Current through Rules and Regulations filed through September 23, 2024
Health insurance policies and plans, except limited benefit insurance policies, shall provide coverage for diabetes self-management training and medical nutrition therapy when prescribed by a physician licensed to practice medicine pursuant to Title 43. Minimum standards for diabetes self-management training and medical nutrition therapy shall conform to the following:
(1) Diabetes self-management training and medical nutrition therapy services must be provided by a diabetes self-management training program that meets the following criteria:
(a) The program has been recognized by the federal Centers for Medicare & Medicaid Services (CMS), or
(b) Obtains or receives approval, accreditation or certification by a national organization assessing standards of quality in the provision of diabetes self-managment education.
(2) Diabetes self-management training programs shall be provided when any of the following criteria are met and when the service is prescribed by a physician licensed to practice medicine pursuant to Title 43.
(a) Upon a physician's diagnosis that an insured or dependent has diabetes;
(b) Upon a significant change in a health care insurance policyholder's/ dependent's diabetes related condition;
(c) Upon a change in a health care insurance policyholder's/dependent's diagnostic levels;
(d) Upon a change in treatment regimen;
(e) Upon a patient's initiation of insulin therapy;
(f) Upon identification of inadequate diabetes control as evidenced by diagnostic laboratory tests falling outside of acceptable ranges;
(g) Upon determination that a patient is at high risk for complications based on inadequate glycemic control documented by acute episodes of severe hypoglycemia or acute severe hyperglycemia occurring in the patient's history during which the insured needed emergency room visits or hospitalization;
(h) Upon determination that a patient is at high risk based on at least one of the documented diabetes related complications including:
1. Lack of feeling in the foot or other foot complications such as foot ulcers, deformities or amputation;
2. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye;
3. Kidney complications related to diabetes, when manifested by albuminuria without other cause, or elevated creatinine.
(3) Medical nutrition therapy services shall be provided in addition to diabetes self-management training when prescribed by a physician licensed to practice medicine pursuant to Title 43 when the following criteria are met:
(a) Upon a physician's diagnosis that an insured or dependent has diabetes;
(b) Upon a significant change in a health care insurance policyholder's/ dependent's diabetes related condition;
(c) Upon a change in a health care insurance policyholder's/dependent's diagnostic level;
(d) Upon a change in treatment regimen;
(e) Upon a patient's initiation of insulin therapy;
(f) Upon identification of inaequate diabetes control as evidenced by diagnostic laboratory tests falling outside of acceptable ranges;
(g) Upon determination that a patient is at high risk for complications based on inadequate glycemic control documented by acute episodes of severe hypoglycemia or acute severe hyperglycemia occurring in the patient's history during which the insured needed and received emergency room visits or hospitalization;
(h) Upon determination that a patient is at high risk based on at least one of the documented diabetes related complications including:
1. Lack of feeling in the foot or other foot complications such as foot ulcers, deformities or amputation;
2. Pre-proliferative or proliferative retinopathy or prior laser treatment of the eye;
3. Kidney complications related to diabetes, when manifested by albuminuria without other cause, or elevated creatinine.
(4) Instructions in diabetes self-management training shall be provided by healthcare professionals meeting any or all of the following criteria:
(a) Certified diabetes educator;
(b) A certified, registered or licensed health professional with expertise in diabetes satisfying criteria for Medicare coverage for diabetes education and training pursuant to 42 CFR Part 410.
(5) Instruction in medical nutrition therapy shall be provided by healthcare professionals meeting any or all of the following criteria:
(a) Registered dietitian;
(b) A certified, registered or licensed health professional with expertise in medical nutrition therapy satisfying criteria for Medicare coverage for medical nutrition therapy pursuant to 42 CFR Part 410.
(6) Primary or initial diabetes self-management training and medical nutrition therapy services shall be provided in group settings for a total of 10 hours in the initial year after diagnosis unless the following criteria are met:
(a) A group session is not available within 2 months of the date diabetes self-management training or medical nutrition therapy are ordered; or
(b) The insured's physician documents that the insured has special needs that will hinder effective participation in a group training session.
(7) Secondary or follow-up diabetes self-management training and medical nutrition therapy shall be provided during individual patient meetings or sessions within the first 12 months after a primary or initial diabetes self-management training or medical nutrition therapy group session.
O.C.G.A. Secs. 33-2-9, 33-24-59.2.
