coverage of diabetes self-management education and education relating to diet as and treatment of their diabetes including information on proper diets. …
November 1996
WEST VIRGINIA INFORMATIONAL LETTER
NO 102
TO: ALL ACCIDENT AND SICKNESS INSURANCE COMPANIES AND HEALTH MAINTENANCE
ORGANIZATIONS LICENSED TO DO BUSINESS IN THE STATE OF WEST VIRGINIA
RE: INSURANCE FOR DIABETICS
The purpose of this informational letter is to place interested
persons on notice of the Commissioners enforcement position with regard to
insurance coverage of diabetes self-management education and education
relating to diet as required by W Va Code 33-15C-1 and 33-16-16 These
statutes provide that major medical or similar comprehensive-type medical
coverage policies shall include coverage for diabetes self-management
education to ensure that persons with diabetes are educated as to the
proper self-management and treatment of their diabetes including
information on proper diets Coverage for self-management education and
education relating to diet which has been prescribed by a licensed
physician is limited to: 1 visits medically necessary upon the diagnosis
of diabetes; 2 visits under circumstances whereby a physician identifies
or diagnoses a
significant change in the patients symptoms or conditions
that necessitates changes in a patients self-management; and 3 where a
new medication or therapeutic process relating to the persons treatment
and/or management of diabetes has been identified as medically necessary by
a licensed physician
Self-management education and education relating to diet may be
provided by: 1 the physician as part of an office visit for diabetes
diagnosis or treatment; 2 a licensed pharmacist for instructing and
monitoring a patient regarding the proper use of covered equipment,
supplies and medications prescribed by a licensed physician; 3 a
certified diabetes educator certified by a national diabetes educator
certification program; or 4 a registered dietitian registered by a
nationally recognized professional association of dietitians upon the
referral of a physician For the education to qualify for insurance
coverage, the national diabetes educator certification program and the
nationally recognized professional association of dietitians must be
certified to the Commissioner of Insurance by the Commissioner of the
Bureau of Public Health
Informational Letter No 102
November,
1996
Page 2
Some confusion has arisen as to when coverage is required under major
medical or similar comprehensive-type medical coverage policies for insulin
dependent persons with diabetes and those with gestational diabetes The
language of the statute is clear and unambiguous on this point, and it is,
therefore, the position of this Office that coverage is required by statute
only in those instances where the education has been prescribed by a
licensed physician As such, insurers may cover, but are not required to
cover, any counseling or educational services by pharmacists, dietitians or
diabetes educators which has not been prescribed by a licensed physician
Inquiries regarding this letter should be directed, in writing, to
Donna S Quesenberry, Associate Counsel, Legal Division, West Virginia
Insurance Commission, PO Box 50540, Charleston, WV 25305-0540
Hanley C Clark
Insurance Commissioner
Source:freemason-wa.org
