Diabetes is a disease that requires a lot of self-management along with the help of various medical equipment and medication such as blood glucose monitor, test strips, insulin, and syringes. Without any health insurance coverage, it will almost be impossible to receive sufficient treatment to manage the symptoms and prevent complications from arising. Although individuals with pre-existing conditions have difficulties getting health insurance coverage in the past, the recent health care reform has significantly made the process much easier for diabetes patients to obtain a policy and receive proper health care. If you have recently been diagnosed with diabetes and/or need to subscribe to a new health insurance policy, this article will give you a wide series of information that will be of help:
- Health Insurance 101: What is Health Insurance?
- Do I Really Need Health Insurance?
- The Two Main Branch of Health Insurance Provider
- What are Managed Care Plans?
- What is Health Savings Account (HAS)?
- The USA's 25 Largest Health Insurance Companies
- The Top 6 Best Rated Health Insurance Companies
- Other Countries with Health Care Insurance Coverage Systems
- What is Obamacare?
- What is a Health Insurance Marketplace?
- Can Diabetes Individuals Be Denied or Charged Extra for Health Care Coverage?
- The 4 Categores of Coverage in Marketplace
- What is a Catastrophic Plan?
- Can I Apply for a Catastrophic Plan?
- Who Can Buy Health Coverage in a Marketplace?
- When Can I Buy Coverage in a Marketplace?
- When Does the Coverage Begin?
- How Can I Sign Up for Coverage in the Marketplace?
- What Do I Do If I Need Help Finding and Choosing A Health Plan?
- What if I Am Already Enrolled in a Marketplace Plan?
- Options for Individuals Under 26 Years Old
- What is Student Health Insurance?
- What is the Difference Between COBRA and HIPAA?
- Can I Purchase Health Insurance from Outside of the Marketplace?
- What is the Cheapest Insurance I Can Get Through the Marketplace?
- How to Save on Out-of-Pocket Costs with a Silver Plan?
- How to Save on Health Insurance Coverage?
- What is Medicare?
- Does Medicare Cover Diabetes Services and Supplies?
- What are Medigap Plans? Do I Need Travel Insurance If I Am Traveling?
- What if I Cannot Afford Insurance?
- What is Medicaid?
- What is CHIP?
- Federal Programs Available for Financial Assistance
- State Progarms Available for Financial Assistance
- Local Programs Available for Financial Assistance
- Health Coverage for American Indians & Alaska Natives
- Pharmaceutical Assistance Programs
- Where to Find More Information About Plans Available to Me?
Health insurance is a form of insurance that provides coverage for an individual who requires medical treatment and/or management. Depending on what type of policy the individual has chosen, the insurance company will either make direct payment to the health provider or reimburse the individual after the payment.
What is “Provider” and “Insured”?
When you are reading about health insurance information, you will come across two commonly used terms: “provider” and “insured”. The term “health provider” includes any facilities or professionals that provide health care to the individuals; in other words, health provider can be a hospital, a clinic, an emergency clinic, a doctor, a laboratory facility, a pharmacy, and any health care practitioners. The term “insured” is the subscriber of the health insurance policy – that means you.
Other Useful Terms for Insurance
Coinsurance: It is the percentage of costs you are required to pay for your covered services after you have paid your deductible.
Copayment: It is sometimes referred to as “copays”. It is a fixed fee you are required to pay for each covered health care service after you have paid your deductible.
Deductible: It is the amount of expenses you have to pay for your covered services before your insurance provider begins to pay for the rest of your expenses.
Durable Medical Equipment (DME): Any equipment and supplies that are ordered by your health care provider as an everyday necessity use. This includes wheelchairs, crutches, blood testing monitor and strips, oxygen equipment, and CPAP machines.
Out-Of-Pocket Maximum: the amount of annual expenses you pay for your medical care before your insurance plan starts to pay 100% of the covered medical expenses.
Plan Year: Refers to a 12-month period of benefits being covered by a group health plan.
Policy Year: Literally means the same thing as a plan year, only individual health care insurance policies refer it as policy year.
Premium: A monthly subscription payment you make to your health insurance provider.
What is the Difference Between Life Insurance, Term Insurance, and Health Insurance?
By definition, life insurance is a contract between a life insurance provider and an individual. In the event of the insurer’s death, the provider will pay a specific amount of money to the beneficiary. Term insurance (also known as term life insurance) is similar to life insurance in the sense that the provider will pay a specific amount to the beneficiary in the event of the insurer’s death. However, what is different between a life insurance (also known as universal life insurance or whole life insurance) and term life insurance is that term life insurance only covers a specific time duration as agreed by the insurer and the provider whereas life insurance offers coverage for life.
Unlike life insurance and term insurance, health insurance offers coverage for the insurer’s health care benefits and expenses. To make the explanation even simpler, health insurance covers the insurer’s health-related expenses; life insurance covers the insurer’s family against financial suffering after the insurer’s death.
If you are wondering if funeral expenses are covered by health insurance, the answer is no. According to IRS regulations, it is actually illegal to write off funeral-related expenses as a medical expense. However, there are exceptions to the rule. There is a type of Medicare plan called Medicare Medical Savings Account (MSA) that will allow the insurer to set up a direct unused funds account in which the money will go towards paying for the funeral expenses.
The answer is YES. As of 2014, the Patient Protection and Affordable Care Act (PPACA or Obamacare) states that all individuals residing in the United States must have health insurance. Unless the individuals qualify for an exemption, failure to comply will result in a tax penalty in the following year. In 2016, the penalty is $695 per adult and $347.50 per child with a maximum penalty of $2,085 per family, or 2.5% of the annual household income as stated in the tax return whichever amount is greater. By definition, health insurance coverage includes any plans purchased in the Marketplace, insurance coverage offered by employer, private insurance coverage, Medicare, Medicaid, state Children’s Health Insurance Programs (CHIP), most TRICARE plans, and the Veterans health care program.
Having said that, some individuals can be exempted from the penalty if they meet any of these qualifications:
- US citizens that live abroad for longer than 330 days out of a year
- US citizens that states another country as their main residence on their tax files
- International students living in the United States
- US residents or citizens who cannot afford coverage and suffering from financial hardship
- US residents or citizens who do not file a tax return because their income falls under a certain level as stated by IRS
- US residents or citizens who are currently in prison
- US residents or citizens who are a member of an Indian tribe
- US residents or citizens who have membership from a health care sharing ministry
- US residents or citizens who are members of a religion that can exempt healthcare coverage based on faith-based religious exemptions
In the United States, the two main branches of health insurance provider are public (government-owned) health insurance provider and private health insurance provider.
- Public health insurance requires that a premium be collected from the insured on a monthly basis. As the system is owned and ran by the government, this premium fee adjustment depends on what type of coverage the individual wish to receive and what is their yearly income in the previous year and projected income of current year. As of 2016, the premium is 2.5% of the insurer’s income or $695 per individual maximum. Due to inflation, the 2017 fee will be adjusted.
- In the United States, various medical health programs such as Medicare, Medicaid, TRICARE, and Indian Health Service are all included under the public health insurance program.
- Private health insurance is solely owned by for-profit insurance companies. Unlike public health insurance policies, individuals also need to pay a monthly premium fee. However, this fee is not reflective of the previous year annual income.
According to the health reform legislation that has been passed in 2014, all citizens and residents must subscribe to a health care insurance plan no matter whether it is public or private policy. Failure to comply will result in a fine.
The term “managed care plans” is a way for health insurers to help control costs by forming a network and contracting certain health care providers and medical facilities to provide healthcare for their members at a reduced price. In the United States, there are 3 types of managed care plans:
- Health Maintenance Organizations Plans (HMO)
- Preferred Provider Organizations Plans (PPO)
- Point of Service Plans (POS)
When it comes to managed care plans, the more restrictive the plan, the lower the premium. Vice versa, the more flexible the plan, the higher the premium.
Main Categories of Managed Care Health Insurance Plan in the United States
In the United States, there are 5 main categories of health insurance plans. In order to choose the most fitting plan for yourself and your family members, it is important that you understand the difference amongst these different plans before you decide which plan best fits your needs.
- Indemnity Plan – it is a type of medical insurance plan that compensates the patient and/or provider for the expenses.
- Conventional indemnity Plan – A type of indemnity plan that allows the patients to receive service from any provider of their choices without any penalty or refusal of reimbursement.
- POS (Point-of-service) Plan – POS is often labeled as an “PPO/HMO” hybrid plan. It is sometimes referred as an “open-ended” HMO plan if it is offered by a health maintenance organization. Similar to a conventional indemnity plan, patients are reimbursed for receiving service outside of the network.
- PPO (Preferred Provider Organization) Plan – A type of indemnity plan that reimburses patients for receiving service from a selected network of health care providers. If the patient chooses to receive care from outside the network, they may have to pay higher deductibles and coinsurance rates, or require to pay the full price of the service received.
- EPO (Exclusive Provider Organization) Plan – A more restrictive version of the PPO plan that only allows patients to receive service from a specified network of providers. Patients will be denied reimbursement if they choose to receive service from a non-network provider. The only exception is when the patients need medical assistance in emergency situations.
- HMO (Health Maintenance Organization) Plan – A type of plan that provides comprehensive medical service to patients in a particular geographic region for a fixed, prepaid fee.
