Evidence-Based Programs → DSMES

 

Diabetes Self-Management Education and Support

 

This page is intended to provide an overview of diabetes self-management education and support (DSMES) programs for a state health department audience. Information is also provided on diabetes self-management training (DSMT), which is the term applied to the program by the Centers for Medicare and Medicaid Services (CMS) when defining the reimbursable Medicare benefit. The page is organized into the following sections:

  1. Introduction to DSMES
  2. Medicaid Coverage for DSMES
  3. Key DSMES Medicaid Benefit Decision Points
  4. Facilitators and Barriers to Medicaid Beneficiary Enrollment in DSMES
  5. Medicare Coverage for DSMT

Introduction to DSMES

DSMES is an evidence-based program to help people with diabetes manage blood sugar, improve overall health, foster healthy coping strategies, and prevent or delay diabetes-related complications. The program can be tailored to individual needs, goals, and life experiences and is intended to help participants learn strategies to manage their diabetes. DSMES participants have been shown to have better diabetes-related outcomes, including reductions in A1C and all-cause mortality and improvements in quality of life and self-efficacy (see additional studies that highlight the benefits of DSMES here, here, and here). DSMES and diabetes self-management training (DSMT) refer to the same general programming, where DSMT refers to the recognized term for the specific services covered by Medicare.

Those with type 1, type 2, or gestational diabetes are all eligible to participate in DSMES, but a payer may require a referral from a provider. Medicare and many Medicaid benefits cover up to ten hours of initial training (generally one individual session and up to 9 group-based sessions) and up to two hours of follow-up sessions each calendar year after completion of the initial training period. While initial DSMT is a “once-in-a-lifetime” benefit, Medicare beneficiaries can participate in recurring follow-up sessions each year, as needed.

DSMES is traditionally delivered by diabetes care and education specialists who help participants develop a unique diabetes management plan. A multidisciplinary DSMES team can include registered nurses, mental health specialists, or community health workers (CHW). DSMES can be delivered in-person, virtually, via telehealth, telephone, text messaging, or web-based/mobile phone application (however covered delivery methods vary by payer). It can be delivered in a variety of settings, including traditional health care facilities like hospitals and clinics, federally qualified health centers (FQHCs), or pharmacies, as well as community-based organizations, and faith-based organizations.

As captured in the 2020 consensus report released by ADA, the Association of Diabetes Care & Education Specialists (ADCES), and other leading diabetes organizations, the infographic below describes the four key times that DSMES is most beneficial: at diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop, and when transitions in life and care occur.

Diabetes-Self-Management---four-critical-times

While there are many ways DSMES providers support participants outside the structured curriculum, formal complimentary diabetes support programs also exist, such as the University of Illinois Chicago’s Diabetes Empowerment Education Program (DEEP). These programs are often reimbursable and can be utilized alongside DSMES programming to reinforce effective diabetes management strategies.

Requirements and Resources for DSMES Delivery Organizations

To ensure appropriate quality and standardized delivery of DSMES services, all certified programs are required to adhere to the National Standards for DSMES. The six standards are intended to guide the delivery of DSMES to ensure that programs are evidence-based, tailored to the specific needs of individuals, and provide a framework for ongoing support of patients and their families. These standards are revised by a team of interested parties and subject matter experts every five years.

ADA and ADCES are authorized by CMS to serve as the accrediting bodies for DSMES. ADA grants “recognition” to organizations through the Education Recognition Program (ERP), while ADCES grants “accreditation” through the Diabetes Education Accreditation Program (DEAP). DSMES providers recognized or accredited by these organizations must also adhere to the National Standards for DSMES to access Medicare and some Medicaid reimbursement. Accreditation and recognition requirements and processes for both organizations are compared here.

A DSMES Toolkit, developed by the CDC, provides resources to increase the uptake of DSMES for individuals or organizations that deliver the program. The toolkit is designed to communicate the clinical and economic benefits of DSMES services, clarify the process for establishing a DSMES program and meeting minimum national standards to be eligible for reimbursement, provide resources and tools to become a recognized or accredited DSMES provider, and describe common barriers to DSMES use (including tips for overcoming these barriers).

