(a) Health benefit plans provided by HMOs must provide coverage for the services in paragraphs (1) through (7) of this subsection and must contract with providers that agree to comply with the minimum practice standards outlined in subsection (b) of this section. Services to be covered include:
(1) office visits and consultations with physicians and practitioners for monitoring and treatment of diabetes, including office visits and consultations with appropriate specialists;
(2) immunizations required by Insurance Code Chapter 1367, Subchapter B, Coverage for Childhood Immunizations;
(3) immunizations for influenza and pneumococcus;
(4) inpatient services, and physician and practitioner services when the insured is confined to:
(A) a hospital;
(B) a rehabilitation facility; or
(C) a skilled nursing facility;
(5) inpatient and outpatient laboratory and diagnostic imaging services;
(6) diabetes equipment and supplies in accordance with §21.2605 of this title (relating to Diabetes Equipment and Supplies); and
(7) diabetes self-management training, in accordance with subsection (b)(1)(A)(iii) of this section and §21.2606 of this title (relating to Diabetes Self-Management Training);
(b) HMOs must contract with providers who, at a minimum, provide care that complies with subsection (a) of this section that includes:
(1) for all insureds:
(A) at initial visit by the insured:
(i) a complete history and physical including an assessment of immunization status;
(ii) development of a management plan addressing all of the following that are applicable to the insured:
(I) nutrition and weight evaluation;
(II) medications;
(III) an exercise regimen;
(IV) glucose and lipid control;
(V) high risk behaviors;
(VI) frequency of hypoglycemia and hyperglycemia;
(VII) compliance with applicable aspects of self care;
(VIII) assessment of complications;
(IX) follow up on any referrals;
(X) psychological and psychosocial adjustment;
(XI) general knowledge of diabetes; and
(XII) self-management skills;
(iii) diabetes self-management training given or referred by the physician or practitioner as required by §21.2606 of this title and §21.2607 of this title;
(iv) referral for a dilated funduscopic eye exam to be performed by an ophthalmologist or therapeutic optometrist for an insured with Type 2 Diabetes.
(B) at every visit the following:
(i) weight and blood pressure taken,
(ii) foot exam performed without shoes or socks, and
(iii) dental inspection.
(C) every six months the following:
(i) review of the management plan, and
(ii) glycosylated hemoglobin test.
(D) annually the following:
(i) lipid profile,
(ii) microalbuminuria;
(iii) influenza immunization;
(iv) referral for a dilated funduscopic eye exam performed by an ophthalmologist or therapeutic optometrist; and
(v) for insureds under 18 years of age, a referral for a retinal camera examination to be performed by an ophthalmologist or therapeutic optometrist.
(2) For treatment of an insured 65 years of age and over or an insured with complications affecting two or more body systems:
(A) minimum practice standards as set forth in paragraph (1) of this subsection; and
(B) specific inquiries into and consideration of treatment goals for comorbidity and polypharmacy.
(3) For pregnant insureds with pre-existing or gestational diabetes:
(A) minimum practice standards as set forth in paragraph (1) of this subsection; and
(B) enhanced fetal monitoring based on the standards promulgated by the American College of Gynecologists and Obstetricians.
(4) For insureds with Type 1 Diabetes:
(A) minimum practice standards as set forth in paragraph (1) of this subsection;
(B) an initial diagnosis, consideration of hospitalization due to the insured's:
(i) age;
(ii) physical condition;
(iii) psychosocial circumstances; or
(iv) lack of access to outpatient diabetes self-management training as required in §21.2606 of this title or §21.2607 of this title; and
(C) ongoing management, which includes quarterly office visits, at which evaluation includes:
(i) weight;
(ii) blood pressure;
(iii) ophthalmologic exam;
(iv) thyroid palpation;
(v) cardiac exam;
(vi) examination of pulses;
(vii) foot exam;
(viii) skin exam;
(ix) neurological exam;
(x) dental inspection;
(xi) results of home glucose self-monitoring;
(xii) frequency and severity of hypoglycemia or hyperglycemia;
(xiii) medical nutrition plan;
(xiv) exercise regimen;
(xv) adherence problems;
(xvi) psychosocial adjustment;
(xvii) reevaluation of short- and long-term self-management goals;
(xviii) anticipatory guidance related to issues of Type 1 Diabetes;
(xix) glycosylated hemoglobin;
(xx) counseling for high-risk behaviors; and
(xxi) for insureds under 18 years of age, growth assessment.
(c) Health plans provided by HMOs must periodically assess physician and organizational compliance with the minimum practice standards contained in subsection (b) of this section.
(d) Health benefit plans provided by entities other than HMOs must provide coverage at a minimum for:
(1) office visits and consultations with physicians and practitioners for monitoring and treatment of diabetes, including office visits and consultations with appropriate specialists;
(2) immunizations required by Insurance Code Chapter 1367, Subchapter B, Coverage for Childhood Immunizations;
(3) immunizations for influenza and pneumococcus;
(4) inpatient services, physician, and practitioner services when an insured is confined to:
(A) a hospital;
(B) a rehabilitation facility; or
(C) a skilled nursing facility;
(5) inpatient and outpatient laboratory and diagnostic imaging services;
(6) diabetes equipment and supplies in accordance with §21.2605 of this title; and
(7) diabetes self-management training in accordance with §21.2606 of this title.
Source Note: The provisions of this §21.2604 adopted to be effective April 13, 1999, 24 TexReg 2939; amended to be effective February 9, 2004, 29 TexReg 1201; amended to be effective November 7, 2021, 46 TexReg 7408
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