American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Reference from the Diabetes Experts

CHAPTER 18

Health Care System

• Health Insurance 101

• Types of Health Insurance

• Types of Coverage with Private Insurance

• Diabetes Coverage with Medicare

• Denied Insurance Claims

• Diabetes Care in the Hospital

• Home Health Care and Nursing Homes

As a person with diabetes, you will probably learn more about the health care system than many other people. You will see multiple health care providers and purchase various medications, equipment, and supplies.

Making the most out of the health care system takes diligence. In this chapter, you’ll find an introduction to navigating your health insurance. The chapter includes background information on some of the most common types of health insurance as well as benefits and costs to look out for with your diabetes. You’ll also find tips on dealing with denied insurance claims, preparing for hospital stays and surgery, and finding an assisted living facility or care in your home.

Health Insurance 101

Medical care is expensive, and costs continue to rise every year. Diabetes can make health care even more expensive—even if you have insurance. Not only do you have to pay for routine care, but you also have to be prepared for the unexpected. Getting the best insurance coverage possible is critical, not only for your pocketbook, but also for your health.

Why It’s Important

People with diabetes should be especially diligent about understanding and maintaining health insurance because managing diabetes can be expensive and having adequate insurance can improve the affordability and accessibility of your health care. Losing or letting your health insurance lapse can be problematic and expensive.

Before you leave your old insurance—or the employer who is supplying it—be sure you understand the steps you have to take to protect your current coverage or obtain new coverage. The important thing is not to get caught without insurance, even briefly. Insurance is like having an umbrella in case it rains. The day you forget your umbrella, you can be sure it will rain.

Throughout the course of your life, your career, and your diabetes, you’ll need to periodically evaluate your health insurance situation to make sure it is still appropriate for your health care needs. It’s a good exercise to go through before you make any major changes.

Evaluating Your Health Insurance

• Ask yourself if your health care needs are being met.

• Ask yourself if your health care costs are affordable.

• If you are unhappy with your current situation, evaluate the options.

• Are there changes you want to make that could affect your health insurance? For example, do you want to switch jobs, retire, get married or divorced, or move out of state?

Whatever your answers, don’t be too quick to jump ship. Any change in your health insurance coverage requires careful evaluation. You need to make sure that any new situation provides the health care coverage you need.

New laws make it easier for people with diabetes to obtain and keep the coverage they need for appropriate treatment. Some of these laws are federal laws that affect all U.S. residents, but others are state laws that vary from state to state.

Affordable Care Act of 2010

On March 23, 2010, the Affordable Care Act was signed into law. The act includes many reforms to our health care system, including prohibiting discrimination due to preexisting conditions, changes to dollar limits on insurance coverage, and new options for obtaining health insurance. The following sections outline the most significant changes for people with diabetes. For more information on the new health care reforms visit www.healthcare.gov or www.diabetes.org.

Tips for Changing Jobs or Insurance Companies

• Talk to your new employer’s benefits coordinator or the insurer.

• Read all you can, and make a list of questions.

• You should be prepared to ask for details on the cost of monthly premiums, copayments, deductibles, coinsurance, and coverage (including non-dollar limits on benefits) for diabetes-related care and supplies like test strips, diabetes education, durable medical equipment, and so on.

• Also be sure that your policy covers office visits (including specialists), laboratory tests, hospitalizations, and preventive care.

• Be prepared and be persistent to get all of your questions answered.


Preexisting Conditions

Beginning in 2014, insurance companies will no longer be able to refuse to sell or renew policies because of a preexisting condition such as diabetes. Higher rates based on preexisting conditions will not be allowed in the individual or small-group marketplaces. For children under 19, insurance companies cannot deny policies due to preexisting conditions as of September 2010.


Types of Health Insurance

You can obtain health insurance in several ways. If you are employed or if your spouse is employed, you can often obtain insurance from an employer. If you leave your job, you can purchase transitional coverage, such as COBRA or state continuation coverage, or you can purchase coverage through a conversion policy.

If you are unemployed or self-employed, other insurance options include individual coverage or coverage through the federal or state high-risk pool programs. People who are over 65, disabled and unable to work, or have a very low income may have other insurance options, such as Medicare and/or Medicaid. It is worthwhile to investigate all of your insurance options because you may not realize that you are eligible for certain programs. For example, the Affordable Care Act expands eligibility for Medicaid.

Employment-Based Insurance

You may have the option of joining a group policy offered by your employer. These are often called group policies because you join a large pool of insured customers, which can help drive costs lower for the entire plan and broaden the range of available benefits. Group policies are usually open to all employees, regardless of their health. Many policies will also cover your spouse and/or children for an additional fee.

Employer-sponsored health care is considered a tax-exempt expense, so if you pay a fee or premium for health care coverage, you may have it deducted from your paycheck before taxes are taken out.

COBRA

If you are laid off or choose to quit your job for whatever reason, you may need insurance coverage while you make the transition from job to job or from work to retirement. Fortunately, a federal law called the Consolidated Omnibus Budget Reconciliation Act (COBRA) may help you.

COBRA Facts

• Under COBRA, you will have to pay for the total cost of your coverage (including the share your employer previously paid on your behalf) and may be charged up to 2% more than the rate the insurance company was charging your employer for coverage.

• Once you have been laid off, voluntarily leave your job, or are not eligible for coverage on your parents’ health plan, you have 60 days to accept COBRA benefits.

• Employers with fewer than 20 employees, the federal government, and churches are exempt from COBRA requirements.

State Continuation Insurance

If you work for an employer with fewer than 20 employees, state continuation coverage may be an option for you when you leave your job. Available in most states, state continuation coverage is similar to COBRA in that it allows you and/or your dependants to continue receiving the health care coverage you had as an employee.

State Continuation Insurance Facts

• You will have to pay both your share of the monthly premium as well as what your employer paid toward your health coverage while you were employed, plus an administrative fee that varies from state to state.

• In most states, the continuation coverage policy has the same types of benefits as were available under the group plan. However, for some states, the coverage is limited to hospital, surgical, or major medical benefits only and might not include certain group policy benefits, including dental care, vision care, prescription drugs, and similar supplementary benefits.

• Not all states offer continuation coverage, and the states that do offer it vary widely in how to sign up for coverage and how long coverage lasts.

• To find more information on state continuation coverage, contact your state’s Department of Insurance.

Conversion Insurance and HIPAA

When your group health insurance ends, many states require employers to offer you a conversion policy regardless of your health or physical condition. When you convert your policy, you remain with the same insurer but begin paying for your own insurance. This is called a conversion plan because you convert from a group to an individual plan.

Conversion coverage is almost always more expensive than the group plan you may have had while employed, and it usually provides fewer benefits. However, it may be your only choice for coverage and is preferable to going without insurance.

Conversion Insurance Policy Facts

• Conversion policies are not available in all states.

• In some states you must use up any COBRA or state continuation coverage that you are eligible for before purchasing a conversion policy.

• In other states, you can buy a conversion policy immediately after losing or leaving your job.

• If at all possible, be sure to explore all insurance options as far in advance as possible, including the application process.

HIPAA Facts

• HIPAA policies must be offered without preexisting condition exclusions to anyone who has had continuous coverage in a health plan for the previous 18 months (without significant breaks in coverage), the last day of which must have been under a group health plan.

• HIPAA is available to people not currently eligible for coverage under any group plan, Medicare, or Medicaid.

• People must first use up any COBRA or state continuation coverage available to them.

Individual Insurance

If you are self-employed, unemployed, or do not receive health insurance as an employment benefit, you may not be eligible for any form of group insurance coverage. Finding an affordable policy under these circumstances may be difficult. If at all possible, don’t forfeit health insurance altogether. Having diabetes makes health insurance an absolute necessity. Individual policies are contracts between individuals and an insurance company. You’ll want to be especially careful to review the policy for costs and coverage.

High-Risk Pool

If you have been turned down for insurance due to your health status, you might want to consider high-risk pool health insurance. This kind of insurance is offered in over 30 states to people who have lived in the state for 6–12 months and are ineligible for group or individual coverage due to a preexisting condition. Coverage is generally adequate; the costs can vary widely among the different states that offer it. Some states have waiting lists to buy into the pool. Some states may impose an exclusion period for coverage of certain health conditions.

The Affordable Care Act established a new temporary federal high-risk pool program (the Pre-Existing Conditions Plan or PCIP) that operates in every state. To qualify for coverage in PCIP, you must have been uninsured for at least 6 months and have been denied health coverage because of a preexisting condition. The PCIP is a transitional coverage program until January 1, 2014, at which point exclusion for coverage due to preexisting conditions will be prohibited. Coverage in PCIP is comprehensive and may be less costly than coverage in the traditional state high-risk pool, although those costs vary from state to state. For more information, go to www.pcip.gov.

Be sure to inquire about all the high-risk pool coverage options in your state.

Medicare

The federal insurance program Medicare covers a portion of hospital bills, provider fees, and other expenses for people over the age of 65 and for some people with disabilities who cannot work. Even if you get Medicare, you may still have to pay for a portion of your medical bills.

Most people over the age of 65, those with end-stage renal disease, and those with certain severe disabilities are eligible for Medicare. However, some people who have worked at state or local government jobs may not be eligible for Medicare. If you are unsure about your eligibility for Medicare, contact your local Social Security Administration office or the Medicare hotline at 1-800-MEDICARE (1-800-633-4227).

Medicare coverage for people with diabetes has improved dramatically in recent years thanks to the efforts of the American Diabetes Association. You can sign up for Medicare 3 months before the month of your 65th birthday. For more information, contact your local Social Security Administration office, listed under the United States Government listing in your telephone book. Bring your birth certificate when you apply.

Medicaid

If you have a low income, you might be eligible for Medicaid, a joint federal and state health care program. Medicaid eligibility varies from state to state, so you will have to contact the Medicaid office in your state to find out whether you qualify. The Affordable Care Act requires that in 2014, all states’ Medicaid eligibility levels be set at 133% of the Federal Poverty Level.

In general, prior to 2014, to qualify for Medicaid you must meet certain income limits as well as other criteria. For example, in most states, in addition to having income below a certain level, you must also be a child under age 19, elderly or disabled, a parent, or pregnant. Ask about what health expenses will be covered. If you have questions, a social worker can help you with this.

The health care provisions under Medicaid can change as states exercise their discretion in distributing funds. Most states provide coverage for essential diabetes care, but some states are trying to reduce this coverage due to state budget difficulties. For more information about how these changes may affect you, contact your local Social Security Administration office or call 1-800-772-1213.

CHIP

The Children’s Health Insurance Program (CHIP) is available to children and some pregnant women and some parents whose income may be too high for Medicaid but who cannot afford other health insurance options. It is also sometimes called S-CHIP. Each state varies in its eligibility requirements for this program. To find information on CHIP in your state, go to www.insurekidsnow.gov or contact 1-877-KIDS-NOW.

Health Insurance Exchanges

Exchanges are new marketplaces that will be established in each state to offer health insurance coverage to individuals and small businesses. Established by the Affordable Care Act, the state exchanges will go into effect in 2014 and will grant Americans the ability to choose among a variety of health insurance plans based on benefits, costs, provider networks, and more.

Types of Coverage with Private Insurance

However you are covered, there are different agreements between insurers and providers as to how services will be provided. If you have insurance through your job, some employers may offer an array of health plans and service options. Other employers may have settled on a single insurance company offering a single type of service.

The major types of insurance plans are fee-for-service and managed-care plans. You’ll need to consider your diabetes care needs when comparing and selecting a health insurance plan. Coverage under Medicare will be discussed in the next section.


Comparing Policies

Pay special attention to what you may have to pay as a deductible, copayment, coinsurance, out-of-pocket limits, and annual limits. There may be a separate deductible for pharmacy benefits. Plans with lower premiums usually have higher deductibles and/or copayments, or may limit benefits.


Fee-for-Service Plans

These plans require you to pay a certain amount—a deductible—before your insurance pays benefits. Usually, you can choose your own providers among a wide range of health care professionals and hospitals with whom your insurer is affiliated.

Basics of Fee-for-Service Plans

• You must first pay an out-of-pocket deductible for your health care.

• Once you have met your yearly deductible, your insurance company will pay for the remaining expenses during the year, according to the particulars of your contract.

• Often, insurance companies will also require that you pay a portion of the cost of visits or health care (the copayment) and/or a percentage of your expenses (coinsurance), even after the deductible is met.

• However, most plans have out-of-pocket limits. Check the plan for a description of these limits.

• Check to see whether preventive health care, such as mammograms, Pap smears, or well-child visits, is covered by your plan. The Affordable Care Act requires that, after September 23, 2010, all new or renewed health plans must provide free access to certain preventive services. For information about which preventive services must be available without cost sharing, visit www.healthcare.gov.

Changes to Limits under the Affordable Care Act of 2010

Some insurance policies have annual dollar limits for covered services. Under health reform law, insurers will have restrictions placed on their ability to establish annual dollar limits. In 2014, annual dollar limits on essential benefits will be completely banned. Lifetime dollar limits on essential benefits such as hospital stays will be prohibited for new or renewed health plans after September 23, 2010.

HMO, PPO, and POS Managed-Care Plans

Under managed-care plans, you or your employer pay a fixed premium and you typically receive a comprehensive care package, ranging from routine office visits and preventive care to hospitalization. The three main types of managed-care plans are preferred provider organization (PPO), health maintenance organization (HMO), and point of service (POS).

Types of Health Care Plans


PPO: The insurance company has a contract with hospitals or doctors to provide care at a discounted rate. You may have more flexibility in your choice of in-network providers or specialists without the need for a referral from a primary care provider. However, if you choose to see an out-of-network provider, you may pay more.

