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Research Reports: Research Full Report

Advancing Diabetes-Related Equity Through Diabetes Self-Management Education and Training

Existing Coverage Requirements and Considerations for Increased Participation

Carr, Derek JD; Kappagoda, Manel JD, MPH; Boseman, Letia DHSc, MPH; Cloud, Lindsay K. JD; Croom, Brittany JD, MPH

Author Information
Journal of Public Health Management and Practice: March/April 2020 - Volume 26 - Issue - p S37-S44
doi: 10.1097/PHH.0000000000001109

Abstract

Many people living with diabetes in the United States need help managing their blood glucose levels. According to the Centers for Disease Control and Prevention, 30.3 million Americans, or 9.4% of the population, have diabetes.1 In 2015, 1.5 million adults were diagnosed—more than 4 100 every day.1 One in 3 adults in the United States, 84.1 million individuals in total, has prediabetes, which often leads to type 2 diabetes.1 Although diabetes affects individuals from all socioeconomic backgrounds, underserved communities such as lower-income populations, populations with low educational achievement, and communities of color disproportionately bear the burden of type 2 diabetes and its related health effects.1 People of color are more likely to be diagnosed with the disease, are less likely to have positive diabetes control indicators, such as low A1c levels, and experience worse health outcomes overall.2–4

The American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) consider diabetes self-management education and training (DSME/T)—“the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care”—central to addressing America's diabetes epidemic.5,6 Research shows that by giving patients the tools necessary to manage their diabetes, DSME/T substantially improves health outcomes and reduces health care expenditures.7,8 Indeed, 1 study found that individuals who receive DSME/T are 4 times less likely to experience a major diabetes-related medical complication.9 DSME/T incorporates patients' unique needs and experiences into individualized education and support plans that promote behaviors and solutions such as healthy eating, physical activity, self-monitoring, medication use, risk reduction, management of acute and chronic complications, and problem-solving strategies to address psychosocial issues and establish healthy habits. However, participation in DSME/T remains low.10

Insurance coverage for DSME/T offers 1 approach for facilitating access to and delivery of DSME/T. However, the 2014 National Diabetes Education Program National Diabetes Survey showed that many individuals do not know whether their insurance covers DSME/T or similar programs.11 To provide the data necessary to understand the extent of insurance coverage for DSME/T, we conducted a survey of DSME/T coverage requirements for private insurers, state Medicaid programs, and Medicare. Previous national surveys have not focused on DSME/T or comprehensively examined Medicaid coverage of DSME/T services.

Methods

Using a public health law research protocol, we conducted a comprehensive survey to systematically identify, review, and code insurance coverage requirements for DSME/T.12 First, we searched the Westlaw legal database for all statutes and regulations (“laws”) related to insurance coverage for DSME/T. All laws in the 50 United States and the District of Columbia (collectively “states”) that had been codified as of May 1, 2017, were searched for the terms diabetes, diabetes and Medicaid, diabetes education, diabetes training, diabetes and insulin, and variations of these terms. We also searched for the same terms in all federal statutes and regulations that had been codified as of May 1, 2017. The research team developed the search terms on the basis of existing knowledge and by reviewing previously identified state laws requiring insurance coverage for DSME/T. Key word searches were also supplemented by examination of the table of contents of each relevant section of state law.

We reviewed each law for provisions regulating private insurance, Medicare, and Medicaid DSME/T coverage. Where state law did not address Medicaid DSME/T coverage, we reviewed publicly available subregulatory Medicaid materials such as managed care contracts, provider manuals, provider bulletins, state Medicaid plans, and state Medicaid agency guidance (“subregulatory Medicaid policies”). Results were cross-referenced with other national surveys of diabetes-related insurance coverage requirements maintained by the National Conference of State Legislatures13 and Thomson Reuters WestLaw service.14

We developed a coding scheme to capture specific features of these laws and subregulatory Medicaid policies and to account for cross-jurisdictional variation.15,16 Two legal researchers independently reviewed and redundantly coded each law and subregulatory Medicaid policy. Discrepancies were minor and were resolved by consensus. We also developed a protocol (see Supplemental Digital Content Appendix I, available at http://links.lww.com/JPHMP/A627) and codebook (see Supplemental Digital Content Appendix II, available at http://links.lww.com/JPHMP/A628) so that the study may be replicated and extended longitudinally, allowing future research to capture changes to current laws and policies accurately.15,16

