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Medicaid Contract Purchasing Specifications

For Care of Individuals With Asthma

A TECHNICAL ASSISTANCE DOCUMENT

(October 2003)

Part 1. Services Related to Asthma

§101. In General
§102. Scope of Benefit
§103. Diagnostic and Treatment Services for Enrollees with Asthma
§104. Pharmacotherapy Services for Enrollees with Asthma
§105. Asthma-Related Health Education Services
§106. Asthma-Related Tobacco-Use Counseling Programs
§107. Asthma-Related Case Management Services
§108. Guidelines
§109. Coverage Determination Standards and Procedures
§110. Definitions

§101. In General

(a) Duty to Identify Enrollees With Asthma - Contractor, and each provider participating in Contractor's provider network, shall:

(1) comply with the requirements of §103(a) to identify newly enrolled individuals with asthma;

(2) make reasonable efforts to identify other enrollees with asthma; and

(3) ensure that such information regarding whether an individual is an enrollee with asthma is recorded in the enrollee's medical file.

(b) Basic Service Duty - Contractor shall, for each enrollee with asthma, cover and furnish, or arrange for the furnishing of, the items and services enumerated in §102(a) in accordance with:

(1) the guidelines enumerated in §108; and

(2) the coverage determination standards and procedures under §109.

(c) Delivery of Services - Contractor shall furnish, or arrange for the furnishing of, items and services covered under §102(a) for each enrollee with asthma in accordance with the requirements for delivery of services enumerated in Part 2.

§102. Scope of Benefit

(a) Covered Items and Services - Contractor shall furnish, or arrange for the furnishing of, to each enrollee with asthma:

(1) items and services enumerated in subsection (b) that are not excluded from coverage under subsection (c); and

(2) asthma case management services described in §107.

(b) Items and Services - The items and services covered under this purchasing agreement are:

(1) Diagnostic and Treatment Services described in §103;

(2) Pharmacotherapy Services described in §104;

(3) Health Education Services described in §105;

(4) Tobacco-Use Counseling Services described in §106 ;

(5) Vaccinations for influenza, in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP) and the National Asthma Education and Prevention Program;

(6) Referral and consultation services for pregnancy-related services for enrolled individuals with asthma; and

(7) Other services (Drafter: Insert other services specified by Purchaser) .

(c) Items and Services Not Covered

(1) Complementary alternative medicine, including acupuncture, homeopathy, and herbal medicine;

(2) Other services (Drafter: Insert other services specified by Purchaser)

§103. Diagnostic and Treatment Services for Enrollees with Asthma

(a) Identification of Newly Enrolled Individuals with Asthma - Contractor shall ensure that:

(1) each provider participating in Contractor's provider network determines at the first encounter whether an enrollee presents with a history of asthma or asthma-like symptoms; and

(2) each primary care or pediatric provider participating in Contractor's provider network conducts an initial assessment (as described in subsection (b)) to establish or verify an asthma diagnosis at the first encounter and gathers and reviews previous medical records for each enrollee.

(b) Initial Assessment - Contractor shall require each primary care or pediatric provider participating in Contractor's provider network to:

(1) take a complete medical history of each enrollee at the first encounter to determine whether the enrollee has experienced or is currently experiencing episodic symptoms of airflow obstruction (e.g., wheezing, shortness of breath, tightness in the chest or cough) which vary throughout the day or occur or worsen at night; and

(2) conduct a physical examination to evaluate the enrollee for wheezing, hyper-expansion of the chest, use of accessory muscles and respiratory rate and to check for signs of other allergic diseases (e.g., atopic dermatitis/eczema, swelling of and/or nasal mucosa, clear nasal discharge).

(c) Diagnosis of Asthma - If, after the initial assessment conducted under subsection (b), asthma is suspected, the provider should perform additional diagnostic steps in accordance with the Guidelines described in §108 to establish a clear diagnosis of asthma, including the following:

(1) (A) For adults and children over 5 years of age, these steps must include:

(i) documenting reversible airflow using spirometry to evaluate airflow obstruction,

(ii) establishing a pattern of symptoms and history of recurrent episodes, and

(iii) ruling out other conditions.

(B) For children under 5 years of age, the provider should rely on clinical judgment and response to asthma treatment for the diagnosis.

