Bridging the Coverage Gap

Abstract

Background

Cardiac rehabilitation (CR) is a guideline-supported, evidence-based intervention that improves cardiovascular outcomes, yet access remains inconsistent for Medicaid beneficiaries because coverage policies vary across states.

Project Rationale

We evaluated Medicaid reimbursement for outpatient CR services across all 50 U.S. states to identify policy variation that may contribute to inequitable access for vulnerable populations.

Project Summary

A cross-sectional survey review of state Medicaid fee schedules, provider manuals, coverage policies, and direct communication with Medicaid agencies assessed reimbursement for Current Procedural Terminology codes 93797 and 93798. Most states provided coverage, but important geographic variation remained, with several states lacking reimbursement for one or both services. Limited coverage frequently occurred in regions with large Medicaid populations, potentially restricting access to guideline-supported cardiovascular care.

Take-Home Messages

State Medicaid reimbursement policies remain an important determinant of access to outpatient CR. Greater policy consistency may reduce disparities and improve equitable delivery of evidence-based cardiovascular care.

Visual Summary

Cardiovascular disease (CVD) remains the leading cause of morbidity, mortality, and health care expenditure in the United States, affecting nearly one-half of adults (48.6%)¹ and accounting for approximately 1 in every 3 deaths. As the prevalence of CVD continues to increase, the associated annual direct and indirect costs are projected to exceed $1.8 trillion by 2050, underscoring the need for evidence-based strategies that improve cardiovascular outcomes while reducing health care utilization and costs. Consequently, the projected rise in CVD prevalence is expected to substantially increase the demands on health care systems and public insurance programs, reinforcing the need for effective strategies to address the growing clinical and economic burden of CVD.²

Cardiac rehabilitation (CR), reimbursed under current procedural terminology (CPT) codes 93797 (without continuous electrocardiographic [ECG] monitoring) and 93798 (with continuous ECG monitoring), is a comprehensive, guideline-supported secondary prevention intervention that improves functional capacity, quality of life, and long-term cardiovascular outcomes across a broad spectrum of cardiovascular conditions.³ Participation in CR has been associated with approximately 25%-30% reductions in all-cause mortality, up to a 31% reduction in hospitalizations among patients with heart failure, and a dose-dependent reduction in adverse cardiovascular events, making it one of the most effective and cost-efficient interventions in contemporary cardiovascular care.3, 4, 5

CR is currently recommended for patients with multiple guideline-supported cardiovascular conditions, including myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention, chronic heart failure, heart valve surgery, and heart transplantation.³ Despite its broad clinical applicability, Medicaid reimbursement for outpatient CR services is independently determined at the state level, resulting in substantial variation in coverage and access.⁶ This fragmented reimbursement landscape may leave Medicaid beneficiaries, particularly those residing in nonexpansion states or states with limited CR coverage, that is without access to an intervention associated with improved survival, fewer hospitalizations, and enhanced quality of life.^3,5, 6, 7 Because Medicaid disproportionately insures low-income and historically underserved populations, state-level variation in CR reimbursement may further widen existing disparities in access to evidence-based cardiovascular care. Consequently, communities already experiencing a disproportionate burden of CVD, including rural, racial and ethnic minorities, and socioeconomically disadvantaged individuals, may be particularly vulnerable to the downstream consequences of limited CR access.6, 7, 8

Given the established benefits of CR and the critical role of Medicaid in providing health care coverage for vulnerable populations, understanding state-level variation in CR reimbursement is essential to identifying potential gaps in access to evidence-based cardiovascular care. Therefore, we evaluated Medicaid coverage for outpatient CR across the United States to characterize geographic variation in reimbursement and identify opportunities to improve equitable access to guideline-supported secondary prevention services.

Project Rationale

CR is a cornerstone of secondary cardiovascular prevention; however, substantial variation in state-level Medicaid reimbursement policies may limit equitable access to this evidence-based intervention. The absence of a contemporary national assessment of Medicaid coverage represented an important knowledge gap regarding geographic variation in access to CR. This project was undertaken to characterize state-level Medicaid reimbursement policies and identify opportunities to improve equitable access to CR.

