Managing Diabetes: Health Plan Coverage of Services and Supplies 
(25-FEB-05, GAO-05-210).					 
                                                                 
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.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-210 					        
    ACCNO:   A18240						        
  TITLE:     Managing Diabetes: Health Plan Coverage of Services and  
Supplies							 
     DATE:   02/25/2005 
  SUBJECT:   Diseases						 
	     Health care programs				 
	     Health care services				 
	     Health insurance					 
	     Health statistics					 
	     Health surveys					 
	     Medical supplies					 
	     Standards (health care)				 
	     CDC Behavioral Risk Factor Surveillance		 
	     System						 
                                                                 
	     Diabetes						 
	     Federal Employee Health Benefits Plan		 
	     National Health and Nutrition			 
	     Examination Survey 				 
                                                                 

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GAO-05-210

United States Government Accountability Office

GAO

                       Report to Congressional Requesters

February 2005

MANAGING DIABETES

                 Health Plan Coverage of Services and Supplies

GAO-05-210

February 2005

MANAGING DIABETES

Health Plan Coverage of Services and Supplies

                                 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 (see figure).

Estimated Percentage of Individuals Ages 18 and Older with Diabetes, With
and Without Health Coverage, Who Reported Receiving Diabetes Services,
2003

                 United States Government Accountability Office

Contents

  Letter

Results in Brief
Background
Most States Require Insurance Policies to Cover Diabetes Services

and Supplies, Although Specific Requirements Vary

Selected Health Plans Providing Coverage Not Subject to State Regulation
Cover Most but Not All Diabetes Services and Supplies

Nationwide, Receipt of Diabetes Services and Control of Related Health
Conditions Are Uneven Agency Comments

                                       1

                                      4 6

                                       9

                                       12

                                     16 22

Appendix I Scope and Methodology

Appendix II	Summary of Diabetes Coverage Requirements in State Laws or
Regulations, 2004

  Appendix III GAO Contact and Staff Acknowledgments 31

GAO Contact 31 Acknowledgments 31

Tables                                                                  
                      Table 1: Services for Managing Diabetes               7 
             Table 2: Diabetes Services Covered by the Three Largest FEHBP 
                                    Plans, 2004                            13 
             Table 3: Range among States in Estimates of Diabetes Services 
                    Received by Individuals with Diabetes, 2003            21 
                 Table 4: Indicators of Services and Supplies for Managing 26 
                                                                  Diabetes 

  Figures

Figure 1: Number of States Requiring Coverage of Diabetes Services and
Supplies, 2004 10 Figure 2: Diabetes Services Covered by 13 Large
Employers' Self-Funded Health Plans, 2004 15

Figure 3: Diabetes Supplies Covered by 13 Large Employers' Self-

Funded Health Plans, 2004 16 Figure 4: Estimated Nationwide Percentage of
Individuals Ages 18

and Older with Diabetes Who Reported Receiving

Diabetes Services, 2003 18 Figure 5: Estimated Nationwide Percentage of
Individuals Ages 18

and Older with Diabetes, With and Without Health

Coverage, Who Reported Receiving Diabetes Services,

2003 20

Abbreviations

ADA American Diabetes Association
Alliance National Diabetes Quality Improvement Alliance
BRFSS Behavioral Risk Factor Surveillance System
CDC Centers for Disease Control and Prevention
ERISA Employee Retirement Income Security Act of 1974
FEHBP Federal Employees Health Benefits Program
NHANES National Health and Nutrition Examination Survey
OPM Office of Personnel Management

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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separately.

United States Government Accountability Office Washington, DC 20548

February 25, 2005

The Honorable Joe Barton The Honorable Fred Upton House of Representatives

Diabetes afflicts an estimated 18 million Americans, and the number of
newly diagnosed cases has been rising, according to the Centers for
Disease Control and Prevention (CDC).1 Diabetes is characterized by a high
level of blood glucose, which damages nerve endings and blood vessels;
this damage in turn leads to serious health complications such as
blindness, heart disease and stroke, kidney disease, and poor circulation
in the extremities potentially resulting in foot or leg amputations.
Complications like these can be delayed or prevented with proper care,
provided that such care is accessible and used.2 Specifically, federal
health agencies and national organizations recommend that individuals with
diabetes receive certain services to manage their disease-including
periodic tests for blood glucose,3 eye and foot exams, medical nutrition
therapy, and diabetes education-along with other services, such as
cholesterol tests, smoking cessation services, and influenza
immunizations, which help reduce the risk of complications. Supplies that
many individuals with diabetes use to track and control their blood
glucose levels include blood glucose monitors; test strips; insulin; and,
to administer insulin, insulin pumps or disposable needles and syringes.

Because diabetes services and supplies can be costly, you and others have
raised concerns about whether individuals with diabetes have access to and
receive all the services and supplies they need. Certain national

1Diabetes is a disease in which the body does not produce or properly use
the hormone insulin, which converts sugar, starches, and other food into
energy. The vast majority of individuals with diabetes are adults.
According to CDC, from 1997 through 2002, the annual number of newly
diagnosed cases among adults rose by 47 percent.

2Controlling levels of blood glucose, blood pressure, and cholesterol-in
combination with other, regular preventive care services for eyes,
kidneys, and feet-can delay or prevent complications.

3Unless otherwise stated, "test(s) for blood glucose" or "blood glucose
test(s)" in this report refers to tests for a specific compound in the
blood called A1c, also called HbA1c, hemoglobin A1c, or glycosylated
hemoglobin. An A1c test measures the average level of glucose in a
patient's blood over the preceding 3 months.

organizations concerned with diabetes patient care have advocated state
laws mandating that health insurance cover certain services and supplies
benefiting these individuals. Although states generally do not regulate
employment-based benefit plans, such as health plans provided by
employers, they do regulate insurance; consequently, health coverage
employers provide through the purchase of insurance is generally subject
to state insurance regulation.4 Although the exact number is unknown, many
individuals with diabetes have health coverage not subject to state
insurance regulation because their employers self-fund their health plans;
that is, the employers pay the cost of health benefits directly, instead
of purchasing insurance. In addition, the Federal Employees Health
Benefits Program (FEHBP)-through which the federal Office of Personnel
Management (OPM) contracts with private health insurance carriers to offer
health coverage to federal employees, retirees, and their dependents5-is
not subject to state insurance requirements.6

In this context, we examined the following three questions:

1.	To what extent do state laws or regulations require health insurance
policies to cover diabetes services and supplies?

