Understanding What Your Health Insurance Covers

Medical insurance claim formWhen you think about the 2010 health care reform law, known as the Affordable Care Act (ACA), some popular provisions probably come to mind: the ban on insurance companies being able to deny coverage because of a pre-existing condition like diabetes; the elimination of the Medicare prescription drug coverage gap, known as the “doughnut hole”; or the part that allows young adults to stay on their parents’ plan until they are 26 years old.

But you may be surprised to know that one of the most popular provisions is also one of the least discussed—a requirement that health insurers give consumers a consistent, easy-to-understand description of each plan’s benefits and coverage. According to a Kaiser Family Foundation tracking pollThis image is associated with an external link., 60 percent of Americans gave this provision a “very favorable” rating.

Beginning in September 2012, the health reform law requires that health insurers give customers a “Summary of Benefits and Coverage,” plus a uniform glossary containing commonly used language in insurance documents. All health insurers must use the same format to tell people which services are covered under a plan and how much they will be responsible to pay themselves. The summary will include additional helpful information, such as how much you must spend before the plan will cover services (a “deductible”), whether you need a referral to see a specialist and how much you have to pay for doctor’s office visits and prescription drugs.

How the Summary of Benefits and Coverage Helps Individuals with Diabetes

Have you ever had health insurance that you thought would cover everything you need to treat diabetes, but instead were told that coverage for a service was denied or that you would have to pay for most of it yourself? With the Summary of Benefits and Coverage provision in place, it will be far easier to tell what your plan will cover and how much you will have to pay—before you even enroll in the plan.

The American Diabetes Association worked closely with the U.S. Department of Health and Human Services (HHS) to ensure that the final format would be helpful to the nearly 26 million individuals with diabetes in the United States. We are happy to say that HHS was responsive to our suggestions, and now insurers will be required to include a general coverage example for managing type 2 diabetes in the information they provide to their customers. This will provide a helpful snapshot of how much financial protection a sample patient with type 2 diabetes might get from the plan over the course of a year for services including prescriptions, medical equipment, diabetes education, lab tests and doctor’s office visits.

As diabetes treatment is individualized and can vary from person to person, the type 2 diabetes management example won’t estimate your actual costs for managing your diabetes, but it can help you see how deductibles, copayments and coinsurance can add up and help you compare plans.

If you have health insurance through your employer, you should receive your plan’s Summary of Benefits and Coverage during your next open enrollment period. If you buy insurance yourself, the Summary of Benefits and Coverage will help you make an apples-to-apples comparison of which services each plan covers and generally how much it covers. To take a sneak peek at what the Summary of Benefits and Coverage will look like, check out this sampleThis image is associated with an external link..

Look to previous blog entries to read more about how other provisions of health care reform can help you and first-hand stories of how health care reform has helped people with diabetes.

For more information on the Summary of Benefits and Coverage, visit the healthcare.gov website.

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7 Responses to Understanding What Your Health Insurance Covers

  1. Joan Hood says:

    I noticed you mention nothing but type 2 what about the T1’s?

    • American Diabetes Association says:

      Hi Joan,

      Insurers might not provide detailed coverage examples for type 1 diabetes, but all the other benefits we’ve described would still apply to you. You’ll still have useful information about what an insurance plan covers and how much appointments, prescriptions, supplies and so on will cost you.

      Even for a person with type 1, the type 2 coverage scenario can be a useful way to compare plans and see generally how “full” the coverage is, because many of the treatments are the same.

      Take a look at this sample Summary of Benefits and Coverage to see all of the non-diabetes-specific information provided. Hopefully it will give you a feel for the general usefulness of the document as a whole. http://cciio.cms.gov/resources/files/Files2/02102012/sample-completed-sbcfinal.pdf.pdf

      The pre-existing condition part of the law is also of great benefit to people with type 1 diabetes, as is the provision that allows young adults to stay on their parents’ plans until age 26.

    • Yes what about Type 1 diabetics???

  2. Leonor says:

    I have a 9 yr old daughter diagnosed with type 1 last September. I had a insurance since she was born. I pay $8,000 a year for this insurance for the whole family, and I just receive this notification that nothing of lancets, strips, insulin or the pump can be covered by my insurance!!!! Can you believe that??? Not even the 12,000 dollars I paid for hospitalization for five days. Because my insurance covered until the last day of September and since my daughter was in the hospital from the 23th to the 29th and I did not send the bills on time, they are not responsible of that. Unbelievable!!!

    • That is unbelievable when will people with serious diseases get relief Your insurance should have covered based on the service date not when they received the insurance claim so CALL them have it resubmitted! Do not give up I do insurance claims for my employer all the time and we do not give up because it is typical for insurance companies deny the first time around and they count that you won’t ask for it to be reviewed. Keep on getting the hospital to resubmit your claim until they see that the service date was before the end of September 31st. Just a thought!

  3. kelly mcgill says:

    Gee make the terms of agreement more readable, talk about the least they could do.

  4. Kira Nathan says:

    health insurance is very important because it gives us a level of security during times of need.

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