Mo. Code Regs. tit. 13 § 70-3.260

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 70-3.260 - Payment Policy for Asthma Education and In- Home Environmental Assessments

PURPOSE: This rule establishes the MO HealthNet payment policy for asthma education and in-home environmental assessments. To improve the health of MO HealthNet's participants with asthma and to reduce MO HealthNet's costs associated with participants with uncontrolled asthma, MO HealthNet will implement a statewide asthma education and home assessment program focusing on youth participants who are most at risk of having uncontrolled asthma.

(1) The following definition(s) will be used in administering this rule:

(A) Asthma Education-direct training of the patient and family by qualified asthma education provider in areas including, but not limited to, avoiding triggers, medication compliance, proper use of inhalers, and use of durable medical equipment;

(B) In-Home Environmental Assessment-thorough and detailed analysis of the home environment by a qualified environmental assessment provider evaluating for asthma triggers including, but not limited to, rodent excrement, mites, animal dander, insects, dust, mold with recommendations for remedial actions;

(C) Uncontrolled Asthma-those with a primary diagnosis of asthma with one (1) or more asthma-related hospitalization in a twelve-(12-) month period, two (2) asthma-related emergency department visits in a twelve- (12-) month period, or three (3) or more urgent care visits in a twelve- (12-) month period, and over use of rescue inhalers and/or under use of inhaled corticosteroids;

(D) Qualified Academic University-Based Centers.

1. The academic university-based center responsible for tracking asthma educators must meet the following criteria:

A. Serve as a contractor for the Centers for Disease Control (CDC) National Asthma Control Program (NACP) funded by Missouri Asthma Prevention and Control Program (MAPCP);

B. Maintain a comprehensive database that contains information on individuals trained receiving Expert Panel Report 3 (EPR-3) compliant asthma training;

C. Staff providing the training must be a Certified Asthma Educator as recognized by the National Association of Asthma Educators; and

D. Provide training that focuses on educational/behavioral objectives in four (4) key areas-

(I) Inhaled corticosteroid adherence;

(II) Inhaled technique;

(III) Environmental trigger reduction; and

(IV) Regular check-ups with control measures.

2. The academic university-based center responsible for tracking asthma in-home environmental assessors must meet the following criteria:

A. Serve as the contractor for the CDC NACP funded MAPCP;

B. Provide a vital linkage between health care providers and public health resources through a Central Access Point (CAP);

C. Maintain a comprehensive database that contains information on individuals trained specific to Home Environmental Assessments (HEAs) for asthma trigger identification and reduction in the home setting; and

D. Track quality indicators and collect required outcomes data;

(E) Qualified providers (asthma education and environmental assessment)-a professional with appropriate training, as defined in section (4) of this regulation, in asthma education or environmental/home assessment, as evidenced by a national and/or state certification from an accepted program; and

(F) Youth participants-any individual younger than the age of twenty- one (21).

(2) Definition and Description of Medical Services.

(A) Asthma education-

1. Asthma education non-physician, (thirty- (30-) minute sessions, twice per year); or

2. Preventive medicine counseling, individual, (fifteen- (15-) minute sessions four (4) times per year); or

3. Preventive medicine counseling, individual, (thirty- (30-) minute sessions twice per year); or

4. Self-Management Education using standardized effective curriculum, individually, either incident to a clinical encounter or as preventative service, (ninety- (90-) minute session once per year).

(B) Asthma Environmental Assessment: Asthma environmental assessments may include, but are not limited to, a thorough assessment of the home including home history and ownership, building occupant behaviors and job history, home cleaning techniques, laundry processes, pets and pests histories, kitchen processes, structure deficiencies, ventilation and moisture conditions, conducting and recording basic air sampling procedures, and examination of the external environment of the home to identify and support the reduction of disease causing agents leading to medical complications of asthma. In-home assessments for asthma triggers do not include remediation of issues identified in the home.