2.	To what extent does health coverage not subject to state insurance
requirements-specifically, coverage provided by the largest health plans
participating in FEHBP and the largest private self-funded health
plans-include diabetes services and supplies?

3.	To what extent do individuals with diabetes, including those with
health coverage and those without, receive diabetes services and supplies?

4The Employee Retirement Income Security Act of 1974 (ERISA) preempts
state laws that "relate" to employee benefit plans but specifically does
not preempt state laws regulating insurance. See 29 U.S.C. S: 1144(a) and
(b)(2)(A) (2000). Like insurance purchased by employers, insurance
purchased directly by individuals is subject to state regulation.

5More than 8 million federal employees, retirees, and their dependents
were enrolled in FEHBP in 2003.

6Under federal law, coverage-or benefit-related provisions in FEHBP
contracts preempt state or local laws or regulations relating to health
insurance or plans. See 5 U.S.C. S: 8902(m)(1) (2000).

To answer these questions, we obtained information from federal health
agencies and national organizations concerned with diabetes patient care,
and we identified 10 services and nine supplies that individuals with
diabetes may need.7 To examine the extent to which states require health
insurance policies to cover diabetes services and supplies, we reviewed
state laws and regulations related to diabetes coverage.8 To assess the
extent to which health coverage not subject to state requirements-such as
coverage provided by the largest plans participating in FEHBP and by
selected large employers' self-funded plans-includes diabetes services and
supplies, we contacted the three largest national plans participating in
FEHBP-Blue Cross and Blue Shield, Mail Handlers, and Government Employees
Hospital Association, Inc.9-as well as a random sample of 15 of the
largest 50 Fortune 500 companies regarding their plans' coverage of
diabetes services and supplies in 2004.10 We received responses from all
three FEHBP plans, which covered approximately 5.3 million people in 2003,
and from 13 of 15 of the employers we contacted, which together employed
about 2.4 million people in 2003.11 To collect information on the extent
to which individuals with diabetes with and without health coverage
receive diabetes services and supplies, we analyzed data provided by CDC
from an annual national survey of individuals ages 18 and older known as
the Behavioral Risk Factor Surveillance System (BRFSS). This survey,
conducted by the states, consists of self-reported

7We identified 10 diabetes services, including blood glucose tests, lipid
(cholesterol) management, urine protein screening, eye exams, foot exams,
influenza immunization, blood pressure management, smoking cessation,
diabetes self-management education (hereafter called diabetes education),
and medical nutrition therapy. We also identified nine diabetes supplies,
including blood glucose monitors, glucose control solutions, test strips,
lancet devices and lancets, alcohol swabs, therapeutic shoes for diabetic
foot disease, insulin, insulin pumps, and disposable needles and syringes.

8Throughout this report, we include the District of Columbia in our
discussion of states.

9Each of these three FEHBP plans offers two coverage options, but coverage
for the diabetes services and supplies we reviewed was identical in both
options.

10Because employers may offer their employees more than one health plan
option, we asked employers to provide coverage information related to the
health plan that had the largest enrollment. One of the employers in our
review provided different benefits for hourly employees than for salaried
employees within the same health plan. For this health plan, we included
information on the coverage for salaried employees.

11We relied on the information reported by officials of the health plans
reviewed and did not independently verify their responses. Because of our
sampling approach, we cannot generalize our findings to all FEHBP plans or
to all large employers.

data gathered from telephone interviews.12 We used data collected during
2003, the most recent year available. We also obtained data from another
CDC survey known as the National Health and Nutrition Examination Survey
(NHANES). Unlike BRFSS, this survey combines an in-home interview with a
physical examination to assess the health of a nationally representative
sample of the noninstitutionalized U.S. population, including a
representative sample of individuals with diabetes.13 We used data
collected by this survey from 1999 through 2002 for individuals ages 18
and older. To assess data reliability, we reviewed CDC documentation of
its data collection and discussed the data and their appropriate use with
CDC officials. We determined that the data were sufficiently reliable for
our purposes.

We conducted our work according to generally accepted government auditing
standards from July 2004 through January 2005. Additional details about
our scope and methodology appear in appendix I.

In 2004, 47 states had laws or regulations related to coverage of diabetes
services or supplies, although the specific coverage requirements varied
by state. States most often required coverage of two diabetes services:
diabetes education and medical nutrition therapy. Forty-five states
required diabetes education, and 27 required medical nutrition therapy.
National organizations concerned with diabetes patient care have worked
with states to develop laws and regulations addressing these services in
particular because other services, such as eye and foot exams, were
thought to be covered by most health plans as general medical services. In

  Results in Brief

12The BRFSS data we obtained contained information from 50 states and the
District of Columbia. Each year the survey asks a range of health
questions over the telephone, including if respondents have previously
received a diagnosis of diabetes, whether they have health coverage at the
time of the survey, and how many times they received any of a number of
different health services. The survey does not identify what type of
health coverage a respondent has, that is, whether a respondent is covered
by a private health plan or a program such as Medicare, the federal health
program that covers adults ages 65 and older and certain individuals with
disabilities.

13Estimates from BRFSS and NHANES were analyzed separately and, when
possible, stratified by health coverage (respondents with health coverage
and those without). For both surveys, the analysis used data only for the
sample reporting a diagnosis of diabetes before the survey period,
excluding women with gestational diabetes. We excluded estimates whose 95
percent confidence intervals exceeded plus or minus 10 percentage points.
Most estimates from BRFSS were stratified by state, although state
estimates could not be broken down by health coverage; NHANES estimates
were limited to the national level.

addition, 47 states had coverage requirements related to diabetes
supplies, although some states were more specific than others about which
supplies must be covered.

The plans we contacted that provide coverage not subject to state
insurance requirements-specifically, the 3 largest health plans
participating in FEHBP and 13 of the largest employers' self-funded
plans-covered most of the diabetes services and supplies we reviewed, in
most cases without limits on the coverage. Each of the 3 FEHBP plans and
the 13 self-funded plans we contacted covered at least 7 of the 10
diabetes services, such as an annual blood glucose test, cholesterol and
blood pressure monitoring, and influenza vaccinations. Services covered
less often included diabetes education, medical nutrition therapy, and
smoking cessation therapy. All 16 plans also covered at least five of the
nine diabetes supplies we reviewed, including insulin and
insulin-administering supplies; most of these plans also covered blood
glucose monitors, glucose control solutions, alcohol swabs, and
therapeutic shoes.

