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Diabetes Matters: Making Sure You Have the Right Insurance Coverage

July 31, 2012

Even though the U.S. Supreme Court has judged most portions of the Affordable Care Act constitutional, many provisions of the act will not go into effect until 2014 - including the provisions that ban discrimination based on "pre-existing conditions." In the meantime, people with diabetes and other pre-existing conditions still may find it difficult to find health insurance that provides adequate coverage at an affordable rate.

"Until 2014 - or perhaps even beyond that if the Affordable Care Act is repealed - people who have individual health insurance policies still need to be aware that pre-existing conditions such as diabetes may not be covered if they change insurance providers," says Kristi Caracappa, Health Insurance Information Service Coordinator at Washington Hospital.

"Many people are fortunate to have health insurance coverage under group policies provided by their employers," she notes. "Many others are covered by Medicare or Medi-Cal. But even with employer- or government-provided insurance, people with diabetes need to be careful about the coverage in plans they choose. For example, are diabetes testing supplies covered? Are diabetes medications, including insulin, covered? How many diabetes screenings for fasting blood glucose and A1C levels are allowed each year? What co-payments and deductibles are required? Health insurance providers all offer a variety of different plans, and you have to know what coverage you need."

Caracappa will be presenting a free Diabetes Matters seminar, "Getting the Most Out of Your Insurance When You Have Diabetes," on Thursday, August 2 from 7 to 8 p.m. The seminar will be held in the Conrad E. Anderson, M.D. Auditorium at 2500 Mowry Avenue in Fremont. A Diabetes Support Group meeting will follow Caracappa's presentation from 8 to 9 p.m.

At the seminar, Caracappa will discuss both private and government health insurance programs, including how the different insurance programs cover screenings and treatments for medical conditions like diabetes, as well as other health problems related to diabetes.

In speaking with the Washington Hospital diabetes educators, Caracappa found that diabetes can raise your risks for many health complications such as heart disease, kidney disease, nervous system damage, poor wound healing, dental problems and eye disease. "If you have diabetes, you need to consider how your health insurance will cover these conditions," she emphasizes. "For example, I recall counseling a patient who changed from a 'Medigap' Medicare Supplement Insurance policy into a Medicare Advantage plan. The Medicare Advantage plan had much higher out-of-pocket expenses for a patient receiving kidney dialysis. Unfortunately he later needed to have dialysis. It was a costly decision for the patient."

Caracappa also will briefly discuss other health insurance options established by the federal government for high-risk and/or low-income people, such as:

  • Pre-Existing Condition Insurance Plan (PCIP) - This program, created through the Affordable Care Act, allows people with diabetes and other pre-existing conditions who have been uninsured for six months or more to get insurance. Available since 2010, this program will continue until the Affordable Care Act's provisions banning discrimination against pre-existing conditions are fully implemented in 2014.
  • Health Insurance Portability and Accountability Act (HIPPA) - This act, passed in 1996, allows people who meet certain criteria to buy individual health insurance when they lose their group health insurance, even if they have a pre-existing condition. HIPPA does not regulate what people can be charged for such coverage, however.
  • Consolidated Omnibus Budget Reconciliation Act (COBRA) - This act requires employers to offer continuation of health insurance coverage to employees (and their covered dependents) when they lose their group health benefits under certain circumstances such as job loss, reduction in hours worked, or death of the covered spouse. Coverage is generally limited in time (18-36 months), and qualified individuals may be required to pay the entire premium, plus a two percent administration fee. COBRA generally applies to employers with 20 or more employees.

"Finding the right health insurance coverage can be complicated, especially for people with diabetes and other chronic health conditions," Caracappa says. "Our goal is to help people learn more about what health insurance options may be best for them."

To register for the Diabetes Matters seminar on August 2, visit www.whhs.com or call 510-745-6556 for more information. The Health Insurance Information Service at Washington Hospital provides free, confidential information to help people make informed decisions about their health insurance. To get answers to your health insurance questions over the phone or to schedule a personal consultation appointment, call 800-770-9447 between 8 a.m. and 5 p.m., Monday through Friday.

For additional information about diabetes and health insurance, including how the Affordable Care Act will help provide improved health insurance access to people with diabetes, visit the Web site of the American Diabetes Association at www.diabetes.org and type "health insurance" into the search box.