1. Asthma environmental assessment non-physician, two (2) assessments per year.

(3) Recipient Criteria. In order to qualify for, and receive, asthma education and/or in-home environmental assessments, the participant must have a primary diagnosis of asthma and meet the MO HealthNet Division's (MHD) definition of a youth participant with uncontrolled asthma or at risk for an asthmatic attack. MHD will include the following criteria in defining participant eligibility:

(A) Age;

(B) Inpatient hospital stays;

(C) Emergency room and urgent care visits;

(D) Overuse of rescue inhalers; and

(E) Under use of inhaled corticosteroids.

(4) Qualified Provider Criteria. A qualified provider must meet the minimum education and certification requirements to qualify as a provider of asthma education and/or in-home environmental assessments set forth in this subsection.

(A) Asthma Education-

1. Asthma educators must have the credentials set forth in this subsection:

A. Shall be certified by a national program or a state program. Eligibility criteria for admission into the certification programs are determined by the administrator of the program;

B. Asthma educators must have one (1) of the following certifications in good standing:

(I) Current and active National Asthma Educator Certification (AEC); or

(a) Thirty-five (35) CEU every five (5) years; or

(b) Retake AEC asthma educator exam within the timeframes set forth by the AEC;

(II) State certification. The provider must have a current certificate from a Missouri state training program provided by an accredited institute of higher education, such as a university, that provides a training program utilizing asthma education curriculum incorporating similar guidelines to national certification programs. It is preferable that the curriculum is also accredited. Upon successful completion of the training program a certificate must be provided. A certificate means that the student has successfully completed the training program and is competent to provide asthma education services;

(a) Program may contain a mix of didactics with practicum work in the field; and

(b) The graduates are required to maintain the same number of CEUs as the national program-

I. Thirty-five (35) CEUs every five (5) years; or

II. Retake certification exam every seven (7) years.

C. The qualified academic university-based center responsible for tracking asthma educators will maintain an up-to-date database of credentialed asthma education providers in Missouri and will monitor compliance with national and state certifications;

2. Mentor program. A mentee is someone who is working towards a certificate. Once certified, the asthma educator can become a mentor for individuals that are seeking their national certification.Mentors, who must be an enrolled Medicaid provider, can have a maximum of three (3) mentees at a time. Mentors have the capability of billing MHD for their services, while mentees cannot. Services provided by a mentee under the supervision of the mentor can be billed to MHD by the mentor. The asthma education activities and interventions of the mentee shall be performed pursuant to the mentor's order, control, and full professional responsibility. The mentor shall maintain a continuing relationship with the mentee and shall meet with the mentee at a minimum of one (1) hour per month faceto- face. The mentor shall review all patient care, evaluate the quality of care delivered, and terminate any mentee relationship that fails to conform to the standard of care. Individuals that qualify for a mentorship are individuals not certified as asthma educators and seeking either national or state certification. These individuals can be mentored for a maximum timeframe of eighteen (18) months to obtain one thousand (1,000) hours of service. Once the one thousand (1,000) hours are obtained, the mentee must attempt to obtain the National AEC or the state certification. In the event the mentee fails the National AEC test or the state certification process, the mentee may no longer provide asthma education services to enrolled MO HealthNet participants.

(B) In-Home Environmental Assessors must have the credentials set forth in this subsection:

1. Shall be certified by a national program or a state program. Eligibility criteria for admission into the certification programs are determined by the administrator of the program;

2. An in-home environmental assessor must have one (1) of the following certifications in good standing:

A. National Certification-

(I) National Environmental Health Association (NEHA) Healthy Home Specialist; or

(II) Building Performance Institute (BPI) Healthy Home Evaluator Micro-Credential;

B. State Certification. The provider must have a current certificate from a Missouri state training program provided by an accredited institute of higher education, such as a university, that provides a training program utilizing curriculum incorporating similar guidelines to national certification programs. It is preferable that the curriculum is also accredited. Upon successful completion of the training program a certificate must be provided. A certificate means that the student has successfully completed the training program and is competent to provide in-home environmental assessment.

