Part I.
Texas Department of Insurance
Chapter 21.
Trade Practices
Subchapter R. Diabetes
28 TAC §§21.2601-21.2607
The Commissioner of Insurance adopts new Subchapter R, §§21.2601
- 21.2607, concerning minimum standards for benefits provided to enrollees
with diabetes in health benefit plans and coverage under health benefit plans
for equipment and supplies and self-management training associated with the
treatment of diabetes. The sections are adopted with changes to the proposed
text as published in the December 4, 1998, issue of the
Texas Register
(23 TexReg 12184).
The new sections are necessary to implement legislation enacted by the
75th Legislature in Senate Bills 162 and 163, amending Chapter 21, Subchapter
E by adding Article 21.53D, Guidelines for Diabetes Care, which requires the
Commissioner by rule to adopt minimum standards for benefits provided to enrollees
with diabetes in health benefit plans, and Article 21.53G, Coverage for Supplies
and Services Associated with Treatment of Diabetes, which requires coverage
under health benefit plans for equipment and supplies and self-management
training associated with the treatment of diabetes. After receiving public
comments on the proposed rules, the department has made changes based upon
the public comments, as well as for clarification, punctuation, and consistency.
The following revisions to the referenced sections were made: the definitions
of diabetes equipment, set forth in §21.2601(4), and diabetes supplies,
set forth in §21.2601(5), were clarified by deleting the phrase "includes
but is not limited to" and adding a reference to §21.2605 as part of
the definitions of both equipment and supplies.
Subsection (d) was added to §21.2602 to clarify that review of medical
necessity of benefits provided under this subchapter is permitted. Section
21.2603 was changed by deleting subsection (b), which stated that basic benefits
shall not be subject to dollar limitations other than the plan's lifetime
maximum benefit amounts. Section 21.2605(11) was changed to require that prescription
medication provided under that section was limited to items which bear the
legend "Caution: Federal Law prohibits dispensing without a prescription."
Concerns were expressed that the coverage or provision of self-management
training to caretakers of insureds who, due to their age or other circumstances,
could not participate in self-management training, was a provision of benefits
beyond those required by the statute. Accordingly, §21.2606 was changed
to limit coverage for self-management training provided to an insured's caretaker
to the same circumstances coverage for training would ordinarily be provided
to an insured, and only then if the training was being provided to a caretaker
instead of the insured. Additionally, subsections (e)(4) and (e)(5) were omitted
and language contained in those sections which address the administration
of medications was moved to §21.2606(e). Sections 21.2606(e)(2) and (e)(3)
were changed to require coverage for training only if a physician or practitioner
orders the training in writing.
Comments were received regarding the failure to include licensed health
care providers with recent approved continuing education in diabetes, educational
principles and behavioral strategies who are not Certified Diabetes Educators
(CDEs) in the rules as a source of self-management training. This source of
training, which is recognized in the standards for self-management training
promulgated by the American Diabetes Association (ADA), was not included in
the proposed rules because, unlike the ADA, neither TDI nor an insurance company
has the means or expertise to evaluate each individual provider's assertion
of sufficient continuing education and experience to provide self-management
training or to approve the education and experience relied upon by the provider.
Some commenters argued that licensure of a provider was sufficient evidence
that the provider was competent to provide self-management training. However,
the ADA in its comments concerning self-management training indicated that
the scope of practice of a licensed health care provider, such as a dietician,
often prevents such a provider from acquiring the depth of knowledge required
to manage the intricacies of a chronic disease such as diabetes. Therefore,
licensure as a health care provider alone is not indicative that the provider
meets the national standards for self-management training. A fourth paragraph
was added to §21.2606(a), requiring coverage for self-management training
from, "a licensed health care professional, including a physician, a physician
assistant, an advance practice nurse, a registered nurse, a licensed or registered
dietician, or a pharmacist, who has been determined by his or her licensing
board to have recent didactic and experiential preparation in diabetes clinical
and educational issues." This language permits a provider to seek a determination
from his or her licensing board that the provider has received sufficient,
relevant continuing education and experience to enable the provider to provide
diabetes self-management training. It should be noted that none of the licensing
boards currently provide such determinations, and it is not the intention
of the rule to suggest that these licensing boards should issue them. However,
the rule recognizes that recent didactic education and experience can qualify
a provider to perform self-management training and that the provider's board
is in the best position to evaluate the type and extent of education and experience
received by its licensees.
In response to comments that the rules seem to place undue emphasis on
the certified diabetes educator (CDE) as a source of self-management training,
the order of paragraphs (1) and (3) of §21.2606(a) was transposed. Additionally,
in response to numerous comments that the phrase, "a multidisciplinary team
directed by a CDE" implied a supervisory relationship, §21.2606(a)(2)
was changed to "a multidisciplinary team coordinated by a CDE."
The requirement that self-management training plans be "regularly updated"
was deleted from §21.2606(c) in response to comments that the self-management
training requirements in the proposed rule appeared to usurp the role of the
dietician in providing ongoing medical nutritional counseling by dieticians.
The two year phase-in period before the training requirements in §21.2606
was extended for an additional year to facilitate coverage of self-management
training while allowing providers to meet the requirements. Accordingly, all
references to the date 1/1/2001 in §21.2607 and elsewhere in the rules
in which §21.2607 is cited were changed to 1/1/2002.
All other changes in the rules reflect alterations required by the changes
discussed above, or to correct punctuation, grammatical, or typographical
errors.
New §21.2601 defines terms used in this subchapter. New §21.2602
describes in general the requirements for coverage provided by Articles 21.53D
and 21.53G. New §21.2603 sets forth how benefits required under this
subchapter are to be made, subject to deductible, copayment, or coinsurance
requirements. New §21.2604 sets forth minimum standards for benefits,
services, and care to be provided to insured individuals with diabetes, including
self-management training. New §21.2605 sets forth the type of supplies
and equipment to be covered as required benefits, as well as the circumstances
under which additional equipment and supplies will become required benefits
as improvements occur in the treatment, monitoring, equipment, and supplies
associated with diabetes. New §21.2606 sets forth the standards for self-management
training to be covered or provided and sets forth the requirements for health
care practitioners who provide the training that is covered or provided. New
§21.2607 sets forth a phase-in period until January 1, 2002 to allow
coverage for self-management training obtained from certain providers by individuals
who live in areas that are currently underserved by providers who meet the
requirements set forth in new §21.2606.
Medical Necessity. A commenter stated that the rules do not allow for the
review of medical necessity.
Agency Response: The proposed rules did not prohibit the application of
medical necessity. However, to clarify that a review of medical necessity
is permitted, language specifically permitting it was added at §21.2602(d).
