Assuring Access to Covered Medicaid Services

January 4, 2016

Andrew Slavitt, MBA
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services, Room 445G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201

Dear Mr. Slavitt,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit these comments to the Centers for Medicare and Medicaid Services (CMS) at the U.S. Department of Health and Human Services (HHS) related to its November 2, 2015 final rule with comment "Medicaid Program; Methods for Assuring Access to Covered Medicaid Services." Representing more than 90,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Every day we work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research. We are committed to evidence-based strategies for improving the nation's health through food and nutrition, including as providers of covered Medicaid services in many states.

The Academy largely supports the final rule with comment period and offers the below recommendations for improving data collection and assuring access to covered Medicaid services.

A. CMS's Role in Preventing and Treating Chronic Disease in the Medicaid Population

Medicaid and the Children's Health Insurance Program (CHIP) provide health care coverage for 71,566,548 Americans as of September 2015, or almost 25 percent of the American population.2 The Kaiser Commission on Medicaid and the Uninsured ("Kaiser Commission") notes the high rate of Medicaid beneficiaries afflicted with chronic conditions. Specifically, "[n]early one in ten low-income, non-elderly adult Medicaid beneficiaries have been diagnosed with diabetes, more than two in ten with chronic obstructive pulmonary disease, [and] nearly three in ten with heart disease."3

As a result of the U.S. Supreme Court decision in Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (2015), CMS remains the sole entity able to enforce and ensure states are providing the minimally required level of beneficiary access to covered Medicaid services. As this final rule with comment notes, "[t]he lack of a private right of action underscores the need for stronger non-judicial processes to ensure access, including stronger processes at both the state and federal levels for developing data on beneficiary access and reviewing the effect on beneficiary access of changes to payment methodologies." Thus, without a judicial process by which beneficiaries or stakeholders can demand compliance with statutory requirements, it is necessary to focus on "the primacy of CMS's role in ensuring access." We agree with CMS that, "To give meaning to coverage requirements and options, beneficiaries must have meaningful access to the health care items and services that are within the scope of the covered benefits," consistent with the requirements of section 1902(a)(30)(A) of the Act.

B. Ensuring Access to Covered Services

The Academy agrees with CMS that the requirements of this final rule with comment period should be considered as "a component of a broader strategy to ensure access in the Medicaid program." We offer solutions to achieve this strategy, with the understanding that adequate access to care cannot be determined by simply examining rates alone. As provided in the final rule with comment period, "[u]nder the [Social Security] Act, rates are neither economic nor efficient if they do not also ensure that individuals have appropriate access to covered services." CMS rightfully confirms that "access to care is not always about payment rates but rather that when enough providers are enlisted in the program, states may need to find ways to connect beneficiaries with the care and services they need." Thus, measurement of adequate access to care is also determined by the presence of definitively robust (rather than perfunctory) coverage of services, consideration of the availability of qualified and effective providers, the actual utilization of covered services, and the experiences of beneficiaries.

1. Services (Theoretically) Covered for Various Medicaid Beneficiaries?

Coverage of preventive services for Medicaid beneficiaries varies widely among and within states depending upon beneficiaries' age and eligibility. As the Kaiser Commission notes, "[u]nder Medicaid, states must cover preventive services for children, while coverage of preventive services for adults in Medicaid has historically been considered optional."4 Whether covered as medically necessary primary care-relevant services for children, covered by states as optional services for adults, or mandated as U.S. Preventive Services Task Force (USPSTF)-recommended preventive services for adults eligible for Medicaid as a result of its expansion pursuant to the Affordable Care Act, beneficiaries have access to significantly different covered services. Unfortunately, data are presently unavailable to ascertain how, why, where, and to what extent the variations exist.

2. Present Unavailability of Consistent, Quality Data

The Academy supports CMS "requiring that states review data and trends to evaluate access to care for covered services and conduct public processes to obtain public input on the adequacy of access to covered services in the Medicaid program." In addition, we support the flexible framework proposed in this final rule with comment period to document measures supporting beneficiary access to services, which we agree should be effective in obtaining comprehensive, usable data focusing on the three goals outlined by CMS:

  • The extent to which enrollee needs are met;
  • The availability of care and providers; and
  • Changes in beneficiary utilization.

