Case Studies and Resources

General Tools and Resources

Medicaid Provision of Preventive Services Regulation – Questionnaire to Prepare for a Dialogue with State Medicaid Officials
As states turn their focus to improving population health, and since community prevention programs provided by a broader array of health professionals generally have not previously been reimbursed by Medicaid, new tools and methods are needed to help in the implementation process. This questionnaire is designed to prepare advocates to engage in a dialogue with their state Medicaid officials about pursuing these new opportunities. [doc; Nemours]

Preparing for Reimbursement
Through the Affordable Care Act, the landscape for healthcare is changing quickly. Hear firsthand from Dr. Stephen Cha, Chief Medical Officer at the Center for Medicaid and CHIP Services, about the new Medicaid reimbursement provision for non-medical providers delivering preventive care services, and what asthma programs should consider when engaging their state Medicaid offices. [podcast; EPA]

Working towards Reimbursement: The Experience in Kansas City
Kevin Kennedy, Managing Director and Environmental Hygienist, Center for Environmental Health, Children’s Mercy Hospital and Clinics, describes the key steps his program is taking to prepare for reimbursement for home visitation and assessment services and how they are engaging with two state Medicaid offices. [podcast; EPA]

EPA Value Proposition Toolkit
A value proposition is a tool to help you communicate the unique value and benefits of your program to funders. It demonstrates that the health outcomes a program creates and the economic savings a program generates outweigh the program operating costs. Whether you are starting a new pilot project or you are a part of a well-established program, value propositions are effective tools to prepare your program for reimbursement as well as new funding streams. [url; EPA]

Effective Strategies for Obtaining Reimbursement
Hear ways that asthma programs may benefit from new opportunities in today’s changing healthcare landscape. Learn about the Medicaid reimbursement provision for non-medical providers delivering preventive care services and how to effectively engage your state Medicaid office and managed care plans on reimbursement for asthma care services. Hear recommendations and key steps taken by one program that advocated for and received approval from CMS for Medicaid reimbursement as a Targeted Case Management program. [webinar; EPA]

Affordable Housing’s Place in Health Care: Opportunities Created by the Affordable Care Act and Medicaid Reform
This report examines the ways healthcare changes created by the Affordable Care Act (ACA) and earlier Medicaid reforms have created the potential for affordable housing providers to collaborate with healthcare providers, insurers, and other institutions to support the well-being of low-income and vulnerable individuals and families. [pdf; National Housing Conference]

Case Studies

Reports that Describe Multiple Programs

Asthma Self-Management Education and Environmental Management: Approaches to Reimbursement
This document is a resource for asthma program managers and partner organizations who are considering options for implementing or redesigning reimbursement mechanisms to increase access to evidence-based asthma management practices. It describes challenges and successes in detail, provides program contact information, and includes a list of actions that have led to enhanced and expanded reimbursement for asthma services. [pdf; CDC]

Community-Based Prevention, Health Education, and Counseling in Medicaid
With a focus on diabetes and asthma, this memo looks at recent initiatives to prevent or delay the onset of chronic conditions, and to reduce their impact on patients’ health and health spending, through community-based programs, health education, and counseling targeted to at-risk individuals as well as diagnosed patients. It then considers existing options for providing these services within state Medicaid programs, and how CMS could encourage greater use of these approaches. [pdf; Nemours]

Another Link in the Chain Update: State Policies and Practices for Case Management and Environmental Investigation for Lead-Poisoned Children
This report describes the results of a 2001 survey conducted by the National Center for Healthy Housing to assess state policies and practices for case management and environmental investigation for lead-poisoned children. [pdf; NCHH]

Investing in Best Practices for Asthma: A Business Case
This report (updated in 2010) describes six evidence-based programs that are achieving their goals of bringing asthma under control cost-effectively. [pdf; Asthma Regional Council]

National Environmental Leadership Award in Asthma Management
The National Environmental Leadership Award in Asthma Management celebrates the outstanding programs and leaders who are improving the lives of people with asthma by delivering strong environmental asthma management as part of their comprehensive asthma care services. This website provides summaries of award-winning programs, including health plans and providers who have integrated environmental management into their practice and other programs who are reimbursed by payers to provide home-based environmental management of asthma triggers. [url; EPA]

