Diabetes and Insurance

Within the United States each state regulates the laws that pertain to health insurance. There are some federal regulations and laws, including COBRA (Consolidated Omnibus Budget Reconciliation Act) and the privacy act (HIPPA), which are in effect across all states. Understanding your options as an individual with diabetes means doing research as to the specific laws and insurance options within the state in which you reside.

Some individuals may qualify for Medicare Part B, which provides a set rate coverage that does not include co-pays or deductibles, leaving these to the patient to cover. It is possible to have Medigap, Medicaid or Medicare HMO coverage that does not require any co-pays or deductibles or covers the payments through a supplemental policy. Private insurance companies will list deductibles and co-pays in the policy. Most policies have a set limit as to the number of doctor’s visits or other services that are provided under the coverage. Knowing the specifics of your policy is important in scheduling medical appointments and ensuring that any treatment options or equipment you select is covered partially or fully by the policy.

Guaranteed Health Insurance Coverage

People that do not qualify for Medicare or Medicaid and are not currently insured may still be able to get health insurance in a state that offers guaranteed health insurance coverage. Not all states offer this option but, if available, it provides that any resident, regardless of health status, must be insured. This coverage becomes effective if you have been without health care coverage for 63 days from health insurance through an employer or through a private coverage option.

Children diagnosed with diabetes may qualify for health care coverage under a plan that is in place for one or both of the parents.  Not all health insurance programs offer dependent coverage but there are programs that do both as employer sponsored policies as well as private insurance. S-CHIP is offered in all states to provide health insurance coverage for children of low income parents. Many families can qualify for this insurance for children even if parents are covered on their employer’s health insurance policy.

Research into the management of pediatric diabetes and the type of insurance the family has shows interesting results. Children that were privately insured had better HbA1c levels, more frequent use of insulin pens and higher use of multiple daily injections or insulin pumps for effective blood glucose regulation. Conversely children using public insurance limited use of the insulin pen and had higher HbA1c levels with lower rates of use of insulin pumps. 1

Training and Education

Medicare and many private insurance companies now provide, within the policy coverage, for doctor ordered medical nutrition therapy as well as diabetes self-management training. This can include up to 10 hours of diabetes self-management training depending on the policy and the doctor’s prescription. In addition each person can be prescribed up to 2 hours of self-training per year and an additional 2 hours of medical nutritional training. The training must be provided by a recognized program or a recognized healthcare provider. Checking to make sure that the individual or organization selected is approved for coverage is important.

Most training, both self-management and nutritional, is completed in a group setting. There may also be community based meetings that are available for diabetics and their families regarding nutrition and self-management. Many of these may be offered at no cost to participants and therefore require no insurance coverage to attend. However, it is essential to verify that the provider is knowledgeable and has the appropriate training to receive the information required on self-management and nutrition.

Insurance Policy Coverage

Depending on the specifics of the policy, various medical equipment and supplies may be covered under the policy along with doctor’s office visit, emergency room visits, ambulance transportation, and hospitalization. This may include covering insulin pumps, related supplies and training and education on the use of the insulin pump. Individual policies will have a deductible that the diabetic must cover, with the insurance then paying out as per the policy on any amounts over that level and up to the coverage limit.

Most individual’s seeking insurance coverage privately in the United States will be covered for all prescribed diabetes supplies including medications and associated services. Options for additional equipment or medical supplies that are not prescribed but are beneficial to the patient are typically not covered under insurance. This is true for employer provided insurance as well as private insurance and Medicare or Medicaid.

Recent research has shown true benefits to providing reimbursement for physical exercise and activity programs for those diagnosed with type 2 diabetes, gestational diabetes and prediabetes. This statement is supported by the American Diabetes Association as well as the American College of Sports Medicine as a cost saving option for insurance companies to provide to diagnosed patients with these types of diabetes. 2

Another key consideration which is not offered on most health insurance policies is the treatment of mental health problems, such as depression, that are more prevalent in populations of people over the age of 18 with diabetes. In a research report using the Behavior Risk Factor Surveillance System from the year 2007, it was found that several factors including ethnicity, age, lack of health insurance and unemployment were the greatest factors for diabetics with serious psychological distress failing to get treatment for their mental health condition. 3

Private health insurance companies can refuse coverage to any individuals based on a pre-existing condition or based on age, health status and even the gender of the individual with the condition. High risk pools have been established in many states to provide coverage to those that have existing health conditions and have difficulty in being privately insured. There may also be options for insurance through Blue Cross Blue Shield which will insure many people that have difficulty finding adequate insurance coverage through a private insurance company. Employer policies cannot deny coverage based on health status.

New healthcare laws recently passed by congress may significantly change the way insurance is provided. The final implications of these laws are not yet known, but will develop over the coming months and years.

References

1 Wintergerst, K. A., Hinkle, K. M., Barnes, C. N., et al. (2010). The impact of health insurance coverage on pediatric diabetes management. Metabolism Clinical and Experimental , 40-44.

2 Pahor, M. (2011). Consideration of Insurance Reimbursement for Physical Activity and Exercise Programs for Patients With Diabetes. The Journal of the American Medical Association , 1808-1809.

3 Li, C., Ford, E. S., Zhao, G., et al. (2010). Undertreatment of Mental Health Problems in Adults With Diagnosed Diabetes and Serious Psychological Distress. Diabetes Care , 1061-1064.

4 This article was originally published July 12, 2012 and last revision and update of it was 9/10/2015.