The CDC continues to report that “diabetes is the largest and fastest growing chronic disease in the nation”. In 2007, the total cost of diabetes was 147 billion a year and increased in 2012 to 245 billion. In 2012, about 39% of people with diabetes were insured by private/employer based insurance and 44% were insured by Medicare, a government health program created for people over 65. The number of people with diabetes covered by ACA or Affordable Care Act has not been listed at this time but all participants should be covered since “pre-existing” conditions no longer exist. Starting in 2014, job based plans could not deny patients with pre-existing conditions either. Each state has different mandates related to diabetes care coverage so always check with your individual state. Each insurance plan within the state may vary as well. Most states (excluding four) since 2009 require coverage for direct treatment of diabetes including the supplies and equipment used by the patient at home. Medicare Part B requires a premium from you but covers diabetes screenings, diabetes self management programs, nutrition services for diabetes, glucose testing supplies and associated diabetes supplies. Medicaid is an insurance plan for low income individuals and is funded through federal and state money and offers certain diabetes benefits. Other health insurance options include the VA-Veterans Affairs for those who served in the armed forces and provides medical care for diabetes. Health insurance plan changes for the following year are available starting in the fall (generally Oct. 15- Dec.7). If purchasing a brand new plan, it may extend thru February.
Most patients try to get in their required tests and examinations prior to December 31 since they have already meet their yearly deductible. I often hear my patients complain about their health insurance bills, phone experiences with the insurance company and lack of knowledge when they talk about health insurance benefits. Many are unaware of the benefits of their health insurance. They also do not look for changes or costs from year to year in their existing plans. Let’s look at ways to be more familiar with your insurance provider so you can make better informed decisions and understand what you are entitled to especially with diabetes.
- Do not call on Mondays. Most people are trying to get through after the weekend with a limited amount of people working the phone lines. The same usually applies for Friday afternoons so try to call on Tuesday, Wednesdays, Thursday or Friday mornings for the least amount of frustration while waiting on hold. If you are computer savvy, you may be able to accomplish the same thing online with no wait.
- Have available or order the Summary of Care and Benefits. Most people receive this once a year or only once if they renew their existing plan and place it somewhere never to be found again. Not knowing what you are entitled to in writing can be challenging when on the phone with a representative. This pamphlet is usually presented in simple language, not medical wording. It can be ordered in other languages if English is not the primary language. There is a document called the “Evidence of Coverage” which may need to be specially ordered since it has more benefit specifics.
- Have your actual insurance card and ID numbers along with the medical prescription. When placing a call to your insurance company, have your current card available since they will ask for information and numbers found on the card. It is suggested that you carry your health insurance card at all times except a Medicare card since it is your social security number. Most individuals memorize their social security numbers so it should not present a problem. You should also have your prescription available so you can give the correct procedure codes from your doctor. Since these are extremely specific, make sure you can read them accurately before giving the information. This will allow the representative to find out if your test or treatment is covered in a more timely matter.
- Supervisor or nurse. If you are unhappy with the answer, continue asking questions. Many times insurance companies employ registered nurses as case managers who may be more acquainted with your medical condition and are more willing to talk to you in detail. They also may be more empathetic to your medical problems. If there is no nurse case manager, a supervisor may have additional authority and information.
- Check the medical bill and match to the explanation of benefits. You will receive both of these important papers after your test/procedure/treatment. The explanation of benefits from the insurance company will show you what they have paid and what you still owe to the provider. You may be able to negotiate with the provider if you owe a large amount of money after insurance coverage. Work with the billing department or billing specialist in the office not the provider for further reductions.
- Get it on paper. Everything that is discussed on the phone about benefits and coverage should be faxed or E-mailed in writing for future proof. It is difficult to get a verbal answer and make it stick with a unique situation. It is especially important if the decision is not followed through in the proper manner. Make sure to get a name (first) and ID number from the representative you are speaking to. You may be able to record the conversation as they often do for quality assurance.
- Take your notes. Write down the date, time, issue, case number if given, and representative’s name and ID number in a place you will easily find it. Place it on a calendar and follow up in 2 weeks if you did not resolve the problem in one phone call. You will not need to repeat every detail again to a new agent.
- Be polite. Many times we are infuriated on these phone calls and forget proper manners. The person would appreciate you being pleasant with “please and thank you” along with a personal name. Kindness gets the job done more than hostility and rudeness.
- Know the meaning. “Durable medical equipment.” This term includes insulin pump supplies, blood glucose meters and accompanying supplies as well as oxygen, wheel chairs and hospital beds. “Out of pocket max” means the most you pay before the plan covers 100%. “Donut Hole” means the time your Medicare plan stops paying for medications which you must pay out of pocket for a period of time. “Premium” is money you personally pay towards your insurance monthly or annually. There are many words to understand and keeping a list may be helpful to refer back to as needed.
- Know how to choose. Be aware of what you choose or what your employer chooses. They may offer you different plans with high deductibles or low premiums which may not be a benefit in the end. Understand what you paid out of pocket last year to get an idea about the following although it is not a guarantee.
This is just a brief introduction to Insurance 101. Each year it seems to get more complicated so stay informed and ask questions. You can look on many sites on line to comparison shop as well as hiring an insurance professional to guide you through the process. Good Luck!
NOTE: Consult your Doctor first to make sure my recommendations fit your special health needs.
She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past.
She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups.