Islets of Hope state diabetes insurance coverage laws

Information for this article was compiled and edited by Lahle A. Wolfe, Islets of Hope.

Important Disclaimer

This information for general information purposes only.  

It is not intended to be used a recommendation or endorse- ment of any program or entity

This information is not intended to serve as any form of medical or legal advice.

Article Sources

National Conference of State Legislatures

Government Accountability Office (GAO) report number GAO-05-210 entitled "Managing Diabetes: Health Plan Coverage of Services and Supplies;" released on March 28, 2005.

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Federal Laws Pertaining to Persons with Diabetes

Diabetes Assistance Programs

Need to file an insurance complaint in the State of Texas?

You can file a complaint with the carrier (either your HMO or your insurance company), or you may file a complaint at the Department of Insurance.

A complaint form may be accessed electronically at www.tdi.state.tx.us, by calling 1-800-2523439, or by writing to Texas Department of Insurance, P. O Box 149091, Austin, TX, 78714-9091.

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Texas - State Diabetes Insurance Coverage Laws

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Texas has mandated coverage for diabetes care.

S.982 - signed 6/19/99, effective 9/1/99. It expands a 1997 law, and includes coverage for nutrition therapy

Summary of Provisions

• Requirement related to diabetes?  Yes
• Diabetes Education services covered?  Yes
• Medical nutritional therapy covered?  No
• Diabetes supplies covered?  Yes
• Specified supplies covered?  Yes

Texas Department of State Health Insurance

If you have questions about insurance in Texas, contact the Texas Diabetes Council staff at (512) 458-7490 or send an email . The Council does not provide or guarantee insurance coverage. While the Council can provide information about resources, it is the responsibility of the individual seeking health insurance to provide information regarding eligibility status and application information to the appropriate insurance resource.

Texas State Law requires insurance companies to cover the following (equipment covered by laws is listed in the Texas Administrative Code, §21.2605(a)(b)(c)).  Additionally, SB 163 passed in 75th legislative session related to insurance coverage for persons with diabetes. Art. 21.53G of the Texas Insurance Code was amended effective 9/1/97. Bill author was Judith Zaffirini with coauthors Carona, Duncan, Lucio, and Shapleigh . The bill sponsor was Berlanga.

Rules written by Dept. of Insurance and adopted in April, 1999 requiring HMOs, and indemnity carriers* to pay for:

Diabetes equipment & supplies:

A health benefit plan shall provide coverage for equipment and supplies for the treatment of diabetes for which a physician or practitioner has written an order, including:

• blood glucose monitors, including those designed to be used by or adapted for the legally blind;
• test strips specified for use with a corresponding glucose monitor;
• lancets and lancet devices;
• visual reading strips and urine testing strips and tablets which test for glucose, ketones and protein;
• insulin and insulin analog preparations;
• injection aids, including devices used to assist with insulin injection and needleless systems;
• insulin syringes;
• biohazard disposal containers;
• insulin pumps, both external and implantable, and associated appurtenances, which include:
  (A) insulin infusion devices;
  (B) batteries;
  (C) skin preparation items;
  (D) adhesive supplies;
  (E) infusion sets;
  (F) insulin cartridges;
  (G) durable and disposable devices to assist in the injection of insulin; and
  (H) other required disposable supplies;
• repairs and necessary maintenance of insulin pumps not otherwise provided for under a manufacturer's warranty or purchase agreement, and rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump;
• prescription medications which bear the legend "Caution: Federal Law prohibits dispensing without a prescription" and medications available without a prescription for controlling the blood sugar level;
• podiatric appliances, including up to two pairs of therapeutic footwear per year, for the prevention of complications associated with diabetes; and
• glucagon emergency kits.

(b) As new or improved treatment and monitoring equipment or supplies become available and are approved by the United States Food and Drug Administration, such equipment or supplies shall be covered if determined to be medically necessary and appropriate by a treating physician or other practitioner through a written order.

(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.

Source: 28 TAC §21.1605(a)(b)(c)

Diabetes medication:

(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.

Source: 28 TAC §21.1605(c)

Diabetes education:

(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).

(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 counseling and instructions on the proper use of diabetes equipment and supplies shall be provided or covered as part of the training.

(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.

*Self-funded plans are excluded from the rules, as the Texas Department of Insurance does not regulate self-funded health benefit plans.

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Page Updated  03/09/2007