Such review can be performed only if the health benefit plan generally provides
for medical necessity review and is subject to all laws and rules applicable
to medical necessity determinations. Distinction between HMO and Indemnity
Requirements. A commenter was puzzled by the distinction between HMOs and
insurers in these rules, as the underlying statute, Article 21.53G, makes
no such distinction. The commenter was concerned that the administrative burden
on HMOs seems disproportionate to that required by insurers and is not supported
by the statute.
Agency Response: The rules implement two statutes, Articles 21.53D and
21.53G. The department is aware that these rules may impact HMO and indemnity
plans differently. The distinction between HMO plans and indemnity plans is
due to the inherent differences between such plans and other statutes applicable
to each. Indemnity plans provide for reimbursement for care received from
any qualified provider chosen by the insured while HMOs provide health care
services through a network of qualified contracting providers and thus HMO
plans have administrative responsibilities that indemnity plans do not. These
rules reflect, but do not cause, that distinction. §§21.2601(2)
and 21.2606(e)(4) and (5). Commenters stated the rules appear to require coverage
for the training of a caretaker of an insured, which constitutes an additional
benefit not authorized by Article 21.53G. The commenters also believed this
was an unprecedented provision of benefits to an individual other than the
insured. The commenters proposed that the definition of caretaker be amended
and that §21.2606(e)(4) be amended to permit coverage for a caretaker
only where the caretaker was a member of the same plan as the insured.
Agency Response: The department disagrees. Although Article 21.53G does
not specifically address the provision of training to a family member or significant
other who provides care to an insured who is a diabetic, it clearly supports
coverage for training of the caretaker of a child or person otherwise unable
to manage their own care. The statute requires that all insureds receive benefits,
including training, that will assist the insured in managing the disease.
The department anticipates that the cost of training a caretaker is the same
as for an insured. Coverage for training of a caretaker of an insured who
cannot perform his or her own diabetes management will ensure that the condition
of the insured will be effectively managed and advances the legislative intent
behind Article 21.53G, which is to reduce costs associated with complications
caused by inadequate treatment and control of diabetes. However, the department
agrees that the statute does not authorize coverage for a caretaker beyond
coverage that would be provided for self-management training to the insured.
Accordingly, the department has modified the language of §21.2606(e)
to require coverage for self-management training provided to a caretaker only
under the same circumstances in which self-management training to an insured
would be covered. This language, along with the definition of caretaker at
§21.2601(2), allows a caretaker to undergo self-management training in
lieu of, rather than in addition to, the insured. The department has also
changed the language of §§21.2606(e)(2), and (e)(3) to clarify that
coverage for training is required only if a physician or practitioner orders
the training in writing. §21.2601(4) and (5). A commenter stated the
language "includes but is not limited to" should be stricken from the rule
as Article 21.53G(1) is very specific in its definition of diabetes equipment
and supplies.
Agency Response: Article 21.53G(1) does not contain the sole definition
of diabetes equipment and supplies. Article 21.53G(5) also requires carriers
to cover new or improved diabetes equipment and supplies, upon approval by
the FDA. Additionally, §21.2605 clarifies the definition of diabetes
equipment by describing the various types of insulin pumps and the specific
associated appurtenances as well as podiatric appliances. The department has
further clarified this section by deleting the language "includes but is not
limited to" as requested and adding a reference to §21.2605 as part of
each definition. §21.2601(7). A commenter proposed that the definition
of health benefit plan be amended to specifically state that disability insurance
is exempt from application of the rules.
Agency Response: The department disagrees that a change is needed. The
language of §21.2601(7)(C)(i)(III) tracks the language of Insurance Code
Articles 21.53D and 21.53G. While the term "disability insurance" is not used,
the language of the statutes and the rule defines disability insurance and
clearly exclude disability policies from the application of the statute and
the rules. §21.2601(8). A commenter stated the rules do not clearly apply
only to insureds with diabetes. The commenter suggested that throughout the
rule the word "insured" be replaced with "insureds with diabetes."
Agency Response: The term "insured" for purposes of this subchapter is
defined in §21.2601(8) as a person enrolled in a health benefit plan
who has been diagnosed with insulin dependent or noninsulin dependent diabetes,
elevated blood glucose levels induced by pregnancy or another medical condition
associated with elevated glucose levels. The department believes this definition
adequately addresses the commenter's concerns. §21.2603(b). A commenter
stated this section requires that basic benefits shall not be subject to dollar
limitations other than the plan's lifetime maximum benefit amounts. The comment
believes this section of the rule exceeds the scope of Article 21.53G(6).
Agency Response: The department agrees that Article 21.53G does not specifically
require this particular subsection and has therefore deleted the section as
proposed. The department does not believe that Article 21.53G allows carriers
to place dollar limits on diabetes equipment and supplies required to be covered
by a health benefit plan. Article 21.53G(6) prohibits a plan from imposing
a deductible, copayment or coinsurance that exceeds a deductible, copayment
or coinsurance required by the plan for treatment of other analogous chronic
medical conditions. It must also be noted that testimony at the public hearing
on the rules from the American Diabetes Association and research conducted
by the department indicates that there is no other condition or disease analogous
to diabetes in terms of the efficacy of early, effective treatment and management
in minimizing the long term, debilitating effects on an insured.
§21.2604.A commenter stated that the statute does not require many
of the items listed as minimum standards. Another commenter stated that the
minimum standards in the rule reflect that Article 21.53G requires minimum
standards based on standards adopted and implemented by the Texas Diabetes
Council whose standards are based on the clinical practice recommendations
of the American Diabetes Association.
Agency Response: This portion of the rule is implementing Insurance Code
Article 21.53D. This article does not list specific benefits to be provided;
instead, it directs the Commissioner in consultation with the Texas Diabetes
Council to adopt minimum standards for benefits to be provided to insureds
with diabetes. The minimum standards in §21.2604 reflect standards developed
by the Texas Diabetes Council, which are based on national standards of the
American Diabetes Association (ADA). §21.2604(b). A commenter requested
confirmation that complications involving two or more body systems is not
an additional mandate to cover pharmaceuticals for treatment of these conditions
when, for example, such pharmaceuticals are not contained in a particular
evidence of coverage.
Agency Response. It is not possible for the department to respond to the
commenter's question about complications involving "two or more body systems"
without more information about the commenter's particular concerns. However,
the department does confirm that Article 21.53G requires that equipment and
supplies associated with the treatment of diabetes must be provided under
this subchapter as part of a plan's basic benefits, regardless of the existence
of pharmacy or durable medical equipment riders in the evidence of coverage
relating to the plan. §21.604(b) & (c). A commenter was concerned
that the requirements of (21.2604 necessitate additional reporting requirements.
