July 9, 1998 98-R-0735
FROM: Jerome Harleston, Senior Attorney
RE: HMO Coverage of Asthma-related Treatment and Services
You want to know the types of covered services HMOs provide for the treatment and management of asthma.
HMOs provide a wide variety of services for the treatment of asthma depending on the condition's severity. Most HMOs participate in the BREATHE (Better Respiration Equals Asthma Treatment and Health Education) program, which (1) identifies current practice guidelines for treating asthma patients, (2) educates physicians, case managers, specialty nurses, hospitals, and patients about asthma, and (3) offers nurse case managers to work with patients who have frequent and severe asthma attacks.
HMOs provide a comprehensive asthma education program in which patients are taught (1) basic facts about asthma; (2) inhaler, spacer, and holding chamber techniques; (3) about medications and their side effects; (4) how to develop a self-management plan for when and how
to take emergency action; (5) appropriate environmental control measures to avoid exposure to known allergens and irritants; and (6) self-monitoring.
Patients who suffer from mild intermittent asthma may get relief through the use of covered drugs like inhaled beta 2-agonist or sodium cromoglycate or nedocromil. Others may require allergen exposure.
Patients who suffer from mild persistent asthma may take daily covered medication of (1) anti-inflammatory agents like corticosteriod, cromolyn, or nedocromil; (2) sustained-release theophylline; or (3) leuotriene modifiers. These patients may also be considered for referral to a specialist if control of the condition is not achieved.
Patients with moderate persistent asthma may take daily increased dosage of the anti-inflammatory medication corticosteriod and a long-acting bronchodilator for nighttime symptoms. They may also be considered for specialist referral. Severe persistent asthma patients are treated in much the same ways as patients with moderate persistent asthma except that they may ultimately need to take steroids. Referral to a specialist is highly recommended for these patients.
Patients who have a confirmed diagnosis of asthma and are under pharmaceutical management are referred to a specialist for asthma treatment if they experience one or more of the following within one year: (1) hospitalization or two emergency-room visits with a diagnosis of asthma, (2) three or more visits to primary care physician for emergency treatment requiring nebulization (a device driven by a small air compressor that allows asthma medication to be inhaled), (3) a condition that causes substantial interference with their quality of life (e.g., school or work loss, inability to participate in sports, nocturnal asthma, significant side effects from medications), (4) three or more daily medications, (5) potential allergic component that would benefit from immunotherapy, (6) chronic coughing lasting more than two months, (7) use of beta 2-agonist four or more times per week along with anti-inflammatory medication, (8) use of daily oral steroids for more than two weeks or (9) excess liability in pulmonary function with the use of anti-inflammatory medications.
Some plans require the purchase of durable medical equipment (DME) rider for reimbursement for the purchase of a areochamber-mask. Most plans cover nebulization.