This post is written by Cathy Carver, M.S., A.N.P., C.D.E., and Lynn Wickwire, and submitted for publication by the Joslin Patient & Family Advisory Council
The Affordable Care Act’s (ACA) open enrollment period begins on November 1 when consumers (and small businesses) can purchase health insurance plans that become effective on January 1, 2016. This period applies to individuals and families who are not subject to an exemption or do not have qualifying coverage, like employer-sponsored health insurance. This is a good time to review your current health insurance in terms of coverage and cost.
It is important for people with diabetes to have good health insurance plans. Diabetes requires a lot of planning and budgeting in order to be managed effectively.
Take the time to see what you are eligible for and the related costs. Find a resource in your community that can explain available options. Many state exchanges provide “navigators” who can help with plan benefits and cost comparisons. Many people sign up for high deductible plans that require a large expenditure of funds on your part before the plan pays for anything. A co-pay or deductible should not keep you from getting the medical treatment you need. Here is a list of what you should look for in a plan. A few pointers in reconsidering your current plan or deciding to get covered in the marketplace include:
- Know your ambulatory patient services or outpatient care needs. If you have type 1 diabetes (T1D), you should look for a plan that provides the opportunity to see your endocrinologist at least four times a year. If you have type 2 diabetes (T2D), you also may need to see your PCP four times a year. There are different costs associated with each plan and you should consider your network carefully.
- Research prescription drug coverage. Under the ACA, all individual and small-group plans cover at least one drug in every category and class. If you have diabetes you should look for a plan that covers the individualized medications you need. You also should check to see how drug and supply costs including insulin pens, meters, strips and pump and continuous glucose monitor (CGM) supplies will be counted towards out-of-pocket caps on medical expenses.
- Price out the costs in different plan options you are considering. Two things you must consider when selecting new coverage are the cost of coverage and out-of-pocket expenses. Depending on where you live and what is being offered in the marketplace, you most likely have cost options. One of those options is a high-deductible health insurance (HDHI) plan. Another would be a plan with high co-pays. Both are financially attractive since they help keep premiums low, BUT can have long-term, detrimental consequences for people with diabetes. Do the math over a year of medical costs and do not just consider the monthly premium.
In taking care of chronic conditions like diabetes, bills can add up fast, discouraging you from important check-ups or testing. Over 29 million Americans have diabetes. It disproportionately affects some communities – 13.2 percent of African Americans and 12.8 percent of Hispanics over 20 are diagnosed with diabetes.
Under the ACA, insurers can no longer deny coverage based on pre-existing conditions. For the first time, Americans can live free from fear of denial or getting dropped because of conditions like diabetes. Also, there now are caps on annual out-of-pocket expenses. Moreover, the ACA requires “essential health benefits” that are of particular value to people with diabetes, such as coverage for outpatient care, mental health care, lab tests and prescription medications.
For those without coverage or whose current coverage is unaffordable, you may be eligible for health insurance through the exchanges found through healthcare.gov. These exchanges offer a wide range of policies and options for coverage. Plans differ on how benefits are offered and how much people will pay in out-of-pocket expenses for care and supplies. Some plans are made more affordable by a subsidy that’s determined by your income. If you have tried shopping for private insurance plans before, premiums with a diabetes diagnosis often meant a huge monthly premium or a denial. That’s simply no longer the case.
In addition to Joslin Diabetes Center, there are organizations including Get Covered America that have resources to tell you specifically about your new options under the ACA. Whether you are knowledgeable or need more guidance – do yourself a favor and double-check what your costs and options are for a good plan.
Diabetes care is better under the Affordable Care Act – but you should carefully consider the tradeoffs between managing your diabetes and managing your budget. Take the time to investigate your options. It will benefit you in the long run.