In general terms, when shopping for self procurred insurance a person can buy as much or as little insurance as they are comfortable with. Each plan will have its limitations on what and what isn’t covered and if you want better coverage you look at a higher priced policy. As for MDI vs pump, yes some plans don’t cover the purchase or supplies for a pump . . .some do.
We tend to seperate maximums into different areas. Major medical which includes most illinessess and accidents typically have very high lifetime maximums (1 million or more) and depending on the policy may have maximum out of pockets expenses per year or incidence. For other items outside of the normal major medical situations, like theraputic massage, mental health or physical therapy there tends to be much lower yearly limits depending on the policy.
Another option is employeer supplied insurance. Usually our choices are limited to few policies from low cost to higher cost. Again the higher cost product generally provide better coverage and/or better cost benefits with lower copays and cost sharing on our part. The major advantage to us is much lower premiums as our employeers tend to pick up the lions share of the monthly cost. For what a lot of people pay at work, they couldn’t to any better going by themselves.
know little about how health insurance in America works, and I am curious:
Are there levels of coverage you can choose from? So maybe you pay so much a month for basic coverage, more for better coverage and so on. YES, THAT IS HOW MINE WORKS
Generally, does your insurance company pick and choose what is covered? For instance, would your insurance cover you for MDI but not pumps? YES, ALTHOUGH I THINK PUMPS ARE USUALLY COVERED FOR T1 BUT WHO KNOWS. DOCS CAN ALWAYS ARGUE YOUR CASE FOR YOU WITH INSURANCE.
How do maximums work? Is there an overall coverage maximum or are their maximums for each coverage type (e.g., up to $500 per year for massages) I HAVE 2 MILLION LIFETIME MAX. HOPE I NEVER REACH IT. SOME THINGS ALSO HAVE CAPS PER YEAR (LIKE PT, PSYCHOTHERAPY. SOME EVEN HAVE A MAX NUMEBR OF DAYS PERS YEAR FOR INPATIENT MEDICAL. I have never had a us plan that covered massage:)
I know my questions are very general, but anything you could explain about your system would be awesome. Thanks!
SOME US PLANS ARE GREAT, SOME are awful and some people have nothing. The lack of equity is one of the problems. BUt the lucky, like me, have great plans.
Kelly ,
Insulin pumps and supplies , as far as I know , have to be of medical necessity under Pacific Blue Cross .Prescribed by one’s Diabetes Specialist .
I believe that it is now illegal in the US to exclude people from health ins based on pre-existing health conditions.
This was never an issue for me, as I always had employer based heath insurance, and have worked for big institutions companies , which take everyone as it, with complete coverage, no exceptions.
I have great coverage and always have. The main way having diabetes has affected me is that I have felt that either my husband or I need to work for a fairly large employer, as being self-employed (at least in the past) made getting good heath ins as a diabetic much harder if not impossible in the past.
Kelly,
Levels of coverage depend on how much you can pay. You choose from what the insurance companies offer. That would be the day if I got a massage out of my insurance. I’m on medicare + the supplementary insurance provided by my pension. For the drug coverage, for instance, the company restricts me to 5 strips a day even though the doc writes for 7. Obviously, I go out and buy more every 3 months out of pocket, and I am happy to have enough money to do it.
Medicare is otherwise good as long as you have supplementary insurance besides it. For pre-medicare people, there are umbrella type policies that will pay up to a couple million over a lifetime if you have the money to spend for the premium!
When I ran a business, I looked over what the insurers offered and chose one that my employees could have, one that provided care for newborns as well as the parents. Since we were making a profit, it was ok. Employers and unions have a lot of say in the choice of health care here.
It’s all in what you have the money for. Freedom to make money for the insurance companies and freedom to spend it for individuals.
Things are changing big time on the insurance front, but here’s how it has been up until recently.
If you’re lucky, you get employer-sponsored coverage. If you have a family, most likely the policy covers them, too. However, every year fewer and fewer employers offer coverage because the costs have become exorbitant. A good portion of those companies only offer one or very few options - you take what you can get and the insurance company tells you what they will cover. You’re lucky if they actually cover what they say they cover, because they spend lots of money employing people to solely deny claims. Some employers have multiple options from low-cost, low-coverage to high-cost, high-coverage. I’m fortunate to have great coverage at a “reasonable” cost. Most plans cover pumps for Type 1, the big ones are starting to cover CGMS for Type 1, too. I have no idea about limits, because my plan doesn’t have any that I know of. Some people mention that they have a durable medical equipment limit of $1000-$5000, though.
