CHAPTER 1358. DIABETES
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1358. DIABETES
SUBCHAPTER A. GUIDELINES FOR DIABETES CARE; MINIMUM COVERAGE
REQUIRED
Sec. 1358.001. DEFINITION. In this subchapter, "enrollee" means
an individual entitled to coverage under a health benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.002. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including:
(1) an individual, group, blanket, or franchise insurance policy
or insurance agreement, a group hospital service contract, or an
individual or group evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884; or
(E) a health maintenance organization operating under Chapter
843;
(2) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health
benefit plan that is offered by:
(A) a multiple employer welfare arrangement as defined by
Section 3 of that Act; or
(B) another analogous benefit arrangement; and
(3) health and accident coverage provided by a risk pool created
under Chapter 172, Local Government Code, notwithstanding Section
172.014, Local Government Code, or any other law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.003. EXCEPTION. This subchapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) only for dental or vision care; or
(F) only for indemnity for hospital confinement;
(2) a small employer health benefit plan written under Chapter
1501;
(3) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(6) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1358.002.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.004. ADOPTION OF MINIMUM STANDARDS. The commissioner,
in consultation with the Texas Diabetes Council, by rule shall
adopt minimum standards for coverage provided to an enrollee with
diabetes.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.005. COVERAGE REQUIRED. (a) A health benefit plan
must provide coverage in accordance with the standards adopted
under Section 1358.004.
(b) Coverage required under this section may not be subject to a
deductible, coinsurance, or copayment requirement that exceeds
the deductible, coinsurance, or copayment requirement applicable
to other similar coverage provided under the health benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. SUPPLIES AND SERVICES ASSOCIATED WITH DIABETES
TREATMENT
Sec. 1358.051. DEFINITIONS. In this subchapter:
(1) "Diabetes equipment" means:
(A) blood glucose monitors, including noninvasive glucose
monitors and glucose monitors designed to be used by blind
individuals;
(B) insulin pumps and associated appurtenances;
(C) insulin infusion devices; and
(D) podiatric appliances for the prevention of complications
associated with diabetes.
(2) "Diabetes supplies" means:
(A) test strips for blood glucose monitors;
(B) visual reading and urine test strips;
(C) lancets and lancet devices;
(D) insulin and insulin analogs;
(E) injection aids;
(F) syringes;
(G) prescriptive and nonprescriptive oral agents for controlling
blood sugar levels; and
(H) glucagon emergency kits.
(3) "Nutrition counseling" has the meaning assigned by Section
701.002, Occupations Code.
(4) "Qualified enrollee" means an individual eligible for
coverage under a health benefit plan who has been diagnosed with:
(A) insulin dependent or noninsulin dependent diabetes;
(B) elevated blood glucose levels induced by pregnancy; or
(C) another medical condition associated with elevated blood
glucose levels.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.038(a), eff. September 1, 2005.
Sec. 1358.052. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to a health benefit plan that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including:
(A) an individual, group, blanket, or franchise insurance policy
or insurance agreement, a group hospital service contract, or an
individual or group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation operating under
Chapter 842;
(iii) a fraternal benefit society operating under Chapter 885;
(iv) a stipulated premium company operating under Chapter 884;
(v) a reciprocal exchange operating under Chapter 942; or
(vi) a health maintenance organization operating under Chapter
843; and
(B) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health
benefit plan that is offered by a multiple employer welfare
arrangement as defined by Section 3 of that Act; or
(2) is offered by an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.053. EXCEPTION. This subchapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or another limited benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care; or
(G) only for indemnity for hospital confinement;
(2) a small employer health benefit plan written under Chapter
1501;
(3) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(6) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1358.052.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.054. COVERAGE REQUIRED. (a) A health benefit plan
that provides coverage for the treatment of diabetes and
conditions associated with diabetes must provide to each
qualified enrollee coverage for:
(1) diabetes equipment;
(2) diabetes supplies; and
(3) diabetes self-management training in accordance with the
requirements of Section 1358.055.
