Questions to Ask Your Health Insurance Provider About Diabetes Insurance Coverage
Over the last few weeks, many blogs have focused on healthcare policy and insurance concerns. Appropriate care for chronic illnesses depends on the ability to obtain medical consultation, supplies, and medications. Indeed, "going bare" with an illness such as diabetes is a prescription for potential bankruptcy.
A piece on National Public Radio discussed the insurance woes of two individuals with chronic illness: a young man with colo-rectal cancer who recently lost his job (and insurance) and a woman with a brain tumor that worked part-time without insurance. Both discussed the trials of obtaining appropriate medical care and how the new healthcare policy may alleviate some of the worry behind the payment of medical costs. In both cases, life was very stressful. Even with medical insurance, out-of-pocket costs are substantial.
What questions should you ask of your insurance company after your child or teen is diagnosed with diabetes? (These questions are handed to our new patients at diagnosis.)
- Do you have a PPO, POS, HMO, or an Indemnity Insurance Plan? These distinctions truly matter as the policy's rules may dictate specific healthcare providers, the need for referrals by your primary care practitioner, co-payments, and high-end deductibles. Prescription medication often has a separate plan. Know ahead what your responsibilities are and be prepared.
- Do you need a referral from your primary care physician for diabetes follow-up visits? If so, how long is the referral good for? Or for how many visits? Keep in mind that most diabetes teams would like for you to visit every 3 to 4 months. If you come to the office without a referral, it is likely that you will not be seen due to hospital or clinic policy. (Exceptions are made in extenuating situations by the healthcare provider.)
- Do I have an office co-payment for an office visit, or do I pay the total amount and get reimbursed? If I go "out of network" to a particular provider, do I have a higher co-payment? And, is a particular diabetes team important to you? If that is the case, you need to determine which providers the insurance company will cover to determine if you want to pay "out-of pocket" and get partially reimbursed (especially with some indemnity plans).
- Where am I allowed to get my blood work done? Can I use my clinic/hospital lab or must I go to a specific laboratory (Quest diagnostics, Laboratory Corporation of America <Labcorps>, etc.) This is a very important matter especially with small children who dread having blood drawn via vein. In my institution, Children's National Medical Center, children are required to get annual laboratory work where a venipuncture is required once a year. The other three times, only a hb A1c is necessary, which can be obtained by a finger stick and determined in a DCA 2000 Analyzer in each of our outpatient sites. Some of the labs will not allow patients to receive the finger stick Hb A1c and require them to get the A1c drawn via vein and sent to their lab. We often write letters of medical necessity to the insurance company to avoid having to do venipunctures at every visit.
- Does my insurance pay for medical nutrition therapy (a dietician or nutritionist)? As you know by now, medical nutrition therapy is an integral component of diabetes management. Carbohydrate counting, portion control, glycemic index, etc., are essential concepts that are critical to managing diabetes successfully. We ask our patients to see the dietician at least once yearly and before beginning intensive insulin therapy (basal/bolus and insulin pump).
Does my insurance plan reimburse for:
- Blood glucose meters (am I limited to a particular brand of meter based on my insurance company requirements)?
- Or a certain number of test strips/month? We often write prescriptions as follows: One touch ultra test strips, Accuchek Aviva test strips, freestyle test strips, Bayer test strips, "any brand" test strips etc. Test 4 - 8 times/day; Dispense: 30 day supply: 240 test strips; Refill 30 days (or 4 times etc.) (medically necessary)
We write the prescriptions in this way to ensure that our patients obtain enough strips to test as frequently as necessary.
1. Insulin syringes.
2. Insulin. (Am I limited to a particular brand of insulin?) Do I need prior authorization to use insulin pens? This is very important especially if you wish to insulin in schools, as many schools require insulin in pen form if you do basal/bolus therapy. Some insurance companies have higher co-pays based on brand of insulin simply because they reached a better deal with the pharmaceutical company. Most insulins in a certain category behave similarly. Sometimes the diabetes physician may want to use certain insulin for specific reasons and may have to write on the prescription that is medically necessary and fight with the insurance company to have the same co-pay as for the other insulin.
4. Ketone test strips--can you use individually foil wrapped ketone strips? Can you use blood ketone test strips (precision extra)?
5. Glucagon emergency kit. Can you have one for home and one for school? Can you have one at each parent's home if there is joint custody?
6. Does my insurance plan have a mail order program for maintenance medication? It may be cheaper to get your prescriptions by mail.
7. Does my insurance plan have a DME (durable medical equipment contract (for diabetes supplies other than medication, as in syringes, test strips, lancets, etc?) This is an extremely important aspect of an insurance plan. Does it cover an insulin pump in full, or a percentage? Does the plan cover continuous glucose sensors, pens, etc? Do you need pre-authorization ?
It is extremely important to make a detailed list of questions to ask any potential insurance plan to make an educated choice. My suggestion is to ask your diabetes team the plusses and minuses of each insurance plan in your locality. In this way, you will be able to decide which is best for your family.