Need advice for an uninsured pre-diabetic friend

Type 2
1

A friend came to me this week, worried that she’s pre-diabetic. We did some testing, and I think she’s right. Her FBG was between 105-120 every time she tested and she’s spiking over 200 after meals and staying there awhile.

After seeing her numbers I strongly encouraged her to talk to her doctor. The problem is, she’s self-employed and uninsured, and is afraid to have a diagnosis on her records for fear she’ll never be able to buy her own insurance after that. Unfortunately, I know from my own experience that she’s right about that too. Right now her business is just starting and she can’t afford private insurance.

She’s 30 years old, at or slightly under healthy weight, extremely health-conscious and exercises all day at work as an organic farmer. She seems to be already doing everything right. But she also has a strong family history of T2.

I’m not a doctor and not comfortable giving medical advice, but as a friend I felt OK telling her what’s worked for me. I recommended she eat as low-carb as possible, spread out her eating throughout the day to help avoid spikes, take various supplements, keep an eye on her FBG by testing occasionally, and if insurance is important to her – find a way to get some as soon as possible, and get in and see a doctor. Or, just get in there and see someone, insurance or not! I also gave her Gretchen Becker’s book to read.

What advice would you give someone in her situation?

2

If it weren’t for the possible future insurance issues, I’d suggest she get to a doctor immediately, because regular spikes over 200 suggest that she’s gone beyond pre-diabetes, even if her fasting glucose control isn’t gone yet. Given that she’s young and thin, that family history may not really be T2 – it may, for instance, be MODY, which is often mistaken for T2 and runs strongly in families (it’s very plainly genetic, with specific varieties tied to specific genes) – and she may have issues that can’t be controlled dietarily.

I think she should do more than check fasting BG occasionally. Elevated sugars like she’s seeing post-meal are doing damage all the time they’re up there, while fasting control is often one of the last things to go. Send her to Jenny’s Blood Sugar 101 site, to learn about the levels at which damage has been found to occur – what she needs to be doing is whatever will keep her BG under those levels. For many people, that’s carb restriction (especially if you’re avoiding the diabetes medications, which without a diagnosis she won’t have access to), but she may find something else that works for her – in order to know, though, she’s going to need to experiment, which means eat and then test, repeatedly.

Another thing she can do for herself is A1C testing. There are home kits available, where you put a blood spot on the specially prepared paper and then send it in; they’re reputedly about as accurate as the lab versions. That will give her a good idea of how her BG is doing over time, which is also a good indicator of the risk for future complications.

I’d also suggest that if she can’t get her BG down to the safe levels and keep it there with dietary restriction, she’s going to have to bite the bullet and go to the doctor to get access to the medications, possibly including insulin. One thing that occurs to me to check into is whether, if she gets catastrophic-coverage-only insurance (so it basically pays only if you’re in the hospital), is that enough to make her diabetes NOT a pre-existing condition, even if she’d have no coverage for the treatment itself? If so, that might be something she could afford to do, and then she’d still be eligible for better coverage later.

3

I’m not sure if there have been changes since I found this information and there probably are other sites with information related to insurance coverage.

from http://www.isletsofhope.com/diabetes/state-law/texas-1.html
Texas has mandated coverage for diabetes care.

S.982 - signed 6/19/99, effective 9/1/99. It expands a 1997 law, and includes coverage for nutrition therapy

Summary of Provisions

Requirement related to diabetes? Yes
Diabetes Education services covered? Yes
Medical nutritional therapy covered? No
Diabetes supplies covered? Yes
Specified supplies covered? Yes
Texas Department of State Health Insurance

If you have questions about insurance in Texas, contact the Texas Diabetes Council staff at (512) 458-7490 or send an email . The Council does not provide or guarantee insurance coverage. While the Council can provide information about resources, it is the responsibility of the individual seeking health insurance to provide information regarding eligibility status and application information to the appropriate insurance resource.

