Rule R590-200. Diabetes Treatment and Management.

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Rule R590-200. Diabetes Treatment and Management.

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Table of Contents
R590-200-1. Authority.
R590-200-2. Purpose.
R590-200-3. Applicability and Scope.
R590-200-4. Definitions.
R590-200-5. Minimum Standards and General Provisions.
R590-200-6. Severability.
KEY
Date of Enactment or Last Substantive Amendment
Notice of Continuation
Authorizing, Implemented, or Interpreted Law
R590-200-1. Authority.
This rule is promulgated pursuant to Subsections 31A-2-201(1) and 31A-2-201(3)(a) in which the commissioner is empowered to administer and enforce this title and to make rules to implement the provisions of this title. The authority to set minimum standards by rule for coverage of diabetes is provided in Section 31A-22-626.

R590-200-2. Purpose.
The purpose of this rule is to establish minimum standards of coverage for diabetes. Diabetes includes individuals with:

(1) complete insulin deficiency or type 1 diabetes;

(2) insulin resistance with partial insulin deficiency or type 2 diabetes; and

(3) elevated blood glucose levels induced by pregnancy or gestational diabetes.

This coverage will be provided at the levels consistent with the coverage provided for the treatment of other illnesses or diseases.

R590-200-3. Applicability and Scope.
(1) This rule applies to all health care insurance policies sold in Utah.

(2) This rule does not prohibit an insurer from requesting additional information required to determine eligibility of a claim under the terms of the policy, certificate or both, as issued to the claimant.

R590-200-4. Definitions.
For purposes of this rule the commissioner adopts the definitions as particularly set forth in Section 31A-1-301 and in addition, the following:

(1) "Health care insurance" means insurance providing health care benefits or payment of health care expenses incurred, including prescription insurance. Health care insurance does not include accident and health insurance providing benefits for:

(a) dental and vision;

(b) replacement of income;

(c) short term accident;

(d) fixed indemnity;

(e) credit accident and health;

(f) supplements to liability;

(g) workers compensation;

(h) automobile medical payments;

(i) no fault automobile;

(j) Medicare supplement insurance plans;

(k) equivalent self-insurance;

(l) any type of accident and health insurance that is a part of or attached to another type of policy; or

(m) long term care insurance.

(2) "Diabetes" means diabetes mellitus, which is a common chronic, serious systemic disorder of energy metabolism that includes a heterogeneous group of metabolic disorders that can be characterized by an elevated blood glucose level. The terms diabetes and diabetes mellitus are considered synonymous and defined to include persons using insulin, persons not using insulin, individuals with elevated blood glucose levels induced by pregnancy, or persons with other medical conditions or medical therapies which wholly or partially consist of elevated blood glucose levels.

(3) "Diabetes self-management training" means a program designed to help individuals to learn to manage their diabetes in an outpatient setting. They learn self-management skills that include making lifestyle changes to effectively manage their diabetes and to avoid or delay the complication, hospitalizations and emergency room visits associated with this illness. This training includes medical nutrition therapy.

(4) "Medical equipment" means non-disposable/durable equipment used to treat diabetes and will be treated per the standard deductibles, copayments, out of pocket maximums and coinsurance of the policy.

(5) "Medical nutrition therapy" means the assessment of patient nutritional status followed by therapy including diet modification, planning and counseling services which are furnished by a registered licensed dietitian.

(6) "Medical supplies" means the generally accepted single-use items used to manage, monitor, and treat diabetes, and to administer diabetes specific medications. Medical supplies will be treated per the standard deductibles, copayments, out of pocket maximums and coinsurance of the policy.

R590-200-5. Minimum Standards and General Provisions.
(1) Coverage for the treatment of diabetes is subject to the deductibles, copayments, out-of-pocket maximums and coinsurance of the plan.

(2)(a) All health care insurance policies will cover diabetes self-management training and patient management, including medical nutrition therapy, when deemed medically necessary and prescribed by an attending physician covered by the plan.

(b) The diabetes self-management training services must be provided by a diabetes self-management training program that is accepted by the plan and is:

(i) recognized by the federal Health Care Financing Administration; or

(ii) certified by the Department of Health; or

(iii) approved or accredited by a national organization certifying standards of quality in the provision of diabetes self-management education.

(c) Diabetes self-management training programs shall be provided upon a health care insurance policyholder's/dependent's diagnosis with diabetes, upon a significant change in a health care insurance policyholder's/dependent's diabetes related condition, upon a change in a health care insurance policyholder's/dependent's diagnostic levels, or upon a change in treatment regimen when deemed medically necessary and prescribed by an attending physician covered by the plan. The plan must provide no less than the minimum standards required by the selected self- management training services provider program.

(3) All health care policies will cover the following when deemed medically necessary:

(a) blood glucose monitors, including commercially available blood glucose monitors designed for patients use and for persons who have been diagnosed with diabetes;

(b) blood glucose monitors to the legally blind which includes commercially available blood glucose monitors designed for patient use with adaptive devices and for persons who are legally blind and have been diagnosed with diabetes;

(c) test strips for glucose monitors, which include test strips whose performance achieved clearance by the FDA for marketing;

(d) visual reading and urine testing strips, which includes visual reading strips for glucose, urine testing strips for ketones, or urine test strips for both glucose and ketones. Using urine test strips for glucose only is not acceptable as the sole method of monitoring blood sugar levels;

(e) lancet devices and lancets for monitoring glycemic control;

(f) insulin, which includes commercially available insulin preparations including insulin analog preparations available in either vial or cartridge;

(g) injection aids, including those adaptable to meet the needs of the legally blind, to assist with insulin injection;

(h) syringes, which includes insulin syringes, pen-like insulin injection devices, pen needles for pen-like insulin injection devices and other disposable parts required for insulin injection aids;

(i) insulin pumps, which includes insulin infusion pumps.

(j) "medical supplies" for use with insulin pumps and insulin infusion pumps to include infusion sets, cartridges, syringes, skin preparation, batteries and other disposable supplies needed to maintain insulin pump therapy;

(k) "medical supplies" for use with or without insulin pumps and insulin infusion pumps to include durable and disposable devices to assist with the injection of insulin and infusion sets;

(l) prescription oral agents of each class approved by the FDA for treatment of diabetes, and a variety of drugs, when available, within each class; and

(m) glucagon kits.

R590-200-6. Severability.
If any provision or clause of this rule or its application to any person or situation is held invalid, such validity shall not affect any other provisions or application of this rule which can be given effect without the invalid provision or application, and to this end the provisions of this rule are declared to be severable.

KEY
insurance law

Date of Enactment or Last Substantive Amendment
April 30, 2001

Notice of Continuation
March 31, 2006

Authorizing, Implemented, or Interpreted Law
31A-2-201; 31A-22-626


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For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.


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