Top-notch diabetes control often requires higher-than-average costs for diabetes equipment (meters, test strips, syringes, etc.) and key medical interventions (medications, education, visits to primary care physicians, specialist exams, etc.). Because of these costs, people with diabetes frequently ask how to choose the right health plan with the right coverage at a price they can afford. The best method is comparing the “diabetes alphabet soup”—or coverage specifics—of different plans. The ideal time to do this is during the open enrollment period with their employer or during the sign-in period for the health market exchanges under the Patient Protection and Affordable Care Act. To help make this task easier, the most important specific coverage items for people with diabetes are outlined below. (Click here for a downloadable PDF of “Items in Plan Coverage.”)
Items in health insurance plan coverage.
Let’s take a deeper dive into the language of health care that will help you shop for health insurance.
About the Patient Protection and Affordable Care Act
If you are not able to obtain health insurance through your employer and are not yet eligible for Medicare, your best option may be purchasing a major medical plan on the government health marketplace exchange under “Obamacare.” Review each plan’s coverage carefully using the table. In addition, make sure the plan you choose meets all the Affordable Care Act (ACA) requirements under the law, especially coverage of the 10 essential health benefits: doctor’s office visits; emergency room services and hospitalization; pregnancy and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services and devices; laboratory services; preventive services; chronic disease management; and children’s health services (including oral and vision care).
These full benefit plans are known as qualified health plans (QHPs). A QHP is also eligible for purchase with an Obamacare subsidy, which is a premium tax credit. Subsidies are helpful to people who are earning less than 400 percent of the federal poverty level. But it’s important to understand that a subsidy is based on that given year’s income. If you earn more than expected in 2018, you may need to repay some of — or the entire — subsidy you collected.
To obtain more information on the health marketplace in your state, visit https://www.healthcare.gov or call (800) 318-2596.
Diabetes: Your protections under the law
You cannot be denied coverage or charged more because you have a pre-existing condition such as diabetes. This is true for new plans sold both inside and outside the government health insurance marketplace under the ACA. Plans can only set higher premiums based on age, tobacco use, family size, and geography.
In addition, plans must limit how much you pay out of pocket for benefits and must provide certain health services aimed at preventing disease at no charge. Plans cannot set a dollar limit on the amount the insurance company will spend on “essential health benefits” either in a given year or during the entire time you’re enrolled in that plan. However, plans can still impose other types of limits on benefits, such as number of doctor visits, prescription drugs, or days in the hospital.
Health plans outside of the ACA
Health insurance can also be purchased directly from a health insurance company outside of the government marketplace. These plans, which go by many different names, may or may not meet all of the same minimum requirements as plans sold through the marketplace. In addition, you will not be able to get federal subsidies to help pay the premiums for these private health plans. These are the main types of plans.
Health maintenance organization (HMO)
Covers only care provided by doctors and hospitals inside the HMO’s network. Patients are usually required to get a referral from their primary-care physician to see a specialist.
Preferred provider organization (PPO)
Covers care provided by both in-network and out-of-network providers, but patients usually pay a higher percentage of the cost for out-of-network care.
Exclusive provider organization (EPO)
Similar to HMOs. Health care received by out-of-network providers is not covered, but patients may not need a referral to see a specialist.
Point of Service (POS) plan
Hybrid of an HMO and a PPO. A referral to see a specialist may be required, but coverage for out-of-network care may also be available with higher out-of-pocket costs.
National, federally administered health insurance program authorized in 1965 that covers the cost of hospitalization, medical care, and some related health services for most people over age 65 and certain other eligible individuals. There are multiple parts of Medicare.
Part A: Hospital insurance
Part B: Medical and outpatient insurance (A and B constitute Original Medicare). People with diabetes are concerned with Part B, which covers the following: most medically necessary doctors’ services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, medical nutrition therapy, diabetes self-management training, continuous glucose monitoring, mental health care, insulin used in insulin pumps, external insulin pumps, blood glucose meters, test strips, lancets, lancet devices, glucose control solutions, therapeutic shoes and inserts, and some home health and ambulance services. You do pay a monthly premium for this coverage.