- Group Model HMO Plan – An HMO plan that contracts one multi-specialty medical group to provide care for their members.
- Staff Model HMO Plan – An HMO plan that allows members to receive services from limited providers where all the health care professionals are employees of the HMO organizations. They all have to see the patients at the HMO facilities.
- Network Model HMO Plan – An HMO plan that allow members to receive services from multiple physician groups.
- Individual Practice Association (IPA) HMO – An HMO plan that allow groups of independent medical professionals to provide service to the members. These medical professionals are allowed to see the members at their own offices.
- Fee-for-Service Health Plans – This is the traditional kind of health care policy. Health insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. You can choose any doctor you wish and change doctors any time. You can go to any hospital in any part of the country. With fee-for-service health plans, the insurer pays only part of your doctor and hospital bills. You pay a monthly fee, called a premium.
HMO: Health Maintenance Organizations Plans
As mentioned earlier, an HMO is a prepaid health plan in which you pay a monthly premium and receive comprehensive health care service for you and your family. The service includes all minimum essential coverage services such as visits to doctor’s office, hospital services, emergency care services, surgery, laboratory tests, x-rays scans, vaccinations, and preventive care services. Depending on your plan, you may also receive other optional services such as physical therapy services, occupational therapy services, vision care, dental care, mental wellness services, medication coverage, supplies coverage, and equipment coverage. The HMO network doctors and other health care professions who are under contract with the provider usually carry out these services. As a result, your choices of health care professionals and facilities tend to be limited to those that have contracts with the HMO to provide health care. However, in cases of emergencies when a medical procedure is deemed necessary, members will be able to seek services from doctors and facilities who are not part of the network.
When it comes to services, you will need to pay a co-payment fee for each visit to a facility. For example, you may need to pay a $10 for a doctor’s visit, a $20 for an emergency clinic treatment, or a $45 for a hospital emergency treatment. There may be a small co-payment for each office visit, such as $5 for a doctor’s visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service health insurance.
The advantage of HMOs is that you will receive a fixed fee for your covered medical treatments and medication prescription. And because most of the doctors receive salaries from the provider, they are much less likely to suggest unnecessary treatments and hike up treatment fees for their own profit. Instead, it is in their interest to treat your problems before they become serious health issues. Also because of the same reason, all treatment fees are automatically calculated by the HMO systems so that there is much less paperwork and claim form nightmares that need be filed, negotiated, claimed, and reimburse for each treatment service and medication prescription. Instead, all you need for your visits is your membership card. Just one swipe like a credit card, all the claims and calculations will be tabulated within the HMO computer systems.
The disadvantage of having an HMO plan is that you may have to wait longer to be treated than a few-for-service insurance plan because you are only limited to seeing the doctors within the network. Choosing to seek treatment from a doctor or facility out of the network means that you will need to pay for the rest of the treatment bill from your own pocket. At the same time, seeing a specialist may become a frustrating experience because you need a referral letter from your family doctor in order to be transferred to the specialist. This means sometimes you may need to see your primary care physician, go through the blood tests and x-rays, get back to the family doctor just to be referred to a specialist. And if the specialist is dissatisfied with the lack of information from your tests, he may reorder blood tests and x-rays. Combined with long waiting gap between doctor visits, it may take a long time before you find out what is happening to your body. For individuals who are suffering from a debilitating disease, a month can be a life or death situation.
Another disadvantage to HMO plans is that the range of health services can greatly differ from each other. So if you decide to purchase an HMO plan, make sure you go over all the details on service coverages as certain treatments may not be covered while others can be provided on a very limited basis. And before choosing an HMO plan, it is always a good idea to talk to your friends who are enrolled in the HMO you are planning to select. Ask them about their doctors, the service they receive, and the waiting time for their appointments. You can also do a quick research online or ask on the diabetes forum for others’ opinion.
POS: Point-of-Service Plans
Unlike HMO plans, POS plans allow your more flexibility when it comes to picking your preferred medical professionals and facilities. Instead of limiting your choices within the network, POS plans allows you to seek services from some out-of-network services under some circumstances. If the doctor refers you to a specialist out of the network, the health care provider will pay for most if not all of the bill. On the other hand, if you seek a covered treatment from a doctor or facility outside the network without your family doctor’s referral, your health insurance provider will only pay for part of the cost and you will have to pay the coinsurance fee. Although that may mean that you have to pay more for your treatment, you do not have to get stuck waiting in the referral limbo like the HMO plan referral process.
PPO: Preferred Provider Organizations
PPO plans are known for having the most flexibility when it comes to choosing your doctors and treatment facilities. Unlike HMO plans that require you to select a primary care physician, PPO plans allow you to seek treatment from any doctor and facility you choose whether within the network or outside of the network. You do not even need a referral in order to receive service from a specialist. As long as the service is covered by the plan, your provider will cover the charge of the treatment whether you receive care from within or outside of the network. Out of the three plan categories, you are most likely to receive treatment with the least amount of waiting time when it comes to PPO plans.
Now for the disadvantage of selecting a PPO plan. PPO plans tend to have the higher monthly premium rate out of all 3 categories of plans. This is a price to pay in exchange for the flexibility in choosing your preferred physicians and treatment facilities from both within and outside of the network without a referral. And even though your provider will cover the payment of your treatment, you will need to go through the claim process when it comes to receiving treatment outside of the network. This also means that you will need to pay for the service upfront, and your provider will later reimburses your payment after you file your claim. If you do not mind this process and do not mind paying upfront, you can have wider selections to choose from and you will find the waiting time for an appointment may be much shorter than an HMO plan. But if you do not have sufficient funding, this may become a big problem. Even if you can fully pay for the treatment, you will likely need to wait for a month before your provider reimburse you the covered cost. For individuals who have a tight budget to juggle, this may not be the best choice of plan.
A Health Savings Account is a tax-free medical savings account that individuals contribute into regularly and retrieve the funds for medical expenses. These expenses can be used for any medical, dental, and vision related issues. However, the contributions from the health savings account can not be used to pay health insurance premiums. The funding can be invested in a high deductible health plan, withdrawn for non-medical use at a penalty fee, or rollover into a retirement account for Medicare use.
According to the NAIC (National Association of Insurance Commissioners), the top 25 health insurance companies in the USA in 2015 were:
- Unitedhealth Group
- Wellpoint Inc. Group
- Kaiser Foundation Group
- Aetna Group
- Humana Group
- HCSC Group
- Coventry Corp. Group
- Highmark Group
- Independence Blue Cross Group
- Blue Shield of CA Group
- Cigna Health Group
- BCBS of MI Group
- Health Net of California, Inc.
- BCBS of NJ Group
- BCBS of FL Group
- Regence Group
- BCBS of MA Group
- Carefirst Inc. Group
- Wellcare Group
- HIP Ins. Group
- Metropolitan Group
- Unumprovident Corp. Group
- Universal Amer Fin Corp. Group
- Lifetime Healthcare Group
- BCBS of NC Group
- BlueCross BlueShield
Being one of the largest health care insurance provider in the United States, BlueCross BlueShield has a wide network of health care professionals and facilities available. So if you live in a big city, BlueCross BlueShield is definitely your number 1 choice provider. It has an excellent range of plans that are suitable for individuals of different age groups and different health care needs. With an impressive prescription coverage list, this is a great provider for individuals who have diabetes. In situations where you need to relocate to another state, BlueCross BlueShield can make the plan selection a smooth process by helping you select a similar plan from the destination state. Out of all the healthcare insurance providers, BlueCross BlueShield excels in their customer service and 24 hour medical hotline service.
- Kaiser Permanente
Kaiser Permanente is a great HMO provider. With a more affordable premium than the rest of the providers, Kaiser is a great provider for older individuals who require more specialized medical needs. Although it limits members to doctors and facilities within the network, the waiting time for an appointment is relatively short. The downside is that Kaiser Permanente is only available in 8 states: California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington DC; and the District of Columbia. This can pose a problem if your dependent children attend college in states that do not have Kaiser Permanente. Under such circumstances, your children will not have health coverage until they return to the home state. In addition, like BlueCross BlueShield, a 24 hours medical hotline is available to help you.
Humana is a great provider that has a wide array of HMO, PPO, and traditional indemnity plans. They pride themselves mostly in offering very affordable low premium work insurance plans and Healthcare Saving accounts for tax-reduction use. For those who have a tight budget to manage, Humana is definitely the way to go. Moreover, Humana is known for supplying Medicare supplemental plans such as Medicare Advantage plans. Partnering up with Wal-Mart pharmacies, Humana offers a preferred prescription drug plan to make prescriptions very affordable for elderly patients who have special daily prescription medication needs.
Similar to Humana, Aetna is known for providing affordable low-premium health care plans through the Marketplace, dental plans, vision plans, student health insurance, and international insurance. It also provides supplemental insurances so that you can truly customize your health care insurance to cater to your special needs. And if you are in the younger generation bracket who prefer using webchats, texting, and twitter for assistance, Aetna is definitely the choice for you. But if you prefer more a traditional method of seeking assistance such as calling their customer service, you may find that you will need to wait a long time before you receive assistance.