Agency Response. The language of this section does not specify additional
reporting requirements or processes beyond those with which that all carriers
are already required to comply under other applicable provisions of the Insurance
Code and rules promulgated by the department. §21.2604(d). Two commenters
stated that the rule requires health benefit plans other than HMOs to provide
coverage for certain childhood immunizations under Article 21.53F including
immunizations for influenza and pneumococcus, while Article 21.53G does not
require coverage for immunizations.
Agency Response: The department acknowledges that immunizations are not
listed in Insurance Code Article 21.53G; however, §21.2604 implements
Article 21.53D, which requires the Commissioner, in consultation with the
Texas Diabetes Council to adopt minimum standards for benefits, rather than
Article 21.53G. Immunizations are included in the minimum standards set by
the Texas Diabetes Counsel and the department believes this benefit should
be provided as immunizations give effect to the intent of the Legislature
to reduce complications in insureds that would result in more costly care
and benefits. §21.2604(d)(1). A commenter stated that the language "appropriate
specialists" is not defined in the rules and should be replaced with the term
"licensed health care practitioners" since both the rules and Article 21.53G
utilize that term.
Agency Response: The department disagrees. Section 21.2604(d)(1) requires
coverage of office visits and consultation with appropriate specialists. These
appropriate specialists are known in the medical community and are experts
in their area of specialization. An insured with diabetes should have coverage
and access to a full range of specialists if determined medically necessary
by their treating practitioner or physician. As an example, an insured because
of diabetes may require the care of a nephrologist for renal disease, a cardiologist
for vascular disease, or an exam by a therapeutic optometrist due to diabetes.
This minimum standard reflects the standards developed by the Texas Diabetes
Council for treating diabetes.
§21.2605. A commenter expressed concern about a carrier's ability
to control coverage of costs of equipment when the physician or practitioner
has not specified a certain piece of equipment, and inquired whether the section
requires coverage for the most expensive piece of equipment when a lesser
priced piece would suffice.
Agency Response. The intent of Article 21.53G is to permit the insured's
physician or practitioner to determine the particular type and amount of equipment
and supplies necessary to manage and control the insured's diabetes. Therefore,
the rules defer to the expertise of the physician or practitioner in determining
whether to require coverage of a specific type of equipment or supplies. The
department also included language in §21.2602 that clarifies that medical
necessity determinations may be applied to any benefits covered pursuant to
this subchapter. However, in making these determinations, it should be noted
that Article 21.53D requires that the minimum standards set forth in §21.2604
apply to benefits provided to insureds with diabetes pursuant to a health
benefit plan. §21.2605(a)(11). A commenter provided suggested language
to prevent the writing of prescriptions for over-the-counter foodstuffs.
Agency Response. The department agrees with the commenter that Article
21.53G was not intended to cover prescriptions for over-the-counter foodstuffs.
The department believes that the language of §21.2605(a) as proposed
addresses this concern. The department worked with the Texas State Board of
Pharmacy in developing the language relating to medications available without
a prescription to eliminate non-medications such as foodstuffs and has retained
this language. However, the department has incorporated the commenter's language
limiting prescription medications to those that fit the definition of Federal
Legend Drugs. §21.2605(b). A commenter stated that the coverage for new
and improved treatment and monitoring equipment and supplies is reasonable;
however, the rule should require that such equipment and supplies be safe
and effective, not experimental, and be medically necessary and appropriate.
The commenter stated that FDA approval does not necessarily guarantee that
the new drug or device is safe or effective for all patients.
Agency Response: The department disagrees. Section 21.2605(b) directly
tracks the language of Article 21.53G(5), "on approval [of the FDA] of new
or improved diabetes equipment or diabetes supplies, each benefit plan subject
to this article must include coverage of the new or improved equipment and
supplies if medically necessary and appropriate as determined by a physician
or other health care provider." §21.2605(c). A commenter stated this
provision, which requires "dispensed as written" coverage of diabetes medications
and equipment, undermines a drug formulary and interferes with an HMO's ability
to reduce medical costs and control premiums. Another commenter requested
verification that if a drug formulary is utilized by a carrier an HMO can
impose otherwise applicable formularies.
Agency Response: The department disagrees that the rule will increase costs
for HMOs. Applicable drug formularies may be utilized provided that the insureds'
practitioner has not indicated that medication must be dispensed as written
and the formularies are imposed in conformity with all applicable rules promulgated
by TDI relating to drug formularies. Scientific literature supports the need
for some diabetics to receive specific brands of insulin. Changing brands
of insulin due to formulary requirements can result in decreased control of
blood sugar with subsequent complications. Medical literature supports the
cost effectiveness of good blood sugar control. The department believes that
the long term cost of care will be reduced, not increased, by this requirement.
§§21.2604 and 21.2606. A commenter suggested the rules include minimum
standards for meal planning and food education.
Agency Response: The minimum standards set forth in §21.2604 include
access by each insured to diabetes self-management training which requires
an individualized plan for each insured based on his or her own particular
needs and conditions. This may include, if necessary, meal planning and food
education, which would be part of the nutritional counseling which is required
by the statute and the rule. Therefore, the rules ensure that the type of
training requested by the commenter is available for any insured to whom it
would apply.
§21.2606.A commenter applauded the proposed section's utilization
of the National Standards for Diabetes Self-Management Education Programs
which incorporates the consensus opinion and recommendations of the varied
diabetes-related organizations called upon to improve diabetes treatment outcomes
in the 1993 National Diabetes Advisory Board task force and the resulting
recommendations. The commenter states that in adhering to these national standards,
the rule emphasizes the importance of a qualified, multi-faceted approach
to diabetes care. All health care team members are collectively qualified
to teach the required program areas while focusing on program structure, process
and outcomes to achieve a quality medical intervention effort.
Agency Response: The department agrees and appreciates these comments.
Comment. A commenter believed that the structure of §21.2606 violates
the standards of the American Diabetes Association (ADA) regarding self-management
training in that it is more restrictive and in conflict with the diabetes
self-management training standards for the ADA particularly in its requirement
that dieticians work under the direction of a Certified Diabetes Educator
(CDE). Other commenters believed §21.2606(a) violates recognized standards
of health care by requiring that self-management training be provided by a
CDE or through a multidisciplinary team under the direction of a CDE. Commenters
believe that the term "direction" is not adequate to provide guidance and
that CDEs alone cannot provide the medical nutrition therapy nor can they
direct another better educated and trained health professional in providing
it.
