1. (a)

   1. (1) Pursuant to Acts 1997, No. 1249, § 2, every individual and group health insurance policy as defined in this part shall include coverage for one (1) per lifetime training program per insured for diabetes self-management training, when medically necessary.
   2. (2) Training that is compensable under the policy may include one (1) or more than one (1) visit from the physician or healthcare provider.
   3. (3) The diabetes self-management training that is compensable under the policy shall include additional training sessions offered by the healthcare provider, as prescribed by a physician, on grounds of medical necessity and when the diabetic patient's condition changes or worsens upon a determination by that physician that it is a significant change in the diabetic patient's condition.

2. (b)

   1. (1) Any training for diabetes self-management shall only be covered in the healthcare policy:

      1. (A) When medically necessary as determined by a physician; and
      2. (B) If it is provided by an appropriately licensed health care provider credentialed as required by Acts 1997, No. 1249, and defined in 23 CAR § 113-103(4).

   2. (2)

      1. (A) As to additional requirements, the physician for the diabetic patient must be licensed under Arkansas Code § 17-95-201 et seq.
      2. (B) The diabetes educator shall only provide diabetes self-management training within his or her scope of practice after having demonstrated expertise in diabetes care and treatment.
      3. (C) The physician or diabetes educator shall only provide such training after having completed an education training program required by his or her licensing board when such program is in compliance with the National Standards for Diabetes Self-Management Education and Support, developed by the American Diabetes Association.

   3. (3) For the patient's training to be compensable under the healthcare policy, the physician must issue a written prescription ordering the training for the:

      1. (A) Patient; and/or
      2. (B) Patient’s:

3. (i) Parent;

   1. (ii) Spouse; or

      1. (iii) Legal guardian.

   2. (4) For compensable coverage, the:

      1. (A) Training must be successfully completed by the:

         1. (i) Diabetic patient; and
         2. (ii) Parent, spouse, or legal guardian;
      2. (B) Healthcare provider must certify such successful completion; and
      3. (C) Healthcare provider shall provide such written certification to the referring physician and healthcare insurer providing the coverage.

   3. (5)

      1. (A) A healthcare insurer is not required to pay benefits unless and until the healthcare provider provides certification that the insured individual has successfully completed the diabetes self-management training.

      2. (B) Additionally and to facilitate the payment of benefits due under this part, healthcare insurers shall routinely obtain from all appropriate Arkansas state licensing boards a list of licensed or certified health care professionals who have:

         1. (i) Demonstrated expertise in diabetes care and treatment; and
         2. (ii) Completed the educational program in compliance with the ADA program required by that Arkansas state licensing board.
         3. (c) The coverage required under this part and Acts 1997, No. 1249, shall be consistent with other benefits provided in the health insurance policy and subject to all policy limitations, applicable deductibles, coinsurance, other patient cost-sharing amounts or out-of-pocket limits, as well as referral, prior authorization, or other utilization review requirements or processes.
         4. (d) The provisions of Acts 1997, No. 1249, and this part do not prohibit healthcare insurers from selectively negotiating contracts with qualified providers of diabetes self-management training programs, to the extent such contracts are not inconsistent with this part.

4. (e)

   1. (1) The healthcare insurers may legitimately exclude from coverage diabetes self-management training, diabetes equipment, supplies, and related services that are not medically necessary for the treatment of Type I, Type II, or gestational diabetes or other types, provided that such determinations are:

      1. (A) Made by the patient's licensed physician or physicians;
      2. (B) Consistent with Acts 1997, No. 1249, and this part, as well as other applicable laws and rules; and
      3. (C) Not at variance with generally accepted standards of the medical profession.
   2. (2) Nothing in this part shall be deemed to exclude or prohibit review and final determination of a claim on appeal as provided by the applicable health insurance policy or plan, after initial coverage determination on medical necessity is made by a licensed physician as required by this part.

Codification Notes: “ADA” means American Diabetes Association.