Managing Diabetes with a High-Deductible Insurance Plan
For a person with any type of diabetes, a high-deductible health plan (HDHP) isn’t usually a cost-saving option, although they are often touted as such.
Instead, HDHPs are ideal for people with minimal healthcare needs including doctor’s appointments, medications, and medical technology. When choosing a healthcare plan, the HDHP may look tempting due to its lower premium costs, but it’s critical to consider other factors that affect your overall medical expenses.
An HDHP likely isn’t going to save you money if:
- You have a chronic illness or other ongoing health condition
- You have young children—who are likely to experience the flu, ear infections, etc.
- You are aging and thus more likely to develop new health concerns
That being said, some type of health insurance is better than no health insurance at all. Having health insurance coverage of any type qualifies you for copay cards, which can lower your out-of-pocket cost for some medications.
Let’s take a closer look at HDHPs and what to do if you’re currently enrolled in this type of insurance plan, with insights from Christel Marchand Aprigliano, chief advocacy officer at Beyond Type 1.
What is a high-deductible insurance plan?
A high-deductible insurance plan (HDHP) sounds like a great idea at first:
- your monthly premium is relatively low
- you get 100% coverage for the basics of preventive health care (annual check-ups, vaccinations, initial mammograms, colonoscopy, etc.)
- comes with a health savings account (HSA) which you can move money into pre-tax to spend on medical expenses
- some employers will also contribute to your HSA accounts to make HDHPs more enticing for you because it’s more affordable for them
What qualifies as preventive care varies depending on age and gender.
Preventive care does not include things like: appointments with any type of specialist, screening for specific health conditions, mammograms after the initial mammogram detects something significant, additional appointments with your primary care (even for an ear infection), alternative medicine (acupuncture, massage, chiropractor, etc.).
As soon as you need any medical support beyond the basics of preventive care, you’ll be paying a lot out-of-pocket until you meet your deductible.
What is a deductible?
A deductible is the amount you have to spend before your insurance plan will begin to cover other expenses outside of preventive care.
For any medical expenses beyond preventive care, you’ll pay out-of-pocket until you hit the deductible amount, which will be at least around $1,400 for an individual and $2,800 for a family plan. The maximum out-of-pocket for an HDHP cannot be more than about $7,000 for an individual or $14,000 for a family.
These maximum out-of-pocket amounts are dictated by the IRS and increase annually.
Let’s break this down further to fully understand:
- First, you pay for everything beyond preventive care out-of-pocket until you meet your deductible. This includes all specialist visits, diabetes medications, and supplies.
- Secondly, the insurance plan will pay a percentage once you meet your deductible—which means you will still be paying for some of the expenses out-of-pocket, too.
- Lastly, when you meet your annual out-of-pocket maximum, the insurance company will pay 100 percent of your in-network medical expenses until the policy period resets (once per year).
This means, for example, that if you end up in the emergency room with a broken ankle, sprained wrist, back injury, severe case of the flu, injury from a car accident, concussion, etc., you’ll likely walk away with a hefty medical bill, adding up to many thousands of dollars.
Why a high-deductible plan isn’t ideal for a person with diabetes…
If you have the choice between an HDHP and another type of plan, the other type of plan is likely best. (If your only choice is an HDHP, keep reading for recommendations on how to maximize your coverage.) An HDHP simply isn’t going to save you money if you have a chronic condition like diabetes that requires regular costly medications, supplies, technology and healthcare appointments.
Even if your diabetes regimen is fairly simple and you have no other health conditions or complications, you’ll be paying a great deal out-of-pocket for insulin, pump supplies, glucose meter supplies, continuous glucose monitor (CGM) supplies and necessary appointments with your endocrinologist.
It could also be risky because you might avoid going to the doctor or the ER when you suspect something is wrong. You may not get the care you need when you need it, which could allow that health concern to worsen, threatening your overall well-being and safety.
If you’re on a high-deductible health plan with diabetes…
If you simply don’t have a choice and you’re on an HDHP, here are a few things to consider to keep your costs to manage the benefits and limits of your insurance coverage:
- Ask your insurance company (or your employer’s benefits specialist, usually in your human resources department) if there is pre-deductible or first-dollar coverage for insulin, other medications, retinopathy screenings, or blood sugar testing supplies. Instead of paying the full price until you meet your deductible, this type of coverage allows you to pay a copay price or co-insurance price as if you have already met your deductible. A huge money-saver. This is a fairly new offering, starting 2019, but not all employers offer “pre-deductible” coverage, so you’ll need to ask your insurance company.
- Take advantage of any copay cards for insulin, medications, test strips, CGM sensors, glucagon, etc. While many insurance companies will only count the cash amount you pay out-of-pocket after the copay card is used toward your deductible, it can still lower your initial out-of-pocket costs significantly.
- Consider using a test strip subscription program if you’re checking your blood sugar with a glucose monitor. These programs can cost nearly the same or less as a copay for test strips through your insurance, but you can get far more test strips than insurance decided you need. These programs completely bypass health insurance so there is no prior authorization or prescription required!
- Ask your insurance company about any diabetes medical equipment programs they work with that could reduce the cost of your CGM or insulin pump supplies.
- Use your HSA account! The human resources department of your employer can set a specific percentage of your paycheck to automatically go into this account—and many employers will add funds, too, if you’re using it. Whatever you don’t spend will roll over to the next year, but it’s sitting there waiting to be used on health-related expenses. Ask your insurance company what types of expenses you cannot use your HSA funds to pay for. Here are some tips on getting the most out of your HSA if you have diabetes.
Dealing with health insurance as a person with diabetes can be exhausting, frustrating and truly stressful. You’re trying to manage a serious health condition that requires daily care, and it often feels like your health insurance company only wants to make it harder.
The more you research and learn about your insurance plan, the more power you have. Reach out to your health insurance company and get answers to your questions, push for information, and raise a ruckus when you don’t feel heard.
Educational content related to type 1 diabetes is made possible with support from Lilly Diabetes, an active partner of Beyond Type 1 at the time of publication. Beyond Type 1 maintains full editorial control of all content published on our platforms.