Medicaid Adapts to Extreme Heat: Evolving State-Based Coverage of Home Air Conditioning

Abstract

Anthropogenic climate change is increasing the frequency and severity of extreme heat events, leading to increased morbidity and mortality. Many of the populations at greatest risk from the health threats of extreme heat are also more likely to receive health insurance coverage from the Medicaid program. While Medicaid has not historically covered air conditioners, an increasing number of states are offering coverage. Of the Medicaid programs administered by the 50 states and Washington DC, 13 currently offer an air conditioner coverage benefit and 2 have applied to offer coverage to the federal government. Most of these states have obtained various types of waivers under the Social Security Act to cover air conditioners. Section 1115 waivers tend to offer more flexible and holistic coverage. The states offering coverage vary in the types of air conditioners covered, the approximate frequency with which air conditioners have been furnished, and the billing codes utilized. The lack of a specific billing code or procedure modifier code for air conditioners is a barrier to tracking the effectiveness, reach, and implementation of air conditioner coverage policies within and across states.

Introduction

Adaptation to extreme heat

Extreme heat is the top weather-related killer in the United States, ¹ and heat waves are becoming more frequent and severe due to anthropogenic climate change. ² Centers for Disease Control and Prevention (CDC) National Syndromic Surveillance Program data suggest heat-related illnesses, such as cardiovascular and respiratory complications, are already increasing with abnormally high summer heat in the U.S. ³

Extreme heat morbidity and mortality is characterized by differences across regions and race/ethnicity groups as well as by gender and age. The southwestern states of Arizona, California, and Texas accounted for an outsized number of heat-related deaths compared to their populations between 2004 and 2018. ¹ However, recent years have brought unprecedented heat to states with historically mild summers. In particular, a “heat dome” (referring to high pressure trapping heat over an area) ⁴ during the summer of 2021 resulted in hundreds of deaths in the northwest. ⁵ Overall, most of the country experienced higher rates of heat-related emergency department visits in 2022 than in 2018 to 2021. ³ Significant racial/ethnic inequities in heat-related morbidity and mortality exist. American Indian/Alaska Natives have the highest national rate of heat-related deaths, followed by non-Hispanic Black Americans. ¹ These disparities are likely due to a multifaceted set of issues, including racial residential segregation in which racial and ethnic minorities are more likely to live in urban areas characterized by structures that trap heat such as asphalt with limited cooling green space ⁶ and disproportionate exposure to air pollution that exacerbates cardiovascular conditions.^{7 -9}

As anthropogenic climate change leads to extreme heat, air conditioners (ACs) can be an important adaptation tool. During the 2021 heat dome event in Oregon, none of the people who died in Multnomah County had central air conditioning. ¹⁰ Research indicates that air conditioning lowers the risk of hospitalization for diseases including cardiovascular disease, ischemic heart disease, ischemic stroke, respiratory disease, pneumonia, dehydration, heat stroke, diabetes, and acute renal failure. ¹¹ There are effective ways to cool rooms without ACs, but alternatives like fans may not prevent heat-related illness if the room temperature rises above 95°F. ¹² Evidence suggests that people with more social vulnerabilities are also more likely to live in areas like parts of the southwest where hotter climate conditions make reliance on fans unsafe. ¹³

AC use emits air pollutants from processes like electricity generation and manufacturing that ultimately contribute to atmospheric greenhouse gas emissions and ground-level air pollution.^14,15 However, the Environmental Protection Agency and Department of Energy’s ENERGY STAR has certified certain central and room ACs (only window units and through-the-wall units) as meeting strict energy performance standards, meaning these ACs require less electricity from sources like power plants.^16,17

Types of ACs relevant to this discussion include: (1) central ACs, which circulate cool air through a system of supply and return ducts, and are generally used to cool an entire home, (2) window and through-the-wall AC units, which typically cool one room at a time, (3) portable ACs, which are generally single-duct or dual-duct devices attached to an adjustable window bracket that cool one room, (4) ductless mini split ACs including heat pumps, which generally provide more energy efficient cooling and can heat and cool an entire home or one room.

