Almost everyone with diabetes has a run in with health insurance concerns at one time or another. A quick search of "diabetes" and "insurance" brings up hundreds of forum topics with people talking about their insurance woes. Most people with diabetes either have insurance that won't cover enough of their diabetes needs, like test strips, labs, and doctor's visits or don't have insurance to help at all.
If you have insurance, how do you get them to give you the coverage you want and need? If you don't have insurance what other options do you have? There are a couple of things you can do to help insurance maneuvering go smoother and we’ve listed some of them below. We’ve also included some helpful links for further reading.
Know your Insurance
Your physician and diabetes healthcare team will help determine what you need for good control. Be sure to obtain any referrals that may be needed to see specialists, such as an endocrinologists or internist or diabetes educator who specializes in glucose control and handling of diabetes complications. From their suggestions, you want to check with your insurance company to see what they cover, which brands they cover, and what amounts they cover. Find out if you have to visit certain pharmacies for your supplies. Your copay may be lower if you order your medications and supplies by mail. You should ask about test strips, insulin, medications, lancets, syringes, insulin pumps, continuous glucose monitors and any other supplies your team suggests. Also, ask if they reimburse for cash purchases from companies that don't accept insurance payment.
Most insurance companies cover insulin pumps and supplies. The pump companies will help you through the insurance process if you contact them. Visit our Current Insulin Pumps page for links. Some insurance companies still don’t cover CGMs but coverage is becoming more common so make sure you ask. They have been covered in people with Type 1 diabetes. Dexcom, makers of the Seven Plus Continuous Glucose Monitoring System, will actually contact your doctor and insurance company to help this process along if you are purchasing their monitor. Medtronic, makers of the Guardian System, has negotiated in-network coverage rates with some major insurance companies. Their specialists can help you figure out if you have coverage under your current plan.
My Insurance Says I Don't Need That Many Strips
One of the common excuses insurance companies use to deny you all the test strips you want is "you don't need to test as often as you do." Since diabetes is mostly a self-managed disease and varies from person to person, there's no formula to determine exactly how many strips you need. Although there's a minimum amount you should be testing and the rare individual will test too much, only you and your diabetes healthcare team can determine these numbers. This means you need data to backup the amount of test strips you are requesting. This can come in the form of smart chart record books, logbooks, meter downloads and online tracking. An elevated A1c test, history of severe hypoglycemia, or the presense of diabetes complications shows that you need the extra test strips. Here are some other things you should bring to your doctor's and insurer's attention:
- Any complications related to hyperglycemia
- Paramedic visits or ER visits for hypoglycemia
- Hypoglycemia Unawareness
- Glucose Variability
- You have a job that requires alertness at all times (safety concerns)
- Your job increases the chances of low blood sugars
- You live alone or your spouse leaves for work early before you get up
- History of High A1cs
Dealing with Diabetes If You Don’t Have Insurance
One of the biggest challenges with any long-term health condition is finding appropriate insurance. Dealing with diabetes without insurance can be tough but there are options available.
Diabetes Assistance Programs
If you lack health care coverage, many drug companies provide healthcare assistance if you meet specific requirements. Take a look at our Diabetes Assistance page for sites that can help you get specific assistance. For the pharmaceutical sites, determine who manufactures the drug you need and contact them to see what assistance they can provide.
Online Stores & Generic Medications
Visiting places like the Diabetes Mall will help save tons of money, especially on recurring costs like test strips. Try to buy generic medications, when possible, like in Walmart's $4 Prescription Program. Some generic medications will be less expensive than your copay when you simply pay cash for them. As always, consult your doctor.
Diabetes is a pre-existing condition so you have to inform your possible insurer about it, otherwise you could run into issues with claims later on. The term pre-existing condition refers to a physical or mental condition for which you obtained medical advice, care, or treatment before enrolling in a policy. Luckily, preexisting conditions were addressed last year in the Affordable Care Act. From the healthcare.gov site:
National program established July 1, 2010
A Pre-Existing Condition Insurance Plan (PCIP) will provide new coverage options to individuals who have been uninsured for at least six months because of a pre-existing condition. States have the option of running this new program in their state. If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. This program serves as a bridge to 2014, when all discrimination against pre-existing conditions will be prohibited.
- HIPAA-eligible - HIPAA established special protections for certain people when they lose group health coverage
- Individual Insurance - for people who do not have access to employer-sponsored group health coverage and they do not qualify for public programs, such as Medicare or Medicaid
- High-Risk Pools - uninsured people with diabetes who have been continually uninsured for six months or more
- COBRA - permits employees and their dependents, in some circumstances, to continue on an employer's group health plan even after coverage would otherwise end
- State Continuation - some employees and/or their dependents who have lost group health insurance coverage to continue receiving their existing coverage following specified qualifying events.
- Conversion - when group coverage ends (for example, if you leave your job, get divorced from an insured worker, or if your employer stops offering health benefits), you have the right to buy a non-group health insurance policy from your former group insurer.
- TAA Tax Credit - health care tax credit (HCTC) is equal to 65 percent of the premium paid for "qualified" health coverage for people eligible for the credit and their dependents.
Other Insurance Information Resources:
Timeline: What's Changing and When - Timeline showing when different parts of the Affordable Care Act will take effect
Georgetown University Health Policy Institute - Health insurance and coverage help for consumers everywhere