Medicaid Coverage of Guidelines-Based Asthma Care Across 50 States, the District of Columbia, and Puerto Rico, 2016-2017

Katherine Pruitt; Annie Yu; Barbara M. Kaplan, MPH; Joy Hsu, MD, MS; Pamela Collins, MPA, MSA

Prev Chronic Dis. 2018;15(9):E110

Abstract and Introduction

Abstract

Asthma affects more than 24 million Americans, including 6.2 million children. Although asthma cannot be cured, it can be effectively managed with care based on nationally recognized guidelines. Ensuring the availability and accessibility of guidelines-recommended treatments and services can help patients receive the most appropriate care. In this article, we describe the American Lung Association's Asthma Guidelines-Based Care Coverage Project (the Project) to determine the extent of asthma care coverage and associated barriers in state Medicaid programs — information that has been previously unavailable. The Project tracked coverage for 7 areas of guidelines-based asthma care and 9 barriers related to accessing care in Medicaid programs for all 50 states, the District of Columbia, and Puerto Rico. Results from the Project show a lack of consistent and comprehensive coverage across states, as well as coverage-related challenges to accessing asthma care within states.

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Table 1. Categories of Care and Barriers to Accessing Asthma Care Defined, American Lung Association's Asthma Guidelines-Based Care Coverage Project, 50 US States, the District of Columbia, and Puerto Rico
Terminology	Definition
Categories of Care
Quick relief medications	Fast acting or quick relief medications intended to provide immediate relief of bronchoconstriction and its accompanying acute symptoms.
Controller medications	Long-term control medications taken daily on a long-term basis to control persistent asthma.
Devices	Devices that assist with monitoring symptoms or properly administering asthma medication (includes nebulizers, peak flow meters, and valved-holding chambers).
Allergen testing	Allergy tests for asthma triggers to identify and reduce exposure to allergens (skin or in vitro testing).
Allergen immunotherapy	Preventive treatment through incremental injected or ingested increases of the allergen to make the immune system less sensitive to the substance.
Home visits	Education, assessment, and intervention of the patient's home environment to address triggers.
Asthma self-management education	Patients and families learn to use prescribed asthma-control medicines and equipment correctly, recognize symptoms of an asthma episode and respond appropriately and mitigate asthma triggers.
Barriers
Age limits	This barrier indicates that the treatment is only covered if a patient is under the age of x and applied only if it is more restrictive than FDA-approved guidelines.
Age restrictions	This barrier indicates that the treatment is only covered for patients over the age of x and applied only if it is more restrictive than FDA-approved guidelines.
Copayments	Payment that must be made to receive the treatment even when it is covered by the health plan (in this case Medicaid or Medicaid-managed care plans).
DME	A device is covered only as DME, which could result in having to pay full price for the device at a retail pharmacy.
Eligibility criteria	A plan will only provide the treatment after a patient has experienced an incident, such as numerous visits to the emergency department.
Prior authorization	This barrier requires the provider to get approval from the insurance company (in this case Medicaid or Medicaid-managed care plans) before the treatment will be covered (ie, paid for).
Quantity limits	There is a limit on the number of treatments covered each month or under a certain amount of time.
Specialty visit limitations	This is when a plan only allows a patient to see a fixed number of specialists per year.
Stepped therapy	This means a plan requires a patient to try and fail on a different treatment before the insurance company (in this case Medicaid or Medicaid-managed care plans) will pay for the treatment that his/her provider prescribes.

Abbreviations: DME, durable medical equipment; FDA, Food and Drug Administration;