(i) Young children with asthma symptoms should be treated as suspected enrollees with asthma.

(ii) The provider should supplement the medical history and physical examination required under subsection (b) for children described in clause (i) by inquiring about allergies, family history of asthma and perinatal exposure to aeroallergens and passive smoke.

(2) Classification of Asthma Severity

(A) The severity of the symptoms and signs of asthma must be classified in accordance with the classification system established in the Guidelines described in §108 and the severity classification is recorded in the enrollee's medical record.

(B) Asthma severity classification should be established at the initial visit and reevaluated at each subsequent visit to ensure proper treatment.

(C) Classification should be assigned as the most severe category in which any degree of symptoms occurs along with findings from peak flow testing or spirometry and the type and amount of medications being taken.

(d) Treatment of Asthma

(1) If it is determined that the enrollee needs additional tests to aid or confirm an asthma diagnosis, Contractor shall ensure that these services are provided in accordance with the Guidelines described in §108;

(2) If the enrollee has been diagnosed with asthma, Contractor shall ensure that care for each such enrollee is provided in accordance with the Guidelines described in §108 under an individual treatment plan described in §107(b) and developed in consultation with and through referrals to an experienced asthma provider (as defined in §110) ;

(3) In accordance with the Guidelines described in §108, Contractor shall ensure that routine follow-up care is provided for enrollees with asthma, including:

(A) physicians visits at least every 1 to 6 months, based on severity;

(B) spirometry performed at least every 1-2 years in the stable patient and more frequently in the unstable patient; and

(C) review of medication use, the enrollee's treatment plan and self-management skills at every visit; and

(4) Contractor shall ensure that access to specialty care is provided consistent with §201(a) and the Guidelines described in §108. 1

(e) Control of Factors Contributing to Asthma Severity - Contractor shall ensure that, consistent with the Guidelines described in §108, primary care providers and pediatricians participating in Contractor's provider network:

(1) recommend measures to control asthma "triggers," including:

(A) determining exposures and sensitivities to irritants and allergens through appropriate skin and blood testing and assessing ways to reduce exposures to these irritants and allergens; 2

(B) assessing enrollee for exercise induced bronchoconstriction (EIB); and

(C) discussing smoking avoidance with every enrollee who smokes or who is exposed to environmental tobacco smoke (ETS);

(2) provide appropriate referrals to providers of specialty services on an expedited basis when, including referrals to appropriate mental health professionals for counseling and treatment for enrollees with significant psychiatric, psychosocial, or family problems that interfere with their asthma treatment; and

(3) treat/prevent co-morbid conditions, focusing in particular on rhinitis, sinusitis, gastro-esophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD).

(f) Covered Diagnostic and Treatment Items and Services - In addition to the pharmacotherapy services described in §104, the health education services described in §105 and the tobacco-use counseling services described in §106 , the following items and services necessary for the diagnosis and treatment of asthma are covered:

(1) allergy testing;

(2) chest X-rays;

(3) inhalers and spacing devices;

(4) peak flow meters;

(5) other devices and supplies for patient self-monitoring;

(6) outpatient services;

(7) physician services;

(8) inpatient services;

(9) oxygen;

(10) immunotherapy;

(11) dust mite covers;

(12) nicotine patches and other supplies required in connection with tobacco-use counseling programs described in §106; and

(13) [Drafter: Insert other services specified by Purchaser]

§104. Pharmacotherapy Services for Enrollees with Asthma

Contractors shall ensure that, consistent with the Guidelines described in §108 , primary care providers and pediatricians participating in Contractor's network prescribe medication according to the severity of the enrollee's asthma and monitor each enrollee's beta2-agonist use.

(a) Enrollees 5 Years of Age or Younger with Asthma 3 - As determined by the treating physician and in accordance with the Guidelines described in §108, the following prescription drugs shall be provided to enrollees five (5) years of age or younger with mild or moderate persistent asthma:

(1) Inhaled corticosteroids with nebulizer, metered-dose inhaler (MDI) with holding chamber, with or without a face mask or Dry-powder inhaler (DPI);

(2) Corticosteroid tablets or syrup;

(3) Inhaled short-acting ß2 agonist;

(4) Inhaled long-acting ß2 agonist; and

(5) Any other drugs, not on Contractor's formulary, that are prescribed by the treating physician in accordance with the Guidelines described in §108 and are pre-approved by Contractor.