Medicaid Coverage for DSMES

A LawAtlas Policy Surveillance Program tool compiles information on health insurance coverage laws for DSMES. The interactive map details the extent of private and public coverage for the program, in addition to specific benefit requirements related to diagnoses, cost sharing, providers, program features, and approved program locations. A static recreation of the map is provided below. This map incorporates data from ChangeLab Solutions (2017) and has been updated to include additional coverage information obtained by NACDD and its partners as of July 2025. However, information is provided with the understanding that it is not guaranteed to be correct or complete and conclusions drawn from this information are the responsibility of the user.

State-Medicaid-Coverage-for-DSMES

Making the Case for Medicaid Coverage for DSMES

A ChangeLab Solutions publication titled, Establishing and Operationalizing Medicaid Coverage for Diabetes Self-Management Education and Support: A Resource Guide for State Medicaid and Public Health Agencies, developed in collaboration with NACDD and funded by CDC, examined strategies for supporting state health department and Medicaid agency staff in their efforts to increase coverage and utilization of DSMES services in their states. The publication offers guidance for public health professionals at state health departments who are working with their colleagues at state Medicaid agencies to make the case for covering DSMES. The five key steps are summarized below:

  1. Build relationships and maintain communication between state health departments and state Medicaid agencies: Key actions include identifying the right Medicaid contacts, engaging agency leadership early, and understanding each agency’s mission and goals. Public health professionals are encouraged to participate in Medicaid meetings and host regular collaborative discussions to align on shared priorities. Public health can provide valuable resources, such as data analysis, outreach, and staff support, to help Medicaid navigate policy implementation. These partnerships can also promote innovative approaches like value-based care and population health strategies.
  2. Gather data and create a budget projection: For most Medicaid agencies, staying within budget is critical, so providing accurate cost projections and determining potential cost savings for covering DSMES is important. To produce budget projections, data will need to be gathered on the eligible Medicaid population, the cost of offering the service, and the expected cost savings in other areas of the budget. The Budget Projection Template for DSMES and Budget Projection Template for DSMES Instructions can be used to estimate the total cost of providing DSMES to eligible beneficiaries.
    Budget Projection Template for DSMES
    Budget Projection Template for DSMES Instructions
  3. Assess Medicaid coverage options for DSMES: Various pathways can be used to achieve Medicaid coverage for DSMES, including (1) requiring coverage through state law, administrative code, or budget documents; (2) incorporating DSMES as a covered service in the Medicaid State Plan or a section 1115 demonstration waiver; and (3) delivering DSMES through Medicaid MCOs. It is important to consider state-specific dynamics related to how the Medicaid program is constructed and delivered and complementary benefits, such as the National Diabetes Prevention Program (National DPP) lifestyle change program, when determining the most viable coverage mechanism for DSMES.
  4. Engage leadership and influence decision making: To advocate for Medicaid coverage of DSMES, clear and strategic communication with state Medicaid decision-makers is vital. This involves sharing compelling evidence, including clinical benefits, economic impact, and health equity considerations. Effective advocacy includes presenting data from reputable sources (like the ADA, ADCES, CDC), highlighting potential cost savings, and emphasizing quality of care improvements such as those included in the DSMES Consensus Report. Building two-way communication at both leadership and operational levels helps ensure progress. Identifying champions within Medicaid or public health leadership strengthens advocacy efforts. Timing is also key—align messaging with Medicaid budget cycles, contract negotiations, or legislative sessions. Understanding your state’s Medicaid coverage decision process is essential.
  5. Operationalize and sustain the benefit once coverage is achieved: After a state decides to cover DSMES, Medicaid and public health must collaborate to implement and support the benefit effectively. Key steps include defining roles, such as Medicaid handles benefit design and billing, while public health leads outreach and education. A shared work plan with clear tasks and timelines helps coordination. States must enroll DSMES providers, educate them on the benefit, and promote awareness among health care providers and beneficiaries. Ongoing evaluation through claims data and surveys ensures continuous improvement and alignment with national standards.

