Pumps and Insurance

Never dealt much with insurance other than 'yes, I have it' until now..

The group I will ultimately have insurance with when I graduate says they do not have you undergo medical underwriting and that my diabetes will be covered. What does this actually mean, does anyone know?

I also don't understand PPO other than what it stands for.. are insurances that are PPO better insurances to begin with?

And does that mean more or less likely to cover pumps?

Do you wind up with a ton of waiting periods?

I just noticed there haven't been any responses to this question, so I thought I'd contribute the little I know, and hope somebody who knows more will jump in. I don't really know what "medical underwriting" means, but I've always had group insurance and never had an issue with "pre-existing conditions".

PPO is different from HMO in that there is a large list of doctors that are in their "network" (fully covered to the percentage your insurance pays) and you can choose who to go to. HMO's are places like Kaiser, where all your services must be in that facility. Most people consider PPOs as better insurance (and the premiums are somewhat higher), though HMO's do have their advantages such as labs, testing, and I believe procedures and hospitalization all being included. To give an example, I prefer PPO's because you can choose doctors and the care is more personal and the system less huge and daunting to connect with. However, as I'm now 63 with Type 1 and other conditions and mostly retired. I thought what would happen if I had something major: 20% (my coverage) of a huge bill is still way more than I can afford. I had planned to switch to Kaiser, but ended up moving to a rural county where it isn't available.

Pumps: Kaiser (as an example of an HMO) covers pumps (and I believe supplies?) 100%. My PPO insurance only covers "durable medical equipment" the same 80% as everything else, so I would pay 1,000 and 20% of supplies. (Fortunately Animas allowed me to classify as low income so my pump was free and another 30% is taken off my supplies). "Durable Medical Equipment" is what you should look under when you have a coverage brochure to see pump and pump supplies coverage.

I had an amazingly easy pump process compared to some I've heard of. I contacted Animas directly (I don't see an endo, only PCP), they filed all the insurance paperwork and contacted my doctor to sign the form. I had my pump in a matter of weeks. Not sure what else you mean about waiting periods. Oh, I have a $500 deductible which I know is small but every year I forget it and am surprised when I get larger bills!

Hope this helps.

Pumps and their supplies are covered as DME, or durable medical equipment. With any policy, you should check the DME coverage. I have federal BCBS (a PPO) and I had to pay about $1,000 out of pocket for my pump and then I pay about $100 for each 3-month shipment of supplies (infusion sets and reservoirs).

HMOs vs PPOs
- The big advantage of HMOs is that they generally provide more generous coverage for the necessities (tests, supplies, insulin, etc). But they can be more strict. You generally have to get a referral from your primary care doc for ANY specialty care. And because cost containment is the goal of an HMO, you may find that you're more limited in terms of choices (Docs to see, supplies to get, insulin to use, test strips, etc). PPOs are great if you can afford them. But I know when I first came out of grad school, my budget was tight and I wanted predictable costs, so I went with an HMO. I wasn't pumping at the time, but never had any issue getting supplies covered.

I would think a PPO would be MORE likely to cover a pump. Because you generally have a larger cost-share with a PPO, they are probably more likely to provide coverage for things. HMOs tend to be more strict with everything and may be more likely to deny coverage for a pump. THAT SAID, pumps are now the standard of care for T1 and I don't think they are ever denied anymore for T1s.

If your group will cover you, you should have the same coverage options as anybody else covered by the same group. Your diabetes as a previous condition shouldn't make any diffrence.

The HMO is going to be managed much more closely and, as Zoe says, will generally cost you less out of pocket for a wide variety of services than a PPO.
When I first started working for my current employer, they offered a BCBS HMO/PPO plan which really was the best of both worlds. None of my diabetes specialists team was covered by the HMO or would participate in the BCBS HMO program, so the PPO came in handy even though it was more expensive to see my specialists.

Eventually, either my employer or BCBS, I'm still not sure which, discontinued that service and I had to choose. Going with the PPO was an easy decision for me because I had been seeing most of my specialists since my diagnosis. I didn't see any reason to go with the HMO and their care providers at this stage in the game.

If you are starting from scratch with your specialists, my GF has Kaiser HMO and doesn't have any complaints about the level of care their specialists provide. Granted, she does not have diabetes, but she seems happy with Kaiser.

Moving over to a CGMS and a pump was pretty painless through my PPO and any delays I experienced was not because of my insurance coveage. It did take awhile but BCBS PPO, most definitely, was not the bottleneck. Like Zoe, there was never an issue regarding whether or not the PPO was going to cover them as DME or which pump I wanted to go with and they cleared it pretty quickly.