HMO: The insurance company has a contract with a network of providers that will provide your care. Generally, you’ll need to see a primary care provider first for a referral before seeing specialists, and your choice in doctors may be limited. The HMO may not pay for care from out-of-network providers or if you see a doctor without a referral.

POS: You’ll see a primary care provider first, just like an HMO, but you may have more flexibility about seeing providers out of network. However, if you see an out-of-network provider, you may pay more in the form of a separate deductible, copayment, or portion of the total bill.


Basics of Managed-Care Plans

• Your cost is generally lowest if you seek care from the network of participating providers and hospitals.

• You generally have lower deductibles to satisfy and limited paperwork to process.

• You also may not be expected to pay large out-of-pocket amounts for services.

Limited-Benefit Plans

Sometimes, insurers will offer limited-benefit plans for consumers. They are sometimes called bare bones, mandate-light, or minimum benefit plans. They offer more limited coverage than most other health plans and may have restrictions on the type of care covered, including items and services essential for people with diabetes.

Covering Your Diabetes Needs

Obtaining insurance coverage is only the first step. What is covered is just as important for people with diabetes. Today, thanks to the efforts of the American Diabetes Association and its allies, 46 states and the District of Columbia require that state-regulated insurance plans provide comprehensive coverage of diabetes supplies, equipment, and education.

But be careful—only about one-half of the private plans in any given state are regulated by the state. The other plans are regulated under federal law and are exempt from state-mandated benefit laws.

Your insurance policy is a contract between you and the insurance carrier that outlines the services covered. Like any contract, you need to read it carefully to make sure it meets your health care needs.

Coverage of Diabetes Care

Your plan may include coverage for office visits and annual or semi-annual physical exams and laboratory tests. Some insurance companies will only provide partial coverage or will require a copayment for each visit. Others may not always cover routine physical examinations but will pay for a specific medical problem or medical emergency.

Tips for Coverage of Diabetes Care

• Check to see that your carrier considers routine diabetes care (e.g., diabetes supplies, visits with your dietitian) part of the treatment for diabetes and provides coverage.

• Check to see if there are any limits on how many visits are allowed.

• Check to see how much you will have to pay per visit.

• Ask if your plan includes diabetes self-management education and medical nutrition therapy.

• Find out if visits to other members of your health care team are covered and under what conditions. Some carriers will provide coverage for routine physicals but will not cover visits to a dietitian, for example.

• You may recognize that treating your diabetes is a team effort, but not all insurance carriers provide coverage that supports this.

Coverage of Medical Equipment

If your health insurance covers durable medical equipment, it may pay for a blood glucose meter, a fingerstick device, pens, pen needles, syringes, a pump, infusion sets, a continuous glucose monitor, and/or an insulin injector. Some insurance plans may cover some or all of these supplies under the prescription drug benefit. As there may be differences in copayment or coinsurance depending on how your diabetes supplies are covered, be sure to check your insurance policy for clarification.

Tips for Coverage of Medical Equipment

• Many insurers cover blood glucose meters and strips, often under a separate coverage agreement. Read the policy and talk to your human resources department or your insurer to be sure.

• Today, more and more plans will pay for an insulin pump if it is prescribed by your provider as “medically necessary.”

• Check your policy to see that none of these items is specifically excluded.

• Your provider may have to write a letter explaining why each of these items is necessary. This serves as your “prescription” for these items.

Coverage of Medication and Supplies

If your insurance covers prescription medications and/or medical supplies, it usually will pay for insulin, lancets, syringes, pens, glucose meter strips, and insulin pump supplies, if you have a prescription for them.

Tips for Coverage of Medication and Supplies

• Purchases of prescription drugs and supplies may require a copayment and/or a separate deductible.

• However, if your coverage includes prescription drugs, always ask your provider to write a prescription for insulin. Most insurance plans will reimburse you for insulin with a prescription.

• It is a good idea to ask the insurance company in advance what is covered. What medications are covered? Is there a prescription plan to reduce costs? How often can prescriptions be refilled? Is copayment required for each prescription? Which pharmacies accept your health insurance?

• Always keep a record of the name of the person who answers your questions along with the date, in case you need this information to appeal a denied claim.

Other Things You Should Know about Your Plan

• What mental health benefits are covered? The services of a social worker or psychologist can help you through the rough spots in coping with diabetes.

• Does the plan cover the services of specialists, such as an endocrinologist, podiatrist, eye doctor, or dentist, whose care is very important to people with diabetes?

• What kind of home health care coverage is included? Are there any limitations?

Diabetes Coverage with Medicare

Medicare coverage can be complicated. You’ll need to do some research to find the best options for your situation and what benefits are covered. This section provides an overview of the major parts of Medicare that cover diabetes care, medication, equipment, and supplies.

