Assembly Bill A10406

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  10406

                          I N  A S S E M B L Y

                              May 25, 2012
                               ___________

Introduced  by  M. of A. PEOPLES-STOKES -- read once and referred to the
  Committee on Health

AN ACT to amend the public health law and the insurance law, in relation
  to establishing diabetes prevention demonstration programs

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Article 2 of the public health law is amended by adding a
new title 4-A to read as follows:
                               TITLE IV-A
               DIABETES PREVENTION DEMONSTRATION PROGRAMS
SECTION 255. DIABETES PREVENTION DEMONSTRATION PROGRAMS; ESTABLISHMENT.
  S 255. DIABETES PREVENTION DEMONSTRATION PROGRAMS;  ESTABLISHMENT.  1.
THE  DEPARTMENT MAY ESTABLISH DIABETES PREVENTION DEMONSTRATION PROGRAMS
THROUGH A REQUEST FOR PROPOSALS  PROCESS  TO  ENHANCE  THE  QUALITY  AND
COST-EFFECTIVENESS  OF  CARE  RENDERED TO MEDICAID-ELIGIBLE PERSONS WITH
PRE-DIABETES WHO MAY BE AT RISK FOR DIABETES WHICH  CAN  RESULT  IN  THE
NEED FOR CARE AND TREATMENT THAT RESULTS IN HIGH MEDICAID EXPENDITURES.
  2.  IN  ORDER  TO  BE  ELIGIBLE TO SPONSOR AND TO UNDERTAKE A DIABETES
PREVENTION DEMONSTRATION  PROGRAM,  THE  PROPOSED  SPONSOR  SHALL  BE  A
NOT-FOR-PROFIT  ORGANIZATION  WITH A PROGRAM PROVIDING PATIENT EDUCATION
ON PHYSICAL ACTIVITY AND DIET USING  EVIDENCE-BASED  SERVICES  THAT  HAS
EXPERIENCE  PROVIDING COST-EFFECTIVE COMMUNITY-BASED DIABETES PREVENTION
CARE TO SUCH PATIENTS WITH PRE-DIABETES.
  3. THE DEPARTMENT  SHALL  APPROVE  DIABETES  PREVENTION  DEMONSTRATION
PROGRAMS  WHICH  ARE  GEOGRAPHICALLY  DIVERSE AND REPRESENTATIVE OF BOTH
URBAN AND RURAL SOCIAL SERVICES  DISTRICTS.  THE  PROGRAM  SPONSOR  MUST
ESTABLISH, TO THE SATISFACTION OF THE DEPARTMENT, ITS CAPACITY TO ENROLL
AND SERVE SUFFICIENT NUMBERS OF ENROLLEES TO DEMONSTRATE THE COST-EFFEC-
TIVENESS OF THE DEMONSTRATION PROGRAM.
  4.  THE DEPARTMENT SHALL ESTABLISH THE CRITERIA, INCLUDING THE DIAGNO-
SIS OF PRE-DIABETES AS MAY BE SPECIFIED  BY  THE  DEPARTMENT,  BY  WHICH
INDIVIDUALS  WILL BE IDENTIFIED AS ELIGIBLE FOR ENROLLMENT IN THE DEMON-
STRATION PROGRAMS. PERSONS ELIGIBLE FOR ENROLLMENT IN THE  DEMONSTRATION