Project Description

We conducted a cross-sectional survey of Medicaid reimbursement policies for outpatient CR across all 50 U.S. states. Coverage was evaluated for CPT codes 93797 (without continuous ECG monitoring) and 93798 (with continuous ECG monitoring), the standard billing codes for structured outpatient CR programs. Medicaid coverage information was obtained through a systematic review of publicly available state Medicaid fee schedules, provider manuals, reimbursement policies, and coverage documents. When coverage status could not be confirmed from publicly available sources, state Medicaid agencies were contacted directly by email or telephone to verify reimbursement policies and resolve discrepancies.

States were categorized as Full Coverage, defined as reimbursement for both CPT codes 93797 and 93798; No Coverage, defined as no identifiable reimbursement for either code; or Partial/Inconclusive Coverage, defined as reimbursement for only 1 CPT code or the inability to definitively determine coverage despite review of available documentation and direct communication with the state Medicaid program. Kansas was conservatively classified as inconclusive because reimbursement could not be consistently verified across all participating managed care organizations. Geographic variation in CR reimbursement was summarized using state-level heat maps and contextualized with state Medicaid enrollment data to identify regions where reimbursement limitations may disproportionately affect Medicaid beneficiaries.

Project Deliverables

Our review of Medicaid CR coverage across all 50 U.S. states identified substantial variation in reimbursement for outpatient CR services. For CPT code 93797 (CR without continuous ECG monitoring), 41 states provided reimbursement, 8 states (Arkansas, Georgia, Iowa, Louisiana, Mississippi, Nevada, New Jersey, and Utah) provided no reimbursement, and Kansas was classified as Partial/Inconclusive because coverage could not be consistently verified across all participating Medicaid managed care organizations (Figure 1). Tennessee also administers Medicaid through managed care organizations; however, CR coverage could not be verified across all participating plans.

Figure 1.

State Medicaid Coverage for Standard Cardiac Rehabilitation Services for State-by-State Medicaid Coverage for CPT 93797 (Outpatient CR Without ECG Monitoring)

Green = covered; yellow = partial/inconclusive; red = not covered.

For CPT code 93798 (CR with continuous ECG monitoring), 43 states provided reimbursement, 6 states (Arkansas, Georgia, Louisiana, Mississippi, Nevada, and Utah) provided no reimbursement, and Kansas remained classified as partial/inconclusive because reimbursement status could not be definitively confirmed (Figure 2). A complete summary of state coverage classifications for both CPT codes is presented in Table 1.

Figure 2.

State Medicaid Coverage for Standard Cardiac Rehabilitation Services

Figure 1 shows state-by-state Medicaid coverage for Current Procedural Terminology (CPT) 93798 (outpatient cardiac rehabilitation [CR] with electrocardiogram [ECG] monitoring). Green = covered; yellow = partial/inconclusive; red = not covered.

Table 1.

State Medicaid Coverage of Cardiac Rehabilitation Services

Coverage Category	CPT 93797 Without Continuous ECG Monitoring	CPT 93798 With Continuous ECG Monitoring
Full coverage	41 states	43 states
Partial/inconclusive Coverage	Kansas (1 state)	Kansas (1 state)
No coverage	Arkansas, Georgia, Iowa, Louisiana, Mississippi, Nevada, New Jersey, and Utah (8 states)	Arkansas, Georgia, Louisiana, Mississippi, Nevada, and Utah (6 states)

CR = cardiac rehabilitation; ECG = electrocardiogram.

Figure 3 summarizes the percentage of each state's population enrolled in Medicaid as of December 2024.⁹ New Mexico, Alaska, California, and New York had the highest Medicaid enrollment, each exceeding 30% of the state population. Louisiana, Kentucky, West Virginia, and Arkansas were among the states with enrollment between 25% and 30%, whereas Utah, Wyoming, Kansas, New Hampshire, North Dakota, South Dakota, Texas, and Nebraska had the lowest enrollment, each below 15%.⁹

Figure 3.