Keep in mind that the two main parts of Medicare coverage are Part A and Part B. There are also Medigap plans, Medicare Advantage Plans, and Prescription Drug Plans.

Part A

Part A helps to pay bills for medical care provided in hospitals, skilled nursing facilities, hospices (for people who are terminally ill), and, in some cases, your home. Generally, people covered by Medicare get Part A. You will pay deductibles and coinsurance.

Part B

Part B helps to pay for health care provider services, ambulance services, diagnostic tests, outpatient hospital services, outpatient physical therapy, speech pathology services, home health services, and medical equipment and supplies.

It is critical for people with diabetes to purchase Medicare Part B. You can get Part B by paying a monthly fee. Part B also has deductibles and coinsurance amounts that you pay.

Part B and Diabetes Screening, Care, Equipment, and Supplies

Medicare Part B coverage includes:

• Diabetes screening test per 12-month period for beneficiaries with identified risk factors (for the specific risk factors, go to www.cms.gov/DiabetesScreening).

• Blood glucose meters, lancets, test strips, and other supplies for the meter, whether you are on insulin or not.

• Insulin pumps and supplies (including insulin) for people who meet certain qualifications.

• Diabetes self-management training and medical nutrition therapy.

• Medicare will help pay for annual podiatry checkups, therapeutic footwear and shoe inserts, checks for diabetic retinopathy, and kidney dialysis.

Your health care provider must certify in writing that you need all of these items to manage your diabetes, that is, that they are “medically necessary.” Make copies of your provider’s written statement. Give a copy of it to your pharmacist each time you purchase these supplies so that it can be submitted along with your Medicare claim.

Medicare Parts A and B Don’t Cover

• Diabetes pills, insulin if you are not using an insulin pump, or syringes.

• Regular eye exams, prescription sunglasses, or contact lenses.

• Routine foot care, such as nail trimming or removal of corns and calluses.

• Custodial care provided in a nursing home or private home when that is the only kind of care needed. Custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating, taking medicines, and other activities of daily living.

For more information on Medicare, call the Medicare hotline at 1-800-MEDICARE (1-800-633-4227). For a more detailed explanation of Medicare, ask for a free copy of the Medicare & You handbook and check out the Medicare Plan Finder at www.medicare.gov.

Medigap

Even in its present state, Medicare does not cover everything you need for your diabetes care. To fill gaps in your coverage, you can choose from the many Medigap plans available from private insurance companies.

Medigap plans pick up some of the charges that Medicare won’t cover. These Medigap plans are standardized and regulated by state and federal law. There are a number of different Medigap plans that provide different benefits.

A particular plan’s benefits are the same, regardless of which private insurance sells it. However, the costs may vary. Be sure to compare plans between insurance companies before purchasing a Medigap plan.

The booklet “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare,” written by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and the National Association of Insurance Commissioners (NAIC), is updated every year and is available at www.medicare.gov or through any insurance company.

Ask for it, or call Social Security to have it sent to you. It will be very helpful in face of the changes that regularly occur in Medicare. It contains the federal standards for Medigap policies and general information about Medicare.


Medigap Tip

You cannot be denied Medigap coverage if you apply within the 6-month period beginning the first day of the month when you are 65 years or older and enrolled in Medicare Part B.


Medicare Advantage Plans

Medicare Advantage Plans are another option to help pay for care and medications not provided under Medicare Part A and B. If you choose to purchase a Medicare Advantage plan, you will not need to purchase a Medigap policy.

Medicare Advantage plans provide Medicare Part A and B benefits and may cover other services, such as prescription drugs. They are like HMOs and PPOs, and you usually see an assigned or network provider instead of choosing your own physician.

Medicare Advantage plans are not available everywhere, and you may have to pay a monthly premium for these policies.

Prescription Drug Plans (Part D)

Medicare works with private companies to offer optional prescription drug plans as part of Medicare Part D. These plans were introduced when the Medicare Modernization Act (MMA) was enacted in 2003.

Under these plans, you will have a member card that gives you discounts on prescription drugs. The cost of plans and availability vary by state. Some have annual deductibles and monthly drug premiums.

If you have a lower income, you may be eligible for one of the prescription drug subsidies available to some beneficiaries under Medicare. For information on whether you qualify for a subsidy, contact Medicare directly at 1-800-MEDICARE for more information.