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD15790-03-2
              

A. 10406                            2

PROGRAMS  SHALL BE LIMITED TO INDIVIDUALS WHO RECEIVE MEDICAL ASSISTANCE
PURSUANT TO TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW.
  5. ENROLLMENT IN A DEMONSTRATION PROGRAM SHALL BE VOLUNTARY. A PARTIC-
IPATING  INDIVIDUAL  MAY  DISCONTINUE  HIS OR HER ENROLLMENT AT ANY TIME
WITHOUT CAUSE. THE COMMISSIONER SHALL REVIEW AND APPROVE ALL  ENROLLMENT
AND MARKETING MATERIALS FOR A DEMONSTRATION PROGRAM.
  6.  THE  DEMONSTRATION PROGRAM SHALL OFFER EVIDENCE-BASED SERVICES AND
INTERVENTIONS DESIGNED TO ENSURE THAT THE ENROLLEES RECEIVE HIGH  QUALI-
TY, PREVENTATIVE AND COST-EFFECTIVE CARE, AIMED AT REDUCING THE DEVELOP-
MENT  OF  DIABETES.  THE  DEMONSTRATION PROGRAM MAY INCLUDE SCREENING OF
ELIGIBLE ENROLLEES, DEVELOPING AN INDIVIDUALIZED  CARE  MANAGEMENT  PLAN
FOR EACH ENROLLEE AND IMPLEMENTING THAT PLAN.
  7.  THE  DEPARTMENT  SHALL  BE RESPONSIBLE FOR MONITORING THE QUALITY,
APPROPRIATENESS AND COST-EFFECTIVENESS OF A DEMONSTRATION  PROGRAM.  THE
DEPARTMENT  SHALL UTILIZE, TO THE EXTENT POSSIBLE, ALL POTENTIAL SOURCES
OF FUNDING  FOR  DEMONSTRATION  PROGRAMS,  INCLUDING,  BUT  LIMITED  TO,
PRIVATE PAYMENTS AND DONATIONS. ALL SUCH FUNDS SHALL BE DEPOSITED BY THE
COMMISSIONER AND CREDITED TO THE DIABETES PREVENTION ACCOUNT WHICH SHALL
BE  ESTABLISHED  BY  THE  COMPTROLLER IN THE SPECIAL REVENUE-OTHER FUND.
ADDITIONALLY, TO THE EXTENT  OF  FUNDS  APPROPRIATED  THEREFOR,  MEDICAL
ASSISTANCE  FUNDS, INCLUDING ANY FUNDING OR SHARED SAVINGS AS MAY BECOME
AVAILABLE THROUGH FEDERAL WAIVERS OR OTHERWISE UNDER TITLES 18 AND 19 OF
THE FEDERAL SOCIAL SECURITY ACT, MAY  BE  USED  BY  THE  DEPARTMENT  FOR
EXPENDITURES IN SUPPORT OF THE DIABETES PREVENTION PROGRAM.
  8.  PAYMENTS SHALL BE MADE BY THE DEPARTMENT TO THE ENTITY RESPONSIBLE
FOR THE OPERATION OF THE DEMONSTRATION PROGRAM ON  A  FIXED  AMOUNT  PER
MEMBER  PER LENGTH OF THE PROGRAM AND SHALL  REIMBURSE THE PROGRAM SPON-
SOR FOR THE SERVICES  RENDERED  PURSUANT  TO  SUBDIVISION  SIX  OF  THIS
SECTION.  THE DEPARTMENT SHALL PROVIDE AN INTERIM REPORT TO THE GOVERNOR
AND THE LEGISLATURE ON OR BEFORE  DECEMBER  THIRTY-FIRST,  TWO  THOUSAND
THIRTEEN  AND  A  FINAL  REPORT  ON OR BEFORE DECEMBER THIRTY-FIRST, TWO
THOUSAND FOURTEEN ON THE RESULTS OF  THE  DEMONSTRATION  PROGRAMS.  BOTH
REPORTS  SHALL  INCLUDE  FINDINGS  AS  TO  THE  DEMONSTRATION  PROGRAMS'
COST-EFFECTIVENESS IN PREVENTING THE DEVELOPMENT OF DIABETES AND ASSOCI-
ATED COMPLICATIONS.  IN THE FINAL REPORT,  THE  DEPARTMENT  SHALL  OFFER
RECOMMENDATIONS AS TO WHETHER DEMONSTRATION PROGRAMS SHOULD BE EXTENDED,
MODIFIED, ELIMINATED OR MADE PERMANENT.
  S  2.  Subparagraph (A) of paragraph 15-a of subsection (i) of section
3216 of the insurance law, as amended and such paragraph  as  renumbered
by chapter 338 of the laws of 2003, is amended to read as follows:
  (A)  Every policy which provides medical coverage that includes cover-
age for physician services in a  physician's  office  and  every  policy
which  provides  major  medical  or  similar comprehensive-type coverage
shall include coverage for the following equipment and supplies for  the
treatment  of  diabetes,  if recommended or prescribed by a physician or
other licensed health care  provider  legally  authorized  to  prescribe
under title eight of the education law: blood glucose monitors and blood
glucose  monitors  for  the  visually impaired, data management systems,
test strips for glucose monitors and visual reading  and  urine  testing
strips,  insulin,  injection aids, cartridges for the visually impaired,
syringes, insulin pumps  and  appurtenances  thereto,  insulin  infusion
devices,  and  oral agents for controlling blood sugar. In addition, the
commissioner of the department of health shall provide and  periodically
update by rule or regulation a list of additional diabetes equipment and
related  supplies  such  as are medically necessary for the treatment of
diabetes, for which there shall also be coverage.  Such  policies  shall

