Hi everyone! I have had an insulin pump for years and got a new insurance last year. I have been fighting with my insurance company because they are saying my pump supplies are now considered "medical equipment" and my deductible for this is $5000! I am esentially paying for my supplies out of pocket without any kind of help. I have BlueCross BlueShield of New England. Has anyone else ran into this problem? Any ideas on what to do? Im desperate!
Hi Kristina,
That's terrible and that's a large chunk of money to have to shell out. I live in the USA and have Medicare and its not easy but my deductible is not that high! I am not quite sure what you can do. Not sure how things work in England. What pump are you using?
Hi Kristina,
Ouch, sorry to hear that. Are you on insurance through the Affordable Care Act? My son, also a type 1, is on MVP insurance in New York, and his deductible went up to $4000 mid year, and now he is paying 100% of his pump and sensor supplies. He has switched insurance for next year to BCBS. It is more expensive per month for his premium, but will pay much better for his expenses. I have BCBS through my school retiree insurance and it is excellent. Can you shop around for another plan for next year?
Lots (most?) of insurance plans consider pump supplies as durable medical equipment and cover them at 80%, but only after you have met your deductible for the year!
I'm in the same boat come Jan 1st. Everything out of pocket until I've spent $5,000.
Some plans treat strips as DME too and some as Rx. There are even some plans that cover insulin as no cost to the patient, as preventive medication.
The only thing to do is to is shop around for an insurance company & policy that has better coverage, if that is an option for you.
I'm going to assume you buy your own insurance through the marketplace and are in the US, because if this is the case you will really benefit from doing something today.
As an Omnipod pump user I have quite a high per-year expense for supplies (the Omnipods cost $25 each and last three days), however even on Omnipod my total cost for the year (everything excluding insurance premiums) is only in the range $3000-$4000.
For this reason I chose a plan with a low deductible (a "gold" plan with a $1500 deductible) and a low percentage co-pay on DME (10%). Most, perhaps all, diabetics, even pump users who use CGMs, are in the same situation.
Of course I pay more per year in premiums - about $2500 more - and this has to be factored in to the equation. The numbers also vary from state to state and within states, because insurance rates are set by geographical area and the areas are smaller than the states (mostly.) The premiums (alone) vary by age as well.
So you have to do the math for your particular yearly needs, remembering to add all the numbers up (DME, prescriptions - typically test strips and insulin are handled as prescriptions but the insurance company can treat them as DME if they are used with a pump).
In your case you may want to change to a "gold" plan, particularly if you are in a year when you will change your pump (a large add to the yearly bill). Remember you can change every year now, a very good thing.
The good news is that most insurance companies are open today, the very bad news is that you only have one day left (today) to change your insurance for next year.
BTW, insulin dependent diabetics using MDI will get completely different numbers and are probably going to be best off with a Bronze plan, assuming no complications and general health outside the diabetes.
I believe most insurance companies will start to follow the rules established by the Federal government for Medicare. I don't think the ACA requires this, but it doesn't make sense for insurers to implement two sets of rules; sure some of them could reduce payments through extra bureaucracy, but the ACA changes the playing field for insurers so that the cost of the bureaucracy comes out of their pockets at the end of the day.
The Medicare rules are totally clear (or were, last time I checked, over a year ago). Pumps and all the supplies for the pumps, including insulin, are treated as DME. That means that the pumps and the insulin should come out of the basic Medicare, but because for diabetics on MDI insulin is a prescription item insurers, including Medicare prescription insurers, do tend to just treat it as prescription, despite the rules.
I believe that all insurers will do this in the future; pumps and supplies with the exception of insulin will be treated as DME, insulin will be treated as a prescription benefit.
I'm also pretty sure that insurers will start following the Medicare rules for BG meters and test strips. IRC Medicare has explicit rules for those and treats them as DME, but my memory isn't as good on that point.
Assuming I'm right about what Medicare says this would mean insurers would all convert to treating test strips as DME supplies. At present I pay $10/month for insulin (Humalog, cost $478.02) and $30/month for test strips (cost $467) because the latter are a "preferred brand", but that makes no sense because there are no "generic" test strips.
Most non-pump diabetics would gain from the change on a silver plan because the per-month cost of the test strips they use times 20% is less than the "preferred brand" co-pay. At the Wal-Mart cost ($77.83/box of 50) that's equivalent to 2 boxes; 100 strips/month. Ok, IDDs typically use more, but most test strip users are non-ID T2s.
For me, of course, I would pay more; my Gold plan would have me paying 10%, so I would pay $46.70/month. Notice that this isn't that much more, and maybe my insurance company (moda) would stop limiting my test strip usage to 300/month, and Wal-Mart would actually be able to supply what I need without several visits every month!
Of course I wouldn't actually pay that; people would start asking why Wal-Mart and Walgreens (who charge the same price) charge so much more for test strips than suppliers on the Internet. E.g. Amazon Prime sell a box of 50 for GBP23.20, that's $36.46; half the price and they certainly do make a profit!
One way or another things will move around, but if the ACA works as intended (i.e. it doesn't get messed up in the next couple of years) we will be in a position to compare plans and be sure that the plan we chose will deliver what we need. If that happens the costs will go down because of the reduced complexity and the increased competition that results, insurance company profits will probably go up to; it's the pharmacies that are making the money at present.