The Academy shares the consistent, ongoing frustrations of HHS,5 MACPAC,6 the Kaiser Commission,7 and other researchers who have sought to definitively identify the extent and scope of coverage for Medicaid services, particularly primary care-relevant preventive services. Neither the Academy's research nor that obtained by others has been successful in comprehensively or accurately assessing access, utilization, and efficacy. For a variety of reasons detailed below, the Academy believes only CMS — despite its previous difficulties9 — has the authority and ability to work with each and every state to demand and tabulate necessary data related to beneficiary access to covered Medicaid services.

a. Uncertainty and Variety of Coverage for Obesity-Related Services

It is the Academy's experience and conclusion after reviewing available research that coverage for obesity-related services is particularly varied and ill-defined among states and among beneficiary categories. HHS recognizes obesity-related services as "those services that help address unhealthy weight. Medicaid and CHIP programs can cover a range of services to prevent and reduce obesity including Body Mass Index (BMI) screening, education and counseling on nutrition and physical activity, prescription drugs, and surgery."10 Coverage of those services, however, may either be predicated upon either their medical necessity (for children and some adults eligible through traditional Medicaid) or mandated as A or B rated recommendations from USPSTF. And, as detailed below, coverage for counseling is not necessarily included after a screening reveals a patient has obesity, nor do covered counseling services and the counseling necessarily comport with national clinical guidelines or USPSTF recommendations.

The Academy earnestly hopes that this final rule with comment period will finally provide the basis by which one might actually be able to accurately identify the nature and scope of states' actual coverage of primary care-relevant preventive services, which is essential to any accurate assessment of beneficiaries' access to these mandated and medically necessary services. At present and to the extent it can be known, these medically necessary and USPSTF-recommended services are not being covered as anticipated and needed. In 2014, HHS concluded from available research and surveys that,

Coverage of obesity-related preventive services was less widespread. In a 2011 survey of state Medicaid programs, the Kaiser Commission on Medicaid and the Uninsured found that 35 states cover both obesity screening and healthy diet counseling in their fee-for-service program. A 2012 review of Medicaid state plans found that only 19 states specified coverage of healthy diet counseling and 17 specified coverage of obesity screening in both managed care and fee-for-service programs. (While additional states may cover these services as well, it was difficult to ascertain the policies based on state plan review.)"11

Even if surveys reveal that states technically provide some measure of coverage for obesity-related services, there is little evidence to suggest that many states' coverage truly resemble national clinical guidelines or associated USPSTF recommendations such that they are likely to produce the desired results. For example, USPSTF member David Grossman stated that the USPSTF's recommendation for screening for obesity and concomitant intensive counseling (either at the doctor's office or after referring patients out for weight-loss help) "found 12 counseling sessions was the minimal amount needed for significant weight loss, but we didn't see any benefits to going for over 26 sessions."12 From available research, few if any states cover the minimal number of sessions needed to make an impact.

Despite the clarity of this recommendation both from task force members and the detailed USPSTF recommendation itself, CMS inexplicably (and without any proffered rationale) dramatically limited the scope of preventive services states are required to cover to receive additional federal matching funds in published "Questions & Answers on ACA Section 4106: Improving Access to Preventive Services for Eligible Adults in Medicaid."13 Even though the USPSTF recognizes that the intensity and frequency of services, the location at which services are provided, and the provider's qualifications are essential to successful, effective care, CMS has to date wholly disregarded these factors in its sub-regulatory guidance. The Academy questions the unspecified reasons behind, and fundamentally disagrees with, CMS's answer to Question 28 in the guidance document, which stated that, "Provided that the services are medically necessary, states are required to follow only the summary of recommendations for the services that have a rating of A or B from the USPSTF."14 However, as the detailed USPSTF recommendations and USPSTF members' analyses make clear, USPSTF summary recommendations neither encapsulate the scope, frequency, intensity, or providers needed to produce desired results and is thus insufficient to assure actual access to these effective, recommended services.