Agency Response: As proposed, §21.2606(a)(2) did not require that
licensed dieticians be supervised by a CDE. The rule required, for coverage
of diabetes self-management training only, that licensed health care practitioners,
which includes pharmacists, nurses, physicians and dieticians, who were not
certified as CDEs, could provide self-management training required by the
statute and rules as long as the practitioners had recent didactic and experiential
preparation in diabetes clinical and educational issues and that they affiliate
themselves either with a treatment team directed by a CDE or an ADA recognized
program. To clarify this issue, §21.2606(a)(2) has been changed by replacing
"under the direction of" to "coordinated by" a CDE. The adopted rules also
include a new paragraph (a)(4), that allows coverage for self-management training
provided by a licensed health care professional, including a physician, a
physician assistant, an advance practice nurse, a registered nurse, a licensed
or registered dietician, or a pharmacist, who has been determined by his or
her licensing board to have recent didactic and experiential preparation in
diabetes clinical and educational issues.
Comment. Several commenters stated that while recognizing that a CDE is
needed for comprehensive self-management training, many diabetics need only
nutritional counseling that can be provided by a dietician alone. One commenter
believes that the rules establish an inferior standard for self-management
training and do not ensure quality. Another commenter wanted the rules to
cover nutritional counseling by registered or licensed dieticians without
requiring supervision or direction by a CDE. Another commenter stated the
proposed rules will no longer allow registered dieticians to be part of the
Diabetic Management Team or to treat and train diabetics and believes that
this is a disservice to the medical community.
Agency Response: These comments reflect that some confusion may exist about
the difference between diabetes self-management training and the provision
of on-going services to an insured for management of diabetes. The department
recognizes the importance of a properly trained dietician in the management
of diabetes and that many insureds may need primarily, or even at times, only
nutritional counseling. The rules do not restrict or prohibit the provision
of nutritional counseling by a dietician nor are they intended to restrict
an insured's right to select a practitioner under a health benefit plan that
provides coverage for nutritional counseling or to restrict a dietician from
being involved in self-management training. Article 21.53G requires a plan
to provide coverage for diabetes supplies and equipment and self-management
training. Self-management training is provided or covered only upon initial
diagnosis of diabetes or when a change in the condition of the insured or
treatment modalities affecting the insured occurs and involves comprehensive
training about all aspects of the nature of diabetes and the effect of and
interactions among such factors as other illnesses, stress and medications,
as well as diet and nutrition, upon the insured. The statute does address
coverage of on-going monitoring associated with medical nutrition therapy
or counseling. Although self-management training does include a nutritional
counseling component, it is not comparable to or intended to be a substitute
for medical nutrition therapy or counseling. An insured initially diagnosed
with diabetes requires self-management training that meets the overall educational
needs of an insured that are broader than nutritional counseling alone. Self-management
training is narrowly defined at §21.2601(6) as instruction enabling an
insured or a caretaker to understand the care and management of diabetes,
including nutritional counseling and proper use of diabetes equipment and
supplies. The rules assure coordination of all of these educational needs.
No member of the team delineated in §21.2606(a)(2) is excluded from providing
training in their area of expertise, although the rules reflect the highest
standard for comprehensive diabetic self-management training. The department
has changed the phrase "directed" to "coordinated" to clarify that the CDE's
role is to assure that an insured receives all required aspects of self-management
training rather than to supervise or instruct other team members in carrying
out the training that they are providing under their respective professional
licenses. The department has also omitted the phrase "and regularly updated"
from §21.2606(c), which requires the development of an individualized
management plan. The inclusion of this phrase, which was inadvertent, may
have created the false impression that self-management training involved on-going
monitoring of an insured which would include nutritional counseling.
Comments. Commenters believed this section will increase medical costs
and discourage some diabetics from seeking medical education and counseling.
Agency Response: The department disagrees. Article 21.53G requires the
department to adopt rules concerning self-management training. Section 21.2606
applies only to self-management training under specific circumstances or at
certain times. Self-management training as required by the statute and rules
is not on-going treatment or counseling. Coverage for training as set forth
in §21.2606 will ensure that the training is coordinated and complete.
The department also believes that costs will decrease and availability of
competent, coordinated training will increase since insureds will not have
to seek out training from different providers and separately compensate them.
Comment. Commenters believe CDEs who are not working as part of an ADA
approved team provide substandard training. Commenters proposed that the coverage
be provided only for ADA approved training programs unless the plan can show
that an ADA recognized program is not available.
Agency Response: The department disagrees. Certification as a diabetes
educator demonstrates that the individual health care professional has met
standards set by peers in the specialty practice of diabetes education and
validates that a professional has knowledge and expertise in diabetes education.
Access to the various types of self-management training delivery varies throughout
the regions of Texas. ADA recognized programs are primarily concentrated in
the larger urban areas of the state. The department conferred with representatives
of the Texas Diabetes Council and the ADA in determining that the highest
quality diabetes self-management training can be made available to the largest
number of insureds throughout Texas by proposing coverage for training delivered
by multidisciplinary teams coordinated by a CDE, or a program approved by
the ADA, or individuals who are CDEs. However, the department has reversed
the order in which the acceptable methods of delivery of self-management training
are listed in §21.2606(a), not because the rules requires that an ADA
approved program should be utilized unless one is not available, but to lessen
the emphasis that was apparently being placed upon the option of self-management
training provided by a CDE alone. §21.2606(a)(2). A commenter stated
that the rule allows diabetes self-management training to be provided by a
social worker and that Article 21.53G(4) specifies that diabetes self-management
training be provided by a health care provider or practitioner who is licensed,
registered or certified in this state to provide appropriate health care services.
The commenter believed social workers are not licensed to provide health care
services and thus they request social workers be stricken from the rule.
Agency Response: The department disagrees. The department believes social
workers are not excluded from providing health care services. Licensed master
social workers--advanced clinical practitioners are included in Insurance
Code Articles 21.52 and 3.70-2 as practitioners that are eligible for reimbursement
for the provision of services which fall within the scope of their licenses.
No provision of the Insurance Code defines health care services to exclude
mental health care services. §21.2606(g). A commenter stated this rule
appears to require insurers to direct insureds in finding or choosing a physician,
that insurers are not similar to HMOs in this regard, and that individual
insureds should find and access the physicians or practitioners of their own
choosing.
Agency Response: It appears the commenter has misinterpreted this rule.
