This month, I would like to introduce you to Manel Kappagoda, JD, MPH. Manel is a project director and senior staff attorney at ChangeLab Solutions, a national non-profit organization with the mission of creating healthier communities for all, through better laws and policies.Manel and her colleague Derek Carr, analyzed laws addressing insurance coverage for Diabetes Self-Management Education and Training (DSME/T*) in partnership with the Temple University Policy Surveillance Program.

As we all know, DSME/T provides people with diabetes the knowledge and skills necessary for effective diabetes self-care. However, the majority of eligible PWD do not receive this intervention, often due to challenges related to insurance coverage and reimbursement. Manel and her colleagues developed online resources that answer many common questions about insurance coverage for DSME/T.

Here are two websites that are part of my conversation with Manel:
http://lawatlas.org/dataset/diabetes-self-management-education-laws
http://changelabsolutions.org/publications/DSMET-State-Profiles.

Manel, tell us about these resources and how they will it benefit people with diabetes?

Thanks for this opportunity to get the word out about these resources. ChangeLab Solutions and the Policy Surveillance Program at Temple University conducted a 50-state analysis of laws and policies addressing public and private insurance coverage for DSME/T. The research findings can be accessed through an interactive website and in short state-specific fact sheets, both of which are available at LawAtlas. Visitors can use the website to generate maps and tables that highlight selected features of DMSE/T laws across states; and to download prepared summaries of current law and the underlying legal data, codebooks, and protocols. This research will allow PWD, diabetes educators, other public health professionals, and policymakers to understand the insurance coverage landscape for DSME/T in all 50 states.

Why do diabetes educators need to know about DSME/T reimbursement?

Current literature overwhelmingly demonstrates that DSME/T is effective for diabetes management. DSME/T participants generally experience reduced HbA1c levels, reduced BMI, reduced blood pressure, and better clinical care outcomes. Nevertheless, very few people with diabetes receive DSME/T. Participation rates are low even among patients with insurance. For example, a 2015 study of 110,064 Medicare beneficiaries concluded that only 5% of those with recently diagnosed diabetes received DSME/T services. We see similar participation rates among those with private insurance and Medicaid. There are many reasons why people don’t participate in DSME/T. One reason is that PWD may be unaware that their insurance covers DSME/T or their providers may be unaware that their patients have such coverage. We wanted to help people understand the insurance coverage landscape for DSME/T, making sure they know that their insurance provider should be covering these services.

What are the resources available to diabetes educators related to insurance reimbursement on the local level?

Insurance coverage is regulated at the state and federal level, not the local level. This means that diabetes educators need to understand their state’s laws and policies related to insurance coverage, as well as federal laws related to Medicare and Medicaid. For this reason, our research focused on state laws, state Medicaid policies, and federal Medicare and Medicaid provisions.

Typically, I ask my patients to call their insurance to find out how many hours of DSME/T they are eligible for – is there anything else I should do?

I would recommend that patients look up their state on the LawAtlas website and see what coverage the law requires. They will then have this information when they call their insurance company. If the insurance company gives them information that differs from the information on the LawAtlas website, the patient can ask why their insurance coverage differs from the coverage required under state or federal law.

How about pre diabetes – is education for prediabetes reimbursed, and if so, how?

Typically, provisions requiring DSME/T coverage do not apply to pre-diabetes; however, some insurance providers do cover pre-diabetes interventions. The National Diabetes Prevention Program (NDPP) is an evidence-based lifestyle management program that aims to prevent type 2 diabetes. Some private insurers cover NDPP, as does the Medicaid program in Montana. Medicare is expected to expand coverage to include the NDPP in 2018. For more information about NDPP, go to the Center for Disease Control and Prevention’s website. For more information about coverage for NDPP, go to the National Association of Chronic Disease Directors website.

What are other important points that are helpful?

Programs like DSME/T and NDPP are critically important. They empower people living with diabetes or pre-diabetes to take charge of their own health, and research shows us that they’re cost-effective. We need to increase participation in these programs. We hope that by providing information about health insurance coverage for these programs, we can help address one barrier to access.

* Note: DSME/T AND DSME/S are interchanged