CurrentIndependent HealthPolicy N/A

Payment of Cost-Sharing for Certain Covered Services

This rider amends the member contract to waive member cost-sharing for specified diabetic services and certain maternity-related services while federal waiver funding is available; it applies to covered members of Independent Health under the referenced contract.

Policy Summary

PayerIndependent Health

PolicyPayment of Cost-Sharing for Certain Covered Services

Policy CodePolicy N/A

Change TypeMaterial — Added waiver-funded elimination of member cost-sharing

Effective DateN/A

Next Review DateN/A

Key ActionWhen prescribing or referring diabetic services or supplies, document the authorized referral so those services qualify for waived member cost-sharing while waiver funding is available.

SourceLink

POLICY UPDATE CHANGES

Waiver funding will apply toward member deductible and out-of-pocket limit for listed covered diabetic services and maternity care while funding is available.

12 monthspostpartum coverage (months)

1annual diabetic foot exam

1annual dilated retinal exam

Multiplediabetes equipment/supplies

Waived Cost-Sharing Coverage Criteria

Policy Summary

PayerIndependent Health

PolicyPayment of Cost-Sharing for Certain Covered Services

Policy CodePolicy N/A

Change TypeMaterial — Added waiver-funded elimination of member cost-sharing

Effective DateN/A

Next Review DateN/A

Key ActionWhen prescribing or referring diabetic services or supplies, document the authorized referral so those services qualify for waived member cost-sharing while waiver funding is available.

SourceLink

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Waived Cost-Sharing Criteria

Waiver-funded elimination of member cost-sharing applies to the following services and supplies when covered under the Contract and as described below.

Waiver funding applies toward member deductible and out-of-pocket limit for listed covered services while funding is available; these services are not subject to member Cost-Sharing when covered under the Contract.

Diabetic services (covered without member cost-sharing)

Primary care office visits for the diagnosis, management, and treatment of diabetes (Cost-Sharing may apply to other services provided during the same visit; if the diabetic service is not the primary purpose of the visit, the Cost-Sharing amount for the visit may still apply).
One office visit annually to perform a diabetic foot exam (including when performed by a Specialist).
One office visit annually to perform a dilated retinal examination (including when performed by a Specialist).
Diabetes self-management education services provided by a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law, or their staff during an office visit; non-physician certified educators (certified diabetes nurse educators, certified nutritionists, certified dietitians, and registered dietitians) covered upon Referral of the Physician or authorized prescriber; education provided in group settings when practicable and in-home when Medically Necessary; initial, refresher, and when a significant change in condition necessitates education are covered.
Laboratory procedures and tests for the diagnosis and management of diabetes are covered without member Cost-Sharing.
Diabetic equipment and related supplies when prescribed by Your Physician or other Provider legally authorized to prescribe, including (but not limited to) insulin preparations; insulin pumps and infusion devices; disposable insulin and pen cartridges; insulin cartridge delivery; injection aides; syringes and lancets; glucose monitors, control solutions, and strips (including features for visually impaired members); glucagon for injection; glucose kits; drawing-up devices for the visually impaired; automatic blood lance kits; cartridges for the visually impaired; equipment for use of the pump including batteries; glucose reagent strips and tapes; urine testing products for glucose and ketones; oral anti-diabetic agents and glucose tablets/gels; and additional supplies designated by the NYS Commissioner of Health. Note: this rider does not apply to diabetic insulin as it is not subject to cost-sharing under other Contract sections.

Maternity-related services (covered without member cost-sharing during pregnancy and up to 12 months postpartum)

Urgent care services; outpatient mental health and outpatient substance use services including partial hospitalization program services; all Preventive Care services listed in the Contract; Additional Benefits, Equipment and Devices listed in the Contract; all Prescription Drugs covered under the Contract; and services listed in the Outpatient and Professional Services section — these are not subject to member Cost-Sharing when obtained during pregnancy or within 12 months after delivery.
Members remain responsible for applicable Cost-Sharing for Physician, nurse practitioner, and midwife services for delivery and for inpatient Hospital and birthing center services for delivery.
Members continue to be responsible for Cost-Sharing for Emergency Services; inpatient mental health services; inpatient substance use services; Ambulance and Pre-Hospital Emergency Medical Services; Inpatient Services generally; and Pediatric Vision Care as listed in the Contract.

All other Contract terms remain in effect except as modified by this rider; coverage and the absence of Cost-Sharing apply only while waiver funding is available.

Diabetic and Maternity Coding / Coverage Windows

Diabetic services and supplies (service-level descriptors)mixed

	Primary care office visits for the diagnosis, management, and treatment of diabetes (Cost-Sharing may apply to other services provided during the same visit or if diabetes service is not the primary purpose of the visit).
	One office visit annually for diabetic foot exam (including when performed by a Specialist).
	One office visit annually for dilated retinal examination (including when performed by a Specialist).
	Diabetes self-management education services provided by a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law, or their staff during an office visit; certified diabetes nurse educators, certified nutritionists, certified dietitians, and registered dietitians in a group setting when practicable upon physician referral; in-home when medically necessary.
	Laboratory procedures and tests for the diagnosis and management of diabetes.
	Diabetic equipment and related supplies when prescribed by a Physician or other Provider legally authorized to prescribe: Acetone reagent strips; Alcohol or peroxide by the pint; Acetone reagent tablets; Alcohol wipes; All insulin preparations; Automatic blood lance kit; Cartridges for the visually impaired; Diabetes data management systems; Drawing-up devices for the visually impaired; Disposable insulin and pen cartridges; Equipment for use of the pump including batteries; Glucose acetone reagent strips; Glucagon for injection; Glucose kit; Glucose monitor with or without special features for visually impaired, control solutions, and strips for home glucose monitor; Glucose reagent tape; Injection aides; Glucose test or reagent strips; Injector (Busher) Automatic; Insulin infusion devices; Insulin cartridge delivery; Insulin pump; Lancets; Oral agents such as glucose tablets and gels; Oral anti-diabetic agents; Urine testing products for glucose and ketones; Syringe with needle; sterile 1 cc box; Additional supplies designated by NYS Commissioner of Health by regulation.
	Prescription drugs for the treatment of diabetes that are on Our Formulary when prescribed by Your Physician or other Provider legally authorized to prescribe.
	This rider does not apply to diabetic insulin as it is not subject to cost-sharing under other sections of this Contract.