Data from CDC's 2003 nationwide survey showed that a majority of
individuals with diabetes ages 18 and older reported receiving at least
one diabetes service within the past 12 months; a much smaller proportion,
however, reported receiving five services that experts recommend that
individuals with diabetes receive at least once a year. Nationwide, an
estimated 88 percent of individuals with diabetes had received a test for
blood glucose within the past 12 months, whereas an estimated 33 percent
had received five services: blood glucose and cholesterol tests, eye and
foot exams, and an influenza vaccination. Receipt of services and supplies
among individuals with diabetes varied by service, state, and whether an
individual had health coverage. For example, an estimated 71 percent of
individuals with diabetes who had health coverage at the time of the
survey had received eye exams, compared with 46 percent of those who
lacked health coverage. Other CDC survey data indicate that many
individuals with diabetes do not have adequate control of diabetes-related
conditions that may increase their risk of complications.

We provided a draft of this report to CDC for comment. The agency provided
us with technical comments, which we incorporated into the report as
appropriate.

Background

Diabetes, a chronic disease, was the sixth leading cause of death in the
United States in 2000, contributing to the loss of more than 200,000
lives, according to CDC. Type 1 diabetes, in which the body fails to
produce insulin, is usually diagnosed in children and young adults. Type 2
diabetes, in which the body fails to use insulin properly, is associated
with aging, a family history of diabetes, physical inactivity, and obesity
and accounts for 90 to 95 percent of all diabetes cases. Although type 2
diabetes occurs most often among adults, it is increasingly being
diagnosed in children and adolescents.14 One study found that, on average
in 2002, individuals with diabetes incurred about $13,243 in health care
expenditures, compared with about $2,560 in expenditures for individuals
without diabetes.15 These estimates include costs attributed to
complications of diabetes, such as cardiovascular disease, neurological
symptoms, and kidney disease.

Federal health agencies and national organizations concerned with diabetes
patient care have identified a number of services and supplies that
individuals with diabetes often need to help manage their disease. Table 1
lists services considered important for diabetes patient care by the
American Association of Diabetes Educators; the American Dietetic
Association; and the National Diabetes Quality Improvement Alliance
(Alliance), a consortium of 13 private-sector organizations and government
agencies, including the American Diabetes Association (ADA),

16

CDC, and the Centers for Medicare & Medicaid Services.

14CDC estimates that more than 200,000 people under 20 years of age had
diabetes in 2002, but no data currently exist to determine the extent to
which type 2 diabetes has emerged among U.S. children and adolescents.

15American Diabetes Association, "Economic Costs of Diabetes in the U.S.
in 2002," Diabetes Care, vol. 26, no. 3 (2003).

16The Alliance uses nine services-blood glucose (A1c) management, lipid
(cholesterol) management, urine protein screening, eye exams, foot exams,
influenza immunization, blood pressure management, aspirin therapy, and
smoking cessation therapy-as performance measures to assess and report on
the quality of diabetes care for adults with diabetes. For women of
childbearing age with diabetes, the Alliance also recommends prepregnancy
counseling on the importance of glucose management before conception.

Table 1: Services for Managing Diabetes

                      Service Importance for patient care

Blood glucose (A1c) managementa	Regular, frequent monitoring of glucose in
the blood (as HbA1c, hemoglobin A1c, or glycosylated hemoglobin) reduces
the risk of complications such as nerve damage, kidney disease, and vision
disorders.

Lipid (cholesterol) management 	Individuals with diabetes are at increased
risk of coronary heart disease. Lowering serum cholesterol levels can
reduce this risk.

Urine protein screening for kidney disease 	Diabetes is the leading cause
of end-stage renal (kidney) disease. The earliest clinical evidence of
kidney disease is the appearance of low but abnormal levels of a protein
(albumin) in the urine. Early detection and treatment of this condition
may prevent or slow the progression of diabetic kidney disease.

Eye exam for eye disease 	Individuals with diabetes are at increased risk
of blindness caused by retinopathy, or diseases of the retina, the
light-sensitive tissue at the back of the eye that is needed for vision.
The prevalence of retinopathy is strongly related to the duration of
diabetes, but treatment can prevent or delay onset.

Foot exam to detect problems with Individuals with diabetes are at
increased risk of foot ulcers and amputations. Annual foot

                           circulation and sensation

exams and management of risk factors can prevent or delay poor outcomes.

Influenza immunization 	Individuals with diabetes are considered to be at
increased risk of complications, hospitalization, and death from
influenza, as well as of secondary infections, such as pneumonia,
resulting from influenza.

Blood pressure management 	Controlling blood pressure in patients with
diabetes reduces diabetes complications, diabetes-related deaths, strokes,
heart failure, and other complications.

Diabetes education 	Diabetes education teaches individuals to manage their
disease through activities including exercise and blood glucose
monitoring.

Medical nutrition therapy 	Medical nutrition therapy is a specific
nutrition service and procedure used to treat illnesses or health
conditions. It involves an in-depth nutrition assessment, changes in diet
as appropriate, and follow-up monitoring and evaluation.

Smoking cessation therapy: counseling or Individuals with diabetes who
smoke are more likely to suffer nerve damage and kidney drugs disease.
Smoking also damages and constricts blood vessels, which can worsen foot
ulcers and leg infections. In addition, smoking increases blood pressure
and blood glucose.

Sources: American Association of Diabetes Educators, American Diabetes
Association, American Dietetic Association, and National Diabetes Quality
Improvement Alliance.

Note: In addition to the services listed in this table, the Alliance also
recommends aspirin therapy to help prevent stroke, heart attack, and other
cardiovascular problems in adults with diabetes. Because aspirin is an
over-the-counter medication not typically covered by health plans, we
excluded aspirin therapy from our review.

aA1c tests differ from traditional home glucose monitoring, which usually
involves pricking a finger, putting a drop of blood on a test strip, and
placing the strip into a meter that displays the level of glucose in the
blood. A1c tests are done in a health care provider's office and measure
the average level of glucose in the blood over the preceding 3 months. For
some patients, daily (or sometimes hourly) self-testing for glucose level
is recommended to provide a short-term glucose assessment, but experts
recommend at least one A1c test annually for all diabetes patients to
assess a patient's general glucose level.

In addition to such services, according to federal agencies and
organizations concerned with diabetes patient care, individuals with
diabetes often need certain supplies to manage their disease. Needed
supplies may include blood glucose monitors, glucose control solutions
(used to check the accuracy of testing equipment and test strips), test
strips, lancets and lancet devices (used to prick the skin for a blood
sample to self-test blood glucose levels), insulin (when necessary),
insulin pumps (to administer insulin), disposable needles and syringes
(also to administer insulin), alcohol swabs, and therapeutic shoes (for
individuals with severe diabetic foot disease).