Bar Plot Detailing Percentage of U.S. Medicaid Enrollees Per State

Data obtained by December 2024 Medicaid & Children’s Health Insurance Program (CHIP) Enrollment Data Highlights (https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-december2024.pdf).

Comparison of the reimbursement maps with state Medicaid enrollment demonstrated substantial geographic variation. Among states with high Medicaid enrollment, California, New York, Kentucky, and West Virginia provided reimbursement for both CPT codes, whereas Arkansas and Louisiana, which also had enrollment exceeding 25%, and Mississippi, with enrollment approaching 20%, did not reimburse either code. States without comprehensive CR reimbursement were concentrated primarily in the South, Mountain West, and portions of the Midwest, whereas comprehensive reimbursement was more common in the Northeast, Upper Midwest, and West.

Project Outcome, Impact, and Future Directions

Economic and policy implications

From a health economics perspective, limited Medicaid reimbursement for CR may represent a missed opportunity to invest in an evidence-based intervention associated with improved cardiovascular outcomes and lower health care utilization. Given the projected growth in the economic burden of CVD, expanding access to CR may offer substantial long-term value for both patients and health care systems.2, 3, 4, 5

Our findings demonstrate substantial variation in Medicaid reimbursement for outpatient CR across the United States, highlighting state-level policy as a potentially modifiable determinant of access to guideline-supported secondary prevention. States that expanded Medicaid eligibility under the Affordable Care Act were more likely to provide reimbursement for both CR CPT codes, whereas several nonexpansion states with among the highest CVD burdens lacked comprehensive CR coverage.^6,7 Although this analysis was not designed to evaluate patient-level outcomes, these findings suggest that state Medicaid reimbursement policies may influence equitable access to evidence-based cardiovascular care and represent an important opportunity to reduce disparities through evidence-informed policy.

Health equity considerations

Medicaid CR coverage gaps represent a potential source of inequity that may disproportionately affect populations already experiencing socioeconomic, geographic, and racial disparities in cardiovascular health. Variation in Medicaid reimbursement extends beyond insurance coverage alone and may further exacerbate these existing inequities in access to evidence-based cardiovascular care. Because Medicaid disproportionately serves low-income and historically underserved populations, inconsistent CR coverage may disproportionately affect rural communities, Black populations, and socioeconomically disadvantaged individuals who already experience a greater burden of CVD and barriers to health care access.6, 7, 8

These disparities are further compounded by structural and socioeconomic barriers, including transportation limitations, financial constraints, reduced geographic access to CR programs, and competing work or caregiving responsibilities that may limit participation in center-based rehabilitation. Communities already experiencing a disproportionate burden of CVD may therefore be disproportionately affected by inconsistent Medicaid coverage for CR, potentially widening existing inequities in access to evidence-based secondary prevention.

Recommendations and future directions

We propose the following strategies to address gaps in Medicaid coverage for CR and improve equitable access to evidence-based cardiovascular care. Collectively, these approaches may help reduce disparities in CR access while supporting broader efforts to improve cardiovascular outcomes among Medicaid beneficiaries.

• 1.Encourage broader Medicaid reimbursement for CR services, including CPT 93797 and CPT 93798, to reduce state-level variation in access and improve availability of guideline-supported rehabilitation services.
• 2.Expand home-based and telehealth-enabled CR programs, supported by broader Medicaid reimbursement, to improve access for rural, transportation-limited, and geographically underserved populations while reducing disparities in CR participation.^8,10
• 3.Incorporate CR participation into Medicaid value-based care initiatives to encourage health systems to prioritize preventive cardiovascular care and long-term clinical outcomes.
• 4.Improve provider awareness of CR eligibility criteria and referral pathways, particularly in institutions serving rural, minority, and socioeconomically disadvantaged populations.
• 5.Consider federal guidance and technical assistance to support state Medicaid programs evaluating CR coverage policies and implementation strategies.
• 6.Evaluate patient-directed interventions, including financial incentive programs and other approaches designed to improve CR referral, enrollment, and program completion among Medicaid beneficiaries.

