HBA-EVB C.S.S.B. 982 76(R)BILL ANALYSIS Office of House Bill AnalysisC.S.S.B. 982 By: Madla Insurance 5/13/1999 Committee Report (Substituted) BACKGROUND AND PURPOSE It is estimated that more than 1.7 million Texans suffer from diabetes. It is also estimated that the probable annual cost of diabetes in Texas is $4 billion. Most forms of diabetes can be managed properly with diet and exercise or a combination of diet management, exercise, and glucose-lowering medication. A component of the 1997 legislation that requires health benefit plans to provide certain benefits for diabetics is the mandate that diabetics be provided self-management training. The law specifies that diabetes self-management training (training) must be provided by a health care practitioner or provider who is licensed, registered, or certified in Texas to provide appropriate health care services, and that such training includes training provided to a qualified insured after the initial diagnosis of diabetes in the care and management of that condition, including nutrition counseling and proper use of diabetes equipment and supplies. If training programs are provided only by diabetic educators certified by the American Association of Diabetic Educators, there may be too few educators in relation to the number of diabetics that need training. The result could be reduced access to training and increased costs. C.S.S.B. 982 sets forth that a licensed, registered, or certified health care practitioner or provider who provides training must do so acting within the scope of practice authorized by the practitioner's or provider's license, registration, or certification. Those practitioners and providers include a licensed dietitian, a licensed pharmacist, a licensed physician, a licensed physician assistant, a licensed registered nurse, and a diabetes educator who is certified by the National Certification Board for Diabetes Educators, among others. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that this bill does not expressly delegate any additional rulemaking authority to a state officer, department, agency, or institution SECTION BY SECTION ANALYSIS SECTION 1. Sets forth legislative intent. SECTION 2. Amends Section 1, Article 21.53G, Insurance Code, by adding Subdivision (5) to define "nutrition counseling." SECTION 3. Amends Section 4, Article 21.53G, Insurance Code, as follows: Section 4. DIABETES SELF-MANAGEMENT TRAINING. (a) Sets forth that a licensed, registered, or certified health care practitioner or provider who provides diabetes selfmanagement training (training) must do so acting within the scope of practice authorized by the practitioner's or provider's license, registration, or certification. Provides that selfmanagement training includes nutrition, rather than nutritional, counseling. (b) Provides that coverage for training provided by a health benefit plan under this article to a qualified insured must include coverage for the following, if provided on the written order of a physician or health care practitioner, including the written order of a health care practitioner practicing under protocols jointly developed with a physician: (1) a program recognized by the American Diabetes Association; (2) training given by a multidisciplinary team: (A) the non-physician members of which are coordinated by a diabetes educator who is certified by the National Certification Board for Diabetes Educators; or a person who has completed at least 24 hours of continuing education that meets guidelines established by the Texas Board of Health and that includes a combination of diabetes-related educational principles and behavioral strategies; (B) that consists of at least a licensed dietitian and a registered nurse and is authorized to include a pharmacist and a social worker; and (C) each member of which, other than the social worker, has recent didactic and experiential preparation in diabetes clinical and educational issues as determined by the member's licensing agency, in consultation with the commissioner of public health (commissioner), unless the member's licensing agency, in consultation with the commissioner, determines that the core educational preparation for the member's license includes the skills the member needs to provide diabetes selfmanagement; (3) training provided by a diabetes educator certified by the National Certification Board for Diabetes Educators; or (4) training in which one or more of the following components are provided: (A) the nutritional counseling component provided by a licensed dietitian, for which the licensed dietitian is required to be paid; (B) the pharmaceutical component provided by a pharmacist, for which the pharmacist is required to be paid; (C) any component of the training provided by a physician assistant or registered nurse, for which the physician assistant or registered nurse is required to be paid, except that the physician assistant or registered nurse is prohibited from being paid for providing a nutrition counseling or pharmaceutical component unless a licensed dietician or pharmacist is unavailable to provide that component; or (D) any component of the training provided by a physician. (c) Prohibits a person from providing a component of training under Subsection (b)(4) unless the subject matter of the component is within the scope of the person's practice. SECTION 4.Effective date: September 1, 1999. Makes application of this Act prospective to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2000. SECTION 5.Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE The substitute differs from the original by reorganizing text for the purpose of clarification. The substitute differs from the original by adding a new SECTION 1 that sets forth legislative intent. The substitute differs from the original by redesignating SECTION 1 of the original as SECTION 3 of the substitute. The substitute differs from the original by adding a new SECTION 2 that defines "nutrition counseling." This subject was discussed in SECTION 1 (proposed Section (4)(c), Article 21.53G, Insurance Code) of the original. The substitute differs from the original in SECTION 3 (Section 4(a), Article 21.53G, Insurance Code) of the substitute by making nonsubstantive changes. The substitute differs from the original in SECTION 3 (Section 4(b), Article 21.53G, Insurance Code) of the substitute, by providing that coverage for diabetes self-management training (training) provided by a health benefit plan under this article to a qualified insured must include coverage for certain training and training programs, if provided on the written order of a physician or health care practitioner, including the written order of a health care practitioner practicing under protocols jointly developed with a physician. The original bill requires a health benefit plan to provide training or coverage for training for which a physician or practitioner has written an order to each insured or the caretaker of the insured from certain training and training programs or personnel. The substitute also differs from the original in Section 4(b) by including a person who has completed at least 24 hours of continuing education that meets the guidelines established by the Texas Board of Health, rather than approved continuing education, and a licensed dietitian and a registered nurse, rather than a dietitian and a nurse educator who collaborate routinely, as members of a multidisciplinary team. The substitute differs from the original in Section 4(b) further by providing that each member of a multidisciplinary team, other than a social worker, has recent didactic and experiential preparation in diabetes clinical and educational issues as determined by the member's licensing agency, in consultation with the commissioner of public health (commissioner), unless the member's licensing agency, in consultation with the commissioner, determines that the core educational preparation for the member's license includes the skills the member needs to provide training. The original bill required each member to have recent didactic and experiential preparation in diabetes clinical and educational issues. The substitute also differs from the original in Subsection (b)(4), by including training in which one or more of the following components are provided: (A) the nutrition counseling component provided by a licensed dietitian, for which the licensed dietitian is required to be paid, rather than a licensed dietitian, who may provide any nutritional counseling component; (B) the pharmaceutical component provided by a pharmacist, for which the pharmacist is required to be paid, rather than a pharmacist, who may provide any pharmaceutical component; (C) any component of the training provided by a physician assistant or registered nurse, for which the physician assistant or registered nurse is required to be paid, except that the physician assistant or registered nurse is prohibited from being paid for providing a nutrition counseling or pharmaceutical component unless a licensed dietician or pharmacist is unavailable to provide that component; rather than a physician, a physician assistant, a registered nurse, or an advanced practice nurse, who may provide any other component of the training, or (D) any component of the training provided by a physician. The substitute differs from the original in SECTION 3 (Section 4, Article 21.53G, Insurance Code) of the substitute, by adding a new Subsection (c), to prohibit a person from providing a component of training under Subsection (b)(4) unless the subject matter of the component is within the scope of the person's practice. Also in SECTION 3, the substitute differs from SECTION 1 of the original by deleting proposed Section 4(d), Article 21.53G, Insurance Code, thus removing rulemaking authority delegated to the appropriate licensing board of practitioners or providers authorized to provide training. Proposed Section 4(d) required the appropriate licensing board of practitioners or providers authorized to provide training, in consultation with the Texas Diabetes Council, by rule, to determine the recent didactic and experiential preparation in diabetes clinical and educational issues to qualify licensees of the board to provide the training, and, by rule, to determine and define the component or components of training. The substitute differs from the original by redesignating SECTION 2 of the original (effective date and prospective clause) as SECTION 4 of the substitute. The substitute differs from the original by redesignating SECTION 3 (emergency clause) of the original as SECTION 5 of the substitute.