Insurance Coverage Overview
Understanding the Ins and Outs of Your Health Care Plan
Group or Individual Private Health Insurance Plans
Most Americans with health coverage are covered by one of these plans. Your employer contracts with a large health plan (eg, BlueCross® BlueShield®, Aetna®, or CIGNA®*) to manage employees' health benefits. As an employee, you may have health plan options, such as a choice between a fee-for-service, Preferred Provider Organization (PPO), or Health Maintenance Organization (HMO). The options usually have different costs. When you take a new job and/or sign up for new health coverage, ask about the coverage for diabetes supplies. For additional information, contact your benefits and human resources manager. (Also see Medicare Coverage: Get the Facts.)
Employer Self-Funded Plans
These plans are similar to group or individual private health plans. Large companies use these plans for all of their employees. The plans are not required to follow state laws. This doesn't mean they don't cover diabetes supplies, but they aren't required to do so by law.
Coverage of Diabetes Supplies
Most of these plans cover some of the cost of diabetes supplies; however, each plan is different.
Ways in Which Insurance Plans Differ:
- What type of monitors and strips are covered? Some plans only allow care providers to prescribe one or two types of monitors and strips. If you are told you can only get a particular monitor, but you want a different one because it has special features, then you might need your care provider to write a prescription and/or letter.
- Which benefit covers diabetes supplies? Some plans cover diabetes supplies under your prescription benefit and some cover them under your Durable Medical Equipment benefit (see Diabetes Supplies: Are You Covered?).
- How do you get reimbursed? Some plans require you to pay for your supplies up front and submit a claim for reimbursement. Some charge a co-payment at the time of purchase.
- Is there a mail-order requirement? Some plans may require you to order supplies from a mail-order company, or it may save you money to do so. Ask your health plan about ordering options.
- What quantity of strips can you receive at one time? Some plans only allow you to get a certain number of test strips, and other supplies, to cover a specified period of time -- eg, 30 days.
Insurance Coverage Glossary
Care providers: The professionals who provide your health care (physicians, nurse practitioners, diabetes educators, etc.).
Co-pay: The amount of money your health plan requires you to pay as part of the cost of a service or benefit. This must be paid when the service is provided.
Deductible: The sum of money you must pay for medical services, medications, or supplies before your health plan begins to cover the cost during an annual period.
Durable Medical Equipment (DME): Supplies you need to care for your health in your home that are not medications or services provided by your care provider.
Health Maintenance Organization (HMO): There are various types of HMOs. In staff-model HMOs, you typically choose from the care providers they have on staff. In other HMOs, you choose your care providers from listings of independent care providers with whom the health plan has negotiated rates.
Preferred Provider Organization (PPO): There are various types of PPOs. Generally, you choose your care providers from listings of independent care providers with whom the health plan has negotiated rates.
Prescription (pharmacy) benefit: This is the part of your health plan that covers medications.
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