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SELF-MANAGEMENT DIABETES SELF-MANAGEMENT EDUCATION AND TRAINING

REIMBURSEMENT/ADVOCACY

Resources from National Organizations for the Business Case and Promotion of DSME/T Medicare Medicaid Commercial Insurance Coverage of Community Health Workers and Peer Leaders for DSME/T

Resources from National Organizations for the Business Case and Promotion of DSME/T
  • Promoting Diabetes Self-Management Education (DSME/T) to Providers - Resources Available from the American Association of Diabetes Educators (AADE)
  • Patient Centered Medical Home and Meaningful Use
    Patient Centered Medical Home: The National Committee for Quality Assurance (NCQA) 2014 Patient Centered Medical Home Standards and Guidelines (Standard 4: Element B, Care Planning and Self-Care Support and Element E, Support Self-Care and Shared Decision Making) directly address self-management education and support. More information can be found at on the NCQA Recognition Training website and NCQA Patient Centered Medical Home website.

    Meaningful Use: The PCMH 2014 standards align with the Medicare and Medicaid EHR Incentive Program Stage 2 Meaningful Use objectives. The release of the updated PCMH standards in March 2014 coincides with the start of Stage 2 of Meaningful Use for most eligible professionals. By complying with the EHR incentive program requirements, providers can obtain incentive payments and avoid downward payment adjustments.
  • Building the Business Case for Diabetes Self-Management: A Handbook for Program Managers by Kerry E. Kilpatrick, PhD and Carol A. Brownson, MSPH (2008) covers a broad range of topics related to building a business case for implementing self-management interventions in diabetes. Readers who are new to the concept of establishing a business case will likely want to review the handbook step-by-step. This handbook was conceived to meet the need to assemble in one place the rationale, methods and tools for building a business case for self-management of diabetes.
  • Administration on Aging Resource
    Diabetes Self-Management Training Initiative.
    The Administration on Aging developed a DSMT Toolkit to provide Area Agencies on Aging, community planners, and healthcare professionals with valuable information and insights that can help them operate cost-effective, accredited DSMT programs that can meet CMS requirements for Medicare reimbursement. Diabetes Self-Management Training Initiative (has links to toolkit chapters and other resources). DSMT Toolkit (pdf file of Toolkit)
  • Sample Publications to Support DSME/T Efforts at State Level
    Innovative Approaches to Reduce Diabetes Costs, April Reese in the NC Medical Journal. Ms. Reese discusses approaches to reduce diabetes costs in NC. Diabetes self-management is a required benefit of Medicare, Medicaid, and private insurance in NC.

    Benefit Cost Analysis. Diabetes Education Recognition Program, North Carolina Diabetes Prevention and Control Program. This document outlines how the state derived their final conclusion that their Diabetes Education Recognition Programs offers a 21 percent return on investment

Medicare Reimbursement for DSME/T

For a complete description of the Medicare coverage of diabetes self-management training (DSMT) view the Medicare Benefit Policy Manual, Chapter 15, Section 300 or the final rule from the US Department of Health and Human Services (Expanded Coverage for Diabetes Outpatient Self-Management [final rule] Program Memorandum B-01-40. 2001).

Medicaid

Health Insurance Coverage Laws for Diabetes Self-Management Education and Training This law atlas shows which states have laws that require coverage for both private insurance plans and Medicaid, and provides information on legal requirements, including when DSME/T coverage is triggered, what specific activities are covered, and the standards that DSME/T must meet.

Medicaid Coverage for Diabetes Self-Management Education This document describes the recent experiences of three states Colorado, Mississippi, and New York with state health departments that have collaborated with state Medicaid agencies to make Diabetes Self-Management Education (DSME) reimbursement a reality.

National Council of State Legislatures (NCSL) tracks diabetes coverage and has some information for Medicaid related to diabetes education. State-by-state tables outline State Insurance and Medicaid Requirements and Programs. Per NCSL: "Medicaid covers the health care needs for qualified low-income people and those who have few resources. There are special expanded eligibility terms for pregnant women. Medicaid is jointly funded by federal and state governments; covered populations and benefits vary among states. As a condition for receipt of federal funding, states must provide certain services, such as in- and out-patient care, doctor visits and long-term care. While services such as prescription drugs are optional under federal law all states and territories have chosen to include them. Other details of benefits such as prescribed insulin, disposable needles, syringes, monitors and blood glucose strips are determined by each state's Medicaid policy and are listed by state."

Commercial Insurance

Most states (46) have commercial health insurance mandates in place to cover diabetes self-management education. View the National Council of State Legislatures website.

Health Insurance Coverage Laws for Diabetes Self-Management Education and Training This law atlas shows which states have laws that require coverage for both private insurance plans and Medicaid, and provides information on legal requirements, including when DSME/T coverage is triggered, what specific activities are covered, and the standards that DSME/T must meet.