Health Insurance Coverage Laws and Policies for Diabetes Self- Management, Education and Training (DSME/T)

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1 ESSENTIAL INFORMATION August 2016 Health Insurance Coverage Laws and Policies for Diabetes Self- Management, Education and Training (DSME/T) Prepared by the Policy Surveillance Program and ChangeLab Solutions SUMMARY This map provides an overview of state laws that require insurance coverage for Diabetes Self- Management, Education and Training (DSME/T). Fact sheets for each state include epidemiological data on the state s diabetes burden and provide a summary of insurance coverage for DSME/T in the state, including Medicaid coverage in sub-regulatory Medicaid materials such as managed care contracts, provider manuals, and Medicaid agency guidance. ABOUT DSME/T & THE DATA More than 29 million U.S. adults have diabetes and about 86 million have blood glucose at levels considered to be prediabetic or are at an increased risk of developing type 2 diabetes. Teaching patients to monitor and manage their diabetes is an important method for controlling this disease. Many states require all public and private health insurance plans to cover diabetes self-management education and training (DSME/T). This map shows which states have laws that require such coverage for both private insurance plans and Medicaid, and provides information on legal requirements for, among other things, when DSME/T coverage is triggered, what specific activities are covered, and the standards that DSME/T must meet. Click any state below to view all data on that state's DSME/T laws. This map only includes information on Medicaid coverage required by state laws or regulations. Fact sheets on each state page provide additional information on Medicaid coverage, including coverage requirements in sub-regulatory Medicaid materials such as contractual agreements with managed care organizations, Medicaid provider manuals, and state Medicaid agency guidance. Some findings from the dataset include: Forty-one states and the District of Columbia require all or nearly all private health insurance policies to cover DSME/T. Only 14 states require such coverage for all or nearly all Medicaid beneficiaries. Twenty-seven states allow any licensed health care practitioner to deliver DSME/T to individuals under a private health insurance policy. The data reflect DSME/T laws and policies in effect on August 1, As used on this site, the effective date indicates the date that the state legislature last updated the law, and the valid through date indicates the date the research team reviewed the law or policy for inclusion in the dataset. NAVIGATING THE DATA There are two ways to navigate the data using the interactive map: (1) By selecting a state from the map; or (2) By selecting criteria that detail the characteristics of the laws. 1 of 5

2 Option 1 State by state: Using the map, click on the state of interest. A table will appear with details about that state s law. The first row of the table includes a link to the state fact sheet. Option 2 Multiple states: To view the law across multiple states, you may use the questions to filter through various criteria. Clicking on a question will expand the answers/criteria for you to select. In some cases, secondary questions may appear after answering one of the primary questions these secondary questions dig deeper into the detail of that specific area of the law. The map will change based on the criteria you select. For both Medicaid and private insurance coverage, the primary questions addressed are: Does the law require insurance plans to cover DSME/T? o What triggers coverage of DSME/T? o Is there a coverage cap for DSME/T? o What type of cost-sharing does the law on DSME/T explicitly permit? o Does the law on DSME/T specify cost-sharing amounts? o What type(s) of health care practitioners can order DSME/T? o What type(s) of health care practitioners can deliver DSME/T? o What qualifications are required for DSME/T providers? o What program features are required as a part of DSME/T? o In what settings may DSME/T be conducted? Along with the responses, there are a few interactive symbols that appear in the columns: Clicking on a red gavel symbol will display the full text of all statutes and regulations related to the topic within the chosen jurisdiction that have been included in the dataset. These are the legal texts that have been used to answer the questions displayed above. Clicking on a red statute symbol will display the specific statutory and/or regulatory citations supporting that selected characteristic of the law. Each citation is also clickable, and clicking on the citation text will display the text of the law linked to that citation. Clicking on a question mark symbol, or caution note, will reveal unique features of the statutory and/or regulatory law(s). These caution notes alert users to important differences and greater detail about the criteria selected. GLOSSARY A1c: A measurement of an individual s average blood sugar level for the past two to three months. According to the American Diabetes Association (ADA), an A1c of 6.5 percent or greater indicates diabetes, and an A1c between 5.7 percent and 6.4 percent indicates prediabetes. 1 Affordable Care Act: The Affordable Care Act, signed into law in March 2010, reformed the United States health care system by, among other things, expanding Medicaid, establishing health insurance marketplaces, providing federal subsidies to help low-income populations purchase coverage, and enacting anti-discrimination provisions. 2 Alternative Benefits Plan (ABP): A health insurance plan designed by individual states and provided to certain Medicaid beneficiaries, including adults newly eligible for Medicaid coverage under the Affordable Care Act. 3 2 of 5