Case Studies: The Benefits of Home Visits for Children with Asthma
NCHH collected success stories from multiple asthma home visiting services in Maryland, Michigan, Oregon, Pennsylvania, and Washington that illustrate the positive health outcomes and strong return-on-investment of such services. [pdf; NCHH]

A Case Study in Payment Reform to Support Optimal Pediatric Asthma Care
This case study explores the role of emerging payment models in supporting care redesign for patients with poorly controlled pediatric asthma. It describes the Community Asthma Initiative (CAI), a successful initiative developed at Boston Children’s Hospital that has culturally sensitive education and environmental remediation services to improve outcomes for high risk patients. The paper then goes on to review payment reforms in several states to assess how new models can support services similar to those offered by the CAI. [pdf; Brookings Institution]

Information about Individual States and Localities

CA: Medicaid Reimbursement for Home-Based Asthma Services in California
This case study summarizes the current healthcare financing landscape for home-based asthma services in California, emphasizing public financing. Based on survey findings and interviews with state Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

DC: Medicaid Reimbursement for Home-Based Asthma Services in the District of Columbia
This case study summarizes the current healthcare financing landscape for home-based asthma services in the District of Columbia, emphasizing public financing. Based on survey findings and interviews with Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

DE: Medicaid Reimbursement for Home-Based Asthma Services in Delaware
This case study summarizes the current healthcare financing landscape for home-based asthma services in Delaware, emphasizing public financing. Based on survey findings and interviews with state Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

MA: Massachusetts 2010 Appropriations Bill
The FY 2010 MA state budget included a provision directing Medicaid to establish a bundled payment for asthma care. The language begins on page 297 (Section 154) and includes the following passage: “…the global or bundled payments shall reimburse expenses necessary to manage pediatric asthma, including, but not limited to, patient education, environmental assessments, mitigation of asthma triggers and purchase of necessary durable medical equipment.” [url; Mass.gov]

Read a blog entry from AsthmaCommunityNetwork.org about this appropriations bill. [pdf; ACN, NCHH]

MI: Priority Health
In 1999, Priority Health partnered with the Asthma Network of Western Michigan (ANWM) to provide home-based case management for members in their service area with moderate to severe asthma. Priority Health reimburses ANWM for providing asthma education, conducting home assessments, meeting with providers to develop individual asthma management plans, working with social workers who provide social service referrals for members, and conducting in-service training for schools and daycare centers. A particular focus is reducing exposure to secondhand tobacco smoke, and implementing measures to reduce triggers in the home. [pdf; EPA]

MO: Medicaid Reimbursement for Home-Based Asthma Services in Missouri
This case study summarizes the current healthcare financing landscape for home-based asthma services in Missouri, emphasizing public financing. Based on survey findings and interviews with state Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

NY: New York State Medicaid Redesign
In October 2011, the Health Disparities Workgroup of the New York State Medicaid Redesign Initiative, announced their final recommendations to include promotion of population health through Medicaid coverage of primary and secondary community-based chronic disease preventive services. Among other conditions, the workgroup recommended that Medicaid be expanded to include coverage of lead poisoning and asthma home visits.

On April 14, 2014, Governor Andrew M. Cuomo announced that New York has finalized terms and conditions with the federal government for a groundbreaking waiver that will allow the state to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms. The waiver amendment dollars will address critical issues throughout the state and allow for comprehensive reform through a Delivery System Reform Incentive Payment (DSRIP) program. The DSRIP program will promote community-level collaborations and focus on system reform, specifically a goal to achieve a 25% reduction in avoidable hospital use over five years. Safety net providers will be required to collaborate to implement innovative projects focusing on system transformation, clinical improvement and population health improvement.

NY: Monroe Plan (Medicaid Managed Care in Rochester, NY)
This report describes an initiative to improve the health and health-related quality of life for children with asthma, to develop and sustain partnerships with key community stakeholders, and to institutionalize innovative clinical models in asthma care. This final narrative report outlines the experiences of the Monroe Plan in designing, implementing, and evaluating a sustainable approach to improving asthma care management that includes home environmental assessment. [pdf; Center for Healthcare Strategies, Inc.]