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Gap in Drug Coverage or “Donut Hole”

The “donut hole” is a gap in the Medicare drug benefit that appears when a Medicare beneficiary surpasses the prescription drug coverage limit. When this happens, seniors are required to pay the full cost of their medications out of pocket until they reach the catastrophic coverage limit, at which point Medicare Part D then pays the full cost of the medications for the remainder of the year. Starting in 2011, seniors who reach the donut hole will receive a 50% discount on brand-name prescription drugs and a discount on generic drugs. The Affordable Care Act includes a provision focused on completely closing the donut hole by 2020. Visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for the latest information.


Other Drug Assistance Programs

Some states offer assistance for medications. In addition, some pharmaceutical companies offer drug assistance to qualifying individuals. You can visit www.rxassist.org for a list of statewide drug assistance and pharmaceutical company assistance programs.


Denied Insurance Claims

Having a claim denied is bound to happen at some point. Just when you think you’ve done all of your homework and think you know just what is and what is not covered by your health insurance, you receive a claim marked “DENIED.”

To resolve the situation fairly and efficiently, it will help if you have all the paperwork on hand to support your claim.

Tips for Denied Claims

• When your claim is denied, you will receive an explanation of benefits from your insurance company, which should include a reason for the denial of your claim.

• If you do not understand the reason for the denial, you may want to call an insurance company representative for a thorough explanation.

• Make sure to ask for and record the name of the person with whom you are speaking.

• Understanding what the problem is may help you better organize the papers and documents you need to support your claim.

• Contact your human resources department if your policy is through your employer. They can often explain why it wasn’t covered or help you work through the system more quickly.

• You will have a certain period of time in which to appeal the denied claim. State laws vary on the amount of time allowed to appeal, so make sure to check the law in your state or contact your state’s department of insurance.

Double-check that the claim form has been completed correctly. If it has, get the rest of your paperwork in order. Make sure you have a prescription for every piece of equipment you need, even if it does not require a prescription at the pharmacy. Sometimes, just submitting the prescription and receipt will be enough. Some companies may also want a letter of explanation from your health care provider.


Copies Only

Never send any original documents to your insurance company. Make copies of everything you plan to submit and keep them in a safe place. Send in the copies, and keep the originals. Send all pertinent paperwork by registered mail so you have a record that they have been received.


Tips for Appeals

• Write to the claims manager of your insurance company, explaining what is wrong. It helps to address the claims manager by name.

• Point out the items that have been denied payment and ask for a written response to your request.

• Give your address and phone number and that of your provider.

• Also, send your provider a copy of your appeal request for his or her records.

• State that you will call the insurance company on a certain date if you have not received a response by that time. On that date, call the claims manager and discuss your case. Two or three weeks is a reasonable period of time to wait.

Sometimes claims are denied for simple reasons. Maybe a clerk was unfamiliar with the newest equipment for diabetes care. Requesting an appeal moves the decision out of the clerk’s hands and into those of people who should have greater familiarity with blood meters, test strips, and other equipment.

If you work for a company that is self-insured (which many larger employers are), appeal directly to your human resources manager or to the head of the company first. Often they can easily remedy the situation.

State Insurance Commissioner

Write to your state labor department if your claim is still denied. Your state insurance commissioner acts as a consumer complaint department. Do not hesitate to contact this office. They can also provide you with an opportunity for a hearing. This is where your paperwork is most important.


Don’t Give Up

Even if you are denied again, don’t give up! Request an insurance hearing.


Tips for Writing the State Insurance Commissioner

• Include the name of your insurance company.

• Detail the coverage provided in your policy as you understand it, along with a copy of your policy.

• Describe what happened (this should include copies of all letters or details of phone conversations between you and the insurance company).

• Specifically request a hearing to determine the insurance company’s responsibility for payment.

An insurance hearing is like a court hearing in many respects. Both you and the insurance company will be allowed to state your case. You must also submit copies of all the documents you sent to the commission. Some people represent themselves, whereas others have lawyers.

A decision may be made right away or within the ensuing few weeks. If you are dissatisfied with the decision, you still have the option of taking your case to small-claims court.

Check with your local small-claims court, because each system has a different way of handling cases. You can find a listing in the city or county government section of the telephone book. The judges there understand that most people represent themselves. The judge will want to hear your side of the story and see copies of your documents.

Diabetes Care in the Hospital

At some point, you may need to stay in the hospital. A hospital stay doesn’t always mean that there is a life-threatening problem—it can include anything from routine elective surgery to a life-threatening emergency.

When you are admitted to a hospital, you may feel that you are no longer in charge. All of a sudden, your daily routine is disrupted, and you may have to face a recovery period that lasts from days to weeks or even months.

As unpleasant as it seems now, taking time to plan for how to handle hospital stays will pay off in the long run. You can take steps that will help get you the best possible care, whether you face an emergency situation or one for which you can plan ahead. Because, the truth is, the people who get the best care are the ones who take a proactive role in their health care, are well informed, and know what questions to ask.