Medicaid and extreme heat

The Medicaid program will likely face more severe impacts related to extreme heat than many insurers because Medicaid is more likely to cover populations at increased risk from extreme heat. Medicaid is a means-tested program for low-income children and their families and certain low-income adults. Poverty itself puts people at risk for a range of adverse health effects, including the risks of chronic stress. ¹⁸ Medicaid is also more likely than private insurers to cover people with comorbidities like coronary heart disease, asthma, and chronic obstructive pulmonary disease (COPD), as well as racial/ethnic minority groups including Black Americans.^6,19,20 About one-fifth of non-institutionalized Medicaid or Children’s Health Insurance Program (CHIP) recipients aged 19 to 64 have basic action difficulties, meaning limitations or difficulties in movement and mental functioning. Medicaid and CHIP also cover over 30 000 children, who are uniquely susceptible to extreme heat. ²¹ Estimates for the health costs of extreme heat in the U.S. vary and can be as high as a billion dollars each year.^22,23 The Office of Management and Budget expects higher morbidity rates related to climate change to cause health care utilization to grow, increasing total expenditures by Medicaid and other insurers. ²⁴

Medicaid regulations specify that covered equipment and appliances must be items that primarily and customarily serve a medical purpose and are generally not useful to an individual in the absence of a disability (Title 42 of the Code of Federal Regulations, section 440.70(b)(3)(ii)). Therefore, ACs are generally excluded from Medicaid coverage. However, the federal agency that runs Medicaid—the Centers for Medicare & Medicaid Services (CMS)—can approve waivers under the Social Security Act allowing states to meet the goals of the program through innovations like covering ACs. Despite the heightened health risks faced by Medicaid beneficiaries as extreme heat events become increasingly common, no studies to-date have examined how Medicaid may ameliorate these risks by covering the cost of AC. This is an important research gap that can reveal the potential role Medicaid policy can play in preventing heat-related morbidity and mortality among particularly vulnerable groups. To address this research gap, this analysis explores the different mechanisms states have employed to cover ACs via Medicaid. Figure 1 depicts the complex relationship between anthropogenic climate change, increased morbidity and mortality among Medicaid beneficiaries, and adaptation through Medicaid coverage of ACs.

Figure 1.

Conceptual model: Effects of Medicaid AC coverage.

Caption: A conceptual model detailing the effects of a Medicaid AC coverage policy.

Methods

To characterize state Medicaid coverage policies, this analysis reviewed potentially relevant waivers, program guidance, and other program materials for all 50 states and the District of Columbia. Initial data collection took place from June through October 2023, but efforts were made to identify subsequent changes in policy by verifying if waivers on the CMS website have been amended or expired, and reaching out to the initial outreach contacts for all 50 states and the District of Columbia to confirm that the policies described in this article are still current in June 2024. A draft of this article was shared with the states with coverage policies to welcome comments in June 2024.

For the initial data collection, mentions of AC coverage were generally first identified in a state’s programmatic guidance by searching online state government resources for mentions of AC or cooling assistance. Relevant guidance documents were then traced back to the corresponding waiver, which could be accessed on the CMS website. Each Medicaid agency was emailed to confirm if their policy was being correctly described, including verification of the absence of relevant policies.

All states with coverage policies were asked to confirm that the appropriate waivers and other policy documents describing the benefit were identified, as well as to answer questions regarding implementation, including the types of AC covered, the year coverage began, any applicable billing codes, and the approximate frequency of coverage. Of the states with coverage policies, Montana was not able to answer any questions due to short staffing and staff workloads ²⁵ and Florida did not respond to the questions in multiple outreach attempts, though the Florida Medicaid Director has confirmed elements of the state’s policy in a public panel discussion. ²⁶ All other states with coverage policies did respond to questions and clarifications. Colorado, New Jersey, and Oregon Medicaid staff agreed to be interviewed via Microsoft Teams about their states’ respective policies. These interviews were unstructured and delved more deeply into how these policies had been or were being implemented, including the steps a patient would take to receive an AC and any relevant community partnerships. Certain states without coverage policies did not respond to multiple outreach attempts. However, since no evidence of coverage was identified, this analysis assumes there is no AC coverage policy in such states.

Results

Coverage summary

As depicted in Figure 2, 13 states offer an AC coverage benefit under Medicaid, though other states may cover ACs in exceptional circumstances as discussed later in this article. Table 1 summarizes the results across all states with current coverage policies. Five states (Florida, ²⁷ Michigan,^28,29 Minnesota,^{30 -33} Montana, ³⁴ and Colorado^{35 -38}) offer coverage through section 1915(c) waivers, 4 states (Massachusetts, ³⁹ New Jersey, ⁴⁰ North Carolina,^41,42 and Oregon ⁴³ ) offer coverage through section 1115 waivers, New York^{44 -46} and Texas^{47 -49} offer coverage through both 1115 and 1915(c) waivers, California offers coverage through 1115 and 1915(b) waivers,^50,51 and Nevada offers coverage through a Money Follows the Person Program. ⁵² States vary widely in when coverage was initiated (from 1999 to 2022) and the types of ACs covered (e.g. portable ACs, window units). However, most states rely on a general billing code for services like “environmental modifications” that can include ACs, and some do not receive bills for ACs at all because they are paid for in other ways, such as capitated payments. For this reason, many states could not provide information on how many ACs they generally furnish annually, or even if they have ever furnished an AC.

