State Medicaid Coverage for Home Visits

Transcription

1 Cvered Withut Barriers State Medicaid Cverage fr Hme Visits Cvered Sme Cverage N Cverage States fr which data is nt yet available NH VT MA RI CT NJ DE MD DC: HI Last Updated: June 30,

2 Asthma Guidelines-Based Care Initiative: Benchmarks fr Key Aspects f Optimal Cverage It is estimated that 22 millin Americans have asthma, f whm six millin are children, representing eight percent f ur natin s yuth. 1 Asthma is the third leading cause f hspitalizatins fr children under the age f 15 and is a leading cause f schl absences due t a chrnic disease. Asthma is respnsible fr $62.8 billin annually in healthcare csts, 10.5 millin missed schl days, 14.2 millin missed days f wrk and csts $5.9 billin in lst prductivity. While the number f peple having asthma attacks decreased frm 2001 t 2010, asthma still claims the lives f 3,600 Americans each year. Since 1991, the Natinal Asthma Educatin and Preventin Prgram (NAEPP) Expert Panel Reprt 3: Guidelines fr the Diagnsis and Management f Asthma (EPR-3) and similar reputable, scientific dcuments including the Guide t Cmmunity Preventive Services have defined evidence-based best practices fr what is needed t reduce the disease burden fr patients living with asthma. Research shws that while the number f peple living with asthma has increased, peple with asthma are better managing their disease. Hwever the gains have nt been universal. African Americans, fr example, are tw t three times mre likely t die frm asthma than any ther racial r ethnic grup. Numerus studies and pilt prgrams have demnstrated that adherence t guidelines-based care results in better patient utcmes, including fewer hspitalizatins, fewer days f missed schl and wrk and reduced treatment csts. At the current time it is nt knwn t what extent guidelinesbased care is being cvered by state Medicaid prgrams as the standard f care. Asthma rates are disprprtinately high in lw-incme and minrity ppulatins, especially amng African Americans and Puert Ricans. Lw-incme children and adults are mre likely t be hspitalized fr asthma than thse with higher incmes. Accrdingly, Medicaid was the mst cmmnly expected primary payer fr asthma-related hspital stays fr bth children and adults, aged 18 t Additinally, children with Medicaid were almst 50 percent mre likely t receive care in the emergency department than their classmates nt n Medicaid. 3 Adding t the challenges Medicaid patients face, this ppulatin is mre likely t have lw health literacy, making it mre difficult fr them t manage their asthma r ther chrnic diseases. 4 1 Centers fr Disease Cntrl and Preventin. Mst Recent Asthma Data. (Accessed ) 2 Barrett ML (ML Barrett, Inc), Wier LM (Truven Health Analytics), and Washingtn R (AHRQ). Trends in Pediatric and Adult Hspital Stays fr Asthma, HCUP Statistical Brief #169. January Agency fr Healthcare Research and Quality, Rckville, MD. Asthma-Trends-Hspital-Stays.pdf. 3 Finklestein JA, et al. Cmparing asthma care fr Medicaid and nn-medicaid children in a health maintenance rganizatin. Archives f Adlescent and Pediatric Medicine, June 2000; 154(6): Express Scripts. Medicaid Sptlight: A $50 Billin Prblem That Hits the Yung and Pr the Hardest. Available at: Page 1