3. The qualifying academic university-based center responsible for tracking asthma in-home environmental assessors will maintain an up-to-date database of credentialed asthma in-home environmental assessment providers in Missouri and will monitor for compliance with national and state certifications.

(5) Process for Enrollment in Asthma Education and In-Home Environmental Assessments.

(A) A physician's referral as part of a normal office visit for evaluation and management is necessary for both asthma education and in-home environmental assessment. The physician must prescribe the service in the participant's plan of care for services to be considered.

(B) As part of the referral, a physician determines and specifies the level and type of asthma education and in-home environmental assessment based on available history and in consultation with asthma educators and in-home environmental assessors, as needed.

(C) The physician must seek prior authorization from MHD.

(6) Qualifying Academic University-Based Centers will evaluate, certify, and track physician referrals. Qualifying academic university-based centers will function to handle physician referrals for asthma education and environmental home assessment statewide for qualified asthma educators and in-home environmental assessors when requested by the physician by providing MHD with the following services:

(A) The qualified academic university-based centers must maintain a website with an up-to-date provider list for physicians and their offices to utilize to consult asthma educators and asthma in-home environmental assessors to provide services to participants once a prior authorization has been approved.

1. The qualified academic university-based center responsible for tracking asthma in-home environmental assessors must maintain an up-to-date list of all certified in-home environmental assessors in the state; and

2. The qualified academic university-based center responsible for tracking asthma educators must maintain an up-to-date list of all trained asthma educators in the state;

(B) An up-to-date provider list must also be available to providers on the Department of Social Services' website https://dssapp.dss.mo.gov/providerlist/sprovider.asp.

(C) The qualified academic university-based centers must make referrals to qualified local community providers after receiving the physician referral for asthma education and/or environmental home assessments, if requested by the prescribing physician;

(D) The qualified academic university-based centers must maintain a website with an up-to-date provider list for physicians and their offices to utilize to consult asthma educators and asthma in-home environmental assessors to provide services to participants once a prior authorization has been approved; and

(E) An up-to-date provider list must also be available to providers on the Department of Social Services' website https://dssapp.dss.mo.gov/providerlist/providers.asp

(7) Model/Algorithm for identifying the eligible population. The youth participant must have a primary diagnosis of asthma and-

(A) One (1) or more inpatient stays related to asthma; or

(B) Two (2) or more emergency department visits related to asthma; or

(C) Three (3) or more urgent care visits related to asthma; or

(D) One (1) emergency department visit or one (1) urgent care visit related to asthma with a high rate of short-acting beta-agonist inhaler fills and/or low rates of inhaled corticosteroid refills; or

(E) Responsible provider prescribes services in the plan of care.

(8) Authorization Limits.

(A) All services will require a prior authorization.

(B) Annual limit of asthma education visits will be dependent on the codes used, but shall not exceed one (1) hour per year with the exception of one (1) ninety- (90-) minute self-management session and two (2) in-home environmental assessments that are allowed annually. Any additional asthma education and environmental in-home assessments will need to go through the prior authorization process and be deemed medically necessary.

(9) Reimbursement Methodology for Asthma Education and In-Home Environmental Assessments.

(A) MHD shall provide reimbursement for asthma education and in-home environmental assessments to enrolled asthma educators and environmental assessors who are currently certified and in good standing with the state.

(B) Reimbursement for services is made on a fee-for-services basis. The maximum allowable fee for a unit of service has been determined by MHD to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charge (should be the provider's usual and customary charge to the general public for the service), or the maximum allowable per unit of service. Reimbursement shall only be made for services authorized by MHD or its designee.

(C) Except as otherwise noted in the plan, state developed fee schedule rates are the same for both public and private providers of asthma education and asthma environmental assessments. The agency's fee schedule is published at http://www.dss.mo.gov/mhd/providers/index.htm and are effective for services provided on or after the effective date of the state plan amendment.

13 CSR 70-3.260

Adopted by Missouri Register December 15, 2016/Volume 41, Number 24, effective 1/29/2017