Texas State Law requires insurance companies to cover the following (equipment covered by laws is listed in the Texas Administrative Code, §21.2605(a)(b)(c)). Additionally, SB 163 passed in 75th legislative session related to insurance coverage for persons with diabetes. Art. 21.53G of the Texas Insurance Code was amended effective 9/1/97. Bill author was Judith Zaffirini with coauthors Carona, Duncan, Lucio, and Shapleigh . The bill sponsor was Berlanga.

Rules written by Dept. of Insurance and adopted in April, 1999 requiring HMOs, and indemnity carriers* to pay for:

Diabetes equipment & supplies:

A health benefit plan shall provide coverage for equipment and supplies for the treatment of diabetes for which a physician or practitioner has written an order, including:

blood glucose monitors, including those designed to be used by or adapted for the legally blind;
test strips specified for use with a corresponding glucose monitor;
lancets and lancet devices;
visual reading strips and urine testing strips and tablets which test for glucose, ketones and protein;
insulin and insulin analog preparations;
injection aids, including devices used to assist with insulin injection and needleless systems;
insulin syringes;
biohazard disposal containers;
insulin pumps, both external and implantable, and associated appurtenances, which include:
(A) insulin infusion devices;
(B) batteries;
(C) skin preparation items;
(D) adhesive supplies;
(E) infusion sets;
(F) insulin cartridges;
(G) durable and disposable devices to assist in the injection of insulin; and
(H) other required disposable supplies;
repairs and necessary maintenance of insulin pumps not otherwise provided for under a manufacturer’s warranty or purchase agreement, and rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump;
prescription medications which bear the legend “Caution: Federal Law prohibits dispensing without a prescription” and medications available without a prescription for controlling the blood sugar level;
podiatric appliances, including up to two pairs of therapeutic footwear per year, for the prevention of complications associated with diabetes; and
glucagon emergency kits.
(b) As new or improved treatment and monitoring equipment or supplies become available and are approved by the United States Food and Drug Administration, such equipment or supplies shall be covered if determined to be medically necessary and appropriate by a treating physician or other practitioner through a written order.

(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.

Source: 28 TAC §21.1605(a)(b)(c)

Diabetes medication:

(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.

Source: 28 TAC §21.1605(c)

Diabetes education:

(a) A health benefit plan shall provide diabetes self-management training or coverage for diabetes self-management training for which a physician or practitioner has written an order, including a written order of a practitioner practicing under protocols jointly developed with a physician, to each insured or the caretaker of the insured in accordance with the standards contained in Insurance Code Article 21.53G, Sec. 4(b) and (c).

(b) A person may not provide a component of diabetes self-management training under subsection (a) of this section unless the subject matter of the component is within the scope of the person’s practice and the person meets the education requirements as determined by the person’s licensing agency in consultation with the commissioner of health.

(c) Self-management training shall include the development of an individualized management plan that is created for and in collaboration with the insured and that meets the requirements of the minimum standards for benefits in accordance with §21.2604 of this title (relating to Minimum Standards for Benefits for Persons with Diabetes).

(d) Nutrition counseling and instructions on the proper use of diabetes equipment and supplies shall be provided or covered as part of the training.

(e) Diabetes self-management training shall be provided, or coverage for diabetes self-management training shall be provided to an insured or a caretaker, upon the following occurrences relating to an insured, provided that any training involving the administration of medications must comply with the applicable delegation rules from the appropriate licensing agency:

(1) the initial diagnosis of diabetes;
(2) the written order of a physician or practitioner indicating that a significant change in the symptoms or condition of the insured requires changes in the insured’s self-management regime;
(3) the written order of a physician or practitioner that periodic or episodic continuing education is warranted by the development of new techniques and treatment for diabetes.

(f) An HMO shall provide oversight of its diabetes self-management training program on an ongoing basis to ensure compliance with this section.

(g) Health benefit plans provided by entities other than HMOs shall disclose in the plan how to access providers or benefits described in subsection (a) of this section.

*Self-funded plans are excluded from the rules, as the Texas Department of Insurance does not regulate self-funded health benefit plans.

also: Would the Partnership for prescription assistance be useful in herr situation? http://www.pparx.org/ 1-888-4ppa-now (1-888-477-2669).