Postpartum coverage window

Duration12 months after delivery

Applicability windowApplies to covered services obtained during pregnancy and within 12 months of delivery

Scope noteWaiver funding applies toward member deductible and out-of-pocket limit for listed covered maternity-related services during this 12-month postpartum period

Provider Requirements and Billing Notes

Billing Rule

Maternity-related Waived Cost-Sharing — Provider Billing & Documentation Requirements

For maternity-related waived cost-sharing, providers must confirm the service is for a pregnant member or delivered within 12 months postpartum to qualify for waived cost-sharing. Waived categories include urgent care; outpatient mental health and outpatient substance use services (including partial hospitalization); preventive care services; items and services listed in Additional Benefits, Equipment and Devices; Prescription Drugs covered under the contract; and outpatient and professional services listed in the contract. Note: Cost-sharing still applies for physician, nurse practitioner, and midwife services for delivery and inpatient hospital and birthing center services for delivery, as well as Emergency Services, inpatient mental health and substance use services, ambulance/pre-hospital emergency services, inpatient services, and pediatric vision care.

Verify pregnancy or delivery date in medical record to support waived cost-sharing eligibility (during pregnancy or within 12 months after delivery).
Document clinical indication and relation to pregnancy in the claim/encounter and medical record.
For services that are part of the waived categories but are billed together with non-waived services (for example, an office visit that includes a non-maternity primary purpose), document the primary reason for the visit; cost-sharing may still apply to non-maternity services provided at the same visit.
When billing outpatient professional services and preventive services that are waived during pregnancy/postpartum, submit the appropriate pregnancy-related diagnosis codes and place of service so claims adjudicate correctly.
Do not expect waived cost-sharing to apply to delivery and inpatient birthing facility charges or Emergency Services; bill and code these services per standard contract terms.
For outpatient mental health/substance use services and partial hospitalization provided during pregnancy or within 12 months postpartum, include documentation of pregnancy/postpartum status on the claim or in the supporting records if requested.
If a service is specifically excluded from waived maternity cost-sharing in the contract, follow normal benefit and cost-sharing rules and document accordingly.

Documentation Required

Diabetic Services — Referral, Documentation, and Billing Implications

For diabetes-related waived services, ensure referrals and documentation meet the contract requirements and bill using appropriate codes and modifiers so diabetic education, annual diabetic foot and retinal exams, laboratory testing, and diabetes equipment/supplies are recognized as waived when applicable.

Obtain and document a referral from the patient’s physician or other authorized prescriber when referring to non-physician certified diabetes educators, nutritionists, dietitians, or registered dietitians for diabetes self-management education (DSME).
Document the indication for DSME: initial diagnosis of diabetes, significant change in symptoms/condition requiring education, or a documented need for refresher education.
Provide DSME in a group setting when practicable; document if home education is provided and the medical necessity for home delivery.
Bill DSME, annual diabetic foot exam, and annual dilated retinal exam using the appropriate CPT/HCPCS codes and include referral/authorization documentation in the medical record to support waiver of cost-sharing.
Ensure durable medical equipment and supplies for diabetes (insulin pumps, monitors, lancets, glucose strips, glucagon, etc.) are prescribed by an authorized provider and supported by clinical documentation; submit prescriptions and supporting records with DME/supply claims as required.
When diabetic services are rendered during a visit where the primary purpose is not diabetes care, clearly itemize services and document the primary reason for the visit — cost-sharing may still apply to non-diabetic services provided at the same encounter.

Defined Terms

Cost-Sharing (member financial responsibility)

DefinitionCost-Sharing = member financial responsibility such as copays, coinsurance, and deductible contributions

Waiver effectFederal waiver funding will apply toward member deductible and Out-of-Pocket Limit for specified covered services while funding is available

Exclusions (examples)Members remain responsible for applicable Cost-Sharing for emergency services, inpatient services generally, and certain delivery-related inpatient and professional delivery services

When appliedWaived for listed diabetic and maternity-related covered services as described in the Contract while funding is available

Diabetes self-management education

Service descriptionDiabetes self-management education: instruction designed to teach proper self-management and treatment of diabetes, including nutrition

Qualified providersPhysicians, other health care providers authorized to prescribe under NY Education Law Title 8, or their staff; certified diabetes nurse educators; certified nutritionists; certified dietitians; registered dietitians

Referral requirementNon-physician medical educators covered when provided upon referral of Your Physician or other Title 8 authorized prescriber

Setting and frequencyCovered during initial diagnosis, when a physician diagnoses a significant change necessitating education, or for refresher courses; may be provided in group settings when practicable

In-home provisionEducation will be provided in the member's home when Medically Necessary