Part C: Medicare Advantage Plans. These plans are offered by private insurance companies that contract with the government. They provide hospital and medical benefits included in Original Medicare coverage (with the exception of hospice care) and cover additional health benefits beyond Original Medicare. Currently, they are the only Medicare options that offer both health and prescription drug coverage in one plan.
Part D: These plans (sometimes called Prescription Drug Plans (PDPs) add drug coverage to Original Medicare. The plans cover insulin not used in a pump, certain medical supplies to administer insulin (syringes, needles, alcohol swabs, and gauze), inhaled insulin devices, glaucoma tests, foot exams and treatment. They are offered by private insurance companies contracted with the government. Medicare beneficiaries may already have drug coverage from an employer or union of TRICARE (military health plan, the Department of Veterans Affairs [VA], the Indian Health Service or a Medicare Supplement Insurance [Medigap] policy). If this is the case, it’s best to compare your current coverage to the Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options for the specific prescription medications you take for your diabetes. Also note that your Medicare Advantage Plan (Part C) will disenroll you and you’ll go back to Original Medicare if both of these apply: 1) your Medicare Advantage Plan includes prescription drug coverage and 2) you join a Medicare Prescription Drug Plan (Part D).
Medicare Supplement Plans: Also known as Medigap Plans, these plans are sold by private insurance companies to help cover some of the health-care costs and benefits not covered by Original Medicare, Part A and Part B. To be eligible to enroll in a Medicare Supplement Plan, you must be enrolled in both Medicare Part A and Part B and live in the state in which the plan is being offered.
A health-care program funded jointly by states and the federal government for families and individuals with limited financial resources. It provides health coverage to about 69 million Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. Federal law requires states to provide certain mandatory benefits and allows states the choice of covering other optional benefits. Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and s-ray services, and home health services. Optional benefits include prescription drugs, case management, physical therapy, and occupational therapy. For a list of mandatory and optional benefits for Medicaid programs, visit: https://medicaid.gov/medicaid/benefits/list-of-benefits/index.html.
Health savings accounts (HSAs) and flexible spending accounts (FSAs)
These accounts may be offered by employers as a way for you to set aside money to pay for medical costs, referred to as “qualified expenses.” These expenses include deductibles, copayments and coinsurance, and even monthly prescription costs. Sometimes employers will also contribute funds to these accounts. To pay for qualifying expenses throughout the year, the employee usually receives a debit card. These accounts also have tax benefits, but they differ between plans. Utilizing one of these accounts can be a very smart move to save you money on your diabetes health care. But knowing which account to select takes some education on the key differences between HSAs and FSAs.
Key differences between HSAs and FSAs.
Which account should you choose? It may be best to opt for an HSA if you qualify because the limits are higher and you can carry over your contributions from year to year. If you don’t qualify, sign up for the FSA.
How much should you contribute? Be sure your contribution is enough to cover your plan’s deductible, expected medication costs, anticipated doctor’s visits, and any planned treatments or surgeries. Use the worksheets typically provided by employers to help determine the ideal amount. These accounts can be quite complicated, so ask your human resources representative any questions you have.
Over-the-counter (OTC) medications
Under the ACA, insurers must cover certain OTC preventive medications at 100 percent with no copayments, coinsurance, or deductibles, but only when the patient obtains a prescription. In addition, FSAs and HSAs also reimburse the cost of OTC medicines when they are purchased with a provider’s prescription. Eligible prescribed OTC expenses include acid controllers, antidiarrheal medications, cold sore remedies, sleep aids, painkillers, respiratory treatments, and others. To get these reimbursed from a FSA or an HSA, the employee needs to provide a sales receipt that reflects the date of sale and the amount of the charge, along with a copy of the prescription, according to the Internal Revenue Service.
Optimal diabetes control requires daily vigilance to healthy behaviors. It also requires regular medical interventions by qualified providers and specialists and prescription medications. People with diabetes need a quality health plan to help them secure these interventions and medications at their most affordable costs.