What Is Covered?
Don't wait to ask your health insurance provider
When you were diagnosed with diabetes, what worried you most? Figuring out what you could eat? Injecting insulin?
The cost of managing diabetes might not have occurred to you right away, but it probably didn't stay out of mind for long. People with diabetes average twice as much in health care costs as people who don't have the disease. That's why having health insurance is vital—and so is knowing what your insurance covers. The coverage offered by private health insurers, employer-based group plans, Medicare, Medicaid, and other programs varies widely. Right after your diagnosis—seriously, the day after—read your policy and highlight any areas of confusion. (Some basic terms are defined in a glossary below.) Then check your insurance provider's Web site, or call the insurer or your employer's benefits representative, and ask questions. Here are some that need answers:
Am I covered right now?
If you have recently been diagnosed with diabetes and you're in the process of buying individual health insurance, you may have problems getting coverage (find out what to do if you don't have insurance, here). If you have purchased individual coverage, or are about to enroll or have recently enrolled in a group plan (after switching jobs, for instance), your diabetes care may not be covered right away. Most insurance companies impose a "preexisting condition exclusion period"—a waiting period after your enrollment before your diabetes care will be paid for. Find out how long any waiting period will be. If you're in a group plan, federal law limits the wait to no more than 12 months. You may be able to get the period reduced or waived.
Where can I go?
Find out which health care providers and pharmacies are covered under your plan. Check if you need to get a referral to see a specialist, including your endocrinologist, optometrist, and podiatrist. Does your policy pay for diabetes education, including visits with a registered dietitian or certified diabetes educator? If you belong to a health maintenance organization (HMO) or an exclusive provider organization (EPO), your doctors must be in-network for their services to be covered. In a preferred provider organization (PPO), you may see an out-of-network physician, but check to make sure that you can afford higher out-of-network costs. And remember: The doctors and pharmacies that are covered under your plan may change throughout the year—doctors can drop insurers in the middle of the year and vice versa.
What supplies and medications are covered?
Your doctor, nurse, or educator can give you a sense of what you'll need in the months to come. When you check with your insurance company, you'll want to find out how many test strips per month are covered under your policy. This may vary depending on whether or not you are on insulin. For many diabetes supplies, your policy may cover only certain brands. So before you buy that less expensive blood glucose meter or are given one free of charge, make sure the test strips that go with it are covered.
Ask also about insulin, type 2 medications, lancets, syringes, insulin pens, insulin pumps, continuous glucose monitoring systems (CGMs), and any other supplies you need. Many insurance companies don't yet cover CGMs. You may have to try writing, calling, sending copies of bills, and getting a doctor's note (or a "letter of medical necessity") to argue your case for getting the device covered. Many plans also require "prior authorization" of certain prescription drugs, including paperwork from your doctor explaining why you need the medication. Note that many employers use one insurer for health care coverage and another for prescription drugs. Make sure that nothing you need falls through the cracks between the two.
What tests are covered?
See if your insurance company covers the tests you need regularly: A1C, lipid panel, metabolic panel, microalbuminuria test, and eye exam. Many plans will cover A1C tests only two or three times a year, leaving you to pay out of pocket for any extra tests that your doctor recommends. Your policy may also cover a test only if you wait a minimum number of days between tests.
How much will it cost me?
To begin budgeting for your annual health expenses, tally what you'll have to pay for regular office visits. Add up the cost of your diabetes supplies, including ongoing purchases like insulin and test strips. Factor in possible hospital stays and emergency room visits. Assume you will reach your policy deductible, and make sure you can afford it. Find out if there's a limit on how much you have to spend out of pocket in a year, and if there's a limit on what the insurance company will pay out. If you have individual coverage, weigh your monthly premiums against your annual deductible and the services provided. If you're covered under an employer's group policy, find out what your employer pays for your coverage each month. It's important to know what your insurance would cost you should you lose your job.
What about health savings accounts or flexible spending accounts?
These accounts may be offered by your insurer or your employer as a way to save tax dollars on anticipated health expenses. In an HSA, you can roll over unused dollars into the next calendar year, but in an FSA, you must use them up or you lose them for the year. Both options allow you to set aside part of your salary on a pretax basis. They are great choices for people in high-deductible plans and with lots of individual health expenses throughout the year.
What happens if my claim is denied?
If you receive an explanation of benefits (EOB) saying a service is not covered, when you believe it should be, you will have to submit an appeal of the denied claim. Many insurers require you to file the appeal within days of the denial.
What if I have Medicare?
If you are covered by Medicare, figure out first what coverage you have. Medicare part A typically includes inpatient hospital and emergency room visits, while part B covers doctor's office visits, lab tests, and diabetes supplies. Medicare part D is your prescription drug coverage. Supplies like meters and strips are covered under Medicare's "durable medical equipment" clause. Find out how to get your insulin covered. Whether you use a pump or not determines which part of the Medicare program pays for your insulin. In general, Medicare does not cover pumps for people with type 2.
Staying on top of your diabetes means also staying on top of your insurance coverage. Examine any EOB summaries you receive, and be sure to check your policy periodically. What is covered under your policy can change, and those changes are easy to miss.
Flummoxed by insurance mumbo jumbo? Here's a glossary of basic terms:
COBRA: a 1986 law (the Consolidated Omnibus Budget Reconciliation Act) under which former employees and family members who have lost health insurance may have the right to continue receiving benefits temporarily at a former employer's group rate. The insured person generally must pay the full policy premium, including the part once paid by the employer.
Co-pay: an out-of-pocket payment that an insured person must make upfront for a medical service, such as a doctor's visit or prescription medicine. The co-pay amount is set by the insurance policy and varies with the type of service.
Deductible: the amount that an individual must pay out of pocket for health care expenses in a given year before an insurer starts paying for medical claims under a policy. Not all health plans have a deductible.
Explanation of benefits (EOB): a statement from an insurance company after a medical claim is filed detailing the cost of treatment, the portion paid by the insurer, and the amount due from the insured person.
Formulary: a list of prescription medications, both brand-name and generic drugs, that an insurance policy covers, in part or in full. The list separates medications into tiers; "preferred" drugs cost the patient less in a co-pay than other medications.
Group plan: a health insurance plan covering a number of people under one policy. Most group plans are provided through employers. Group rates are generally lower than individual rates.
Preexisting condition: a medical condition that exists before a patient gets health insurance coverage. If you have no current health policy, many insurers may deny you coverage because of the condition. If you are enrolling in a group plan, you may face a waiting period before coverage begins.
Referral: sending a patient from one medical provider to another for services. Often a referral must be approved by an insurer for a service to be covered