Health coverage may be provided through the purchase of insurance policies
that are subject to state laws and regulations or through means other than
insurance. Health coverage provided through the purchase of insurance in a
given state, whether purchased by individuals or by employers, is subject
to insurance requirements in that state, including requirements to cover
specified illnesses, services, or supplies.17 For example, states often
require coverage of cancer-screening services such as mammography or tests
for colorectal cancer.18 These state requirements are in addition to
coverage requirements established by federal law. In 2001, two-thirds of
Americans younger than 65 (the age at which people generally become
eligible for Medicare),19 received health coverage through their own
employer or that of a family member. Large private employers often
self-fund their health plans,20 and coverage provided by these plans is
not subject to state insurance regulation, although it is

17Health insurance policies may also cover services or supplies that they
are not required to cover.

18See Private Health Insurance: Coverage of Key Colorectal Cancer
Screening Tests Is Common but Not Universal, GAO-04-713 (Washington, D.C.:
June 17, 2004), and Private Health Insurance: Federal and State
Requirements Affecting Coverage Offered by Small Businesses, GAO-03-1133
(Washington D.C.: Sept. 30, 2003).

19Medicare provided health coverage to almost 35 million beneficiaries
ages 65 and older and 6 million individuals with disabilities in 2002 (the
most recent data available), including individuals with end-stage renal
disease. Medicare covers the diabetes services that we reviewed, except
smoking cessation therapy, and the diabetes supplies that we reviewed,
except alcohol swabs and disposable needles and syringes. The program
generally does not cover insulin, although it may cover insulin when used
with an insulin pump.

20In 2002, about 78 percent of employers with more than 500 employees
offered at least one self-funded plan, compared with about 29 percent of
employers that had 100-499 employees and about 13 percent of small
employers (those with fewer than 50 employees).

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

generally subject to federal requirements.21 Health coverage provided by
the federal government is also not subject to state insurance regulation.
For FEHBP, OPM is responsible for contracting with private health
insurance carriers to offer health benefit plans to federal employees. By
federal law, the terms of any FEHBP contract negotiated by OPM that relate
to coverage or benefits preempt any inconsistent state or local law or
regulation. OPM routinely preempts state requirements to ensure a
consistent set of benefits among nationwide FEHBP plans, according to an

22

OPM official.

In 2004, 47 states had laws or regulations related to coverage of diabetes
services or supplies, although specific requirements varied by state (see
fig. 1 and app. II). Forty-five states required insurance policies to
cover specific services or supplies for diabetes.23 Two more states,
Mississippi and Missouri, required "mandated offerings"; that is, these
states required insurance policies to provide coverage for diabetes at the
option of purchasers. Some states' requirements applied only in narrow
circumstances. For example, Arizona and Wisconsin required coverage of
diabetes supplies only when a health insurance policy covered the
treatment of diabetes.24 The services most frequently specified in state
requirements were diabetes education and medical nutrition therapy: 45
states required that insurance policies cover diabetes education, and 27

21The most significant of these are included in ERISA. See 29 U.S.C. S:S:
1001 et. seq. (2000). ERISA does not require that any employer provide
health coverage. For most employers that do provide health coverage, it
specifies several requirements, but coverage for diabetes services and
supplies is not among them.

22OPM does not impose specific coverage requirements on FEHBP plans,
including for diabetes services and supplies.

23Alabama, Idaho, North Dakota, and Ohio did not require coverage of
diabetes services or supplies. Except for Idaho, these states have
considered or are considering legislation to require coverage of specific
diabetes services or supplies. State requirements generally applied to
both individual and group health insurance policies, but requirements in
Illinois, Montana, and Oregon applied only to group policies. Alaska's
requirements applied only to policies covering pharmacy services.

24Wisconsin law also required coverage of diabetes education programs only
if the policy covered expenses for the treatment of diabetes.

states required coverage of medical nutrition therapy.25 State
requirements may have focused more often on these two services in part
because national organizations concerned with diabetes patient
care-including ADA, the American Dietetic Association, and the American
Association of Diabetes Educators-have supported "model" legislation
centered on these two services. According to ADA and the American Dietetic
Association, the organizations focused on these two services in particular
because others, such as eye and foot exams, were thought to be covered by
most policies as general medical services. 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.

Figure 1: Number of States Requiring Coverage of Diabetes Services and
Supplies, 2004

                                Number of states

                                       47

abetesiDeducationservicesM

edicalnutritiontherapyservices

iabetessupplies

D

                               Specifiedsupplies

Source: GAO.

25In addition, six states required coverage of nutrition counseling or
education that includes information on proper diet. Florida, which we did
not count among these six, required coverage of "outpatient
self-management training and educational services used to treat diabetes"
and stated that any policy "may require that nutrition counseling be
provided by a licensed dietician."

Some states had specific requirements regarding the coverage of certain
services, such as diabetes education. Forty-two states specified at least
some criteria for the training or education that health care professionals
must have to provide diabetes education. These criteria varied widely from
state to state. To provide diabetes education in Louisiana, for example,
health professionals must have demonstrated expertise in diabetes and must
have completed an educational program in compliance with the National
Standards for Diabetes Self-Management Education established by ADA. In
contrast, several states required educators to be licensed professionals
with expertise in diabetes but did not define the term expertise. Eight
states referred to ADA's national standards in setting their requirements
for diabetes education programs. Some of these states required programs to
be consistent with these standards, while others mentioned them as an
example of acceptable standards.

Among the 47 states whose laws or regulations required coverage of
diabetes supplies, specific coverage requirements varied. For example, 19
states did not specify which supplies must be covered; instead, these
states typically required coverage of all medically necessary equipment
and supplies prescribed by a physician. The remaining 28 states specified
covered supplies, either in laws or regulations, but the number of
supplies varied among the states. For example, Michigan had requirements
related to insulin, blood glucose monitors, test strips, lancets, lancet
devices, syringes, and insulin pumps. In contrast, Mississippi required
coverage of equipment and supplies, including supplies used in connection
with blood glucose monitoring and insulin administration, but did not
specify which supplies. Some states that listed covered supplies also
prescribed procedures for adding new supplies to the list. For example, in
New Jersey, the Commissioner for Insurance, in consultation with the
Commissioner of Health, may update the list of supplies.