Cigna is a very well-known international health insurance company. Although only available in 12 states, Cigna has a relatively good range of different plans for individuals with various needs. What makes it a great provider is that it is not trying to hard sell you their product by to provide you with lots of useful information to make the decision yourself. At the same time, their website has many handy tools that allow you to specifically search for certain medication to find out whether they are covered by the medical plans. Instead of trying to find information in the fine prints, Cigna is straight-forward and helpful. Another important brownie point is that Cigna is most well known for its dental supplemental plan. With a wide selection of plans to choose from, it can save you a lot of expenses if you have several children who require dental care treatments. By far, no other insurance companies have provided such a great coverage on dental care.
Although slightly on the expensive side, Assurant collaborates with secondary networks to allow much more choices of doctors and facilities. For the higher premium fee, you will also enjoy great customer service as well as fast claim services so that money returns to your pocket faster than many other insurance providers.
Insurance Company to Avoid: UnitedHealthCare
There are several reasons why you should avoid UnitedHealthCare. It is very expensive and not worth the price. Having a reputation of denying claims and having horrible out-sourcing customer service, UnitedHealthCare has a terrible online presence with pages and pages of customers reporting their negative experience with the company. And for not including Novolog as a covered medication, UnitedHealthCare is not a friendly insurance provider for diabetic patients. If you are a university student, be careful with your school health insurance because UnitedHealthCare partners with many universities to provide “affordable” health care plans. Before you decide on other factors, check to see if any of your diabetes medications, supplies, and equipment are being included in the coverage. If your needs are not covered, no matter how low “affordable” the plan is, it is useless to you as a diabetic patient.
When it comes to picking a dependable health care insurance provider, bigger is not always better. If you compare top largest provider list with the most popular provider list, you can see the UnitedHealthCare is the biggest provider yet the least dependable. With too much service being out-sourced, many of the customer service agents have limited knowledge on the products and coverage regulations. The company is at a point where it is more focused on taking in more money and not on providing the service to its customers. On the other hand, although BlueCross BlueShield is a relatively smaller company, it is a much more personable and dependable provider who has established a 24-hour medical hotline to better serve its customers. So when you are deciding on which provider to choose, do not be afraid to consider smaller companies who have a great network of doctors and coverage. This is especially true if you live in a smaller city or a rural town where most of the local doctor and hospitals signed a contract with a local insurance provider.
For individuals who are planning to work or study in another country in the near future, and are worried about their health system, here is a list of commonly visited countries that have health care coverage systems:
Australia has both a public health system called Medicare and a private health insurance coverage system. The public health system allows all Australia residents free access to hospital care and covered non-hospital medical treatment service.
Canada has a public universal healthcare system that is funded by taxpayers’ money. Private health insurance is also available to cover services that the public health care system does not cover such as optometry, dentistry, and certain medications. These supplementary private health insurance benefits are often included with work benefits.
France has a non-for-profit health insurance fund program. All French citizens must contribute a portion of their salaries for health care benefits. Each fund is independently negotiated so that each subscriber has a different pre-arranged medical expense price.
Germany provides a basic health insurance policy to all German citizens. Supplementary private health insurance plans are also available.
Japan has a national health insurance system and an employee health insurance system. The national system is catered to individuals who do not have employee health insurance. All residents of Japan as well as visitors on a one-year visa must enroll in either an employee or national health insurance coverage. As for services that are not covered by these two insurance systems, there are supplementary private health insurances available.
United Kingdom provides free medical, health care, and prescription to all citizens. Their system is mainly funded by taxpayer’s money. Visitors from Canada and Australia can benefit their free health care system should an emergency medical situation arise. Aside from the public health care system, supplementary private health insurance plans are also available. The most common providers are BUPA, Aviva, Groupama Healthcare, AXA, WPA, and PruHealth.
Obamacare is the unofficial name for the Affordable Care Act (ACA), also known as the Patient Protection and Affordable Care Act (PPACA). It is a health reform legislation that was signed on March 23, 2010 by President Barack Obama and enacted as of 2014. This set of laws offers affordable care and health care coverage protection for all Americans. Under the Affordable Care Act:
- There is no annual Dollar Limit on Essential Health Benefits: Most health plans cannot set a dollar limit on what they spend on “essential health benefits” for an individual’s care during a given year.
- There is no Lifetime Dollar Limits on Coverage: Health insurance plans cannot set a dollar limit on the amount the insurance company will spend on “essential health benefits” over the course of the time a person is enrolled in that plan.
- There is a charge limit on Drug Costs for People with Medicare: Medicare members receive a discount rate on covered brand-name medication so that they can afford these medications.
- All coverage plans must provide a summary of Benefits and Coverage: For the consumer’s protection, all individuals have the right to read the summary of all health plan’s benefits so that they can better understand the plans’ coverage and easily compare plan benefits.
In 2014, the healthcare reform in the United States have more or less converted into one universal healthcare insurance coverage system (although there are still benefit discrepancies amongst each state) and a universal platform of coverage plans. Health Insurance Marketplace is sometimes referred to as Health Insurance Exchange in some states. It is a service provided by the government to help individuals, families, and small businesses to compare and shop for various private health insurance options all in one place. All the plans offered in the Marketplace must be approved by the government Patient Protection and Affordable Care Act and must meet all the requirements for specific health benefits, consumer protection, and the covered cost.
What Benefits Are Covered In the Marketplace?
According to the Affordable Care Act of the United States, health insurance sold in the Marketplace must include a set of essential health benefits that includes:
- doctor’s office visits
- emergency room services and hospitalization
- and newborn care
- mental health and substance use disorder services
- prescription drugs
- rehabilitative services and devices
- laboratory services
- preventive services
- chronic disease management
- children’s health services (including oral and vision care)
The specific details on these benefits for these services can vary by plan. When shopping for a health plan, it is important to inquire about all the benefits pertaining to diabetes treatments, supplies, equipment, and prescription drugs.
Under the Obamacare legislations, it is illegal for health care providers to deny coverage or ask for an extra premium from individuals who suffer from pre-existing coverage. This law holds true for new plans being offered on the Marketplace and on private health insurance provider platforms. Providers can only set a higher premium based on age, tobacco use, family size, and income status, and the area where the individual resides. At the same time, the ACA act has set maximum limits as to how much an individual may have to pay out-of-pocket for their services and medications.
Diabetes-related Benefits Covered in the Marketplace
When it comes to individuals with diabetes, insurance policy coverage for certain treatments, supplies, and equipment can really make it a life and death situation. As a result, the Obamacare Act has made many changes to the healthcare system to ensure diabetic patients get the care they need to stabilize their symptoms and get healthier. The first most important change is that Marketplace plans cannot set an annual spending cap limit for essential health benefits. At the same time, these diabetes treatments are covered free of charge as part of free preventive care necessities:
- Diabetes screening for adults who have high blood pressure
- Gestational diabetes screenings for pregnant women
- Medical nutrition therapy for diabetic patients
Other diabetes-related benefits include:
- Children and young adults can stay on their parent’s coverage until age 26 as long as the policy covers dependents.
- Employment-based plans and new coverage plans cannot deny children coverage based on pre-existing conditions of diabetes and any other health conditions.
- New coverage plans cannot deny coverage based on pre-existing conditions of diabetes and any other health conditions.
- There is no lifetime spending limit on coverages.
Although there have been many positive changes and protection offered to individuals with diabetes, there are still limitations that providers can impose on various coverage plans. These includes limits on benefits that are not listed as basic health care necessity needs. They can limit the number of doctor visits available, number of prescription medications and supplies, or covered days in the hospital due to certain procedures. For more information on your rights as a diabetic individual, please visit www.healthcare.gov for more information.
To make the selection easier, all marketplace plans are separated into four different categories: Bronze, Silver, Gold, and Platinum. These classes are not classified by the quality of care but by your monthly premium and deductible for receiving care. In general, bronze plans have a low premium rate but a high deductible cost. On the other end of the spectrum, platinum plans have a high premium rate but a low deductible cost.
- Bronze Plan: You pay 40% and the plan pays 60%. This category has the lowest monthly premium and the highest deductible. Depending on which plan you choose, the deductible can be thousands of dollars before the provider pays for the rest of your expenses. This is a good choice for individuals who wish to have the lowest cost way of protecting themselves against serious illnesses and injury emergencies.
- Silver Plan: You pay 30% and the plan pays 70%. This category has a moderate monthly premium charge and a moderate deductible rate. It is a good choice for individuals who wishes to qualify for the extra savings on deductible, copayment, and coinsurance payments. Although the insurers have to pay a slightly higher premium, they can save much more money from the cost-sharing reduction benefits. This is the perfect plan for diabetes patients who require many medical health care treatments.
- Gold Plan: You pay 20% and the plan pays 80%. Although this category has a high monthly premium fee, it makes up for having a low deductible rate. It is a good choice for people who require frequent medical treatments and ongoing medical supplies.
- Platinum Plan: You pay 10% and the plan pays 90%. This category has the highest monthly premium and lowest deductible rate. Depending on how much you have to pay for your medical expenses, this may be a way to reduce your overall expenses by paying a higher monthly premium.
Once you select a category, the Marketplace will show you a list of plans from various insurance providers. Depending on where you live, the availability of providers and plans may vary. Amongst all the companies, you are most likely to come across national chain brands such as Blue Cross Blue Shield, Aetna, United, Cigna, Humana, and Kaiser.
