Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-8 - Therapeutic and Diagnostic Services
Section 5160-8-53 - Diabetes prevention and self-management training
Universal Citation: OH Admin Code 5160-8-53
Current through all regulations passed and filed through September 16, 2024
(A) Definitions. For the purposes of this rule, the following definitions apply:
(1)
"Diabetes self-management training" (DSMT) is the
education and instruction of an individual with diabetes by a qualified
provider for the purpose of providing the individual with necessary skills and
knowledge to participate in the management of the individual's diabetes,
including the self-administration of injectable drugs.
(2)
"National
Diabetes Prevention Program" (NDPP) is an evidence-based, educational and
support program administered by the centers for disease control and prevention
(CDC) designed to assist at-risk individuals from developing type 2
diabetes.
(B) DSMT.
(1)
Providers.
(a)
Rendering providers. The following providers may render
or supervise a DSMT service:
(i)
A physician;
(ii)
A physician
assistant;
(iii)
An advanced practice registered nurse;
(iv)
A registered
nurse;
(v)
A registered dietitian nutritionist; or
(vi)
A
pharmacist.
(b)
Billing ("pay-to") providers. The following providers
may receive medicaid payment for submitting a claim for a DSMT service on
behalf of a rendering provider:
(i)
A physician;
(ii)
A physician
assistant;
(iii)
An advanced practice registered nurse;
(iv)
A licensed or
registered dietitian;
(v)
A pharmacist;
(vi)
A professional
medical group;
(vii)
A federally qualified health center;
(viii)
A rural health
clinic;
(ix)
An ambulatory health care clinic; or
(x)
A
hospital.
(2)
Coverage.
(a)
Payment for
diabetes self-management training can be made when the following criteria are
met:
(i)
The
individual has a current diagnosis of diabetes.
(ii)
The individual
has not previously received diabetes self-management training.
(iii)
Training is
provided in a setting other than an inpatient hospital or an emergency
department.
(b)
Payment may be made, with prior authorization in
accordance with rule
5160-1-31 of the Administrative
Code, for follow-up sessions not to exceed a total of two hours of individual
training or group training in any combination.
(C) NDPP.
(1)
Providers.
(a)
Rendering providers. The following providers may render
or supervise an NDPP service:
(i)
A physician;
(ii)
A physician
assistant;
(iii)
An advanced practice registered nurse;
(b)
Billing ("pay-to") providers. The following providers may
receive medicaid payment for submitting a claim for an NDPP service on behalf
of a rendering provider:
(i)
A physician;
(ii)
A physician
assistant;
(iii)
An advanced practice registered nurse;
(iv)
A professional
medical group;
(v)
A federally qualified health center;
(vi)
A rural health
clinic; or
(vii)
An ambulatory health care clinic;
(2)
Coverage.
(a)
Payment for an NDPP service can be made when all of the
following criteria are met:
(i)
The individual is eighteen years or
older;
(ii)
The individual is overweight;
(iii)
The individual
is not currently pregnant; and
(iv)
The individual
does not have a diagnosis of type 1 or type 2 diabetes.
(v)
At least one of
the following criteria is met:
(a)
The individual has been diagnosed with
prediabetes;
(b)
The individual has a history of gestational diabetes;
or
(c)
The individual has had a high-risk result on a
prediabetes test.
(D) Claim payment.
(1)
No
payment will be made for a DSMT or NDPP service provided on the same date of
service as medical nutrition therapy.
(2)
Payment for a
covered service performed in a hospital is made in accordance with Chapter
5160-2 of the Administrative Code.
(3)
Payment for a
covered service rendered by a federally qualified health center (FQHC) or rural
health clinic (RHC) is made in accordance with Chapter 5160-28 of the
Administrative Code.
(4)
Payment for a covered service rendered in any other
setting is the lesser of the submitted charge or the amount shown in appendix
DD to rule
5160-1-60 of the Administrative
Code.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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