A diabetes diagnosis forces you to adjust to some major life changes. More importantly, you’ll also have to figure out how to get affordable coverage for your diabetes. Anyone recently diagnosed with diabetes can use this guide when learning to navigate their health insurance.
Also Read: How To Prepare For Open Enrollment 2022
In this guide, you’ll find information on:
- What it means to be diagnosed with diabetes.
- What your health insurance already covers.
- Coverage your diabetes needs.
- Where diabetics can get affordable coverage.
- How Medicaid and Medicare are effected.
What Does It Mean To Be Diagnosed With Diabetes?
If you were recently diagnosed with either type one or type two diabetes, you may be wondering how your health insurance is about to change. Diabetes takes a lot of self-management and changes in lifestyle. Any seasoned diabetic will tell you that your medical expenses are about to change drastically.
According to the US Census Bureau, over 28 million Americans are uninsured. This can be incredibly problematic for those who were recently diagnosed and are uninsured or don’t have good coverage. Diabetics pay over twice as much for their medical expenses than those without diabetes. The American Diabetes Association, reports that diabetics on average pay over $16,000 in medical costs per year. Almost $10,000 of those expenses are diabetes-related.
Finding good coverage that’s affordable with good coverage for your diabetes can be difficult. It can be especially difficult and even stressful if you’ve only recently been diagnosed. Here, you’ll find all the information you’ll need to know when you’re shopping for health insurance this open enrollment season.
What Your Health Insurance Can Cover For Your Diabetes
There is no annual dollar limit with your Essential Health Benefits (EHB). Most plans cannot set dollar limits on what you spend on these essential benefits. We’ll cover more about what EHB covers later in this article. Revisit what coverage you’ll need to maintain your diabetes, and what you could possibly need in the future.
After you’ve figured out what you may need to maintain your diabetes, you will need to check the Summary of Benefits Coverage (SBC) in your current insurance policy. This section of your policy tells you if it covers durable medical equipment like a glucose meter, and other essential supplies.
Insurance providers must provide you a SBC when you need a major change in your policy. Recently diagnosed diabetics find this section especially helpful. If you haven’t received a SBC yet, or you don’t plan to change your health insurance coverage, you can always ask your insurance provider for the SBC.
If you need more help navigating your SBC, you can also ask your health provider for a glossary of terms. They will provide you with a glossary in your native language if you’re not a native English speaker.
When looking through your glossary and SBC, check to see what your coverage is for:
- Labs and lab testing
- In-network and out-of-network coverage
- Durable medical equipment such as an insulin pump
What Essential Health Benefits Cover For Diabetics
Even though there’s lots of extra things that diabetics will need coverage for, there’s plenty that your health insurance automatically covers.
Any health insurance policies issued after 2014 must include Essential Health Benefits (EHB). This ensures policyholders have coverage for things like hospitalizations and prescription drugs. You can read more about what Essential Health Benefits cover and other terms you should be familiar with in our ultimate health insurance guide.
Your EHB covers chronic disease management for things like diabetes, including preventative care. This means that diabetes and cholesterol screenings are covered. This can be helpful for tracking, monitoring, and preventing diabetes and diabetic flair ups for those who:
- Are obese
- Are Pregnant
- Have high blood pressure
- Have certain genetic traits
If you have kids and you’ve recently been diagnosed with either type one or type two diabetes, preventive care is vital for your whole family. Since diabetics can be impacted by genetics, you should have coverage that also monitors your children’s health.
What Your Diabetes Needs Coverage For
Depending on your health plan, you may need different coverage. Some diabetics can control their blood sugar levels with a healthy lifestyle and minimal prescription drugs. Other diabetics may need a medical pump and frequent visits to specialists. Every diabetic has different needs. That’s why you should find a plan that’s catered to your needs.
Speak with your doctor to see what they recommend for your diabetes management. Since you’ve just been diagnosed, you may have to go through several treatment options for your diabetes to see what works for you.