Results

As of May 1, 2017, 48 states require some or all insurers to cover DSME/T services. Forty-five states enacted these coverage requirements through state law (ie, statutes or regulations), while 3 states indicate only coverage in subregulatory materials (eg, contracts). The characteristics of these laws and policies vary greatly among states. These variations include, for example (1) the types of insurers that must cover DSME/T services, (2) when such coverage is required, (3) limitations on the amount or scope of coverage, (4) allowable cost-sharing requirements, and (5) whether covered DSME/T services must meet any specified standards.

Private insurance coverage

Private insurance refers to coverage provided by an employer, purchased through a state or the federal Health Insurance Marketplace, or purchased directly from an insurer. As of 2016, more than two-thirds of Americans (67.5%) had private insurance coverage, with most (55.7%) receiving coverage through their employer.17,18 Individuals with private insurance coverage are more likely to be non-Hispanic white or Asian and earn higher incomes.17–19 For example, in 2016, only 56.5% of African Americans and 52.4% of Hispanics had private insurance coverage, compared with 73.9% of non-Hispanic whites and 74.2% of Asians.17–19 Similarly, in 2016, 86.6% of households at or above 400% of the federal poverty level had private insurance coverage, compared with only 28.6% of households at or below 100% of the federal poverty level.17,19

Forty-three states require most or all private insurance policies to provide coverage for DSME/T (Figure 1). Two other states (Mississippi and Missouri) require only that health insurers offer plans that provide such coverage. All private insurance DSME/T coverage requirements were enacted through state legislation. Laws in roughly half of these states (22 out of 45 total) explicitly specify that insurers must cover DSME/T following a patient's diabetes diagnosis, while nearly as many (21/45) do not specifically indicate when coverage is required. Many states' laws also include specific circumstances beyond an initial diabetes diagnosis that trigger required coverage, including a change in a patient's health status (22/45 states), a change in a patient's treatment (9/45), and when a patient requires reeducation or refresher training (13/45).

FIGURE 1
FIGURE 1:
States Mandating Private Insurance DSME/T Coverage

Coverage minimums

Laws in 14 states establish the minimum amount of DSME/T services that insurers must cover. For example, Oregon requires insurers to cover 1 assessment and training program after an initial diabetes diagnosis and at least 3 hours annually thereafter. Connecticut requires coverage for up to 10 hours of initial DSME/T (ie, when a patient receives DSME/T services for the first time) and 4 hours of follow-up DSME/T (ie, DSME/T services received after the completion of an initial DSME/T program). Similarly, Illinois requires only that insurers cover at least 3 visits of initial DSME/T and 2 visits of follow-up DSME/T, while Nebraska requires only that insurers cover at least $500 every 2 years for initial and follow-up DSME/T services. In contrast, Virginia prohibits insurers from imposing any annual caps on DSME/T coverage.

Cost sharing

No state laws categorically prohibit cost-sharing requirements for DSME/T services. The types of permissible cost sharing explicitly allowed include coinsurance (25/45 states), copayments (19/45), and deductibles (34/45). Thirty-four states impose restrictions on cost-sharing amounts such as limiting them to amounts equal to or less than those applicable to similar covered services.

Additional characteristics

Seventeen states require that covered DSME/T services comply with standards established by a state or national accrediting or certification entity such as the ADA or the AADE. Every state requires patients to receive a referral or prescription to qualify for DSME/T coverage. Coverage requirements also vary on the basis of the types of practitioners permitted to order DSME/T, the types of practitioners permitted to deliver DSME/T, and the settings in which DSME/T may be provided.

