Substantial Variation in Medicaid Coverage for Hematopoietic Cell Transplantation

Substantial Variation in Medicaid Coverage for Hematopoietic Cell Transplantation

Medicaid is a jointly funded federal-state program that provides payment for health services for pregnant women, children, parents, seniors and disabled individuals.  States establish and administer their own Medicaid programs and determine the type, amount, and scope of services within federal guidelines which mandate coverage of certain benefits.  Optional benefits that can be provided by the state can lead to a wide variation of benefits offered.  Hematopoietic cell transplant (HCT) is not a mandatory covered service for adults, and each state has the discretion to choose whether to cover it and the extent of the coverage. Variation in state policies can impact access to care for patients. At the same time, many patients rely on Medicaid for HCT coverage – according to HCUPnet data, Medicaid paid for 3,064 HCT hospitalizations (16% of HCT discharges) in the US in 2010. A national comparison of Medicaid coverage for HCT was undertaken to learn more about state variation.  Information on HCT coverage benefits for 2012 was collected from state Medicaid websites and was compared to the recommendations for minimum benefits that have been developed by the National Marrow Donor Program in collaboration with physicians, transplant centers and payors (www.marrow.org/payor).  Data was coded on a three point scale depending on whether individual state coverage met minimum benefits criteria (score 2), provided some but not minimum benefits (score 1), or did not provide any benefits (score 0) for the following 5 categories: 1) transplant procedure and disease indications, 2) donor search, 3) medications, 4) clinical trials, and 5) patient food, lodging and transportation. Data were available for 47 states (Figure). No state provided minimum coverage benefits in all 5 categories and only three states met the minimum in 4/5 categories. Our study highlights substantial variation in Medicaid coverage by state for HCT which may serve as a barrier to access to HCT for some patients.  In light of the Affordable Care Act and the determination of Essential Benefits by individual states, a common framework for complex medical procedures such as HCT may be beneficial.