This section of the rule does not require insurers to provide a list of providers
to insureds; it requires insurers to disclose in their health benefits plans
the types of individuals, as specified in §§21.2606(a) and 21.2607,
for whom the insurer is required to provide coverage. §21.2606 &
§21.2607 Commenters believed the rules will create a reduction in ADA
approved self-management training programs. Commenters expressed concerns
with a reduction in access to diabetes self-management training under the
proposed rules in rural areas, noting that there are slightly over 500 CDEs
in Texas and that this limited number could not serve the needs of the entire
diabetic population in the state.
Agency Response: The department's research indicates that at the time of
the public hearing held January 5, 1999, there were 662 CDEs in Texas, which
represented an increase of 162 since May 1998. The availability of CDEs and
ADA-recognized programs for insureds throughout Texas was a significant consideration
in drafting the rules. Section 21.2607 has been changed in the adopted rules
to provide a phase-in period until 1/1/2002. Prior to that date, self-management
training will be covered when provided by the appropriate licensed provider
even if that provider does not meet the requirements of §21.2606(a).
The phase-in also gives eligible health care providers time to become a CDE,
to affiliate himself or herself with an ADA approved program or a multidisciplinary
team, or to obtain a determination from the appropriate licensing board as
required by the rules. The department believes that ultimately the rules will
result in a net increase in both the number and the quality of self-management
training programs.
21.2607.A commenter believed that §21.2607 does not adequately address
the immediate access and cost concerns of insureds and that a two year delay
will not provide an adequate period to allow the various concerned parties
to evaluate the quality, access and costs of the training provided during
the phase-in period, possibly resulting in the substitution of the requirements
of §21.2607 for those of §21.2606 on a permanent basis.
Agency Response: The department disagrees. The purpose of the phase-in
period is not to permit a trial run under standards that fall below those
established by the Texas Diabetes Council and the ADA. The purpose of the
phase-in is to allow insureds to have access to self-management training while
health care providers and industry prepare for full compliance with the requirements
of §21.2606. As previously discussed, the number of CDEs and ADA recognized
programs has increased since May of 1998. However, in response to comments
concerning the length of time it takes to become a CDE, the department has
extended the phase-in period for an additional year until 1/1/2002. §21.2607(b).
A commenter questioned why §21.2607(b) applies only to HMOs whereas health
benefit plans provided by insurers covers self-management training prior to
1/1/2001 (now 1/1/2002) from one of the sources named in §21.2606.
Agency Response: The commenter misinterprets §21.2607. The phase-in
and rules pertaining to providers of self-management training apply to both
insurers and HMOs. Subsection (b) differs from subsection (a) because the
differences between indemnity and HMO systems require different implementation
mechanisms. Additionally, §21.2607(b) tracks the requirements for HMOs
set forth in other rules. §21.2607(e). A commenter believed language
should be amended to specifically indicate that benefits provided under this
subsection are subject to a deductible, co-payment or coinsurance requirement.
Agency Response: This recommendation was not incorporated by the department.
Section 21.2603 indicates that all benefits provided under these rules are
subject to applicable deductible, copayment or coinsurance requirements. This
section applies to all benefits provided under §21.2607.
General. Commenters wanted more options for preventive health care and
suggested that registered dieticians play an important role in treatment of
diabetes.
Agency Response: The department agrees that a variety of options should
be available to an insured seeking self-management training. The rules ensure
this by providing coverage from alternative sources of training. The rules
also contain a phase-in period, which was extended by the department for an
additional year, until 1/1/2002, to ensure that providers have ample time
to meet the requirements of (21.2606.
Comment. A commenter stated that an insured was refused coverage for training
provided by a dietitian because the dietitian did not bill through a physician's
office.
Agency Response: Although the department cannot comment in this order about
the specific incident reported by the commenter, it encourages the commenter
and/or the insured to contact the Consumer Protection Division of the department
about the denial of these benefits, particularly if the services were provided
pursuant to a health benefit plan issued, issued for delivery, or renewed
after January 1, 1998, the effective date of Article 21.53G.
Comment. A commenter stated health insurance should reward patients with
some reduction in annual insurance rates when patients achieve or maintain
desirable weight and/or blood sugar levels.
Agency Response: The department acknowledges the commenter's suggestion.
However, the Insurance Code does not provide the department with the authority
to require such a reduction. It should be noted that Insurance Code Articles
26.33 and 26.89 allow carriers who issue plans to large and small employers
to establish premium discounts and reductions in copayments or deductibles
for insureds who adhere to programs for health promotion and disease prevention.
Comment. Numerous commenters stated that they support the intent behind
Articles 21.53D and 21.53G, which is to increase access to care and self-management
education for all insureds with diabetes and to ensure that the care received
is quality care.
Agency Response: The department agrees with and appreciates these comments.
The department believes that the rules accomplish the Legislature's intent
to provide access to benefits and self-management training to Texans who have
diabetes.
For: American Association of Diabetes Educators; American Diabetes Association;
Office of Public Insurance Counsel; Texas Diabetes Council; Texas Nurses Association.
For with changes: Diabetes & Glandular Disease Clinic; Health Insurance
Association of America; Prudential Insurance Company of America; Texas Association
of Health Plans; Texas Association of Life Health Insurers; Texas Pharmacy
Association; Texas Society of Health System Pharmacists. Against: Texas Dietetic
Association.
The new sections are adopted under the Insurance Code, Chapter
21, Subchapter E, as amended by the 75th Legislature in Senate Bills 162 and
163, and Article 1.03A. Insurance Code Article 21.53D(3) provides that the
commissioner shall by rule adopt minimum standards for benefits to enrollees
with diabetes. Article 21.53G(7) provides that the commissioner may promulgate
rules and regulations as are necessary and proper to carry out the provisions
of Article 21.53G. Article 1.03A provides that the Commissioner of Insurance
may adopt rules necessary for the conduct and execution of the duties and
functions of the Texas Department of Insurance only as authorized by a statute.
§21.2601.Definitions.
The following words and terms, when used in this subchapter, shall
have the following meanings, unless the context clearly indicates otherwise:
(1)
Basic benefit--Health care service or coverage, which is
included in the evidence of coverage, policy, or certificate, without additional
premium.
(2)
Caretaker--A family member or significant other responsible
for ensuring that an insured not able to manage his or her illness (due to
age or infirmity) is properly managed, including overseeing diet, administration
of medications, and use of equipment and supplies.
(3)
Diabetes--Diabetes mellitus. A chronic disorder of
glucose metabolism that can be characterized by an elevated blood glucose
level. The terms diabetes and diabetes mellitus are synonymous.
(4)
Diabetes equipment--The term "diabetes equipment"
includes items defined in Insurance Code Article 21.53 G §§1(1)
and §5, and §21.2605 of this title (relating to Diabetes Equipment
and Supplies).
