No. 27557 (Amendment): R414-90. Diabetes Self-Management Training

DAR File No.: 27557
Filed: 11/22/2004, 02:01
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to clarify program access requirements and service coverage within the diabetes self-management training program.

 

Summary of the rule or change:

In Subsections R414-90-3(2) and (3), the words "approved through" are included to indicate that qualified providers not certified or recognized by the American Association of Diabetes Educators (AADE) and licensed health care providers not recognized by the American Diabetes Association (ADA), must be approved through the Utah Department of Health. Also, "educators" is deleted and replaced with "instructors" to correctly refer to qualified providers that participate in the diabetes self-management training program. In addition, the acronym "ADA" is included in Subsection R414-90-3(3) to further clarify the American Diabetes Association as the acronym is later used in the text of the rule. Finally, in Section R414-90-4, the phrase "covering the 15 ADA core curriculum content areas" is added to specify certified training that meets all of the standards of the National Diabetes Advisory Board.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the changes to this rule only clarify program access requirements and service coverage within the diabetes self-management training program.

 

local governments:

There is no budget impact to local governments because the changes to this rule only clarify program access requirements and service coverage within the diabetes self-management training program.

 

other persons:

There is no budget impact to other persons because the changes to this rule only clarify program access requirements and service coverage within the diabetes self-management training program.

 

Compliance costs for affected persons:

There are no compliance costs because the changes to this rule only clarify program access requirements and service coverage within the diabetes self-management training program.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This change clarifies rule language without changing how Medicaid administers this program. There is no fiscal impact on businesses involved in this diabetes program. Scott D. Williams, MD

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

01/14/2005

 

This rule may become effective on:

01/15/2005

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-90. Diabetes Self-Management Training.

R414-90-1. Introduction and Authority.

Diabetes self-management training is an educational program that teaches individuals how to successfully manage and control diabetes. Diabetes self-management training is a component of the Utah Medicaid State Plan and is authorized by 42 CFR 440.130, October 2003 ed., and Utah Code Section 26-18-3.

 

R414-90-2. Client Eligibility Requirements.

Diabetes self-management training is available to Traditional Medicaid clients, Non-Traditional Medicaid clients, and Primary Care Network (PCN) clients who are diabetic and receive a physician referral for services.

 

R414-90-3. Program Access Requirements.

(1) Diabetes self-management training is limited to services approved by a physician, under a comprehensive plan that is essential to ensure successful diabetes self management by the individual patient.

(2) Qualified providers for the diabetes self-management training program include registered nurses, registered pharmacists and certified dieticians licensed by the state. These providers are required to be certified or recognized by the American Association of Diabetes Educators (AADE) or approved through the Utah Department of Health as diabetes [educators]instructors.

(3) Diabetes self-management training services provided by a home health agency, may only be provided by a licensed health care provider who is certified by an American Diabetes Association (ADA) program or [recognized by]approved through the Utah Department of Health.

(4) Home Health Agency participation in diabetes self-management training is limited to providing services to the patient who is receiving other skilled services in the home based on physician order and plan of care, when the home is the most appropriate site for the care provided.

 

R414-90-4. Service Coverage.

(1) Patient assessment for the diabetes self-management program includes a review of medical history, risk factors, health status, resource utilization, knowledge and skill level, and cultural barriers to effective diabetes self-management.

(2) Diabetes self-management training is limited to a maximum of 10 hours of outpatient services.

(3) Diabetes self-management training is limited to training presented by a certified program that meets all of the standards of the National Diabetes Advisory Board covering the 15 ADA core curriculum content areas. The program must also be recognized by the American Association of Diabetes Educators or be certified by the Utah Department of Health.

(4) Diabetes self-management training includes group sessions, but must allow for direct, face to face interaction between the educator and the patient.

(5) Diabetes self-management training must be sufficient in length to meet the goals of the basic comprehensive plan of care. Individual sessions must be sufficient in number and designed to meet the individual's cultural and learning needs.

(6) A maximum of 10 sessions per year may be approved by a physician and through prior authorization.

(7) Repeating any or all of a diabetes self-management program is limited to new conditions or a change in the health status of the client that warrants the need for new training.

(8) The following services are also covered:

(a) annual eye examination that includes dilation;

(b) annual physical;

(c) glycosylated hemoglobin laboratory test with foot examination;

(d) blood sugar review; and

(e) blood pressure reading every 3 to 4 months.

(9) Diabetes self-management training does not cover charges for facility use.

 

R414-90-5. Reimbursement.

Medicaid payments for approved diabetes self-management training are based on the established Medicaid fee schedule, unless a lower amount is billed. The fee schedule was established after internal and external consultation with diabetes experts. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.

 

KEY: Medicaid

[September 16, 2004]January 15, 2005

26-1-5

26-18-3