I have found myself once again with the threat of losing my current health insurance… I am going to have to give up my current current position which has health insurance benefits for a position which does not in order to finish school… In the long run it will be worth all of the hassle and I will have much better job security, make more money, and be able to start a family finally!!!
So, I am one of the people that are going to be able to have the unique opportunity to not be excluded because of my diabetes. I am attempting to pick a "gold" policy on the exchange… but I an curious how that will actually work… for example-
If I pick a policy that normally covers insulin pumps and supplies with certain criteria (and we all know they pick very vague criteria so they can exclude people as much as possible), won't they just deny my claim?
And additionally, I am trying to pick a plan that covers CGM because its something my endocrinologist really wants me to have. I have hypoglycemia unawareness, a A1C of 7.1, insulin sensitivity, and frequent excursions from high to low and high again. Whats to stop the new health insurance company from just saying no so that they don't have to pay for it?
It just seems to me that if you pick a new insurance company, they will try and deny every claim they can so they don't have to pay and will increase their profits?
I've had several run-ins with Blue Cross (HCSC, IL,TX, NM, OK and, I believe, MT...) about various supply issues and get the "Medicare says you need 4x test strips/ day letter every April. Although I looked up where the dude who signed it's house is on Zabasearch.com and *know* where he lives if it comes down to that. I generally rely on Medtronic to get that stuff. The first time, the doc was all on board with getting me a pump to replace my medieval R/NPH regime (in 2008...). It's worked great since then but if you tell them you need it, they call the doc and arrange the letter of medical necessity (since a prescription isn't enough for those %&$#heads...) and then badger Blue Cross until they give it up. I don't bother calling BCBS since the front line people seem to always be oriented towards denying stuff. You have to build your medical need with your doc and then use that to leverage stuff out of them. I think that this particular issue would be a useful one to get a class action suit going on to force their hand, as you could pull *all* health insurers including government health systems into the case and make the point arguing about the number of strips needed to maintain good health or whatever insurance is supposed to cover. It might have some risk (of losing...) and there's not a huge amount of evidence that's pro-extreme testing (i.e. enough...) but I think that there's pretty clear evidence of collusion. It may also help that our interests (getting strips) are congruent with big Pharm who might have some interest in getting on board with a case. For now, I don't think anyone has any experience with exchange insurance which makes me nervous about it.
I don't have an answer for you as I have no experience with this. I understand your fears but I am not sure that you have to be as fearful as you are--as long as you read the policy carefully. It seems to me that you are trying to "cross a bridge" before you even know there is a bridge. If the insurance company says, in its policy, that it covers insulin pumps and cgms, why do you think they will deny you? Of course, we all have to meet certain criteria for a pump or a cgm but most endos know how to help you meet those criteria if he/she agrees you need one or both. The criteria that I have seen are fairly specific. And you seem to have those criteria by your own account. Hypo unawareness is a major one. Irritating to document, but specific enough, at least in my view. If you are concerned about the criteria, then compare insurance companies that carry pump & cgm coverage and see which criteria seem appropriate to you. As well as checking the reputation of the company. And be sure your endo uses that insurance company to avoid greater out of pocket costs.
I would be curious about your decision after you make it and then the results down the road re the pump/cgm issues. Good luck.
I can see where it might seem like I am jumping ahead presuming they won't pay for it… but there are so MANY choices on the exchange and I will need to pick one that works for me… having said that, I am unable to find specific information about the new plans with regard to whether or not they cover pumps or cgms. I can see they all offer DME coverage, and then it says "some equipment requires prior authorization".
I just know from experience that they could potentially deny my claim. It took months to get my pump approved with my current insurance and I still can't get a CGM because what my endo and I consider "documented hypo unawareness" and "frequent excursions" isn't what the insurance company considers to be. They just keep denying it. AT one point they said if I wanted a CGM I would have to quit treating my lows at home and go to the hospital in order to have my lows documented properly. What a huge waste of money a resources.
Anyways, I am more curious about what is in place to stop them from just denying claims as they see fit?
I keep seeing this complaint. After you visit the exchange and get the list of plans why not call them directly and get the information. Take names and numbers and write it all down. Then compare the options and decide from there.
I finally got the answers to see questions after waiting on the phone for nearly an hour.
At e California exchange phone line they told me at all bronze,silver gold etc have the same rules for all the companies that insure.
All platinum policies cover diabetic pump supplies and finger sticks and cgm at 90 percent. Gold covers at 80 percent. Silver covers 80 percent too. Which I found surprising. The actual pumps are covered e same only you are permitted a new pump every 5 years. The pumps are only warranted for 4 years. So we need to be extra careful for that last year.
There is a loop hole tho. If you change carriers your clock is reset and you can get a new pump.