Costs of Plans on Marketplace
When it comes to cost of plan, one size does not fit everyone. There is no fixed premium fee for each plan because the cost is calculated based on your age, your income, the number of individuals in your family, the number of children in your family, where you live, and your tobacco usage. In order to get a quote on all the plans, the marketplace offers a questionnaire in the beginning of the application process. By filling out all the information, the marketplace program will quickly calculate a quote for all the plans.
Please note that these plans are illegal charge you extra because of your sex and your pre-existing health conditions. So for diabetes patients, you do not have to worry about needing to pay extra because of your current health conditions or be denied coverage.
What is a Catastrophic Plan?
For individuals who are under the age of 30 years old and are healthy, they may not need any medical health care at all. In order for them to be exempted from needing to pay hundreds of dollars for health services they do not need, they can subscribe to a plan called “Catastrophic Plan”. This type of high-deductible health plan is only to protect individuals during an emergency health situation. In order for it to become active, you need to pay 100% of the high deductible rate before the plan starts paying for the rest of your expenses. These plans are also available for individuals who suffer from financial hardship and cannot afford their current plan.
Although the catastrophic plan is mainly for emergency use only, the plan does cover 3 annual primary care visits and preventive health services. These services are available to the subscriber even if the deductible has not been met. The preventive services includes:
- Vaccines for Diphtheria, Herpes Zoster, Pertussis, Hepatitis A, Human Papillomavirus (HPV), Hepatitis B, Influenza (Flu), Meningococcal, Mumps, Measles, Pneumococcal, Rubella, Tetanus, and Varicella
- Screening for:
- Blood pressure
- Colorectal cancer
- Hepatitis B
- Hepatitis C
- Lung cancer
- Tobacco Use
- Prevention counseling for sexually transmitted infection (STI)
- Alcohol abuse screening and counseling
- Aspirin use to prevent cardiovascular disease
For women, these preventive services are also included:
- Screening for:
- Breast cancer
- Cervical cancer
- Chlamydia infection
- Human Papillomavirus
- Rh incompatibility
- Gestational diabetes
- Urinary tract infection
- Breastfeeding training and counseling
- Folic acid supplements
- Domestic violence intervention and counseling
For children, extra preventive services are included depending on their age:
- Screening for:
- Behavioral issues
- Cervical dysplasia
- Developmental issues
- Hearing problems
- Hematocrit and hemoglobin count
- Sickle cell anemia
- Lead exposure
- Oral health phenylketonuria (PKU)
- Vision problems
- Fluoride chemoprevention supplements
- Iron supplements
Can I Apply for Catastrophic Plan?
Paying a monthly deductible can be a financial burden to some people. Although the premium of a catastrophic plan can be very attractive, this plan option may not be for everyone.
In general, it is only suitable if:
- You are healthy and rarely see the doctor.
- You want lower premiums and/or cannot afford other plans due to financial hardship.
- You do not mind having a high deductible.
- You are not eligible for Medicaid.
- You are not eligible for a subsidy based on your income.
- You do not want to pay for the monthly premium and have enough funds should health issues arise.
For individuals with diabetes, this plan option is simply out of the question unless you have sufficient funding to pay for all your health expenses and only want the best of all services, medical equipment, and supplies without needing to worry about the cost. But for the majority of diabetic patients who have limited funding, the Marketplace plans are the best options. Due to the Obamacare regulations, you do not have to pay extra for your pre-existing medical conditions or be denied coverage because you have diabetes.
Who Can Buy Health Coverage in a Marketplace?
In general, anyone who is an American citizen or legal resident can buy from the Health Care Marketplace. Temporary foreign workers who hold a working visa can also purchase a plan from the Marketplace if they are not offered health insurance through their employers. However, not everyone can buy insurance from the Marketplace at a discounted price. Only individuals who make less than 400% of the Federal Poverty Level will be allowed to buy discounted insurance. If they cannot afford the insurance, they may be eligible for various benefits such as Medicaid and CHIP. To find out whether you are eligible for any discounts or low income benefits, visit your state’s Marketplace website and enter your information in the application questionnaire. From the information, the marketplace system will come up with the best plans for your needs and alert you of any eligible benefits. If you have any questions or difficulty filling out the application online, you can always visit a local Marketplace office for assistance. To find your nearest Marketplace office, please visit your state’s Marketplace website for more information.
When Can I Buy Coverage in the Marketplace?
According to the Obamacare regulations, all individuals can purchase or change their current plans during the annual open enrollment period which starts every fall. After the open enrollment period ends, you must wait until the next open enrollment period to buy insurance in the Marketplace. However, you may still purchase a plan outside of the open enrollment period if you qualify for exemptions that allow you to sign up for health insurance outside of the yearly open enrollment period. If you have recently experienced these changes in life events:
- Moving to another state
- Losing your current health coverage
- Getting married
- Having a baby
- Adopting a child
- Losing your job and you are experiencing financial hardship
If you qualify for this special enrollment period (SEP), you have up to 60 days following the event to enroll in a plan on the marketplace. You may also have a 30 days grace period if you have just experienced a job change. After the grace period, you will have to wait until the next open enrollment period to purchase a plan from the marketplace.
For individuals who earn below 30% of the average income, they have the option to enroll in Medicaid and the Children’s Health Insurance Plan (CHIP).
When Does the Coverage Begins?
The start of your coverage depends on when you purchase your plan from Marketplace. For 2017 open enrollment, if you purchase your plan from November 1 to December 15, 2016, your plan will begin on January 1, 2017. But if you purchase a plan between December 15, 2016 and January 31, 2017, your coverage will begin the first day of the following month of your purchase.
How Can I Sign Up for Coverage in the Marketplace?
There are a number of ways you can sign up for coverage in the Marketplace. You can fill out an application either online or over the phone for the quickest way to sign up for coverage. If you have any questions or concerns about your current situation, you may choose to visit a local Marketplace office in person to find out whether you are eligible for financial help paying for private health insurance or if you are eligible for coverage under your state’s low income programs such as Medicaid, CHIP, or Tricare. Once your eligibility is determined, you can compare plans and buy one that meets your needs.
In order to make the process as straightforward as possible, you will need to prepare several things. Here is a checklist of what you will need for the application:
- Have all the Social Security numbers of everyone in the household. If you do not have a social security number, you should have your document number or alien number if you are a legal immigrant.
- Have your family’s gross salary amount as listed on your tax return. Make sure you have W2 forms as evidence.
- If you currently have an insurance plan, have the policy numbers ready for case referral.
- Research the providers and medical specialists ahead of time and have your preferred list ready for referral during the application process. This way, you can quickly check each plan’s network for your preferred providers and doctors.
- Have your medication list on hand so that you can check to see if a certain insurance plan covers your medication or whether you need to copay some of the medications and supplies.
- Review the details of each plan. Read through the basic benefits, and services and benefits you need for your diabetes needs such as insulin, syringes, blood glucose testing monitor and strips…etc.
- Calculate ahead of time how much you can afford as your monthly premium. It is better to find out earlier than to realize you cannot afford to make the payment later as you will not be able to switch to another plan without going through a lot of trouble.
- You should find out how much financial help you can include into your premium costs. The help may help lower your monthly costs.
What Do I Do If I Need Help Finding and Choosing a Health Plan?
If you need any help filling out your application, or you need help choosing a health plan for your specific needs, there are trained people called “Navigators” that can help you explore your coverage options and the enrollment process. These navigators can be a certified insurance agent, a certified enroller, and a county services agency. To find the nearest help, you can find the information on your state’s Marketplace website or by searching on the following website: localhelp.healthcare.gov.
What if I Am Already Enrolled in a Marketplace Plan?
Before open enrollment starts, you should get a notice from your plan about renewing your coverage. Open enrollment provides a new opportunity to compare other plans available to you and make sure you are getting all the financial assistance you qualify for. During this time, you should contact the Marketplace to make sure you are still getting the right amount of tax credit to buy a plan and see if you are enrolled in the best plan for you. Since health plans and plan prices change every year, you may find a new plan that meets your needs and is more affordable.
If you are under the age of 26 years old, you may have more healthcare insurance options than you think. For healthy individuals, opting for the catastrophic plan or sticking with your parents’ plan as a dependent may be the best choice. However, being an individual with diabetes, you are very likely to need regular doctor checkups, diabetes medications, and various diabetes supplies and equipment. Although you may choose to stick with your parents’ plan, your spending may eat into their quota. This can create a problem if your parents also have certain health issues that require regular treatments and care. So what can you do?
Option 1: If you are currently a university student, you can actually purchase a fully insured student health plan from your university. These health plans are classified as Affordable Care Act approved health insurance coverage. So that means you do not have to pay for the tax penalty. But before you choose this option, make sure that the plan will cover your diabetes-related treatment, medications, supplies, and equipment.
Option 2: If you are a university student and you decide to opt out of the university student health plan, you can choose to purchase a plan through the Marketplace platform. In this case, you are eligible for receiving the premium tax credit, co-sharing benefits, and even discount in your plan premium. You may also be eligible to receive low cost or free coverage health care benefits from your state Medicaid program.
