Most health plans now cover this common disease to some degree. But what should you consider while buying health insurance if you have diabetes? You’ll learn about that and more.
According to the CDC, more than 30 million Americans are living with diabetes.
That’s about 10 percent of the population.
Some 85 million have prediabetes, a condition that can lead to Type 2 diabetes if not properly treated.
If you’re currently part of either group, this article is for you.
The same is true if you happen to join either group in the future. And make no mistake, many will do just that. Around 1.5 million Americans are diagnosed with the disease every year, says the American Diabetes Association.
Why? Because managing any form of diabetes is no easy task. For many, it means seeing doctors and specialists. And not just once in a while, but regularly. It often means taking insulin, and sometimes various drugs, too. And it usually means buying and using glucose meters and other pieces of medical equipment as well.
Affording all of that would be a real challenge if health insurance didn’t cover it. Thankfully, most plans help people pay for those and many other diabetes treatments, services, supplies, and medications.
Keep reading to learn more about that as well as more about:
As you’ve already heard, most health insurance plans cover diabetes treatments, services, medications, and equipment.
That hasn’t always been the case. Before the Affordable Care Act, insurance companies could deny coverage to Americans with diabetes (and other pre-existing conditions). Or they could charge them more because of their diabetes diagnosis. And they could put yearly and lifetime limits on how much they’d spend on diabetes care, too.
Little of that’s allowed today thanks to the ACA or Obamacare, as the law’s also known. In fact, only certain kinds of health plans can treat people with diabetes or other pre-existing conditions in these ways.
If you get your health coverage through an employer, it likely must follow the law and cover your diabetes care. The same is true of plans you buy through the Obamacare marketplace or directly from insurers. Medicare and Medicaid also cover most diabetes treatments, services, medications, and equipment.
These plans don’t always cover diabetes equally or fully, though, as you’ll learn below.
Employer-sponsored or job-based plans and diabetes coverage
As mentioned, health plans you get from an employer “more than likely” have to cover your diabetes care.
When don’t employer-sponsored or job-based plans have to provide this coverage? When the companies or organizations that offer them “self-insure.” That means they pay their employees’ healthcare costs directly.
The good news is most employers or plans will still help you with your diabetes costs even if they’re not required to. That means they’ll probably cover things like:
Employer plans may cover your trips to see a diabetes educator or dietitian, too. That is, if your physician thinks they’re medically necessary.
People who have diabetes – especially those with Type 1 or Type 2 diabetes – need more medical care than average.
What does that mean? Take the “specialist visits” mentioned a few paragraphs ago. People with chronic diabetes often need to see an ophthalmologist (eye doctor) every year or so following their diagnosis. This is because diabetes can cause cataracts, glaucoma, and a number of other diseases and problems. Many also need to see an endocrinologist and a podiatrist now and then. And if complications pop up, they may need to see a cardiologist or a nephrologist as well.
Will the health insurance you get from an employer cover visits to those specialists? There are so many job-based policies these days, and they’re all so different, that it’s impossible to say. But most of these plans cover trips to see a specialist, as long as your doctor prescribes or recommends them.
That doesn’t mean your employer plan will pay 100 percent of the cost of those specialist visits. It might make you pay toward a deductible first. Or it may charge you copayments or coinsurance for each trip.
The same is true of the many medications you might have to take after you’re given a diabetes diagnosis. If a doctor prescribes drugs to treat the disease, your employer coverage should pick up some or all the tab. How much it picks up, though, depends on the specifics of the plan.
And how about the “diabetes devices and equipment” included in the bullet-pointed list above? Again, if your doctor or physician prescribes it, your job-based health policy should cover at least some of the bill.
In other words, you probably won’t have to pay the full cost for diabetes equipment or supplies like:
You might have to pay a portion of it, however.
In short, don’t assume employer-provided health coverage pays for every service, supply, or drug you need. It should cover some, or even most, of your diabetes costs. Don’t be surprised if you have to pay for some out of pocket.
Health plans you buy through the Affordable Care Act “marketplace” should cover most of your diabetes care. As should most of the plans you buy directly from insurance companies. (Some people call these “off-marketplace” plans.)
The off-marketplace plans you’ll want to keep an eye out for are the ones called short term, term, or temporary. They can do things other health plans that have to follow the ACA can’t. An important example: they can refuse to cover people with pre-existing conditions--like diabetes. Or they can charge those people higher premiums than they charge people with fewer health problems. (To learn more about this type of coverage, read our article on short-term health insurance.)
Pretty much any other health insurance plan you get from the marketplace or from an insurer directly, should at least help you pay for diabetes care.
That’s because the law requires these policies to cover 10 categories of “essential health benefits.” Included among these benefits are things like doctor visits, hospitalizations, emergency care, and prescription drugs.
At least three of those four categories – doctor visits, hospitalizations, and prescription drugs – are important to Americans with diabetes. As are these two categories of care: laboratory services and preventive or wellness services.
For example, one of the preventive services all marketplace plans – besides grandfathered ones – need to cover are Type 2 diabetes screenings for overweight adults 40 to 70 years old. They also need to cover gestational diabetes screenings for women who are 24 to 28 weeks pregnant or are at a high risk of developing this disease.
Marketplace health plans must cover these screenings without charging a copay or coinsurance. Even if you haven’t met your yearly deductible.
You’ll likely have to pay toward your deductible for other kinds of diabetes coverage, though. Or you might have to deal with copays or other out-of-pocket costs.
For more information on how these and other plans do and don’t cover such services, check out our article on health insurance and preventive care.
As you might imagine, Medicare also covers a lot of diabetes treatments.
And that’s not just true of Original Medicare (also known as Medicare Part A and Part B). It’s also true of Medicare Part D, Medicare Advantage, and Medicare Supplement plans, too.
Here are some of the specific ways Medicare plan parts cover diabetes care.
If you’re hospitalized due to this disease, Medicare Part A pays for a semi-private room, your meals, any treatments or medications you receive as an inpatient, and more.
For more information on what Medicare covers in these situations, see our Guide to Medicare.
Part B covers almost every other kind of care you might need if you have diabetes. That includes Type 1, Type 2, gestational, or prediabetes. It covers not only doctor and specialist visits, but also:
Medicare Part B covers the following services for people with diabetes, too:
Part B doesn’t always cover insulin. It only covers it if your doctor says you need an insulin pump for medical reasons.
Even when it does cover a diabetes treatment, you typically have to pay toward your deductible before Part B kicks in. After that, you pay just 20 percent of the Medicare-approved amount.
If you must take insulin and you want Medicare to help pay for it, you need Part D coverage.
Part D may cover other related supplies, too, like:
And of course, Part D often pays for prescription medications diabetes patients take, too.
Part D plans don’t have to cover all these supplies, by the way. Many do, but some don’t. They also don’t have to cover specific diabetes drugs. So, you might have to do a bit of digging to find one that covers your preferred medications.
To learn more about this Medicare component, read our Medicare Part D article.
Medicare Advantage and Medicare Supplement can help you pay for diabetes treatment.
Medicare Advantage plans do that by providing all your Part A and Part B benefits. But they also do it by providing additional benefits. Some cover prescription drugs, for example. Some cover deductibles or copays.
Medicare Supplement (also called MedSup or Medigap) plans cover deductibles, copays, coinsurance, and some other charges. MedSup won’t pay for your diabetes care directly, but it can pay many of the costs tied to that care.
What to know more about these forms of coverage? Check out our Medicare Advantage guide or this article, “When Does it Make Sense to Get a Medicare Supplement Plan?”
First, some good news. Federal law requires every state Medicaid program to provide mandatory benefits. A few examples include:
Now for the bad news. Medicaid considers many benefits that are important for people with diabetes to be “optional.” That includes:
That doesn’t mean your state’s Medicaid program won’t cover any diabetes treatments. Some may cover every one of them. Others may cover just a few.
To find out either way, you’ll need to contact your local agency.
To be honest, the best kind of health insurance for a person who’s been diagnosed with some form of this disease is:
Since health care varies so much between different states and providers, it’s hard to recommend a specific plan. Beyond that, consider the following before you choose one plan over another.
The first thing people who have diabetes should consider is what each plan does and doesn’t cover.
That’s because diabetes patients require a lot of medical care. Maybe you need to see your doctor more regularly than someone who doesn’t have diabetes. Or maybe you need to see one or more specialists to help you manage certain symptoms. You also may need equipment or medication to help you manage the disease.
Whatever the case may be, make sure any health insurance policy covers as many of those things as possible.
After that, look at how fully the plan covers those treatments. Look at the out-of-pocket costs you’ll have to pay whenever you need those treatments.
Some of those out-of-pocket costs – which include copays and coinsurance charges – may change depending if they’re in or out of a plan’s network. So, pay close attention to those details, too.
Finally, examine the premiums attached to the policies you’re eyeing up.
Of course, if your goal is to get health insurance with the best diabetes coverage for the lowest price, you can’t consider these components in a vacuum. You’ve got to consider them together, as a group. After all, what’s the point of choosing the plan with the “cheapest” premium if you have to pay through the nose whenever you see your doctor, pick up a prescription, or buy more test strips and syringes?
For starters, look at your policy’s Summary of Benefits and Coverage. You may have a physical, printed version of this lying around your home. It could be stuffed inside a desk drawer or a safe.
If you can’t find it, don’t worry. You can get one from the insurance company with very little fuss.
This document won’t tell you everything you need or want to know, though. It’ll tell you the basics of what your plan covers. And the deductibles, copays, and other out-of-pocket costs associated with that coverage.
To learn more about which medications your plan covers, look for its formulary. You might be able to find this online, but you also might have to contact the insurer to gain access to it.
You may also have to contact the insurance company for specific information on things like how many times you can see your doctor each year or what you’ll pay if you go to see a specialist.
Many companies have helplines for this purpose. Online chat may be an option for you, too.
If you have any concerns about how your health plan does or doesn’t cover your diabetes care needs, contact the insurance company. Explain your situation. Ask questions. Someone there may be able to help.
Talk with your doctor or physician, too. They may be able to make changes to your treatments, medications, or supplies so they’re more affordable. They also may be able to suggest alternatives – including where you can purchase those products and services.
You might be able to find some of those alternate sources and options on your own. Some people with diabetes save money by getting drugs and supplies from places like Costco or Walmart. Or they go to community health centers or local medical schools for certain kinds of care.
Focusing on “self-management” could help a lot here, too. What does that mean? Exercise more. Eat healthier foods. Improving in either area may allow you to swap out your current medications and treatments for less expensive ones down the road.
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