Figure 2.

Medicaid coverage of ACs.

Caption: Graphic showing the 13 states that offer AC coverage, 2 that have applied to cover ACs, and remaining 35 states and District of Columbia, which generally do not cover ACs. This graphic was generated to show states in their approximate locations, with allowances made to allow all states to be the same size.

Table 1.

Comparison of state AC coverage policies.

State	Primary coverage mechanism	Year coverage first offered	Applicable billing code(s)	Approx. coverage frequency	Type of AC covered
California	1115 Waiver and 1915(b) Waiver1,2	2022 3	None (Community Supports are not directly billed)	Unknown	Portable AC or window unit
Colorado	1915(c) Waivers4 -7	Unknown; at least since 2017 8	General billing code for Home Modifications	1 covered in last year 9	Only in-room units
Florida	1915(c) Waiver 10	–	–	–	Single room AC (max 250 ft capacity) 11
Massachusetts	1115 Waiver 12	2020 13	None (Flexible Services are not billed directly)	Unknown	Not specified; window units would be the norm
Michigan	1915(c) Waivers14 -17	2015	General billing codes for Environmental Modifications or Adaptive Medical Equipment and Supplies	Unknown; though staff recall an ICO furnishing 1 AC	Central AC or other types as reasonable/cost-effective
Minnesota	1915(c) Waivers18 -21	Unknown; over 20 years 22	General billing code for Environmental Accessibility Adaptations	Less than 1 per year	Window units
Montana	1915(c) Waiver 23	–	–	–	Single room AC 23
Nevada	Money Follows the Person Program 24	2012 25	General code for Community Transition Services	Unknown	Portable ACs
New Jersey	1115 Waiver 26	In development	In development	In development	In development
New York	1115 Waiver and 1915(c) Waivers27 -29	1999 30	General billing code for Environmental Modifications	3 covered ACs in the last 5 y	Not specified
North Carolina	Pilot Under 1115 Waiver31,32	2022	General billing code for Home Remediation Services 33	Unknown	Not specified 34
Oregon	1115 Waivers 35	2013	In development	~4400 in 2022; ~3000 in 2023	Portable ACs
Texas	1115 Waiver and 1915(c) Waivers36 -38	Unknown 39	General billing code for Minor Home Modifications or Adaptive Aids	Unknown	Window or portable AC under the 1115 waiver, not specified for 1915(c) waivers

Many waivers operate under concurrent authorities and the authority listed here is the primary authority for the AC coverage policy. State staff did not respond to prompts marked with “–.” Where the chart says “unknown,” state staff responded but did not know the answer.

^1.California Advancing & Innovating Medi-Cal (CalAIM; CA-17). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81091

^2.California Advancing and Innovating Medi-Cal (CalAIM; formerly “Medi-Cal 2020”). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81046

^3.California Medicaid program staff. September 5, 2023FW: [External] Coverage Question from MPH Student.

^4.CO HCBS Waiver for Community Mental Health Supports (CMHS; 0268.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81106

^5.CO Complementary and Integrative Health (HCBS-CIH) Waiver (0961.R02.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81166

^6.CO Persons with Brain Injury (HCBS-BI) Waiver (0288.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81111

^7.CO Elderly, Blind, and Disabled (HCBS-EBD) Waiver (0006.R09.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81121

^8.Colorado Department of Local Affairs/Division of Housing for Home Modification Programs. Home Modification LOOK BOOK. Published online 2017. https://hcpf.colorado.gov/sites/hcpf/files/Home%20Modification%20Look%20Book-Updated%20July%202017.pdf

^9.Conversation with Colorado Office of Community Living HCBS Staff. June 26, 2023.

^10.FL Developmental Disabilities Individual Budgeting Waiver (0867.R02.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81351

^11.Florida Agency for Health Care Administration. Developmental Disabilities Individual Budgeting (iBudget) Waiver. Florida Agency for Health Care Administration. https://ahca.myflorida.com/medicaid/home-and-community-based-settings-rule/developmental-disabilities-individual-budgeting-ibudget-waiver#:~:text=The%20purpose%20of%20the%20Medicaid%20iBudget%20Waiver%20is,budgeting%20approach%2C%20and%20provide%20enhanced%20opportunities%20for%20self-determination.

^12.MassHealth. Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82006

^13.Massachusetts Medicaid program staff. Re: Coverage Question from MPH Student. August 8, 2023.

^14.MI Health Link HCBS Waiver (1126.R01.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82131

^15.MI Habilitation Supports Waiver (0167.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82091

^16.Michigan Medicaid program staff. Medicaid AC Coverage Paper - MI. July 2, 2024.

^17.Michigan Department of Health and Human Services Behavioral and Physical Health and Aging Services Administration. Minimum Operating Standards for MI Health Link Program and MI Health Link HCBS Waiver. Michigan Department of Health and Human Services. Published January 2023. https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder2/Folder3/Folder1/Folder103/Minimum_Operating_Standards_for_MI_Health_Link.pdf?rev=3f859e91696d412c8660cd4d4128abed&hash=E9915D49596AE2B531334567ABCD6B1E

^18.MN Developmental Disabilities (DD) Waiver (0061.R08.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82186

^19.MN Brain Injury (BI) Waiver (4169.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82166

^20.MN Community Alternative Care (CAC) Waiver (4128.R08.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82171

^21.MN Community Access for Disability Inclusion (CADI) Waiver (0166.R07.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82181

^22.Minnesota Medicaid program staff. RE: Coverage Question from MPH Student. July 18, 2023.

^23.MT Montana Big Sky (0148.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82371

^24.MONEY FOLLOWS THE PERSON GRANT | Consumer Factsheet. State of Nevada Department of Health and Human Services Division of Health Care Financing and Policy. Published June 23, 2026. Accessed June 19, 2024. https://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Pgms/Grants/Money_Follows_the_Person_FactSheetMFP.docx

^25.Nevada Medicaid program staff. RE: Coverage Question from MPH Student. August 22, 2023.

^26.New Jersey FamilyCare Comprehensive Demonstration (formerly New Jersey Comprehensive Waiver). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82571

^27.NY Children’s Waiver (4125.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82661

^28.NYS OPWDD Comprehensive Waiver (0238.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82681

^29.New York Medicaid Redesign Team (formerly called Partnership Plan). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82656

^30.New York Medicaid program staff. RE: Coverage Question from MPH Student. August 16, 2023.

^31.North Carolina Department of Health and Human Services. Healthy Opportunities Pilots. North Carolina Department of Health and Human Services. Published August 15, 2023. Accessed August 19, 2023. https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/healthy-opportunities-pilots

^32.North Carolina Medicaid Reform Demonstration. Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82766

^33.North Carolina Department of Health and Human Services. Healthy Opportunities Pilot Fee Schedule and Service Definitions. Published online March 2023. https://www.ncdhhs.gov/healthy-opportunities-pilot-fee-schedule-and-service-definitions/open

^34.North Carolina Medicaid program staff. RE: [External] Coverage Question from MPH Student. July 19, 2023.

^35.Oregon Health Plan. Medicaid.gov. Published April 20, 2023. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/82956

^36.TX Deaf Blind with Multiple Disabilities (0281.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/83271

^37.Texas Healthcare Transformation and Quality Improvement Program. Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/83231

^38.TX Community Living Assistance & Support Services (CLASS) Waiver (0221.R06.00). Medicaid.gov. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/83256

^39.Texas Medicaid program staff. RE: Coverage Question from MPH Student. September 27, 2023.

Overview of coverage approaches

Section 1915(c) waivers generally limit coverage to populations eligible for an institutional level of care, with the idea that services like home modifications can be covered to allow a beneficiary to live safely in their home or community. Specifically, the 1915(c) waivers that facilitate AC coverage are limited to individuals eligible for the level of care of a nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or hospital in Minnesota; a nursing facility or hospital in Colorado; a nursing facility or ICF/IID in Michigan; a nursing facility in Montana; and an ICF/IID in Florida. Generally, beneficiaries must have certain care needs (e.g. a medical statement explaining the need for a constant external temperature) ⁵³ to potentially receive an AC, and these decisions are often reviewed on a case-by-case basis. ⁵⁴ Under one of Michigan’s waivers, ²⁸ managed care entities called Integrated Care Organizations (ICOs) can offer coverage for beneficiaries eligible for both Medicare and Medicaid in certain regions of the state.^55,56 ICOs are also able to furnish ACs as a supplemental service to individuals who do not meet the waiver’s level of care requirements if it is the most cost-effective alternative for meeting the enrollee’s needs. ⁵⁷

Texas and Nevada also tie eligibility to preventing institutionalization. Texas relies on an 1115 waiver and two 1915(c) waivers and requires that individuals must be eligible for a nursing facility or ICF/IID level of care in order to receive an AC. Likewise, Nevada can cover ACs through Medicaid’s Money Follows the Person (MFP) Program for beneficiaries residing in an institution for 90 days or more, not counting short-term rehabilitation stays. In Nevada, beneficiaries must already be eligible for certain 1915(c) waivers in order to qualify for MFP, but the statutory authority is not directly tied to these waivers. ⁵⁸

New York has historically covered ACs through two 1915(c) waivers limited to individuals eligible for the level of care of a nursing facility, ICF/IID, or hospital. However, in January 2024, CMS approved an 1115 waiver that will allow the state to cover medically necessary ACs as an allowable Health-Related Social Needs (HRSN) Service. Medicaid programs can cover clinically appropriate and evidence-based HRSN interventions through flexibilities including waivers to address a beneficiary’s unmet, adverse social conditions that contribute to poor health outcomes. ⁵⁹ Through its 1115 waiver, New York will also be able to cover utility costs for up to 6 months for certain beneficiaries, including those transitioning out of institutional care or congregate settings. When implemented, these policies have the potential to expand New York Medicaid beneficiaries’ ability cool their homes with ACs.

Massachusetts and California rely on broad 1115 authority but make coverage optional for external entities that coordinate Medicaid benefits. In Massachusetts, medically necessary ACs are covered as an allowable HRSN Flexible Service, meaning they are optional for Accountable Care Organizations, or provider networks that coordinate care for members younger than age 65 in the state.^60,61 Flexible Services are available to beneficiaries with both a health need and a risk factor. ⁶² California relies on an 1115 waiver and 1915(b) waiver that authorize managed care plans, or private insurance plans that contract with the state to provide Medicaid benefits, to fund medically-necessary ACs as In Lieu of Services and Settings (ILOSs). ⁶³ Generally, in all states with managed care delivery systems, managed care plans have the flexibility to provide ILOSs—a substitute for a covered service or approved setting—when medically appropriate and cost effective. California’s waivers identify certain ILOSs that are approved for coverage, including ACs, in the category of housing deposits.

Finally, North Carolina, New Jersey, and Oregon rely on 1115 waivers to provide broad coverage aiming to address HRSN. North Carolina covers ACs through the Healthy Opportunities Pilots under section 1115 authority operating in 3 regions of the state. In order to qualify, beneficiaries must also have at least 1 qualifying physical or behavioral health condition and 1 qualifying social risk factor. ⁶⁴ New Jersey’s 1115 waiver was approved by CMS in 2023 and would allow the state to cover medically necessary ACs as an allowable HRSN service under housing supports. New Jersey is still in the planning stages for the implementation of this policy. ⁶⁵ Oregon is currently implementing an 1115 waiver to cover ACs for certain populations, including individuals at-risk of becoming homeless and those experiencing extreme weather events. ⁴³ Like New York, Oregon’s waiver allows the state to cover utility costs for up to 6 months for certain beneficiaries, including those transitioning out of institutional care or congregate settings.

Oregon has also covered ACs through 2 other pathways—a managed care flexibility under an 1115 waiver and a state-funded program—and its experience transitioning between these approaches is instructive. Oregon allows managed care organizations known as coordinated care organizations (CCOs) to pay for flexible services including ACs. ⁶⁶ However, the way CCO rates are set disincentivized furnishing ACs because they were not counted as medical expenditures. CCOs cover over 75% of the Oregon Medicaid population but beneficiaries not served by CCOs are disproportionately elderly, meaning some of the most at-risk beneficiaries could not benefit from this policy.^19,67 After the 2021 “heat dome” event resulted in over a hundred deaths in Oregon, it became clear the previous policy had been insufficient.

Oregon Senate Bills 1536 (2022) and 762 (2021) funded the Oregon Medicaid agency to mitigate the impacts of extreme temperature and wildfire smoke events. Oregon partnered with Tribes and community-based organizations to identify at-risk beneficiaries and distribute ACs, ultimately furnishing 4400 ACs in 2022 and another 3000 ACs in 2023. ⁶⁸ With authority and additional funding from Oregon Senate Bills 1529 (2024) and 1530 (2024), the Oregon Medicaid agency purchased an additional 4400 ACs. ⁶⁹ Along with the devices, Oregon also furnishes recipients with a $100 gift card for utility costs. ²⁶ The same legislation that empowered Oregon to furnish ACs also included protections for renters to install and run these products, and Oregon established a phone line to handle tenants’ rights complaints. ⁷⁰ Feedback from the 2022 distribution was positive, but community-based organizations did cite lack of upfront funding for administrative costs as a challenge. ⁶⁷ There were also reports of CCO staff answering beneficiary calls who were not aware of the AC distribution policy. Notably, in 2022 the state’s CCOs distributed fewer ACs than state personnel and their partners did, despite covering over three-fourths of the Medicaid population.