3 In 2015, the American Lung Assciatin received a cmpetitive award frm the Centers fr Disease Cntrl and Preventin s (CDC) Natinal Center fr Envirnmental Health t track asthma guidelines-based care in state Medicaid prgrams fr the 23 CDC-funded Natinal Asthma Cntrl Prgram states. As part f this prject, a grup f key stakehlder rganizatins was cnvened t discuss and key cmpnents f guidelines-based asthma care cverage fr state Medicaid prgrams. The infrmatin that fllws represents thse discussins. This dcument defines benchmarks fr asthma guidelines-based care fr seven different criteria, which, if cvered, tgether encmpass key elements f the NAEPP EPR-3 guidelines, Cmmunity Guide and ther relevant guidelines. There are prven-effective higher intensity interventins that are nt highlighted in this tracking dcument. Higher intensity treatments, such as a mderate intensity hme visit interventins r cverage f mre medicatin types f cntrller medicatins, might lead t better health utcmes fr patients n Medicaid. The American Lung Assciatin sught advice frm a range f experts t develp the plan and identify cnferees wh culd prvide expert review and participate in develping the cnsensus benchmarks. Fundamental t the success f this prject was the inclusin f a wide range f perspectives and expertise. 11 peple, representing 11 rganizatins and six Lung Assciatin staff frmed the Advisry Cmmittee and met nce in persn and then crrespnded via and phne. The members f the Advisry Cmmittee are nted (see Appendix). Thrughut the dcument, barriers t care are cited as an impediment t guidelines-based care. Belw is a list f cmmn barriers that will be tracked as part f the prject. In additin t the barriers belw, there are systemic barriers t access care. Systemic barriers present a challenge fr Medicaid patients access t care, but since the barriers are systemic, they cannt be tracked in the discrete categries described in this dcument. Barriers Barrier Definitin Tracked fr Cmpnents Age Limits (AL) Age Restrictins (AR) This barrier indicates that the medicatin is nly cvered if a patient is a certain age. Typically it means patients under the age f x. *This barrier nly applies prvided it is nt cntradicting FDA apprval. Similar t Age Limits, this barrier indicates that the medicatin is nly cvered fr patients f a certain age. Typically it means, patients ver the age f x. *This barrier will nly be applied All Cmpnents All Cmpnents Page 2

4 C-Payments (C-Pay) Durable Medical Equipment (DME) Eligibility Criteria Prir Authrizatin (PA) Quantity Limits (QL) Specialty Visit Limitatins Stepped Therapy (ST) prvided it is nt cntradicting FDA apprval. This is a payment that must be made t receive the prescriptin, even when it is cvered by the insurance cmpany (in this case Medicaid r Medicaid managed care plans). This means a device is cvered nly as DME, which culd result in having t pay full price fr the device at a retail pharmacy. This means a plan will nly prvide the service after a patient has experienced an incident(s), such as numerus visits t the Emergency Department. This barrier requires the prvider t get apprval frm the insurance cmpany (in this case Medicaid r Medicaid managed care plans) befre the medicatin will be cvered (i.e. paid fr). Fr the purpse f this prject, prir authrizatin nly applies t medicatins listed n the frmulary. There is a limit n the number f treatments cvered each mnth. This is when a plan nly allws a patient t see a fixed number f specialists per year. This means a plan requires a patient t try and fail n a different medicatin befre the insurance cmpany (in this case Medicaid r Medicaid managed care plans) will pay fr the medicatin that their prvider prescribes. All Cmpnents All Cmpnents All Cmpnents All Cmpnents All Cmpnents All Cmpnents All Cmpnents Page 3

5 I. Quick Relief Medicatins Fast acting r quick relief medicatins are taken t prvide immediate relief f brnchcnstrictin and its accmpanying acute symptms 5. There are tw classes f these medicatins: Antichlinergics and Inhaled Shrt-Acting Beta2-Agnists (SABAs) 6. Data cllected n quick relief medicatins will include cverage f each f the fur types f medicatins and any barriers t access that medicatin. The cllectin f the data is brand neutral. Benchmark fr Guidelines-Based Care: One medicatin per medicatin type with n barriers. Class Medicatin Type Benchmark SABA Antichlinergics Albuterl Sulfate Levalbuterl Ipratrpium Ipratrpium with Albuterl 5 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n The ERP3 recmmends that SABAs are the drug f chice fr treating acute asthma symptms and exacerbatins and fr preventing EIB (Evidence A). 2. The EPR3 cncludes that ipratrpium brmide, administered in multiple dses alng with SABA in mderate r severe asthma exacerbatins in the ED, prvides additive benefit (Evidence B). Page 4