For example, the USPSTF recommends the following as elements of effective obesity prevention and treatment:

  • "Although intensive interventions may be impractical within many primary care settings, patients may be referred from primary care to community-based programs for these interventions." (Emphasis added.)
  • "The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions." (Emphasis added.)15

Wilensky and Gray concluded that, "Even states indicating that they follow a specific standard of care may only follow that standard for the subset of services they actually cover. In addition to the lack of specificity, confusion relating to the term 'medical necessity' made it difficult to determine which services are covered by Medicaid programs."16 Significant questions that must be addressed in states' reviews include the following: after a provider conducts assessments for obesity, does counseling follow? If so, what is the nature of the counseling? Is it provided by a primary care provider who has neither the time, training, nor cost-incentive to provide it? Is it merely pro-forma counseling provided in combination with another unrelated office visit?17 Are covered services provided according to national clinical guidelines? Are the most qualified and effective providers — such as RDNs — legally and practicably eligible to provide (and be reimbursed for providing) the counseling services upon referral from primary care?

b. Uncertainty and Variety of Coverage for Other Preventive Services

We applaud former Secretary Sebelius, who asserted in 2014 that, "Improving access to preventive services is a priority throughout HHS."18 The Kaiser Commission assessed "coverage of preventive services recommended for non-elderly adults before the ACA was enacted." In so doing, the Kaiser Commission reviewed coverage of preventive services available for many chronic conditions (e.g., diabetes, chronic obstructive pulmonary disease, and cardiovascular disease) and women's preventive services recommended by the Health Resources and Services Administration (HRSA) (e.g., screening for gestational diabetes and breastfeeding support, supplies, and counseling).19

The same concerns arising from coverage of obesity-related services are applicable for services for chronic conditions and women's preventive services. Notably, the USPSTF recommendations for preventing and treating adults with risk factors for cardiovascular disease include elements that surveys and research indicate are not uniformly covered in Medicaid and contain critical elements not specified in the exceedingly brief "summary of recommendations."

  • "The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention."
  • "Because of the intensity and expertise required, most interventions were referred from primary care and delivered outside that setting.
  • "However, for patients with a BMI of 30 kg/m2 or greater, the USPSTF recommends screening these patients for obesity and offering or referring them to intensive, multicomponent behavioral counseling for weight loss."
  • "Interventions were delivered by specially trained professionals, including dietitians or nutritionists, physiotherapists or exercise professionals, health educators, and psychologists."20

The same significant questions about coverage for these services must be addressed in states' reviews, including whether after a provider conducts assessments for obesity, does counseling follow? If so, what is the nature of the counseling? Is it provided by a primary care provider without the time, training, or cost-incentive to provide it? Is it merely pro-forma counseling provided in combination with another unrelated office visit? Are covered services provided according to national clinical guidelines? Are the most qualified and effective providers legally and practicably eligible to provide (and be reimbursed for providing) the counseling services upon referral from primary care?

3. Requiring Review and Analysis of Critical Baseline Data

We are pleased that CMS is both "requesting public comment on the service categories selected for inclusion in baseline access analysis" and is "finalizing the provision to require that states make access data reviews available to the public and to CMS for review." The ability of the public to have robust, detailed information related to beneficiaries' access to care, utilization, and provider type is critical to fulfilling the requirements of section 1902(a)(30) of the Act. As former Secretary Sebelius wrote, "Improving adults' access to preventive services in Medicaid requires increasing awareness of the available services as well as expanding coverage of the services."22 The availability of coverage alone is insufficient if providers and beneficiaries are unaware of it, or if there are insufficient qualified providers able and willing to provide it. For example, according to CBO analysis of claims, among the Medicare population, "approximately 0.5 percent of fee-for-service beneficiaries who are classified as obese used [the available intensive behavioral therapy] service in 2013."23 Thus, the Academy agrees with MACPAC that it is critical for "the federal government to strengthen its program oversight by providing consistent and comprehensive information on state activities for use by CMS and other agency staff.”"24

Specifically, the Academy hopes that the requirement in this final rule with comment period "that states conduct baseline reviews of the core services defined in this regulation and monitor access data to ensure compliance with section 1902(a)(30)(A) of the Act" will ameliorate the ongoing, problematic concerns raised above related to the uncertainty and variety of covered Medicaid services across the states. We support the final rule with comment period’s proposed revision to section 447.204(a)(1) "to incorporate the baseline data review requirement and as part of the information that states consider prior to the submission of a [State Plan Amendment] that proposes to reduce or restructure Medicaid service payment rates."