In 2023, CMS approved an amendment to the Oregon Health Plan 1115 waiver allowing for the provision of ACs as allowable HRSN services. ⁴³ A beneficiary could be eligible for an AC if they are in a targeted population, including those transitioning out of institutions for mental disease and incarceration and individuals at-risk of becoming homeless. Beneficiaries can also be eligible if they reside in a region that is experiencing extreme weather events as declared by the federal government or the Governor of Oregon. Under the waiver, Oregon will primarily cover portable ACs. ⁶⁷ Notably, heat pumps can be covered as heaters, but not as ACs.

In implementing the waiver, Oregon is developing a list of encompassing codes but is emphasizing that individual determinations should be made. Staff are also working to ensure they are able to purchase and store devices ahead of climate events so they can be distributed quickly. ⁶⁷ One point that staff emphasized during the unstructured interview was the importance of honoring the input of community-based organizations. Oregon is also planning to refer beneficiaries who receive ACs directly to housing specialists to help them receive utility assistance.

Emerging Coverage

Two states—Rhode Island and Illinois—have applied to cover ACs under 1115 waivers. Rhode Island’s waiver would cover ACs as a “Healthy Home Good” for individuals receiving Transitional Supports under the state’s Home Stabilization benefit. The state’s Home Stabilization benefit currently covers services to help individuals with behavioral or complex physical health needs find and maintain housing. The state is requesting to expand the scope of the benefit to include all people who are homeless or at risk of homelessness and to include Transitional Supports, such as Healthy Home Goods, including ACs. ⁷¹ Illinois’ waiver would cover ACs as housing supports for beneficiaries who have certain health needs and are experiencing or at risk of homelessness or institutional placement. ⁷² The policy would be limited to the 80% of Illinois Medicaid beneficiaries who are enrolled in managed care. ¹⁹

Coverage outside of defined benefits

Under certain circumstances, states may cover ACs outside of a defined benefit. States may furnish ACs on a case-by-case basis through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit (noted by Utah ⁷³ and Vermont ⁷⁴ ), when medically necessary for patients with severe thermoregulatory issues (noted by Colorado ⁷⁵ ) or in other rare circumstances (noted by Vermont^76,77 and Connecticut ⁷⁸ ), through creative leveraging of other waiver flexibilities (noted by Indiana ⁷⁹ ), and through flexibilities offered to managed care plans such as ILOSs (noted in CMS’s guidance ⁵⁹ and by Iowa, ⁸⁰ Ohio ⁸¹ and Oklahoma ⁸² ). These pathways may offer limited relief outside of a defined AC benefit, but there is no evidence they have been accessed widely. Notably, Vermont has occasionally covered AC units under the EPSDT benefit on a case-by-case basis and through Medicaid coverage exception requests for adults, though staff characterized this as an exception to a general noncoverage policy. In response to outreach for this analysis, Iowa Medicaid program staff asked their managed care organizations if they covered ACs and found that they do not provide coverage, but do refer patients to cooling shelters and other resources. ⁸⁰ Therefore, while this analysis emphasizes coverage policies that are explicit in waivers, demonstrations, and their associated guidance, some states may offer limited coverage outside of a defined benefit. In addition, 2 states that do not cover ACs, Arizona and Washington, have been approved to cover utility costs for up to 6 months for certain beneficiaries, including those transitioning out of institutional care or congregate settings, which could facilitate AC use and access.^83,84

Discussion

Comparison of coverage policies

This review identifies key dimensions of variation in how states have covered ACs via Medicaid, including the type of waiver employed and the decision to rely on external entities to optionally administer the policy. However, in comparing coverage policies, it is important to first recognize the lack of claims data available because in many states there is no billing code or procedure modifier code specific to ACs. Increased tracking through coding or other means would help states, the federal government, and researchers understand the reach and impact of AC coverage policies, as has been suggested by Florida’s Medicaid director. ²⁶

Reliance on 1915(c) waivers generally comes at the price of tying coverage to preventing institutionalization of beneficiaries or helping them transition from an institution back home. This approach focuses on beneficiaries with serious care needs, such as those that require continuous active treatment services. The emphasis on level of care means healthier beneficiaries who may have other risk factors, like working outdoors with multiple comorbidities, will likely not qualify for an AC.

While 1115 waivers require more negotiation with CMS to receive approval and generally require more data collection and reporting, they tend to offer the most transformative and flexible coverage policies. Generally, 1115 waiver policies account for individuals transitioning in and out of institutional care but also beneficiaries at risk of homelessness and who have other risk factors. However, because of the level of review given to 1115 waivers, political considerations may in part determine whether this is a viable option. The state of New Jersey applied to offer housing supports through their 1115 waiver during their last renewal and ultimately could not get that part of the waiver approved at the time. ⁶⁵ Recent encouragement from CMS regarding innovative 1115 waiver policies covering housing services appears to be working,^59,85 as 2 additional states (Rhode Island and Illinois) have applied to cover ACs through 1115 waivers.