While nearly all states have required some coverage of diabetes services
or supplies in the insurance policies they regulate, some states have
authorized a class of health insurance policies that are not bound by many
of the state coverage requirements, which may include those for coverage
of diabetes services and supplies. Known as "flexible health benefit" or
"limited-benefit" policies, and typically marketed to small employers or
individuals, such policies may, through lower premiums, reduce the cost of
coverage. At least two states, Louisiana and Arkansas, have authorized
limited-benefit policies that are not bound by requirements related to

diabetes services and supplies.26 Louisiana has authorized such policies
for individuals not otherwise able to obtain health coverage and for small
employers (3-35 employees), and Arkansas has authorized them for all
groups, regardless of size. ADA is concerned that limited-benefit policies
may not provide sufficient coverage of the services and supplies that
individuals with diabetes need to manage their condition.

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. Few of the plans we contacted placed limits on coverage for
diabetes services and supplies.27

  Selected Health Plans Providing Coverage Not Subject to State Regulation Cover
  Most but Not All Diabetes Services and Supplies

    Three Largest FEHBP Plans Cover Most Diabetes Services and Supplies

The three largest FEHBP plans covered at least 8 of the 10 diabetes
services we reviewed (see table 2). Both diabetes education and medical
nutrition therapy were covered by two of the three plans, although one
plan placed conditions on these services: diabetes education was covered
when provided at a hospital and medical nutrition therapy when provided by
a physician. The three plans stated that coverage requirements for
diabetes services and supplies applied only in cases of medical necessity.
The plans generally did not, however, set monetary limits on their

26According to one study, at least 11 states had legislation as of 2004 to
allow the marketing of policies that do not meet their usual coverage
requirements; this study, however, did not specify whether the states'
legislation included provisions related to diabetes [I. Friedenzohn,
"Limited-Benefit Policies: Public and Private Sector Experiences," Academy
Health Issue Brief, vol. V, no. 1 (2004)]. At least one state, Colorado,
required health insurance policies to comply with some state coverage
requirements, including those for diabetes services and supplies, but not
with others, including those for mammography and prostate cancer
screening.

27Other factors, outside the scope of this review, such as high
co-payments, high deductibles, or transitions in health coverage when
individuals change employers, may create financial and access-to-care
barriers for individuals with diabetes, according to a February 2005
report [Karen Pollitz et al., Falling through the Cracks: Stories of How
Health Insurance Can Fail People with Diabetes (Washington, D.C.:
Georgetown University Health Policy Institute and American Diabetes
Association, Feb. 8, 2005)].

coverage for diabetes services. One exception was smoking cessation
therapy, for which one plan set $100 lifetime limits per enrollee for both
counseling and drug therapy. Another plan set $100 lifetime limits per
enrollee for smoking cessation counseling.

Table 2: Diabetes Services Covered by the Three Largest FEHBP Plans, 2004

                                                                   Government 
                                   Blue Cross and     Mail Employees Hospital 
                           Service    Blue Shield Handlers  Association, Inc. 
                Blood glucose test              X        X 
                     Lipid profile              X        X 
           Urine protein screening              X        X 
                          Eye exam              X        X 
                         Foot exam              X        X 
             Influenza vaccination              X        X 
                    Blood pressure              X        X 
                        management                         
                 Smoking cessation              X        X 
                           therapy                         
                Diabetes education              X          
                 Medical nutrition             Xa          
                           therapy                         

Source: GAO analysis of data from the three largest FEHBP plans.

aCovered for enrollees with a diagnosis of diabetes.

The three FEHBP plans all covered at least seven of nine diabetes
supplies, including blood glucose monitors, glucose control solutions,
test strips, lancets and lancet devices, insulin, insulin pumps, and
disposable needles and syringes. One plan did not cover alcohol swabs, and
two plans did not cover therapeutic shoes. One plan limited its coverage
of supplies; specifically, this plan set lifetime durable medical
equipment limits of $10,000 per person for specific supplies, including
blood glucose monitors and insulin pumps.

Large Employers' Self-Each of the 13 large employers' self-funded health
plans we reviewed Funded Health Plans covered at least 7 of 10 diabetes
services, specifically, blood glucose, lipid, Reviewed Cover Most and
urine tests; eye and foot exams; blood pressure management, and Diabetes
Services and influenza vaccinations. The remaining 3 services were covered
by at least 9

plans (see fig. 2). Among these plans, we found limits on coverage only
forSupplies smoking cessation therapy. One plan, for example, had a
lifetime maximum of three drug therapy treatments for smoking cessation,
and

another plan had a maximum of two smoking-cessation programs per lifetime
for each enrollee for both counseling and drug therapy.

In a few cases, the plans specified certain conditions for coverage. For
example, among the 11 plans offering coverage of diabetes education, 4 did
so only if an employee with diabetes was enrolled in the plan's diabetes
management program. Three of the 10 plans offering coverage of medical
nutrition therapy did so only as part of their diabetes management
program. Of the 9 plans covering smoking cessation therapy, 5 restricted
coverage to drug therapy and did not cover smoking cessation counseling.
Most of the self-funded plans stipulated that diabetes services and
supplies were covered only when medically necessary.28 In addition, 7
plans required waiting periods ranging from 30 days to 6 months after an
employee was hired before health coverage began. One plan did not cover
preexisting conditions-either an injury or illness-occurring during the 90
days before a newly hired employee began the waiting period.

28For example, one health plan told us that it would pay for medically
necessary services, supplies, or treatments that it considers to be
"reasonable, necessary, and customary," which means that such services,
supplies, or treatments must be appropriate and consistent with the
diagnosis or symptoms; consistent with accepted medical standards; not
experimental or investigational; not provided solely on a convenience or
personal basis; and employed appropriately, effectively, and safely with
respect to the type and level of care.

Figure 2: Diabetes Services Covered by 13 Large Employers' Self-Funded
Health Plans, 2004

                             Blood glucose test 13

                                Lipid profile 13

Urine protein screening 13

Eye exam 13

Foot exam 13

                            Influenza vaccination 13

Blood pressure 13management

Diabetes education

Medical nutrition therapy

Smoking cessation therapy 0 510 Number of plans

Source: GAO analysis of data from 13 of the 50 largest Fortune 500
companies.

All 13 self-funded plans covered at least five of nine diabetes supplies,
including insulin, insulin pumps, disposable needles and syringes, test
strips, and lancets and lancet devices, and all but 1 covered blood
glucose monitors (see fig. 3). Only 1 of the 13 plans reported having
limits on the quantity of supplies covered, covering one blood glucose
monitor per year. Two of the 13 plans reported placing conditions on their
coverage of supplies. For example, 1 plan told us that it allowed up to a
90-day supply of items for each claim, and another plan covered
therapeutic shoes when prescribed by a physician and purchased through an
authorized supplier.

