655 members in the nonuse group. Each of the 3 groups had a similar distribution by race and SDI, and comparable proportions of members in each group lived in urban areas and food deserts. Members who used grocery card benefits were more likely to be female (66.6% vs 53.5%) and older (mean age, 62.6 vs 59.6 years), were less likely to be fully dual-eligible (65.2% vs 72.3%), and had a slightly higher CCI score (mean, 2.3 vs 2.0) than members who did not use the grocery card benefits. The median proportion of annual grocery dollars spent was 85.4% in the any-use group and 90.7% in the frequent-use group.

The subset of the study population used to test the parallel trend assumption included 13,268 members in the any-use group, 10,880 members in the frequent-use group, and 3803 members in the nonuse group (21.9%, 21.9%, and 19.3% of the study sample, respectively). Within this subset of the population, we observed approximately parallel preperiod trends in both the use and nonuse groups for all health care utilization outcomes, which provided evidence of parallel pretrends for which it is assumed that these trends would have persisted in the post period (eAppendix Figures B2, B3, B4, and B5; event study estimates in eAppendix Figures B6, B7, B8, and B9).

Table 2 presents the outcomes in the pre- and post periods among all 3 groups, and Table 3 and Table 4 present the DID estimates along with their associated relative changes (RCs). Comparing the any-use vs the nonuse groups (Tables 2 and 3), we found that the any-use group had a marginally significant larger increase in likelihood of a PCP visit (RC, 4.9%; P = .056) and a significantly larger increase in the likelihood of an office visit (RC, 8.7%; P = .047), annual wellness visit (RC, 6.6%; P = .017), and specialist visit (RC, 6.6%; P = .028). In addition, we found that the any-use group had a significantly larger increase in number of office visits (RC, 2.3%; P < .001) and specialist visits (RC, 2.8%; P < .001) than the nonuse group. There were no significant differences among outcomes related to inpatient admissions and ED visits in the any-use group compared with the nonuse group.

Comparing the frequent-use and nonuse groups (Tables 2 and 4), we found that the frequent-use group had a marginally significant larger increase in likelihood of an office visit (RC, 8.7%; P = .060) and a significantly larger increase in the likelihood of an annual wellness visit (RC, 8.4%; P < .01), PCP visit (RC, 5.2%; P = .047), and specialist visit (RC, 7.0%; P = .026). We also found that the frequent-use group had a significantly larger increase in the number of office visits (RC, 2.6%; P < .01) and specialist visits (RC, 3.1%; P < .01) than the nonuse group. The frequent-use group had a marginally significant smaller increase in number of inpatient admissions (RC, –4.1%; P = .061) than the nonuse group. There were no significant differences in the likelihood of an inpatient admission and outcomes associated with ED visits in the frequent-use group compared with the nonuse group.

Compared with any level of grocery card use, frequent grocery card use had similar outcomes, with a slightly larger magnitude in its effect on annual wellness visit and specialist visit outcomes. In addition, frequent grocery card use had a marginally significant effect associated with reducing the number of inpatient admissions.

Results of sensitivity analyses are in the eAppendices. Among the subset of the study population used to test the parallel trends assumption, results indicate that the DID estimates were similar in magnitude to the regression DID estimates of the study population (eAppendix Tables C1 and C2). Among individuals with consistent health status prior to and after the introduction of the grocery card benefit (28,379 members in the any-use group, 23,334 members in the frequent-use group, and 9954 members in the nonuse group), the DID estimates were similar in magnitude, although some results had diminished significance likely due to decreased sample sizes (eAppendix Tables D1 and D2). Results of regression analyses that adjust for potential variation in plans are similar to the main regression analyses (eAppendix Tables E1 and E2).

DISCUSSION

Our study of dual-eligible MA members found that use of grocery card benefits is associated with an increased likelihood of an office visit, annual wellness visit, PCP visit, and specialist visit as well as an increased number of office and specialist visits. Although the magnitude of the estimated differences among the outpatient outcomes is small, these effects can still be meaningful. For many of the outpatient outcomes, the estimated RC is inherently small because the pretreatment means are large.

The study results indicate that addressing HRSNs such as food insecurity and financial stress using nonmedical services such as grocery card supplemental benefits is associated with increased use of outpatient care. Dual-eligible Medicare beneficiaries, who experience more social risk factors, generally have fewer specialty visits than non–dual-eligible beneficiaries, despite having more chronic conditions.^35-38 Both annual wellness and specialist visits can offer opportunities for providers to directly address better management of newly emerging or previously diagnosed health conditions.^39,40 Therefore, dual-eligible members may benefit from having more regular appointments with a PCP, including an annual wellness visit, and from receiving more specialty services.

The relationship between grocery card use and higher-cost care such as ED visits and inpatient admissions should be explored in future research as more data become available. Because office visits can help beneficiaries address acute issues and manage chronic health conditions through primary and specialist care, there is potential for fewer visits to the ED and fewer inpatient admissions over time.⁴¹ The study results of the frequent grocery card use group indicate a trend toward fewer inpatient admissions. A longer post period can assess whether the more costly utilization of ED and inpatient care is reduced due to more regular outpatient visits that help manage chronic conditions.

