Insurance Plan for T1D

In the past I have been ‘turned off’ by lack of info available when searching for health insurance plans. What is covered, what is not, durable supplies (CGM), deductibles, OOP, etc. Generally, I have come to the conclusion that my total medical expense with insurance would exceed the cost of ‘pay as you go’ and therefore have been a ‘cash pay’ patient with a back-up affordable catastrophic plan. Basically “buy now and find out later what your true cost is”.
Bronze Plans offer low premiums but HUGE deductibles and OOP - OK for healthy.
Gold Plans come at high premiums, low deductibles and OOP - OK for some.
Silver Plans generally appear good for those with only a few problems.

When doctor office advisor and I went thru some plans - Ambetter Texas looks good, but discouraged when telephone conversation with Ambetter says True Metrix is covered as replacement for Dexcom (meter vs monitor). Personal call today says Durable are covered (in network) but her list does not confirm Dexcom (or even wheelchairs). I hope Dexcom can advise if Ambetter covers their products.

Any suggestions of what plans to consider, particularly in Texas, that offer affordable premiums with good coverage of Endos, Insulin, CGM, Lab Tests, etc (ATT I am not interested in pumps).

1 Like

Called Dexcom - Ambetter does cover their products but as before I would need to go thru 3rd party (mail order) Byram or Edgepark.

Was Dexcom able to confirm this specifically to the plan in your state?

It is very challenging to find out if things are covered, when they say “yes, when it is medically necessary”. Guess who gets to decide the answer.

But hope it works out for you.

It does sound promising and the option to cancel at any time is still open. If I do acquire insurance, suppose I should schedule everything I’ve ignored for the 1st month and as I’ve been doing, assure that what I pay at front office is ALL I will be charged for.

1 Like

Stopped by an insurance agent set up in the local Walmart and told him that if he could find a plan that covered my Medtronic CGM, we could do business together. A week has now passed and I have not heard a word.

@JJM1 unfortunately the Texas market has become quite small. Available plans vary quite a lot depending on which part of the state you’re in. In my county, only 2 insurers offer plans. I live 1/2 mile from the county line. If I lived in that county I could choose from 4 insurers.

We removed my daughter from my husband’s employer sponsored plan 4 years ago. When researching & comparing available plans, I found it easier to start with Provider directories, drug formularies & summaries of coverage (which show the copay/coinsurance amounts for covered expenses including DME) are available for each plan. Some plans, including my daughter’s, cover diabetes supplies differently than other prescriptions & DME. To find specific coverage, you can search the benefits booklet, also available for each plan. These are all available as .PDF files. The 2 insurers in my county list all specific items covered under DME (insulin pumps, cgm etc). I’m able to search the drug formularies to make sure all of testing supplies, insulin & meds are covered, as well as verify which are preferred brands. I can also determine that Dexcom is not covered under any of the available prescription plans.

I have purchased individual plans through for 3 of the last 4 years. The 2nd year, the gold plan we wanted was not offered on, so I purchased directly from the insurer’s website. lists all insurers with plans available, so it’s much easier to start there & then compare the offerings on the insurer’s sites.

1 Like