Medicaid

The AARC advocates the inclusion of respiratory therapy in all care sites under Medicaid. The following areas provide opportunities for increased access to respiratory therapy by Medicaid recipients. AARC members are encouraged to work directly with their state Medicaid officials to educate them on the value of respiratory therapy.

Asthma Management

First Lady Hillary Rodham Clinton unveiled a Clinton Administration proposal to provide $50 million, on a competitive basis, to a limited number of sates to test and evaluate the effectiveness of innovative disease managed approaches to identify and treat pediatric asthma. Demonstration funds would cover start-up costs for new or expanded efforts in Medicaid to develop: a current practices asthma baseline; an intervention model with appropriate disease treatment protocols, and beneficiary and provider outreach and education. These efforts are intended to provide an incentive for more effective application of existing spending for outreach, case management, and treatment benefits to reduce costly asthma-related medical crises (such as emergency room visits and hospital stays) and to improve quality of life for children with asthma and their families. This proposal has not yet received funding approval by Congress.

Children’s Health Insurance Program (CHIP)

Under the State Children’s Health Insurance Program (SCHIP or CHIP), created by the Balanced Budget Act of 1997, block grants are available to states to expand Medicaid eligibility for children, establish a new program that subsidizes private insurance or combine the two. Congress authorized $40 billion over the next 10 years to help pay for CHIP. All states and the District of Columbia have developed or are in the process of developing a CHIP implementation plan. Like Medicaid’s EPSDT program, CHIP faces a challenge in establishing outreach efforts that ensure enrollment of eligible children. As of March 1999, states have enrolled approximately 828,000 of the estimated 2.5 million uninsured children nationwide targeted under the CHIP according to a joint report from the National Governors’ Association and the National Conference of State Legislatures.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

State Medicaid programs must offer the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to all Medicaid eligible children under age 21. EPSDT offers a broad array of preventive, primary and remedial health care services. When a screening identifies a physical or mental condition, EPSDT requires states to provide all the additional diagnostic, treatment, and follow-up services listed in Medicaid law that are medically necessary to remedy the condition. Although a state may not ordinarily provide the service under its Medicaid plan, it becomes a mandated service for a particular child when the EPSDT screen identifies an illness or condition for which the service is required. Federal law stipulates that the amount, scope, and duration of EPSDT services must be sufficient to reasonably achieve the purposes for which those services are provided.

A number of studies have shown that few states come close to complying with this mandate. According to a study by the National Health Law Program (NHLP), only 37 percent of the 23 million eligible children received a medical screen in 1996. In addition, the overall participation rate was 56 percent in 1996, compared to the 80 percent target rate set by the Omnibus Reconciliation Act of 1989 (OBRA ’89). Child health advocates blame much of the problem on lack of oversight and enforcement at the federal and state levels. The Health Care Financing Administration (HCFA) does not have explicit authority to penalize states for failing to meet the EPSDT requirements.

Medicaid Waivers

Medicaid program waivers provide States the flexibility to develop and test innovative changes in their Medicaid programs. The Health Care Financing Administration (HCFA) offers two types of Medicaid waivers: "program" waivers and "research and demonstration" waivers.

Program Waivers
Usually limited in scope. There are two types of program waivers:

Research and Demonstration Waivers
Waivers that can be broad in scope and permit experimentation in many areas.

Program Waivers

Many programs that include respiratory therapy services are found under Home- and Community-Based Service (HCBS) Waivers. Examples of current HCBS waivers include:

Georgia Waiver No. 40116.90.R2 Effective Date: 10/1/97
Provides transportation, private duty nursing and medical day care services to respiratory or oxygen dependent individuals up to age 21.

Kentucky Waiver No. 40146.90.R1 Effective Date: 10/1/95
Provides private duty nursing and respiratory therapy to ventilator dependent individuals.

New York Waiver No. 40163.90 Effective Date: Approved
Provides case management, respite, medical social services, nutrition counseling, respiratory therapy and home adaptations to developmentally disabled children under age 18 with complex health care needs.

Utah Waiver No. 40183.90 Effective Date: 7/1/98
Provides respite, in-home respiratory care, nutritional evaluation and in-home based treatment, in-home family counseling, portable oxygen for non-medical transportation and activities to technology dependent/medically fragile under age 21.

Home- and Community-Based (HCBS) Waivers

What are HCBS waivers?
Sometimes called 1915(c) waivers (referring to the section of the Social Security Act providing these waivers) HCBS waivers provide states the flexibility to develop alternatives to placing Medicaid —eligible individuals in facilities such as nursing homes. Therefore, states can make services available to beneficiaries who would qualify for Medicaid only if they were residents of a medical facility.

What type of patient receives care under HCBS waivers?
Beneficiaries who receive care under HCBS waivers include the elderly and disabled, the physically disabled, the developmentally disabled, the mentally disabled, and the mentally ill. States may also target HCBS waivers to cover beneficiaries with a specific illness or condition, such as technology-dependent children or individuals with AIDS.