Some common expenses for treatments might include:
- Test strips
- Infusion sets
- Regular visits with your general practitioner
- Endocrinologists and other specialists visits
- Insulin pump with accessories and supplies
Your health insurance should help cover the costs of all these items, and possibly more. Even if you’re not currently using some of these things, you could possibly need them as you continue to learn how to navigate your diabetes.
Your Insulin Pump
You may not currently use an insulin pump. This device can be expensive to get and requires users spend a day in hospital as they learn to get comfortable with their new device.
Many diabetics can live completely comfortable lives without an insulin pump or injections. However, not every diabetic experiences this.
If you’re just learning how to navigate your diabetes, you may find some difficulty in strict lifestyle changes. An insulin pump can help relieve those restrictions with meals, sleep, exercise, and other schedule changes. Insulin pumps can help diabetics keep their blood sugar at a more constant level, and can lessen big swings or prevent low blood sugar.
Younger diabetics may find an insulin pump more convenient and manageable if they have a busier lifestyle to consider. Your pump can reduce the number of injections diabetics will need to take throughout the day. And older diabetics may find their energies or blood sugars stabilizing after using a pump.
Pumps can be expensive to get, and require patients to spend a day in hospital to learn about their pump. On top of the cost of the insulin, itself, getting a pump is truly an investment that costs diabetics thousands every year. Your health insurance will need to cover:
- The pump
- The hospital visit
- Your pump’s brand of insulin
Some pumps may only administer certain brands of insulin. Check with your physician on more information on what you’ll need for your pump.
Where Diabetics Can Get Affordable Coverage From
As of 2014, health insurance companies cannot charge more or deny coverage for a pre-existing condition like diabetes. If you’re currently uninsured, you don’t need to worry about being denied or having a higher premium because of your diabetes. However, since diabetes is a chronic condition that must be regularly maintained, you will have more regular medical expenses such as your prescription medications and insulin.
As you can imagine, this can get expensive. Before you look on the marketplace for health insurance quotes, see if you can get coverage from your:
- Spouse or domestic partner’s plan
- Parent’s plan if you’re under 26
- Medicare or Medicaid
If you can’t get coverage from one of these providers, check out the marketplace before and during open enrollment. Open enrollment begins November 1 and ends in December. Coverage for this year starts in January, 2022.
Diabetics who want to buy health insurance or change plans must do so during open enrollment. If you’ve had extenuating circumstances such as a job loss, had a child, or marriage, you may qualify for special enrollment.
To get a quote, you’ll need the following information:
- Basic contact information
- General information about yourself
- Income level
- Current prescriptions
- Current cost of insulin a month and your deductible for this amount
- Method of insulin administration
- Current dosage
- How much insulin you currently have
- Current health insurance plan
- Citizenship status
If you want to talk to someone about what to expect when you’re applying, or what you should be looking for when you apply, call Quote Purple. Quote Purple works with lots of partners who can compare quotes, and offer advice on what you should look for when you’re shopping around.
Navigating Medicare and Medicaid While Diabetic
Medicaid and other subsidized programs cover over 67 million low-income adults. This includes Americans from children to the eldery.
Many seniors will find themselves being diagnosed with diabetes the old they get. You might be wondering how your Medicare will cover your medical expenses with your diabetes. Since Medicare is a government-subsidized program, there are some things that aren’t covered or are limited.
Diabetics using Medicare may find limitations on high prescription drug costs, which can put them over the coverage gap. In 2020, if you spend $4,020 on covered drugs, you’ll be within the coverage gap. For name brand drugs, you’ll pay no more than 25% on the total drug costs and dispensing fee if you’ve reached the coverage gap. Generic drugs also have the same limit, but the amount you pay will count towards getting out of your coverage gap.
If you need to talk to someone about your coverage options, or need some more help navigating your health insurance with diabetes, call Quote Purple. Our partners can help answer questions about your coverage, and can share some insight about open enrolment for diabetics.