    6. State Examples of DSMES Coverage in Medicaid

    The CDC’s report Emerging Practices in Diabetes Prevention and Control, Medicaid Coverage for DSME describes the experiences of three state health departments – Colorado, Mississippi, and New York – as they worked towards attaining Medicaid coverage for DSME in collaboration with their state Medicaid agency. The CDC transitioned from using the term DSME to the more comprehensive and accurate term DSMES following the publication of this report. Each state was bolstered by strong relationships between state health departments and Medicaid colleagues, compelling use of public health and cost data, and strong contributions from DSME partner stakeholders. These examples are summarized below.

    Colorado

    As of July 1, 2015, Colorado Medicaid began covering DSME for beneficiaries with type 1, type 2, or gestational diabetes. This initiative was the result of collaboration between Colorado Medicaid, the Department of Public Health and Environment (CDPHE), and other stakeholders. To support implementation, a provider toolkit was developed with help from Telligen and CMS resources. Outreach efforts involve leveraging provider networks, FQHCs, and diabetes educators to raise awareness and promote DSME utilization across the state.

    Mississippi

    On April 1, 2015, Mississippi Medicaid began covering DSME for eligible beneficiaries. Coverage requires physician diagnosis, medically necessary certification, and delivery by an ADA-recognized or AADE-accredited provider. This achievement stemmed from the efforts of the Diabetes Coalition of Mississippi, relaunching in 2014 to expand diabetes programs. The state health department supported provider training, outreach, billing guidance, and public education through brochures and radio announcements to promote DSME services statewide.

    New York

    The New York State Department of Health (NYSDOH) partnered with Medicaid officials to secure Medicaid reimbursement for DSME, which became law in January 2009. Initially, delivery of DSME was limited to certified diabetes educators in New York State, but in 2011, eligibility expanded to include other licensed professionals (e.g., nurses, dietitians, pharmacists) delivering care through ADA-recognized or AADE-accredited programs. Despite the policy, uptake remained modest (around 3.5–3.9% of eligible patients). To boost participation, NYSDOH and Medicaid hosted educator conference calls, distributed Q&As, sent regular Medicaid Update newsletters, and maintained a targeted email list to inform and engage DSME providers. For more information on New York State’s benefit, see this article.

    Key DSMES Medicaid Benefit Decision Points

    DSMES Medicaid benefits requirements can vary from state to state. Key state benefit decision points are summarized below.

    Participant Eligibility

    Participant Eligibility: States must select the diagnosis criteria participants must meet to be eligible for DSMES. In addition to diagnosis criteria, states can determine if a physician referral is required. Several examples of Medicaid benefit language are provided below, including ones that both require a referral and one that does not. Of note, DSMES providers interviewed by NACDD have widely reported that referral requirements can create barriers to enrolling Medicaid beneficiaries and others into the program.

    • Arizona: “Coverage is available for up to 10 hours of Diabetes Self-Management Training (DSMT) outpatient services, as defined in 42 United States Code Section 1395x. The services must be prescribed by a primary care practitioner in one of the following circumstances:
      1. the member is initially diagnosed with diabetes or
      2. the member was previously diagnosed with diabetes but a change has occurred in the member’s diagnosis, medical condition or treatment regimen or the member is not meeting appropriate clinical outcomes.
    • Colorado: “A DSMES beneficiary must have:
      1. A diabetes diagnosis
        1. A diagnosis of type 1, type 2, or gestational diabetes is required to qualify for DSMES. According to national coding and diagnostic standards, diabetes is defined as a condition of abnormal blood glucose metabolism using the following diagnostic criteria:
          1. A1C of 6.5% or higher OR
          2. Fasting plasma glucose of 126 mg/dL or higher OR
          3. Two-hour plasma glucose of 200 mg/dL or higher during an oral glucose tolerance test OR
          4. A random glucose test of 200 mg/dL or higher for a person with classic symptoms of hyperglycemia or hyperglycemic crisis
      2. A written referral for DSMES, provided by a physician provider or qualified non-physician provider

      Qualified non-physician providers are defined by Health First Colorado (Colorado’s Medicaid Program) as: a nurse practitioner, clinical nurse specialist, advanced practice registered nurse, physician assistant, nurse midwife, clinical psychologist or clinical social worker and pharmacists who is managing a client’s diabetes education.”