(b) Enrollees Older Than Age 5 with Asthma - As determined by the treating physician and in accordance with the Guidelines described in §108, the following prescription drugs must be provided to enrollees over age five (5) with asthma:

(1) Inhaled corticosteroids (e.g., high, medium and low dose formulations);

(2) Systemic corticosteroids (e.g., high, medium and low dose formulations corticosteroid tablets or syrup);

(3) Inhaled long-acting β2-agonists;

(4) Inhaled short-acting β2-agonists; and

(5) Any other drugs, not on Contractor's formulary, that are prescribed by the treating physician in accordance with the Guidelines described in §108 and are pre-approved by Contractor.

(c) Monitoring Safety and Side Effects of Medications - Contractor shall establish a program to monitor the use of covered pharmocotherapies to ensure that they are prescribed in accordance with the Guidelines described in §108.

(d) Drug Formulary Updates - Contractor shall assess the sufficiency of its drug formulary in the area of asthma treatment and shall update the formulary no less frequently than [Drafter: Insert time frame specified by Purchaser] in accordance with the Guidelines described in §108.

§105. Asthma-Related Health Education Services

(a) In General - Contractor shall provide education on patient self-management to enrollees with asthma, either through the inclusion of:

(1) certified health education specialists (CHES); or

(2) certified nurses who have formal training and experience in the treatment of asthma and are active in relevant continuing education activities in Contractor's provider network or through a requirement that each network provider carry out asthma-related health education functions.

(b) Asthma-related Health Education Services Defined - Asthma-related health education services shall include:

(1) instruction about asthma and asthma triggers;

(2) how and why to take long-term control and quick relief medications;

(3) demonstrations concerning correct technique for use of inhalers and spacing devices to dispense medications, peak flow meters, and nebulizers;

(4) instructions about peak flow and symptom monitoring with patients, when appropriate,

(5) instructions about factors that worsen asthma, how to practice allergen avoidance, and actions enrollees and their family can take to control asthma attacks; and

(6) the development of an written asthma management individual treatment plan (as described in §107(b)).

(b) Duty to Provide Services - Asthma-related health education services shall be provided to each enrollee with asthma, and in the case of an enrollee with asthma who is a child, to family members or other caregivers of such enrolled child.

(c) Duty to Include Enrollee in Development of Individual Treatment Plan - Contractor shall ensure that enrollees with asthma, their family members and other caregivers are involved in the development of such enrollees' written asthma management individual treatment plan (as described in §107(b)).

§106. Asthma-Related Tobacco-Use Counseling Programs 4

(a) In General - Contractor shall ensure that tobacco-use counseling programs are available and accessible to:

(1) enrollees with asthma;

(2) family members of enrollees with asthma, if they are enrolled with Contractor; and

(3) other individuals enrolled with Contractor whose smoking interferes with the treatment for an enrollee with asthma or increases the severity of the enrollee's asthma.

(b) Information on Availability of Tobacco-Use Counseling Programs Programs - Contractor shall:

(1) provide information on the availability of tobacco-use counseling programs for enrollees with asthma and their enrolled family members and other caregivers in materials furnished to new enrollees;

(2) ensure that providers participating in Contractor's provider network remind enrollees with asthma of the availability of such programs at every visit; and

(3) ensure that the availability and coverage of tobacco-use counseling programs is advertised to enrollees and providers participating in Contractor's provider network at least annually, either as part of any general communication to enrollees or providers or as a separate communication.

(c) Referrals to Tobacco-Use Counseling Programs - In the initial encounter with an enrollee with asthma, the treating physician shall determine whether the enrollee or other family members uses tobacco. If so, treating physician shall advise the enrollee or other individual to quit, and if the enrollee or other individual indicates a willingness to quit, refer such individual (if the individual is an enrollee) to a tobacco-use counseling program.

(d) [Drafter: Choose one of the following options as specified by the Purchaser]

Option #1:

Contracting With and Payment To State or Local Health Departments - Contractor shall contract with [Drafter: Insert name of state or local health department program that offers telephone quit line counseling program] to ensure access and availability for enrollees with asthma who smoke and their family members and other caregivers who smoke and who are enrollees and shall reimburse such department for the costs associated with the enrollment in such programs of enrollees' under Contractor's plan.

