Chapter 18
Navigating Health Insurance and Other Healthcare Scenarios
IN THIS CHAPTER
Seeing how the Affordable Care Act applies to people with diabetes
Knowing where you can get insurance
Finding help when you don’t have insurance
Preparing for other healthcare scenarios
Health insurance is a hot-button topic that weighs on everyone’s mind and impacts everyone’s wallet. Most Americans have differing opinions about how it should work — including who and what it should cover. But everyone can agree on one thing: Access to healthcare, medications, and supplies keeps getting more expensive.
People with diabetes should have access to health insurance because it helps them afford medications (including insulin), blood glucose meters, test strips, and insulin supplies. It also allows people with diabetes to visit their healthcare providers for preventive care, routine management, and treatment for life-threatening complications of diabetes.
In this chapter, we give you the lay of the land in terms of the health insurance marketplace, including protections that specifically affect people with type 2 diabetes. These things can change quickly, so stay informed by visiting www.diabetes.org or www.healthcare.gov for updates. You also find tips for finding diabetes care and supplies if you don’t have health insurance. Finally, we give you some specifics on hospital stays, home healthcare, and long-term care.
Protecting People with Diabetes
The Affordable Care Act (ACA), also called Obamacare, was passed in 2010 and afforded Americans — particularly people with diabetes and their families — new health insurance protections.
This protection could change if the ACA is repealed or significantly modified. Whatever happens, it’s important to know how the landscape of health insurance changed for people with diabetes with this act.
Under the ACA, people with preexisting conditions such as diabetes cannot be denied health insurance coverage or charged a higher premium. This is true for both employer-based plans and individual plans. Also, plans cannot cancel insurance policies for people because they’re diagnosed with diabetes or other conditions.
Also, young adults can stay on their parents’ health insurance until they’re 26 years old under the ACA, so children with diabetes don’t need to worry about losing their health insurance until they’re in their mid-20s.
Free preventive care also changed under the ACA because all plans are required to offer it. As a general rule, preventive care covers diabetes screening for adults with certain risk factors or pregnant women. It might cover obesity and high cholesterol screening. Medicare also covers specific preventive care programs for people with diabetes, which we outline later in this chapter.
The ACA also mandated that health insurance plans cover “essential health benefits” such as medications, chronic disease management, and hospitalization — and plans can’t put a cap on how much they’ll pay for these benefits each calendar year or during a person’s lifetime while enrolled in that plan. The details of these benefits vary by plan and by state, so it’s important to do your homework when shopping for plans.
One more thing under ACA: Anyone can request an easy-to-read explanation of his benefits from his health insurance company. It’s called a Summary of Benefits of Coverage (SBC). For instance, you can ask for an example of how the plan might cover a typical patient with type 2 diabetes.
Understanding Health Insurance: Employer, Government, and Individual
Health insurance is offered through three primary channels in the United States today. You can get health insurance through your employer, you can qualify for government-based health insurance such as Medicare or Medicaid, or you can buy health insurance on your own. The following sections tell you what you need to know about each form of insurance.
Employer-based health insurance
Your employer may offer health insurance to its employees; many people are familiar with this type of insurance. The coverage is usually offered for you and your spouse and dependents.
Employer-based health insurance is not the same across all companies. Large companies may offer their employees several health insurance plans to choose from. Small companies may only offer one insurance plan (and some very small companies offer none). Small businesses can buy insurance through a program called the Small Business Health Options Program (SHOP) marketplace, which can make health insurance more affordable.
Generic drugs are cheaper than brand-name drugs, so ask your pharmacist or provider about whether a generic version could be a cost-saving option. This also goes for diabetes supplies like meters and test strips. Switching to a store-brand version could save you money.
Government-based health insurance
Medicare, Medicaid, and the U.S. Department of Veterans Affairs provide health insurance for many Americans. Important coverage for people with diabetes is included within government programs, so read on for more details.
Medicare
Medicare is the federal program that provides health insurance for millions of Americans 65 years of age or older. It also provides health insurance to people with certain disabilities and people with end-stage kidney disease. Medicare is run by the Centers for Medicare and Medicaid Services, which is part of the U.S. Department of Health and Human Services.
You’ll still have to make co-pays and pay for certain services or medications under Medicare. Check out www.medicare.gov for more details.
