R590. Insurance, Administration.R590-200. Diabetes Treatment and Management.
R590-200-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-22-626.
R590-200-2. Purpose and Scope.
(1) The purpose of this rule is to establish minimum standards of coverage for diabetes.
(2) This rule applies to each accident and health insurance policy that provides a health insurance benefit.
(3) This rule does not prohibit an insurer from requesting additional information to determine eligibility of a claim under the terms of a policy, certificate, or both.
R590-200-3. Definitions.
Terms used in this rule are defined in Section 31A-1-301. Additional terms are defined as follows:
(1)(a) "Diabetes" means diabetes mellitus, a common chronic, serious systemic disorder of energy metabolism including a heterogeneous group of metabolic disorders characterized by an elevated blood glucose level.
(b) The terms "diabetes" and "diabetes mellitus" are synonymous and defined to include:
(i) a person using insulin;
(ii) a person not using insulin;
(iii) an individual with an elevated blood glucose level induced by pregnancy; and
(iv) a person with another medical condition or medical therapy that wholly or partially consists of an elevated blood glucose level.
(c) Diabetes includes an individual with:
(i) complete insulin deficiency, or type 1 diabetes;
(ii) insulin resistance with partial insulin deficiency, or type 2 diabetes; and
(iii) an elevated blood glucose level induced by pregnancy, or gestational diabetes.
(2)(a) "Diabetes self-management training" means a program designed to help an individual learn to manage their diabetes in an outpatient setting.
(b) Self-management training topics include:
(i) making lifestyle changes to effectively manage diabetes;
(ii) avoiding or delaying the complications, hospitalizations, and emergency room visits associated with diabetes; and
(iii) medical nutrition therapy.
(3) "Medical equipment" means non-disposable or durable equipment used to treat diabetes.
(4) "Medical nutrition therapy" means the assessment and therapy of a patient's nutritional status including diet modification, planning, and counseling services furnished by a registered licensed dietitian.
(5) "Medical supplies" means a generally accepted single-use item used to manage, monitor, and treat diabetes, and to administer diabetic specific medication.
R590-200-4. Minimum Standards and General Provisions.
(1) Coverage for diabetes treatment is subject to the deductibles, copayments, out-of-pocket maximums, and coinsurance of the policy.
(2)(a) An accident and health insurance policy that provides a health insurance benefit shall cover diabetes self-management training and patient management, including medical nutrition therapy, when medically necessary and prescribed by a physician.
(b) The diabetes self-management training services must be provided by a diabetes self-management training program:
(i) recognized by the Centers for Medicare and Medicaid Services;
(ii) certified by the Utah Department of Health and Human Services; or
(iii) approved or accredited by a national organization certifying standards of quality in the provision of diabetes self-management education.
(c) A diabetes self-management training program shall be provided upon:
(i) a diagnosis with diabetes;
(ii) a significant change in a diabetes-related condition;
(iii) a change in diagnostic levels; or
(iv) a change in treatment regimen.
(3) An accident and health insurance policy that provides a health insurance benefit shall cover the following when medically necessary:
(a) blood glucose monitors designed for diabetic patients;
(b) blood glucose monitors for the legally blind designed for use with adaptive devices;
(c) test strips for glucose monitors, including test strips cleared by the FDA;
(d) visual reading strips for glucose and ketones;
(e) urine testing strips for glucose and ketones;
(f) lancet devices and lancets for monitoring glycemic control;
(g) insulin, including analog, in either vial or cartridge;
