Diabetes and Health Insurance

Diabetes is can take several forms and is a chronic disease where a person’s blood sugar is too high. The disease can be caused by an insulin deficiency, resistance to insulin or a combination of the two. Individuals with diabetes are unable to process sugar correctly, making it into an energy source for the body, because the pancreas does not create enough insulin, or a person’s cells are not responding normally to insulin.

Type 1 can occur at any age, though primarily affecting children and young adults, and requires daily insulin injections as the body produces very little on its own. Type 2 comprises the majority of cases, occurring in teens, young adults and adults, due to being overweight or obese. Gestational diabetes is a form that occurs during pregnancy in non-diabetic pregnant women.

Diabetes has affected an increasing number of people in this country over the years. In the past year, almost every state saw a growth in their adult diabetic population, which can only mean that it needs to be taken more seriously and more actively controlled. Being treated for diabetes is a continuous process, a self-managed routine requiring test strips, meters and insulin injections. These supplies obviously accumulate over time and become costly, making health insurance a grave necessity in order to correctly treat and live with the condition.


Current Coverage Options for Diabetics

Health insurance options for diabetics range from Medicaid, which is a common source for low-income individuals who have the disease, to private health insurance to the exchanges. Any of these sources should adequately cover necessary costs, including supplies and regular testing. According to the essential health benefits provision of the Patient Protection and Affordable Care Act, chronic disease management If coverage through Medicaid or your workplace is not available, there are still more types of health insurance to cover the costs of your medications and treatment.


Individual and Family Plans

Private health insurance was once very expensive for a diabetic, but now you can’t be rated up for your health problems and will pay just as much as the next person. Depending on the stage of your illness and the age of the applicant, diabetes would have been declined by many insurance companies before health reform, but now these things don’t matter so much. Your rates can only go up based on age and tobacco use, AND you have to receive coverage for certain types of care,  like your supplies to treat your diabetes. Children are also accepted for coverage regardless of their health, and not subject to rate increases.

In the past, companies could decline or rate up anyone for having diabetes. Below is a piece of one company’s 2012 underwriting guidelines for diabetes, which details age groups and levels of the illness and whether or not to accept the applicant. As you can see, in most cases, this particular insurer would have declined a diabetic applicant. However, if your case was not very serious or it was under control and being actively managed (for a Type 2 adult) it heavily depended upon your other health risks. Some applicants could get away with as little as a 10 percent increase, which was not an unreasonable cost for access to covered care. Keep in mind, they would also rate up an additional percentage for being over a healthy BMI or having any related health issues.



Having a private health plan is a ideal option for many individuals, especially those who are actively managing their diabetes. In contrast to these underwriting rules, Type 1 diabetics can purchase coverage with any insurer they choose. No exclusion periods or limitations can be placed on your plan, and your rates will not increase due to your health under the health care law.

A number of private plans for individuals also give you access to diabetes management classes, if the carrier offers wellness programs. This educational tidbit may be helpful for those who need assistance getting their diabetes under control, or are looking for direction in how to lead a healthy lifestyle. These programs customize a plan for each individual in order to work towards improved health, through diet, exercise, and treatment, if needed.


Medicaid & CHIP

The state and federally-funded programs Medicaid and CHIP are available to low-income individuals, including diabetics. At the present time, some states have already expanded their Medicaid programs to include non-disabled adults without children who earn up to 138 percent of the federal poverty line. Previously, the program only catered to people with children or disabilities with few resources. Medicaid coverage includes treatment for diabetes, hospital visits, doctor’s office visits and prescriptions, though it varies by state. Medically necessary supplies and treatment will be covered by your plan, and you can receive care from any provider in your network or in the area who is Medicaid-approved.

Every state’s income guidelines and benefits are different, so make sure you find out if you qualify and what is covered before you receive care. Copays are usually very small if they are required at all, and most states do not charge a premium for Medicaid.

Low-income children with diabetes can get covered by the Medicaid program, or CHIP — The Children’s Health Insurance Program — if their household income is a bit higher than the Medicaid limits. With a wider range of acceptance for children under 18, those who are affected by diabetes earlier in life can get the coverage they need if their parent does not have a plan through their employer or individually purchased coverage. Medicaid and CHIP will pay for all medically necessary supplies and medications, which includes insulin, test strips and all other methods of monitoring the illness.


Employer-Sponsored Benefits

If an employer decides to provide health insurance to their employees, diabetes will not disqualify you from getting insured. Under health reform, employer with more than 50 workers have to provide insurance, but they may not supply the most robust array of benefits. Always check the list of covered services and coverage levels offered in your employer’s insurance plan before deciding to enroll. Health insurance through the workplace is the most commonly used form of coverage in our country, whether used by an employee or a dependent family member on the plan. Diabetes should not prevent anyone from receiving the care they need, especially once you are insured. Group plans do impose a waiting period that can last several months, so make sure you have an individual plan in place for those months while you wait.

According to the American Diabetes Association, the organization has worked to pass provisions in 46 states that require fully-insured health plans to cover medications, supplies and care for diabetic plan members.

COBRA and HIPAA also apply to workers who have had health insurance through their employer and have diabetes. If you are laid off by the employer, COBRA coverage may provide temporary continuing coverage of your employee health plan, though it will get more costly than someone out of work would generally like. Otherwise, group health plans before an employee loses their position can be very helpful to a diabetic. More often than private plans, employers include rewards and incentives for workers to improve their health through the health plan’s wellness programs.


Health Insurance Exchanges

The health insurance marketplace in your state offers coverage to individuals and small businesses regardless of health, medical history, income and gender. These rules also apply to the private market, but the tax credits and subsidies offered on the exchange can only be applied to exchange plans. The government has worked out a way for people with moderate income to reduce the cost of premiums and medical care as an incentive to get insured. Private health insurers sell identical plans on the exchange giving access to their provider networks. All ten categories of essential health benefits are included, so you have access to preventive care, hospital care and diabetes supplies.



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Medicaid information


Health Insurance Exchanges