House Bill 656 would require insurers to provide coverage for certain diabetic supplies, medication, and services and require any insurer underwriting Medicare or Medicaid insurance for Pennsylvania residents to provide coverage for hearing aids in accordance with the "Hearing Aid Sales Registration Law."
Any individual, regardless of whether or not they are insulin dependent, would be eligible for the diabetic supplies and education benefits. To qualify for coverage, the benefits must be prescribed by a physician.
Equipment and supplies are defined to include the following: blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics.
Coverage for outpatient self-management training and education must be prescribed by a physician and includes:
To qualify for the hearing aid benefits, a person would need to be covered by Medicare or Medicaid and purchase a hearing aid sold in accordance with the "Hearing Aid Sales Registration Law." There is no requirement that the hearing aid must be prescribed by a physician.
The Council was also requested to review two proposed amendments to House Bill 656. The first amendment, A0388, would provide that diabetes outpatient self-management training and education shall be provided under the supervision of a "certified, registered, or" licensed health care professional, instead of only under the supervision of a licensed health care professional. The second amendment, A0470, would (1) eliminate the proposed coverage for hearing aids, (2) replace the word "orthotics" with the phrase "orthotics related to the treatment of diabetes illness", and (3) provide that diabetes outpatient self-management training and education shall be provided "by an individual with expertise in diabetes self-management, training and education".
As a state law, the measure would be preempted by the federal Employee Retirement Income Security Act of 1974 (ERISA) (PL 93-406), which precludes state laws from applying to the benefit plans of self-insured companies. According to the Pennsylvania Department of Insurance, the percentage of private payers that are preempted by ERISA is approximately 50 percent of all privately insureds.
Council staff examined related legislation, both at the federal level and from other states.
As part of the Federal Balanced Budget Act of 1997, changes in Medicare were enacted concerning diabetes. Through June 30, 1998, Medicare covered blood glucose monitors, testing strips, and lancets only for insulin-using diabetics. Additionally, Medicare covered the cost of outpatient diabetes education in a hospital setting. As of July 1, 1998, Medicare now covers blood glucose monitors, testing strips, and lancets for all diabetics, regardless of whether or not they use insulin. Insulin using diabetics are covered for 100 testing strips and lancets per month, non-insulin using diabetics are covered for 50 testing strips and lancets every two months; in both cases Medicare will cover additional strips and lancets if there is a documented medical need. Medicare now covers education in a non-hospital, certified outpatient setting. Coverage of self-management education requires, as it previously did, a physician's referral. Medicare also covers 80% of the cost of therapeutic footwear for people with a history of diabetic foot disease upon a prescription from a podiatrist. Medicare does not cover the cost of insulin pumps. The above benefits are available to those people covered by Medicare Part B, which includes 91% of those people age 65 and over and people with kidney failure.
There are 29 states which mandate coverage for diabetic supplies and/or education: Wisconsin in 1991; New York in 1993; Minnesota in 1994 (supplies only); Florida, Maine, New Jersey, Oklahoma, Rhode Island, and West Virginia in 1996; Arkansas, Connecticut, Indiana, Louisiana, Maryland, Minnesota (education), Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Tennessee, Texas, Vermont, and Washington in 1997; and, Colorado, Georgia, Kentucky, Massachusetts, and Virginia (which only applies to state employees) in 1998.
Ten states are currently considering legislation. In addition to Pennsylvania, other states with a proposal for mandated diabetic benefits are: Alabama, Illinois, Iowa, Kansas, Michigan, Nebraska, Ohio, Oregon, and Utah. Virginia is considering legislation which would extend coverage to all residents.
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