    • New York: “DSMT is an essential element of diabetes care and may be provided to NYS Medicaid members with: newly diagnosed diabetes; diabetes who are stable; or diabetes who have a medically complex condition such as poor control of diabetes or another complicating factor.”

    Covered Services

    Covered Services: States can determine the total number of individual and group-based education allowable under the Medicaid benefit, both in the first 12 months and in each follow-up year. Under the Medicare DSMT model, ten total hours of education are allowed in the first year. Illinois, included below, determined that individuals may benefit from accessing additional sessions of DSME and/or Diabetes Support programs, so increased the allowable number of annual sessions to 18. Colorado’s example below is more in line with Medicare DSMT.

    • Illinois: “Eligible customers may receive up to 18 hours of DSMES services during each 12-month period beginning with the initial training date, including up to three hours of individual DSMES, and up to fifteen hours of group DSMES “
    • Colorado: “In the initial year, clients who have not previously received any services billed under codes G0108 or G0109 are eligible for one hour of individual and nine hours of group training, performed in any combination of 30-minute increments. This initial education benefit must be provided in a continuous 12-month period starting with the first date the DSMES benefit is provided and reflected on the claim.
    • After the initial 12-month period, a maximum of 2 hours of follow-up training is available as either individual or group education during each following year.”

    ADA-recognition, ADCES-accreditation, and state-based certification

    ADA-recognition, ADCES-accreditation, and state-based certification: It is common for states to require accreditation or recognition to access Medicaid reimbursement for DSMES. Note that many states build their Medicaid benefits to mirror the construction of the benefit in Medicare, where accreditation/recognition are also required. Some states also develop their own certification for DSMES providers. See below for Medicaid benefit language examples from Colorado, Michigan, and Illinois:

    • Colorado: “To provide DSMES, an entity must receive accreditation from the Association of Diabetes Care and Education Specialists or recognition from the American Diabetes Association.”
    • Illinois: “DSMES Provider Enrollment via the IMPACT System: Requirements – Accreditation from the Association of Diabetes Care & Education Specialists (ADCES) or recognition from the American Diabetes Association (ADA)”
    • Michigan: “Effective October 1, 2016, the following DSME (The change to DSMES came in 2020) coverage changes apply:
         A DSME outpatient service must be provided by a program that meets one of the following requirements:
      • Certified as a DSME program by MDHHS; or
      • American Association of Diabetes Care and Education Specialists (ADCES) accreditation by the Diabetes Education Accreditation Program (DEAP); or
      • American Diabetes Association (ADA) recognition requirements by the Education Recognition Program (ERP).”

    Approved service provision location(s)

    Approved service provision location(s): A state’s Medicaid benefit can stipulate the approved locations where DSMES can be delivered, including whether online, distance learning, telehealth, telephone, text message, or web-based/mobile phone app delivery of the program are permitted. Related to in-person provision of services, any Medicaid DSMES reimbursement guidelines closely follow Medicare guidelines that require sessions to be held at a Medicaid-enrolled outpatient facility or local health department. This limits providers’ options to provide sessions in more accessible locations, particularly in rural areas. Examples of approved service provision locations from Michigan and Illinois are provided below:

    • Illinois: “Services may be provided in the home, clinic, hospital outpatient facility, via telehealth, or any other setting as authorized and include: counseling related to long-term dietary change, increased physical activity, and behavior change strategies for weight control; counseling and skill building to facilitate the knowledge, skill and ability necessary for diabetes self-care; and nutritional counseling services.”
    • Michigan: “DSME must be furnished by an enrolled outpatient hospital or local health department (LHD) with the appropriate DSME program requirements on file with and approved by Provider Enrollment, provided by diabetes educators, and ordered by a physician or non-physician medical practitioner responsible for the beneficiary’s diabetic care.”

    Reimbursement

    Reimbursement: Payments for approved DSMES services are based on the state’s established codes and fee schedule. Many states base their reimbursement rates on Medicare DSMT rates, though these rates are often considered inadequate. State Medicaid agencies can provide a higher or lower reimbursement amount. Example fee schedules for Medicare and Colorado are provided below.

