Mo. Code Regs. tit. 13 § 70-25.150

Current through Register Vol. 49, No. 23, December 2, 2024

Section 13 CSR 70-25.150 - 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 youth participants that have uncontrolled asthma.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Administration. Asthma Education and In-Home Environmental Assessment services shall be administered by the MO HealthNet Division. Asthma education and in-home environmental assessments services covered and not covered, the limitations under which services are covered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the MO HealthNet Physician Provider Manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/manuals/, May 14, 2021. This rule does not incorporate any subsequent amendments or additions. Asthma Education and In-Home Environmental Assessment services covered by the MO HealthNet program shall include only those which are clearly shown to be medically necessary.

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

1. "Asthma Education" means 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;

2. "In-Home Environmental Assessment" means 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.

(2) Asthma Education and In-Home Environmental Assessment Services. Asthma Education and In-Home Environmental Assessment Services are interventions for increasing control of asthma symptoms in high risk youth.

(A) A prescribing provider's referral is required as part of a normal office visit for evaluation and management for both asthma education and in-home environmental assessment. The prescribing provider will need to prescribe the service in the participant's plan of care.

(B) As part of the referral, the prescribing provider 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) A prescribing provider is defined as a licensed practitioner authorized to prescribe within their scope of practice either directly or by protocol consistent with their scope of practice under state law.

(D) Asthma education. Asthma educators may bill for-

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).

5. The annual limit for 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.

(E) Asthma Environmental Assessment.

1. An asthma environmental assessor may bill for an asthma environmental assessment non-physician, two (2) assessments per year.

2. 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.

3. In-home assessments for asthma triggers do not include remediation of issues identified in the home.

4. Annual limit for asthma environmental assessment services shall not exceed two (2) in-home environmental assessments.

(F) The prescribing provider will need to seek prior authorization for asthma education and in-home environmental assessment services from MO HealthNet prior to starting the program.

(G) Any additional asthma education and environmental in-home assessments beyond the initial allocation will need an additional prior authorization and be deemed medically necessary.

(3) Participant 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 exacerbation of asthma by meeting the following criteria:

(A) Be currently enrolled in MO HealthNet;

(B) Be twenty (20) years of age or younger; and

(C) Have had one (1) of the following events related to asthma in the last twelve (12) months:

1. One (1) or more inpatient hospital stays;

2. Two (2) or more Emergency Department (ED) visits;

3. Three (3) or more urgent care visits; or

4. One (1) ED 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.

(4) Provider Participation. To be eligible for participation as a provider in the MO HealthNet Asthma Education and In-Home Environmental Assessment services-

(A) All asthma education and in-home environmental assessment service providers must be enrolled as MO HealthNet providers; and

(B) 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.

1. Asthma Education-

A. Asthma educators must have the credentials set forth in this subsection-

(I) 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;

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

(a) Current and active National Asthma Educator Certification (AE-C).

I. These providers must maintain the national certification determined by The National Asthma Educator Certification Board; and

(b) State certification. The provider must have a current certificate from a Missouri state training program.

2. In-Home Environmental Assessments-

A. Asthma In-Home Environmental Assessors must have the credentials set forth in this subsection:

(I) 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;

(II) An In-Home Environmental Assessor must have one (1) of the following certifications in good standing:

(a) National Certification-

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

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

B. State Certification. The provider must have a current certificate from a Missouri state training program.

(I) A Missouri state certificate program means a 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.

(II) Mentor program for asthma educators. 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.

(5) Qualifying Academic University-based Centers function to track and ensure current certification of asthma education providers and asthma environmental assessors 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

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

(I) 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);

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

(III) 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

(IV) Track quality indicators and collect required outcomes data.

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.

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

(I) Serve as the contractor for the CDC NACP funded MAPCP;

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

(III) Staff providing the training must be a Certified Asthma Educator as recognized by the National Association of Asthma Educators; and

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

(a) Inhaled corticosteroid adherence;

(b) Inhalation technique;

(c) Environmental trigger reduction; and

(d) Importance of regular check-ups with assessment of lung function and asthma control.

13 CSR 70-25.150

Adopted by Missouri Register February 1, 2022/Volume 47, Number 3, effective 3/31/2022