Insurance For Diabetics

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 selfmanagement 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, P.O. Box 50540, Charleston, WV 25305-0540. Hanley C. Clark Insurance Commissioner