How costly is diabetes management and treatment?
Diabetes management and treatment is expensive. According to the American Diabetes Association (ADA), the average cost of health care for a person with diabetes is $13,741 a year—more than twice the cost of health care for a person without diabetes.1
Many people who have diabetes need help paying for their care. For those who qualify, a variety of government and nongovernment programs can help cover health care expenses. This publication is meant to help people with diabetes and their family members find and access such resources.
What is health insurance?
Health insurance helps pay for medical care, including the cost of diabetes care. Health insurance options include the following:
- private health insurance, which includes group and individual health insurance
- government health insurance, such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), TRICARE, and veterans’ health care programs
Starting in 2014, the Affordable Care Act (ACA) prevents insurers from denying coverage or charging higher premiums to people with preexisting conditions, such as diabetes. The ACA also requires most people to have health insurance or pay a fee. Some people may be exempt from this fee. Read more about the ACA at HealthCare.gov or call 1–800–318–2596, TTY 1–855–889–4325.
Some terms listed here have many meanings; only those meanings that relate to the financial and medical aspects of diabetes and its management and treatment are included.
affiliation period: a period of time that must pass before health insurance coverage provided by a health maintenance organization (HMO) becomes effective.
coinsurance: an amount a person may still need to pay after a deductible for health care. The amount is most often a percent, such as 20 percent.
coordination period: if a person has more than one health plan, a coordination period is used to figure out which plan pays first and for how long. For example, if a person has an employer group plan and Medicare, the employer group plan is the first payer for the first 30 months the person is eligible for Medicare.
copay (or copayment): an amount a person may have to pay for health care. A copay is often a set fee. A person might pay $10 or $20 for a health care provider’s visit or prescription.
deductible: an amount a person must pay for health care or prescriptions before the health plan(s) will pay.
network: a group of health care providers that gives members a discount. Some plans pay for health care and prescriptions only if received from a network provider.
out of network: health care providers who are not in a plan’s network. In some health plans, health care and prescriptions cost more if received from these providers.
premium: an amount a person must pay periodically—monthly or quarterly—for Medicare, other health plan, or drug plan coverage.
primary payer: the health plan that pays medical bills first, before bills can be sent to a secondary payer.
secondary payer: the health plan that pays medical bills second, after the primary payer has paid its portion.
social worker: a person with special training to help people solve problems in their daily lives, especially people with disabilities or low incomes. A social worker may help with financial and employment issues.
waiting period: the time that must pass before coverage can become effective for an employee or a dependent, who is otherwise eligible for coverage under a job-based health plan.
What is private health insurance?
Insurance companies sell private health insurance plans. Two types of private health insurance are
- Group health insurance. People may be eligible to purchase group health insurance through their employer or union or through a family member’s employer or union. Other organizations, such as professional or alumni organizations, may also offer group health insurance.
- Individual health insurance. People may purchase individual health insurance for themselves and their families. The website HealthCare.gov provides information about individual insurance plans. The website also provides a search function, called the Health Insurance Marketplace, to find health insurance options by state. Depending on their income and family size, some people may qualify for lower-cost premiums through the Health Insurance Marketplace. People can select or change individual health insurance plans during the open enrollment period each year. HealthCare.gov lists open enrollment period dates. The website also provides information about life events that may allow people to enroll outside the open enrollment period.
Employers may have a waiting period before an employee and his or her family members can enroll in the company health plan. Under the ACA, the waiting period can be no longer than 90 days. Certain health plans called health maintenance organizations (HMOs) may have an affiliation period—a time that must pass before health insurance coverage becomes effective. An affiliation period can be no longer than 3 months.
The ACA expanded coverage of preventive services. For example, adults with sustained high blood pressure may have access to diabetes screening at no cost. Adults and children may have access to obesity screening and counseling at no cost.
Each state’s insurance regulatory office, sometimes called the state insurance department or commission, provides more information about health insurance laws. This office can also help identify an insurance company that offers individual coverage. The National Association of Insurance Commissioners’ website, www.naic.org/state_web_map.htm , provides a membership list with contact information and a link to the website for each state’s insurance regulatory office.
