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Insurance Guide

Health insurance got your head spinning? Does the word insurance (in the context of diabetes) give you heart palpitations and sweaty palms? If so, you are not alone. The U-M Pediatric Diabetes team is here to help you navigate through the seemingly complex maze of insurance and shed some light on what we consider must-knows, what ifs, and trusty tips.

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Check out this comprehensive Health Insurance Guide put together by JDRF for additional help in navigating the insurance world.

Must-Knows

In our fast-moving healthcare environment, we want to ensure our patients are up-to-date on important news and understand the options available to them under their health insurance plans. Here are a few updates to consider as you review your insurance options.

Are you up-to-date on DME company news?

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You may ask, what is a DME? A durable medical equipment (DME) company provides some of the tools and supplies you need to manage diabetes. DME companies usually provide medical equipment or specialized items not provided by local pharmacies.

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There are a variety of DME changes occurring that may disrupt your ability to obtain diabetes supplies. In 2017, it was announced that MedEquip would no longer handle patient diabetes testing supplies. DME changes can happen quickly and leave you without supplies, so it is important to stay updated on the latest news. You can subscribe to our clinic newsletter to receive important updates, and if your DME company ever stops issuing supplies, follow the steps below:

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1.  Contact your insurance company to see which DME company is in-network with your insurance plan and can ship diabetes testing supplies. You can find the customer service phone number on the back of your insurance card.

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2.  Once you have selected a new DME company, contact the DME company and make sure they carry your preferred supplies. If so, set up an account and call us to send prescriptions to the new company. (Please keep in mind that it can take 2-3 weeks from setting up an account at a new DME company to begin receiving supplies.)

Are you enrolled in a high-deductible health plan and interested in acquiring new diabetes technology (like a pump or CGM)?

 

You may ask, what is a high deductible health plan? It’s a health plan in which you pay less for the health plan on a monthly basis but must pay a certain amount of money out of pocket as a deductible before your insurance company pays additional expenses for care. Some deductibles can be thousands of dollars. Towards the end of the year, families have usually reached this deductible through various healthcare visits, so it becomes a great opportunity to apply for diabetes equipment that can be covered by the insurance plan. This process is time-sensitive, however: you must apply for your devices as soon as possible before the end of the year.

 

1.  If interested, talk to your endocrinologist and CDE to see what devices you may be able to get covered. You may also be required to attend an Introduction to Insulin Pumps class.

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2.  If you want a specific device, call your diabetes team now (no later than Nov. 1st!) because it can take months to process your application.

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3.  Don’t forget to keep an 8-week log of at least 4 blood sugars per day in your application - make sure you are recording your numbers on a log (you can download weekly logs here) or are downloading them from the meter.

Are you paying for your supplies out of pocket?

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If you are paying for your diabetes supplies out-of-pocket, you may not be taking advantage of certain benefits covered by your health insurance. Determining which supplies are covered by which benefits can be a common and confusing issue for patient families unfamiliar with durable medical equipment (DME) companies. We have had families paying for blood glucose testing strips and ketone strips out of pocket because they did not realize these were not covered by the pharmacy but were covered by the DME or vice versa. Be sure you understand which supplies are covered under your insurance plan to avoid paying for more than you need to.

What-Ifs

Everyone's experience with diabetes and insurance is different. Below are some frequent concerns our patient families have expressed to us. Be sure to check out our Insurance & Supplies FAQs for additional questions, and call us if you have a question that is not covered.

What can I do about the rising cost of insulin?

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If you are concerned about the rising price of insulin, you are not alone. Many people in the T1D community feel we are reaching a crisis in the US because of the rising price of insulin. The insulins that we have traditionally used for patients with type 1 diabetes include rapid-acting analog insulins for over $500 and long-acting insulins that can range from $250-450.

 

Studies using Medicaid data have shown that annual payments for a patient requiring 40 units of insulin a day increased from $771 in 2001 to $2852 in 2014 (a 370% increase) for rapid acting insulin, and from $891 in 2001 to $2848 in 2014 (a 320% increase) for long acting insulin. These costs are increasingly being passed onto patients and their families as the number of individuals on high deductible health plans or who are uninsured grows. You may have seen tragic examples of families using crowdfunding sites like GoFundMe to fundraise to pay for their insulin.

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Recently in January 2023, Medicare Part D went into effect which called for a $35 insulin cap. As a result, Lilly, Novo Nordisk, and Sanofi all reduced the cost of their insulin. Specifically, Lilly capped their monthly costs to $35 per month for all their insulins at participating pharmacies. However, individuals who do not have commercial insurance and do not go to a participating pharmacy have the option of using a savings card in order to have the $35 cap as well. For Novo Nordisk, they will reduce prices of Novolog, Novolog 70/30, Levemir and Novolin by up to 75% starting January 2024. Sanofi will reduce the list price of Lantus by 78% by January 2024 and will cap out of pocket expenses to $35/month at participating pharmacies or with a savings card. Check out this chart for a summary of insulin reductions from these three manufacturers:

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What if my insurance company won’t cover my supplies?