The association between grocery card use and outpatient outcomes is slightly larger in the frequent-use group compared with the any-use group. The frequent-use group, on average, used 16% more grocery card dollars compared with the any-use group and comprised a majority of members (82%) in the any-use group. Therefore, even a relatively small increase in grocery card dollars is associated with a greater likelihood of having annual wellness, PCP, and specialist visits and a larger increase in the number of office and specialist visits. This suggests a potential dose-related positive response between the magnitude of grocery card use and increased outpatient care among dual-eligible MA members. However, although a dose-related response is plausible, the results are not definitive due to possible inherent differences in user groups and other confounding factors.

The study findings build upon prior research that identified associations between food insecurity and financial stress and worse health outcomes,^12,13 including fewer provider office visits and lack of a usual source of care.^14,15 It also aligns with prior findings that food assistance programs and cash transfers for low-income individuals have been associated with decreased need for costly health care services and improved health care utilization.^20-23 However, the mechanism explaining the use of nonmedical services such as grocery card dollars and increased outpatient outcomes is not well known. Among dual-eligible beneficiaries, Medicare is typically the primary payer for outpatient services, with Medicaid serving as additional coverage for cost sharing (eg, coinsurance). Although certain dual-eligible beneficiaries may be responsible for some cost sharing,^42,43 an immaterial share of our study sample had cost-sharing responsibility. Nevertheless, one possible mechanism in our study could be that use of grocery card dollars frees up financial resources to cover other financial barriers to accessing care. For instance, prior research indicates that dual-eligible beneficiaries may not live near specialty care or may have limited access to transportation for traveling to specialty services.^44,45 Therefore, using grocery card dollars may enable beneficiaries to direct financial resources toward transportation needed for primary and specialist care. Possible mechanisms are an area for future exploration.

Our study is one of the first to publish results of nonmedical services offered through MA supplemental benefits and their association with health care utilization. In addition, this work contributes to a larger body of literature assessing how programs aimed at reducing food insecurity impact health. Further work that includes additional years of follow-up is needed to assess longer-term impacts of nonmedical services on health care utilization.

Limitations

Our study has several limitations. First, this study used observational data and cannot definitively conclude that the health care utilization differences by grocery card use group were causally related. Second, our study time frame includes 2 years of complete data. Although we tested the parallel trends assumption of DID models using a subset of the study population that had 5 years of continuous enrollment, we were unable to evaluate the parallel trends assumption using the full study population, and unmeasured differences between individuals who opted to use grocery card benefits and those who did not use them could have affected trends, potentially biasing our estimates. Third, we analyzed outcomes during the first year that the grocery card benefit was offered, which may not capture the longer-term relationship between grocery card use and health care utilization. Fourth, because the study population included members enrolled during the full follow-up period, the findings may not be directly transferable to members who disenroll.

CONCLUSIONS

This observational study of dual-eligible beneficiaries found that those who opted to use a grocery card supplemental benefit had a modest relative increase in office visits, including annual wellness and specialist visits, compared with those who did not, after the benefit’s implementation in 2022. These findings suggest that the 2019 and 2020 policy changes allowing MA plans to offer nonmedical supplemental benefits, such as grocery cards, have had encouraging results for MA members—particularly for dual-eligible members, who may have greater needs than their non–dual-eligible counterparts. Future efforts to increase availability and use of these benefits may lead to better outcomes for an even larger population.

Author Affiliations: Elevance Health (RC, DC, MNL, ASG, JLK), Indianapolis, IN; now with Humana (RC), Louisville, KY; Berkeley Research Group (MF, RT), Washington, DC.

Source of Funding: Elevance Health funded the research and manuscript development.

Author Disclosures: Ms Cobb, Dr Cullen, Ms Locke, Ms Gordon, and Ms Kowalski are or were employed by Elevance Health, which offers Medicare Advantage plans that include supplemental grocery card benefits; data used in this manuscript are from those plans. Ms Cobb, Ms Gordon, and Ms Kowalski own stock in Elevance Health. Ms Cobb presented similar research at the 2024 AcademyHealth Annual Research Meeting, and Ms Kowalski presented similar research at the 2025 AHIP Conference. Mr Francis and Ms Tabak are employed by Berkeley Research Group and contributed to this work under a consulting relationship with Elevance Health.

Authorship Information: Concept and design (RC, DC, MNL, MF, RT, JLK); acquisition of data (RC, DC); analysis and interpretation of data (RC, DC, ASG, MF, RT, JLK); drafting of the manuscript (RC, DC, MNL, ASG); critical revision of the manuscript for important intellectual content (RC, DC, MNL, ASG, JLK); statistical analysis (RC, DC, MF, RT); administrative, technical, or logistic support (RC); and supervision (JLK).

Address Correspondence to: Daniel Cullen, PhD, Elevance Health, 220 Virginia Ave, Indianapolis, IN 46204. Email: daniel.cullen@elevancehealth.com.

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