Option #2:

Contracting With State or Local Health Departments - Contractor shall contract with [Drafter: Insert name of state or local health department program that offers telephone quit line counseling program] to ensure access and availability for enrollees with asthma who smoke and their family members and other caregivers who smoke and who are enrollees

§107. Asthma-Related Case Management Services

(a) In General - Contractor shall operate an asthma management program designed to proactively manage all enrollees with asthma. At a minimum, components of the asthma program shall include, but not be limited to:

(1) educational programming for enrollees and their families or foster parents which is designed to involve enrollees in self-care and care provided by the enrollee's family or caregiver;

(2) educational programming for providers participating in Contractor's network on the treatment of asthma;

(3) a proactive approach to managing asthma, with an emphasis on outpatient management of asthma;

(4) periodic assessment and monitoring to establish whether the goals of asthma therapy have been achieved; and

(5) measurement of the case management program's effectiveness in improving the management of asthma consistent with the requirements of §§206 and 207 .

(b) Written Asthma Management Individual Treatment Plan for Enrollees with Asthma - As required under §103(d) and as part of its Asthma Management Program , Contractor shall ensure that a written asthma management individual treatment plan is developed and implemented for each enrollee with asthma under the direction of the enrollee's primary care provider or an experienced asthma provider participating in Contractor's provider network. The plan should be reviewed and adjusted, as needed, at every subsequent visit. At a minimum, the treatment plan shall:

(1) reflect agreement between the provider and the enrollee on the goals of therapy;

(2) indicate the severity of the enrollee's asthma (e.g., mild intermittent, mild persistent, moderate persistent or severe persistent);

(3) outline the daily treatment and monitoring measures, including medication use, by specifying the items and services covered under §103 and 104 that are appropriate to the health needs of the enrollee with asthma;

(4) specify the manner in which and the providers through whom, the items and services under paragraph (2) shall be furnished to the enrollee with asthma;

(5) in the case of an enrollee with moderate or severe persistent asthma, provide for referrals to consult with an experienced asthma provider (e.g., an allergist, pulmonologist or physician with expertise in asthma management) [Drafter: may insert additional optional language as directed by Purchaser: "and to provide for a standing referral to an experienced asthma provider." ] ;

(6) in the case of an enrollee who has been referred to an experienced asthma provider, provide that such patient be co-managed by the referring provider or monitored by the referring provider in accordance with the experienced asthma provider's written treatment regimen;

(7) provide an enrollee with asthma with a written copy of the asthma management individual treatment plan and training on how to follow the plan (in the case of a child, a copy of the plan must also be given to parents and every other care-giver for the child; in addition, parents of enrollees with asthma shall be encouraged to provide a copy of the plan to the child's school);

(8) provide for an assessment of any environmental or other factors that may contribute to asthma severity and identify all reasonable steps that must be taken to reduce the effect of these factors;

(9) specify the steps necessary to handle worsening symptoms and exacerbations, including how to obtain additional treatment as needed; and

(10) provide for the referral of the enrollee to any other providers or specialists necessary to treat other medical conditions of the enrollee that might interfere with or exacerbate control of asthma (including referrals for services that are not otherwise covered by Medicaid).

§108. Guidelines

(a) In General - Contractor shall structure its coverage of asthma-related treatment to conform with:

(1) The National Asthma Education and Prevention Program's Expert Panel 2 (NAEPP Expert Panel 2) Clinical Guidelines, described in the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, National Institutes of Health (NIH) Publication No. 97-4051, Bethesda, MD 1997; 5

(2) Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics 2002Update 2002: Expert Panel Report. 6

(3) MMWR Recommendations and Reports , Volume 52, Number RR-6, Key Clinical Activities for Quality Asthma Care: Recommendations of the National Asthma Education and Prevention Program (NAEPP) 7and

(4) Updated versions of the above documents.

(b) Tobacco-Use Guidelines - Contractor shall structure its coverage of tobacco-use related services for enrollees with asthma to conform to the most recent version of the following Consensus Public Health Service Guideline: Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline . Rockville, MD: U.S. Department of Health and Human Services. June 2000. 8

§109. Coverage Determination Standards and Procedures

(a) In General - Contractor shall comply with the requirements of this section relating to the determination of whether an item or service enumerated under §102(a) is covered with respect to an enrollee with asthma. Coverage of each item and service enumerated under §102(a) shall be sufficient in amount, duration and scope to reasonably achieve its purpose.