Evaluate Local Hospitals

You’ll want to learn about your local hospitals when planning ahead for hospital stays.

There are three types of hospitals: city or county hospitals, private community hospitals, and hospitals that serve as teaching centers, usually affiliated with a medical school. But these types of hospitals are not mutually exclusive. A county or private hospital can also be affiliated with a medical school.

General Hospital Considerations

• Which hospitals are accepted by your health insurance?

• Does your primary care provider and/or specialist have privileges at a particular hospital?

• If he or she has privileges at several local hospitals, which is preferred?

• Are there advantages or disadvantages to a particular hospital depending on the situation?

Talk to your diabetes care provider to learn about a hospital’s general reputation, as well as its reputation for treating people with diabetes. Discuss the steps you should take in the event of an emergency and agree on which hospital to use. Ask your provider where he or she would go or would send a family member.

You may want to ask any friends, neighbors, or relatives who have had recent hospitalizations. You can also check with your diabetes educator or support group for further input.


Health Insurance in the Hospital

Ask your health insurance company which hospital services they cover and for how much. Also, many insurance companies require you to notify them in advance for any service, except emergencies, so they can pre-approve your treatment. It is important to understand which services require pre-approval because it will determine whether a service is covered.


How to Evaluate a Hospital’s Reputation

• Are there endocrinologists on the staff?

• Does the hospital have diabetes education and dietitians with expertise in diabetes on the staff? Are they available to both inpatients and outpatients?

• Is there a diabetes education program within the hospital or affiliated with the hospital?

• What other types of support services are available to people with diabetes?

• What is the protocol for managing blood glucose levels in the hospital? Will you be able to do any of your own care, such as blood glucose monitoring?

Checking into the Hospital

You’ll also want to plan ahead for your admittance to the hospital. Things will go more smoothly if you’re prepared for questions and inform people of your diabetes and your care preferences.

Tips for Hospital Admittance

• All patients with diabetes who are admitted to the hospital should have their diabetes clearly identified in the medical record. If you have type 1 diabetes, make sure that the classification shows up in your medical record and remind each new caregiver that your basal insulin may never be omitted.

• Make sure all doctors and nurses and other caregivers are aware that you have diabetes.

• Tell them what medications you are taking for diabetes and any other medications you are taking, including any over-the-counter drugs. It helps to prepare a legible list of these ahead of time, including how often you take them and in what doses.

• Explain any allergies or other conditions you may have that could affect the actions of medications.

• Speak up about any other medical conditions you may have, including complications of diabetes. High blood pressure may require special treatment before and during surgery. Heart disease medications may require adjustment.

• Tell them about any recent or frequent low blood glucose reactions. Bring your self-monitoring records with you.

• Tell them about your meal plan. Ask to see the hospital’s dietitian and explain what type of meal plan you’re using, including any special modifications such as less salt, less cholesterol, or less fat.

Blood Glucose Management in the Hospital

Studies have shown that intensive diabetes management is beneficial for people with diabetes who are hospitalized. Your blood glucose control will affect how quickly you recover, how long you are hospitalized, and whether you experience complications during your hospitalization. Your blood glucose needs to be monitored while you are in the hospital, and the results should be available to all members of the health care team. It is a good idea to talk to your provider before any scheduled hospitalization about the plan for achieving your blood glucose targets during your stay.


Meals in the Hospital

Your meal plan will be adjusted to give you adequate nutrition for healing. The type of illness or surgery you have will also influence what you are able to eat. If you are unable to eat solid foods, you will be given adequate nutrition intravenously.


Insulin

Insulin is the most effective and efficient way to keep blood glucose levels in your target range. Even if you are not on insulin at home, you may need insulin during your hospitalization. You can often go back to oral medications after you get better.

If you are acutely ill, need to be in an intensive care unit, or are recovering from surgery, you should receive insulin intravenously. That way, the nursing staff can react very quickly to blood glucose levels that are too high or low and make adjustments in your dose.

Once you are beginning to recover or your illness becomes better, you can often take insulin injections and achieve the same results. You should receive routine doses of both basal and bolus insulin and corrective doses if your blood glucose level goes out of range. If you see that a component of treatment is missing, ask your physician.

If you are used to managing your diabetes at home, you may prefer to give your own injections and do your own blood glucose checks. Ask your provider if that is possible in your hospital and have them write an order so that the rest of the staff will know.

Surgery

If you are facing surgery, it’s perfectly normal to feel apprehensive. When you have diabetes, there is even more to think about. People with diabetes can recover about as quickly as anyone, but blood glucose levels can fluctuate around the time of an operation and high blood glucose levels can complicate your recovery and prolong your hospital stay.