(b) A health benefit plan may require a deductible, copayment,
or coinsurance for coverage provided under this section. The
amount of the deductible, copayment, or coinsurance may not
exceed the amount of the deductible, copayment, or coinsurance
required for treatment of other analogous chronic medical
conditions.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.055. DIABETES SELF-MANAGEMENT TRAINING. (a) Diabetes
self-management training must be provided by a health care
practitioner or provider who is:
(1) licensed, registered, or certified in this state to provide
appropriate health care services; and
(2) acting within the scope of practice authorized by the
license, registration, or certification.
(b) For purposes of this subchapter, "self-management training"
includes:
(1) training provided to a qualified enrollee, after the initial
diagnosis of diabetes, in the care and management of that
condition, including nutrition counseling and counseling on the
proper use of diabetes equipment and supplies;
(2) additional training authorized on the diagnosis of a
physician or other health care practitioner of a significant
change in the qualified enrollee's symptoms or condition that
requires changes in the qualified enrollee's self-management
regime; and
(3) periodic or episodic continuing education training
prescribed by an appropriate health care practitioner as
warranted by the development of new techniques or treatments for
diabetes.
(c) If the diabetes self-management training is provided on the
written order of a physician or other health care practitioner,
including a health care practitioner practicing under protocols
jointly developed with a physician, the training must also
include:
(1) a diabetes self-management training program recognized by
the American Diabetes Association;
(2) diabetes self-management training provided by a
multidisciplinary team:
(A) the nonphysician members of which are coordinated by:
(i) a diabetes educator who is certified by the National
Certification Board for Diabetes Educators; or
(ii) an individual who has completed at least 24 hours of
continuing education that meets guidelines established by the
Texas Board of Health and that includes a combination of
diabetes-related educational principles and behavioral
strategies;
(B) that consists of at least a licensed dietitian and a
registered nurse and may include a pharmacist and a social
worker; and
(C) each member of which, other than a social worker, has recent
didactic and experiential preparation in diabetes clinical and
educational issues as determined by the member's licensing
agency, in consultation with the commissioner of public health,
unless the member's licensing agency, in consultation with the
commissioner of public health, determines that the core
educational preparation for the member's license includes the
skills the member needs to provide diabetes self-management
training;
(3) diabetes self-management training provided by a diabetes
educator certified by the National Certification Board for
Diabetes Educators; or
(4) diabetes self-management training that provides one or more
of the following components:
(A) a nutrition counseling component provided by a licensed
dietitian, for which the licensed dietitian shall be paid;
(B) a pharmaceutical component provided by a pharmacist, for
which the pharmacist shall be paid;
(C) a component provided by a physician assistant or registered
nurse, for which the physician assistant or registered nurse
shall be paid, except that the physician assistant or registered
nurse may not be paid for providing a nutrition counseling or
pharmaceutical component unless a licensed dietitian or
pharmacist is unavailable to provide that component; or
(D) a component provided by a physician.
(d) An individual may not provide a component of diabetes
self-management training under Subsection (c)(4) unless:
(1) the subject matter of the component is within the scope of
the individual's practice; and
(2) the individual meets the education requirements, as
determined by the individual's licensing agency in consultation
with the commissioner of public health.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.056. COVERAGE FOR NEW OR IMPROVED EQUIPMENT AND
SUPPLIES. A health benefit plan must provide coverage for new or
improved diabetes equipment or supplies, including improved
insulin or another prescription drug, approved by the United
States Food and Drug Administration if the equipment or supplies
are determined by a physician or other health care practitioner
to be medically necessary and appropriate.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1358.057. RULES. (a) The commissioner shall adopt rules
necessary to implement this subchapter.
(b) In adopting rules under this section, the commissioner may
consult with the commissioner of public health and other
appropriate entities.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.