6 II. Cntrller Medicatins The NAEPP EPR 3 (Expert Panel Reprt) instructs that lng-term cntrl medicatins be taken daily n a lng-term basis t cntrl persistent asthma 7. Data cllected fr cntrller medicatins will include each f the medicatin types. These data will be brand and generic neutral and include any barriers t access the medicatin. Fr inhaled crticsterids, ne medicatin per class is insufficient because f variatin in age-apprpriate frms f medicatin delivery (e.g. nebulized frmulatins are mre apprpriate fr very yung children than inhaled frmulatins) it cmes in. With the exceptin f Inhaled Crticsterids and LABAs, the benchmark is ne medicatin per medicatin type,. Benchmark fr Guidelines-Based Care: Inhaled Crticsterids: Cverage f inhaled Budesnide and cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate 8 r Mmetasne furate. Systemic Crticsterids: Cverage f ne medicatin per medicatin type withut barriers. LABAs: Cverage f ne medicatin per medicatin type, nly if a cmbined medicatin is nt cvered. Cmbined Medicatins: Cverage f ne medicatin per medicatin type. Crmlyn: Cverage f ne medicatin per medicatin type. Leuktriene Receptr Antagnists: Cverage f ne medicatin per medicatin type. 5-Lipxygense Inhibitr: Cverage f ne medicatin per medicatin type. Methyxanthines: Cverage f ne medicatin per medicatin type. Immunmdulatrs: Cverage f ne medicatin per medicatin type. Class Medicatin Type Benchmark Inhaled Crticsterids Budesnide (nebulized) Beclmethasne Ciclesnide Cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate r Mmesasne furate (brand r generic) Cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate r Mmesasne furate (brand r generic) 7 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n There are a number f medicatins listed by their full clinical name. During the data cllectin prcess, all variatins f the medicatin name, including bth brand and generic names will be searched. There is nt a preference fr ne brand ver anther r fr a brand ver a generic r vice-versa. Page 5

7 Flunislide Fluticasne prpinate Mmetasne furate Systemic Crticsterids LABA 9 Methylprednislne Prednislne Prednisne Frmterl fumarate Salmeterl xinafate Cmbined Medicatins Crmlyn Fluticasne prpinate and Salmeterl Mmetasne furate and Frmterl fumarate Budesnide and Frmterl fumarate Crmlyn Leuktriene Receptr Antagnists Mntelukast Zafirlukast 5-Lipxygenase Inhibitr Zileutn Methylxanthines Thephylline Cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate r Mmesasne furate (brand r generic) Cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate r Mmesasne furate (brand r generic) Cverage f Beclmethasne, Ciclesnide, Flunislide, Fluticasne prpinate r Mmesasne furate (brand r generic) Cverage nly if a cmbined medicatin is NOT cvered Cverage nly if a cmbined medicatin is NOT cvered 9 T be used nly in cnjunctin with inhaled r systemic sterids Page 6

8 Immunmdulatrs Omalizumab Page 7

9 III. Devices Asthma medicatins, discussed abve, can be administered in varius ways. In rder fr prper administratin f medicatin sme devices are required. There are three devices and their cmpnents that are necessary fr guidelines-based care. They are: valved-hlding chambers, nebulizers and peak-flw meters. It shuld be nted there is a distinctin between spacers and valved-hlding chambers. The EPR3 states that valved-hlding chambers are preferable t a generic spacer. 10 As such, the data cllected will be fr cverage f valved-hlding chambers, nt spacers. In additin t the barriers that will be tracked fr medicatins, it will als be nted when a device is included in the durable medical equipment (DME) benefit, rather than n the plan frmulary. Benchmark fr Guidelines-Based Care: Cverage f at least ne nebulizer and peak-flw meter. Cverage f at least tw valved-hlding chambers. Devices Type f Device Nebulizer Peak-Flw Meters Valved-Hlding Chambers Benchmark Cverage f at least ne device withut barriers Cverage f at least ne device withut barriers Cverage f at least tw devices withut barriers 10 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Page 8

10 IV. Allergen Testing The NAEPP guidelines include allergy testing fr patients with persistent asthma, as reducing expsure t allergens may significantly reduce symptms and the need fr medicatins fr patients with asthma 11. Allergens ften can be asthma triggers, as such prviders shuld ask abut expsures t inhaled allergens and their impact n asthma symptms t determine if allergen testing is needed. The NAEPP Guidelines give equal weight t an assessment f sensitivity t allergens being cnducted with skin r in vitr (bld) testing. Cverage f bth skin and in vitr testing will be tracked and any barriers t access them. Benchmark fr Guidelines-base care: Bth in vitr and skin testing be cvered and access t bth is equal. Allergen Testing Skin testing In vitr testing Equal access Benchmark Testing is cvered Testing is cvered Equal access t bth exists 11 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n Page 9

