Diabetes Educators: Referral and Reimbursement

Many primary care physicians, endocrinologists, and other physicians who care for people with diabetes depend on diabetes educators. A diabetes educator can help physicians manage the challenges and barriers of patient-centered care in today’s healthcare environment. Diabetes educators are knowledgeable and trained to recognize the needs of patients with diabetes ancillary capacity.

When to Refer

• The patient has been diagnosed with diabetes
• Patient care has changed from no diabetes medications to taking medications to treat diabetes; or, from oral diabetes medication to insulin
• The patient with diabetes has recently become eligible for Medicare
• The patient is at risk for complications from diabetes*

*The physician may consider the person with diabetes at increased risk if they have:

• Problems controlling blood glucose
• Been treated in an emergency room or stayed overnight in a hospital because of diabetes
• Been diagnosed with diabetes-related eye disease
• Lack of feeling in the feet or other foot problem, such as ulcers, deformity, had an amputation
• Been diagnosed with kidney disease related to diabetes

About CDE and BC-ADM Specialists
Certified Diabetes Educators (CDE) and/or diabetes educators who are Board Certified in Advanced Diabetes Management (BC-ADM) work in an interactive and collaborative manner to educate and empower patients with diabetes to apply self-management skills. Their services not only benefit patients, but the physicians who oversee their medical care.

Insurance Reimbursement
Many health insurance plans, including Medicare and Medicaid reimburse for diabetes self-management education. Patients who are not covered by Medicare should check medical insurance provider to verify coverage. Medicare offers two separate benefits for people with diabetes: Diabetes Self-management Education and Medical Nutrition Therapy.

Medicare Guideline Summary: Diabetes Self-management Education⁶

• Medicare Part B (medical insurance) may cover up to 10 hours of initial diabetes self-management training
• Training is available for people with diabetes who are at risk for complications, or have had certain conditions related to their diabetes during a 12 month time period
• Certain people with diabetes may qualify for up to 2 hours of follow-up training each year

Medicare Guideline Summary: Medical Nutrition Therapy (MNT)
This service is often provided by a Registered Dietician (RD) or Registered Dietician Nutritionist (RDN). Both receive extensive training (Academy of Nutrition and Dietetics) in medical nutrition therapy. RDs and RDNs specialize in assessing a patient’s nutritional requirements and can teach them how to eat well while managing their diabetes. This is a vital element of basic care for people with diabetes, and/or diabetes-related comorbidities such as kidney disease.

Medicare Guideline Summary for MNT⁶

• To be eligible, a patient’s fasting glucose must meet certain criteria
• MNT must be prescribed by a physician
• Medicare covers 3 hours of one-on-one MNT service the first year and 2 hours each year thereafter. Additional hours of service may be requested if changes in the patient’s condition meet qualifying criteria

Medicare Part B covers certain diabetes supplies such as blood glucose self-testing equipment and supplies, therapeutic shoes/inserts, and insulin pumps.

Disclaimer: The above information is provided for reference purposes. The patient or treating physician is advised to check with the medical insurance provider for specific coverage details and reimbursement.