(b) Use of Prior Authorization Procedures for Services Provided in the Written Asthma Management Individual Treatment Plan - Contractor shall not impose any requirement for prior authorization or otherwise limit coverage with respect to:

(1) items and services authorized under the enrollee's written asthma management individual treatment plan described in §107(b) ; and

(2) emergency or urgent care services related to an enrollee's diagnosis or treatment of asthma.

(c) Determinations of Medical Necessity by Contractor - Contractor shall determine the medical necessity of items and services enumerated in §102 as covered services for the diagnosis and treatment of asthma based on the following evidence:

(1) the enrollee's health status;

(2) clinical evidence of asthma;

(3) the opinion and recommendation of the physician furnishing diagnostic and treatment services;

(4) evidence and information provided by the enrollee;

(5) the enrollee's medical record and accompanying supporting documents;

(6) the guidelines enumerated in §108;

(7) opinions of medical practitioners who are experienced in the treatment of asthma or other conditions similar to that of the enrollee with respect to whom a coverage determination is being made; and

(8) professional standards of medical care practice related to the coverage determination that is being made, as reflect in scientific literature published in peer-reviewed journals, results of relevant clinical trials, government-sponsored studies; professional consensus statements; and other sources of valid and reliable clinical evidence regarding the standard of care for individuals with asthma (providing that such sources are free from conflicts of interest).

§110. Definitions

(a) "Asthma education" means providing appropriate information to (1) an enrollee with asthma, and (2) family members and other caregivers of an enrollee with asthma about asthma facts, medications, device and monitoring skills and environmental control measures.

(b) "Asthma management program" means a comprehensive approach toward the patient with asthma that includes knowledge assessment, skill demonstration and education, which includes a written asthma management individual treatment plan for long-term control and treatment of exacerbations (including a description of the role of medications in the plan).

(c) "Experienced asthma provider" means a fellowship-trained, board-eligible or certified allergist or pulmonologist. In certain situations, this may mean other physicians with expertise in asthma management.

(d)[Drafter: Insert other definitions specified by Purchaser]


  1. Primary care physicians should work in partnership with experienced asthma providers to develop a system of co-management and/or consultation to ensure that enrollees with asthma are monitored and treated based on the severity of their asthma.
  2. Clinicians should use whatever testing mechanisms are available locally to aid in the documentation of allergic sensitivities. Although skin testing is the most common approach used by providers, it is time consuming, requires large number of perishable antigen solutions, demands careful and consistent technique and carries an unavoidable risk of potentially lethal anaphylactic reaction. Interested and informed primary care practitioners can perform skin testing, but many refer patients to an allergist or pulmonologist. Blood RAST (Radioallergosorbent test) is available through commercial laboratories and, in general, is more expensive than skin testing. Though technically difficult, RAST testing has reproducible results when performed by a reliable laboratory. The reported findings must be interpreted in light of the individual patient's clinical history. This form of testing is useful for patients not suitable for skin testing: those with severe skin conditions, those on long-acting antihistamine or tricyclic antidepressant medications who have used and are unable to discontinue these medications, and those who are unable to cooperate with skin testing or at risk for anaphylaxis with skin testing. Based on local resources and the patient, the clinician should determine which allergic testing mode is suitable. SE Guzman, Diagnosis and Management of Allergic Rhinitis: AFP Monograph No. 3, 2001.
  3. The Expert Panel's report is available at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm ,
  4. For more detailed description of possible purchasing requirements for enrollees with asthma who smoke, see Sample Purchasing Specifications for Care of Enrollees Who Use Tobacco , Center for Health Policy Research, The George Washington University School of Public Health and Health Services available at www.gwhealthpolicy.org .
  5. These guidelines are available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm .
  6. This document is available at: available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm .
  7. This document is available in PDF format at http:///www.cdc.gov/mmwr/PDF/rr/rr5206.pdf . In.html format, it is available at http://www.cdc.gov/mmwr/preview/mmw.html/rr5206a1.htm .
  8. This document is available at: www.surgeongeneral.gov/tobacco/default.htm ;

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