Medicare is broken down into different parts (A, B, C, D, and Medigap), and you’ve probably heard these terms mentioned on the news or during commercials. You’re not dreaming if you think Medicare is complicated. It’s a large government program that has specific rules and coverage. And it’s been around (and modified plenty) for the past 50 years. Here’s a breakdown of what each part covers:
- Medicare Part A: Medicare Part A covers hospital costs, including skilled nursing facilities, hospice, and some home healthcare.
Medicare Part B: Medicare Part B covers medical costs, including visits to your diabetes care provider, medical equipment and supplies, diagnostic tests, and outpatient visits to a hospital or physical therapy. Part B is important for people with diabetes because it covers things like blood glucose meters, test strips, and lancets. It also covers preventive care such as tests for diabetes, cardiovascular disease, obesity, and eye disease. It covers diabetes education and nutrition therapy.
Medicare Part B covers the following services for diabetes:
- Diabetes education (10 hours at diagnosis and up to 2 hours yearly)
- Dilated eye exam
- Foot exam
- Glaucoma test
- Medical nutrition therapy
Coverage for these services can vary so ask your provider for details.Medicare Part B covers the following supplies for diabetes:
- Blood glucose meters, control solution, and test strips. Continuous glucose monitors (CGMs) may also be covered depending on the manufacturer.
- Insulin pumps (and pump insulin), if medically necessary
- Lancet devices and lancets
- Therapeutic shoes or inserts
You may have to buy these supplies from certain suppliers for coverage under Medicare Part B. Also Medicare offers a national mail-order program for diabetes supplies. For more information on this mail-order program visit www.medicare.gov/what-medicare-covers/part-b/dme-diabetes-national-mail-order-program.html.- Medicare Part C: Medicare Part C is actually a system of Medicare Advantage plans, which are private health plans. They cover Part A, Part B, and sometimes Part D in one package. It’s a different way of receiving Medicare benefits than traditional Medicare. You can find more details about these plans at
www.medicare.gov. Medicare Part D: Medicare Part D covers prescription drugs like pills for blood glucose and insulin supplies. You buy a Part D plan and pay a separate premium and co-pays for your medication. Each plan may cover different medications or brands, so take your time to review plans before making a decision.
Medicare Part D plans usually cover the following supplies for diabetes:
- Blood glucose medications
- Syringes, needles, and alcohol swabs
- Insulin (not given through a pump)
- Medigap: Medigap is private insurance that covers the extra costs of Medicare such as co-pays and deductibles.
Medicare can be confusing. For more details about this complicated government insurance, check out Medicare For Dummies, 2nd Edition, by Patricia Barry (Wiley).
Medicaid and CHIP
Medicaid and the Children’s Health Insurance Program (CHIP) provide health coverage for millions of low-income Americans and their families, and those with disabilities. Medicaid is a joint federal and state program; you can find out more on your state’s Medicaid website or at www.medicaid.gov.
CHIP provides low-cost health insurance for children and teens whose families can’t afford employer-based or individual health insurance, but whose incomes are too high to qualify for Medicaid. Pregnant women may qualify, too. Go to www.insurekidsnow.gov to find out more about this program.
TRICARE
TRICARE is a healthcare program for active-duty and retired service members and their families. Go to www.tricare.mil to find out about eligibility and coverage for diabetes medical care and supplies. The U.S. Department of Veterans Affairs provides healthcare for veterans. Go to www.va.gov for more info.
Some states have Consumer Assistance Programs that can help people with concerns about health insurance and claims: www.healthcare.gov/how-can-i-get-consumer-help-if-i-have-insurance.
Individual health insurance
You may need to purchase your own health insurance if you’re unemployed, if you’re self-employed, or if you don’t qualify for the government-based insurance plans explained in the preceding section. You can buy individual and family health insurance plans on health insurance marketplaces or exchanges. And you buy this plan in your state; some states such as Colorado and California run their own marketplaces, while other states such as Georgia and Hawaii rely on the federal government to run these marketplaces. Visit www.healthcare.gov to find your state’s marketplace. You can also buy individual and family health insurance plans directly from insurance companies.
Fill out an application on the marketplace to find out your health insurance plan options. This will also tell you whether you qualify for government programs such as Medicaid and CHIP or whether you qualify for financial assistance. You can enroll or change plans in the fall or winter for coverage in January of the following year. Certain life events like losing your job, changing your marital status, or having a baby will allow you to change plans at different times.
Coverage for diabetes medication and services varies from plan to plan on the individual marketplace. It’s up to you as the consumer to compare the price of premiums, deductibles, medications, and diabetes supplies.
