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Coverage for diabetic durable medical equipment

TA | December 8, 2008

Q: I was wondering if you could confirm how the Diabetic mandate for each state pertains to a person. Does it depend on where the person resides and works or where the policy was written? Also, if there is a diabetic mandate in a person's insurance policy, does the durable medical equipment for pumps apply to the durable medical equipment maximum on the policy?

A: In short this is a "problem area" with no simple solutions.

All states have some form of required coverage for diabetics but the coverage varies from state to state so we do not have specific information available. Specific coverage provisions are usually addressed by the medical service provider and the insurance company. If there is any discrepancy between the coverage offered by he insurer and what the medical provider expected, your medical provider would likely be able to alert you of the issue. Otherwise, diabetic equipment providers are usually very familiar with the insurance coverage provisions in the state in which they operate since this is the basis of their financial survival. Having the service provider make a request for coverage to the insurer is likely the best way to get specific information on coverage for durable medical equipment.

Keep in mind that the mandate applies only to major medical insurance policies and exempts other types of health insurance like "mini-med" policies. Also some policies like short term medical insurance have a waiting period or exclusion for pre-existing conditions and this also applies to diabetic expenses.

In the event that the state of policy issue is different than the state of residence, check the policy itself for the governing law. It will be clearly stated in the policy in words like "This policy shall be governed by he law of the State of ____". In some cases (for example in multi-state health plans run by a trust for multiple employers) it is possible that the controlling law will be different than either the state of residence and the state of issue. For example, a health plan for the members of an industry association might be headquartered in Texas but the plan members live, work and enrolled in the health plan in Iowa. It this case, Texas law may still govern the contract.

Finally, you should be aware that insurance coverage for diabetic durable medical equipment generates a high level of consumer complaints and dissatisfaction regardless of the state, the insurance company or he medical service provider. This seems to be a function of the pace of America's diabetic epidemic and the rapid recent development of costly technology to treat the disease. Health insurance plans simply have not kept pace. Employers and health plans are reacting in much the same way as chiropractic coverage was handled in the 1980s. Group and individual health insurance coverage is increasingly provided subject to a high policy deductible that reduces the insurance premium and makes these expected medical expenses part of the out-of-pocket expense to the insured. While this approach tends to eliminate disagreements over coverage and claims, it also pushes the cost onto one of the most financially burdened segments of our population. Diabetics, as a group, tend to have lower income, higher levels of unemployment and more financial difficulties than the average of the rest of the population.

 


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