Does Insurance in Your State Cover Diabetes Education?

By Manel Kappagoda and Derek Carr

In the United States, older adults have the highest rates of diabetes of any age group; one-quarter of all adults over the age of 65 have diabetes, according to the 2017 National Diabetes Statistics Report from the Centers for Disease Control and Prevention. Older African-Americans and Latinos bear the greatest burden of the country’s diabetes epidemic. Compared to the general population, they experience higher rates of diabetes and as well as a greater risk of diabetes-related complications such as amputations and blindness.  One strategy to improve health outcomes and quality of life among older adults living with diabetes is diabetes self-management education and training (DSME/T). This program provides information to help people with diabetes manage the condition and incorporates patients’ unique needs and experiences into individualized support plans. Diabetes support plans promote healthy eating, physical activity, self-monitoring, and medication use. Plans also often address risk reduction, management of acute and chronic complications, and problem-solving strategies to establish healthy habits. Research shows that by giving patients the tools necessary to manage their diabetes, DSME/T significantly improves health outcomes and reduces health care expenditures.   

Medicare Covers DSME/T, but Participation Is Low

Despite DSME/T’s effectiveness, participation rates are very low, even among patients with insurance. For example, a 2015 study of Medicare beneficiaries concluded that only 5% of those with recently diagnosed diabetes received DSME/T services. Medicare covers 10 hours of outpatient DSME/T in the year following a patient’s first referral for DSME/T and up to 2 hours of follow-up training in each subsequent year. Patients must be referred by the health care professional treating their diabetes. The low participation rates among Medicare recipients are similar to the rates among patients with private insurance or Medicaid.

Thus, despite the benefits of DSME/T, very few people with diabetes receive these services. To access DSME/T, patients need to be aware that it exists; providers must refer their patients to the service; and patients must have the time and resources, including reliable transportation, to take part in the multi-session program. All these factors contribute to whether patients will successfully access DSME/T or not. In addition, there are special considerations to consider when engaging older adults in DSME/T. Higher rates of multiple medical conditions and declining functional ability may raise additional challenges for older patients. Given these complexities, we recognize that insurance coverage is just one piece of the puzzle when getting people to access this critical service. Nevertheless, our organization was well-positioned to create a resource that would address questions about DSME/T insurance coverage. We felt it was important to make this information widely available for all interested stakeholders given the efficacy of DSME/T in helping patients to control their diabetes.   

How Does Insurance Cover DSME/T Across the Country?

To promote awareness of insurance coverage for DSME/T, ChangeLab Solutions teamed with the Policy Surveillance Program at Temple University to conduct a 50-state analysis of laws and policies on public and private insurance coverage for DSME/T. The team created two sets of online tools pertaining to DSME/T insurance coverage. The first is an interactive database that allows users to look up DSME/T insurance coverage provisions by state and compare provisions across states. The second is a set of state-specific fact sheets, which provide 2-page summaries of each state’s information. Users can generate maps and tables that highlight selected features of relevant laws across states or download prepared summaries of current law and as well as the underlying legal data, codebooks, and protocols.

Join Us in San Francisco

Programs like DSME/T are critically important for all people with diabetes, but especially for adults over the age of 65, one-quarter of whom are living with diabetes. DSME/T empowers people living with diabetes to take charge of their own health, and research shows that it is cost-effective. Increasing participation in these programs can improve the health of a significant number of adults older than age 65 as well as people of color in that age bracket who are disproportionally impacted by diabetes complications. We hope that by providing information about health insurance coverage for DSME/T, we can help address one barrier to access. Join us in San Francisco at the ASA’s Aging in America Conference for our poster session titled “Interactive Database and Survey of Diabetes Self-Management Education and Training Insurance Coverage” to share your experiences with DSME/T and learn more about our interactive database.

Manel Kappagoda is a program director and senior staff attorney at ChangeLab Solutions, where she works on legal and policy interventions that address chronic disease rates and promote healthy, sustainable communities. Derek Carr is a staff attorney at ChangeLab Solutions where he works on issues related to air quality, healthy housing, tobacco control, healthy eating, and active living.

Relevant Resources

Database: Health Insurance Coverage Laws for Diabetes Self-Management Education and Training.

State Profiles: Diabetes Self-Management Education and Training.

Disclaimer: The research described in this article was supported by Cooperative Agreement Number 5U38OT000141-03, awarded to ChangeLab Solutions and funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.