CHAPTER 1358. DIABETES

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES

CHAPTER 1358. DIABETES

SUBCHAPTER A. GUIDELINES FOR DIABETES CARE; MINIMUM COVERAGE

REQUIRED

Sec. 1358.001. DEFINITION. In this subchapter, "enrollee" means

an individual entitled to coverage under a health benefit plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.002. APPLICABILITY OF SUBCHAPTER. This subchapter

applies only to a health benefit plan that provides benefits for

medical or surgical expenses incurred as a result of a health

condition, accident, or sickness, including:

(1) an individual, group, blanket, or franchise insurance policy

or insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage that is offered by:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(C) a fraternal benefit society operating under Chapter 885;

(D) a stipulated premium company operating under Chapter 884; or

(E) a health maintenance organization operating under Chapter

843;

(2) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health

benefit plan that is offered by:

(A) a multiple employer welfare arrangement as defined by

Section 3 of that Act; or

(B) another analogous benefit arrangement; and

(3) health and accident coverage provided by a risk pool created

under Chapter 172, Local Government Code, notwithstanding Section

172.014, Local Government Code, or any other law.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.003. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease;

(B) only for accidental death or dismemberment;

(C) for wages or payments in lieu of wages for a period during

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) only for dental or vision care; or

(F) only for indemnity for hospital confinement;

(2) a small employer health benefit plan written under Chapter

1501;

(3) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(4) a workers' compensation insurance policy;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1358.002.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.004. ADOPTION OF MINIMUM STANDARDS. The commissioner,

in consultation with the Texas Diabetes Council, by rule shall

adopt minimum standards for coverage provided to an enrollee with

diabetes.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.005. COVERAGE REQUIRED. (a) A health benefit plan

must provide coverage in accordance with the standards adopted

under Section 1358.004.

(b) Coverage required under this section may not be subject to a

deductible, coinsurance, or copayment requirement that exceeds

the deductible, coinsurance, or copayment requirement applicable

to other similar coverage provided under the health benefit plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

SUBCHAPTER B. SUPPLIES AND SERVICES ASSOCIATED WITH DIABETES

TREATMENT

Sec. 1358.051. DEFINITIONS. In this subchapter:

(1) "Diabetes equipment" means:

(A) blood glucose monitors, including noninvasive glucose

monitors and glucose monitors designed to be used by blind

individuals;

(B) insulin pumps and associated appurtenances;

(C) insulin infusion devices; and

(D) podiatric appliances for the prevention of complications

associated with diabetes.

(2) "Diabetes supplies" means:

(A) test strips for blood glucose monitors;

(B) visual reading and urine test strips;

(C) lancets and lancet devices;

(D) insulin and insulin analogs;

(E) injection aids;

(F) syringes;

(G) prescriptive and nonprescriptive oral agents for controlling

blood sugar levels; and

(H) glucagon emergency kits.

(3) "Nutrition counseling" has the meaning assigned by Section

701.002, Occupations Code.

(4) "Qualified enrollee" means an individual eligible for

coverage under a health benefit plan who has been diagnosed with:

(A) insulin dependent or noninsulin dependent diabetes;

(B) elevated blood glucose levels induced by pregnancy; or

(C) another medical condition associated with elevated blood

glucose levels.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Amended by:

Acts 2005, 79th Leg., Ch.

728, Sec. 11.038(a), eff. September 1, 2005.

Sec. 1358.052. APPLICABILITY OF SUBCHAPTER. This subchapter

applies only to a health benefit plan that:

(1) provides benefits for medical or surgical expenses incurred

as a result of a health condition, accident, or sickness,

including:

(A) an individual, group, blanket, or franchise insurance policy

or insurance agreement, a group hospital service contract, or an

individual or group evidence of coverage that is offered by:

(i) an insurance company;

(ii) a group hospital service corporation operating under

Chapter 842;

(iii) a fraternal benefit society operating under Chapter 885;

(iv) a stipulated premium company operating under Chapter 884;

(v) a reciprocal exchange operating under Chapter 942; or

(vi) a health maintenance organization operating under Chapter

843; and

(B) to the extent permitted by the Employee Retirement Income

Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health

benefit plan that is offered by a multiple employer welfare

arrangement as defined by Section 3 of that Act; or

(2) is offered by an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.053. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease or another limited benefit;

(B) only for accidental death or dismemberment;

(C) for wages or payments in lieu of wages for a period during

which an employee is absent from work because of sickness or

injury;

(D) as a supplement to a liability insurance policy;

(E) for credit insurance;