(5)
Diabetes supplies--The term "diabetes supplies" includes
items defined in Insurance Code Article 21.53 G §§1(2) and 5, and
§21.2605 of this title (relating to Diabetes Equipment and Supplies).
(6)
Diabetes self-management training--Instruction enabling
an insured and/or his or her caretaker to understand the care and management
of diabetes, including nutritional counseling and proper use of diabetes equipment
and supplies.
(7)
Health benefit plan--A health benefit plan, for purposes
of this subchapter, means:
(A)
a plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness, including:
(i)
an individual, group, blanket, or franchise insurance policy
or insurance agreement, a group hospital service contract, or an individual
or group evidence of coverage that is offered by:
(I)
an insurance company;
(II)
a group hospital service corporation operating under Chapter
20 of the Texas Insurance Code;
(III)
a fraternal benefit society operating under Chapter 10
of the Texas Insurance Code;
(IV)
a stipulated premium insurance company operating under
Chapter 22 of the Insurance Code;
(V)
a reciprocal exchange operating under Chapter 19 of the
Texas Insurance Code; or
(VI)
a health maintenance organization (HMO) operating under
the Texas Health Maintenance Organization Act (Chapter 20A, Texas Insurance
Code);
(ii)
to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 USC §1002), a health benefit plan that is offered
by a multiple employer welfare arrangement as defined by §3, Employee
Retirement Income Security Act of 1974 (29 USC §1002) that holds a certificate
of authority under Insurance Code Article 3.95-2; or
(iii)
notwithstanding §172.014, Local Government Code,
or any other law, health and accident coverage provided by a risk pool created
under Chapter 172, Local Government Code.
(B)
A plan offered by an approved nonprofit health corporation
that is certified under §5.01(a), Medical Practice Act, and that holds
a certificate of authority issued by the commissioner under Insurance Code
Article 21.52F.
(C)
A health benefit plan is not:
(i)
a plan that provides coverage:
(I)
only for a specified disease or other limited benefit;
(II)
only for accidental death or dismemberment;
(III)
for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or injury;
(IV)
as a supplement to liability insurance;
(V)
for credit insurance;
(VI)
dental or vision care only; or
(VII)
hospital confinement indemnity coverage only.
(ii)
a small employer plan written under Chapter 26 of the
Insurance Code;
(iii)
a Medicare supplemental policy as defined by §1882(g)(1),
Social Security Act (42 USC §1395 ss);
(iv)
workers' compensation insurance coverage;
(v)
medical payment insurance issued as part of a motor vehicle
insurance policy; or
(vi)
a long-term care policy, including a nursing home fixed
indemnity policy, unless the commissioner determines that the policy provides
benefit coverage so comprehensive that the policy is a health benefit plan
as described by subparagraph (A) of this paragraph.
(8)
Insured--A person enrolled in a health benefit
plan who has been diagnosed with:
(A)
insulin dependent or noninsulin dependent diabetes; or
(B)
elevated blood glucose levels induced by pregnancy or another
medical condition associated with elevated glucose levels.
(9)
Physician--A Doctor of Medicine or a Doctor of
Osteopathy licensed by the Texas State Board of Medical Examiners.
(10)
Practitioner--An Advanced Practice Nurse, Doctor
of Dentistry, Physician Assistant, Doctor of Podiatry, or other licensed person
with prescriptive authority.
§21.2602.Required Benefits for Persons with Diabetes.
(a)
Notwithstanding §172.014, Local Government Code, or
any other law, health plans provided by a risk pool created under Chapter
172, Local Government Code, delivered, issued for delivery, or renewed on
or after January 1, 1998, that provide benefits for the treatment of diabetes
and associated conditions must provide coverage to an insured for diabetes
equipment, diabetes supplies, and diabetes self-management training programs,
in accordance with §21.2603 of this title (relating to Out of Pocket
Expenses), §21.2605 of this title (relating to Diabetes Equipment and
Supplies) and §21.2606 of this title (relating to Diabetes Self-Management
Training).
(b)
Health benefit plans (other than reciprocal exchanges operating
under Chapter 19 of the Texas Insurance Code) delivered, issued for delivery,
or renewed on or after January 1, 1999, must provide coverage to each insured
in accordance with §21.2603 of this title and §21.2604 of this title
(relating to Minimum Standards for Benefits for Persons with Diabetes).
(c)
Health benefits plans delivered, issued for delivery, or
renewed on or after January 1, 1998, by an entity other than an HMO, which
provide coverage limited to hospitalization expenses, shall provide coverage
to each insured for diabetes equipment, diabetes supplies, and diabetes self-management
training programs, in accordance with §21.2603 of this title, §21.2605
of this title, and §21.2606 of this title, during hospitalization of
the insured.
(d)
A determination of medical necessity may be applied to
benefits required under this subchapter provided it complies with all applicable
laws and regulations.
§21.2603.Out of Pocket Expenses.
(a)
The basic benefits required under this subchapter shall
not be subject to a deductible, coinsurance, or copayment requirement that
exceeds the applicable deductible, coinsurance, or copayment applicable to
other analogous chronic medical conditions or other similar benefits provided
under the plan.
(b)
No more than one copayment shall be charged for a thirty-day
supply of any item of diabetes supplies listed in §21.2605 of this title
(relating to Diabetes Equipment and Supplies). The amount of supplies that
constitutes a thirty-day supply for an insured is the amount prescribed as
a thirty-day supply by the physician or practitioner of the insured.
§21.2604.Minimum Standards for Benefits for Persons with Diabetes, Requirement for Periodic Assessment of Physician and Organizational Compliance.
