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Commonly Asked Questions about Health Insurance
1. What diabetes benefits are available under my health insurance policy? Thanks in part to the American Diabetes Association:
The level of coverage for diabetes benefits varies from policy to policy. In the case of the individual and small group markets, 46 states have laws requiring comprehensive coverage of diabetes supplies, services and medications. Medicare is required by law to cover blood glucose monitoring supplies, insulin pumps and diabetes education services; but the program does not cover oral medications, insulin, or syringes for most seniors in America. The Medicaid program covers or reimburses for most diabetes medications but the program does not always cover diabetes education services or insulin pumps. With regard to large group and special policies, employers have the option to cover specific needs within a policy. 2. What is a pre-existing condition exclusion period? A pre-existing condition is a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period before your enrollment date in an employer’s group health plan. If you had a medical condition in the past, but have not received any medical advice, diagnosis, care or treatment (or any recommendation to seek such care) within the 6 months prior to your enrollment date in the plan, your old condition cannot be considered a pre-existing condition. Moreover, pregnancy cannot ever be considered a pre-existing condition under employer-sponsored group health plans. Your enrollment date is your first day of coverage, or if there is a waiting period to get into the plan, the first day of the waiting period. If you are in an employer-sponsored group health plan, your plan must notify you if it has a pre-existing condition exclusion period (and can only exclude coverage for a pre-existing condition after you have been notified). The plan must also notify you of your right to show that you have prior creditable coverage to reduce the pre-existing condition exclusion period. In most states, the rules governing pre-existing condition exclusion periods for individual health insurance policies are very different from group health plan rules. In most states, individual insurance policies can turn you down for coverage altogether if you have a pre-existing condition. Or, your policy might permanently exclude your pre-existing condition. For more information about pre-existing condition exclusion periods, please refer to your state consumer guide. Individual health insurance policies, however, are not subject to the same consumer protections. The individual health insurance market in most states is characterized by "medical underwriting." That is, insurers in this market decide whether to sell coverage (and if so, what benefits to offer and what premium to charge) based on the health status, prior medical history, age, gender, and other characteristics of applicants. Diabetes is a condition for which most medical underwriters will automatically deny coverage. However, this is not true in all states. For example, in a few states, medical underwriting is illegal. In others, only certain residents must be sold individual health insurance policies. Still other states designate one or more insurance companies (usually Blue Cross Blue Shield) as "insurers of last resort" who cannot turn individuals down for coverage based on their health status. For more information on individual policies in your state, please visit the Georgetown University Health Policy Institute’s Web site for a health insurance consumer guide for your state. In most states, all private insurers in the individual market can medically underwrite coverage at least some of the time. Many (though not all) of these states establish high-risk pools that offer coverage to certain "uninsurable" individuals whom private insurers turn down. Additionally, a federal law, called HIPAA, requires private insurers to guarantee coverage to qualified individuals (known as "federally eligible individuals") who are leaving group health plan coverage and meet certain requirements. For more information about your rights, please refer to your state consumer guide.
People with health insurance that does not adequately cover test strips have fewer options. Different pharmacies have test strips available at varying prices, so shopping around for the lowest cost will help those individuals whose policies cover a percentage of the cost.
Some states have specific definitions of who qualifies as a dependent under a health insurance policy. For example, sometimes, states have specific rules defining the dependent status of stepchildren, disabled children, grandchildren, or domestic partners. Consult your state insurance regulator. If no state law defines dependent, you will have to consult the terms of your insurance policy. Please note that neither employer-sponsored health insurance plans nor individual health insurance policies are required to offer dependent coverage to your spouse, children or domestic partner. If you are unable to obtain dependent coverage for your child, check with your state's Department of Insurance. All 50 states and the District of Columbia have a children's health insurance program for low-income individuals called S-CHIP. Many states also have a high-risk pool that your child may be eligible for if he or she cannot qualify for other health insurance options, including your state’s children’s health insurance program because of their health status.
If you were covered under a group health plan that was sponsored by an employer with less than 20 workers, you may also be qualified for continuation coverage through a state program. Contact your state's Department of Insurance to see if you have state-based continuation coverage rights. You also might be a HIPAA-eligible individual. If you have been continuously covered (under one plan or a series of plans) for at least 18 months before you lost your job-based coverage, and if you elected and exhausted any COBRA or state continuation coverage for which you were eligible, there are health coverage options for you in your state that will not turn you down or impose a pre-existing condition exclusion period. However, depending on where you live, there might or might not be a limit on what you can be charged for this coverage. Finally, if foreign competition and imports were a reason contributing to your layoff, you might be eligible for Trade Adjustment Assistance (TAA) benefits, including subsidies for qualified health insurance.
Social Security Disability Insurance (SSDI) and Medicare Two years after first receiving SSDI benefits, SSDI recipients are automatically eligible for Medicare. Medicare consists of two parts. Part A benefits cover hospitalization and some other care associated with a hospital stay. Part B covers physician services and some other care. If you are low-income and meet certain financial requirements in your state, Medicaid will pay for some or all of your health care expenses not paid by Medicare. Some people choose to purchase one of 10 supplemental policies called Medigap. Medigap offerings and premiums vary by state and by policy. To avoid paying a higher premium, you must purchase a Medigap policy within six months of enrolling in Medicare Part B. For more information about supplemental insurance offerings in your state, consult: The State Health Insurance Assistance Program operating in your area. Telephone numbers may be found at the back of the Medicare & You handbook. Guide to Health Insurance for People with Medicare: Choosing a Medigap Policy. Supplemental Security Income program (SSI) and Medicaid If you are receiving SSI and do not have private health insurance, you are eligible for Medicaid coverage. However, you must separately enroll through your state's Medicaid or Medical Assistance office. Get more information on Supplemental Security Income.