The ADA also provides information about health insurance options at www.diabetes.org/living-with-diabetes/health-insurance .
Keeping Group Health Insurance after Leaving a Job
When leaving a job, a person may be able to continue the group health insurance provided by his or her employer for up to 18 months under a federal law called the Consolidated Omnibus Budget Reconciliation Act, or COBRA. Although people pay more for group health insurance through COBRA than they did as employees, group coverage may be cheaper than individual coverage. People who have a disability before becoming eligible for COBRA or who are determined by the Social Security Administration to be disabled within the first 60 days of COBRA coverage may be able to extend COBRA coverage an additional 11 months, for up to 29 months of coverage. COBRA may also cover young adults who were insured under a parent’s policy after they have reached the age limit and are trying to obtain their own insurance.
Read more at www.dol.gov/dol/topic/health-plans/cobra.htm or call the U.S. Department of Labor at 1–866–4–USA–DOL (1–866–487–2365).
If a person doesn’t qualify for coverage or if COBRA coverage has expired, other options may be available:
- Some states require employers to offer conversion policies, in which people stay with their insurance company and buy individual coverage.
- Some professional and alumni organizations offer group coverage for members.
- Some insurance companies offer short-term stopgap policies designed for people who are between jobs. However, these policies may not meet ACA requirements. For example, they may not cover preexisting conditions.
- People can purchase individual health insurance policies.
Each state’s insurance regulatory office can provide more information about these and other options. Information about consumer health plans is also available at the U.S. Department of Labor’s website at www.dol.gov/dol/topic/health-plans/consumerinfhealth.htm .
What is Medicare?
Medicare is a federal health insurance program that pays health care costs for eligible people who are
- age 65 or older
- under age 65 with certain disabilities
- of any age with end-stage renal disease—total and permanent kidney failure that requires a kidney transplant or blood-filtering treatments called dialysis
What health plans does Medicare offer?
Medicare has four parts:
- Part A (hospital insurance) covers inpatient care, skilled nursing home residence, hospice care, and home health care. Part A has no premium for those who have paid enough Medicare taxes. A premium is an amount a person must pay periodically—monthly or quarterly—for Medicare, other health plan, or drug plan coverage. Part A does have a deductible, an amount a person must pay for health care or prescriptions before the health plan will pay. A person must pay a daily amount for hospital stays that last longer than 60 days.
- Part B (medical insurance) covers services from health care providers, outpatient care, home health care, durable medical equipment, and some preventative services. Part B has a monthly premium based on a person’s income. Rates change each year. After a person pays the deductible each year, Part B pays 80 percent for most covered services as a primary payer. The billing staff of the service provider—hospital or clinic—can calculate how much a person will owe.
- Part C (Medicare Advantage Plans) are part of Medicare and are sometimes called MA Plans. Medicare must approve Medicare Advantage Plans. Each Medicare Advantage Plan must cover Part A and Part B services and may cover other services, too. Medicare Advantage Plans may have Part D prescription coverage. If not, a person can buy a Part D plan separately. Medicare Advantage Plans are not all the same. A person who is thinking of choosing a Medicare Advantage Plan should ask about the rules of the plan. The rules may specify which health care providers or hospitals a person may use. The plan may require a referral from a primary care provider to see a specialist. The plan may not cover medical expenses incurred during travel. How much a person has to pay out-of-pocket each year will vary by plan. People who have a Medicare Advantage Plan cannot have a Medigap plan to help pay out of-pocket costs. See the section on Medigap.Four types of Medicare Advantage Plans are available:
- preferred provider organizations (PPOs)
- private fee for service plans
- special needs plans for certain groups
- Part D (prescription drug coverage) has a premium and covers some medications. Private insurance companies offer different Part D plans approved by Medicare. Costs and coverage vary by plan. A person who has few assets and earns less than 150 percent of the federal poverty level may qualify for extra help to pay Part D premiums and medication costs. People can apply for this help by calling the Social Security Administration, visiting www.socialsecurity.gov to apply online, visiting their local Social Security office, or contacting their state medical assistance (Medicaid) office. People can find the current-year guidelines here or by calling Social Security at 1–800–772–1213, TTY 1–800–325–0778. People can find information and applications for Part D plans at www.medicare.gov . A person can also apply for Part D with an insurance company that sells one of these plans.
