Section 5160-8-53 - Diabetes prevention and self-management training(A) Definitions. For the purposes of this rule, the following definitions apply: (1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs.(2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control and prevention (CDC) designed to assist at-risk individuals from developing type 2 diabetes.(B) DSMT. (1) Providers. (a) Rendering providers. The following providers may render or supervise a DSMT service:(ii) A physician assistant;(iii) An advanced practice registered nurse;(v) A registered dietitian nutritionist; or(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for a DSMT service on behalf of a rendering provider: (ii) A physician assistant;(iii) An advanced practice registered nurse;(iv) A licensed or registered dietitian;(vi) A professional medical group;(vii) A federally qualified health center;(viii) A rural health clinic;(ix) An ambulatory health care clinic; or(2) Coverage. (a) Payment for diabetes self-management training can be made when the following criteria are met:(i) The individual has a current diagnosis of diabetes.(ii) The individual has not previously received diabetes self-management training.(iii) Training is provided in a setting other than an inpatient hospital or an emergency department.(b) Payment may be made, with prior authorization in accordance with rule 5160-1-31 of the Administrative Code, for follow-up sessions not to exceed a total of two hours of individual training or group training in any combination.(C) NDPP. (1) Providers. (a) Rendering providers. The following providers may render or supervise an NDPP service:(ii) A physician assistant;(iii) An advanced practice registered nurse;(b) Billing ("pay-to") providers. The following providers may receive medicaid payment for submitting a claim for an NDPP service on behalf of a rendering provider: (ii) A physician assistant;(iii) An advanced practice registered nurse;(iv) A professional medical group;(v) A federally qualified health center;(vi) A rural health clinic; or(vii) An ambulatory health care clinic;(2) Coverage.(a) Payment for an NDPP service can be made when all of the following criteria are met:(i) The individual is eighteen years or older;(ii) The individual is overweight;(iii) The individual is not currently pregnant; and(iv) The individual does not have a diagnosis of type 1 or type 2 diabetes.(v) At least one of the following criteria is met:(a) The individual has been diagnosed with prediabetes;(b) The individual has a history of gestational diabetes; or(c) The individual has had a high-risk result on a prediabetes test.(D) Claim payment.(1) No payment will be made for a DSMT or NDPP service provided on the same date of service as medical nutrition therapy.(2) Payment for a covered service performed in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.(3) Payment for a covered service rendered by a federally qualified health center (FQHC) or rural health clinic (RHC) is made in accordance with Chapter 5160-28 of the Administrative Code.(4) Payment for a covered service rendered in any other setting is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.Ohio Admin. Code 5160-8-53
Effective: 1/1/2022
Five Year Review (FYR) Dates: 01/01/2027
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02