Finally, reliance on external entities like managed care organizations to optionally administer waiver policies also includes tradeoffs. Managed care organizations can help coordinate care and link beneficiaries with providers. However, there is variability in the efficacy of managed care plans in improving health outcomes.^86,87 Reliance on managed care and other external entities like Accountable Care Organizations can sometimes disproportionately exclude older beneficiaries, as in Massachusetts and Oregon’s 2013 policy. Oregon also found that its state Medicaid agency was able to furnish more ACs than all of the state’s managed care organizations combined in the summer of 2022, despite over 75% of the Medicaid population receiving care through managed care organizations. ⁶⁷ Notably, in Michigan, joint Medicare-Medicaid plans called ICOs can furnish ACs to dual-eligible beneficiaries in certain parts of the state who do not meet the level of care requirements in the state’s 1915(c) waivers, potentially facilitating increased access for older beneficiaries.^28,57 However, Michigan Medicaid program staff only recall one beneficiary who received an AC through an ICO. ⁸⁸

Interactions with other policies

There are other policies that can help beneficiaries access ACs. For example, recently finalized federal standards for In Lieu of Services and Settings (ILOSs) ⁸⁹ could offer state Medicaid plans the opportunity to reexamine the scope of covered ILOSs and perhaps include AC, as noted by one state in conversations regarding this topic. ⁹⁰ Other federal policies that will affect beneficiary access to cooling devices include AC coverage through Medicare Advantage, ⁹¹ cooling assistance through the Low Income Home Energy Assistance Program (LIHEAP), and policies encouraging the manufacture and installation of heat pumps, many of which were created or augmented by the Inflation Reduction Act.^92,93 There is evidence of Medicaid plans working in concert with some of these pathways. 15 Nebraska economic assistance programs, including Medicaid and LIHEAP, have integrated their benefit portals, including applications. This prevents beneficiaries from logging into separate systems to manage their benefits and from filling out duplicate information across multiple applications, resulting in about 30% fewer application questions. ⁹⁴ Certain states also have their own cooling and utility assistance programs such as Virginia’s Senior Cool Care Program, which provides cooling devices to seniors. ⁹⁵ Virginia Medicaid program staff noted that they believe their state’s Medicaid managed care plans have relationships with the local Area Agencies on Aging that run Senior Cool Care and could work with beneficiaries through care coordination to connect them to the program. ⁹⁶ Finally, state housing policies like renter protections and public cooling spaces will also impact beneficiary health and well-being.

Limitations

This analysis has several limitations, including that the absence of a consistent billing code or procedure modifier code for ACs makes it infeasible to track AC coverage across, and sometimes within, states. The inability to track how many ACs have been furnished and the health outcomes of beneficiaries who received them makes any comparison of different coverage policies incomplete. This paper instead strives to illuminate the contours of different coverage policies and describe the limitations and strengths that each present. However, the complexity and heterogeneity of Medicaid programs and the communities they serve means that there likely will not be a single best policy across the board.

Implications for policymakers and researchers

This analysis points to several considerations for policymakers and researchers. First, universal billing codes or procedure modifier codes for ACs would facilitate better understanding of the health impacts of AC coverage. In addition, the finding that Oregon’s Medicaid agency was able to furnish more ACs than all of the state’s managed care organizations combined indicates that research is needed to better understand the benefits and drawbacks of policies administered by managed care organizations, including elements that may make such policies more successful. This is particularly salient as recent rulemaking ⁸⁹ makes it likely that additional states may try to cover ACs through managed care In Lieu of Services and Settings. Finally, additional research on the success of state Medicaid agency partnerships with cooling, utility assistance, and weatherization partners may illuminate additional strategies to help beneficiaries stay cool and afford utility bills.

Conclusion

In the face of increasing extreme heat due to climate change, state Medicaid programs are adapting with innovative policies covering AC in the home. Among 13 states offering an AC coverage benefit and 2 states that have applied to offer a benefit, most employ waivers under the Social Security Act. The type of waiver relied upon influences the policy, with section 1915(c) waivers generally having the primary aim of preventing institutionalization of beneficiaries and section 1115 waivers generally aiming to address the health needs of a beneficiary more broadly. Their flexible and holistic nature make 1115 waivers a more compelling tool for facilitating AC coverage. However, the optimal policy for a state will depend on the current structure of its Medicaid program and other factors, such as the local climate and current utilization of AC across the state. Finding ways to track AC distribution will be an important element of measuring success, and a universal code would facilitate tracking distribution across states.

Appendix 1.

Summary of AC Coverage Policies.

The following table summarizes AC coverage policies among state Medicaid agencies. The source column notes if and when the policy was confirmed. Initial data collection took place from June through October 2023. Efforts were made to identify subsequent changes in policy in June and July 2024.