Option 3: If you have a full-time job, you are mostly likely to be eligible for your employer’s health plan. Go through the summary of the plan and see if they can provide what you need for your diabetes treatment. Although these are private insurance policies, they may sometimes be better quality plan than the Marketplace plans because your workplace actually chips in with your premium payment. These plans sometimes will offer even more preventive care incentives such as paying for your exercise membership fees or even pay you to lose weight. At the same time, these plans often come with better dental and vision care benefits (especially true for government jobs and health care-related jobs).
In a sense, student health insurance plans are similar to workplace insurance plans in that your university will chip in to pay for part of your premium so that you and all the other students can enjoy affordable health care benefits. In addition, most likely, your university will give you several provider choices to choose from. But before you decide to pick the cheapest deal available, make sure you go over the summary of each plan and see if they actually provide sufficient care and service coverage.
One extra benefit of student health insurance is that they sometimes occur traveling health care benefits and study abroad health insurance. If you love to travel, you may want to rethink about student health insurance because you may end up saving money from not needing to purchase extra traveling insurance.
COBRA means Consolidated Omnibus Budget Reconciliation Act. It is a federal regulation that allows individuals to keep their health insurance plan for a certain duration after an occurrence of various life-changing events and cannot get insurance coverage through their job, their spouse’s job, or through the healthcare marketplace. If the individual no longer qualifies for their health coverage due to job loss or reduction in work hours, he or she is allowed a maximum of 18 months of coverage by COBRA. In the event of other qualified events, individuals are allowed up to 36 months of coverage by COBRA. Please note that the COBRA coverage will not affect your eligibility for purchasing a new plan on Marketplace or qualify for your medical tax credit. At the same time, it will not affect your eligibility to receive coverage from low-cost medical coverage such as Medicaid or the Children’s Health Insurance Program.
HIPAA means Health Insurance Portability and Accountability Act. It is a federal legislation that offers health insurance coverage protection for individuals who lose or switch their jobs. It forbids health insurance providers from denying coverage of these individuals because they have certain diseases or pre-existing medical conditions. At the same time, it forces all insurance providers to protect their members’ private information in order to reduce fraud.
The answer is Yes. You can buy health care insurance directly from an insurance provider without going through the Marketplace. However, these plans do not have to comply with the Obamacare Act in meeting all the minimum requirements of the plans sold on the Marketplace. At the same time, you will not be eligible for any assistance, rebate, or reduction in cost for purchasing a private health insurance plan.
The answer to this question has a few interpretation answers. If you define “cheap” as a plan with the lowest monthly premium, then the obvious choice would be the catastrophic plan. This type of plans usually have the lowest premiums. However, please note that it only covers 3 office visits per year along with all free preventive health services. Afterward, you must meet your highly expensive deductible before the insurance provider starts paying for any coverage.
As a diabetic patient, your option of choosing a catastrophic plan is usually are out of the question. So what is “cheapest” insurance plan for you? Under such circumstances, you will need to do some math. Depending on your annual medical expense total, your income, and your financial status, a Silver plan may become cheaper than a Bronze plan.
- If you qualify for both the annual premium tax credit and extra deduction, it is highly likely that your Silver plan will be the cheapest insurance plan. Although you may need to pay a higher premium each month for a Silver plan, you are more likely to reap in more savings for the annual premium tax credit, extra deduction, and coverage payment by the insurance provider.
- If you qualify for the annual premium tax credit (you only actually get the credit if you choose a Silver plan) and the discounted rate benefit for purchasing a plan at a lower price, the Silver plan may still come on top as your cheapest deal.
- If you do not qualify for the annual premium tax credit or the discounted rate benefits, the answer will depend on how much medical service, supplies, and equipment expenses you incur annually. If you are pre-diabetic or suffer from a mild case of diabetes where your blood glucose level stays relatively stable with the help of medication and healthy eating habits, you may find that a Bronze plan will be the cheapest choice.
- On the other hand, if you suffer from Type 1 diabetes or severe cases of Type 2 diabetes, and you require frequent medical services and constant supplies of syringes, blood glucose test strips, and insulin medication, then the Silver plan may become cheaper than the Bronze plan because the insurance provider will begin covering your expenses earlier in a Silver plan than a Bronze plan.
After you complete an application on your state’s Health Insurance Marketplace with all your correct household and income information (mistakes may affect on your eligibility and your monthly premium fee), you can quickly find out if you qualify for a premium tax credit that can be applied to lower your monthly health insurance premium.
In addition, you can also find out if you qualify for cost-sharing reductions benefits. If yes, that means you will need to pay a discounted out of your deductible fee, copayment fee, and other out-of-pocket fees every time you receive medical services and treatments. If you are an individual who requires frequent medical services, this reduction can greatly decrease your annual health care expense.
NOTE! Even if you qualify for these extra benefits, you can only reap in the savings IF you register for a health plan from the silver category. On the other hand, you can use your premium tax credit for a plan in any metal categories. A silver category plan may appear more expensive than a bronze plan. But if you are a frequent medical service user, the cost reduction, the lower deductible fees, and the lower co-payment allow you to incur a lower annual medical expense than a bronze health care plan.
How Does Cost-Sharing Reductions Work?
If you qualify for cost-sharing reduction benefits and you are enrolled in a Silver plan:
- You will get a lower deductible rate. This means that the insurance plan becomes active sooner to pay for your medical costs. The reduction rate will depend on your income status.
- You will receive lower copayments or coinsurance rate. These are the standard fee you must pay for each doctor visit. This fee usually is around $30. But if you are enjoying this benefit, your fee may drop down to $20 or even $15 depending on your income status.
- You will get a lower “out-of-pocket maximum” rate. This is the amount of annual expenses you need to pay for your medical care before your insurance provider pays 100% of the covered medical expenses. Once again, the reduced rate will depend on your income status and how much it deviates from the average annual income of the year (every year the number changes slightly).
To get the most out of your health insurance coverage, here are some tips that will help you maximize your tax credits and deduction savings.
- Always report all your pre-existing conditions when you fill out the Marketplace application. Remember that insurance providers cannot deny coverage based on these conditions. This also means that that cannot limit benefits for those specific conditions either. As a matter of fact, if you omit information about your pre-existing conditions from your application, your insurance providers will have a right to deny your future claims, raise your premium, or even cancel your policy based on the regulations of falsifying your information.
- If you are married and want to maximize your premium tax credit and reduction benefits, do not file tax separately unless you have a specific reasoning or you qualify the benefit criteria as a victim of domestic abuse or spousal abandonment. Under such circumstances, you may claim the premium tax credit even when you file tax separately from your spouse.
- If you have a spouse or a partner, always decide who should be the main applicant for the coverage because your premium will vary depending on your age and your tobacco usage. if you choose the younger person to be the applicant, the premium will be lower than choosing the older of the two as the applicant.
- In order to qualify for premium tax credit and deduction:
- You cannot be claimed as a dependent by another person
- You must enroll in coverage through a Health Insurance Marketplace
- You must not get coverage through your employer
- You must not be eligible for coverage through a government programs such as Medicaid, Medicare, CHIP or TRICARE
- Always report any relevant life changes information to the Marketplace as soon as you can. Changes related to your residence (move to new address), job (job loss, job change, or switching to employed status), estimated income change, relationship (divorce, marriage, widowed), and dependent (babies and adoption) will affect your premium tax credit, reduction rate, and medical tax refund. In some other cases, certain eligible financial assistance program may become available to you, your spouse, and your dependents. To see the detailed list of all the changes you should report, please visit HealthCare.gov.
- Always estimate your medical expense before you look for a plan. From looking at your past year’s records, you can easily get a rough picture on how many visits and the amount of medication, supplies, and equipment you will need in the coming year. From the estimation cost, you can better compare which plan will save you more money than others.
- Consider your options of whether to receive coverage from your employer, your spouse’s work coverage plan, or coverage from the marketplace. Weigh the pros and cons before you finalize your decision. If both you and your spouse require a lot of medical services and treatments, it may make sense to have separate plans.
- Check on the copayment rates. If you need frequent clinic trips, these copayment fees can add up.
- If you have children, you should check on the benefits such as dental care and vision care as they are crucial to your children’s development.
- Always enroll within the open enrollment period. Once you miss the deadline, you will need to purchase an insurance plan from a private insurance provider without enjoying any the premium tax credit, the discounts, or the deductions. If you decide to not get insurance at all, you will need to pay the penalty of the insurance gap.
- Always research the quality of the plan. Not plans are created equal even from the same insurance provider.
- Never auto-renew your insurance policy. Every year, plans change. If the plans have not changed, maybe you have developed new medical conditions that require another plan provide coverage for the new condition treatment. At the same time, new better plans can become available as well. Always review your options before you renew your policy.
- Do not allow an automatic replace plan to replace your discontinued plan. Although the government allows the provider to replace a similar plan with your discontinued plan, you should always read through the new plan before accepting because there are always some differences. In worst case scenario, the new plan does not cover your needs. To avoid getting stuck with a plan that does not take care of your needs, always look for other options as well.
- Do not take COBRA automatically. It is your last option if you lose your job and you absolutely have no other options. That is because COBRA is extremely expensive. You will have to pay the employment policy at a full premium price. Without your employer sharing the cost, that monthly premium fee can double in price. Instead, report your financial hardship and job status change on the Marketplace. Under such circumstances, you will be able to purchase a plan for your needs. In the best case scenario, certain funding and assistance will be available to help you during this difficult time.
