Understanding Your Insurance Coverage

 

Diabetes: Understanding Your Insurance Coverage

Diabetes care is expensive, even if you have health insurance. Find out how to rate your current insurance coverage and any new plans you're considering.

You’ve got enough on your plate just managing diabetes without having to deal with sticker shock when it comes to paying for diabetes care. But the cost of living with diabetes can add up quickly if you don’t have the right insurance coverage for your diabetes treatment needs.
People with diabetes spend an average of $13,741 per year on health care, including medications, supplies, doctor visits, and hospital care, according to a new analysis completed by the American Diabetes Association. Their costs are more than double those of people without diabetes, who spend $5853 annually.
Those who have been living with the disease for a long period of time can face even higher financial demands as complications such as heart disease, neuropathy, loss of vision, and kidney disease mount. A review of data published in the Journal of Cardiac Failure found that older adults who have both diabetes and heart failure could be looking at costs topping $32,000.
All this means that having a solid health plan is going to make a long-term difference to both your diabetes management and your pocketbook. Whether you’re newly diagnosed or comparing different insurance plans, it’s important to consider your budget and your expected diabetes needs when evaluating coverage.
“Think about what costs the most and then ask about those particular items when talking to insurance companies,” advises certified diabetes educator Patricia Bonsignore, MS, RN, of Joslin Diabetes Center in Boston. “Diabetic supplies and copays for appointments and prescriptions are probably the areas that cost people with diabetes the most.” When these supplies aren’t covered, people face difficult choices, sometimes trying to reuse supplies like lancets long after they are working well or cutting back on testing to save test strips. “When shopping around for insurance," she said, "it’s also important to check about coverage for blood glucose strips and insulin.”

Here are the specific questions you should be asking:
1. What is my deductible? A plan can look really good until you realize you will have a budget-breaking deductible. That's the amount you will pay before the health plan kicks in.
2. What are my copays? Once you’ve met your deductible, you may still be responsible for a set amount, called a copay, for doctor visits, medications, and other expenses, with the insurance plan covering the rest. Look for a plan that gives you the best option for your medications – some plans offer very low costs for generics but not brand-name drugs or experimental treatments.
3. What is the out-of-pocket limit? This is the cap that you’ll be expected to pay over the course of each year. Once your deductible and copays reach this limit, the insurance company should be paying 100 percent of any other bills. Higher limits should mean lower premiums.
4. What preventive care is covered? People with diabetes, even early in the course of the disease, need to see ophthalmologists, dentists, podiatrists, and other specialists for preventive screenings at least annually.
5. Are dietitian or certified diabetes educator appointments covered?Working with one of these professionals will help you make the best decisions about your diet and person management plan for diabetes, helping you have better blood sugar control.
6. What supplies are covered? Diabetes treatment involves quite a few supplies, from blood test strips, blood sugar monitors, and lances to syringes and needles needed for those requiring insulin. Find out what supplies and what percentage of the cost of those supplies are covered. For example, pump users will want to ask whether pump supplies are covered at 80 percent or 100 percent, said Bonsignore. You’ll also want to know whether the supplies you could need one day in the future, such as continuous glucose monitors, are covered.
7. Is there a yearly limit on expenses or number of office visits? Also ask what happens once you’ve exceeded the limit. Paying the full cost of necessary medical treatments or medication can be pricey.
8. Is there a limit on reimbursements? Bonsignore suggests asking questions like "Is there a cap on how much is reimbursed per year for prescriptions or a limit on how many blood glucose strips are covered on a monthly basis?”
9. Are your current doctors on the new plan? If you’re considering a switch in insurance providers, check to see whether doctors you’re working with will accept your new plan.
Shopping for health insurance can get complicated quickly. Draw up a chart or spreadsheet that lists the name of each plan you’re considering at the top and then create a running list down the left-hand side that covers key areas of concern based on the questions above – deductible amount, copays for doctors visits, copays for medications, annual caps on reimbursements, supplies covered in the plan, your portion of the cost of supplies, and so on. Once you fill in the numbers, you’ll be able compare your options and calculate your bottom line.

Additional Cost-Saving Strategies

Your diabetes insurance plan isn’t the final word on how much diabetes will cost. Cost-cutting strategies will also help take the sting out of your bills, said Renee Amori, MD, an assistant professor in the division of endocrinology at the Drexel University College of Medicine in Philadelphia. For example:

• Practice prevention. You can reduce the possibility of additional costs from complications later in life by getting good control of diabetes now and getting regular screenings for early signs of complications, said Dr. Amori.
• Investigate flexible spending accounts. These accounts provide some pretax savings on eligible costs, including some health care costs. Talk with your employer about whether your company offers this and how it works.
• Find out about itemized tax deductions. Work with a tax professional to figure out whether your health expenses are deductible. You’ll need to keep thorough records and receipts for every expense throughout the year.
• Look for discount drug programs. Pharmaceutical companies and chain stores with pharmacies are good places to start looking for drug discounts or “frequent flyer” medication purchase programs.
• Talk with your doctor. Don’t expect your doctor to know the ins and outs of every insurance plan, but Amori said your doctor does need to know if you’re struggling to pay for medications or medical visits. Chances are your medical team can work with you on scheduling appointments in accordance with your coverage and choosing medications covered by your plan.

As more parts of the Affordable Care Act take effect, you may find that your coverage options improve. Insurers will no longer be able to deny coverage because of diabetes or limit benefits. For now, keep track of your expenses and continue researching the most cost-effective way of meeting your diabetes treatment needs.