Reimbursement and Sustainability

Coverage policy guidelines are a critical element of DSMES service sustainability but can be challenging to fully understand and apply. It is beyond the scope of this toolkit to address coverage policy guidelines for all payers.

Click this map of DSMES coverage by state to learn which states have laws that require such coverage for both private insurance plans and Medicaid, and to find information on legal requirements for when DSMES coverage is triggered, what specific activities are covered, and the standards that DSMES must meet.

Establishing and Operationalizing Medicaid Coverage of Diabetes Self-Management Education and Support [PDF – 1 MB]
This guide examines strategies for supporting state health department and Medicaid agency staff in their efforts to increase coverage and utilization of DSMES services in their states. It also provides stakeholders with information and resources to help promote the expansion of Medicaid coverage of DSMES services.

The list below provides steps to identify private payers’ DSMES coverage guidelines. The remainder of this section focuses primarily on Medicare reimbursement guidelines.

Note: The terms DSMES and DSMT are often used interchangeably. Although DSMES is the preferred term, CMS requires the use of DSMT in reimbursement documentation, and DSMT is used in this section of the toolkit.