(F) only for dental or vision care; or

(G) only for indemnity for hospital confinement;

(2) a small employer health benefit plan written under Chapter

1501;

(3) a Medicare supplemental policy as defined by Section

1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(4) a workers' compensation insurance policy;

(5) medical payment insurance coverage provided under a motor

vehicle insurance policy; or

(6) a long-term care insurance policy, including a nursing home

fixed indemnity policy, unless the commissioner determines that

the policy provides benefit coverage so comprehensive that the

policy is a health benefit plan as described by Section 1358.052.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.054. COVERAGE REQUIRED. (a) A health benefit plan

that provides coverage for the treatment of diabetes and

conditions associated with diabetes must provide to each

qualified enrollee coverage for:

(1) diabetes equipment;

(2) diabetes supplies; and

(3) diabetes self-management training in accordance with the

requirements of Section 1358.055.

(b) A health benefit plan may require a deductible, copayment,

or coinsurance for coverage provided under this section. The

amount of the deductible, copayment, or coinsurance may not

exceed the amount of the deductible, copayment, or coinsurance

required for treatment of other analogous chronic medical

conditions.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.055. DIABETES SELF-MANAGEMENT TRAINING. (a) Diabetes

self-management training must be provided by a health care

practitioner or provider who is:

(1) licensed, registered, or certified in this state to provide

appropriate health care services; and

(2) acting within the scope of practice authorized by the

license, registration, or certification.

(b) For purposes of this subchapter, "self-management training"

includes:

(1) training provided to a qualified enrollee, after the initial

diagnosis of diabetes, in the care and management of that

condition, including nutrition counseling and counseling on the

proper use of diabetes equipment and supplies;

(2) additional training authorized on the diagnosis of a

physician or other health care practitioner of a significant

change in the qualified enrollee's symptoms or condition that

requires changes in the qualified enrollee's self-management

regime; and

(3) periodic or episodic continuing education training

prescribed by an appropriate health care practitioner as

warranted by the development of new techniques or treatments for

diabetes.

(c) If the diabetes self-management training is provided on the

written order of a physician or other health care practitioner,

including a health care practitioner practicing under protocols

jointly developed with a physician, the training must also

include:

(1) a diabetes self-management training program recognized by

the American Diabetes Association;

(2) diabetes self-management training provided by a

multidisciplinary team:

(A) the nonphysician members of which are coordinated by:

(i) a diabetes educator who is certified by the National

Certification Board for Diabetes Educators; or

(ii) an individual who has completed at least 24 hours of

continuing education that meets guidelines established by the

Texas Board of Health and that includes a combination of

diabetes-related educational principles and behavioral

strategies;

(B) that consists of at least a licensed dietitian and a

registered nurse and may include a pharmacist and a social

worker; and

(C) each member of which, other than a social worker, has recent

didactic and experiential preparation in diabetes clinical and

educational issues as determined by the member's licensing

agency, in consultation with the commissioner of public health,

unless the member's licensing agency, in consultation with the

commissioner of public health, determines that the core

educational preparation for the member's license includes the

skills the member needs to provide diabetes self-management

training;

(3) diabetes self-management training provided by a diabetes

educator certified by the National Certification Board for

Diabetes Educators; or

(4) diabetes self-management training that provides one or more

of the following components:

(A) a nutrition counseling component provided by a licensed

dietitian, for which the licensed dietitian shall be paid;

(B) a pharmaceutical component provided by a pharmacist, for

which the pharmacist shall be paid;

(C) a component provided by a physician assistant or registered

nurse, for which the physician assistant or registered nurse

shall be paid, except that the physician assistant or registered

nurse may not be paid for providing a nutrition counseling or

pharmaceutical component unless a licensed dietitian or

pharmacist is unavailable to provide that component; or

(D) a component provided by a physician.

(d) An individual may not provide a component of diabetes

self-management training under Subsection (c)(4) unless:

(1) the subject matter of the component is within the scope of

the individual's practice; and

(2) the individual meets the education requirements, as

determined by the individual's licensing agency in consultation

with the commissioner of public health.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.056. COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND

SUPPLIES. A health benefit plan must provide coverage for new or

improved diabetes equipment or supplies, including improved

insulin or another prescription drug, approved by the United

States Food and Drug Administration if the equipment or supplies

are determined by a physician or other health care practitioner

to be medically necessary and appropriate.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1358.057. RULES. (a) The commissioner shall adopt rules

necessary to implement this subchapter.

(b) In adopting rules under this section, the commissioner may

consult with the commissioner of public health and other

appropriate entities.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.