How Health Care Reform Affects Your Diabetes Care

Health care reform has brought important benefits to people, including those with chronic conditions like diabetes.

Plans* can no longer deny enrollment because of a pre-existing condition like diabetes. And they must offer a range of benefits that help you manage your illness, no matter your age. Young adults, including those with diabetes, can stay on their parents' plan until age 26.

Savings on Mail-Order Diabetes Supplies for Seniors

The National Mail-Order Program can be used to order diabetic supplies and have them delivered to your home. It costs the same to purchase diabetic supplies whether you get them delivered to your home or purchase them in the store. Some diabetic supplies that can be ordered through a mail order program include:

  • Test strips
  • Lancets and lancet devices
  • Batteries
  • Control solution

You can only use this program if you have traditional Medicare. If you use a Medicare Advantage plan, ask your plan where to get supplies.

Medicare will pay 80% of the cost of your diabetes supplies after you pay your deductible. You pay 20% of the costs.

You can buy supplies by mail order or from a store. But you must buy them from a Medicare-enrolled supplier to get this discount.

Ask your pharmacy if they accept "Medicare assignment." Or call 800-MEDICARE (800-633-4227) to find ones near you that do.

Savings on Drug Costs for Seniors

The new law is helping to close the gap in Medicare coverage for prescription drugs. You probably know this gap as the donut hole.

The donut hole occurs after you and your health plan have spent a combined amount of $3,750 in 2018. After you hit that amount, you’re in the donut hole. That means your health plan will not help pay for your medicines again until you have spent another $5,000 in 2018.

However, it's getting easier to afford your prescription drugs, and it will continue to get easier as the donut hole shrinks. This is great news for older adults with diabetes who use insulin or take diabetes medicine.

Donut hole shrinks. While in the donut hole, in 2018 you pay 35% of the cost for a brand-name medicines. Beginning in 2019 the donut hole will close and you will only pay 25% of the costs of your drugs until you reach the yearly out-of-pocket spending limit.

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For generic medicine, you will pay 35% of the cost in 2018 (37% in 2019). This will steadily decrease to 25% in 2020.

Get out of the donut hole faster.  You pay only part of a medicine's cost, but 95% of the full price counts toward your out-of-pocket costs for brand name drugs. That helps you more quickly reach the amount you need to spend to get out of the donut hole.

Here's an example. Say a brand-name drug costs $98 and has a $2 dispensing fee. In 2018, you pay 35% of $100, which is $35. However, 85% of the price – what you pay plus the 50% manufacturer’s discount -- is counted towards your out-of-pocket costs. This means that $84 (your cost of $35 plus the manufacturer’s discount of $49) is applied to your out-of-pocket maximum, instead of just the $35 you paid. This benefit puts you much closer to the amount you need to get out of the donut hole -- $5,000.

Free Preventive Care Available Now

If you have private insurance, you can get preventive care without paying a copayment or coinsurance. You can even get this care before you pay your deductible. Here's some preventive diabetes care:

If you are enrolled in a plan that existed before March 2010 and hasn't changed substantially, you may be in a grandfathered plan that is exempt from this part of the law. In addition, short term health plans, those that provide coverage for less than 12 months, do not have to offer free preventive care. Check the plan's summary of benefits to see if you can get free preventive care services.

No Lifetime Coverage Limits

Under the Affordable Care Act, health plans can no longer limit the dollar amount they spend toward your care over your lifetime. They also can't cancel your policy to avoid paying for your care when you have diabetes.

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Insurance Benefits

Here are some other insurance benefits* available to those with chronic conditions:

  • Adults with diabetes cannot be kept from enrolling in a health plan because of their condition. The same is true for people with other chronic conditions.
  • Health plans cannot charge premiums based on your health. This means plans can’t increase your monthly premium simply because you have diabetes.
  • Health plans cannot set an annual or lifetime limit on how much they pay for the cost of your care.
  • All health plans sold to individuals and small employers must provide essential health benefits. These plans have benefits that are as comprehensive as plans that large employers offer to workers.
  • If you don't have insurance through your employer, you can buy insurance through your state's Marketplace, also called an Exchange. The Marketplace compares plans and premiums and answers your questions. And depending on how much money you make in a year, you may be able to get help to pay for a health plan when you enroll through your state's Marketplace.
  • You may qualify for Medicaid even if you haven't before, depending on how much money you make in a year and where you live.

*Grandfathered health plans, those that existed before the Affordable Care Act passed and have not significantly changed, are not required to offer all the benefits and protections other plans do. Check with your insurance company or HR department to find out if you’re in a grandfathered plan. Short-term health plans also do not have to offer these benefits and protections. Short-term health policies are those in effect for less than 12 months, although they can be renewed for up to 3 years.

 

WebMD Medical Reference Reviewed by Sarah Goodell on September 18, 2018

Sources

SOURCES:

CDC: "Diabetes Report Card 2012."

American Diabetes Association: "How Health Care Reform is Helping People with Diabetes;"  "Questions and Answers About Health Reform and Diabetes: Updated to Reflect Supreme Court Decision;" and "Medicare's national Mail-Order Program for Diabetes Testing Supplies."

Healthcare.gov: "Pre-Existing Condition Insurance Plan;" "About PCIP;" "Will I Qualify for Lower Costs on Monthly Premiums?"  "Will I Qualify for Lower Out-of-Pocket Costs?" "Do I Qualify for Medicaid?" and "Glossary: Essential Health Benefits."

Medicare.gov: "Closing the Coverage Gap – Medicare Prescription Drugs Are Becoming More Affordable; “More Savings in the Drug Coverage Gap Coming Through 2020;” and "Medicare's Coverage of Diabetes Supplies and Services."
 

HHS.gov: "Affordable Care Act at 3: Increased Savings for Seniors."

CMS.gov: "Expansion of Competitive Bidding Program Will Increase Competition, Maintain Quality, and Save Medicare Billions."

Center for Medicare Advocacy.org: "Medicare's National Mail Order Program for Diabetic Testing Supplies."

CDC: "About the Program."

Medicare.gov: "Closing the Coverage Gap -- Medicare Prescription Drugs Are Becoming More Affordable."

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