A. 10406                            3

also  include  coverage for diabetes self-management education to ensure
that persons with diabetes are educated as to the proper self-management
and treatment of their  diabetic  condition,  including  information  on
proper  diets. Such coverage for self-management education and education
relating to diet shall be limited to visits medically necessary upon the
diagnosis of diabetes, where a physician diagnoses a significant  change
in  the  patient's symptoms or conditions which necessitate changes in a
patient's self-management, or where reeducation or  refresher  education
is  necessary.  Such education may be provided by the physician or other
licensed health care provider  legally  authorized  to  prescribe  under
title  eight  of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by  a  certified  diabetes
nurse  educator,  certified  nutritionist, certified dietitian or regis-
tered dietitian upon the referral  of  a  physician  or  other  licensed
health  care  provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified  nutritionist,  certified  dietitian  or  registered
dietitian may be limited to group settings wherever practicable.  Cover-
age  for  self-management education and education relating to diet shall
also include home visits when medically necessary.   IN  ADDITION,  UPON
RECOMMENDATION  OF  A  PHYSICIAN SUCH POLICES SHALL INCLUDE COVERAGE FOR
DIABETES PREVENTION SERVICES TO PERSONS WITH PRE-DIABETES DIAGNOSED BY A
PHYSICIAN. SUCH SERVICES SHALL INCLUDE, BUT NOT BE LIMITED  TO,  PATIENT
EDUCATION  ON  PHYSICAL ACTIVITY AND DIET USING EVIDENCE-BASED SERVICES.
SUCH COVERAGE  FOR  DIABETES  PREVENTION  SERVICES  MAY  BE  LIMITED  TO
PROGRAMS  THAT  HAVE EXPERIENCE PROVIDING COST-EFFECTIVE COMMUNITY-BASED
DIABETES PREVENTION SERVICES, AND GROUP SETTINGS WHEREVER PRACTICABLE.
  S 3. Subparagraph (A) of paragraph 7 of subsection (k) of section 3221
of the insurance law, as amended by chapter 338 of the laws of 2003,  is
amended to read as follows:
  (A) Every group or blanket accident and health insurance policy issued
or  issued  for  delivery  in this state which provides medical coverage
that includes coverage for physician services in  a  physician's  office
and  every policy which provides major medical or similar comprehensive-
type coverage shall include coverage for  the  following  equipment  and
supplies  for the treatment of diabetes, if recommended or prescribed by
a physician or other licensed health care provider legally authorized to
prescribe under title eight of the education law: blood glucose monitors
and blood glucose monitors for the visually  impaired,  data  management
systems,  test  strips for glucose monitors and visual reading and urine
testing strips, insulin, injection aids,  cartridges  for  the  visually
impaired,  syringes,  insulin  pumps  and appurtenances thereto, insulin
infusion devices, and oral agents for controlling blood sugar. In  addi-
tion,  the  commissioner  of  the department of health shall provide and
periodically update by rule or regulation a list of additional  diabetes
equipment  and  related supplies such as are medically necessary for the
treatment of diabetes, for which there  shall  also  be  coverage.  Such
policies shall also include coverage for diabetes self-management educa-
tion  to ensure that persons with diabetes are educated as to the proper
self-management and treatment of  their  diabetic  condition,  including
information on proper diets. Such coverage for self-management education
and  education  relating  to  diet  shall be limited to visits medically
necessary upon the diagnosis of diabetes, where a physician diagnoses  a
significant  change in the patient's symptoms or conditions which neces-
sitate changes in a patient's self-management, or where  reeducation  or
refresher  education is necessary. Such education may be provided by the