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If you have been told that your supplies aren't covered, call your insurance provider and ask which DME company they work with. Your supplies may be covered under DME benefits instead of pharmacy benefits. Some common scenarios that our families face include:

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  • The supplies are not covered by pharmacy benefits because they are covered under DME benefits

  • The representative you contact at your insurance company may not have the most up-to-date information, and could be giving you incorrect information

  • Different brands of a medicine may be covered by different insurance plans. They may be different in name, but basically the same medicine (Lantus vs. Levemir for long-acting insulins; Humalog vs. Novolog for rapid-acting insulins)

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If you have addressed the reasons above and still can't get your supplies covered, please reach out to our social work team for assistance. 

What if we are losing our insurance coverage and can’t afford our care or insulin. What can we do?

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Our clinic will do everything we can to take care of your child's diabetes. Please contact one of our social workers to determine if your family qualifies for Children's Special Health Care Services (CSHCS).  Children’s Special Health Care Services is a Michigan state program designed to provide coverage for children with chronic diseases, including type 1 diabetes, who don’t have adequate insurance to cover their special health care needs. CSHCS will cover the cost of visits with providers, medications, and supplies for diabetes, but doesn’t provide coverage for health issues unrelated to diabetes. CSHCS can also help lower the costs of co-pays/deductibles for some children with private health insurance.

 

Exciting news! CSHCS has now expanded coverage for individuals up to 26 years of age, effective October 1, 2023. Please contact our social workers to determine if your family qualifies and to discuss the application process. A cost chart can be found here.

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If you are uninsured or have other circumstances that require you to pay out-of-pocket, check out these tips from the Diabetes Leadership Council (DLC) to reduce the cost of your insulin. We also encourage you to check this chart from the Association of Diabetes Care & Education Specialists (ADCES) for cost-saving resources.

What if I’m about to turn 26 and I have CSHCS coverage?

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CSHCS coverage will end the day before your 26th birthday. Please note that regardless of when your 26th birthday falls within the calendar year, you will be charged the full CSHCS yearly fee. However, you may contact your county’s CSHCS representative to request an extension of your coverage from January 1st through your 26th birthday. Find your county’s CSHCS representative here.

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The Children’s Special Health Care Services (CSHCS) program only provides services for children under the age of 26. If you need insurance coverage assistance after you turn 26, program representatives with the Washtenaw Health Plan can help. Call Kelly (734-544-3079) or Ruth (734-544-3068) to find out the best options for you and your family.

What if I have to renew my Medicaid plan? Which one is best for me and my family?

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Medicaid HMO coverage for diabetes varies between plans. Different plans may cover different brands/styles of supplies, such as glucometers, test strips, insulin pumps, continuous glucose monitors (CGMs), etc. Consider contacting MI Enrolls (800-975-7630) to find out what plan options are available in your county. If you are interested in receiving access to devices like an insulin pump or a continuous glucose monitor (CGM), contact the Medicaid plan(s) you are interested in to ask whether they cover these devices.

What if something isn't covered and my prior authorization is denied?

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If your prior authorization is rejected by your insurance company, you should call us to help you through the appeal process and to find out how you can continue getting supplies in the short term. You can also file a complaint with the insurance company and you may want to consider lobbying for better care by telling your story and contacting people in positions to change these policies. You can read about lobbying efforts here.

Trusty Tips

Always be ready.

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When preparing for a call with insurance companies, here are some checklist items you will want to have at the ready:

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  • Your insurance card and social security number

  • Time - you may want to grab a drink or a book (and get comfortable) because this call may take a while

  • Pen and paper - record the name and department of the person you are speaking with. Record the date and time of the call (it’s always good to have some notes on hand to refer back to in case a claim is disputed).

  • Know what questions you want to ask and what your goals and objectives are for the end of the call.

  • Make sure you are speaking to the right person and know that you may need to get bounced around to a few different departments before you have the person you want to speak with - be flexible and patient.

 

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Understand your policy.

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Part of the headache that surrounds health insurance comes from not understanding your policy details. When you enroll in a health insurance plan, you should find out what your deductible is and understand your out-of-pocket costs when getting a new device or visiting a provider. Make sure you are educated on your PPO vs. HMO plans and the answers to these questions for yourself:

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  • Which providers are approved on my plan?

  • What services are covered?

  • When do I need a prior authorization?

  • When do I need a referral?

  • What is my out of pocket payment?

  • What is my deductible?

 

If you know the answers to all these questions, wonderful job! If not, call your insurance company (their number will be on the back of your card) and find out. Knowledge is power!

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Make sure you're getting all your benefits!

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Part of understanding your plan means checking on the benefits you may be paying for and not using. It is easy to miss parts of your insurance plan when you're busy with everyday life, but reading up on your benefits could make life a little easier. For example, many Medicaid HMOs provide both cab transport and mileage reimbursement. Some HMO’s can also provide meal assistance for appointments. These benefits can vary depending on your distance from the hospital.

 

Families can contact the Guest Assistance Program (GAP) directly to learn more about their plans’ benefits by calling 734-764-6893

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Ask for a one-stop shop.

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Some pharmacies have the capacity to bill as a pharmacy and as a DME company. This is called 'split bill.' It allows you to purchase your testing supplies and any other equipment you may need in one place rather than going through a separate company. Ask your local pharmacy if they can offer split bill services to minimize the burden of getting supplies.

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