Discussion

Our findings demonstrate substantial variation in state Medicaid reimbursement for CR, identifying reimbursement policy as a potentially modifiable determinant of equitable access to guideline-supported secondary prevention. Although this study was not designed to evaluate patient-level outcomes, the observed geographic variation in coverage, particularly across states with differing Medicaid expansion status and CVD burden, underscores the potential influence of state reimbursement policy on access to evidence-based cardiovascular care. These findings provide an important foundation for future policy initiatives aimed at improving equitable access to CR while reducing disparities among Medicaid beneficiaries.

CR is a clinically validated, guideline-supported intervention that improves survival, functional capacity, and health-related quality of life across multiple cardiovascular conditions. A Cochrane review demonstrated significant reductions in all-cause mortality and hospitalizations among patients participating in exercise-based CR, whereas greater program participation has been associated with a dose-dependent reduction in adverse cardiovascular events and improved functional outcomes.3, 4, 5 Despite these well-established benefits, CR remains substantially underutilized, particularly among Medicaid beneficiaries who frequently encounter barriers, including limited insurance coverage, transportation challenges, and reduced access to referral and rehabilitation services.^6,8 In states where Medicaid reimbursement for CR is limited, eligible patients may have reduced access to an evidence-based intervention associated with improved survival, fewer hospitalizations, and enhanced functional recovery.3, 4, 5

Although this analysis provides important insights into state-level variation in Medicaid reimbursement for CR, several methodological limitations should be considered when interpreting these findings. As a cross-sectional survey of state Medicaid reimbursement policies, our analysis provides a snapshot of coverage during the study period and does not capture temporal changes in reimbursement policies. We did not systematically evaluate the rationale underlying individual state coverage determinations, which may reflect differences in budgetary priorities, managed care structures, administrative processes, or broader health care policy objectives. In addition, policy-level reimbursement does not necessarily reflect actual patient access, provider participation, reimbursement utilization, or CR participation. Finally, this study was not designed to evaluate associations between state-level Medicaid reimbursement policies and patient-level outcomes, nor did it account for regional differences in CVD burden, health care infrastructure, CR program availability, health care workforce availability, or socioeconomic conditions that may influence access to care. Future studies integrating longitudinal policy analyses with patient-level utilization, clinical outcomes, and qualitative evaluation of state reimbursement decision-making are needed to better define how Medicaid reimbursement policies influence equitable access to CR.

Conclusions

CR remains an important evidence-based component of secondary prevention in CVD, yet substantial variation exists in state-level Medicaid reimbursement policies across the United States. Our analysis identified several states in which Medicaid beneficiaries may face limited access to CR services despite strong guideline support and established clinical benefit. Notably, some states with high Medicaid enrollment and substantial CVD burden were among those lacking reimbursement for standard CR services.

These findings highlight the potential influence of state-level Medicaid reimbursement policies on equitable access to guideline-supported cardiovascular care and suggest that reimbursement policy represents a potentially modifiable determinant of access. Greater consistency in Medicaid reimbursement policies, coupled with innovative delivery models and targeted implementation strategies, may improve access to CR, reduce disparities in CR access, and enhance the delivery of evidence-based secondary prevention services nationwide.

Take-Home Messages

• •Substantial interstate variation exists in Medicaid reimbursement for outpatient CR, resulting in inconsistent access to guideline-supported secondary prevention across the United States.
• •State-level Medicaid reimbursement policies may represent a modifiable determinant of equitable access to CR, particularly for Medicaid beneficiaries in underserved communities.
• •Expanding consistent Medicaid reimbursement, together with innovative CR delivery models and targeted implementation strategies, may improve access to evidence-based secondary prevention and reduce disparities in cardiovascular care.

Visual Summary.

Study Design, Principal Findings, and Clinical Implications of This 50-State Cross-Sectional Policy Analysis Evaluating Medicaid Reimbursement for Outpatient Services Billed Under CPT Codes 93797 and 93798

Substantial state-level variation in reimbursement was identified, with several states lacking coverage for 1 or both CR services. These findings highlight the potential impact of Medicaid reimbursement policies on equitable access to guideline-supported cardiac rehabilitation and underscore opportunities to improve cardiovascular care through broader reimbursement, innovative delivery models, and targeted implementation strategies.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.