28 Tex. Admin. Code § 21.2604 - Minimum Standards for Benefits for Persons with Diabetes, Requirement for Periodic Assessment of Physician and Organizational Compliance
(a) Health benefit plans provided by HMOs
must provide coverage for the services in paragraphs (1) through (7) of this
subsection and must contract with providers that agree to comply with the
minimum practice standards outlined in subsection (b) of this section. Services
to be covered include:
(1) office visits and
consultations with physicians and practitioners for monitoring and treatment of
diabetes, including office visits and consultations with appropriate
specialists;
(2) immunizations
required by Insurance Code Chapter 1367, Subchapter B, Coverage for Childhood
Immunizations;
(3) immunizations
for influenza and pneumococcus;
(4)
inpatient services, and physician and practitioner services when the insured is
confined to:
(A) a hospital;
(B) a rehabilitation facility; or
(C) a skilled nursing facility;
(5) inpatient and outpatient
laboratory and diagnostic imaging services;
(6) diabetes equipment and supplies in
accordance with §
21.2605 of this title (relating to
Diabetes Equipment and Supplies); and
(7) diabetes self-management training, in
accordance with subsection (b)(1)(A)(iii) of this section and §
21.2606 of this title (relating to
Diabetes Self-Management Training);
(b) HMOs must contract with providers who, at
a minimum, provide care that complies with subsection (a) of this section that
includes:
(1) for all insureds:
(A) at initial visit by the insured:
(i) a complete history and physical including
an assessment of immunization status;
(ii) development of a management plan
addressing all of the following that are applicable to the insured:
(I) nutrition and weight
evaluation;
(II)
medications;
(III) an exercise
regimen;
(IV) glucose and lipid
control;
(V) high risk
behaviors;
(VI) frequency of
hypoglycemia and hyperglycemia;
(VII) compliance with applicable aspects of
self care;
(VIII) assessment of
complications;
(IX) follow up on
any referrals;
(X) psychological
and psychosocial adjustment;
(XI)
general knowledge of diabetes; and
(XII) self-management skills;
(iii) diabetes self-management
training given or referred by the physician or practitioner as required by §
21.2606 of this title and §
21.2607 of this title;
(iv)
referral for a dilated funduscopic eye exam to be performed by an
ophthalmologist or therapeutic optometrist for an insured with Type 2
Diabetes.
(B) at every
visit the following:
(i) weight and blood
pressure taken,
(ii) foot exam
performed without shoes or socks, and
(iii) dental inspection.
(C) every six months the following:
(i) review of the management plan,
and
(ii) glycosylated hemoglobin
test.
(D) annually the
following:
(i) lipid profile,
(ii) microalbuminuria;
(iii) influenza immunization;
(iv) referral for a dilated funduscopic eye
exam performed by an ophthalmologist or therapeutic optometrist; and
(v) for insureds under 18 years of age, a
referral for a retinal camera examination to be performed by an ophthalmologist
or therapeutic optometrist.
(2) For treatment of an insured 65 years of
age and over or an insured with complications affecting two or more body
systems:
(A) minimum practice standards as set
forth in paragraph (1) of this subsection; and
(B) specific inquiries into and consideration
of treatment goals for comorbidity and polypharmacy.
(3) For pregnant insureds with pre-existing
or gestational diabetes:
(A) minimum practice
standards as set forth in paragraph (1) of this subsection; and
(B) enhanced fetal monitoring based on the
standards promulgated by the American College of Gynecologists and
Obstetricians.
(4) For
insureds with Type 1 Diabetes:
(A) minimum
practice standards as set forth in paragraph (1) of this subsection;
(B) an initial diagnosis, consideration of
hospitalization due to the insured's:
(i)
age;
(ii) physical
condition;
(iii) psychosocial
circumstances; or
(iv) lack of
access to outpatient diabetes self-management training as required in §
21.2606 of this title or § 21.2607
of this title; and
(C)
ongoing management, which includes quarterly office visits, at which evaluation
includes:
(i) weight;
(ii) blood pressure;
(iii) ophthalmologic exam;
(iv) thyroid palpation;
(v) cardiac exam;
(vi) examination of pulses;
(vii) foot exam;
(viii) skin exam;
(ix) neurological exam;
(x) dental inspection;
(xi) results of home glucose self-monitoring;
(xii) frequency and severity of
hypoglycemia or hyperglycemia;
(xiii) medical nutrition plan;
(xiv) exercise regimen;
(xv) adherence problems;
(xvi) psychosocial adjustment;
(xvii) reevaluation of short- and long-term
self-management goals;
(xviii)
anticipatory guidance related to issues of Type 1 Diabetes;
(xix) glycosylated hemoglobin;
(xx) counseling for high-risk behaviors;
and
(xxi) for insureds under 18
years of age, growth assessment.
(c) Health plans provided by HMOs must
periodically assess physician and organizational compliance with the minimum
practice standards contained in subsection (b) of this section.
(d) Health benefit plans provided by entities
other than HMOs must provide coverage at a minimum for:
(1) office visits and consultations with
physicians and practitioners for monitoring and treatment of diabetes,
including office visits and consultations with appropriate
specialists;
(2) immunizations
required by Insurance Code Chapter 1367, Subchapter B, Coverage for Childhood
Immunizations;
(3) immunizations
for influenza and pneumococcus;
(4)
inpatient services, physician, and practitioner services when an insured is
confined to:
(A) a hospital;
(B) a rehabilitation facility; or
(C) a skilled nursing facility;
(5) inpatient and outpatient
laboratory and diagnostic imaging services;
(6) diabetes equipment and supplies in
accordance with §
21.2605 of this title;
and
(7) diabetes self-management
training in accordance with §
21.2606 of this title.
Notes
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