(a)
Health benefit plans provided by HMOs shall provide coverage
for the services in paragraphs (1) through (7) of this subsection and shall
contract with providers that agree to comply with the minimum practice standards
outlined in subsection (b) of this section. Services to be covered include:
(1)
office visits and consultations with physicians and practitioners
for monitoring and treatment of diabetes, including office visits and consultations
with appropriate specialists;
(2)
immunizations required by Insurance Code Article 21.53F,
Coverage for Childhood Immunizations;
(3)
immunizations for influenza and pneumococcus;
(4)
inpatient services, and physician and practitioner
services when the insured is confined to:
(A)
a hospital;
(B)
a rehabilitation facility; or
(C)
a skilled nursing facility;
(5)
inpatient and outpatient laboratory and diagnostic
imaging services;
(6)
diabetes equipment and supplies in accordance with
§21.2605 of this title (relating to Diabetes Equipment and Supplies),
except notwithstanding §172.014, Local Government Code, or any other
law, this subsection does not apply to health benefits provided by a risk
pool created under Chapter 172, Local Government Code; and
(7)
diabetes self-management training, in accordance with
subsection (b)(1)(ii) of this section, §21.2606 of this title (relating
to Diabetes Self-Management Training) or §21.2607 of this title (relating
to Accessibility and Availability of Diabetes Self-Management Training Prior
to January 1, 2002), except, notwithstanding §172.014, Local Government
Code, or any other law, this subsection does not apply to health benefits
provided by a risk pool created under Chapter 172, Local Government Code;
(b)
HMOs shall contract with providers who, at a minimum, provide
care that complies with subsection (a) of this section that includes:
(1)
for all insureds:
(A)
at initial visit by the insured:
(i)
a complete history and physical including an assessment
of immunization status;
(ii)
development of a management plan addressing all of the
following that are applicable to the insured:
(I)
nutrition and weight evaluation;
(II)
medications;
(III)
an exercise regimen;
(IV)
glucose and lipid control;
(V)
high risk behaviors;
(VI)
frequency of hypoglycemia and hyperglycemia;
(VII)
compliance with applicable aspects of self care;
(VIII)
assessment of complications;
(IX)
follow up on any referrals;
(X)
psychological and psychosocial adjustment;
(XI)
general knowledge of diabetes; and
(XII)
self-management skills;
(iii)
diabetes self-management training given or referred by
the physician or practitioner as required by §21.2606 of this title and
§21.2607 of this title;
(iv)
referral for a dilated funduscopic eye exam to be performed
by an ophthalmologist or therapeutic optometrist for an insured with Type
2 Diabetes.
(B)
at every visit the following:
(i)
weight and blood pressure taken,
(ii)
foot exam performed without shoes or socks, and
(iii)
dental inspection.
(C)
every six months the following:
(i)
review of the management plan, and
(ii)
glycosylated hemoglobin test.
(D)
annually the following:
(i)
lipid profile,
(ii)
microalbuminuria;
(iii)
influenza immunization;
(iv)
referral for a dilated funduscopic eye exam performed
by an ophthalmologist or therapeutic optometrist; and
(v)
for insureds under eighteen years of age, a referral for
a retinal camera examination to be performed by an ophthalmologist or therapeutic
optometrist.
(2)
For treatment of an insured sixty-five years
of age and over or an insured with complications affecting two or more body
systems:
(A)
minimum practice standards as set forth in paragraph (1)
of this subsection; and
(B)
specific inquiries into and consideration of treatment
goals for comorbidity and polypharmacy.
(3)
For pregnant insureds with pre-existing or gestational
diabetes:
(A)
minimum practice standards as set forth in paragraph (1)
of this subsection; and
(B)
enhanced fetal monitoring based on the standards promulgated
by the American College of Gynecologists and Obstetricians.
(4)
For insureds with Type 1 Diabetes:
(A)
minimum practice standards as set forth in paragraph (1)
of this subsection;
(B)
an initial diagnosis, consideration of hospitalization
due to the insured's:
(i)
age;
(ii)
physical condition;
(iii)
psychosocial circumstances; or
(iv)
lack of access to outpatient diabetes self-management
training as required in §21.2606 of this title or §21.2607 of this
title; and
(C)
on-going management which includes quarterly office visits
at which evaluation includes:
(i)
weight;
(ii)
blood pressure;
(iii)
ophthalmologic exam;
(iv)
thyroid palpation;
(v)
cardiac exam;
(vi)
examination of pulses;
(vii)
foot exam;
(viii)
skin exam;
(ix)
neurological exam;
(x)
dental inspection;
(xi)
results of home glucose self monitoring;
(xii)
frequency and severity of hypoglycemia or hyperglycemia;
(xiii)
medical nutrition plan;
(xiv)
exercise regimen;
(xv)
adherence problems;
(xvi)
psychosocial adjustment;
(xvii)
reevaluation of short and long term self-management
goals;
(xviii)
anticipatory guidance related to issues of Type 1 Diabetes;
(xix)
glycosylated hemoglobin;
(xx)
counseling for high risk behaviors; and
(xxi)
for insureds under eighteen years of age, growth assessment.
(c)
Health plans provided by HMOs shall periodically assess
physician and organizational compliance with the minimum practice standards
contained in subsection (b) of this section.
(d)
Health benefit plans provided by entities other than HMOs
shall provide coverage at a minimum for:
(1)
office visits and consultations with physicians and practitioners
for monitoring and treatment of diabetes, including office visits and consultations
with appropriate specialists;
(2)
immunizations required by Insurance Code Article 21.53F,
Coverage for Childhood Immunizations;
(3)
immunizations for influenza and pneumococcus;
(4)
inpatient services, physician, and practitioner services
when an insured is confined to:
(A)
a hospital;
(B)
a rehabilitation facility; or
(C)
a skilled nursing facility;
(5)
inpatient and outpatient laboratory and diagnostic
imaging services;
(6)
diabetes equipment and supplies in accordance with
§21.2605 of this title, except notwithstanding §172.014, Local Government
Code, or any other law, this subsection does not apply to health benefits
provided by a risk pool created under Chapter 172, Local Government Code;
and
(7)
diabetes self-management training in accordance with
§21.2606 of this title or §21.2607 of this title, except, notwithstanding
§172.014, Local Government Code, or any other law, this subsection does
not apply to health benefits provided by a risk pool created under Chapter
172, Local Government Code.
§21.2605.Diabetes Equipment and Supplies.
(a)
A health benefit plan shall provide coverage for equipment
and supplies for the treatment of diabetes for which a physician or practitioner
has written an order, including:
(1)
blood glucose monitors, including those designed to be
used by or adapted for the legally blind;
(2)
test strips specified for use with a corresponding
glucose monitor;
(3)
lancets and lancet devices;
(4)
visual reading strips and urine testing strips and
tablets which test for glucose, ketones and protein;
(5)
insulin and insulin analog preparations;
(6)
injection aids, including devices used to assist with
insulin injection and needleless systems;
(7)
insulin syringes;
(8)
biohazard disposal containers;
(9)
insulin pumps, both external and implantable, and
associated appurtenances, which include:
(A)
insulin infusion devices;
(B)
batteries;
(C)
skin preparation items;
(D)
adhesive supplies;
(E)
infusion sets;
(F)
insulin cartridges;
(G)
durable and disposable devices to assist in the injection
of insulin; and
(H)
other required disposable supplies;
(10)
repairs and necessary maintenance of insulin
pumps not otherwise provided for under a manufacturer's warranty or purchase
agreement, and rental fees for pumps during the repair and necessary maintenance
of insulin pumps, neither of which shall exceed the purchase price of a similar
replacement pump;
(11)
prescription medications which bear the legend "Caution:
Federal Law prohibits dispensing without a prescription" and medications available
without a prescription for controlling the blood sugar level;
(12)
podiatric appliances, including up to two pairs of
therapeutic footwear per year, for the prevention of complications associated
with diabetes; and
(13)
glucagon emergency kits.
