Managing your health can be a lot of work.  You pay close attention to eating right, exercising more and taking the right medicines at the right time, but another big part of the job is to keep up with medical appointments, prescription refills and insurance paperwork.  It can feel overwhelming, and you may be asking yourself some of these questions:

Do I have access to all the medicines, services and care that I need?

What do I do if a medication or device my doctor and I agree would be beneficial for me to try isn’t covered by my insurance?

How can I make this whole process more efficient?

Unfortunately, many newer treatments (that often are more effective) aren’t widely covered by insurance. Here are some tips to help you understand your insurance benefits and what you can do if you feel like you’re hitting a wall in getting access to a medication or technology that may help you better manage your diabetes.  

Learn about all the benefits offered by your health plan.   Read the benefits handbook or explore the member services section of the website. You may also talk with the benefits manager in the human resources department for your employer. You may be surprised to learn that your insurance plan covers more services than you might have realized. For example, most insurance plans have benefits for weight loss classes, gym memberships, and diabetes education classes.

Understanding Explanation of Benefits (EOB).  When your insurance company processes the claim, they generate an Explanation of Benefits (EOB) that is sent to you. This EOB explains what services were billed to insurance and what you’re expected to pay.

Review it carefully.   If you are unclear about the information on your EOB, call your insurance provider. The customer service team can explain the claim and if an error is identified, they can reprocess it.  You may also need to call your provider to check if the service was billed correctly. 

Don’t be afraid to ask questions of your insurance company and provider’s office.

Keep good records. There may be times when you need to document “medical necessity,” which means you show proof that you need something special or extra for your health.  For example, if you have diabetes and the medicine you’ve been prescribed is not getting the results you and your doctor had hoped, keep track of blood glucose readings to be able to show if you have any of the following:  frequent high or low blood glucose readings, A1C above target (7% for most people) or difficulty detecting the symptoms of low blood glucose. 

Don’t take “no” for an answer.  If a treatment you are interested in is not covered, sometimes exceptions can be made.  Explore these steps:

Review your healthcare options including your and your spouse’s plan coverage and evaluate if a plan change is needed during the Open Enrollment period. Also keep in mind you can explore the Healthcare Exchange for additional plan options.

Learn the reason why a treatment may not be covered.  Is it a decision by the insurance company or your employer? 

Ask about the formal exception process. Each health plan has a standard appeals process. Review your “evidence of coverage” for appeal steps. Most insurance companies allow you or your provider to file an appeal within 180 days. When writing the appeal, focus on all the medical reasons that this treatment would be beneficial and provide as much documentation as you can.

Talk with your doctor or healthcare provider to establish a strong reason why you may benefit from a different treatment.  It’s usually best to meet with your healthcare team in person to discuss this and be prepared to show reasons why this is important to you for medical and personal reasons. 

Remember while your insurance company may have denied the coverage that doesn’t mean you can’t receive the treatment/medication. You can choose to pay out of pocket and some providers may be willing to provide the treatment without going through insurance. Talk with your provider about setting up a payment plan for services. In addition, for those enrolled in a “Healthcare Flexible Spending Account “ (FSA) pretax money can be used to pay for your qualified healthcare needs.

Gather Resources.   In addition to reviewing the handbook to understand your insurance benefits, explore additional resources.  The internet is a helpful source of information that you can search in more depth to help explore coverage for specific products such as a new medicine or a device, such as a Continuous Glucose Monitor.  Other good sources of information include:

If you have diabetes and Medicare:   Medicare Coverage of Diabetes Supplies and Services (2018)  https://www.medicare.gov/Pubs/pdf/11022-Medicare-Diabetes-Coverage.pdf

If you are interested in Weight Loss Surgery and have been denied:   What to do when you’re denied (bariatric) weight loss surgery.  https://4617c1smqldcqsat27z78x17-wpengine.netdna-ssl.com/wp-content/uploads/Bariatric-Surgery-Denial.pdf

Getting coverage for the best treatments available often requires the three P’s: patience, persistence and paperwork. Remember—you deserve the best care possible and it’s worth the extra time and effort to ensure that you receive it.


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