I have only been covered under the One Health plan since October 1st and already I'm finding that an important part of my medical care is not covered. I was diagnosed with gestational diabetes and the doctor prescribed a glucometer and testing strips to be used 4 times daily until I deliver. Cost was over $110 and it's $20 per week for the strips!! Could it be a mistake that they are not covered (I just received the turn-down letter today)

Julietur:

You need to check the summary plan description. Also, it would help a bit to know why your claim was denied.

Julietur:

Unless your SPD specifically excludes the procedure you have described, you may not find the answer there. I suggest you call the insurer or third party claims administrator (whomever processes claims for the employer) and ask for the specific reason for the denial.

If after finding out the reason for the denial you still do not agree, follow the written claims review procedures that should be in your SPD.

I'm not surprised - diabetes testing equipment is not covered under some plans. Check to see if the test strips are covered under your Rx plan (odd but sometimes true); the glucometer may or may not be covered - see if they'll cover it as durable medical equipment.

Is your plan fully-insured or self-insured. If fully-insured, you can write your state insurance commissioner to find out whether the plan is in compliance with documents filed in the commissioner's office.

Also New York State, for example, has a state mandate requiring diabetic supplies be covered. But this only applies to fully insured plans. Check with your state insurance commissioner.

Finally, note that the plan I administer covers diabetic supplies all via manual claim and some through the prescription drug card. The problem with manual claims is that depending on the way the insurance company processes them, the bill may not be properly recognized and may be rejected. Usually a phone call to Customer Service resolves this problem. If not, ask to speak with a Supervisor.

Julie:

Some plans only pay for insulin, so excluding things like test strips and meters is not unheard of. However, it is *dumb* from an insurer's perspective to decline them, as the potential complications from diabetes are much more costly than the suppies.

If your service agreement does not specifically exclude diabetic supplies, then appeal it formally. Good luck to you!

Julie: It would be helpful to know what state you are in to determine if diabetes supplies are covered and (if you have a prescription plan) along with insulin under the RX or medical plan. At that point, I'll let you know the state regs on it.