State	AC coverage policy	Source
Alabama	Generally non-covered	Confirmed via email on 06/12/23
Alaska	Generally non-covered	Alaska Medicaid program staff indicated in a 06/21/24 email that AC was covered in some cases and directed researchers to their Medicaid hotline. Hotline staff stated that AC was not covered and attempts to confirm via email were not answered. No defined benefit could be identified.
Arizona	Generally non-covered	Confirmed via email on 06/12/23 and 06/21/2024
Arkansas	Generally non-covered	Confirmed via email on 06/14/23
California	Covered	See Section II citations
Colorado	Covered	See Section II citations
Connecticut	Generally non-covered	Confirmed via email on 06/21/24
Delaware	Generally non-covered	Confirmed via email on 07/10/23
District of Columbia	Generally non-covered	Confirmed via email on 06/20/23 and 06/21/2024
Florida	Covered	See Section II citations
Georgia	Generally non-covered	Confirmed via email on 07/31/23 and 06/21/2024
Hawaii	Generally non-covered	Confirmed via email on 07/10/23 and 06/21/2024
Idaho	Generally non-covered	Confirmed via email on 07/31/23
Illinois	Applied to cover	See Section II citations
Indiana	Generally non-covered	Confirmed via email on 07/31/23
Iowa	Generally non-covered	Confirmed via email on 08/16/23 and 06/21/24
Kansas	Generally non-covered	Confirmed via email on 06/15/23 and 06/27/2024
Kentucky	Generally non-covered	Confirmed via email on 07/11/23 and 06/21/2024
Louisiana	Generally non-covered	Confirmed via email on 06/26/24
Maine	Generally non-covered	Confirmed via email on 08/01/23 and 06/24/2024
Maryland	Generally non-covered	Confirmed via email on 06/16/23
Massachusetts	Covered	See Section II citations
Michigan	Covered	See Section II citations
Minnesota	Covered	See Section II citations
Mississippi	Generally non-covered	No response to outreach; no defined benefit could be identified
Missouri	Generally non-covered	Confirmed via email on 06/20/23
Montana	Covered	See Section II citations
Nebraska	Generally non-covered	Confirmed via email on 07/10/23 and 06/21/2024
Nevada	Covered	See Section II citations
New Hampshire	Generally non-covered	No response to outreach; no defined benefit could be identified
New Jersey	Covered	See Section II citations
New Mexico	Generally non-covered	Confirmed via email on 06/20/23
New York	Covered	See Section II citations
North Carolina	Covered	See Section II citations
North Dakota	Generally non-covered	Confirmed via email on 08/21/23 and 06/24/2024
Ohio	Generally non-covered	Ohio Medicaid program staff indicated in a 07/10/23 email that managed care organizations in the state may be covering ACs, though they did not respond to requests to provide further detail. No defined benefit could be identified.
Oklahoma	Generally non-covered	Confirmed via email on 07/31/23 and 06/26/24
Oregon	Covered	See Section II citations
Pennsylvania	Generally non-covered	No response to outreach; no defined benefit could be identified
Rhode Island	Applied to cover	See Section II citations
South Carolina	Generally non-covered	No response to outreach; no defined benefit could be identified
South Dakota	Generally non-covered	Confirmed via email on 08/08/23 and 06/21/2024
Tennessee	Generally non-covered	Confirmed via email on 06/13/23 and 06/21/2024
Texas	Covered	See Section II citations
Utah	Generally non-covered	Confirmed via email on 07/18/23 and 06/21/2024
Vermont	Generally non-covered	Confirmed via email on 07/20/23
Virginia	Generally non-covered	Confirmed via email on 07/31/23 and 06/24/2024
Washington	Generally non-covered	Confirmed via email on 07/10/23
West Virginia	Generally non-covered	No response to outreach; no defined benefit could be identified
Wisconsin	Generally non-covered	Confirmed via email on 07/11/23
Wyoming	Generally non-covered	Confirmed via email on 06/19/23 and 06/28/2024

Appendix 2.

List of Acronyms.

Air conditioners	ACs
Centers for Disease Control and Prevention	CDC
Centers for Medicare & Medicaid Services	CMS
Children’s Health Insurance Program	CHIP
Coordinated care organizations	CCOs
Early and Periodic Screening, Diagnostic, and Treatment	EPSDT
Health-Related Social Needs	HRSN
In Lieu of Services and Settings	ILOSs
Integrated Care Organizations	ICOs
Intermediate Care Facility for Individuals with Intellectual Disabilities	ICF/IID
Low Income Home Energy Assistance Program	LIHEAP
Money Follows the Person	MFP