Choosing a health insurance plan for diabetes can be a complex yet crucial decision during open enrollment periods. Carefully evaluating your health needs, financial budget, and eligibility is crucial to secure suitable coverage for diabetes medications and supplies at an affordable cost. In this blog post, we will explore the various types of insurance options as well as questions to ask when comparing health insurance options during open enrollment.

Type of health insurance

Health insurance falls into two primary categories: public and private. Private insurance involves coverage obtained either through an employer's or union’s plan or by purchasing a plan from a private insurance company. On the other hand, public insurance comprises government-funded plans at various levels (federal, state, or local), such as Medicare or Medicaid. Your eligibility for different health insurance options is influenced by factors like your employment status, household size, and income.

When to enroll in health insurance

You can select or make changes to your health insurance coverage during the annual open enrollment period.  It is important to check with your specific health insurance provider or government healthcare website to confirm the exact dates for open enrollment as they can change from year to year.

Your coverage will begin at a specific date after open enrollment ends and is valid for a full calendar year. Outside of open enrollment, you can make changes if you experience a significant life event such as getting married, having a baby or losing your current health insurance.

Open Enrollment Questions and Considerations for People with Diabetes

Once you know what health insurance plans you have available to you, you will want to make a comparison chart to see how they stack up against each other. These questions will help you gain a better understanding to make sure the plan you are considering will provide adequate coverage for your diabetes needs.

Cost-Related Questions for People with Diabetes

• What is the monthly premium for this health insurance plan, and can I afford it on an ongoing basis?
• Are there co-payments, deductibles, or coinsurance for doctor's visits, medications, or diabetes supplies, and how much are they?
• What are the annual deductibles for individuals and families, and how do they apply to diabetes care and supplies?
• Are there out-of-pocket maximums on how much I can be required to pay for my healthcare expenses in a year?
• What is the estimated total annual cost for your monthly premium, deductibles, and diabetes supplies?

Benefit-Related Questions

• Does the plan cover preventive services like annual eye exams?
• Are there any restrictions on seeing specialists, such as endocrinologists or diabetes educators?
• Does the plan cover diabetes medical equipment such as insulin pumps or continuous glucose monitors (CGMs)? If yes, what is the coverage like?
• Are there any limitations on types of diabetes supplies covered, such as specific brands of insulin pumps or glucose testing equipment?
• Are visits with an endocrinologist, diabetes educator, and other diabetes care providers covered? Is there a limit to how many visits are covered?
• Is durable medical equipment (such as continuous glucose monitors or insulin pumps) covered?
• Which of your current medications are on the plan’s preferred drug list or formulary? Which medications are not included?
• Does the plan require coinsurance for any services or treatments?
• Are there benefits to using a mail-order or specialty pharmacy? If so, who is their preferred provider?

Access-Related Questions

• Is your current diabetes care team in-network?
• Do any of your current medications or diabetes supplies require prior authorizations?
• Do you need a referral to see a specialist?
• How long does each referral last?
• Does the plan offer out-of-network benefits?
• Are you covered when you travel or go out of state?
• Is there a specific pharmacy that you need to use to refill specialty supplies?
• Are there preferred pharmacies for lower costs?
• Can you obtain a network exception if you want to continue using your current pharmacy?
• Is there a 24/7 nurse line available?
• Are telemedicine services covered? If so, does it have the same coverage as in-person visits?

Tips for communicating with health insurance providers

Insurance providers may not be fully aware of the realities of life with a chronic condition such as diabetes. Below are basic strategies that can help you communicate more effectively with insurance providers:

• Begin Early: You don't need to wait for the open enrollment period to start inquiring about insurance benefits and coverage. Starting early can alleviate stress, providing you with sufficient time to address any concerns or seek clarifications regarding diabetes treatment options.
• Compile a medication and provider list: Prepare a comprehensive list detailing your current medications and healthcare providers. This information will serve as a valuable reference when inquiring about insurance coverage and benefits.
• Obtain a name and reference number: Having the name of the person assisting you and reference number for the interaction can establish accountability and facilitate a faster resolution for any future discrepancies or issues with the information provided.
• Request a supervisor: If necessary, ask to speak with a supervisor. Seeking a higher authority can facilitate more complex inquiries and ensure that your questions and concerns receive the attention they deserve.
• Engage with the diabetes community: Reach out to the diabetes community for insights and advice on effectively navigating discussions with insurance providers. Shared experiences can provide valuable tips for advocating on your own behalf based on what others have done in similar situations.

Frequently ask questions: diabetes and health insurance

Do people with diabetes have to pay more for health insurance?

Despite the regulations established by the Affordable Care Act to prevent health insurance companies from denying coverage or charging higher premiums due to pre-existing conditions like diabetes, individuals managing diabetes may still encounter higher healthcare costs than those without the condition. People with diabetes require regular monitoring, specialized care and medications, and lifestyle adjustments that all contribute to higher healthcare costs.

Should you choose a high or low deductible health plan with diabetes?

High deductible plans typically have lower monthly premiums but require higher out-of-pocket expenses before insurance coverage kicks in. If you have frequent medical expenses due to diabetes, such as insulin pumps, CGMs, and diabetes medications you may end up paying a significant amount out-of-pocket before reaching the deductible.

It can be advantageous to compare the annual out-of-pocket costs of a low deductible plan with a higher monthly premium. Although the monthly expense may be greater, you may end up spending less overall throughout the year, given that your insurance coverage would start earlier.

What is the best health insurance for someone with diabetes?

The best health insurance for someone with diabetes is a plan that combines comprehensive coverage for diabetes-related services and medications with reasonable out-of-pocket costs. However, there is no one-size-fits-all plan for everyone with diabetes, as the choice of health insurance depends on an individual's health and diabetes needs, financial circumstances, and eligibility criteria.

About Amanda Ciprich, MS, RD

Amanda Ciprich, a registered dietitian with a specialization in type 1 diabetes, was diagnosed with T1D herself at the age of 18. With her expertise and personal experience, she has authored two books, including "The Caregiver's Guide to Diabetes: Practical Advice for Caring for Your Loved One." As the founder of T1D Nutritionist, a virtual insurance-based private practice, Amanda provides counseling and guidance to individuals with T1D and their families, supporting them in effectively managing diabetes.

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