Medicaid

Medicaid is the public insurance program that provides coverage for certain low-income individuals and persons with disabilities.20 Under traditional Medicaid, coverage for most preventive services such as DSME/T has been optional, which allows states to choose whether to provide coverage and the scope of such coverage. However, states generally must cover preventive services without copays or deductibles for Medicaid expansion populations.21,22 Medicaid has 2 primary payment structures: fee-for-service and managed care. In a fee-for-service structure, providers are paid for every allowable service they provide to patients. Managed care plans are organized to manage cost, utilization, and quality. States execute contracts with managed care providers to provide Medicaid services. These contracts frequently contain provisions about required coverage that are not included in state statutes or regulations.23 In 2016, 19.4% of Americans received health insurance through a state Medicaid program,18 with 80% of those individuals receiving coverage through managed care arrangements.24 Also in 2016, Medicaid coverage rates were higher among women, persons of color, or both.17,18

At least 33 states cover DSME/T services for some or all Medicaid beneficiaries (Figure 2). Of those 33, 15 states require such coverage by law, and 18 states address coverage through subregulatory Medicaid policies. These coverage requirements vary in scope. For example, 25 states ensure DSME/T coverage regardless of whether a beneficiary receives Medicaid services through a fee-for-service or managed care arrangement. Five states require that Medicaid managed care organizations (MCO) cover DSME/T or similar services. As of 2016, the percentage of Medicaid beneficiaries enrolled in an MCO in these states ranged from 77.0% to 96.8%.24 Three other states cover DSME/T for specific populations.

FIGURE 2
FIGURE 2:
States Mandating Medicaid DSME/T Coverage

Coverage limitations

Twenty-two states impose explicit limitations on the amount of DSME/T services covered for Medicaid beneficiaries. These include 11 of the 15 states with laws requiring DSME/T coverage for some or all Medicaid beneficiaries, and 11 of the 18 states addressing such coverage through subregulatory Medicaid policies. For example, Idaho covers up to 24 hours of group DSME/T and 12 hours of individual DSME/T every 5 years, while Washington State covers 6 hours of DSME/T services per year. Several states explicitly adopt Medicare's coverage limitations—10 hours of initial DSME/T and up to 2 hours of follow-up education every year thereafter—or impose coverage limits substantially identical to Medicare's limits.25

Additional characteristics

At least 19 states require that covered DSME/T services comply with standards established by a state or national accrediting or certification entity such as the ADA or the AADE. At least 20 states require Medicaid beneficiaries to receive a referral or prescription to qualify for DSME/T coverage. Coverage requirements also vary on the basis of the types of practitioners permitted to order DSME/T, the types of practitioners permitted to deliver DSME/T, and the settings in which DSME/T may be provided. This study did not examine cost-sharing requirements associated with Medicaid DSME/T coverage due to complexities and variations with Medicaid cost sharing.26

Medicare

Medicare, the public health insurance program for individuals who are aged 65 years or older, some younger people with disabilities, and people with end-stage renal disease, covers DSME/T services.25 Services cannot exceed 10 hours during the initial 12-month period following a diabetes diagnosis, and the services must be delivered in increments of 30 minutes or longer. Medicare beneficiaries are eligible for 1 hour of individual training and 9 hours of group training, unless a beneficiary's provider can justify otherwise. After the initial 12-month period, 2 hours of follow-up DSME/T are available annually through either individual or group education.27 Importantly, Medicare beneficiaries may be responsible for some out-of-pocket costs for DSME/T services depending on the type of Medicare in which the beneficiary is enrolled (eg, Original Medicare or Medicare Advantage).28–30

Discussion

Substantial differences exist in DSME/T insurance coverage requirements. Many of the populations with the highest diabetes prevalence also have higher rates of Medicaid coverage.18 Compared with non-Hispanic whites (7.4%), the prevalence of diagnosed diabetes is greater among non-Hispanic blacks (12.7%) and people of Hispanic ethnicity (12.1%),1 and Medicaid covers 29.4% of African Americans and 32.0% of people of Hispanic ethnicity compared with only 13.6% of non-Hispanic whites.18 However, although this study found 43 states requiring that private insurers cover DSME/T, we found only 30 requiring such coverage for most or all Medicaid beneficiaries (25 states require DSME/T coverage for all beneficiaries and 5 states require it for those in MCOs).