What services are included in a HCBS waiver?
The Social Security Act lists seven services that may be provided under a HCBS waiver:

  1. Case management,
  2. Homemaker services,
  3. Home health aide services,
  4. Personal care services,
  5. Adult day health,
  6. Habilitation, and
  7. Respite care.
Other services, such as transportation, meal services, etc., may be provided when approved by HCFA to avoid placing beneficiaries in a medical facility. States may design a waiver program and select a mix of services that can be provided either statewide or to a specific region of the state.

What federal requirements are "waived" under this program?
States request waivers from federal requirements that would impede developing community-based treatment alternatives. The federal requirements include:

How does a state receive approval for a HCBS waiver?
State Medicaid agencies must assure HCFA that the cost of providing home- and community-based services will not exceed the cost of care provided in a medical facility. Medicaid agencies must also demonstrate that there are safeguards to protect the health and welfare of beneficiaries. HCBS waivers are initially approved for three years and may be renewed for five-year periods. HCBS waivers are approved by the Medicaid Bureau’s Office of Long-Term Care Services in HCFA.

There are currently over 200 HCBS waivers in effect, serving over 250,000 beneficiaries. Every state, except for Arizona, has at least one HCBS waiver. Arizona is an exception because it runs the equivalent of an HCBS wavier under another waiver, a demonstration or 1115 waiver.

Contact: Mary Jean Duckett
Health Care Financing Administration
410/786-3294
mduckett@hcfa.gov

Freedom of Choice (FOC) Waivers

What are FOC waivers?
Sometimes called 1915(b) waivers (referring to the section of the Social Security Act providing these waivers) FOC waivers allow states to place beneficiaries in primary care case management (PCCM) programs. PCCM programs are fee-for-service programs that are managed by a gatekeeper or prepaid capitated programs such as health maintenance organizations (HMOs) or prepaid health plans (PHPs).

What is the purpose of FOC waivers?
FOC waivers improve beneficiaries’ access to health care through enrollment in a guaranteed provider network. These waivers also monitor beneficiaries’ quality of care. Frequently, beneficiaries in these waiver programs are placed in health care systems focused on health education and preventive medicine.

What federal requirements are "waived" under this program?
HCFA may waive certain provisions in section 1902 of the Social Security Act including:

How does a state receive approval for a FOC waiver?
State Medicaid agencies must assure HCFA that beneficiaries in FOC waiver programs have a choice of at least two or more providers. Not all managed care programs require FOC waivers. Programs that allow beneficiaries to choose between fee-for-service and managed care without restricting a choice of providers do not require FOC waivers. FOC waivers are approved for two years and may be renewed for two-year periods. FOC waivers are approved by the Medicaid Managed Care Team in HCFA’s Office of Managed Care.

As of June 30, 1995, approximately one-third of all Medicaid beneficiaries were in managed care programs including FOC waiver programs, voluntary managed care programs, and demonstration programs.

Contact: Anna Meyers
Health Care Financing Administration
410/786-5364
ameyers@hcfa.gov

Research and Demonstration Waivers

What are Research and Demonstration waivers?
Sometimes called 1115 waivers (referring to the section of the Social Security Act providing these waivers) Research and Demonstration waivers allow states to deviate from Medicaid standards in order to experiment with new policy ideas. In return, states must commit to an experiment that can be formally evaluated.

How do states use Research and Demonstration waivers?
Research and Demonstration waivers may be used by states to initiative small-scale pilot projects that test new benefits or new financing mechanisms, or, major projects that restructure a state’s entire Medicaid program. Which Medicaid policies may be waived under this program? Under Research and Demonstration waivers, states may:

Which Medicaid policies may not be waived under this program?
States may not use Research and Demonstration waivers to waive all Medicaid policies or program requirements, including:

How does a state receive approval for a Research and Demonstration waiver?
State Medicaid agencies must assure HCFA that Research and Demonstration waivers are budget neutral meaning that these programs must not cost more than Medicaid would have spent in the absence of the demonstration. Research and Demonstration waivers are approved for up to five years. Research and Demonstration waivers are approved by the HCFA’s Office of Research and Demonstration.

Most Research and Demonstration waivers have not been large-scale involving a state’s entire Medicaid program. Since 1993, however, more major demonstrations have occurred to restructure the Medicaid program.

Contact: Gloria Smiddy
Health Care Financing Administation
410/786-7723
gsmiddy@hcfa.gov

Smoking Cessation Treatment Services

State Medicaid plans may include coverage and reimbursement for smoking cessation treatment services. The AARC supports the recognition of Respiratory Therapists as providers of these services. An example of this issue is outlined below in the Indiana Medicaid Bulletin and the AARC's response.  

Top Home