- Always research on the providers before you choose one of their plans. Although some companies may rank at the top for their services, it may not be true in your area. For example, even though Blue Cross is a company that provides solid service and plans, they have very limited service in Colorado. If you choose one of their plans in Colorado, you may not receive the care you need. Sometimes, it is better to choose a smaller but local provider if you live in small towns because most medical facilities will sign up to be part of their network.
- Plan your scenarios and know your plan’s limits. Know how much you will need to pay for the same service but in different facilities. For example, if you need stitches on your arm because of an accident, the price of that treatment will be different if you visit your doctor’s clinic versus an emergency clinic versus the hospital emergency department. That treatment in the doctor’s office can cost $100 whereas the same treatment in the emergency room may suddenly come to $1000. But under such stressful circumstances, you may think very little of the cost and more about the severity of the wound. Instead of regretting your choice later, plan ahead and decide what to do in various scenarios.
- Research whether your preferred medical professionals and facilities are included in the coverage network. If a plan does not allow you to receive treatment from your preferred professionals and only gives you subpar physicians and facilities choices, you will want to look for another option even if such plan has the cheapest premium rate. Always compare the hospitals, clinics, rehabilitation center choices before you decide on a plan.
- Always check to see if your plan of choice covers your prescriptions, supplies, and equipment. If you do not check before purchasing, you may realize later that you need to pay for your expensive medication out-of-pocket without any coverage.
- Consider enrolling in a flexible spending account so that you can set money aside from your paycheck for emergency medical use. This way you can pay less tax on your income and you can better prepare yourself should a medical emergency situation occurs.
Medicare is a federal health insurance coverage program for individuals who are 65 years old or older, some individuals who have disabilities, and people who have End-Stage Renal Diseases (also known as ESRD), or suffer from Lou Gehrig’s Disease (ALS) or kidney failure. Medicare includes 4 parts: Part A, Part B, Part C, and Part D. Medicare Part A and Part B are generally called the original Medicare. In general, once you reach 65 years old and receive Social Security checks, the Social Security Administration will automatically enroll you in Medicare Part and Part B. To be exact, the Medicare coverage will become active 3 months before you actually turn 65 years old. Please note that you may ask to delay the activation of Part B as it requires a monthly premium fee. At the same time, if you have not paid Medicare taxes for a minimum of 10 years, you may have to pay a monthly premium for the Medicare health insurance benefits. Your Medicare coverage will be based on your state laws and regulations pertaining to what is classified as a medical necessity coverage.
Medicare Part A: Hospital Care and Services
Medicare Part A usually covers expenses that are related to hospital care, nursing facility care, hospice, care and some home health care.
- Hospital stays.The amount being covered by your Medicare plan depends on how long you have to stay in the hospital. The Medicare Part A plan usually covers up to 90 days of hospital stay per benefit period and may extend an additional 60 days of coverage with a high coinsurance. Please be aware that this 60 extra coverage days are only once in your lifetime.
- Skilled nursing facility care. Medicare will only cover the cost of nursing care for a maximum of 100 days. In the first 20 days, Medicare pays in full for the service. From the 21st to 100th day, you will need to pay a co-payment for every day you require nursing facility care service. After the 100th day, you will need to pay for all cost yourself.
- Home health care. If you are recovering from an illness or injury at home and your doctor orders for short-term skilled care assistance, your Medicare Part A will pay for nurses and some therapists to provide at-home service. You do not need to pay as long as the treatment is Medicare-approved and the provider is certified by Medicare. However, if you need to use certain rehabilitation equipment such as a wheelchair or a clutch, you will need to pay for 20% of the Medicare-approved amount cost.
- Hospice care. Medicare Part A covers most medication costs, and medical and support services for terminally ill patients. Depending what medication is covered, sometimes a small co-pay per prescription is needed for certain outpatient pain medication and symptom management medication. You will also need to pay a 5% co-payment for the approved Medicare amount as set for inpatient respite care services.
- Blood transfusions. You are responsible 100% for the first three pints of blood needed for the transfusion treatment. Subsequently, Medicare Part A pays 80% of any additional amount of blood you need at the hospital. However, the good news is that the hospital often gets blood from a blood bank at no charge. If your hospital has such policy, you will not have to pay for the blood or replace it.
Medicare Part B: Medical Service and Lab Test Costs
Medicare Part B covers for expenses related to doctor visits, outpatient care, medical supplies and equipment, and preventive medical services. If you qualify for Medicare Part A, you are also opt in for Medicare Part B. Unlike Part A, Medicare Part B requires a monthly premium fee taken directly out of your social security payment. For those individuals who have an income higher than the average personal income or household income, they will be required to pay a higher premium than others who have an income at or below average person income or household income. Although you may choose to activate your Medicare Part B at a later time, you will be required to pay a higher monthly premium as a penalty for the late start. In calculation, you will need to pay a lifetime 10% penalty payment for every 12 months you delay enrollment of Medicare Part B. However, you will not need to pay the penalty fee if you opt out of Medicare Part B because you have coverage through your employer and your coverage is considered “creditable”.
- Medical and other services. Medicare Part B pays 80% of doctor visits, treatments, and durable medical equipment such as oxygen, wheelchairs, and crutches. You are responsible for the other 20% of the fee.
- Laboratory and radiology services. All blood tests, X-rays, and other tests are included in Part B coverage.
- Outpatient hospital services. Medicare Part B covers 80% of some outpatient services. For other services, Part B may cover a lesser amount depending on the service.
- Preventive services. Medicare Part B helps pay for various tests, screenings, and vaccinations that are listed in the Medicare regulations. You are also allowed a free one-time physical exam as preventive care service. Part B also includes coverage for alcohol use screening and counseling, obesity screening and counseling, depression screening, sexually transmitted infections screening and counseling, and cardiovascular behavioral counseling.
Medicare Part C: Medicare Advantage Plans
Medicare Part C is often referred to as Medicare Advantage Plan or MA Plans. These approved Medicare Advantage plans are provided by private insurance providers that have contracts with the government. These plans must provide members with all the services of both Part A and Part B Medicare. However, these plans are not all the same as some limit members to receive service from specific health care providers or hospitals and others require members to retrieve a referral from a primary care professional before they are allowed to see a specialist. At the same time, the premium and copayments for these plans all differ vary from plan to plan.
Similar to regular health insurance, there are 4 types of Medicare Advantage Plans are available:
- Private fee for service plans
- Special needs plans
Medicare Part D: Prescription Drug Coverage
Medicare Part D adds medication coverage to the original Medicare Part A and Part B, or Medicare Part C. Similar to Medicare Part C, Medicare Part D plans are offered by private insurance companies approved by Medicare. At the same time, Medicare Part D plans vary in premium cost and coverage. For individuals who earn less than 150% below the federal poverty level qualify for financial help for Part D premiums and their prescription costs.
Other Medicare Health Plans are geared towards individuals who have multiple chronic diseases or those who have special needs:
- Medicare Cost Plans are HMO plans that are similar to the Medicare Advantages plans
- Program of All-Inclusive Care for the Elderly (PACE) offers medical, social, and long-term care services for frail seniors in the community.
- Medicare Innovation Projects are test plans that are used to examine improvements in Medicare coverage, payment, and quality of care.
If you are interested in more information about Medicare, you can call the Social Security Administration at 1-800-772-1213 or visit www.socialsecurity.gov.
Yes, Medicare actually helps diabetic patients to pay for many diabetes services, supplies, and equipment. It also includes coverage of some preventive care services for pre-diabetic individuals. However, the coinsurance payments and deductibles may vary depending on your coverage, your financial status, and the state you are currently residing. And to enjoy the benefits as listed below, you must have subscribed to Medicare Part B and/or Medicare Part D.
Medicare Part B helps pay for:
- Screening tests for people who are at risk of developing diabetes
- Self-management training for diabetes
- Supplies such as glucose monitors, test strips, and lancets
- Insulin, and insulin administration-related equipment such as syringes and/or insulin pumps
- Counseling and training to help obese people lose weight
- Immunization shots
- Foot exams and treatment for diabetic patients
- Eye examinations for diabetic patients to check for glaucoma and diabetic retinopathy
- Nutrition therapy and counseling services for diabetic patients
- Custom therapeutic shoes or inserts for diabetic patients
Medicare Part D helps pay for:
- Diabetes medications as well as other complication medications
- Diabetes supplies such as testing strips, needles, and syringes for injecting insulin
Although certain supplies and medications are covered for diabetic patients, you need to check on your state’s coverage details to find out how much supplies are included within a month or a year. For example, some states may allow coverage for lesser blood glucose test strips than other states. To find out more information about coverage of your medical needs, you can visit Medicare’s official website and research the specific items you need. If you have limited internet access, you may find out the information by calling 1–800–MEDICARE (1–800–633–4227). At the same time, you can request for the free booklet “Medicare’s Coverage of Diabetes Supplies & Services”.