4. Limitations of Proposed Narrowed List of Services Included in Reviews

The Academy understands the need to reduce administrative burden and thus the rationale for "revis[ing] the access review requirements in this final rule with comment period to be more targeted so as to only require measurement of a discrete set of services, which provides additional data on access while reducing administrative burden on states." However, we are concerned that a revision requiring only "that states review and publish access studies for primary care services; physician specialist services; behavioral health services, including mental health and substance abuse disorder treatment; pre- and post-natal obstetric services including labor and delivery; and home health services on an ongoing basis" may not be sufficiently defined to ensure needed data is obtained and all data from primary care-relevant services is reviewed and published.

Our concern is that without explicit acknowledgement that all primary care-relevant preventive services be reviewed and published (i.e., preventive services either provided in a primary care setting or obtained upon referral from a primary care provider) — including all USPSTF recommended services with an A or B rating — crucial data related to primary care services either provided by non-physician providers, such as registered dietitian nutritionists or provided outside the primary care setting may not be included. We are specifically pleased that CMS’s final rule with comment period recognizes this importance of site of service in access to care.

This recommendation fulfills the intention of the final rule with comment period to encourage "program innovations that emphasize preventive care and divert individuals into more appropriate treatment modalities, including serving them in the most integrated setting appropriate to the needs of the individual consistent with Olmstead v. L.C. 527 S.Ct. 581 (1999)." Thus, the Academy urges CMS to ensure states review and publish access studies for all preventive services, including at minimum all preventive services recommended by the USPSTF, under the "primary care services" category specified in the final rule with comment period.

D. Core Access Measures and Thresholds

The Academy appreciates CMS's efforts to investigate and identify the availability and use of various quality and access measures and looks forward to hearing more about the initiatives CMS has "underway to improve the availability of Medicaid and CHIP information on covered services across states, including detail regarding benefit amount, duration, and scope."25 As MACPAC notes, "[e]ven for standardized measures, different methods to collect and report data may affect results." Further, "Notwithstanding the detailed technical specifications on the measures provided by CMS, NCQA, and others, states (and other payers generally) may use different methods to collect and report data for the same measures."26 The Academy strongly agrees with MACPAC and urges that, "CMS should consider noting when states use varying methods to calculate data for the same measures so that differences in results are not incorrectly attributed to health care quality."27

In addition, we note significant and questionable variation in certain of CMS's core sets of health quality measures for both adults and children identified by MACPAC. Although "[b]oth of the core sets include a measure to document weight status using Body Mass Index (BMI)[, t]he adult core set [only] includes an 'Adult BMI Assessment' measure [and t]he child core set includes a 'Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Body Mass Index for Children and Adolescents' measure."28 There is no explanation why there is no corresponding counseling or treatment measure for adults, despite intensive behavioral counseling for obesity being recommended for adults by both the USPSTF and national clinical guidelines.

The final rule with comment period states "that access needs may vary between pediatric and adult populations and we are requiring states to describe within their plans, the characteristics of the beneficiary populations, including considerations for care, services, and payment variations for pediatric and adult populations, as well as individuals with disabilities." However, upon consideration of putatively covered preventive services, it is unclear whether the specified putative coverage conforms to (or even resembles) the underlying USPSTF recommendations or national clinical guidelines that form the basis for mandated or medically necessary coverage.