(b)
As new or improved treatment and monitoring equipment or
supplies become available and are approved by the United States Food and Drug
Administration, such equipment or supplies shall be covered if determined
to be medically necessary and appropriate by a treating physician or other
practitioner through a written order.
(c)
All supplies, including medications, and equipment for
the control of diabetes shall be dispensed as written, including brand name
products, unless substitution is approved by the physician or practitioner
who issues the written order for the supplies or equipment.
§21.2606.Diabetes Self-Management Training.
(a)
A health benefit plan shall provide diabetes self-management
training or coverage for diabetes self-management training for which a physician
or practitioner has written an order to each insured or the caretaker of the
insured from:
(1)
a diabetes self-management training program recognized
by the American Diabetes Association;
(2)
a multidisciplinary team coordinated by a Certified
Diabetes Educator (CDE) who is certified by the National Certification Board
for Diabetes Educators. The team shall consist of at least a dietitian and
a nurse educator; other team members may include a pharmacist and a social
worker. Other than a social worker, all team members must have recent didactic
and experiential preparation in diabetes clinical and educational issues;
(3)
a Certified Diabetes Educator (CDE); or
(4)
a licensed health care professional, including a physician,
a physician assistant, a registered nurse, a licensed or registered dietician,
or a pharmacist, who has been determined by his or her licensing board to
have recent didactic and experiential preparation in diabetes clinical and
educational issues.
(b)
All individuals providing self-management training pursuant
to subsection (a) of this section must be licensed, registered, or certified
in Texas to provide appropriate health care services.
(c)
Self-management training shall include the development
of an individualized management plan that is created for and in collaboration
with the insured and that meets the requirements of the minimum standards
for benefits in accordance with §21.2604 of this title (relating to Minimum
Standards for Benefits for Persons with Diabetes).
(d)
Medical nutritional counseling and instructions on the
proper use of diabetes equipment and supplies shall be provided or covered
as part of the training.
(e)
Diabetes self-management training shall be provided, or
coverage for diabetes self-management training shall be provided to an insured
or a caretaker, upon the following occurrences relating to an insured, provided
that any training involving the administration of medications must comply
with the applicable delegation rules from the appropriate licensing agency:
(1)
the initial diagnosis of diabetes;
(2)
the written order of a physician or practitioner indicating
that a significant change in the symptoms or condition of the insured requires
changes in the insured's self-management regime;
(3)
the written order of a physician or practitioner that
periodic or episodic continuing education is warranted by the development
of new techniques and treatment for diabetes.
(f)
An HMO shall provide oversight of its diabetes self-management
training program on an ongoing basis to ensure compliance with this section.
(g)
Health benefit plans provided by entities other than HMOs
shall disclose in the plan how to access providers or benefits described in
subsection (a) and §21.2607 of this title (relating to Accessibility
and Availability of Diabetes Self-Management Training Prior to January 1,
2002).
§21.2607.Accessibility and Availability of Diabetes Self-Management Training Prior to January 1, 2002.
(a)
Prior to January 1, 2002, an insured may obtain diabetes
self-management training from a source other than the four set forth in §21.2606
of this title (relating to Diabetes Self-Management Training) under the circumstances
set forth in subsections (b), (c) or (d) of this section. Until that date
the components of the self-management training may be obtained from the following
individuals, provided that the individual is licensed, certified or registered
in Texas and has recent didactic and experiential preparation in diabetes
clinical and educational issues:
(1)
a dietician shall provide any nutritional counseling component;
(2)
a pharmacist shall provide any pharmaceutical component;
and
(3)
a physician, a physician assistant, a registered nurse,
or an advanced practice nurse shall provide all other components of the training.
(b)
If the health benefit plan is provided by an HMO and the
sources for the training set forth in §21.2606 of this title are not
available within 75 miles of the site of eligibility of the insured because
the sources are not located within that distance, the HMO is unable to obtain
contracts after good faith attempts, or sources meeting the HMO's minimum
quality of care and credentialing requirements are not located within that
distance, the HMO shall submit a plan to the department for approval, at least
30 days before implementation. For purposes of this subsection, "site of eligibility"
refers to the address of the location that renders the insured eligible for
coverage. The plan shall include the following:
(1)
the geographic area identified by county, city, ZIP code,
mileage, or other identifying data in which the diabetes self-management sources
set forth in §21.2606 of this title are not available along with the
reason the sources cannot be made available;
(2)
a map, with key and scale, which identifies the areas
in which the diabetes self-management sources set forth in §21.2606 of
this title are not available;
(3)
the HMO's general plan for making diabetes self-management
training available to insureds in each identified geographic area by the individuals
listed in subsection (a) of this section;
(4)
the names and addresses of the individual participating
providers who are providing the diabetes self-management training through
the HMO delivery network to insureds covered under the HMO's general plan
required under paragraph (3) of this subsection;
(5)
the names and addresses of other individuals providing
diabetes self-management training to be made available in the geographic area
in addition to those providers participating in the HMO delivery network listed
under paragraph (4) of this subsection; and,
(6)
any other information which is necessary to assess
the HMO's plan.
(c)
If the health benefit plan is provided by an insurer through
an insurance policy with preferred provider benefits and the insurer is unable
to contract with the diabetes self-management training providers set forth
in §21.2606 of this title, as preferred providers within the service
area, the insurer may contract with the individuals set forth in subsection
(a) of this section as preferred providers of diabetes self-management training.
Nothing in this subsection alters the requirements of Insurance Code Article
3.70-3C, §8.
(d)
If the health plan is provided by an insurer through an
insurance policy and the sources for diabetes self-management training set
forth in §21.2606 of this title are not available in the geographic area
in which the insured normally receives services, the insured may receive all
of the training components from the individuals set forth in subsection (a)
of this section.
(e)
A health benefit plan provided by an insurer under subsections
(c) or (d) of this section shall reimburse an insured for training performed
by individuals listed in subsection (a)(1), (a)(2), and (a)(3) of this section.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on March
24,1999.
TRD-9901767
Lynda H. Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Effective date: April 13, 1999
Proposal publication date: December 4, 1998
For further information, please call: (512) 463-6327
Subchapter H. Storage and Sale of Fireworks
Chapter 34.
State Fire Marshal