Figure 3: Diabetes Supplies Covered by 13 Large Employers' Self-Funded
Health Plans, 2004

Insulin 13

Insulin pumps 13

Disposable needles and syringes

13

Test strips 13

Lancets and

13

                                 lancet devices

Blood glucose monitors

Glucose control solutions

                               Therapeutic shoes

                                 Alcohol swabs

0 3 6 912

Number of plans

Source: GAO analysis of data from 13 of the 50 largest Fortune 500
companies.

Data from CDC's 2003 nationwide survey showed that individuals with
diabetes received some but not all diabetes services, and those who had
health coverage were more likely to have received services than those who
did not. The proportion of individuals with diabetes receiving diabetes
services varied widely by type of service and among states. Another CDC
survey, which included a physical examination of participants, indicated
that many individuals with diabetes did not have their diabetes-related
conditions adequately controlled.

  Nationwide, Receipt of Diabetes Services and Control of Related Health
  Conditions Are Uneven

    Individuals with Diabetes Report Receiving Many but Not All Services

National data show that individuals with diabetes ages 18 and older
receive many but not all diabetes services. 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.29 Substantially fewer individuals
reported receiving within the past 12 months the five services recommended
that

29CDC's 2003 BRFSS included a representative sample of 19,162 participants
from 50 states and the District of Columbia who reported receiving a
diagnosis of diabetes from a physician before the survey period.

individuals with diabetes receive at least once a year. Although the
receipt of services varied by service, half or more of the individuals
with diabetes reported receiving each given service. 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. 4).30

30The national BRFSS data had information on 6 of the 10 services we
reviewed for managing diabetes, specifically, A1c tests for blood glucose,
cholesterol tests, eye exams, foot exams, influenza vaccinations, and
diabetes education. With the exception of diabetes education, experts
recommend that individuals with diabetes receive these services at least
once a year. We selected 5 of these services for a combined estimate of
services recommended that individuals with diabetes receive at least once
a year-specifically, A1c tests for blood glucose, cholesterol tests, eye
exams, foot exams, and influenza vaccinations. The 4 services absent from
the national data were urine protein screening, blood pressure management,
medical nutrition therapy, and smoking cessation therapy.

Figure 4: Estimated Nationwide Percentage of Individuals Ages 18 and Older
with Diabetes Who Reported Receiving Diabetes Services, 2003

Percent

                                     88 86

BloodstCholesterglucose te

                                 Foot exam xam

accination education Five v

                                     oltest

vicesser

e eEy

Source: CDC's BRFSS.

Notes: These nationwide estimates were constructed from available state
data. Data represent the estimated percentage of individuals ages 18 and
older nationwide who reported receiving a service within the past 12
months, except for diabetes education, for which respondents were asked if
they had ever received the service (specifically, participants were asked
if they had ever taken a course on how to manage their diabetes). Data for
"Five services" represent the estimated percentage of individuals who
reported receiving all of five services recommended that individuals with
diabetes receive at least once a year: a blood glucose test, a cholesterol
test, a foot exam for sores or irritations, an eye exam in which the
pupils were dilated, and an influenza vaccination.

CDC's survey also indicated that an estimated 82 percent of individuals
with diabetes were taking insulin or diabetes medication to control their
blood glucose.31 Otherwise, use of diabetes supplies was not captured in
CDC's survey.

31Insulin delivery typically requires use of supplies such as insulin
pumps or needles and syringes.

    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. 5).
Moreover, the estimated proportion of individuals with diabetes who
received all of the five diabetes services was more than twice as high for
those who had coverage than for those who did not. For example, although
an estimated 35 percent of those with health coverage had received a blood
glucose test, a cholesterol test, eye exam, foot exam, and influenza
vaccination, just 14 percent of those without health coverage received the
same set of services.

Figure 5: Estimated Nationwide Percentage of Individuals Ages 18 and Older
with Diabetes, With and Without Health Coverage, Who Reported Receiving
Diabetes Services, 2003

                               Percent 100 90 88

CDC's 2003 survey showed substantial variation among states in the receipt
of diabetes services. Depending on the service, the estimated
stateby-state percentages of individuals with diabetes who reported
receiving services varied widely. For example, the estimated
state-by-state percentages of individuals with diabetes who reported
receiving an eye exam ranged from 55 to 84 percent (see table 3). Despite
this state-by-state variation, the same services were generally the most
received across all states. In most states, for example, more individuals
received blood

                                       80

                                       60

                                       40

                                      20 0

                     Bloodglucose test Cholester Foot exam

Influenzaaccination v

                                oltest education

Fivevicesser

                                      xam

e eEyWith health coverage

Without health coverage

Source: CDC's BRFSS.

Notes: These nationwide estimates were constructed from available state
data. Data represent the estimated percentage of individuals ages 18 and
older nationwide who reported receiving a service within the past 12
months, except for diabetes education, for which respondents were asked if
they had ever received the service (specifically, participants were asked
if they had ever taken a course on how to manage their diabetes). Data for
"Five services" represent the estimated percentage of individuals who
reported receiving all of five services recommended that individuals with
diabetes receive at least once a year: a blood glucose test, a cholesterol
test, a foot exam for sores or irritations, an eye exam in which the
pupils were dilated, and an influenza vaccination.

    Receipt of Diabetes Services Varies Widely among States

glucose and cholesterol tests than received foot exams or diabetes
education.

Table 3: Range among States in Estimates of Diabetes Services Received by
Individuals with Diabetes, 2003

                                 Service aState percentages Number of statesb 
                Blood glucose (A1c) test           74 to 97 
                        Cholesterol test           79 to 92 
                               Foot exam           59 to 82 
                                Eye exam           55 to 84 
                   Influenza vaccination           46 to 75 
                Diabetes education (ever           37 to 67 
                               received)                    
                          cFive services           23 to 48 

Source: CDC's BRFSS.

aState percentages reflect the estimated proportion of individuals ages 18
and older with diabetes in a given state who reported receiving a service
within the past 12 months, except for diabetes education.

bNumbers of states vary because not all states provided data for all
diabetes services in 2003. Because the sample sizes of individuals with
diabetes reporting receipt of each service for each state were relatively
small, the confidence intervals were relatively large. Any state whose 95
percent confidence interval for any estimate exceeded plus or minus 10
percentage points was excluded from this analysis.

c"Five services" represents the estimated percentage of individuals who
reported receiving the five services recommended that individuals with
diabetes receive at least once a year: a blood glucose test, a cholesterol
test, a foot exam for sores or irritations, an eye exam in which the
pupils were dilated, and an influenza vaccination.

