Choosing a plan
Choosing the best health insurance plan for someone with type 1 diabetes and the key questions to ask.
Living with type 1 diabetes (T1D) means that having health insurance, and understanding how it works for you, is critical. Whether you are newly diagnosed, moving off your parents’ policy, choosing a new plan, or experiencing a change in coverage, Breakthrough T1D is here to support you.
Overview
When it comes to health insurance for people with T1D, it can seem like decisions are made without a clear reason, and they can surprise you. Our goal is to save you time and lower your frustration by sharing clear information to illustrate what is going on “behind the curtain.” We also aim to help you minimize the time and energy you spend trying to understand your coverage options, and to help you be prepared when working through issues you may experience. Here, we’ll provide information on several key areas to consider as you select and then use your health insurance plan.
If you are starting a new job, going into an open enrollment period or experiencing another change in health insurance, you may have more than one choice. Choosing the best health insurance plan for your diabetes can seem overwhelming, but we will help break it down one step at a time. One thing to note is that timing is important when dealing with insurance. Knowing the important dates will help you be successful. The time of year you’re able to buy a plan can vary.
- If you have health insurance through your employer, talk to your human resources manager about your open enrollment dates, which are typically in the last few months of the year.
- If you are eligible for Medicare, that plan’s open enrollment period begins October 15 and goes through December 7 each year. Use the Medicare Plan Finder tool for more information. If you’re unsure if you qualify, find more information at Medicare.gov.
- You may see health plans being offered on other websites or by insurance brokers. These health plans being offered outside of healthcare.gov may not cover pre-existing conditions (including T1D), may have very high deductibles, may not cover any prescriptions or doctor visits, and will not be eligible for government tax credits. Use extreme caution if buying a health plan from anywhere other than healthcare.gov.
- Outside of open enrollment periods, certain life events, called “qualified life events”, allow you to make changes to your health insurance plan. Examples of events that can trigger a window to change your health plan include job or insurance loss, moving to a new state, marriage, divorce, birth/adoption of a child, and turning 26. Like any other open enrollment period, be mindful of dates. You may only have 30 days to make changes after the date of the event. Talk to your HR department or go to healthcare.gov to learn about the exact events that can trigger a special enrollment period.
- All states have public health insurance options for those who qualify: Medicaid and the Children’s Health Insurance Program, which is managed differently by each state. These programs offer low-cost or free health insurance for some low-income adults, children, pregnant women, elderly adults and people with disabilities. As someone with type 1 diabetes, it’s important to find out if you qualify and check the enrollment periods for health insurance through the state at Healthcare.gov.
Choosing a plan can be overwhelming, but understanding the key things I should consider as a T1D patient and what I can expect to experience makes the process less daunting.”
What are the total costs associated with a health insurance plan?
A key part of choosing health insurance for type 1 diabetes is cost. Understanding your total costs can be a balancing act between what you pay upfront and what you expect to pay out-of-pocket when you seek care. Here are two components that go into the costs associated with an insurance plan:
- Your monthly premium
- Out-of-pocket costs like co-pays, coinsurance and deductibles when you receive medical services, undergo procedures or buy medical devices
With a condition like type 1 diabetes, you may purchase some prescription medicines or use some medical services more regularly than others, so it’s important to consider these factors to get an accurate estimate of your total costs.
Lastly, you may want to consider the type of insurance plan you purchase. Health insurance plans are designed in different ways, and those differences can impact the type of care available and how much it may cost you. PPOs, HMOs, EPOs and HDHPs may seem like alphabet soup, but understanding the various types of health insurance available will help you more accurately estimate your costs. For example, if you purchase a high-deductible health plan (HDHP), you will be responsible for paying most of your healthcare costs until you meet the plan’s deductible. In some cases, your deductible may run as high as several thousand dollars. Because many insurance plans begin at the first of the year, it’s important to understand what services you will need and when they will be used.
Helpful tip
With a high deductible, you will pay out of pocket until you reach your annual deductible amount. To manage this, think of your fixed monthly costs as your monthly premium amount and one-twelfth of your deductible amount. So, if your annual deductible is $1,200, you should try to save $100 each month (your deductible divided by 12 months) to cover any costs until you hit that full $1,200 in services. That means your total monthly costs would equal $200: $100 (1/12 of the deductible) + 100 (monthly premium). If you have access to a health savings account or flexible spending account, you can save these dollars tax-free as you pay for medical services.
Planning for costs
When thinking about the plan type best suited to your needs, an easy question to ask yourself is:
Would you rather pay more of a set amount each month (premium) and less when you see the doctor (co-pays, co-insurance or deductible)?
– OR –
Would you prefer to pay less of a set amount each month (premium) and more when you need to see the doctor (co-pays, co-insurance or deductible)?
One way to get a sense of your costs is to use tools from the Affordable Insulin Project to help calculate what you will pay each year. Consult the Affordable Insulin Project site to explore their tools.