Other Medicare health plans are for certain groups, such as frail people living in the community and people with multiple chronic illnesses, and include hospital and medical coverage. Some pay for prescribed medications, too. State health insurance programs—called Medicaid—partially finance and administer these services. The plans include the following:
- Medicare Cost Plans are HMOs, like the ones offered as Medicare Advantage plans, only out-of-network providers are paid as if the policyholder had Original Medicare. Original Medicare is Medicare Part A and Part B.
- Program of All-Inclusive Care for the Elderly (PACE) combines medical, social, and long-term care services for frail people who live and get health care in the community.
- Medicare Innovation Projects are special projects that test improvements in Medicare coverage, payment, and quality of care.
Read more about Medicare Cost Plans and Demonstration or Pilot Programs on the state Medicaid website at www.medicaid.gov or call 1–800–MEDICARE (1–800–633–4227). State Medicaid offices can provide more information about PACE. See the section on Medicaid.
Does Medicare cover diabetes services and supplies?
Medicare helps pay for the diabetes services, supplies, and equipment listed below and for some preventive services for people who are at risk for diabetes. However, coinsurance or deductibles may apply. A person must have Medicare Part B or Medicare Part D to receive these covered services and supplies.
Medicare Part B helps pay for
- diabetes screening tests for people at risk of developing diabetes
- diabetes self-management training
- diabetes supplies such as glucose monitors, test strips, and lancets
- insulin pumps and insulin if used with an insulin pump
- counseling to help people who are obese lose weight
- flu and pneumonia shots
- foot exams and treatment for people with diabetes
- eye exams to check for glaucoma and diabetic retinopathy
- medical nutrition therapy services for people with diabetes or kidney disease, when referred by a health care provider
- therapeutic shoes or inserts, in some cases
Medicare Part D helps pay for
- diabetes medications
- insulin, excluding insulin used with an insulin pump
- diabetes supplies such as needles and syringes for injecting insulin
People who are in a Medicare Advantage Plan or other Medicare health plan should check their plan’s membership materials and call for details about how the plan provides the diabetes services, supplies, and medications covered by Medicare.
Read more at www.medicare.gov/Pubs/pdf/11022-Medicare-Diabetes-Coverage.pdf (PDF, 1,023 KB) or call 1–800–MEDICARE (1–800–633–4227) to request the free booklet Medicare’s Coverage of Diabetes Supplies & Services.
Where can a person find more information about Medicare?
A person can find more information about Medicare by
- visiting the Medicare website
- calling 1–800–MEDICARE
Medicare website. Read more about Medicare at www.medicare.gov , the official U.S. Government website for people with Medicare. The website has a full range of information about Medicare, including free publications such as Medicare & You, which is the official Government handbook about Medicare, and Medicare Basics—A Guide for Families and Friends of People with Medicare.
Through the Medicare website, people can also
- find out if they are eligible for Medicare and when they can enroll
- learn about their Medicare health plan options
- find out what Medicare covers
- find a Medicare Prescription Drug Plan
- compare Medicare health plan options in their area
- find a health care provider who participates in Medicare
- get information about the quality of care provided by hospitals, home health agencies, and dialysis facilities
Calling Medicare. Calling 1–800–MEDICARE (1–800–633–4227) is another way to get help with Medicare questions, order free publications, and more. Help is available 24 hours a day, every day, and is available in English, Spanish, and other languages. TTY users should call 1–877–486–2048.
Access Personal Medicare Information
People who enroll in Medicare can register with www.MyMedicare.gov , a secure online service, and use the site to access their personal Medicare information at any time. People can view their claims and order history, and see a description of covered preventive services.
What is Medigap?
A Medigap plan, also known as a Medicare supplement plan, can help pay what Original Medicare does not pay for covered services. Insurance companies sell Medigap coverage. People who have a Medicare Advantage plan cannot also have a Medigap plan. A person can buy a Medigap policy from any insurance company licensed to sell the policy in the person’s home state.
