Expanded Medicare Coverage of Diabetes Self-Management Education―Is It Working?
David Holtzman 

David Holtzman, J.D. is Director of Government Affairs for the American Association of Diabetes Educator.  He has been active in the areas of third party coverage and reimbursement for diabetes self-management education, equipment and supplies for nearly a decade.  The views expressed here do not necessarily reflect the views of the AADE. 

Expanded Medicare Coverage of Diabetes Self-Management Education―Is It Working?

The Balanced Budget Act of 1997 expanded Medicare coverage of diabetes testing and self-management training. But anecdotal information suggests that the availability of diabetes self-management training (DSMT) is harder to find and obtain today than before the benefit was purportedly expanded.  Most of these problems can be attributed to the fact that HCFA established rules for DSMT that created barriers to patient access and provider eligibility.

Three years later these new services are still unavailable to many Medicare beneficiaries with diabetes. On February 27th  HCFA implemented rulemaking establishing patient eligibility for diabetes treatments and the operation of self management education programs that largely follow interim guidance that had been repeatedly criticized for narrowly limiting provider eligibility and patient access.

These rules make it extremely difficult for new entities like pharmacists, physician offices, nurse educators and clinics to provide services because they cannot be reimbursed.  According to HCFAʼs estimates, the estimated 4 million Medicare beneficiaries with diabetes will be limited to a approximately 1,100 approved providers nationwide. 

The laws in over 40 states specifically provide for insurers to pay for quality DSMT services through a broad array of providers.  In many states, Medicare beneficiaries will be forced to travel great distances to obtain DSMT services at HCFA approved sites, while Americans covered by private health insurance or managed care contracts can obtain these services through local hospital outpatient departments, physicians, and non-physician healthcare providers.

A further problem is that the Medicare procedures do not provide enough continuity between program operations prior to the BBA and post-BBA.  Prior to the BBA hundreds of hospital-based outpatient diabetes programs were certified as providers by HCFA or its carriers.  HCFA has designated one mechanism operated by the American Diabetes Association document that they meet the National Standards for Diabetes Self-Management Education Programs. Programs that don't meet ADA's standards are being forced out of the Medicare program, even in the absence of any demonstration that these programs were providing inadequate service. 

As a result of the implementation, hundreds of DSMT providers have lost the ability to be reimbursed for services to Medicare beneficiaries. A survey conducted by AADE  through the Diabetes Council of State & Territorial Disease Directors of diabetes control program coordinators found that nearly 1,000 DSMT providers around the country likely impacted by the  new regulation.

The regulation has produced a disruption in beneficiary access to quality diabetes care.   In some cases, beneficiaries who were enrolled in DSMT programs have been unable to receive services since the February 27 effective date of the final rule because their provider lost the ability to participate as a Medicare provider.

Some programs that want to participate as Medicare providers cannot do so, either because of their current program design or because the financial burden of recognition by HCFAʼs sole credentialing process. Any self-management education program that cannot fit the HCFA mold is facing difficulties, even though there is no evidence that these programs were poor performers. 

Because of inadequate payment rates and other regulatory uncertainties, a number of existing hospital-based programs have been closed or cut back during the two year period the expanded benefit was administered through interim program guidance. The problems facing this class of providers is largely due to HCFAʼs imposition of more comprehensive and expensive credentialing requirements on hospital-based programs without providing the higher level of reimbursement available to physicianʼs offices or clinics providing exactly the same services until recently.

Also, programs that do close are unable to relocate easily to another arrangement.  Once a hospital decides to terminate an education program, there is no easy way for that program to reopen as a different operation because of difficulties in obtaining provider numbers and meeting other new requirements in obtaining the credential required by HCFA.

HCFA has failed to address these problems through the rulemaking process.  These steps are critical to making sure that enough diabetes self-management education programs continue operating to meet the needs of Medicare beneficiaries with diabetes.

In the face of HCFAʼs design of a the diabetes self-management training benefit that unreasonably limits provider eligibility and patient access, HCFA needs to quickly implement policies to (1) revise the patient eligibility standards; (2) allow existing programs a longer transition period to achieve new standards; (3) expand the number and types of methods by which diabetes education programs can become providers; and (4) make it easier for programs in transition to remain eligible as  Medicare providers.

Regrettably, thirty-six months after enactment of the BBA, the promise of Medicare's expanded coverage of diabetes self-management education has yet to be met.  To learn more about reimbursement for diabetes self-management education services or to write your member of Congress regarding HCFA restrictions on access to DSMT, visit the AADE Government Relations web page at  http://www.aadenet.org/gov_frame.html .