If you’re below a certain income level or over 65, you get Medicaid/Medicare coverage. This is government health insurance. They basically set the pricing for everything in the country related to medical services, and until Medicare has a billing code for it, no other insurance company will cover it. It’s not that great, but it is pretty cheap, relatively speaking.
If you don’t have a pre-existing condition and are able to afford $150-$600 a month, you can purchase individual insurance. This sucks b/c they can cancel on you anytime for any reason. Costs are very high, coverage can be very spotty and if you do end up with a “condition” (i.e. cancer), the company will find some way to revoke your coverage or not cover your claim. They will straight up lie to keep from paying for it.
If you’re an unlucky SOB, you make too much money for Medicaid, you make too little to afford individual insurance, you aren’t old enough for Medicare, so you can’t get any coverage. This also applies for anybody with a pre-existing condition (eczema counts here, ok). Then you’re screwed.
All is changing, though, and by 2014, companies cannot reject anyone for pre-existing conditions. They also will not be able to charge exorbitant pricing for pre-existing condition individuals. Companies over a certain number of employees will be fined if they do not provide coverage, but many companies are finding the fine will be less than providing coverage so they’ll screw their employees. It’s all a mess, and if you’re asking because you’re moving here in the future, I highly suggest you make sure you or someone related to you has great employee-sponsored coverage.
On levels of coverage there is also the issue of whether you have deductibles (and for what types of treatment/supplies etc) which often links to how much one’s copay is… Like most insurances if you pay more in copays/deductibles you should be paying less in premiums. Also some (maybe most) insurances restrict who you can see and whether you need a referral to see specialists. I think that the more choice you have the more you might have to pay.
If you have insurance and you want them to pay for something then they dictate what is covered. But it’s not set in stone because some may just require additional paperwork (proving it’s medically necessary) or you can also try to petition your case (which is a lot more work).
As for maximums I’ve never really had to deal with them yet and never looked at really (though maybe I should). The only thing I could think of is that my insurance also covers up to 100$ for eye care (like glasses/contacts/optometrist visits). So I think it varies by what it’s covered
In Canada, our provincial governments run the “public” health care system. This includes owning/running all the hospitals, paying the health professionals like doctors and specialist, etc. A doctor can open a private practice and employ other doctors and nurses, but the doctors are all paid a flat rate for services from the gov.
This side of the health care system is funded through taxes – income taxes paid to the province, health care premiums which are mandatory in some provinces and taxes funneled down from the federal government.
The provinces each decide what is “public” and what is not. So what is free in one province is not in another. My province doesn’t pay for insulin pumps, while Ontario has an assistance plan.
There is a “private” side of our health care, and that’s all the things that you need that your government says you must pay on your own – prescription drugs, medical supplies, vision care, paramedical, dental, elective surgery, nursing care, etc. You can purchase individual insurance coverage for these things or you can have employer-paid coverage, or you can pay out-of-pocket for. Private coverage varies greatly depending on your employer.
I wanted to add that in private health insurance there is no pre-existing condition clauses. Costs are controlled through co-pays and maximums. My insurance company covers CGMs but only 90% of cost up to $400 every 5 years. Big help.
Kelly,
You mention that “elective” surgeries are covered through private extended health coverage but I think you mean some surgeries that have been delisted from provincial health plans because they are often unnecessary. For example having your gallbladder out would be an elective surgery and would be covered under the provincial health system whereas circumcission or a face lift would not be covered because these procedures are not medically necessary. If complications develop from not being circumcised then circumcission would be covered under the provincial health system.
I live in Ontario and recieved my insulin pump paid for by the province and I recieve a check every 3 months to cover the cost of pump supplies. I know coverage for “extras” varies from province to province but overall the Canadian system is great. No one goes bankrupt from illness in Canada.
Yes, this is true. And it’s funny you mention circumcisions, because my three-year-old just had this done. It was paid for by the province because in his case it was deemed medically necessary. Yes, when I wrote “elective” surgeries I was thinking about laser eye surgery, for instance.
We all have different opinions about the health care system. There are parts of our system that are great and some that are not.
Kelly, by “laser eye surgery”, I presume that you mean for conditions like far-sightedness, myopia, astigmatism, etc. which can be corrected wearing lens. By eyecare, you must mean glasses and lens right? I’m not familiar with paramedical.
We are grateful(Robyn’s thread) for my Hubby’s work group insurance. They did cover pumps and supplies(haven’t asked them since our Province covers them). No Insurance co-pays for anything, just 1 small yearly payment.
People do not get to have coverage for pre-existing conditions, including meds, appointments, supplies, for 2 years, as a penalty, for most insurances.
That’s awful. I didn’t know that. Can you get coverage if you just pay a higher premium, or is it an all-out no-go? Can you get coverage through Blue Cross?
