By Sacha Uelmen, RDN, CDCES
During the pandemic, many diabetes self-management education and support (DSMES) services have found one silver lining in the last few years: increased options to reach people with diabetes (PWD). Early in the Covid-19 pandemic, the Association of Diabetes Care & Education Specialists (ADCES) worked tirelessly with our members, Medicare, the American Diabetes Association (ADA) and others to ensure that Medicare’s diabetes self-management training (DSMT) benefit was included in the flexibilities to expand telehealth during the public health emergency (PHE). Throughout the duration of the pandemic, the Secretary of Health and Human Services (HHS) has renewed the PHE every 90 days to continue those flexibilities. Early on, the Administration made a commitment to provide 60 days’ notice to the states in advance of ending the PHE. While many programs were able to start providing DSMT via telehealth, others were waiting for a longer-term, more permanent solution.
This new legislation, signed into law by President Biden on December 29, 2022, extends the public health emergency flexibilities that have allowed Accredited and Recognized DSMES programs to furnish Medicare beneficiaries with diabetes care and education via telehealth and receive reimbursement for those services through the end of 2024.
Let’s start with a little bit of background about why this advocacy and future efforts are needed:
The Balanced Budget Act of 1997, enacted on August 5, 1997, provides for Medicare coverage for DSMT services provided by a “certified provider.” This amended the Social Security Act (The Act) by adding a new section providing the Centers for Medicare & Medicaid Services (CMS) with the statutory authority to regulate Medicare outpatient coverage of DSMT services. The first National Standards for Diabetes Self-Management Education were implemented around 1984, and ADA became the first National Accrediting Organization for Medicare, and DSMES, as we know it today, started to take shape. When I have spoken with those who were involved in that process, they tell me that their primary goal was to be able to receive reimbursement for the care and education being provided above and beyond traditional primary care. ADCES became an Accrediting Organization (AO) for Medicare in 2009.
The Social Security Act, another piece of legislation enacted into law in 2014, restricts the utilization of and reimbursement for telehealth. DSMT is one of the services included as billable via telehealth, but the Act further establishes only specific healthcare professionals who can furnish these services via telehealth. As we continue to unravel this story, we learned that while DSMT is an approved service to be furnished via telehealth, only a very small portion of healthcare professionals approved via the National Standards for DSMES were included as providers approved to furnish telehealth services, which included Registered Dietitians, Nurse Practitioners and Advanced Practice Nurses. Over 50% of DSMES services nationally are led by Registered Nurses, Pharmacists, and other healthcare professionals directly involved in the provision of DSMES, a unique service focused on multidisciplinary team care and education.
Now, let’s fast forward to March 2020 as our country and our specialty were reeling from this new Covid-19 disease, an international crisis and a national public health emergency began. Prior to this time, the ability for some healthcare professionals to provide DSMES through telehealth was possible, but it was not truly accessible for several reasons. First, the hardware and software that were required to do this were very limiting and costly. Next, the PWD had to travel to a location where they could receive telehealth--they could not participate from their own home. The Law required that there be an originating site (where the PWD was accessing telehealth) and a Distant Site, where the healthcare professional delivered the service. Furthermore, Medicare beneficiaries were only eligible for telehealth if they lived within a rural designated zip code. Given the complexity of this process, very few programs actually delivered DSMES via telehealth and those who did were mostly providing it for free or as part of a grant-funded project. In the ADCES National Practice Survey in 2021, we found that 7 out of 10 respondents were interacting with patients virtually through telehealth, compared with only 1 in 10 in the previous survey completed in 2017.
Now, what is an Omnibus? If you don’t know, you’re not alone! I certainly had to do my research and go way back to my Schoolhouse Rock days and the jingle about how a bill becomes a law. An
Omnibus bill is a way to bundle a package of budget measures and policy changes to be accepted in one vote. The Omnibus Bill passed at the end of 2022 contained a lot of different measures including a ban of TikTok from federal devices, increasing nutrition assistance, changes to Medicaid, among many other items detailed in the full legislation linked here. We’ll focus on the flexibilities that impact telehealth for all Medicare providers and beneficiaries, and how that impacts DSMES: SEC. 4113. ADVANCING TELEHEALTH BEYOND COVID–19
Telehealth flexibilities are now in effect through the end of 2024 including:
- Expanding the originating site to include any site at which the patient is located, including the patient's home
- Extending the ability for federally qualified health centers and rural health clinics to furnish telehealth services
- Extending coverage and payment for audio-only telehealth services
Additional waivers were included as part of the Covid -19 public health emergency and clarified by CMS to ensure that DSMT services could continue to bill and be reimbursed for DSMES services provided via telehealth here (see question #43). DSMT can be offered audio-video and audio-only.
What’s next? Each Congress runs for a two-year term, with the 118th Congress beginning now. The Omnibus bill included language requiring the Secretary of Health and Human Services to study the integrity of telehealth services through medical record review and produce a final report near the end of 2024. Additional work will need to be done to ensure that DSMT is a benefit that can be offered through different modalities permanently.
Please see our Advocacy information page here and keep your eye out for future Calls to Action!
See existing flexibilities through our ADCES Telehealth and DSMT: FAQ
What are you waiting for? Get started with Telehealth and DSMES Today: The Art of Telehealth