No. 27316 (New Rule): R414-90. Diabetes Self-Management Training

DAR File No.: 27316
Filed: 07/28/2004, 05:06
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary because Diabetes Self-Management Training is a component of the Utah Medicaid State Plan and teaches individuals how to successfully manage and control diabetes.

 

Summary of the rule or change:

This is a new rule for Diabetes Self-Management Training.

 

State statutory or constitutional authorization for this rule:

Section 26-18-3 and 42 CFR 440.130 (October 2003)

 

Anticipated cost or savings to:

the state budget:

There is an estimated savings of $1,100 to the State General Fund and $2,900 of federal funds because of an estimated 5 to 1 benefit cost ratio of diabetes self-management training programs.

 

local governments:

There is no cost to local governments as a result of this rulemaking because the program is solely funded by state and federal dollars.

 

other persons:

Qualified providers that participate in diabetes self-management training programs may experience $1,000 in additional revenue from additional services they provide.

 

Compliance costs for affected persons:

A qualified provider may experience an average increase in revenue of $35 for additional services provided.

 

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

The Department believes that this rule will reduce utilization costs that come from office visits, emergency room visits, and hospital visits. Patient compliance with recommended regimens should increase with a treatment plan that includes self-care, diet, and exercise. Scott D. Williams, MD, Executive Director

 

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:

09/14/2004

 

This rule may become effective on:

09/15/2004

 

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 the Utah Department of Health as diabetes educators.

(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 program or recognized by 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. 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

2004

26-1-5

26-18-3