Part 1.
TEXAS DEPARTMENT OF INSURANCE
Chapter 21.
TRADE PRACTICES
Subchapter R. DIABETES
28 TAC §§21.2601, 21.2602, 21.2604, 21.2606
The Texas Department of Insurance proposes amendments to §§21.2601,
21.2602, 21.2604, and 21.2606 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 amendments are necessary to implement
legislation enacted by the 76th Legislature in Senate Bill 982, amending Article
21.53G, Coverage for Supplies and Services Associated with Treatment of Diabetes.
The amendments are also necessary to clarify applicability of the sections
to health benefits provided by a risk pool created under Chapter 172, Local
Government Code, consistent with Insurance Code Article 21.53D.
The proposed amendments to §21.2601 remove unnecessary language and
add a definition for nutrition counseling. The proposed amendments to §21.2604
establish that, consistent with Article 21.53D, Insurance Code, the provisions
relating to diabetes equipment and supplies and diabetes self-management training
apply to health benefits provided by a risk pool created under Chapter 172,
Local Government Code, and delete references to §21.2607, which is being
simultaneously proposed for repeal elsewhere in this issue of the
Texas Register.
The proposed amendments to §21.2606 identify the
components of diabetes self-management training and those individuals or entities
who may provide diabetes self-management training and the required training
for those individuals. The proposal also includes grammatical and other changes
to conform language to
Texas Register
style
guidelines.
Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing,
has determined that for each year of the first five years the proposed sections
will be in effect, there will be no fiscal impact to state and local governments
as a result of the enforcement or administration of the rule. There will be
no measurable effect on local employment or the local economy as a result
of the proposal.
Ms. Stokes has determined that for each year of the first five years the
proposed amendments are in effect, the public benefits anticipated as a result
of the proposed amendments will be the identification of components of diabetes
self-management training and clarification of the applicability of certain
provisions to health benefits provided by a risk pool. Ms. Stokes also has
determined that any economic costs to entities required to comply with these
amendments, as well as any costs to a covered entity qualifying as a small
or micro business under Government Code §2006.001, for each year of the
first five years the proposed amendments will be in effect, are the result
of the legislative enactment of SB 982, and not as a result of the adoption,
enforcement, or administration of the proposed amendments. The total cost
to a covered entity would not vary between the smallest and largest businesses.
Therefore, it is the department’s position that the adoption of these
proposed amendments will have no adverse economic effect on small businesses
or micro-businesses. Regardless of the fiscal effect, the department does
not believe it is either legal or feasible to exempt small businesses or micro-businesses
from the requirements of these proposed amendments. To do so would allow differentiation
in the provision of diabetes self-management training or coverage for diabetes
self-management training between small business health carriers compared to
large health carriers.
To be considered, written comments on the proposal must be submitted no
later than 5:00 p.m. on February 10, 2003 to Gene C. Jarmon, General Counsel
and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box
149104, Austin, Texas 78714-9104. An additional copy of the comment must be
simultaneously submitted to Margaret Lazaretti, Director of Project Development,
Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin,
Texas 78714-9104. A request for a public hearing should be submitted separately
to the Office of the Chief Clerk.
The amendments are proposed under the Insurance Code Article
21.53G, 21.53D and §36.001. Article 21.53G determines and defines the
component or components of self-management training and provides that the
commissioner shall adopt rules as necessary for the implementation of the
article. Article 21.53D §3 provides that the commissioner shall by rule
adopt minimum standards for benefits to enrollees with diabetes and that each
health care benefit plan shall provide benefits for the care required by the
minimum standards. Section 36.001 provides that the Commissioner of Insurance
may adopt rules to execute the duties and functions of the Texas Department
of Insurance as authorized by statute.
The following articles are affected by this proposal: Insurance Code Article
21.53G and 21.53D
§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)
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 [
(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)
Nutrition counseling--As defined in §701.002
of the Texas Occupations Code.
(10)
[
(11)
[
§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, 21.2605
[
(d)
A determination of medical necessity may be applied to
benefits required under this subchapter provided it complies with all applicable
laws and regulations.