    Many Individuals with Diabetes Do Not Have Adequate Control of Related
    Conditions That May Increase Their Risk of Complications

For 1999-2002, data from CDC's NHANES-a nationally representative survey
that involves a physical examination to assess each participant's
health-indicated that many individuals with diabetes ages 18 and older did
not have adequate control of related conditions that could lead to health
complications.32 Experts say that controlling blood glucose and
cholesterol levels lowers the risk of nerve damage, vision disorders, and
cardiovascular disease; detecting renal disease early decreases the risk
of kidney failure.33 Yet data from CDC's NHANES showed that about 19
percent of examined participants with diabetes had poor control of their
blood glucose,34 and about half of them had cholesterol levels putting
them at increased risk for cardiovascular disease. In addition, about 40
percent were at increased risk of renal disease, as evidenced by a
positive test for abnormal levels of a protein in their urine.35 The data
also showed that about 38 percent of individuals with diabetes who did not
have health coverage had glucose levels indicative of poor control,
compared with about 16 percent of those who had health coverage.

Agency Comments 	We provided a draft of this report to CDC for comment.
The agency provided us with technical comments, which we incorporated into
the report as appropriate.

As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies to interested
congressional committees and members and make copies available to others
upon request. In addition, the report will be available at no charge on
the GAO Web site at http://www.gao.gov.

32CDC's NHANES included a nationally representative sample of 904
participants who reported a diagnosis of diabetes.

33The Diabetes Control and Complications Trial Research Group, "The Effect
of Intensive Treatment of Diabetes on the Development and Progression of
Long-Term Complications in Insulin-Dependent Diabetes Mellitus," New
England Journal of Medicine, vol. 329 (1993); and U.K. Prospective
Diabetes Study Group, "Association of Glycaemia and Macrovascular and
Microvascular Complications of Type 2 Diabetes: Prospective Observational
Study," British Medical Journal, vol. 321 (2000).

34Poor control of blood glucose is measured by the Alliance as an A1c
value greater than 9 percent.

35Diabetes is the leading cause of end-stage renal disease.

If you or your staffs have any questions about this report, please contact
me at (202) 512-7118. Another contact and key contributors to this report
are listed in appendix III.

Kathryn G. Allen Director, Health Care-Medicaid and Private Health
Insurance Issues

                       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. We also reviewed information prepared by
the American Diabetes Association (ADA) and the American Dietetic
Association and interviewed officials there, as well as from states and
the National Conference of State Legislatures. In addition, we reviewed
state requirements for limited-benefit policies-which are not required to
comply with coverage requirements usually applicable to health
insurance-in Louisiana, Arkansas, and Colorado.

To examine the extent to which the largest plans participating in the
Federal Employees Health Benefits Program (FEHBP) and the largest
selffunded employer plans cover diabetes services and supplies, we
obtained information from the three largest national FEHBP plans-Blue
Cross and Blue Shield, Mail Handlers, and Government Employees Hospital
Association, Inc.-which together covered approximately 5.3 million people
in 2003, or about 65 percent of employees, retirees, and their dependents
covered by FEHBP plans. We also contacted a random sample of 15 of the 50
largest Fortune 500 companies, ranked by the number of employees,
regarding their plans' coverage of diabetes services and supplies in 2004
and received responses from 13 of them. Together these 13 large companies,
which had self-funded health plans, employed about 2.4 million people in
2003. Because employers may offer their employees more than one health
plan option, we asked employers to provide coverage information related to
the health plan that had the largest enrollment. We relied on the
information as reported by officials of the health plans reviewed and did
not independently verify their responses. Because of our sampling
approach, we cannot generalize our findings to all FEHBP plans or to all
large employers. Although we received responses from most (16 of 18) of
the FEHBP plans and employers we contacted, our results may still reflect
some selection bias, in that employers offering more benefits might have
been more likely to respond than those offering fewer benefits.

Appendix I: Scope and Methodology

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:

o 	BRFSS is a nationwide telephone survey conducted every year by state
health departments, with technical and methodological assistance provided
by CDC. A "cross-sectional" or point-in-time survey, BRFSS samples the
civilian noninstitutionalized population of adults ages 18 and older in
the United States, including the 50 states and the District of Columbia;1
all data from BRFSS are self-reported. The survey's purpose, methods, and
data analyses are available at http://www.cdc.gov/brfss. We used data from
CDC gathered during 2003 about services individuals with diabetes reported
receiving within the 12 months preceding the survey, which represented the
most recent information available. BRFSS 2003 included a representative
sample of 19,162 participants with diabetes. In addition to questions from
the core sections of the survey, we used questions from a
diabetes-specific section, which included data from 46 states in 2003, to
collect data on disease management practices from respondents with
diabetes.

o 	NHANES is a nationally representative survey, whose data are collected
every year and released every 2 years by CDC, that samples the civilian
noninstitutionalized U.S. population. It is a two-part survey, consisting
of an in-home interview plus a health examination in a mobile examination
center. Its purpose, methods, and data analyses are available at
http://www.cdc.gov/nchs/nhanes.htm. We used NHANES data from 1999-2002-the
most recent information available-for adults ages 18 and older, which
included a representative sample of 904 participants with diabetes. We
relied on NHANES results from the physical examinations, which included
laboratory tests, for specific test values for individuals who had
reported a prior diagnosis of diabetes, including tests for blood glucose,
cholesterol, and kidney disease.

We examined data provided to us by CDC from each survey separately. When
possible, the data were stratified by health coverage status (respondents
who reported having health coverage and those who

1Although CDC's BRFSS is conducted in Puerto Rico, the Virgin Islands, and
Guam as well, we did not include these territories in our review.

                       Appendix I: Scope and Methodology

reported not having it).2 For both surveys, we used data only from
respondents who reported receiving a diagnosis of diabetes before the
survey period. Most of CDC's estimates from BRFSS were stratified by
state, although we could not develop state-level estimates by health
coverage; NHANES estimates were limited to the national level. We analyzed
a total of 10 indicators for diabetes services and supplies from both
surveys (see table 4).