Regardless of the cause of your hospital stay, it’s essential that your diabetes be closely managed the entire time you are there. By taking an active role and by doing everything you can, you can help yourself recover on schedule.

The first question you will probably ask yourself is whether the surgery is necessary (unless it is an emergency situation). You’ll want talk to your provider about the risks and alternatives of surgery as well as how to manage your diabetes during your hospital stay.

Pre-Surgery Questions

• Are there alternatives? What are the consequences of not having the surgery? If you are still in doubt, get a second opinion.

• What are the risks involved and the likelihood of the risks arising? Feel free to ask all of the questions you may have. Even minor surgeries have some degree of risk. You have the right to have that described to you in advance.

• If you want an explanation of tests or other procedures to expect, ask. Unanswered questions can produce anxiety.

• Who will manage your diabetes before, during, and after surgery? Will you be under the care of your diabetes care provider, an endocrinologist, or a hospital physician who specializes in diabetes?

• What is the protocol for managing glucose levels before, during, and after surgery?

Write down your questions prior to meeting with your health care provider, so you remember to ask all of them.

You will receive an intravenous insulin drip prior to and during surgery to keep your blood glucose on target. Ask your diabetes provider to work with your surgeon as much as possible. Certain medications need to be stopped before surgery, some as long as a week ahead of time. Make sure you discuss all of the medications you are taking with your surgeon.

Surgery 101

• The surgeon will meet with you at least once before your operation to explain the surgery and what to expect afterward. It’s a good idea to have a list of questions ready.

• The anesthesiologist, who administers the anesthesia to keep you pain free and manages your insulin drip during surgery, will also visit you to tell you what to expect and, sometimes, to offer alternatives.

• The nurses caring for you will also be able to answer questions or address concerns you may have.

• After the operation, don’t hesitate to ask for medication for pain or nausea. Short-term use of these medications does not affect blood glucose levels.

• You may want a second opinion when a provider recommends surgery. Some insurance companies require second opinions. See chapter 17 for more about second opinions.


Lower A1C before Surgery

If your surgery is elective, try to bring your A1C levels as close to normal as possible before you are hospitalized. This will help you withstand the stress of the surgery and may help reduce the chances of infection and speed healing after the operation.


Home Health Care and Nursing Homes

Many people today are turning to home health care for a variety of reasons, especially because hospitals prefer to keep hospital stays as short as possible. Home health care services include nursing care and physical, respiratory, occupational, or speech therapy; chemotherapy; nutritional guidance; personal care such as bathing or dressing; and homemaker care.

Home health care can include health professionals who help you when you are bedridden with a long illness or housebound for a short period. They may provide blood testing or send a nurse into your home to administer medicines and other treatments. Home health care workers include professionals, trained aides who help professionals, and volunteers.

Coverage for Home Health Care

• Check with your health insurance plan or your company’s benefits officer to see if home health care benefits are covered.

• Don’t hesitate to ask the agency you are considering hiring how much they charge for each service, and ask your insurance carrier what services will be covered.

• If Medicare covers you, you may have some limited benefits. Usually, Medicare home health care benefits are restricted to the homebound and bedridden.

• The Department of Veterans Affairs, the military, and worker’s compensation may also be other sources of help for home health care.

If full-time care is needed, an extended-care, assisted-living, or nursing home is often the best option. It is important that you visit prospective sites. It is also a good idea to talk to friends, family, neighbors, or coworkers who have family members in these types of facilities.

Resources for Finding Assisted-Living Facilities

• Private or public case management social workers, including those with whom you may be in contact during a hospital stay

• Your local office on aging

• The county or state department of health

• Your primary care provider

• Your religious leader or pastoral counselor

• Local organizations or law firms for the retired or elderly

Assisted living facilities and nursing homes can be very expensive. There are four possible sources of payment: private insurance, Medicare, Medicaid, and self-pay or private pay. Different facilities ask for different types of payments. It is important that you understand what you get for the required fees. The admissions coordinator should provide details of regular monthly charges and exactly what they do—and do not—include. Ask if there is something specific you should know about that is not covered. Ask about how they routinely care for diabetes and how they handle acute situations related to high or low blood glucose episodes.

As an alternative to nursing homes, many people are turning to assisted-living communities or foster care homes. Many of these facilities are suitable for people who do not require full-time nursing care but who might enjoy the benefit of nursing staff and neighbors close at hand.

Check to see what nursing or other services are provided before you choose an assisted-living community. There is a wide array of living situations, from communities that function much like individual apartments, to individual units that provide nursing services, to full-time nursing centers. Check to see whether any of these facilities might meet your needs.



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