It’s great to have options, especially when you have a chronic illness and have unique medical needs. With the Affordable Care Act (ACA), employer-sponsored care, and commercial plans purchased directly from the insurer, individuals with diabetes can chose a plan that best covers their needs. It is hard though, to understand which plan covers what, and how to estimate what your yearly cost will be with diabetes.
Consider all of the variable costs:
• Diabetes complications: retinopathy, gastroparesis (digestion problems), ketoacidosis or DKA (when you have ketones in your urine, often associated with high blood sugar), foot problems, kidney issues
• Hospitalizations – due to blood sugar, complications
• Prescription drugs
• Durable Medical Equipment (Insulin pump supplies, continuous glucometer supplies)* my highest cost by far!
When estimating your yearly costs, it’s also hard to find what costs what on the insurance websites. Please take note of the following items when considering which plan is best for you and your diabetes:
Durable Medical Equipment (DME) * Especially Important for Type 1 Diabetes
One very confusing part of insurance costs is that items such as insulin pump supplies and continuous glucometer supplies are often categorized under Durable Medical Equipment (DME). The automated calculators on the insurance sites never include these items. Unless you have to purchase these items, many do not know where they would be categorized - this includes many insurance service reps.
Where to find the cost of DME: You can find DME info in the “Summary of Benefits” document, which is often a link under the main information section. If you cant find the Summary of Benefits on the website easily, as a customer service rep for this document.
If you are looking at insurance through an employer, the summary documents do not often include the DME or full summary of benefits. Be aggressive, and ask for the full document. Sometimes, the “better” more expensive option actually has a lower percentage of DME covered.
For me, a type 1 diabetic, the DME is the most expensive thing involved in my disease, so I always make sure to see how much I will pay for these products.
Plan Premium: Plan Premium is what you pay per month. With a chronic illness, it might pay to shell out a larger monthly payment, than a greater deductible or out of pocket maximum. Often, it the premium if greater, you get better benefits, and lower deductibles and copayments. It might seem like a lot to pay $300 + per month for an ACA plan, but you may end of paying less for other things, such as an initial deductible, copayments, or hospital stays. With employer-sponsored plans, a High Deductible Health Plan (HDHP) may seem like a low cost option, as they have low or zero premiums, but they will include high monthly costs for services and DME, and will include a high deductible out of pocket. HDHP plans are hard to manage with a chronic illness – unless you are a millionaire!
Plan Deductible: A deductible is what you pay out of pocket before your plan coverage kicks in. It’s important to understand that often the less expensive plans have a greater deductible. It is not always the case, but especially on the ACA plans, you should keep this in mind. With a deducible, you must spend the entire amount before anything is covered. Then, you still have to pay the copayment amount. So if your deductible is $3,000, and then labs are covered 80%, you pay the full rate until the $3,000 is spent, and then you still pay 20% of the cost.
Lab Costs and Location Requirements: Some plans cover lab services, such as your blood work and A1C tests at 100%, while some do not. Under the Summary of Benefits document, look for Outpatient Laboratory/Pathology. There will be a percentage of how much the plan covers. You are responsible for the rest. If your plan has a deductible, you will have to pay that before the lab work is covered. Remember, with diabetes you will have a lot of lab work, so remember to note the coverage level! After 24 years of diabetes, I get lab work done every two months or more to not only track my blood sugar, but to track my kidney function, and now my thyroid level.
Also, remember, if you are in an HMO, you will have designated or capitated lab sites. If you don't go to one of these sites, you will pay a lot more! These specific sites are determined by you primary care doctor.