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Open Enrollment: 5 Tips to Help People with Diabetes Choose Health Insurance Wisely

It's open enrollment time. Get the most from your health insurance benefits with these expert tips.

Open EnrollmentIf you're among the 30 million people living with diabetes, your choice of health insurance can have a big impact on your wallet—and your health.

Its decision time for 223 million 1,2 Americans who get their health insurance at work, through Medicare or buy their own coverage privately or through Affordable Care Act health insurance marketplaces. If you’re among the 30.3 million with diabetes, your choice can have a big impact on your wallet and your health in 2019.

Sure, health insurance is complicated—96% of Americans in one recent survey didn’t understand key features that affect what they pay for doctor visits, drugs, hospital stays and more.3 And comparing plans isn’t fun—in a 2015 study from the Aflac insurance company, people said they’d rather clean their toilet than research their health benefits! 4 But picking the plan that’s best for you can save you money (an average of $728 in one recent University of the Pacific study of 2,262 people in Medicare Part D prescription drug plans ) and help you get the medications, doctor visits and other healthcare you need.

These five steps can help:

#1 Hit the Deadline

Open enrollment for people with Medicare coverage runs from October 25, 2018 to December 7, 2018. If you buy your own insurance privately or through a state marketplace, open enrollment runs from November 1 to December 15. Employers that provide health insurance usually have a similar enrollment period in the fall, when you can switch plans or opt to keep what you’ve already got. Miss the deadline and you’ll most likely get stuck with the plan you currently have for this year. But in some cases, you could wind up without health insurance on January 1—and would need a short-term policy until another enrollment window opens. Don’t go without insurance. In one recent study, people with type 1 who went without health insurance for just 30 to 60 days were five times more likely to end up in the emergency room.6 They also had higher blood sugar levels, raising long-term risk for complications.

#2. Don’t Automatically Renew Your Current Plan 

It may no longer fit your health needs—you may take new medications or see new doctors or use a new pharmacy that isn’t in the plan’s network (where you get the best rates.) Another reason not to automatically stick with your current plan: The way it covers drugs, doctor visits and other services may be different next year. That could mean higher costs, which can have a big effect on your health. In an October 2018 study of 160,250 women and men with type 2 diabetes, those with higher co-pays for their diabetes drugs were more likely to skip doses or simply stop taking their medications.7

Plan changes can have a big effect on people with diabetes. Health plans can drop or add medications to their formulary—the list of drugs covered under the plan—and also move drugs from one tier of coverage to another, which affects your out-of-pocket cost. For example, one large company that manages pharmacy benefits for health plans across the US changed its list of covered drugs, devices and services in October of 2018. The changes affected widely-used diabetes drugs including the insulin products Humalog (replaced with Novolog), Apidra (replaced with Fiasp), Lantus and Toujeo (replaced with Basaglar, Levemir, or Tresiba), all blood glucose test kits and test strips (replaced with OneTouch), and the SGLT2 inhibitor drug for diabetes Jardiance (replaced with Farxiga or Invokana), the insulin sensitizer ACTOS (replaced with pioglitazone). Covered types of needles and syringes for insulin also changed.8

Formulary changes in 2017 led the American Diabetes Association to issue a statement criticizing the practice. “The American Diabetes Association is deeply concerned with recent trends in prescription drug formulary designs that result in frequent changes in drug coverage for individuals with diabetes,” the statement says. “…. Excluding a medication from the prescription drug formulary list can jeopardize the health of many patients with diabetes. In addition to the possibility that the replacement medication is not appropriate for the patient, formulary changes disrupt the continuity of care and burden patients with unanticipated, increased cost-sharing. These additional costs could result in individuals with diabetes being unable to afford medications essential to maintaining their health."9

But plans can also make changes that could save you money for the healthcare you need—so it’s worth shopping around. While insurance plans vary widely, a quick review of changes in some Medicare plans found new additions in selected states and plans that—in those specific plans only—made custom shoes and inserts more affordable, added a $6 copay for some insulin brands and dropped the copays for test strips and lancets, but added limits on the number it would cover to 4-5 of each per day. 

#3. Do Your Homework

“Each policy is different,” notes Carla Cox, PhD, RD, CDE, CSSD, FAADE, CPT, a spokesperson and fellow of the American Association of Diabetes Educators.10 “Be aware of the deductible and look at the cost of insulin over the year for you.”

Look closely at the cost of medications you take regularly, such as insulin, and also at how the plan covers doctor visits and diabetes supplies and equipment. Think carefully about plans with lower monthly premiums and a higher deductible. You’ll have to pay more for drugs and healthcare until you’ve met that deductible, which could make your care very expensive. “With Medicare in particular, I suggest to my patients that they check coverage for insulin and testing supplies and think about the monthly cost under different plans,” says Veronica J Brady, Ph.D., MSN, CDE, Associate Professor in the Department of Internal Medicine at the University of Nevada, Reno, School of Medicine and an advanced practice registered nurse in endocrinology.11 “This is a drug you’ll need for life. I also sometimes have this conversation with my patients who have private insurance or insurance through their job if they tell me they’re thinking about a cheaper plan with lower premiums and a higher deductible. You have to look at what that means for paying for insulin and supplies.”

In order to compare plans and see which may work best for you, first gather information about the medications you currently take, the doctors you see regularly and other medical services you use regularly, recommend the Juvenile Diabetes Research Foundation and the Affordable Insulin Project.

If you have Medicare, also have handy the Annual Notice of Changes your current plan sends each fall; it describes upcoming changes in that plan for next year.

#4. Research Plan Options Online

For Medicare, use the plan finder.

If you buy your own insurance, log into healthcare.gov or use information from the websites of private health insurers that offer plans in your area. In addition to comparing monthly premiums to pay for health insurance, pay attention to the out-of-pocket costs you’ll pay for drugs, doctor visits and other services through co-pays, coinsurance and deductibles. You may pay less out of pocket for a plan with a higher monthly premium and a lower deductible. Some high deductible plans also allow you to save money, tax-free, in a Health Savings Account or Flexible Spending Account to cover out-of-pocket costs.

#5. Check How Plans Cover Your Diabetes Needs

Use the online formulary for the plans you are considering to check how the plan covers the medications you take; you can also use doctor locater services on plan websites to check if the doctors you use are in the plan’s network. It’s also smart to check how the plan helps you pay for devices (like insulin pumps and glucose monitors) and supplies (like test strips and lancets); this information is usually in “durable medical equipment” section of documents about the plans you are considering.  Also look at how the plans cover the cost of lab tests you get regularly, such as A1c tests.

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