What you need to know to navigate diabetes and private health insurance

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Samantha Markovitz, NBC-HWC

Navigating diabetes and private health insurance is one of the most important and potentially confusing aspects of living with the condition. As a person with diabetes or a caregiver to someone with diabetes, understanding the details of the policy (and how to move through the system overall) is key to getting what you need.

11 practical tips for approaching private insurance

Diabetes and private health insurance can be complicated, but you can absolutely figure it out and receive care to your satisfaction. Thankfully, if you have coverage through an employer (including the employer of a partner or parent), directly from the insurer, or from a healthcare exchange, the "rules" are all pretty much the same!

Each policy varies in the details, but you can follow these tips to help demystify the process:

1. Understand your plan. Start by studying your summary of benefits, then familiarize yourself with the in-network providers, preferred pharmacies and suppliers, and formulary. Having a clear picture of what's covered, what's not, and where you may need to anticipate hurdles — like referrals and prior authorizations — will help you figure out how to move forward.

2. Maximize your coverage. Figure out if there are any perks to your plan, like diabetes supplies covered at preventative care prices, discounts on certain quantities of prescription items from the mail-order pharmacy, or a wellness offering that can help pay for fitness or meditation programs.

3. Anticipate your costs. Calculate your approximate monthly health-related expenses based on your summary of benefits and keep an eye out for outliers that pop up. Having an idea of what the charges will look like in advance will assist in highlighting additional costs that should be covered under your plan but weren't, perhaps due to administrative error or another misunderstanding. If you find an error, you'll be prepared to have it adjusted before it's too late.

4. Escalate your concerns. When you call your insurance company's member services line, you may not reach someone who is as knowledgeable about the ins and outs of diabetes care as you are, causing a dead-end conversation. Try patiently explaining why the information they're giving you doesn't apply or isn't helpful to your specific inquiry. If they're unable to adjust, you may request to speak to a supervisor (and keep going up until someone is able to address your concerns.)

5. Know the magic words. Of course, "please" and "thank you" can go a long way in getting what you need or want, but there are some other words and phrases that can help. If you're having trouble getting coverage for something, ask your physician or a representative from the drug or device company to tell you how to best phrase the concern to get the outcome you need. You might be surprised how rephrasing a question can lead to the answers you're looking for!

Edgepark can also help customers navigate private insurance. Edgepark customers can contact the company for help if they're having trouble getting coverage. Edgepark works with insurance companies to verify coverage for patients, ensuring they can get the supplies they need.

6. Keep records. Unfortunately, there may be times when it takes more than one call to the insurance company to get the task handled. To keep everything organized, ask for a reference number for the conversation, and if possible, the name of the person you spoke with on that day. Additionally, keeping your own medical records (or having electronic access to them) can help you quickly provide requested documentation or show the need for continuity of care.

7. Review your doctor's notes. When you have the opportunity, take a look at the notes from your past medical visits to make sure that they were documented properly. Everyone makes mistakes, but it's easier to fix an error that way than having your doctor submit notes and find out that a typo or the wrong diagnosis code is the reason for a denial (and having to start from scratch).

8. Prepare for the possibility of denial. You'll likely receive a denial at some point. It happens! To bounce back, have an idea of who in your doctor's office can most efficiently support your appeal, facilitating communication with the doctor, pharmacy/supplier, and insurance company and making sure that completed paperwork is faxed back quickly.

9. Be aware of nonmedical switching. If you familiarize yourself with the plan formulary (drugs and prescription items covered under your plan), you'll know in advance if your current medications and devices are covered. However, it's possible that your insurance company can decide to no longer cover what you and your doctor have already found to work for your diabetes management. This is called "nonmedical switching," and it happens frequently. Work with your doctor to go through the appeal process, if necessary.

10. Ask for assistance. Your insurance company may offer the services of a patient advocate who can help you navigate their system. There are also private patient advocates and nonprofits like the Patient Advocate Foundation that provide this service. These advocates can help you better understand the process and feel more supported throughout.

11. Harness the power of the diabetes community. Even though it may feel like it sometimes, you are not alone in having to navigate diabetes and private health insurance. Reach out to friends who have traveled this road before you, or search the internet (including social media) to find firsthand stories about how others have successfully made it through what you're attempting now. Additionally, both JDRF and the American Diabetes Association have insurance guides that may contain the information you need.

A worthwhile effort

Regardless of your insurance policy, the principle remains the same. Your health insurance company functions as a gatekeeper of sorts and your goal is to get what you need (specialist appointments, lab work, medications, and equipment) approved promptly so you can access the care you need affordably and efficiently.

Ultimately, you are the best advocate for your own diabetes needs, so empowering yourself with the necessary knowledge (and patience) will help you get what you need from your insurance company.

Were you recently impacted by job loss? Explore the Health Insights blog for helpful guidance, such as tips around ensuring health coverage and staying hopeful throughout the process.

Samantha Markovitz, NBC-HWC

Bio: Samantha Markovitz, NBC-HWC is a Mayo Clinic-trained National Board Certified Health and Wellness Coach and the author of “Type 1 Diabetes Caregiver Confidence: A Guide for Caregivers of Children Living with Type 1 Diabetes.” Drawing from her own experience in living with T1D, Samantha is dedicated to empowering individuals and families to live well and thrive while managing health challenges and achieving their goals.

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