NY: Medicaid Reimbursement for Home-Based Asthma Services in New York
This case study summarizes the current healthcare financing landscape for home-based asthma services in New York, emphasizing public financing. Based on survey findings and interviews with state Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

OH: Medicaid Reimbursement for Lead Follow-Up Services in Ohio
This case study summarizes the current healthcare financing landscape in Ohio for lead follow-up services. The case study is based on survey findings and interviews with the state Medicaid agency, the state health department, and other stakeholders. It describes the current healthcare landscape, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

OR: State Plan Amendment for Targeted Case Management (Multnomah County, OR)
Multnomah County Environmental Health used this State Plan Amendment (SPA) to add their Targeted Case Management-Healthy Homes Program to Oregon’s state plan under Title XIX of the Social Security Act-Medical Assistance Program. As part of the process involved in the submission of this SPA, Oregon state submitted a waiver to CMS to waive certain federal requirements, including the ability to get reimbursement for community health workers. This process was discussed in a February 13, 2014, webinar hosted by AsthmaCommunityNetwork.org, Effective Strategies for Obtaining Reimbursement. [url; EPA]

RI: Medicaid Reimbursement for Lead Follow-Up Services in Rhode Island
This case study summarizes the current healthcare financing landscape in Rhode Island for lead follow-up services. The case study is based on survey findings and interviews with the state Medicaid agency, the state health department, and other stakeholders. It describes the current healthcare landscape, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

SC: Medicaid Reimbursement for Home-Based Asthma Services in South Carolina
This case study summarizes the current healthcare financing landscape for home-based asthma services in South Carolina, emphasizing public financing. Based on survey findings and interviews with Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

TX: Medicaid Claims Process for Lead Poisoning Follow-Up Services

Reimbursement for Healthy Homes Services: A Case Study of Leveraging Existing Medicaid Authority in Texas
This brief outlines the two Medicaid claims processes that generate reimbursements to partially support the Texas Childhood Lead Poisoning Prevention Program (TxCLPPP). TxCLPPP began filing claims filing process for Environmental Lead Investigations (ELIs) in 2011 and filed their first Medicaid Administrative Claim in the last federal quarter of 2011. [pdf; NCHH]

TxCLPPP Job Description Summaries for Medicaid Administrative Claiming
This document provides descriptions of staff positions within the TxCLPPP that provide allowable/reimbursable activities and functions. This document was provided to CMS. [pdf; TxCLPPP]

Letter to Regional CMS Administrator Regarding Medicaid Administrative Claiming for Lead Poisoning Follow-up Services
You may also read an example of the communication and justification from the State Medicaid Director notifying CMS of the state’s intent to add TxCLPPP staff to the State’s Medicaid Administrative Claim.
[pdf; TxCLPPP]

Medicaid Manual Governing Claims for Environmental Lead Investigations in TX
Environmental lead investigations (ELIs) are a required Texas Health Steps (THSteps) benefit for clients birth through 20 years of age with elevated blood lead levels (EBLL). [pdf; TxCLPPP]

TX: Project TEACH (Targeting Environmental Aspects of Children’s Health)
Project TEACH is funded through the Delivery System Reform Incentive Payment (DSRIP) pool created under Texas’s 1115 Healthcare Transformation waiver. Project TEACH is designed to improve access to care through collaborative efforts and promote transformation of the healthcare delivery system. The primary goal of TEACH is to identify and educate children and families about environmental hazards in the home that can potentially expose them to lead and asthma triggers in an effort to improve the overall quality of life of our clients. [doc]

VT: Medicaid Reimbursement for Home-Based Asthma Services in Vermont
This case study summarizes the current healthcare financing landscape for home-based asthma services in Vermont, emphasizing public financing. Based on survey findings and interviews with Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]

WA: Medicaid Reimbursement for Home-Based Asthma Services in Washington
This case study summarizes the current healthcare financing landscape for home-based asthma services in Washington, emphasizing public financing. Based on survey findings and interviews with Medicaid agencies, state health departments, and other stakeholders, it describes the current state of healthcare, other important funding mechanisms, key barriers, next steps, and lessons learned. [pdf]