Did you know... Florida Medicaid doesn't cover outpatient occupational therapy services for adult stroke survivors?
If you're here on TheBrainyOT site, odds are that you are someone who knows and loves a stroke survivor (or several). Today I am going to educate you a bit about the governing body responsible for this policy, the policy that excludes outpatient occupational therapy for adults, and what you can do to increase the accessibility of outpatient therapy services for yourself, your loved one, and/or your clients.
The Governing Body Responsible
Medicaid covers 68.8 million people in the United States per Medicaid's July 2020 Enrollment Report. Coverage applies to eligible low-income adults, children, pregnant women, elderly adults, and people living with disabilities. Some states have elected to expand Medicaid coverage to allow individuals that earn up to 138% of the federal poverty level to enroll in Medicaid. 12 states have not elected Medicaid expansion: Alabama, Georgia, Florida, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, & Wyoming (Kaiser Family Foundation, 2020).
Medicaid is partially implemented at the federal level by the Centers for Medicare and Medicaid Services (CMS). However, unlike Medicare which is governed solely at the federal level, Medicaid is the result of cooperative federalism. Cooperative federalism refers to the joint efforts from both state and federal governments as they work together for a common cause. Several federal mandatory guidelines are in place for all Medicaid plans, regardless of the state.
Per Medicaid (2020), mandatory benefits include the following:
Inpatient hospital services
Outpatient hospital services
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services (as a result, OT services are covered for individuals ages 0-20 nationwide)
Nursing Facility Services
Home health services
Physician services
Rural health clinic services
Federally qualified health center services
Laboratory and X-ray services
Family planning services
Nurse Midwife services
Certified Pediatric and Family Nurse Practitioner services
Freestanding Birth Center services (when licensed or otherwise recognized by the state)
Transportation to medical care
Tobacco cessation counseling for pregnant women
Did you notice a major part of the recovery process that was missing? Yes- rehabilitative services! Occupational therapy, like speech and physical therapy, is an optional benefit. This means that it is up to the states to factor in whether they will cover these services beyond the mandatory requirements put in place by CMS.
Per Medicaid (2020), additional optional benefits include the following:
Prescription Drugs
Clinic services
Physical therapy
Occupational therapy
Speech, hearing and language disorder services
Respiratory care services
Other diagnostic, screening, preventive and rehabilitative services
Podiatry services
Optometry services
Dental Services
Dentures
Prosthetics
Eyeglasses
Chiropractic services
Other practitioner services
Private duty nursing services
Personal Care
Hospice
Case management
Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
Services in an intermediate care facility for Individuals with Intellectual Disability
State Plan Home and Community Based Services- 1915(i)
Self-Directed Personal Assistance Services- 1915(j)
Community First Choice Option- 1915(k)
TB Related Services
Inpatient psychiatric services for individuals under age 21
Other services approved by the Secretary*
Health Homes for Enrollees with Chronic Conditions – Section 1945
Optional benefits, like occupational therapy, are decided upon individually by each state.
Exclusion Policy of Outpatient Occupational Therapy for Adults
At the time of this blog post, 45 states have elected to cover outpatient occupational therapy services for adults ages 21 and older. See the map below:
In addition to the U.S. capital, Washington D.C., the following states do not cover outpatient occupational therapy services:
Alabama
Arkansas
Florida
Lousiana
Maryland
The information regarding outpatient occupational therapy coverage for adults was gathered via each state's Medicaid policy manual.
Below, please find the verbiage of the Florida Medicaid coverage (or lack thereof) of occupational therapy services (Agency for Health Care Administration, 2019):
Notice that occupational therapy services are not covered for adult clients, but physical therapy is? When I reached out to ACHA to better understand the reason for this distinction and value of physical therapy over occupational therapy, the representative was unable to provide me with a reason. Occupational therapists: make your worth known!! Our clients benefit tremendously from our services and occupational therapy is the only spending category that reduces hospital readmissions according to Rogers et al. (2017).
This begs the following question: How can I secure medically necessary outpatient occupational therapy services for myself, my loved one, or my client in the states where coverage is excluded?
The following information will be specific to Florida Medicaid, as this is the state in which I live and the program that I have been able to research most extensively. Florida Medicaid does have a small population of individuals that can secure therapy services, despite their age.
Florida Medicaid waivers that enable outpatient occupational therapy coverage for adults include:
"The Long-Term Care program provides long-term care services and supports to eligible disabled individuals age 18-64 and elderly individuals age 65 or older, including individuals over the age of 18 with a diagnosis of cystic fibrosis, AIDS, or a traumatic brain or spinal cord injury. Program recipients receive their services through competitively selected managed care organizations." (Agency for Healthcare Administration, n.d.)
"The purpose of the Medicaid iBudget Waiver is to provide home and community-based supports and services to eligible persons with developmental disabilities living at home or in a home-like setting, utilize an individual budgeting approach, and provide enhanced opportunities for self-determination. The iBudget Waiver is designed to promote and maintain the health of eligible individuals with developmental disabilities, to provide medically necessary supports and services to delay or prevent institutionalization, and to foster the principles and appreciation of self-determination." (Agency for Healthcare Administration, n.d.)
As you can see, stroke survivors living in the community don't fall into either of the above-mentioned waiver programs. The Long-Term Care Waiver covers a range of specific diagnoses and states that the individual must require a nursing facility level of care. The Developmental Disabilities Individual Budgeting Waiver applies only to individuals with the following diagnoses: Down syndrome, cerebral palsy, Prader-Willi syndrome, spina bifida, epilepsy, and autism.
What Can You Do to Advocate?
Once again, the information presented in the preceding portion of this blog post is relevant to Florida Medicaid in particular. However, I urge you to explore your own state and the policies regarding outpatient occupational therapy reimbursement for adults, especially policies pertinent to stroke survivors. One alternative to your state Medicaid program for yourself, your loved one, or your client is to enroll in a Medicaid Managed Care program, if available in your state. Medicaid Managed Care programs may cover occupational therapy services in states where "straight" Medicaid does not (this is the case for many programs in Florida).
Another way to advocate is to write an email to your state Medicaid governing body. Below please find a link to submit a pre-written email to the Agency for Health Care Administration (AHCA), the administration responsible for Florida's Medicaid. I challenge you to click this link, modify the email to represent your unique relationship to the issue at hand, and add any information pertinent to your unique situation. Let's fight for coverage of outpatient occupational therapy for adult stroke survivors!
Thank you NeuroNerds! Stay Brainy!
-Crystal @TheBrainyOT
References:
Agency for Health Care Administration. (n.d.). Federal waivers. https://ahca.myflorida.com/Medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/index.shtml
Agency for Health Care Administration. (2019). Florida Medicaid outpatient hospital services. https://ahca.myflorida.com/medicaid/review/Specific/59G-4.160_Outpatient_Coverage_Policy_2019.pdf
Kaiser Family Foundation. (2020). Status of state Medicaid expansion decisions: Interactive map. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Medicaid. (2020). Mandatory & optional Medicaid benefits. https://www.medicaid.gov/medicaid/benefits/mandatory-optional-medicaid-benefits/index.html
Rogers, A. T, Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74(6). 668–686. https://pubmed.ncbi.nlm.nih.gov/27589987/