I actually pay 30% for my DME which played a bit into my decision to go with the Omnipod because it has a significantly less up front cost. I will pay more over the life of the pump, but the higher maintenence cost at 30% is not that bad.

Good luck!!

It really all depends on the insurance company you are dealing with. My HMO is really great, I do NOT need referalls for specialist BUT I do have to stay in network, but we have a huge network so its not really a problem. I have dual coverage with my HMO being my primary, and my husband's PPO being my secondary. With the PPO any hospitalizations were very expensive. Often a deductuble and coisnurance. With my HMO as long as I stay in network, I pay 400 dollars and that is it. No hidden surprise charges. My premiums are less, and my coverage is really really good. You just have to know how your insurance works when you are dealing with HMO's and follow their guidelines. I dont think the quality of care is any different with a PPO or an HMO at least in my experience the same Dr's I saw when the PPO was my primary are also in network with my HMO.

Im not sure how Keiser works but my advice to anyone when deciding between an HMO or a PPO look over both products, the deductibles, copays, co-insurance, what their referral process is and go from there. BUT HMO's are not necessarily a bad thing.

Thanks. I may try talking to Animas as well after I've talked to the family physician's group some more... I was looking at either their pumps or the omnipods. It's worth a try.

I checked the brochure and couldn't find anything about durable medical equipment, but I now know the right questions to ask. Thank you!

My student health insurance said they would 'cover the insulin for them but not the pump itself because it's available over the counter'. ?????????? Yes, because I'm going to go drop $6,000 OTC for a pump while I'm in school and in debt up to my eyeballs from tuition and living costs.

The PA at the endo's office seemed very adamant that Aetna would cover it- but I guess because I have the craptacular student insurance, they won't.

Thanks for mentioning that they are the standard- I can use that at some point too.

Thank you. Did they cover any other pumps?

After I get my questions answered about the PPO I'm looking at, I"ll take a look at an HMO. Thank you!

Yeah, my first phone call to my insurance company was to ask if it mattered which pump I wanted to use. They told me it didn't matter but I told them it would be either the Animas or the Omnipod. The customer service person didn't even hesitate and said, yeah, they would cover either.

I just checked my current policy, and it says they cover DME's. I only talked to the pharmacy division about whether or not they covered pumps- I guess I should have talked to the actual insurance division. I know who I will be calling tomorrow.

I don't understand all this crap!

I have a toll free number on the back of my insurance card for Member Services. That's the first number on the list and the number I called.

There is a list of numbers, including one for provider services, a 24/7 nurse helpline, and pharmacy services.

Member Services seemed to be the catch-all and I figured they could connect me to whoever I needed to talk to. I also have a number for Pre-Authorization Review who I did have to talk to at some point regarding paperwork, but I do believe that Member Services eventually connected me to that department.

I went directly to Metronic and had them do all the insurance work. They work with these companies everyday and know who to talk to and what questions need to be asked. I don't think I ever spoke directly with the insurance company. Medtronic then came back and told me what the cost would be for the pump and future supplies.

I suspect if you talk directly to your insurance company your head will hurt once you're done.

You are probably right. My head hurt yesterday just trying to figure out what the heck 'co-insurance' means when talking about pharmaceuticals! I finally figured out the insurance I will be getting is through United Health Care, so I called and asked someone who was very nice.

I have an appt tomorrow with the CDE + one of the doctors I've been seeing at the family physicians group... I may ask them about pumps at that time and then submit a request through Omnipod.

I agree with Jim; I went directly to Animas and they did all the work for me. Even if it isn't me, somebody was paying them $5,000 for the pump so they are motivated to make it work. I never bothered with the insurance company beyond looking in my book and seeing I had 80% coverage for DME.

When I finally found the policy, it said if you go through Student Health Services they cover 100% of the DME cost. In network preferred providers, 80/20. Out of network was 60/40. But the cap is $2500- which makes me think the omnipod might be possible where the others wouldn't be.

If your income is low, though, do talk to the pump companies to see if you qualify for a fee waiver (I don't know if you will still be a student or doing some kind of internship before you actually begin your practice).

Yes, let's try... zero for income. :/ But I will give it a shot tomorrow or Tuesday after talking with the doctor- I don't want to give them a surprise.

Same here, Animas did it all for me other than some stuff I had to sign for the endo. Same with the Dexcom, I sent logs and they did the rest.

I got my pump right before I switched to my HMO. I had already met my deductible that year with my PPO so I didnt want to wait till the first of the year, but yes my HMO covers pumps and supplies as well.