Table 2. State Medicaid Program Coverage of Guidelines-Based Asthma Care Categories, American Lung Association's Asthma Guidelines-Based Care Coverage Project, 50 US States, the District of Columbia, and Puerto Rico ^a
State	Quick Relief Medication(4 Types)	Controller Medication(20 Types)	Medical Devices(3 Types)	Allergy Testing(2 Types)	Allergen Immunotherapy	Home Visits	Asthma Self-Management Education
Alabama	Y	Y	V	Y	Y	Y	Y
Alaska	Y	V	N	N	N	N	Y
Arizona	V	V	V	V	V	N	V
Arkansas	Y	V	N	N	N	N	N
California	V	V	V	V	V	N	V
Colorado	V	V	Y	V	V	N	N
Connecticut	Y	Y	Y	Y	Y	Y	Y
Delaware	Y	V	Y	Y	Y	V	Y
Florida	V	V	V	V	V	V	V
Georgia	V	V	Y	Y	Y	V	V
Hawaii	V	V	V	V	V	N	V
Idaho	Y	Y	Y	Y	Y	N	Y
Illinois	V	V	V	V	V	N	V
Indiana	Y	V	V	V	V	V	V
Iowa	Y	V	Y	Y	Y	N	N
Kansas	Y	Y	V	Y	Y	Y	Y
Kentucky	Y	V	V	Y	Y	N	V
Louisiana	V	V	V	V	V	V	V
Maine	Y	Y	Y	Y	Y	N	Y
Maryland	V	V	V	V	V	V	V
Massachusetts	V	V	V	V	V	V	V
Michigan	V	V	V	V	V	V	V
Minnesota	V	V	V	V	Y	V	V
Mississippi	Y	V	V	V	N	N	N
Missouri	Y	V	NA	V	V	N	V
Montana	Y	V	Y	Y	Y	N	Y
Nebraska	Y	V	V	Y	Y	N	V
Nevada	V	V	V	V	V	N	Y
New Hampshire	V	V	V	Y	Y	N	NA
New Jersey	V	V	V	N	N	N	N
New Mexico	V	V	V	N	V	N	N
New York	V	V	V	V	V	N	V
North Carolina	Y	Y	V	Y	Y	N	Y
North Dakota	Y	Y	Y	V	Y	N	N
Ohio	V	V	V	V	V	N	N
Oklahoma	Y	Y	V	Y	Y	N	N
Oregon	V	V	V	V	V	V	V
Pennsylvania	V	V	V	V	V	V	V
Rhode Island	V	V	V	Y	Y	N	Y
South Carolina	V	V	V	V	V	V	V
South Dakota	N	V	Y	N	N	N	N
Tennessee	Y	V	V	N	V	N	N
Texas	Y	V	V	V	V	V	V
Utah	V	V	V	V	V	N	V
Vermont	Y	V	Y	Y	Y	N	Y
Virginia	V	V	V	V	V	V	N
Washington	V	V	V	Y	Y	V	V
West Virginia	Y	V	V	V	N	N	N
Wisconsin	V	V	V	N	N	N	N
Wyoming	Y	Y	Y	Y	Y	Y	N
District of Columbia	V	V	V	V	V	N	V
Puerto Rico	V	V	V	Y	Y	V	Y
Totals
Yes	23	9	12	19	21	4	13
Varies	28	43	37	26	24	16	23
No	1	0	2	7	7	32	15
NA	0	0	1	0	0	0	1

^aN indicates that none of the items in the category is covered in any Medicaid plan; NA indicates that data were not available for the state; V indicates that not all items in the category were covered in all Medicaid plans (some items in category may have varying coverage across plans or no coverage at all); and Y indicates that all items in the category of care are covered in all Medicaid plans. Data collected as of June 30, 2017.

Table 3. Frequency ^a and Total Possible Occurrences of Barriers for Treatments and Services Among State Medicaid Programs Covering the Category of Care, American Lung Association's Asthma Guidelines-Based Care Coverage Project, 50 US States, the District of Columbia, and Puerto Rico ^b
Barriers	Quick Relief Medication	Controller Medication	Medical Devices	Allergy Testing	Allergen Immunotherapy	Home Visits	Asthma Self-Management Education
Barriers	% (No.)
Age limits	4.0 (149)	10.2 (749)	13.0 (69)	0 (29)	0 (15)	0 (8)	0 (10)
Age requirement	1.4 (147)	4.5 (734)	0 (64)	0 (29)	6.3 (16)	0 (8)	0 (10)
Copayment	74.7 (178)	73.1 (886)	58.2 (67)	53.7 (41)	52.6 (19)	0 (8)	20.0 (10)
Durable medical equipment benefits	NA	NA	71.3 (94)	NA	NA	NA	NA
Eligibility criteria	0.7 (148)	1.9 (734)	5.8 (69)	0 (29)	0 (15)	0 (8)	0 (10)
Prior authorization	26.4 (163)	39.2 (824)	32.5 (80)	28.1 (32)	23.5 (17)	22.2 (9)	9.1 (11)
Quantity limits	58.7 (172)	52.2 (820)	68.7 (99)	28.6 (35)	31.3 (16)	22.2 (9)	9.1 (11)
Specialty visit limitation	NA	NA	NA	0 (14)	0 (15)	0 (8)	0 (10)
Step therapy	17.7 (153)	23.6 (768)	NA	0 (29)	0 (15)	0 (8)	0 (10)

^aFrequency of a barrier is the occurrence of the barrier divided by the total possible occurrences of the barrier.
^bData collected as of June 30, 2017.