11 V. Allergy Treatment Allergen Immuntherapy The NAEPP Guidelines and the American Academy f Allergy, Asthma & Immunlgy state the need fr allergen immuntherapy fr patients wh have knwn allergen sensitivities (as determined by an allergy test) and whse symptms cannt be cntrlled by medicatin. 12,13 T determine the cverage f allergen immuntherapy, reimbursement fr the fllwing CPT cdes will be assessed and barriers t access them, including limits n visits t specialists. The CPT cdes are Benchmark fr Guidelines-Based Care: Asthma patients with a knwn allergen have access t cverage f at least ne CPT cde fr allergen immuntherapy. Allergen Immuntherapy Allergen Immuntherapy Benchmark Access t allergen immuntherapy withut barriers. 12 Cx, L, et al. Allergen immuntherapy: A practice parameter third update. en-immuntherapy-jan-2011.pdf 13 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n Page 10

12 VI. Hme Visits The NAEPP Guidelines and the Guide t Cmmunity Preventive Services each include hme visits and that interventins be made available fr patients with allergic asthma. 14,15 Hme visits and interventins are cmprised f three cmpnents, educatin, assessment and interventin, and are categrized by level f intensity. The fllwing definitins are adapted frm the Guide t Cmmunity Preventive Services: Minr Intensity Interventin: An interventin that addresses the hme envirnment, has at least tw cmpnents, and addresses either integrated pest cntrl r tw ther triggers. A minr intensity interventin des nt need t cver supplies. Mderate Intensity Interventin: An interventin that addresses the hme envirnment, has at least tw cmpnents, and addresses tw asthma triggers. The interventin includes prviding at least tw supplies frm the mderate supply list. Majr Intensity Interventin: An interventin that addresses the hme envirnment has have at least tw cmpnents, and addresses tw asthma triggers. The interventin includes prviding at least 2 supplies, including ne frm the majr supply list. Benchmark fr Guidelines-Based Care: Minr intensity interventin hme visit is cvered. Data will be cllected n cverage f a hme visit and interventin. The recrded data will include if a state has reimbursement fr a minr envirnmental remediatin r if hme visits are nt cvered. State Medicaid prgrams that are cvering mderate r majr envirnmental will be acknwledged, hwever, this infrmatin will nt be recrded as part f the benchmark data. Cmpnents f Hme Visit Self-Management Educatin Envirnmental Assessment Scial services Crdinated care Asthma Triggers Smking / Secndhand Smke Mld/ dampness Pests (Integrated Pest Cntrl) Pets Dust mites VOCs Cmbustin surces 14 Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n Guide t Cmmunity Preventive Services. Asthma cntrl. Last updated: 9/27/2013. Page 11

13 Supply List Mderate Intensity Supplies Impermeable mattress cvers Impermeable pillw cases Traps r gel bait (as part f integrated pest management) Tlkit f hyp allergenic cleaning items HEPA filter vacuum Air cnditiners (small unit) Lw-txicity pesticides (as part f integrated pest management) Caulk, sealant fr patching hles (as part f integrated pest management) Integrated pest management Repairing minr leaks Majr Intensity Supplies Carpet remval r replacement Air cnditining systems Ventilatin Systems Repairing majr leaks Extensive structural repairs (e.g., rf replacement) Hme Visits and Interventin Hme Visit and Interventin Benchmark Minr intensity interventin hme visit withut barriers. Page 12

14 VII. Self-Management Educatin The NAEPP Guidelines states patients with asthma have access t asthma self-management educatin. 16 Since asthma is a chrnic disease that requires daily mnitring and maintenance by the patient, asthma self-management educatin is key in imprving patient utcmes. Reimbursement fr asthma self-management educatin will be tracked and any barriers t it will als be tracked. Disease management prgrams will nt cunt as self-management educatin. Benchmark fr Guidelines-Based Care: Asthma self-management educatin is cvered withut barriers. Self- Management Educatin Asthma self-management educatin Benchmark Educatin is cvered Updated: Nvember 9, Natinal Heart, Lung, and Bld Institute, Natinal Asthma Educatin and Preventin Prgram. Expert Panel Reprt 3: Guidelines fr the diagnsis and management f asthma. Bethesda, MD: US Department f Health and Human Services, Natinal Institute f Health. Pg ; pub. N Accessed n NOTE: Neither the results f this American Lung Assciatin initiative nr the recmmendatins cntained in this dcument in any way represent an fficial CDC psitin. They d hwever, represent a brad agreement frm multi-disciplinary stakehlders interested in reducing asthma mrbidity and mrtality. Page 13