Moreover, although 19 states require that Medicaid-covered DSME/T services adhere to state or national standards, research suggests that, in practice, Medicaid beneficiaries still may not receive the same quality of DSME/T as other patients and that they are less likely to receive DSME/T services consistent with ADA recommendations.31 To advance diabetes-related health equity, both public and private insurers may consider providing coverage for the full cost of DSME/T services that meet national, evidence-based standards for effective DSME/T.5

The source of private insurance and Medicaid DSME/T coverage requirements also differs: all private insurance DSME/T coverage requirements are codified in state law, whereas most states address Medicaid DSME/T coverage through subregulatory Medicaid policies. Codified (ie, statutory or regulatory) coverage requirements provide greater transparency about the existence, scope, and extent of DSME/T coverage, as well as an opportunity for public input prior to any changes to the requirements.32 In contrast, contracts and other subregulatory Medicaid policies are often easier to amend without a public notice and comment period. For example, 1 state's 2015 contracts with Medicaid MCOs included explicit language about DSME/T coverage, but this language does not exist in more recent contracts.33,34 It is unclear whether the state's Medicaid program continues to cover DSME/T, but the discrepancy in contract language, at a minimum, creates ambiguity about what benefits are covered.

These differences in coverage, however, do not fully explain low participation rates. Nearly all (43) states require private insurers to cover DSME/T, but a 2014 study found that only 6.8% of privately insured persons participate in DSME/T within the first year following a diabetes diagnosis.10 A 2015 study found that only 5% of Medicare beneficiaries recently diagnosed with diabetes participated in DSME/T.35 These participation rates are consistent with findings from a 2011 study on Medicaid beneficiaries receipt of DSME/T,31 suggesting that insurance coverage alone is insufficient to facilitate participation in DSME/T. Nevertheless, given research finding that uninsured status is associated with underutilization of health services and a lack of access to care, DSME/T participation rates might be even lower absent insurance coverage for DSME/T.36

Several factors likely contribute to low participation rates. Disparate participation rates based on geographic area37,38 and socioeconomic status39 point to structural factors, such as availability of DSME/T providers and the patient's ability to commit the time and resources necessary to complete a DSME/T program.40 At program, physician, and patient levels, studies have found that DSME/T programs conduct insufficient outreach and education efforts41 and that physicians and other health care providers often do not refer patients for DSME/T services.42,43 These low referral rates are particularly problematic considering this study's finding that most patients must receive a referral or prescription for DSME/T services as a prerequisite to insurance coverage for those services. Reimbursement rates and administrative requirements also may play a role in low referral and participation rates.41,44

The National Council on Aging has provided recommendations to the Centers for Medicare & Medicaid Services on strategies to help facilitate DSME/T participation by Medicare recipients, many of which are equally applicable to private insurance and Medicaid DSME/T coverage. These suggestions, which address many of the factors identified as contributing to low DSME/T participation rates, include (1) streamlining reimbursement when a registered nurse or pharmacist provides DSME/T services to encourage provider participation; (2) allowing patients with diabetes to self-refer to DSME/T to address low referral rates; (3) classifying DSME/T as a preventive service to eliminate patient cost-sharing requirements and reduce the financial burden on patients; and (4) allowing reimbursement for DSME/T telehealth delivery in community settings to increase patients' access to providers.45

Implementing these suggestions for Medicare populations may require changes to federal policy. However, many of these approaches could be implemented at the state level to facilitate participation in DSME/T among those with private insurance and Medicaid. Decision makers interested in exploring the expansion of DSME/T coverage for Medicaid beneficiaries may consider looking to the Medicare coverage of DSME/T for guidance.29 In some states with minimal or no required coverage of DSME/T for Medicaid beneficiaries, mirroring the Medicare benefit may increase access to DSME/T and have the added benefit of simplifying communication related to DSME/T for providers and other stakeholders. Additional research may help identify how various characteristics of state laws requiring insurance coverage for DSME/T affect whether patients receive DSME/T services; the quality of services received, particularly for Medicaid recipients; and efficacy of services.

Finally, when thinking about how to increase access to and efficacy of DSME/T, it is worth considering the broad-based socioeconomic policies that may help address the barriers that patients—particularly lower-income patients—face when trying to access DSME/T. Strategies that strengthen reliable transportation options for lower-income patients so that they can attend appointments; increase access to DSME/T through telehealth providers; increase access to healthy food in communities so that patients can act on the nutritional counseling they receive as part of a DSME/T program; provide access to stable housing and safe places to exercise; and expand insurance coverage for DSME/T to fill in the gaps identified by this study may help.

