Most States Require Insurance Policies to Cover Diabetes Services and Supplies, Although Specific Requirements Vary

In 2004, 47 states had laws or regulations related to coverage of diabetes  services or supplies, although specific requirements varied by state (see  fig. The model legislation also  includes coverage of “diabetes equipment and supplies,” and 47 states  required such coverage. Twenty-eight states identified which supplies  must be covered, although their specific requirements varied. Some states had specific requirements regarding the coverage of certain  services, such as diabetes education. Selected Health Plans Providing Coverage Not Subject to State Regulation Cover Most but Not All Diabetes Services and Supplies

The 3 largest plans participating in FEHBP—Blue Cross and Blue Shield,  Mail Handlers, and Government Employees Hospital Association, Inc.— and the 13 large-employer self-funded plans we contacted covered most of  the diabetes services and supplies we reviewed. All 16 plans covered at  least 7 of the 10 diabetes services, as well as at least five of nine diabetes  supplies. Large Employers’ Self- Funded Health Plans Reviewed Cover Most Diabetes Services and Supplies

Each of the 13 large employers’ self-funded health plans we reviewed  covered at least 7 of 10 diabetes services, specifically, blood glucose, lipid,  and urine tests; eye and foot exams; blood pressure management, and  influenza vaccinations. 2). Among these plans, we found limits on coverage only for  smoking cessation therapy. 3). In a nationwide telephone  survey conducted in 2003, the majority of individuals with diabetes  reported receiving at least one of six identified diabetes services for which  national data were available. For example, an estimated 88  percent had received a test for blood glucose within the past 12 months,  and an estimated 52 percent had received diabetes education. A much  smaller proportion, 33 percent, had received the five services  recommended that individuals with diabetes receive at least once a year— specifically, a blood glucose test, a cholesterol test, an eye exam, a foot  exam, and an influenza vaccination (see fig. Individuals with Diabetes Who Have Health Coverage More Likely to Receive Services Than Those Who Lack Coverage

According to CDC’s 2003 survey, in comparison with individuals with  diabetes who lacked health coverage, a larger proportion who had health  coverage reported receiving one or more services. For example, an  estimated 90 percent of individuals with diabetes who had health coverage  at the time of the survey had received a blood glucose test, compared with  71 percent of those who reported not having such coverage (see fig. The agency  provided us with technical comments, which we incorporated into the  report as appropriate. Appendix I: Scope and Methodology

To assess health care coverage and receipt of diabetes services and  supplies, we obtained information from federal health agencies and  national organizations concerned with diabetes patient care and identified  10 services and nine supplies that individuals with diabetes often need. To  determine the extent to which states require coverage of diabetes services  and supplies for the health insurance policies they regulate, we examined  state laws and regulations from September 2004 through December 2004  related to diabetes and the extent to which they required coverage of  specific services and supplies. To assess information on the extent to which individuals with diabetes  receive diabetes services and use supplies, we analyzed data for  individuals ages 18 and older provided by the Centers for Disease Control  and Prevention (CDC) from two nationwide surveys: the Behavioral Risk  Factor Surveillance System (BRFSS) for 2003 and the National Health and  Nutrition Examination Survey (NHANES) for 1999–2002:    BRFSS is a nationwide telephone survey conducted every year by state  health departments, with technical and methodological assistance  provided by CDC.
Why GAO Did This Study

Diabetes, which afflicts millions of Americans, is a manageable disease whose effects can be mitigated with proper care, regularly received. Experts recommend certain services and supplies for managing diabetes. Because these can be costly, concerns exist about whether individuals with diabetes have access to and receive what they need. Little is known, however, about health plan coverage of diabetes services and supplies. GAO reviewed the extent to which (1) states require insurance policies to cover diabetes services and supplies, (2) health coverage not subject to state requirements includes diabetes services and supplies, and (3) individuals with diabetes ages 18 and older receive services and supplies. GAO analyzed all 50 states' and the District of Columbia's laws and regulations pertaining to diabetes coverage. GAO also obtained from selected health plans providing coverage not subject to state requirements--13 large-employer plans and 3 plans in the Federal Employees Health Benefits Program (FEHBP)--information on coverage of 10 services and nine supplies identified as important for individuals with diabetes. In addition, GAO obtained national data from the Centers for Disease Control and Prevention (CDC) on individuals' receipt of diabetes services and supplies. GAO received technical comments from CDC and incorporated them in the report as appropriate.

What GAO Found

In 2004, 47 states, including the District of Columbia, had laws or regulations related to coverage of diabetes services or supplies, although specific requirements varied by state. Services for which states most often required coverage were diabetes education (45 states) and medical nutrition therapy (27 states). All 47 required coverage of diabetes supplies, although some states were more specific than others about which supplies must be covered. Health plans GAO contacted that provide coverage not subject to state insurance requirements--those offered by 13 large Fortune 500 companies and the 3 largest health plans in FEHBP--covered most of the services and supplies recommended for individuals with diabetes, generally without limits on the coverage. Each plan covered at least 7 of 10 diabetes services, such as an annual blood glucose test, cholesterol and blood pressure monitoring, and influenza vaccinations, as well as at least five of nine diabetes supplies, such as insulin and insulin-administering supplies. According to a 2003 CDC nationwide survey, the majority of individuals with diabetes reported receiving at least one diabetes service within the past 12 months. Significantly fewer individuals, however, reported receiving five services that individuals with diabetes are recommended to receive at least once a year. For example, an estimated 88 percent reported receiving a test for blood glucose, whereas an estimated 33 percent had received the five recommended services: blood glucose and cholesterol tests, eye and foot exams, and an influenza vaccination. Receipt of diabetes services and supplies varied by service, state, and whether an individual had health coverage. For example, 71 percent of individuals with diabetes who had health coverage at the time of the survey received eye exams, compared with 46 percent of individuals with diabetes who lacked coverage.