Medigap plans are also known as Medicare Supplement Plan. They are extra health insurance that you may purchase from a private insurance provider to pay for health care expenses that are not covered by Medicare. They also offer coverage for emergency health care if you need to travel outside of the United States. These plans are only available for individuals who are currently under coverage from Medicare part A and B plans. Those who are currently under Medicare Advantage plans cannot receive coverage from a Medigap plan. If you wish to find out more information about Medigap plans, please refer to our article “Diabetes Travel Insurance Guide”.
Being employed does not mean that you can afford health insurance. Although your employer may offer “affordable” health care coverage, if the plan costs more than 9.5% of your income or does not cover at least 60% of your covered benefits cost, you should look for a better plan on the Health Care Marketplace. In many cases, you will be able to get a better plan at a lower cost with more coverage and deductions. In cases where your income qualifies as low-income standards, you will be eligible for purchasing a plan at discounted rate or even qualify for Medicaid.
In addition, if you are unemployed or disabled, you should apply through the Marketplace as well. The system will immediately alert of the most suitable eligible government programs for your needs.
In both cases, whether you are employed or not, you should never skip the Marketplace application process thinking that you will not be able to afford health care coverage. It is here to provide you with options and solutions. Being an American, you have every right to receive these basic needs. Unlike Marketplace plans, you can enroll in government-funded programs such as Medicaid, CHIP, or Tricare any time of the year. If you qualify for the program, your coverage begins immediately.
Medicaid is a low-cost or free health coverage provided by both federal and state programs for low-income individuals, children, seniors, pregnant women, and others with disabilities. In order to qualify, an individual must fulfill one of these requirements:
- Require Medicaid so that the individual can work
- Has a grossed earned income that is a specific percentage below the average income standard (the percentage differs for each state’s set requirement for low income benefits)
- Children up to age 19 in families that qualify as low-income families
- Pregnant women who qualify as low-income individual
- Children in foster care or adoption agencies
Similar to Medicare, Medicaid comes in 4 parts:
- Part A: Hospitalization cost coverage
- Part B: Coverage for medical treatment services, laboratory fees, x-rays, durable medical equipment fees, and outpatient care services
- Part C: Also known as Medicare Advantage Plan. It is offered by private approved companies by Medicare
- Part D: Coverage for medical prescriptions
Depending on the financial status of the individual, they may need to pay a very low-cost premium for the coverage. For some individuals, coverage is absolutely free.
NOTE: individuals who qualify for Medicare and meet the requirements for Medicaid can be qualified for dual eligible for both programs. If a person has both types of coverage and he receives certain medical treatments that are covered by both Medicare and Medicaid, Medicare will pay first and Medicaid will pay second for the rest of the treatment cost. In some cases, Medicaid may pay for services that Medicare does not, vice versa in other cases. For more information about the income requirement for dual eligibility, please refer to the Medicaid official website.
What Services Are Included for Medicaid?
Medicaid coverage is separated into mandatory benefits and optional benefits. Mandatory benefits are those listed by federal Medicaid policies as necessities for all states. Optional benefits are those services that have been included by the state as necessities and are covered by the state funding. These mandatory benefits may differ from state to state.
|List of Medicaid Benefits|
|Mandatory Benefits||Optional Benefits|
For more information about the coverage details of the Medicaid benefits, please visit your state’s Medicaid official website.
CHIP stands for Children’s Health Insurance Program. Some states prefer to use the name “Healthy Families Program” instead. This state-run program service provides health care coverage for children who are 19 years or younger. It is available for individuals carrying child. To be more exact, the coverage is for the individual’s unborn child. The coverage includes services for labor with delivery and will end after the first month after birth. After that, only the baby will be eligible for CHIP. However, certain families who qualify as low-income families but are not eligible for Medicaid for various reasons (for example, the parents’ earning qualify for low-income family but too much to qualify for Medicaid) are also eligible for CHIP program.
What Benefits and Services Are Included for CHIP?
Often times, CHIP is run as an extension of Medicaid. Therefore, individuals who qualify for CHIP are also entitled to Medicaid benefits as well. At the same time, each state includes other benefits specifically geared towards the well-being of children. These includes:
- Routine health check-ups
- Immunization shots
- Doctor visits
- Medication for various prescriptions as listed in the CHIP coverage details
- Dental prevention services and care services such as dental checkups, cleanings, and fillings
- vision prevention services and care services such as eye examinations and glasses prescription
- Inpatient / outpatient hospital care services
- Laboratory and X-ray services
- Emergency services (the specific coverage details may vary from state to state)
- Special health needs treatment
- Pre-existing conditions treatments (such as diabetes)
However, please note that because CHIP a state program, certain states may choose to enforce a limited enrollment fee, monthly premium cost, deductible fees, coinsurance fees, and copayments for children and pregnant women enrolled in CHIP. However, the total of the medical expenses must be limited to 5% of a family’s annual income as stated in the federal law. Children and teens who qualify for CHIP can remain covered as long as they still qualify. However, they need to renew their coverage once a year by proving that they still qualify for the program based on their parents’ income and financial status. For more information, you can learn more about the CHIP program and the coverage details in your state by visiting the CHIP program website www.insurekidsnow.gov. For those who have limited internet and computer access, you can call the hotline 1-877-543-7669.
NOTE: There is no specific open enrollment period for CHIP. You may apply for your child at any time of the year. To apply, please visit healthcare.gov for more information on the application. You may also visit your local Medicaid and CHIP agency for assistance.
Who Can Apply for a Child?
Typically, the parents of the child can apply for their child. But in cases where the child is under the custody of the grandparents or relatives, whoever the legal guardians are will have the authority to apply for the child. Moreover, in cases where the child is in foster care or under care by an adoption agency, the authorized representative can apply on behalf of a child. For teenagers who are living on their own, the state may allow them to apply for Medicaid on their own behalves or allow a social worker to apply for them.
The following federal programs can provide more resources for people with diabetes:
- Department of Veterans Affairs (VA) operates certain hospitals and clinics specifically serve veterans who suffer from service-related health problems and/or issues and veterans who need financial aid. For more information about veterans’ health and financial benefits and assistances, please visit www.va.gov/healthbenefits/online or contact 1–877–222–8387.
- TRICARE is a health care program that is specialized in helping uniformed service members, retirees, and their family members. These individuals include:
- Current active service members
- Military retirees
- Family members of a currently active duty service member or a veteran
- Members of the National Guard/Reserves who have been on active duty for 30 days
- Family members of members of the National Guard/Reserves who have been on active duty for 30 days
TRICARE offers additional coverage for those qualifying individuals who already benefit from Medicare Part A and Part B. For example, it may offer extra financial aid for veterans who require financial assistance for obtaining a service animal. Other benefits may include extra financial aid for artificial limb and mental health care service. To learn more about TRICARE, please visit www.tricare.mil.
- The Indian Health Service is a program that helps members from federally recognized American Indian or members of the Alaska Native tribes. To learn more about the Indian Health Service, please visit their website at www.IHS.gov.
- Social Security Administration
- The Hill-Burton Free and Reduced-Cost Health Care Program is a federally-funded program that helps individuals who have no health care insurance and in need of financial assistance with hospital care costs. Individuals who are in this current unfortunate situation can receive more information about this program by visiting their website at www.hrsa.gov/gethealthcare/affordable/hillburton or contact their toll-free number 1–800–638–0742/.
- Bureau of Primary Health Care a program run by the Health Resources and Services Administration (HRSA). It offers primary and preventive health care assistance to medically underserved individuals via community health center events and programs. For un-insured individuals, the Bureau will offer health care services based on the family size, income and financial status of the family. To find your nearest health centers, please visit http://findahealthcenter.hrsa.gov or contact the toll-free number 1–888–ASK–HRSA (1–888–275–4772)
- Supplemental Security Income (SSI) is a federally funded safety net program that provides financial assistance in monthly stipends to children with disabilities and individuals qualify as low-income individuals with few assets. People who receive SSI may also be qualified to receive food stamps and Medicaid coverage.
- Read more about both SSDI and SSI and how to apply at www.ssa.gov or by calling 1–800–772–1213, TTY 1–800–325–0778.
- Women, Infants, and Children (WIC) is a federally-funded program run by the U.S. Department of Agriculture. This program provides services and assistances to women who qualified as low-income individuals and are pregnant, breastfeeding, and recently postnatal individuals. This program also provides help and services to infants and children up to age 5 who are at risk of suffering from malnutrition. The services include:
- Provision of supplemental foods
- Health care referrals
- Education on nutrition and health care of infants and toddlers
- Breastfeeding education and consultations
In order to qualify for the WIC program, the individual must meet the criteria for residential location, financial needs, and nutrition risks as stated in the WIC regulations. Women who suffer from gestational diabetes are considered as qualified applicants who are at a nutrition risk threat. Infants and toddlers born from a gestational diabetic mother also qualify for assistance through the WIC program if the mother also qualifies for financial need requirements and has resided at a particular state for a minimum of required duration. For more information about the application process and the requirements, please visit the WIC website at www.fns.usda.gov/wic or contact the WIC’s national headquarters at 703–305–2062.
- Social Security Disability Insurance (SSDI) is a federal insurance plan that offers financial assistance to individuals who cannot work via a monthly stipend. In order to qualify for SSDI, individuals must have earned enough SSDI work credits when they pay Social Security taxes. This plan becomes active when the individual suffers from an illness or injury that prohibits him or her from working for a minimum of 1 year. Individuals may have the option to keep their SSDI payments dormant.