For people who are 65 and older, federal law says that in the first 6 months a person has Part B, companies cannot deny an application or limit payment for anything Original Medicare covers. Some states make insurance companies sell at least one Medigap coverage plan to those under 65 with Medicare. State insurance offices can explain the plans in their state. Find local offices on a map at www.naic.org/state_web_map.htm .
What other federal programs can help?
The following federal programs can provide more resources for people with diabetes:
- Department of Veterans Affairs (VA)
- The Indian Health Service
- The Hill-Burton Free and Reduced-Cost Health Care Program
- Bureau of Primary Health Care
- Social Security Administration
- Social Security Disability Insurance (SSDI)
- Supplemental Security Income (SSI)
- Women, Infants, and Children (WIC)
The VA runs hospitals and clinics that serve veterans who have service-related health problems or who simply need financial aid. Read more at www.va.gov/healthbenefits/online or call 1–877–222–8387.
TRICARE—the health care program serving uniformed service members, retirees, and their families worldwide—is available to people who are
- active duty service members
- military retirees
- family members of an active duty service member or a military retiree
- members of the National Guard/Reserves on active duty for 30 days
- family members of someone who is in the National Guard/Reserves on active duty for 30 days
TRICARE for Life is a specific TRICARE plan that offers secondary coverage for people who have Medicare Part A and Part B. Read more about TRICARE and access phone numbers for its four regions at www.tricare.mil .
The Indian Health Service may help members of federally recognized American Indian or Alaska Native tribes. Read more on the Indian Health Service website at www.IHS.gov . American Indians or Alaska Natives may also be eligible for help from public, private, and state programs.
The Hill-Burton Free and Reduced-Cost Health Care Program can help people who are uninsured and need help with the cost of hospital care. Although the program originally provided hospitals with federal grants for modernization, today it provides free or reduced-fee medical services to people with low incomes. The U.S. Department of Health and Human Services administers the program. Read more at www.hrsa.gov/get-health-care/affordable/hill-burton/index.html or call 1–800–638–0742 (1–800–492–0359 in Maryland).
The Bureau of Primary Health Care, a service of the Health Resources and Services Administration (HRSA), offers primary and preventive health care to medically underserved populations through community health centers. For people with no insurance, the Bureau bases fees for care on family size and income. To find local health centers, call 1–888–ASK–HRSA (1–888–275–4772) and ask for a directory, or visit http://findahealthcenter.hrsa.gov .
The Social Security Administration can provide information about eligibility for Medicare. People can contact the agency at 1–800–772–1213, visit the agency website at www.socialsecurity.gov , or check with their local Social Security office to learn if they are eligible for Medicare.
The Social Security Administration also provides the following programs:
- SSDI is a federal insurance plan that pays a monthly amount to people who cannot work. People earn SSDI work credits when they pay Social Security taxes. A person must have enough credits based on age to qualify. Then, if an illness or injury prohibits a person from working for at least a year, SSDI payments may be an option. A chart shows how many work credits a person needs at www.socialsecurity.gov/retire2/credits3.htm .
- SSI is a federal safety net program that pays a monthly amount to disabled children and adults who earn little and have few assets. A person who gets SSI may be able to get food stamps and Medicaid, too.
Read more about both SSDI and SSI and how to apply at www.ssa.gov or by calling 1–800–772–1213, TTY 1–800–325–0778.
WIC provides the following services to low-income pregnant, breastfeeding, and postpartum women, as well as infants and children up to age 5 who are at nutritional risk:
- supplemental foods
- health care referrals
- nutrition education
- breastfeeding information
The U.S. Department of Agriculture administers the program. Applicants must meet residential, financial need, and nutrition risk criteria to be eligible for assistance. Having gestational diabetes is considered a medically based nutrition risk and would qualify a woman for assistance through the WIC program if she meets the financial need requirements and has lived in a particular state the required amount of time. The WIC website provides a page of contact information for each state and for American Indian and Alaska Native tribes.