We encourage CMS to include measures related to utilization, provider type, and the frequency and intensity of covered services in Medicaid. Coverage of a service without the matching frequency or intensity that is either deemed medically necessary or is recommended by the USPSTF is coverage in name, but not in substance. The state of South Carolina has offered potentially helpful measures related to obesity worthy of CMS's consideration.29

D. Improving Delivery Models and Access to Qualified Providers

The Academy supports the final rule with comment period's statement that, "Care coordination is an important aspect of a well-designed health care system and this regulation does not intend to discourage states from implementing care coordination programs or other efforts that seek to lower cost and improve the quality of care. Such activities should enhance access to care by arranging for individuals to receive appropriate care when needed." Further, we support the factors CMS lists as affecting whether Medicaid beneficiaries have adequate access to Medicaid services, “including but not limited to: The beneficiaries' health care needs and characteristics; state or local service delivery models; procedures for enrolling and reimbursing qualified providers; the availability of providers in the community; the capacity of Medicaid participating providers; and Medicaid service payment rates to providers." Lastly, we support the final rule with comment period's assertion that, "To align with the statutory requirements, states may employ any number of strategies to ensure or improve access to care that are targeted toward one or more of these factors."

Access to care is complex and multifaceted and must be considered holistically within the context of the delivery system design. We fully support CMS's recognition that "the delivery system model and payment methodologies can improve access to care by making available care management teams, physician assistants, community care coordinators, telemedicine and telehealth, nurse help lines, health information technology and other methods for providing coordinated care and services and support in a setting and timeframe that meet beneficiary needs." Enhanced use and coverage of registered dietitian nutritionist services is an effective strategy for improving access to higher quality care at a lower cost.30 To that end, we enthusiastically support CMS's recognition that states' remediation efforts required as part of the access monitoring review plan process are likely to include “improving outreach to providers; reducing barriers to provider enrollment; providing additional transportation to services; or improving care coordination."

E. Conclusion

The Academy sincerely appreciates the ongoing opportunity to work with CMS in its efforts to assure beneficiaries' access to covered Medicaid services. Please contact either Jeanne Blankenship by telephone at 202-775-8277 ext. 1730 or by email at jblankenship@eatright.org or Pepin Tuma by telephone at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 "Total Monthly Medicaid and CHIP Enrollment," Kaiser Family Foundation website. Accessed January 4, 2016. Available at http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/.

3 "The Role of Medicaid for Adults with Chronic Illnesses." Kaiser Commission on Medicaid and the Uninsured. Accessed January 4, 2015. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8383.pdf.

4 "Coverage of Preventive Services for Adults in Medicaid Kaiser Report. Accessed January 4, 2016. Available at http://files.kff.org/attachment/coverage-of-preventive-services-for-adults-in-medicaid-issue-brief.

5 Report to Congress on Preventive Services and Obesity-related Services Available to Medicaid Enrollees. Accessed January 4, 2016. Available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf ("While additional states may cover these services as well, it was difficult to ascertain the policies based on state plan review.").

6 MACPAC Comments to Congress on HHS Reports, dated June 30, 2011. Accessed January 4, 2016. Available at https://www.macpac.gov/wp-content/uploads/2015/01/MACPAC_Comments-HHS_Reports_to_Congress_Dec2010.pdf ("The compilation of state Medicaid programs' coverage of obesity-related services is a difficult and complex undertaking, because information on state coverage of obesity-related services is not readily available at the federal level. The basis of the compilation of state coverage of obesity-related services included in the report was based on an article in Public Health Reports, for which the authors conducted a state-by-state review of Medicaid provider manuals, EPSDT program manuals, codes and regulations, and fee schedules publicly available on state websites. Even then, the authors were not always able to conclusively determine whether states covered particular treatments.") (Internal citations omitted).

7 We note that the Kaiser Commission was unable to obtain any response from 22% of states for its survey on coverage and cost sharing for preventive services. In addition, the Kaiser Commission identified challenges in accurately identifying coverage in its November 2014 report, because states responded to questions about coverage of recommended preventive services "with service-specific caveats, most notably that service was covered only if medically necessary." "Coverage of Preventive Services for Adults in Medicaid Kaiser Report. Accessed January 4, 2016. Available at http://files.kff.org/attachment/coverage-of-preventive-services-for-adults-in-medicaid-issue-brief.

8 See, e.g., Lee JS, Sheer JLO, Lopez N, Rosenbaum S. Coverage of Obesity Treatment: A State-by-State Analysis of Medicaid and State Insurance Laws. Public Health Reports July- August 2010; 125:596-604; Wilensky, Sara E. and Gray, Elizabeth A., "Coverage of Medicaid Preventive Services for Adults: A National Review" (2012). Health Policy and Management Faculty Publications. Paper 113 ("It is difficult to ascertain exactly which preventive services are covered by state Medicaid agencies.").