§21.2604.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), [
(7)
diabetes self-management training, in accordance with subsection
(b)(1)(iii)
[
(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[
(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
18
[
(2)
For treatment of an insured
65
[
(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 [
(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, [
(7)
diabetes self-management training in accordance with §21.2606
of this title [
§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
, including a written order of a
practitioner practicing under protocols jointly developed with a physician,
to each insured or the caretaker of the insured
in accordance
with the standards contained in Insurance Code Article 21.53G, Sec. 4(b) and
(c)
[
[(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)
A person may not provide a component of diabetes self-management
training under subsection (a) of this section unless the subject matter of
the component is within the scope of the person’s practice and the person
meets the education requirements as determined by the person’s licensing
agency in consultation with the commissioner of health.
[
(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)
Nutrition
[
(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)
of this section
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on December 30, 2002.
TRD-200208568
Gene C. Jarmon
Acting General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: February 9, 2003
For further information, please call: (512) 463-6327
28 TAC §21.2607
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Insurance or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Insurance proposes the repeal
of §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 repeal is necessary to remove language for which
the statutory authority has expired. Contemporaneously with this proposed
repeal, proposed amendments to §§21.2601-21.2606 are published elsewhere
in this issue of the
Texas Register
.
Kim Stokes, Senior Associate Commissioner, Life, Health and Licensing,
has determined that for each year of the first five years the proposed repeal
is in effect, there will be no fiscal impact to state and local governments
as a result of the enforcement or administration of the rule. There will be
no measurable effect on local employment or the local economy as a result
of the proposal.
Ms. Stokes has determined that for each year of the first five years the
proposed repeal is in effect, the public benefits anticipated as a result
of the proposed repeal will be the removal language for which the statutory
authority has expired. Regardless of the fiscal effect, the department does
not believe it is either legal or feasible to exempt small businesses or micro-businesses
from the requirements of the proposed repeal. To do so would allow differentiation
in the provision of diabetes self-management training or coverage for diabetes
self-management training between small business health carriers compared to
large health carriers.
To be considered, written comments on the proposal must be submitted no
later than 5:00 p.m. on February 10, 2003 to Gene C. Jarmon, General Counsel
and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box
149104, Austin, Texas 78714-9104. An additional copy of the comment must be
simultaneously submitted to Margaret Lazaretti, Director of Project Development,
Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin,
Texas 78714-9104. A request for a public hearing should be submitted separately
to the Office of the Chief Clerk.
The repeal is proposed under the Insurance Code Articles 21.53D
and §36.001. Article 21.53D §3 provides that the commissioner shall
by rule adopt minimum standards for benefits to enrollees with diabetes. Section
36.001 provides that the Commissioner of Insurance may adopt rules to execute
the duties and functions of the Texas Department of Insurance as authorized
by statute.
The following articles are affected by this proposal: Insurance Code Article
21.53D
§21.2607.Accessibility and Availability of Diabetes Self-Management Training Prior to January 1, 2002.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on December 30, 2002.
TRD-200208571
Gene C. Jarmon
Acting General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: February 9, 2003
For further information, please call: (512) 463-6327
Subchapter B. INSURANCE CONSUMER HEALTH INFORMATION PRIVACY
§
]5, and §21.2605 of this title (relating to Diabetes Equipment
and Supplies).
(relating to Diabetes Equipment and Supplies)
].
(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.
§21.2603 of this title, §21.2605 of this title
], and §21.2606
of this title, during hospitalization of the insured.
except
] notwithstanding §172.014, Local Government Code, or any other
law, this subsection
applies
[
does not apply
] to health
benefits provided by a risk pool created under Chapter 172, Local Government
Code; and
(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
applies
[
does not apply
] to health benefits provided by a risk pool created under
Chapter 172, Local Government Code;
and §21.2607 of this title)
];
eighteen
]
years of age, a referral for a retinal camera examination to be performed
by an ophthalmologist or therapeutic optometrist.
sixty-five
] years of age and over or an insured with complications affecting two
or more body systems:
or §21.2607
of this title
]; and
except
] notwithstanding §172.014, Local Government
Code, or any other law, this subsection
applies
[
does not
apply
] to health benefits provided by a risk pool created under Chapter
172, Local Government Code; and
or §21.2607 of this title, except
], notwithstanding §172.014,
Local Government Code, or any other law, this subsection
applies
[
does not apply
] to health benefits provided by a risk pool created under
Chapter 172, Local Government Code.
from:
]
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.
]
Medical nutritional
] counseling
and instructions on the proper use of diabetes equipment and supplies shall
be provided or covered as part of the training.
and §21.2607 of this
title (relating to Accessibility and Availability of Diabetes Self-Management
Training Prior to January 1, 2002)
].
Chapter 22.
PRIVACY