Diabetes & the Essential Benefits of the ACA
By Catherine Carver, MS, ANP, CDE
Vice President, Advocacy and Planning
Joslin Diabetes Center, Boston, MA
A co-pay or deductible should never keep you from getting the medical treatment you need. In taking care of chronic conditions like diabetes, the bills can add up fast, discouraging you from important check-ups or testing. The good news is, under the Affordable Care Act (ACA), managing your diabetes gets better with improved coverage.
Diabetes is among many common chronic conditions that requires a lot of planning and budgeting in order to be managed effectively. Over 26 million Americans are diabetic. It disproportionately affects some communities -- 19 percent of African Americans and 12 percent of Hispanics over 20 are diagnosed diabetic. With so many people affected, across every background, there is a lot at stake with the new changes to health insurance taking place.
That’s why it’s important that in Diabetes Awareness Month, we raise awareness not only about the condition, but about the ways the health care law has fundamentally improved coverage.
Under ACA, all policies must no longer deny coverage based on pre-existing conditions. For the first time, Americans can live free from fear of denial or getting dropped because of conditions like diabetes. Also, there are now caps on annual out of pocket expenses. Moreover, the ACA requires “essential health benefits” that are of particular value to people with diabetes, such as coverage for outpatient care, mental health care, lab tests and prescription medications.
For those without coverage or whose current coverage is unaffordable, you may be eligible for health insurance through the new exchanges found through healthcare.gov. These exchanges offer a wide range of policies and options for coverage. Plans differ on how benefits are offered and how much people will pay in out-of-pocket expenses for care and supplies. The kicker? For some, these plans are made more affordable by a subsidy provided that’s determined by your income. If you have tried shopping for private insurance plans before, you know premiums with a diabetes diagnosis can mean a huge monthly premium or a denial. That’s simply no longer the case.
It will pay to take the time to see what you are eligible for yourself or find a resource in your community who can show you your options. During Diabetes Awareness Month, Joslin Diabetes Center is taking the opportunity to highlight these provisions and what you should look for under the new law. A few pointers in reconsidering your current plan or deciding to get covered in the marketplace include:
1. Know your ambulatory patient services or outpatient care needs. If you have type 1 diabetes, you will want to look for a plan that provides you with the opportunity to see your endocrinologist at least four times a year. If you have type 2 diabetes, you may need to see your PCP four times a year, as well. There are costs associated with each and you should consider your network carefully.
2. Research prescription drug coverage. Under the ACA, all individual and small-group plans cover at least one drug in every category and class. If you have diabetes you will want to look for a plan that covers the individualized medication you need. You should also check to see how drug and supply costs will be counted towards out-of-pocket caps on medical expenses.
3. Price out the costs in the payment structure. Two things you must must, must, must consider when selecting new coverage are the cost of coverage and out-of-pocket expenses. Depending on where you live and what is being offered in the marketplace, you most likely have cost options. One of those options is a high-deductible health insurance (HDHI) plan. Another would be a plan with high co-pays. Both are financially attractive since they help keep premiums low, but can have long-term, detrimental consequences for people with diabetes. Do the math over a year of medical costs and do not just consider the monthly premium.
In addition to the Joslins Diabetes Center, there are organizations like Get Covered America that have resources to tell you specifically about your new options under the ACA. Whether you are knowledgeable yourself and can volunteer or need more guidance – do yourself a favor this month and get educated.
Taking care of diabetes will get better under the Affordable Care Act. You should never have to decide between managing your diabetes and managing your budget. But only if you step up and find out your options.
Changes to Medicare Diabetes Supplies Mail Order Policy
Catherine Carver, MS, ANP, CDE
Vice President, Advocacy and Planning
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Page last updated: March 11, 2014