Page 16 - Diabetes

Let’s take a deeper dive into the tive services; chronic disease manage- existing condition such as diabetes.
language of health care that will help ment; and children’s health services This is true for new plans sold both
you shop for health insurance. (including oral and vision care). inside and outside the government
These full benefit plans are known as health insurance marketplace under
About the Patient Protection qualified health plans (QHPs). A QHP is the ACA. Plans can only set higher
and Affordable Care Act also eligible for purchase with an Obam- premiums based on age, tobacco use,
If you are not able to obtain health acare subsidy, which is a premium tax family size and geography.
insurance through your employer and credit. Subsidies are helpful to people In addition, plans must limit how
are not yet eligible for Medicare, your who are earning less than 400 percent much you pay out of pocket for benefits
best option may be purchasing a major of the federal poverty level. But it’s and must provide certain health ser-
medical plan on the government health important to understand that a subsidy vices aimed at preventing disease at no
marketplace exchange under “Obam- is based on that given year's income. If charge. Plans cannot set a dollar limit
acare.” Review each plan’s coverage you earn more than expected in 2018, on the amount the insurance company
carefully using the table. In addition, you may need to repay some of—or the will spend on “essential health benefits”
make sure the plan you choose meets all entire—subsidy you collected. either in a given year or during the
the Affordable Care Act (ACA) require- To obtain more information on the entire time you’re enrolled in that
ments under the law, especially cover- health marketplace in your state, visit plan. However, plans can still impose
age of the 10 essential health benefits: https://www.healthcare.gov or call other types of limits on benefits, such
doctor’s office visits; emergency room 1-800-318-2596. as number of doctor visits, prescription
services and hospitalization; pregnancy drugs or days in the hospital.
and newborn care; mental health and Diabetes: Your protections
substance use disorder services; pre- under the law Health plans outside of the ACA
scription drugs; rehabilitative services You cannot be denied coverage or Health insurance can also be pur-
and devices; laboratory services; preven- charged more because you have a pre- chased directly from a health insurance
TABLE 1: ITEMS IN PLANS COVERAGE

PLAN A PLAN B PLAN C
In-home care covered? Q Q Q
Telephone case manager services covered? Q Q Q
Each type of medication that I am taking is covered in the amount that I need? Q Q Q
Mail-order medication covered? Q Q Q
Special diabetes shoes covered? Q Q Q
Includes a limit to my out-of-pocket medical expenses? Q Q Q
Number of meter test strips that I need each month covered? _________ _________ _________

Plan covers all “essential health benefits” under the Patient Protection and Affordable Care Act? Q Q Q
Lets me apply my out-of-network spending toward my maximum out-of-pocket payments? Q Q Q
All or several of my over-the-counter medications are covered with a prescription from my provider? Q Q Q
Nutrition therapy and diabetes self-management education are covered, initially and each year after? Q Q Q
Same pharmacy I currently use is in-network? Q Q Q

Continuous glucose monitoring covered (equipment, training and evaluation of results)? Q Q Q
Out-of-network providers’ fees will be paid to some extent? Q Q Q
Visits to specialists (ophthalmologist, podiatrist, etc.) require a referral from my primary care provider? Q Q Q
Every type of insulin pump covered? Q Q Q
Receive notices from the health plan that my prescription medications need refilling? Q Q Q
Amount of money that I have to pay for the following is how exactly much? _________ _________ _________
• Annual deductible? _________ _________ _________
• Monthly premium? _________ _________ _________
• Copay (fixed rate paid at each doctor’s visit)? _________ _________ _________
• Co-insurance (percent of insurer’s payment for medical intervention paid by patient)? _________ _________ _________
Glucose meter of my or my doctor’s choice is covered? Q Q Q
Each of my providers (doctors, dietitian, hospital) is in-network in the health plan? Q Q Q

14 March/April 2018