3 Cost-sharing: The health care costs paid by the patient rather than the insurance company. Common forms of cost-sharing include deductibles, copayments, and coinsurance. DSME/T: The National Standards for Diabetes Self-Management Education and Support define DSME/T as [t]he ongoing process of facilitating the knowledge, skill, and ability necessary for prediabetes and diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes or prediabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. 4 However, states use varying definitions of DSME/T, and each individual states definition generally determines the scope of insurance coverage for DSME/T services. Federal Poverty Level (FPL): Income guidelines issued by the United States Department of Health and Human Services (DHHS). Federal and state governments and agencies often use the measure when setting eligibility criteria for certain public programs, including Medicaid. DHHS annually adjusts the FPL based on the Consumer Price Index for All Urban Consumers. 5 Managed Care: A health care delivery system organized to manage cost, utilization, and quality. The managed care organization (MCO) receives a specified (capitated) payment to provide most or all health care services to members. This contrasts with a fee-for-service payment model where providers are reimbursed for each individual service delivered. Medical Nutrition Therapy (MNT): Federal law defines medical nutrition therapy as nutritional diagnostic, therapeutic, and counseling services provided by a registered dietitian or nutrition professional for the purpose of managing diabetes or a renal disease. 6 National Standards: Developed by a joint task force established by the AADE and ADA, the National Standards for Diabetes Self-Management Education and Support set forth best practices in providing DSME/T. 4 The National Standards address numerous components of successful DSME/T programs, including: internal structure, external input, access, program coordination, instructional staff, curriculum, individualization, ongoing support, patient progress, and quality improvement. 4 Prior Authorization: When an individual must receive permission from their insurance company prior to receiving coverage for certain medical services. Telemedicine: Providing medical services and treatment through two-way, real time communication between a health professional and patient rather than thorough a traditional in-person, face-to-face meeting. STATISTICAL DEFINITIONS Statistics included in individual state fact sheets generally come from the Center for Disease Control and Prevention s Behavioral Risk Factor Surveillance System (BRFSS). 7 Through telephone surveys conducted by each state, BRFSS aggregates health-related information into a single database. The following definitions provide additional information on specific statistics included in the fact sheets. % of Adults with Diagnosed Diabetes: The percentage of survey respondents who indicated they had been told they had diabetes by a doctor, nurse, or other health care professional. Women with only gestational diabetes were not included. 8 New Cases of Diabetes / 1,000 Adults: Adults who reported having diagnosed diabetes were asked at what age they were diagnosed. The number of years each person had been diagnosed with diabetes was calculated by subtracting the age at which they were diagnosed from their current age. Adults who had a 3 of 5

4 value of zero were identified as having been diagnosed with diabetes within the last year. In addition, half of the adults who had a value of one were classified as having been diagnosed with diabetes within the last year. 8 Completed a DSME/T Class: The percentage of survey respondents who answered yes to the question: Have you ever taken a course or class in how to manage your diabetes yourself? 8 Daily Self-Monitoring Blood Glucose: The percentage of survey respondents who answered 1 or more times per day to the question: About how often do you check your blood for glucose or sugar? 8 Overweight or Obese: The percentage of survey respondents whose self-reported weight and height corresponded with a BMI of 25 or greater. The survey calculated BMI as weight in kilograms divided by the square of height in meters. 8 Physical Inactivity: The percentage of survey respondents who reported no physical activity in the past 30 days when asked: During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? 8 High Blood Pressure: The percentage of survey respondents who indicated they had been told they had high blood pressure by a doctor, nurse, or other health care professional. The survey did not define high blood pressure. 9 High Cholesterol: The percentage of survey respondents who indicated they had been told they had high cholesterol by a doctor, nurse, or other health care professional. The survey did not define high cholesterol. 10 Fair or Poor General Health: The percentage of survey respondents who answered fair or poor when asked: Would you say that in general your health is? Poor Mental or Physical Health At Least 1 Day in the Past 30 Days: The percentage of survey respondents who answered one or more than one to either of the following questions: Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? 8 Inability to Do Usual Activities At Least 1 Day in the Past 30 Days: The percentage of survey respondents who answered one or more than one to the question: During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as selfcare, work, or recreation? 8 Visit a Health Professional for Their Diabetes: The percentage of survey respondents who answered one or more to the question: About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? 8 Received 2 or More A1c Tests in the Past Year: The percentage of survey respondents who answered two or more to the question: About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for hemoglobin A one C? 8 ADDITIONAL INFORMATION For more information about this topic please see: 4 of 5

5 Fact Sheet Summarizing the National Landscape for DSME/T Insurance Coverage: Diabetes Information from the CDC: Medicare DSME/T Information: This collection of laws does not provide legal advice nor does it address enforcement of laws, administrative policies, case law, or any other sources of law. Should you have a specific question about these laws in your state, please contact an attorney in your jurisdiction. This publication was supported by the Grant or Cooperative Agreement Number 5U38OT awarded to ChangeLab Solutions and funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. ChangeLab Solutions is a nonprofit organization that provides legal information on matters relating to public health. The legal information in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state ChangeLab Solutions REFERENCES 1. Diagnosing Diabetes and Learning About Prediabetes. American Diabetes Association website. Accessed August 29, Centers for Medicare & Medicaid Services. Affordable Care Act. Medicaid website. Accessed August 29, Centers for Medicare & Medicaid Services. Alternative Benefit Plan Coverage. Medicaid website. Accessed August 29, Haas L, Maryniuk M, Beck J, et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2014;37(Supplement 1):S144-S U.S.C. 9902(2) C.F.R Behavioral Risk Factor Surveillance System. Centers for Disease Control and Prevention website. Accessed August 29, Diabetes Atlas. National Diabetes Surveillance System. Centers for Disease Control and Prevention website. Accessed March 11, Prevalence of self-reported high blood pressure among adults aged 18 years with diagnosed diabetes Category: Diabetes. Centers for Disease Control and Prevention website. Accessed August 29, Prevalence of self-reported high cholesterol among adults aged 18 years with diagnosed diabetes Category: Diabetes. Centers for Disease Control and Prevention website. Accessed August 29, of 5