Everyone with health insurance has likely been denied coverage for a service or medication that they thought would be paid for. It feels terrible. And it can be very expensive, too.
Don’t be shy about filing a claim (also called an appeal) once, twice, or even three times. You may need to ask your provider to write a letter on your behalf explaining why you need a particular medication or a particular device like a continuous glucose monitor or an insulin pen as opposed to a syringe (which may be easier for people with dexterity issues). You may also need to write your own letter and provide records.
Asking the Right Questions
Choosing the right insurance coverage, especially when you have a chronic disease like diabetes, can be difficult and frustrating. To help make this process a little easier, the following sections detail questions to ask about diabetes coverage when selecting an insurance plan and questions to ask to determine which plan is right for you.
Questions to ask about diabetes coverage
When considering what insurance plan to sign up for, make sure you compare apples to apples as best you can. Use the following questions to understand how different insurance companies cover diabetes care:
- How many times can I see my diabetes care provider each year?
- Can I see a provider of my choice or will it cost extra?
- How much will I have to pay each visit?
- Does the plan allow me to see a specialist of my choice — such as a podiatrist or dermatologist? Will I need a referral from my primary care physician? And how much extra might it cost?
- Are eye exams covered? How much will they cost?
- Does the plan cover mental health, such as sessions with a therapist?
- Which prescriptions are covered? What’s the co-pay, and does the company offer a prescription plan to reduce costs?
- Does the plan cover blood glucose meters, strips, syringes, pens, or other necessary supplies? Which brands and how many each month?
- Does the plan cover insulin pumps and continuous glucose monitors for people with type 2 diabetes?
- Does the plan cover diabetes education and medical nutrition therapy? How many hours?
Sometimes plans offer tiers of coverage for different medications. When comparing plans, make a list of your current medications and see where they fall in the coverage tier. Add up these co-pays to determine your monthly outlay for medications.
You can ask your provider or pharmacist for assistance in determining coverage for your medication under your plan.
General questions to ask about plans
Use the following questions to choose an insurance plan that best suits your needs:
- How much will the plan cost each year?
- What is the deductible? In other words, how much do I have to pay before I get coverage?
- After I’ve met my deductible, how much will I pay for services?
- What is the co-pay for different services?
- Which doctors can I see as part of my plan?
- Which hospitals can I go to as part of my plan?
- Is home healthcare or long-term care included?
Finding Help for People Who Don’t Have Insurance
Some people can’t afford or don’t have access to health insurance. People with diabetes who are uninsured need assistance paying for basic and specialty care, prescriptions, and supplies. The following sections can help you obtain the care you need.
Primary and specialty care for the uninsured
The Bureau of Primary Health Care oversees a network of community health centers that offer free and sliding-scale services for people who can’t afford medical care. Visit www.bphc.hrsa.gov to find a community health center in your area.
EyeCare America (www.aao.org/eyecare-america) and VISION USA (www.aoafoundation.org/vision-usa) offer free eye exams to low-income and uninsured people. Also, the Patient Access Network Foundation (www.panfoundation.org) offers help with payments for certain treatments and medications that patients can’t afford.
Prescriptions for the uninsured
Partnership for Prescription Assistance (www.pparx.org) helps people find free or low-cost medications by partnering with pharmaceutical companies, doctors, and other groups. Simplefill (www.simplefill.com) is another program that helps patients find low-cost medications.
RxAssist (www.rxassist.org) and NeedyMeds (www.needymeds.org) have websites where you can search for prescription assistance programs.
These are just a few of the programs out there, and the American Diabetes Association doesn’t endorse any particular program. Pharmaceutical companies may also offer their own patient assistance programs for those in need.
Diabetes supplies for the uninsured
Rx Outreach (www.rxoutreach.org) is a nonprofit mail-order pharmacy offering diabetes medications and supplies at a discounted price. CR3 Diabetes Association offers discounted supplies such as pumps, meters, and tests strips (www.cr3diabetes.org). The National Council on Aging also offers a tool for searching for programs that could save you money (www.benefitscheckup.org).
Anticipating Other Healthcare Scenarios
Regular checkups aren’t the only time that you’ll see doctors and nurses. You may check into the emergency room or hospital or need home care or long-term care.
