Current Health Insurance Coverage

Medicare

Health plans vary in the degree to which components of the NAEPP Guidelines are used as part of their clinical practice guidelines.

Medicaid

The Centers for Medicare and Medicaid Services (CMS) encourages state Medicaid programs to accelerate widespread adoption of the NAEPP Guidelines. However, state programs vary in the degree to which components of the NAEPP Guidelines (such as assessing asthma severity, asthma control, medication dispensing appropriate to patients’ asthma severity and control, and outpatient follow-up visits to conduct these assessments) are emphasized in clinical practice guidelines.^10,11 State programs and Medicaid managed care organizations also vary in the degree to which claims data are used to improve health care providers’ or patients’ adherence to NAEPP Guidelines-based medical management.

Commercial/Private

Health plans vary in the degree to which components of the NAEPP Guidelines are emphasized as part of clinical practice guidelines.¹² Health plans also vary in the degree to which claims data are used to improve health care providers’ or patients’ adherence to NAEPP Guidelines-based medical management.

Medicare

Medicare Part B (medical insurance) covers nebulizers (and some medications used in nebulizers if considered reasonable and necessary) as durable medical equipment for Medicare-enrolled providers. If the supplier accepts assignment, the beneficiary must pay 20% of the Medicare-approved amount, and the Part B deductible applies. Depending on the type of equipment, the beneficiary may have to rent or buy it.

Medicaid

All states provide drug coverage, but not all asthma medications and devices are covered.⁴⁰ Barriers to accessing asthma medications or devices include quantity limits, prior authorization requirements, and copayments. Some Medicaid managed care organizations require patients to obtain devices (e.g., spacers) from durable medical equipment vendors instead of pharmacies, which can also be a barrier to access because of the additional time and effort required to visit a separate location.

Commercial/Private

Health plans may cover some (but not all) asthma medications, and plans have the option to charge copayments, require prior authorization, or specify quantity limits on both medications and spacers.

Medicare

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule for Chronic Care Management (CCM) services for Medicare patients with multiple chronic conditions such as asthma or chronic obstructive pulmonary disease. Chronic Care Management services are defined as at least 20 minutes of clinical staff time directed by a physician, certified nurse midwife, clinical nurse specialist, nurse practitioner, and physician assistant per calendar month, with the following required elements:

Patient has multiple (two or more) chronic conditions expected to last at least 12 months or until death.
Chronic conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
A comprehensive care plan has been established, implemented, revised, or monitored.⁵⁵

As asthma is considered one of the eligible chronic care conditions under CCM services, qualified health care professionals may bill and be reimbursed for asthma medication management and asthma self-management education. These asthma related services may be coordinated and delivered with community/social services as long as these asthma-related services under chronic condition management are documented in compliance with the CCM comprehensive care plan format.

Medicaid

Medicaid programs vary in whether Current Procedural Terminology (CPT) codes relevant to providing asthma self-management education services are reimbursable (98960–98962)^{56,57,58,59,60}; types of providers who can bill for providing such services also vary by state.

Medicaid managed care organizations vary in the degree to which they provide asthma self-management education either by in-house staff members (e.g., certified asthma educators within disease management programs) or by contracting with and reimbursing external educators in the clinic or community setting.^62,63

Commercial/Private

Health plans vary in the degree to which they provide asthma self-management education either by in-house staff members (e.g., certified asthma educators within disease management programs) or by contracting with and reimbursing care coordinators, community health workers, external educators, or community-based organizations in the clinic or community setting.^64,65

Medicare

Home visits by home and community-based clinical service providers that are directed and coordinated by a physician, certified nurse midwife, clinical nurse specialist, nurse practitioner, and physician assistant per calendar month, may be covered as part of Chronic Care Management Services.

Medicaid

States and Medicaid managed care organizations have varying policies on whether home visit services are available or reimbursable for patients with asthma.^85,86 States also vary in their designation of which providers are eligible to be reimbursed for delivering such services.²⁶ Medicaid managed care organizations vary in the degree to which they provide home visit services for asthma, either by in-house staff members or by contracting with and reimbursing providers from health care or community organizations.^87,88,89

Commercial/Private

Health plans vary in the degree to which they provide home visit services for asthma, either by in-house staff members or by contracting with and reimbursing external providers from health care or community organizations.^90,91,92