    • Medicare:
      G0108 – Individual: $53.05 per patient x ½ hour (1 unit)
      G0109 – Group (2 or more participants): $15.20 per patient x ½ hour (1 unit)
      Reimbursement rates above reflect 2025 Medicare National Payment Amount. These are National Average rates and the actual rate paid to any specific program will likely be somewhat higher or lower depending on the MAC locality, facility, and/or provider type. You can find state-specific fee schedules on the CMS website here.
    • Colorado:
      G0108 – Individual: $45.24 per patient x ½ hour (1 unit)
      G0109 – Group: $12.42 per patient x ½ hour (1 unit)
      Reimbursement rates reflect 2025 Colorado Medicaid physician fee schedule here.
    • Illinois:
      G0108 – Individual: $55.00 per patient x ½ hour (1 unit)
      G0109 – Group (2 or more individuals): $16.00 x ½ hour (1 unit)
    • Ohio:
      G0108 – Individual: $40.22 per unit x ½ hour (1 unit)
      G0109 – Group: $11.25 per unit x ½ hour (1 unit)

    Considerations for Improving a DSMES Medicaid Benefit

    States working to establish or improve their DSMES Medicaid benefit should consider the following factors that may facilitate access to the benefit or increase Medicaid beneficiary enrollment. These factors are based on interviews NACDD has conducted in recent years with DSMES suppliers, as described in the next section.

    • Improve low reimbursement rates.
    • Reduce or remove co-pays tied to the DSMES Medicaid benefit.
    • Allow for more flexibility in group and individual session requirements and in delivery location requirements (e.g., requirements that sessions must be held at a Medicaid-enrolled outpatient facility or local health department).
    • Expand Medicaid benefit eligibility (to all ages, to fee-for-service populations, to populations enrolled in MCOs, etc.).
    • Simplify the referral process as needed.

    Facilitators and Barriers to Medicaid Beneficiary Enrollment in DSMES

    NACDD, through funding and support from the CDC, partnered with four states (Delaware, Illinois, Michigan, and Missouri) to conduct a DSMES Enrollment Project pilot. The purpose of this pilot was to gain insights into facilitators and barriers to the uptake of DSMES services within Medicaid through a series of discussion groups. The facilitators and barriers identified through the project are summarized below.

    Facilitators to Medicaid Beneficiary Enrollment in DSMES

    DSMES Adaptations

    Flexible delivery – providing DSMES services (1) virtually, (2) during the evening or on weekends, and (3) at centrally located churches or community centers to better meet the needs of participants.

    Virtual delivery – reimbursing for virtual sessions helped to improve participation among Medicaid beneficiaries, particularly among women with gestational diabetes.

    Adapted services – adapting DSMES services culturally and linguistically to better meet participant needs.

    Marketing and Outreach

    Outsourcing marketing – working with a third party (e.g., umbrella hub organizations, community care hubs) for marketing and outreach of DSMES services.

    Direct outreach – placing a direct phone call or facilitating an in-person conversation can increase enrollment success compared to mass texts or generalized outreach.

    Partnerships and Networks

    Strong partnerships – developing and maintaining strong partnerships (with community organizations, primary care providers, etc.) can support marketing and other efforts to enroll DSMES participants.

    Networking – having access to both formal and informal networks to collaborate and problem-solve with other DSMES providers facing similar challenges.

    Referral Systems

    Strong referral systems – establishing referral protocols can improve access to DSMES services, especially when integrated into electronic health records (EHRs).

    Barriers to Medicaid Beneficiary Enrollment in DSMES

    Participation-Related Challenges

    Social drivers of health are conditions in the environments in which people are born, live, learn, work, play, pray, and age that affect a wide range of health, functioning, and quality of life outcomes. These drivers can make it difficult for Medicaid beneficiaries to participate in DSMES services. Providers often lack the capacity and resources to substantively address these challenges.

    Class timing and flexibility – Medicaid beneficiaries are often younger adults with fixed work schedules, making it difficult for them to attend in-person classes.