       Table 4: Indicators of Services and Supplies for Managing Diabetes

               Diabetes indicatora             Data source     Population     
Percentage of patients who report receiving    BRFSS    National and state 
              one or more A1c tests                        
Percentage of patients with a measured A1c    NHANES         National      
                test value >9.0%                           
Percentage of patients who report receiving    BRFSS    National and state 
          at least one cholesterol test                    
     Percentage of patients with a measured      NHANES         National      
       total cholesterol value >=200 mg/dl                 
Percentage of patients who report receiving    BRFSS    National and state 
               a dilated-eye exam                          
Percentage of patients who report receiving                                
       at least one foot exam for sores or        BRFSS    National and state
                   irritations                             
Percentage of patients who report receiving    BRFSS    National and state 
           an influenza immunizationb                      
     Percentage of patients who report ever       BRFSS    National and state 
    taking a diabetes self-management course               
Percentage of patients who report currently    BRFSS    National and state 
      taking insulin or diabetes medication                
Percentage of patients with a negative test   NHANES         National      
        for nephropathy (kidney disease)c                  

Source: CDC.

aUnless otherwise noted, we used data from BRFSS about respondents'
receipt of diabetes services within the past 12 months. NHANES data came
from 1999-2002.

bThe BRFSS question asks participants if they have received a "flu shot,"
thus potentially excluding respondents who may have received an intranasal
immunization for influenza.

cA negative test for nephropathy is defined as a ratio of urinary albumin
to urinary creatinine of <17 for men and <25 for women.

2Specifically, BRFSS asked respondents, "Do you have any kind of health
care coverage, including health insurance, prepaid plans such as HMOs, or
government plans such as Medicare?" NHANES asked about health insurance
status, including the type of coverage, but we did not stratify NHANES
data by the type of health coverage because of insufficient sample sizes
of respondents with diabetes. We did not identify any data sources on the
number of individuals having coverage subject to state insurance
requirements or not subject to state requirements. We therefore could not
assess whether individuals with different types of coverage differed in
receipt of diabetes services and supplies.

Appendix I: Scope and Methodology

We assessed the reliability of the NHANES and BRFSS data provided by CDC
by (1) reviewing existing information about the data and the methods used
to collect them and (2) interviewing and working with agency officials
knowledgeable about the data. We determined that the data were
sufficiently reliable for the purposes of this report. Our review had
several data limitations. First, BRFSS data were self-reported for each
service we reviewed, and both BRFSS and NHANES used self-reported
diagnoses of diabetes from participants, a practice that can result in
recall bias. Second, BRFSS is a telephone survey, which limits data
collection to individuals who have telephones. Third, both surveys are
cross-sectional; that is, they provide information at one point in time.
For example, although health coverage was assessed at the time the surveys
were conducted, we could not determine whether participants' coverage
changed over the survey year.

Appendix II: Summary of Diabetes Coverage
Requirements in State Laws or Regulations,
2004

Diabetes Requirement education Medical nutrition State related to diabetes
services therapy servicesa Diabetes supplies Specified supplies

Alabama

Alaska X Xb Xb Xb

Arizona X Xc

Arkansas X X X X	

California X X X X	

Colorado X X X X	

Connecticut X X X X	

Delaware X Xd

District of Columbia X X X X 	

Florida X X X	

Georgia XXXX	

Hawaii XX X	

Idaho

                              Illinoise X X X X Xf

Indiana X X X	

Iowa XX X	

                                Kansas X X X XXg

Kentucky X X X X	Louisiana X X X X	Maine XX XX	Maryland X X X
X	Massachusetts X X X X X	Michigan X X X Xh	Minnesota X X X X	Mississippii
X X X X X	Missourii X X X	Montanae X X X X	Nebraska XXXXX	Nevada XX X	New
Hampshire X X X X Xj	New Jersey X X X X	New Mexico X XXX X	New York X X
XX	North Carolina X X X	

Appendix II: Summary of Diabetes Coverage Requirements in State Laws or
Regulations, 2004

Diabetes Requirement education Medical nutrition State related to diabetes
services therapy servicesa Diabetes supplies Specified supplies

Alabama

North Dakota Ohio Wyoming XXXX

           Oklahoma              X           X            X           X       
           Oregon e              X           X                        X       
         Pennsylvania            X           X            X           X       
         Rhode Island            X           X            X           X       
        South Carolina           X           X                        X       
         South Dakota            X           X            X           X       
          Tennessee              X           X                        X       
            Texas                X           X                        X       
             Utah                X           X            X           X       
           Vermont               X           X            X           X       
           Virginia              X           X            X           X       
          Washington             X           X            X           Xk      
        West Virginia            X           X                        X       
          Wisconsin              X           Xl                       Xc      

Totals 47 45 27 47

Source: GAO.

aWe did not include states with coverage requirements related to nutrition
that did not refer specifically to medical nutrition therapy. As a result,
Nevada, Tennessee, Texas, and West Virginia-which required coverage of
nutrition counseling-and New Jersey and New York-which required education
that includes information on proper diet-are omitted here. We also omitted
Florida from this column, although the state required coverage of
"outpatient self-management training and educational services used to
treat diabetes" and further stated that any policy "may require that
nutrition counseling be provided by a licensed dietician."

bAlaska required coverage of education, medical nutrition therapy, and
supplies only when coverage was otherwise provided for pharmacy services.

cArizona and Wisconsin required coverage of equipment and supplies only
when a policy covered expenses incurred for the treatment of diabetes.

dDelaware required coverage of supplies only when the contract or policy
provided prescription drug coverage.

eRequirements in Illinois, Montana, and Oregon applied only to group
policies.

fIllinois required certain supplies-blood glucose monitors, cartridges,
and lancets and lancing devices-to be covered only if the policy provided
a durable medical equipment benefit. Coverage of other supplies-insulin,
syringes and needles, test strips, oral agents to control blood sugar, and
glucagon emergency kits-was required only if the policy provided a drug
benefit.

gKansas required coverage of insulin only if coverage was otherwise
provided for prescription drugs.

hMichigan required expense-incurred policies and HMO contracts to cover
insulin and other medications to treat diabetes only if they otherwise
provided pharmaceutical coverage.

Appendix II: Summary of Diabetes Coverage Requirements in State Laws or
Regulations, 2004

iMississippi and Missouri required insurance policies to provide diabetes
coverage only at the option of purchasers, a requirement referred to as a
"mandated offering."

jIn New Hampshire, insurers were required to cover medically appropriate
or necessary equipment only if they covered durable medical equipment.
Insurers were required to cover insulin, oral agents, and equipment only
if they provided a prescription rider.

kIn Washington, coverage for equipment and supplies was required only when
the contract or plan included pharmacy services.

lWisconsin required coverage of self-management education programs only if
the policy covered expenses for the treatment of diabetes.

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact Katherine Iritani (206) 287-4820

Acknowledgments 	Lisa A. Lusk, Jennifer Major, Adrienne Griffin, Craig
Winslow, and Ellen W. Chu made key contributions to this report.

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