9 See, Final Rule with Comment Period ("CMS's review of state payment rate methodologies for compliance with this requirement was on a case-by-case basis and was hampered by the lack of consistent information related to beneficiary access.").

10 Report to Congress on Preventive Services and Obesity-related Services Available to Medicaid Enrollees. Accessed January 4, 2016. Available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf.

11 Report to Congress on Preventive Services and Obesity-related Services Available to Medicaid Enrollees. Accessed January 4, 2016. Available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf (Internal citations omitted).

12 Hellmich N, “Obamacare requires most insurers to tackle obesity.” Accessed January 4, 2016. Available at http://www.usatoday.com/story/news/nation/2013/07/04/obesity-disease-insurance-coverage/2447217/.

13 "Questions & Answers on ACA Section 4106 Improving Access to Preventive Services for Eligible Adults in Medicaid." Medicaid.gov website. Accessed January 4, 2016. Available at https://www.medicaid.gov/affordablecareact/provisions/downloads/4106-faqs-clean.pdf.

14 Id. (Emphasis added.)

15 "Final Recommendation Statement Obesity in Adults: Screening and Management, June 2012." U.S. Preventive Services Task Force website. Accessed January 4, 2016. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/obesity-in-adults-screening-and-management.

16 Wilensky, Sara E. and Gray, Elizabeth A., "Coverage of Medicaid Preventive Services for Adults: A National Review" (2012). Health Policy and Management Faculty Publications. Paper 113.

17 See, Id. ("It is often difficult to know whether states cover counseling and health education services that are generally not reimbursable from an office visit.")

18 Report to Congress on Preventive Services and Obesity-related Services Available to Medicaid Enrollees. Accessed January 4, 2016. Available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf.

19 Coverage of Preventive Services for Adults in Medicaid Kaiser Report. Accessed January 4, 2016. Available at http://files.kff.org/attachment/coverage-of-preventive-services-for-adults-in-medicaid-issue-brief.

20 "Final Recommendation Statement, Healthful Diet and Physical Activity: Counseling Adults with High Risk for CVD." U.S. Preventive services Task Force website. Accessed January 4, 2016. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd.

21See, Wilensky, Sara E. and Gray, Elizabeth A., "Coverage of Medicaid Preventive Services for Adults: A National Review" (2012). Health Policy and Management Faculty Publications. Paper 113 ("It is often difficult to know whether states cover counseling and health education services that are generally not reimbursable from an office visit.").

22 Report to Congress on Preventive Services and Obesity-related Services Available to Medicaid Enrollees. Accessed January 4, 2016. Available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/rtc-preventive-obesity-related-services2014.pdf.

23 "Estimating the Effects of Federal Policies Targeting Obesity: Challenges and Research Needs." Congressional Budget Office website. Accessed January 4, 2016. Available at https://www.cbo.gov/publication/50877.

24 MACPAC Comments to Congress on HHS Reports, dated June 30, 2011. Accessed January 4, 2016. Available at https://www.macpac.gov/wp-content/uploads/2015/01/MACPAC_Comments-HHS_Reports_to_Congress_Dec2010.pdf.

25 Id.

26 Id. (Internal citations omitted.)

27 Id.

28 Id. (Emphasis added.)

29 South Carolina Obesity Action Plan. Accessed January 4, 2016. Available at http://www.scaledown.org/pdf/sc-obesity-action-plan.pdf.

30 See, e.g., "Nutritional Counseling Bulletin." South Carolina Healthy Connections Medicaid website. Accessed January 4, 2016. Available at https://www.scdhhs.gov/press-release/nutritional-counseling-bulletin. ("The program includes an initial screening, five additional face to face behavioral counseling visits/encounters with a physician, physician assistant, and/or a nurse practitioner, an initial dietitian visit for nutritional counseling and five follow up visits with a dietician. Obesity-management related treatment for children will continue to be covered as a part of the Medicaid Early Periodic Screening Diagnosis and Testing (EPSDT) Program.").