    Co-pays – Even small co-pays can deter participation, particularly for Medicaid beneficiaries.

    Benefit Design

    Delivery requirements – Many Medicaid DSMES reimbursement guidelines closely follow Medicare guidelines that require sessions to be held at a Medicaid-enrolled outpatient facility or local health department. This limits providers’ options to provide sessions in more accessible locations, particularly in rural areas. Group scheduling requirements also reduce providers’ ability to provide flexible scheduling options to Medicaid beneficiaries.

    Low reimbursement rates – Medicaid reimbursement rates are often not sufficient to cover the educator’s time, making DSMES services difficult to financially sustain, especially for smaller organizations.

    Referrals

    Burdensome referral processes – the DSMES referral process can be more time-consuming and complex than other referral processes—resulting in physician frustration and reluctance to refer to DSMES. Additionally, some DSMES providers only use paper or fax referrals and do not have access to EHRs. For more information on referrals, view the Recruitment and Referral page.

    Referring out-of-network – Some DSMES providers noted that referring providers may hesitate to connect patients with DSMES programs outside their network, concerned that patients might ultimately switch all their care to that external provider. While this outcome is theoretically possible, providers participating in discussion groups emphasized that their primary goal is to ensure patients receive needed DSMES services — not to disrupt existing care relationships.

    A sample DSMES referral form is available from ADCES here.

    Reimbursement

    Medicaid claim denials – Medicaid claims may be denied with little or no explanation, meaning the providers must spend time and resources going through appeals and re-submission processes.

    Inconsistent reimbursement across Medicaid managed care organizations (MCOs) – Working with MCOs is challenging as payment and reimbursement can be inconsistent across the different organizations. For more information on MCOs, see the Engaging MCOs to Attain Coverage page.

    ADCES maintains an FAQ document on DSMES and DSMT reimbursement, available here.

    Awareness, Promotion, and Marketing

    Lack of awareness of the benefit by MCOs, providers, and beneficiaries – DSMES services are often under-promoted meaning MCOs, medical providers, and Medicaid beneficiaries may be unaware that DSMES services are covered by Medicaid. Additionally, providers and beneficiaries may also be unaware of what DSMES services are and the value they bring to diabetes self-management.

    Lack of awareness of existing resources – Most DSMES providers expressed a desire for turnkey marketing materials but were unaware of existing marketing and support materials from CDC and other national partners.

    Securing a National Provider Identifier (NPI)– Some providers report the process for securing an NPI presents unique challenges. For more information on NPIs, see the National Provider Identifier section on the Determining Which Providers Can Deliver and be Reimbursed for the National DPP in Medicaid page.

    Medicare Coverage for DSMT

    DSMES and the DSMT refer to the same program, where DSMT refers to the recognized term for the specific services covered by Medicare. CMS uses the term “training” (DSMT) instead of “education and support” (DSMES) when defining the reimbursable Medicare benefit and is used specifically related to billing.

    Medicare Part B covers outpatient DSMT for members with a diabetes diagnosis. Medicare may cover up to 10 hours of initial training, where one hour is individual and the remaining nine hours are devoted to group training. These ten hours of initial training can be split out or grouped together in whatever combination is desired by the DSMES provider. For example, a DSMES provider can deliver their nine total group hours in nine 1-hour sessions or in three 3-hour sessions. Additionally, all sessions may be delivered individually if certain conditions are met, such as limited mobility, auditory impairment, etc. A written order (i.e. a referral) from a treating doctor or other health care provider is required to access DSMT.

    Members may also qualify for up to 2 hours of follow-up training each calendar year. CMS guidance states that “For beneficiaries who start the initial DSMT in one year and complete it in the following year, the follow-up may start in the month after the initial DSMT is completed. The two hours of follow-up per year can then be furnished on a calendar year basis. For beneficiaries who start and complete the initial DSMT in one year, the follow-up may start as of January of the following year. Any unused follow-up hours will be forfeited.” A new referral is required for follow-up DSMT.

    For more information on DSMT, visit the sites and resources linked below.

    Resources

Content Updated: July 30, 2025
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