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Part 109      DIABETES SELF-MANAGEMENT TRAINING

317:30-5-1080.Definitions

[Issued 01-06-2020]
   The following words or terms, when used in this Part, shall have the following meaning, unless the context clearly indicates otherwise:

"AADE" means American Association of Diabetes Educators.

"ADA" means American Diabetes Association.

"CDE" means certified diabetes educator.

"DSMT" means diabetes self-management training.

"OAC" means Oklahoma Administrative Code.

"OHCA" means Oklahoma Health Care Authority.

"Qualified non-physician provider" means a physician assistant or advanced practice registered nurse.

317:30-5-1081.Eligible providers and requirements

[Issued 01-06-2020]
(a) Eligible DSMT providers include any of the following professionals:

(1) A registered dietician (RD) who is licensed and in good standing in the state in which s/he practices, and who is:

(A) Certified as a CDE; and

(B) Fully contracted with SoonerCare as a CDE provider.

(2) A registered nurse (RN) who is licensed and in good standing in the state in which s/he practices, and who is:

(A) Certified as a CDE; and

(B) Fully contracted with SoonerCare as a CDE provider.

(3) A pharmacist who is licensed and in good standing in the state in which s/he practices, and who is:

(A) Certified as a CDE; and

(B) Fully contracted with SoonerCare as a CDE provider.

(b) In order to receive Medicaid reimbursement for DSMT services, professional service groups, outpatient hospitals, Indian Health Services, Tribal Programs and Urban Indian Clinics (I/T/Us), Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) must have a DSMT program that meets the quality standards of one (1) of the following accreditation organizations:

(1) The ADA; or

(2) The AADE.

(c) All DSMT programs must adhere to the national standards for diabetes self-management education.

(1) Each member of the instructional team must:

(A) Be a CDE; or

(B) Have documentation of at least fifteen (15) hours of recent diabetes education or diabetes management experience.

(2) At a minimum, every instructional team must consist of at least one (1) of the CDEprofessionals listed in subsection a, above.

(d) All members of the instructional team must obtain the nationally recommended annual continuing education hours for diabetes management.

317:30-5-1082.Scope of services

[Issued 01-06-2020]
(a) General provisions.  The OHCA covers medically necessary DSMT services when all the following criteria are met:

(1) The member has been diagnosed with diabetes by a physician or qualified non-physician provider working within the scope of his/her licensure;

(2) The services have been ordered by a physician or qualified non-physician provider who is actively managing the member's diabetes;

(3) The services are provided by a qualified DSMT provider [Refer to OAC 317:30-5-1081(b)(2)]; and

(4) The program meets the current ADA or ADE training standards.

(b) Training. DSMT services shall provide one (1) initial assessment per lifetime. Initial DSMT shall be comprised of up to ten (10) hours [can be performed in any combination of thirty (30) minute increments] of diabetes training within a consecutive twelve (12) month period beginning with the initial training date, including:

(1) One (1) hour of individual instruction, consisting of face-to-face encounters between the CDE and the member; and

(2) Nine (9) hours of group instruction.

(c) Follow-up DSMT. After the first twelve (12) month period has concluded, members shall only be eligible for two (2) hours of individual or group DSMT instruction per calendar year.

(d) Referral.  The physician or qualified non-physician provider managing the member's diabetes must submit a DSMT order that includes:

(1) Diabetes diagnosis;

(2) Plan of care;

(3) Number of initial or follow-up hours needed;

(3) Expected health outcomes; and

(4) Any identified barriers that would require individualized member education.

317:30-5-1083.Coverage by category

[Issued 01-06-2020]
   The purpose of DSMT services must be to provide the member with the knowledge, skill, and ability necessary for diabetes self-care.

(1) Adults.  Payment is made for medically necessary DSMT provided by a registered nurse (RN), registered dietitian (RD), or pharmacist certified as a diabetes educator, as described in OAC 317:30-5-1081.Refer to OAC 317:30-5-1082 for units of DSMT training allowed.

(2) Children/adolescents.  Payment is made for medically necessary DSMT for members under twenty-one (21) years of age provided by a RN, RD, or pharmacist certified as a diabetes educator, as described in OAC 317:30-5-1081.  DSMT coverage for children is the same as for adults. Additional DSMT services may be covered under EPSDT provisions if determined to be medically necessary.

317:30-5-1084.Reimbursement methodology

[Issued 01-06-2020]
   SoonerCare shall provide reimbursement for DSMT services as follow:

(1) Payment shall be made to fully-contracted providers. If the rendering provider operates through an enrolled SoonerCare provider, or is contracted to provide services by an enrolled SoonerCare provider, payment may be made to that enrolled SoonerCare provider.

(2) Reimbursement for DSMT services is only made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by OHCA to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider's actual billed charges, consistent with the provider's usual and customary charge to the general public for the service, or the maximum allowable per unit of service.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.