A. Pursuant to Section 2 of Act 1249 of 1997, every individual and group health insurance policy as defined in this Rule shall include coverage for one (1) per lifetime training program per insured for diabetes self-management training, when medically necessary. Training which is compensable under the policy may include one (1) or more than one (1) visit from the physician or health care provider. The diabetes self-management training which is compensable under the policy shall include additional training sessions offered by the health care provider, as prescribed by a physician, on grounds of medical necessity and when the diabetic patient's condition changes or worsens upon a determination by that physician that it is a significant change in the diabetic patient's condition.

B. Any training for diabetes self-management shall only be covered in the health care policy when medically necessary as determined by a physician, and only if it is provided by an appropriately licensed health care provider credentialed as required by Act 1249 of 1997 and defined in Subsection (D) of Section 5 above. As to additional requirements, the physician for the diabetic patient must be licensed under Ark. Code Ann. §§ 17-95-201, et seq. The diabetes educator shall only provide diabetes self-management training within his or her scope of practice after having demonstrated expertise in diabetes care and treatment. The physician or diabetes educator shall only provide such training after having completed an education training program required by his or her licensing board when such program is in compliance with the National Standards for Diabetes Self-Management Education Program, developed by the American Diabetes Association. For the patient's training to be compensable under the health care policy, the physician must issue a written prescription ordering the training for the patient and/or the patient's parent, spouse or legal guardian. For compensable coverage, the training must be successfully completed by the diabetic patient and parent, spouse or legal guardian; the health care provider must certify such successful completion; and shall provide such written certification to the referring physician and health care insurer providing the coverage.

A health care insurer is not required to pay benefits unless and until the health care provider provides certification that the insured individual has successfully completed the diabetes self-management training. Additionally and to facilitate the payment of benefits due under this Rule, health care insurers shall routinely obtain from all appropriate Arkansas State Licensing Boards a list of licensed or certified health care professionals who have demonstrated expertise in diabetes care and treatment and have completed the educational program in compliance with the ADA program required by that Arkansas State Licensing Board.

C. The coverage required under this Rule and Act 1249 of 1997 shall be consistent with other benefits provided in the health insurance policy and subject to all policy limitations, applicable deductibles; coinsurance; other patient cost-sharing amounts or out-of pocket limits; as well as referral, prior authorization or other utilization review requirements or processes.

D. The provisions of Act 1249 of 1997 and this Rule do not prohibit health care insurers from selectively negotiating contracts with qualified providers of diabetes self-management training programs, to the extent such contracts are not inconsistent with this Rule.

E. The health care insurers may legitimately exclude from coverage diabetes self-management training, diabetes equipment, supplies and related services which are not medically necessary for the treatment of Type 1, Type 2 or gestational diabetes or other types; provided that such determinations are made by the patient's licensed physician(s); and provided that such determinations are consistent with Act 1249 of 1997 and this Rule, as well as other applicable laws and rules and regulations; and provided that such determinations are not at variance with generally accepted standards of the medical profession. Nothing in this Rule shall be deemed to exclude or prohibit review and final determination of a claim on appeal as provided by the applicable health insurance policy or plan, after initial coverage determination on medical necessity is made by a licensed physician as required by this Rule.