Additionally, your state may operate a high-risk pool for persons who are ineligible for health insurance through job-based coverage, continuation coverage such as COBRA, or an individual policy. Please refer to the FAQ "What is a high risk pool" below for information on high-risk pools that may operate in your state. Finally, if you are unable to access or afford health insurance options that may be available in your state, please refer to the FAQ "I cannot afford to pay for office visits to see my doctor. What can I do?" below. While it is not health insurance, there may be local free or low-cost clinics in your area where you can access primary medical care. If it has been less than 63 days since losing your health insurance coverage, please refer to the FAQ "I am recently unemployed and have lost my job-based health insurance coverage," which will outline options that may be available to you.
High-risk pools typically offer coverage similar to that sold by private insurers. However, in some states, high-risk pool benefits are limited. For example, these programs might impose high deductibles or limit coverage for certain services such as mental health care, laboratory services, maternity care, or even diabetes supplies. High-risk pool premiums are always more expensive than coverage sold by private insurers. In most state high-risk pools, premiums are 1.5 to 2 times higher than those charged by private insurance companies. In addition, all state high-risk pools adjust premiums for age. This makes coverage especially expensive for people in their 50s or early 60s. Some high-risk pools offer Medicare supplemental coverage for uninsurable residents enrolled in Medicare. In other states, being enrolled in Medicare disqualifies you from eligibility for the high-risk pool. Find out if there is a high-risk pool in your state.
If your doctor is unable to see you because you cannot pay for office visits, there are many free or low-cost health clinics that operate across the country. Another option to consider is seeing a physician for your diabetes treatment needs who is affiliated with a hospital. Most hospitals will provide financial assistance to people who cannot afford visits to a doctor. If you believe that you have difficulty affording your physician visits and the physician is affiliated with a hospital, ask to speak with a financial advisor based in the hospital. Mention to the financial advisor that you require assistance with paying for your medical care. Some hospitals refer to this care as either free care or compassionate care. 12. How do I apply for Medicaid? 13. My child has diabetes and is being kicked off of my job-based health insurance policy because she no longer qualifies as a dependent. Are there any options available to her? Second, if you worked for an employer with less than 20 employees your child may be eligible for state continuation coverage. State continuation coverage refers to a right, enacted in 41 states, for some employees and/or their dependents that have lost job-based health insurance to continue existing group health insurance. Third, in many states, your child has a right, when leaving a fully insured group health plan, to convert their coverage to an individual policy. This is called conversion coverage. To qualify for a conversion policy in most states, your child must have had a certain amount of time during which they were covered under a group policy such as a parent’s job-based coverage or COBRA. Contact the office of your state insurance commissioner for more information. Fourth, no matter how long it has been since your child lost health insurance coverage, they may be eligible for a guaranteed-issue individual policy. Health insurance companies in some states require policies to be offered to all people, regardless of their health status. To find out if your state has guaranteed-issue policies, please contact the office of your state insurance commissioner. Finally, your state may have a high-risk pool that your child can purchase an individual policy through. Please refer to the FAQ "What is a high risk pool" for information on high-risk pools that may operate in your state.
However, some limitations apply, including:
In order to receive coverage for blood glucose test strips and related supplies, a prescription must be written by a physician. This prescription must meet the following guidelines:
Insulin Pumps and Supplies for Use with a Pump
Diabetes Education & Medical Nutrition TherapyMedicare now covers diabetes education services, also known as self-management training and medical nutrition therapy for enrollees with diabetes. Upon the diagnosis of diabetes, or one-time as an enrollee in the Medicare program, a Medicare enrollee is entitled to receive 10 hours of diabetes education. When prescribed by a physician and provided by an appropriately recognized healthcare provider or program, this education will usually occur in a group setting. After this initial training and when prescribed by a physician, a patient can receive up to 2 hours of additional training each year. A physician can also order medical nutrition therapy for a patient with diabetes. A physician can order up to 3 hours of medical nutrition therapy for a patient with diabetes in the first year of diagnosis and 2 hours a year in subsequent years. Co-pays and DeductiblesDeductibles and co-pays for an enrollee's Medicare Part B policy will often apply to the described benefits. The deductibles generally require an enrollee to pay for the first $100 of care purchased in a calendar year. After reaching the deductible, a Medicare enrollee is typically required to pay 20% of all charges for items and services while Medicare pays the remaining 80%. Patients with Medigap, other forms of supplemental insurance including Medicaid or those enrolling in a Medicare HMO are generally not responsible for these deductibles and co-pays. Supplemental policies like these typically cover the usual Medicare Part B deductibles and co-pays within the parameters of the supplemental policy’s insurance program. You can access Medicare or call 1-800-638-6833 for more information about Medicare coverage. A portion of this information was drawn from "Health Insurance Resource Manual" prepared for the American Diabetes Association by Georgetown University’s Health Policy Institute, ©2003, Georgetown University. All rights reserved. |
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