Insurance Matters

by Kathy Spain, R.N., C.D.E., mother of Will, diagnosed age 2

If you or a family member has recently been diagnosed with type 1 diabetes, chances are that meeting the cost of diabetes medications and supplies such as insulin, meters, and test strips, and finding good health coverage are significant concerns for you. You may wonder how you can afford health coverage or how you would go about finding health insurance for a child with diabetes. Are insulin pumps covered? What are the rights of a person with diabetes when it comes to medical insurance? There are many resources to help you answer your questions and to assist you in finding satisfactory coverage. If you have trouble obtaining or keeping your insurance, there are resources to help you explore options.

Covering the Cost of Your Coverage

If you are concerned that you cannot cover the costs of diabetes care, a publication titled “Financial Help for Diabetes Care” can help you learn about your options. Published by the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), this easy-to-read guide offers an overview, with contact information, about resources such as Medicare, Medicaid, and health insurance programs that cover diabetes-related medical expenses or low or no-cost health care for people with diabetes. You can view this publication on the NIDDK website at http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/ or order copies from the National Diabetes Information Clearinghouse at 1-800-860-8747.

Laws Protect You

An important insurance issue a person with diabetes may face is when a new insurer defines diabetes as a “pre-existing condition” and excludes or limits diabetes-related care coverage. There are laws that protect people with diabetes who encounter pre-existing condition exclusions. For people with individual (as opposed to employer-sponsored or group) health insurance coverage, most states now have laws requiring health insurance coverage to include treatment for diabetes. Laws governing health coverage vary from state to state, and you will want to start with the healthcare regulations and laws for your state. “A Consumer Guide for Getting and Keeping Health Insurance,” a resource published by the Institute for Health Care Research & Policy at Georgetown University, is available for each of the 50 states. It can be accessed online at http://www.healthinsuranceinfo.net/.

For those insured through an employer-sponsored group health plan, protection from coverage being denied to a person with diabetes is offered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Act also helps workers who change or lose jobs to maintain their health insurance. (The HIPAA provision, however, only refers to group plans, such as employee health plans, and not individual health plans.) You can read detailed information about HIPAA on the U.S. Department of Health and Human Services web site at http://www.hhs.gov/ocr/hipaa/.

Insurance Programs for Children

For children of families with limited financial resources, there are multiple programs available at the state level. Medicaid is a state-administered program and each state sets its own guidelines regarding eligibility and services. You can find information for your state at the Medicaid site for consumer information at http://www.medicaid.gov/index.html. For families who earn too much to qualify for Medicaid yet still find their resources too modest to cover their children’s diabetes care, the states operate a low-cost private insurance program called the State Children’s Health Insurance Program, or SCHIP. To find out more about this program covering eligible children until the age of 19, go to the Insure Kids Now! Web site offered by the U.S. Health and Human Services Department: http://www.insurekidsnow.gov/; or call 877-KIDS-NOW.

Help with Supplies and Prescriptions

Many drug companies offer pharmaceutical assistance programs to help offset the cost of supplies or prescription medications for people with diabetes who have little or no insurance. Enrollment in the programs requires a letter or application from your doctor. Listed below are some of the companies offering patient assistance:

Aventis – 800-221-4025
Bayer Corporation – 800-998-9180
Bristol-Myers Squibb – 800-437-0994
Eli Lilly & Company – 800-545-6962
Novo Nordisk – 800-727-6500

In addition, the Partnership for Prescription Assistance offers a point of access to 275 assistance programs including 150 programs through pharmaceutical companies that have joined together to provide savings to the uninsured. To see if you qualify for any of these programs, visit http://www.pparx.org or call 1-888-477-2669. The Children with Diabetes Foundation also offers diabetes supplies on a short-term basis for children with diabetes who are in emergency situations in which their families are unable to obtain basic supplies for diabetes care. You can find information on this program at http://www.cwdfoundation.org/Supplies.htm.

Are Pumps and Pump Supplies Covered?

Last, but certainly not least, pumps can present a financial burden for families, with the devices themselves costing on average $5,000 and basic supplies more than $100 a month. Insurance companies vary in their coverage of pumps, but most insurance plans cover costs associated with pump use. Pumps and supplies are usually included in the Durable Medical Equipment (DME) component of major medical plans. Some plans have a deductible or co-pay, so ask your health insurance carrier or check your benefits summary to find your level of coverage. The major pump manufacturing companies have insurance experts who can verify your benefits and out-of-pocket expenses when you consider the purchase of a pump. These manufacturers are aware that their products are costly, and they often are able to work with potential customers and/or their insurance companies to make them more affordable. Here is contact information for several leading pump manufacturers:

Accu-Chek             www.accu-chekinsulinpumps.com/dstrnc_us/     800-280-7801
Animas                   www.animascorp.com       877-767-7373
Deltec Cozmo        www.cozmore.com       800-826-9703
Medtronic MiniMed  www.minimed.com       800-646-4633

As one further option, the Diabetes Trust Foundation provides financial assistance through its Insulin Pump Program for Children, as well as assistance for medications and testing supplies for individuals who qualify. For more information, visit their Web site at http://www.diabetestrustfoundation.org.