John Bowler
@ jbowler
That is a lot of GREAT information its hard to wrap your head around all of these rules and you just helped me see it/understand it a lot better. I have been on Dialysis for 5 years now and being "Disabled" I end up paying my Medicare deductible which I really don't see because its taken directly out of my SSD.
Thank you for posting all of the above it has cleared up several of my questions and concerns!
You are a very important part of our history, along with everyone on dialysis and, therefore, currently on Medicare. Dialysis was the death blow to the pre-ACA US health care system, as the history in this article explains in much more detail:
http://www.ajkd.org/article/S0272-6386(07)00116-3/fulltext
(Thank you for causing me to look for that link - I knew some of the history but not all of it!) The issue is summarized by two sentences near the start of the article:
"In 1961, because 3 of the original [dialysis] patients had survived for a year, Scribner asked University of Washington Hospital administration about starting more patients. They refused, concerned that if his NIH funding ever dried up, the state of Washington would have no choice but to continue to support the patients."
The healthcare providers figured, correctly, that they wouldn't even get paid for dialysis, let alone make a profit. So what happened instead was a shunk-works style mixture of home dialysis and private dialysis companies that bypassed the hospitals and allowed people with enough money to avoid the alternative treatment to dialysis - death.
The article explores the political side in more depth in the section "The Political Story".
What the article doesn't state explicitly is that the dialysis treatment that emerged in 1960 was the first medical treatment that exceeded the resources of the US healthcare system. It was (by 1963) no longer experimental, it had wide spread application to people not covered by Medicare and, most significantly, it was a not a cure, it was an expensive treatment for a condition which would not go away until the patient died because of the low number of transplant kidneys available.
The expense put it beyond the means of the entire private health care system and it was developing it's own parallel health care system (home dialysis and new private dialysis companies) for those patients who were either rich or had not yet been dumped by their insurance company.
I don't think the disability issue is directly relevant to the handling of dialysis, rather I think it's something that ran in parallel. The article references a move in 1971 to extend Medicare to all people with disabilities but this was apparently trumped by the very imminent threat to US healthcare posed by dialysis alone. Consequently general extension of Medicare turned into the Medicare ESRD program.
That said, I do think the disability issue is highly relevant today.
The article above was written in 2007 but really only concerns itself with the political history through 1973, however clearly the politics continued.
The healthcare system that dialysis broke limped along for 35 years with ESRD patients and people who were unable to work for more than two years being covered by the Federal government. Then two things changed.
Firstly the ADA definition of disability (not the Medicare one) was extended to include "major organ failure", so all of us auto-immune diabetics are now disabled under the ADA definition. We're not usually disabled under Medicare because, apart from kidney failure, that uses the SSDI definition which restricts disability to those who can't work.
This change happened in 2008; unlike the ACA it sailed through Congress. Expanding the definition of disability to include more conditions that are expensive to treat helps the healthcare industry because it gives it more opportunities to lobby Congress for Federal funds; funds which go straight into the bottom line profit.
Contrariwise in 2010 the ACA removed the ability of insurance companies to cap lifetime payments. This was their primary defense against problems like dialysis. The ACA did not remove the Medicare coverage of dialysis, but it did remove the insurance industry ability to not cover dialysis.
That means that, now, diabetics who get ESRD don't have to swap to Medicare. That doesn't help Chris, at least according to this page (which may not be correct):
http://www.cahealthadvocates.org/news/reform/2013/faq-about-medicare-and-covered-california.html
According to that once you are on Medicare you are pretty much stuck with it for the rest of your life, however for the rest of us if we face ESRD we now have the ability to continue with private insurance policies. (I think; healthcare.gov did not ask me about kidney problems and the disability question is optional, moda, my insurance company, seems to be trying to scam dialysis patients into signing up for Medicare!)
So that seems to make the first point irrelevant; health insurance really is insurance again (no lifetime cap and it covers all the risks) and everyone will have to have it after 2015. This means that the healthcare industry can rely on getting paid so it won't duck out of non-profitable activities; no more hospitals shutting down emergency rooms etc. This means there is a functioning way of getting paid even for high risk individuals, so all people are equal.
Had this not happened the expanded definition of disability would cover pretty much anyone with a chronic condition and, therefore, pretty much every expensive patient.
The issue, as I see it, is that both changes are in place and either of them could go, at least from the point of the healthcare industry, so long as the Medicare definition of "disabled" is changed from the SSDI one to the ADA one.
I don't think it will happen though; I don't think the ACA will be abolished and Medicare cover all of us. That's because the insurance industry will resist it tooth and nail; they've spent 35 years as puppet insurance, a kind of weird health lottery where we won $2 million if we got sick, but then we died. They're back in the insurance business again.
Likewise the healthcare industry has a tricky choice; can they make more money by defrauding Medicare, or by overcharging private insurers, both of whom can easily run out of money?
Even the pharmacists must see that their current strategy is broken. Putting inflated retail prices on the prescription might fool a few people but the ACA limits the amount patients end up paying and, if the drug suppliers offer kick-backs to the insurers which lower the sticker price below the copay there will be a class-action lawsuit. (Incidentally, this is why the price of test strips will drop like a lead balloon if the insurers have them billed as DME supplies.)
Sorry, that was a bit long, but discovering all the history of dialysis lead to me checking up on lots of things I half knew about.
John Bowler