FSAs and HSAs
Frequently you have the option of opening a special, tax preferred savings account to help you with your health care expenses. The most common accounts of that type are a Flexibile Spending Account (FSA) or a Health Savings Account (HSA). The amount that can be contributed changes every year, so be sure you are aware of that limit if you choose to open one of these accounts.
| Flexible Spending Account (FSA) | Health Savings Account/Arrangement (HSA) |
|---|---|
| Established by an Employer | Established by an employer or an individual |
| Can be used with any kind of health insurance | Must be paired with a High Deductible Health Plan (a deductible of at least $1,350 for self-only coverage, $2,700 for family coverage in 2018) |
| Can use pre-tax dollars to fund it (max $2,650 in 2018) | Can use pre-tax dollars to fund it (up to $3,450/single, $6,850/family in 2018. Those over age 55 can contribute an additional $1,000 per year |
| Funds must be used in same calendar year(“Use It or Lose It”). Some employers allow a short grace period into the next year. | Funds roll over from year to year if not used and can be invested |
| Funds are withheld from your paycheck over the year, but will be made available to you immediately. (If you put in $1,000 over the course of the year, you can access all $1,000 starting on Jan. 1) | Funds are put in slowly over the year and are available only as they are deposited by you and/or your employer |
| Funding amount is set during open enrollment and can’t be changed after that. | Funding amount can be changed during the year, as long as the owner is covered by a HDHP |
| Can be used for certain health expenses, including copays, prescriptions, eyeglasses, dental work | Can be used for certain health expenses, including copays, prescriptions, eyeglasses, dental work |
What diabetes-specific treatments or services does your health coverage plan provide?
Having T1D means relying on a range of different treatments and supplies. Before you choose your plan, you’ll want to think about your treatment (or that of your loved one) and examine how each part of it is covered and how much you would pay via a co-pay or coinsurance. Your policy will also provide details about how frequently you can obtain each supply, and the criteria you need to meet in order to get it.
| Category | Specifics Covered | Location in Policy or Plan Documents |
|---|---|---|
| Medical Devices | Insulin pumps patch pumps continuous glucose monitors (CGMs) | Check the durable medical equipment section, but you may also need to search more broadly in your plan documents. |
| Testing Supplies | Glucose test strips, monitors or meters, glucose control solutions, lancets or lancet devices | Check the durable medical equipment section. |
| Prescriptions | Insulin or other medications you may take | Check your plan’s prescription medicine list or formulary on the plan’s website.* |
| Labs | Regular blood tests like blood-glucose levels, hemoglobin A1c, and c-peptide | These details may be found under the lab testing section in your plan’s policy, but you can also call your health insurance company. Your plan may limit the number of tests you get per year and have a minimum wait time between tests. Before you purchase a plan, it may be helpful to know the co-pay or coinsurance costs of these tests, as they can add to the total amount you spend in a year beyond your monthly premium. |
Are my doctors and hospital in-network?
Your care team is an important part of managing your condition. Selecting a doctor is a very personal decision, and one that can affect how much you pay when you have an office visit. Health insurance plans contract with doctors and facilities to provide care to you. They are grouped in two ways:
- In-Network — these are doctors, hospitals, laboratories, clinics and facilities that work with your health insurance plan and maintain a contract for their services to provide you care at a negotiated rate. You will pay less in-network than out-of-network. And some health insurance plans will not pay at all for out-of-network services.
- Out-of-Network — these are doctors, hospitals, laboratories, clinics and facilities that have not contracted with your health insurance company to provide services to you. While you can receive care or services from an out-of-network provider, you will likely pay a greater percentage of the costs, and some insurers will not pay at all, meaning you’ll pay 100 percent of those costs.
Many times, this decision can come down to cost, doctor preference, care needs and geography or location:
| Consideration | Why it’s important for people with T1D |
|---|---|
| Cost | You will pay more for a doctor, place of care or laboratory that is out-of-network. |
| Doctor Preference | You may have a standing relationship with a doctor, and while that’s important, you will also want to make sure your doctor is still in your plan’s network. |
| Care Needs | Often with T1D you will need to seek care from a specialist, like an endocrinologist. In some cases, you will need a referral from your primary care doctor to see a specialist. Make sure to get a referral if it’s required under your plan. Without it, your visits to the specialist may not be covered. You can find out how a specialist is covered and if there’s a co-pay in the plan’s policy document or Summary of Benefits and Coverage. |
| Geography | While your chosen doctor, facility or lab is closer to your home or office, it may not be in your plan’s network. One further away might be, however, and therefore less expensive to use. If you travel out-of-state, make sure to know your plan’s policy on how services in other states will be covered and at what cost. It’s likely that out-of-state services will be considered out-of-network, but some plans do offer nationwide urgent care in case of an emergency. |
Does the plan offer specific programs or services that could be of value to me?
Some health insurance plans for people with diabetes may offer programs or services of specific interest to people with T1D. For example, some plans may include insulins on their preventive medication list. If you have a HDHP, this has a direct impact on your costs. Preventive medications, including insulin, will not count toward your deductible, so you can get these medicines at lower cost right away. Each plan manages medications differently, so it would be best to call the health insurance company and ask if it has a preventive medication list that includes your insulin.
Also, many insurance plans now offer programs at low or no cost to help people manage chronic conditions like type 1 diabetes. Some plans may include services like educational classes, health tracking wearables or tools available on your device, and support groups. Details can vary by plan and by state, but can be confirmed by calling the health insurance company.
Is there information readily available on how to submit an appeal if needed?
When reviewing your health insurance options, take notice of how plans make information available on their appeals process. Having this information readily available and accessible will be important should you need to appeal a decision (denial to approve or pay for care) made by your health insurance company about your diabetes treatment.
Typically, the appeals contact and process can be found in your policy or Summary of Benefit Coverage. While it may not be the deciding factor in choosing a plan, clear guidance on appeals may be a sign that an insurance plan is consumer friendly. Find more detailed information on how to apply for an exception and how to manage the denials and appeals process.
The Breakthrough T1D Community Forum is our vibrant social network where people with type 1 diabetes, their families, and friends exchange information, answers, and offer support.
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