Your diabetes may not be the thing that prompts you to check into the hospital or decide on a skilled nursing home. In fact, it could be for something completely different like a fall or pneumonia or just not feeling safe living alone. Nevertheless, consider your diabetes when navigating these different scenarios. In this section, you find tips and action steps to take when being admitted to a hospital or long-term-care center or receiving healthcare (such as physical therapy or dialysis) in your own home.
ER visits and hospital stays
No one wants to go to the hospital or emergency room, but inevitably you may find yourself there some day or evening (perhaps even at midnight). Sometimes a hospital visit is easy to predict, like when you have a scheduled surgery. Other times, it’s unexpected, like when you slip on that nasty patch of ice going to the mailbox.
Emergency room visits
The number-one thing to remember when you find yourself in the emergency room (ER) is to tell the doctors and nurses that you have type 2 diabetes. Then tell them about any other conditions such as eye disease or high blood pressure. Also, be sure to tell them if you frequently experience episodes of low blood glucose and describe your own personal symptoms. Don’t be embarrassed. You may not be able to tell a nurse these things when you’re actually experiencing a low. (See more about lows in Chapter 8.)
Consider wearing a medical ID bracelet to inform first responders and ER staff that you have type 2 diabetes. This could be important if you’re unconscious for some reason. Order ID bracelets (from fashion to sport versions) at www.shopdiabetes.org, other online retailers, or your local pharmacy. You can engrave bracelets with your name, the words type 2 diabetes, an emergency contact number, or essential medications like insulin.
Planned hospital stays
If your hospital stay is scheduled, ask the hospital staff how they’ll help you manage your blood glucose during your stay. For example, the staff will probably monitor your blood glucose during your stay so you may not need to worry about bringing your meter or test strips to the hospital. However, specifically ask the hospital staff how they plan to monitor blood glucose and whether to bring your meter. You may also stop taking diabetes pills and switch to insulin during your stay.
Your physical activity and food probably won’t be the same. You may not be able to do all the things that you normally do, so come up with a plan for your hospital stay. If the hospital has a dietitian on staff, you can ask to speak to that person. Ideally, you’ll be able to keep your blood glucose in your target range, which will help you get healthy faster and reduce the risk of complications.
Consider asking your diabetes care provider about which hospital she recommends in your area. You may only have one hospital in town, but if you have alternatives, it’s helpful to know the most respected facility for caring for people with diabetes.
Scheduled surgery
If you’re having a surgery that your doctor schedules ahead of time, you’ll have more time to plan ahead for your hospital stay. Ask your doctor how to best prepare for your upcoming procedure. For example, she may recommend that you have your blood glucose in a certain range. You may also need to stop taking certain medications like blood thinners. Ask whether you’ll need to tweak your insulin regimen beforehand or temporarily withhold any blood glucose medications.
Tell the surgeon and the anesthesiologist that you have type 2 diabetes, and give them a list of all the medications that you take for diabetes and any other conditions. Ask how your blood glucose will be managed during surgery.
Going home: The good and the bad
Getting discharged from the hospital and going home is wonderful. You might be able to sleep in your own bed again or eat your favorite snack. But it can also make some people nervous, especially if they’re worried about taking care of themselves or managing a new regimen.
The hospital should provide detailed instructions about how to take care of yourself, including changes to your diabetes care routine. However, you may consider calling your diabetes care provider, diabetes educator, or another member of your team to follow up. You can also ask them questions, talk about concerns, or schedule an appointment for a checkup.
Home healthcare and long-term care
Home healthcare is an option if you need help taking care of yourself but want to stay in your own home. Sometimes this could happen when you get discharged from the hospital but you still need to do physical therapy or receive care. Sometimes people with type 2 diabetes and kidney failure have dialysis treatments at home.
Several home healthcare agencies provide these services, so check with your health insurance about coverage. Ask for recommendations on these agencies from your diabetes care team and friends and family.
When comparing health insurance plans, don’t forget to look at coverage for home healthcare. Home healthcare is often covered under Medicare, but check your benefits, too.
You may need long-term care if you go to a rehabilitation center or specialty hospital. Long-term care can also refer to a skilled nursing facility or nursing home where doctors and nurses are available 24/7. Choosing these centers is not always easy, so ask for recommendations from people you trust.
If you can, visit the facilities ahead of time and bring a friend or family member for their insight. You can find resources at www.eldercare.gov and compare nursing homes at www.medicare.gov. Hospital discharge planners and social workers can also help.
Long-term care is not always covered under health insurance, and sometimes it’s not fully covered. You can purchase long-term-care insurance to plan for your needs down the road.