Limitations

This study has 3 main limitations. First, the study focused on state laws and subregulatory Medicaid policies that explicitly address DSME/T coverage, and the research team reviewed only subregulatory Medicaid policies publicly available online. The findings may not represent the entire universe of DSME/T insurance coverage. For example, insurance companies and MCOs may provide DSME/T coverage even when they are not required to do so. Second, the search terms may not have captured all relevant state laws and subregulatory Medicaid policies because of the lack of standardized legislative and policy language regarding insurance coverage requirements for DSME/T, although broad searches for the term diabetes reduces the likelihood of any such omissions. Finally, the research team did not analyze whether the DSME/T coverage requirements in state law and subregulatory Medicaid policies satisfy minimum legal requirements under federal law. For example, federal law may prohibit certain quantitative limits on DSME/T services on the basis of the services' classification. Research is indicated to determine whether state DSME/T coverage requirements comply with federal law.

Conclusion

DSME/T is an intervention with demonstrated efficacy in helping individuals manage their diabetes and improve their health status.8 However, despite the persistence of the diabetes epidemic, participation in DSME/T remains low.10,35 Research suggests that increasing DSME/T participation among populations at high risk for diabetes-related complications—residents of rural areas, Medicare recipients, Medicaid beneficiaries, and African American and Hispanic populations, for example—may help address diabetes-related health disparities.31,38,46,47

Although the reasons that patients do not access DSME/T are complex, this research focused on 1 strategy for facilitating delivery of and access to high-quality DSME/T: ensuring that existing health insurance policies cover DSME/T and removing barriers to access. Statutes and regulations in 43 states require private insurers to cover DSME/T services, but only 30 states require such coverage for Medicaid beneficiaries. Moreover, research suggests that DSME/T services received by Medicaid beneficiaries might not meet their needs effectively.31,48 Public health professionals and decision makers may find this analysis helpful in understanding and evaluating the patterns and gaps in DSME/T coverage. Future studies can also use data from this analysis to research the effects of such coverage on diabetes-related health outcomes.

Implications for Policy & Practice

  • Diabetes self-management education and training (DSME/T) is an effective intervention that helps people living with diabetes manage the disease. However, utilization of DSME/T by patients is low and many do not know whether their insurance covers DSME/T.
  • Our research provides the first comprehensive 50-state analysis of laws and policies that require private insurers, state Medicaid programs, and Medicare to cover DSME/T. We find substantial differences in DSME/T coverage requirements among states, with 43 states requiring that private insurers cover DSME/T but only 30 states requiring such coverage for most or all Medicaid beneficiaries. Variations also exist in when coverage is required, limitations on the amount or scope of coverage, allowable cost sharing, and whether services must comply with state or national standards.
  • Many of the populations with the highest diabetes prevalence also have higher rates of Medicaid coverage. The impact of DSME/T insurance coverage on advancing diabetes-related health equity depends on which types of insurers must cover DSME/T and the characteristics of such coverage. Future studies can use these data to research the effects of such coverage on diabetes-related health outcomes.

References

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9. Strine TW, Okoro CA, Chapman DP, Beckles GL, Balluz L, Mokdad AH. The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes. Prev Med. 2005;41(1):79–84.
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11. Piccinino LJ, Devchand R, Gallivan J, Tuncer D, Nicols C, Siminerio LM. Insights from the national diabetes education program national diabetes survey: opportunities for diabetes self-management education and support. Diabetes Spectr. 2017;30(2):95–100.
12. Wagenaar AC, Burris S. Public Health Law Research: Theory and Methods. San Francisco, CA: Jossey-Bass; 2013.
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14. 50 State Statutory Services: Health Care: Mandated Benefits. Mandated coverage for diabetes supplies, education, and self-management. 2017.
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18. United States Census Bureau. Table HIC-1. Health insurance coverage status and type of coverage by sex, race and hispanic origin: 2013 to 2016. https://www.census.gov/data/tables/time-series/demo/health-insurance/historical-series/hic.html. Published 2017. Accessed May 1, 2018.
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34. Florida Agency for Health Care Administration. AHCA contract no. FP###, attachment II, exhibit II-A. 43. http://www.fdhc.state.fl.us/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Exhibit_II-A-Managed_Medical_Assistance_MMA_Program_2015-11-01.pdf. Published 2015. Accessed May 1, 2018.
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Keywords:

diabetes self-management; health equity; health insurance; law and policy; legal epidemiology

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