A. 10406                            4

physician or other licensed health care provider legally  authorized  to
prescribe  under  title  eight  of the education law, or their staff, as
part of an office visit for diabetes diagnosis or  treatment,  or  by  a
certified  diabetes  nurse  educator,  certified nutritionist, certified
dietitian or registered dietitian upon the referral of  a  physician  or
other  licensed  health  care  provider  legally authorized to prescribe
under title eight of the education law. Education provided by the certi-
fied diabetes nurse educator, certified nutritionist,  certified  dieti-
tian  or  registered dietitian may be limited to group settings wherever
practicable.   Coverage  for  self-management  education  and  education
relating  to  diet  shall also include home visits when medically neces-
sary.  IN ADDITION, UPON RECOMMENDATION OF  A  PHYSICIAN  SUCH  POLICIES
SHALL  INCLUDE COVERAGE FOR DIABETES PREVENTION SERVICES TO PERSONS WITH
PRE-DIABETES DIAGNOSED BY A PHYSICIAN. SUCH SERVICES SHALL INCLUDE,  BUT
NOT BE LIMITED TO, PATIENT EDUCATION ON PHYSICAL ACTIVITY AND DIET USING
EVIDENCE-BASED  SERVICES. SUCH COVERAGE FOR DIABETES PREVENTION SERVICES
MAY BE LIMITED TO PROGRAMS THAT HAVE EXPERIENCE PROVIDING COST-EFFECTIVE
COMMUNITY-BASED DIABETES PREVENTION SERVICES, AND GROUP SETTINGS WHEREV-
ER PRACTICABLE.
  S 4. Paragraph 1 of subsection (u) of section 4303  of  the  insurance
law,  as  amended by chapter 338 of the laws of 2003, is amended to read
as follows:
  (1) A medical expense indemnity corporation or a health service corpo-
ration which provides medical coverage that includes coverage for physi-
cian services in a physician's office and every  policy  which  provides
major  medical  or  similar  comprehensive-type  coverage  shall include
coverage for the following equipment and supplies for the  treatment  of
diabetes,  if recommended or prescribed by a physician or other licensed
health care provider legally authorized to prescribe under  title  eight
of  the education law: blood glucose monitors and blood glucose monitors
for the visually impaired, data  management  systems,  test  strips  for
glucose  monitors  and visual reading and urine testing strips, insulin,
injection aids, cartridges for the visually impaired, syringes,  insulin
pumps  and  appurtenances  thereto,  insulin  infusion devices, and oral
agents for controlling blood sugar. In addition, the commissioner of the
department of health shall provide and periodically update  by  rule  or
regulation  a list of additional diabetes equipment and related supplies
such as are medically necessary for the treatment of diabetes, for which
there shall also be coverage. Such policies shall also include  coverage
for  diabetes  self-management  education  to  ensure  that persons with
diabetes are educated as to the proper self-management and treatment  of
their  diabetic  condition,  including information on proper diets. Such
coverage for self-management education and education  relating  to  diet
shall  be  limited  to  visits medically necessary upon the diagnosis of
diabetes, where a  physician  diagnoses  a  significant  change  in  the
patient's   symptoms  or  conditions  which  necessitate  changes  in  a
patient's self-management, or where reeducation or  refresher  education
is  necessary.  Such education may be provided by the physician or other
licensed health care provider  legally  authorized  to  prescribe  under
title  eight  of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by  a  certified  diabetes
nurse  educator,  certified  nutritionist, certified dietitian or regis-
tered dietitian upon the referral  of  a  physician  or  other  licensed
health  care  provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified  nutritionist,  certified  dietitian  or  registered

A. 10406                            5

dietitian may be limited to group settings wherever practicable.  Cover-
age  for  self-management education and education relating to diet shall
also include home visits when medically necessary.   IN  ADDITION,  UPON
RECOMMENDATION  OF  A  PHYSICIAN SUCH POLICES SHALL INCLUDE COVERAGE FOR
DIABETES PREVENTION SERVICES TO PERSONS WITH PRE-DIABETES DIAGNOSED BY A
PHYSICIAN. SUCH SERVICES SHALL INCLUDE, BUT NOT BE LIMITED  TO,  PATIENT
EDUCATION  ON  PHYSICAL ACTIVITY AND DIET USING EVIDENCE-BASED SERVICES.
SUCH COVERAGE  FOR  DIABETES  PREVENTION  SERVICES  MAY  BE  LIMITED  TO
PROGRAMS  THAT  HAVE EXPERIENCE PROVIDING COST-EFFECTIVE COMMUNITY-BASED
DIABETES PREVENTION SERVICES, AND GROUP SETTINGS WHEREVER PRACTICABLE.
  S 5. This act shall take effect on the one hundred eightieth day after
it shall have become a law.