Here are some state-run programs that may provide more resources for individuals who suffer from diabetes:
- Medicare Savings Programs
- Qualified Medicare Beneficiary (QMB) Program
- Qualifying Individual Program (QI) (also known as ALMB)
- Qualified Disabled and Working Individuals Program (QDWI)
- Specified Low-Income Medicare Beneficiary (SLMB) Program
- State Pharmaceutical Assistance Programs (SPAPs)
- State Health Insurance Assistance Programs (SHIPs)
Medicare Savings Programs.
Some states may cover for your Medicare premiums, deductibles, and coinsurance if you have very low income and few assets. Your local social service department can help you determine whether you are eligible for the Medicare Savings Program.
- If you qualify for the Qualified Medicare Beneficiary Program (QMB), your Medicare Part A and Part B monthly premiums and annual deductible will be covered. At the same time, the program will cover your co-insurance and deductible payment amounts for treatments and services as well.
- If you qualify for the SLMB benefits, the program will cover the payment of the Medicare Part B monthly premium.
- If you qualify for the Qualifying Individual Program (QI), the program will cover your Medicare B premium cost. Please be warned that this program is granted on a first-come first-served basis. Once the quota has been met, your state will no longer accept applications until the next year.
- If you qualify for the Qualified Disabled and Working Individuals Program (QDWI), the program will cover your Medicaid Part A premium fees.
State Pharmaceutical Assistance Programs (SPAP)
42 states have this program for low-income individuals to cover their prescription medication costs. Because this is a state-funded program, each participating state has its own rules concerning what medications are covered and how much coverage are given to these low-income individuals. To find out more about your state’s SPAP details, please visit www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx for the details. For those who have limited access to a computer or to the internet, you can find out the details by calling Medicare or the State Health Insurance Assistance Program.
State Health Insurance Assistance Programs (SHIP)
SHIPs is a federal-funded program that offers free health insurance advice to individuals with Medicare plan. The SHIP counselors can help people learn more about programs and benefits that are available to their current status. At the same time, these counselors can help individuals select a suitable Medicare health plan or Medicare Prescription Drug Plan based on their eligibilities and needs. If you would like assistance from a SHIP counselor, you may do so by visiting the official website at www.shiptalk.org. The website will give you more information on your local SHIP office and your nearest SHIP counselors.
The United States government have many public health sectors that can assist individuals with medical care needs. However, there are always a specific group of individuals who fall through the crack and fail to receive assistance. Acknowledging the limits of our government programs, there are local resources from various charitable groups that actively find ways to financially assist and cover expenses of certain individuals with diabetes. Here is a list of local foundations that are known for their efforts:
- Lions Clubs International are known for helping with vision and hearing screening as a result of diabetes. They are also known for their program of sending children with diabetes and other physical challenges to specialized camp. For more information on their program, please visit www.lionsclubs.org.
- American Diabetes Association is known for providing free information to the public about various topics on diabetes. They are also known for assisting diabetic individuals on diabetes-related questions. To learn more about American Diabetes Association, please visit www.diabetes.org.
- Elks clubs often provide charitable fundraising activities to raise funds for the local youth and veterans who are in need of financial and medical assistance. For more information about their programs and fundraisings, please visit www.elks.org.
- Shriners of North America offers free medical treatment for children at Shriners hospitals throughout the United States. To learn more about the details, please visit www.shrinershq.org or www.shrinershospitalsforchildren.org.
For individuals who are of American Indian or an Alaska Native heritage, they may qualify for new health coverage benefits and protections on the Health Care Marketplace platform. Benefits are also available to federally recognized native tribes members and Alaska Native Claims Settlement Act (ANCSA) shareholders through Indian Hospital or Public Health Services (PHS), tribal programs, and urban Indian health programs.
Health Care Marketplace Benefits for American Indians and Alaska Natives:
Unlike other American citizens and residents, members of federally recognized tribes and ANCSA shareholders may enroll in Marketplace coverage plans any time of year even when it is not open enrollment period. In addition, they are allowed to swap for another plan once a month. There may also be extra benefits available for American Indians and Alaska Native members that are not available for other Americans. These benefits may be easier qualification for co-sharing reductions and discount plan prices. At the same time, individuals of federally recognized tribes heritage do not have to pay the penalty tax fee even when they are uninsured.
Low-income Benefits for American Indians and Alaska Natives:
Members of the American Indians and Alaska Natives heritage have lower requirements to qualify for Medicaid, CHIP, and other government funded health care assistance programs. For Indian health programs, tribal programs, and urban Indian programs members are not required to pay the out-of-pocket fees regardless of the income status.
In addition to the previously mentioned benefits, individuals of federally recognized tribes and ANCSA shareholders can enroll in a private health care insurance plan through the Marketplace platform and still keep the benefits and services from the Indian Health Service, tribal health programs, and urban Indian health programs. Individuals who qualify for Medicaid, CHIP, or other government-funded assistance may also keep all the benefits and services from their Indian Health Service, tribal health programs, and urban Indian health programs as well.
How Do I Qualify for All the Benefits?
In order to qualify for all the listed benefits as mention in the previous sections, you must provide the following documents along with their applications:
- A document issued by a federally recognized tribe or an Alaska Native Claims Settlement Act Corporation to confirm your tribal membership or shareholder status
- A certificate of Indian blood heritage issued by the Bureau of Indian Affairs
- A tribal census document
- An enrollment card
- Any other document confirming affiliation with your tribe
If you require financial assistance with your medication, supplies, and equipment, you may want to look into the option of seeking help from various pharmaceutical companies. This is because many pharmaceutical companies provide financial assistance programs to support customers who have financial difficulty paying for their medications and supplies. Please note that these programs are all provided voluntarily by the companies. Therefore, each company may have different benefit quotas and specific requirement criteria. If you are interested in receiving some help with your medication and supplies expenses, here is a list of pharmaceutical assistance programs:
Amylin Pharmaceuticals Inc. (Amylin Patient Assistance Program)
This company offers an assistance program for their consumers who cannot afford their medications as well as educate the younger generation on preventive care and habits that will lead them to better health. To determine your eligibility for their program, please visit their website or call their toll-free number 1-800-292-6363.
Benefits Check Up
Benefits Check Up is a service from the National Council on Aging that offers information on benefits programs for seniors who have limited income and resources. Seniors and their family members can search for financial assistance programs that may help with their prescription drugs, health care, rent, utility bills, grocery necessities, and other needs.
Bridges to Access
GSK offers some of their medication to low-income patients at no cost. To see if you qualify for their assistance program, please visit their official website to fill out their application.
Bristol-Myers Squibb Patient Assistance Foundation
Bristol-Myers Squibb offers assistance for patients who require Daklinza, Eliquis, Empliciti, Nulojix, Orencia, Opdivo, Sprycel, and Yervoy but cannot afford the medication. In order to qualify for their program, please visit their official website for more information or call their toll-free number 1-800-736-0003.
Lilly has known to create many education materials for diabetic patients on how to manage their blood glucose level. To see if you qualify for their patient assistance program, please visit their official website.
NeedyMeds.org offers information on pharmaceutical and medical assistance programs for individuals who require regular treatments and medications for their medical conditions.
The pharmaceutical company NovoLog offers co-payment program as well as a free-of-charge rebate for diabetic individuals who meet their program requirements. For more information, please visit their website.
Partnership for Prescription Assistance
Offers a list of assistance programs that will be beneficial for diabetic patients. These includes programs for free glucose meters, test strips, insulin syringes, medical testing, service animals, and pharmaceutical company programs.
RxAssist offers a comprehensive database of pharmaceutical assistance programs. By inputting your current medication, their directory will return with related eligible program information.
RxHope is a web-based resource that acts as a facilitator in helping people get their medications for free or for a small co-payment.
Takeda Help At Hand Patient Assistance Program
If you currently are taking Amitiza, Lubiprostone, Colycrys, Dexilant, Kazano, Nesina, Oseni, Prevacid, Rozerem, Trintellix, and/or Uloric, you may receive financial assistance for lowering your medication expenses by application for the Takeda Help At Hand Patient Assistance Program. To find out more information, please visit their official website or call their toll-free number 1-800-830-9159.
The first step of receiving help on learning more about available plans is to visit your state Health Insurance Marketplace official website at www.healthcare.gov and read through their tips and instruction pages. If you have limited access to the internet or the computer, you can find the same information by calling 1-800-318-2596. This hotline information phone number is available 24 hours a day, 7 days a week.
As a diabetic patient, you can find out more information by contacting the American Diabetes Association concerning your rights and protection when it comes to purchasing a health care insurance plan from the Marketplace.
If you have any questions concerning your financial status and whether you qualify for the federal and state funded financial assistance medical programs, you can find a lot of your answers by visiting the Medicaid official website at www.medicaid.gov. The website can explain to you more in detail of all the available assistance plan and direct you to your state’s requirement and optional plan coverage through their state web links. Instead of visiting their website, you also have the option to contact their information hotline at 877-267-2323.
We hope that this article may help you better understand the health care insurance system of the United States and the available options you have as a diabetic individual. We would love to hear some feedback from you and your stories on finding your health insurance plans.
Recommended Resource: https://www.diabetes365.org/life-insurance/