Insurance Resources for Persons with Diabetes
Insurance Resources for Persons with Diabetes
www.dshs.state.tx.us
Access to health care continues to be a major obstacle to diabetes management for people with diabetes who cannot afford health insurance. Diabetes is also a pre-existing condition that can cause insurers to deny or limit coverage.
Below is a listing of resources available to Texans with diabetes who find themselves without health insurance. Each program or organization has specific eligibility requirements and/or application procedures, which are detailed in links to their respective sites.*
For information about other insurance issues, click on the "Insurance" button on the navigation bar above.
Texas Diabetes Council staff is available to answer questions you may have about insurance issues at (512) 458-7490 or send an email . The Council does not provide or guarantee insurance coverage. While the Council can provide information about resources, it is the responsibility of the individual seeking health insurance to provide information regarding eligibility status and application information to the appropriate insurance resource.
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may not be accessible to persons with disabilities
Texas Health Insurance Risk Pool
http://www.txhealthpool.com/index.html Offers a group-type health insurance at a calculated cost.
Texas Medicaid
http://www.hhsc.state.tx.us/Medicaid/index.html Site provides a list of Medicaid services in Texas, including eligibility criteria. Medicaid is the State and Federal cooperative venture that provides medical coverage to eligible needy persons.
TexCare Partnership/Children’s Health Insurance Program (CHIP):
http://www.hhsc.state.tx.us/chip/index.html The Children’s Health Insurance Program (CHIP) is a national program designed for families who earn too much money to qualify for Medicaid, yet cannot afford commercial insurance. Coverage is available for qualified children from birth through age 19).
Medicare
http://www.cms.gov Formerly the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS). Detailed information about Medicare and other programs.
Texas Association of Community Health Centers (TACHC):
http://www.tachc.org
These clinics provide public and insurance reimbursable primary health care and preventive services to medically underserved areas.
Children with Special Health Care Needs – Texas Department of State Health Services
http://www.dshs.state.tx.us/cshcn
Covers children with health problems that can improve if they get special services or equipment.
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FAQs Related to Coverage for Equipment, Supplies, & Self-Management Training
The following information is offered to help patients determine whether their health benefit plan covers diabetes equipment, supplies, medication, and/or self-management training.
Will my insurance cover what I need to take care of my diabetes at home?
If you have a health benefit plan that is defined and regulated by the Department of Insurance, then the plan must cover equipment, supplies, medication, and self-management training.
What types of health benefit plans are not required to cover equipment, supplies, medication, and self-management training?
Self-funded plans are not governed by the Department of Insurance; they are not required to cover these items, although they could, depending on the terms of the policy.
How do I find out if my health benefit plan is a self-funded plan?
You may contact the Human Resources unit with your employer or you may call the health plan directly.
What specific equipment is covered?
All equipment is covered, such as a glucose meter, an insulin pump, batteries for the pump. Equipment is listed in the Texas Administrative Code, §21.2605(a)(b)(c).
Equipment and supplies include:
blood glucose monitors (meters), including those designed to be used by or adapted for the legally blind;
test strips specified for use with a corresponding glucose monitor;
lancets and lancet devices;
visual reading strips and urine testing strips and tablets;
insulin and insulin analog preparations;
injection aids, including devices used to assist with insulin injection and needleless systems;
insulin syringes;
biohazard disposal containers;
insulin pumps, both external and implantable, and other supplies, which may include:
(A) insulin infusion devices;
(B) batteries;
(C) skin preparation items;
(D) adhesive supplies;
(E) infusion sets;
(F) insulin cartridges;
(G) durable and disposable devices to assist in the injection of insulin; and
(H) other required disposable supplies;
podiatric (foot) appliances, including up to two pairs of therapeutic shoes per year; and
glucagon emergency kits.
Prescription medications are also considered part of equipment and supplies.
Repairs for the above-mentioned items are also required to be covered.
Where will I go for equipment and supplies?
That will depend on what contractual arrangements your health benefit plan has made.
In some communities, members may be directed to a DME (durable medical equipment) vendor; in other communities, members may be directed to a pharmacy. In some situations, the members may be required to use a mail order service or vendor.
This information should be disclosed in your member handbook.
Will I always get the medication that is prescribed, or will I have to use a generic drug?
All medications, as well as equipment and supplies, are required to be dispensed as written, including brand name products. A substitution may be made if the substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment, including medication.
What will I have to pay for my diabetes equipment and supplies?
Your health benefit plan can only apply a copay or deductible as for a similar condition. Your copay will be for a 30-day supply of any item of diabetes supplies listed in the Texas Administrative Code §21.2605.
For example, if you inject insulin twice a day, you will get as much insulin as is necessary for two injections a day; if you inject up to 6 times per day, then you would get enough insulin to cover up to 6 injections per day.
Where do I go for diabetes self-management training?
Your health benefit plan may arrange this in a number of ways.
You may be directed to a local hospital or community agency that teaches group classes.
Or, you may be able to select a single individual for one-to-one training who is a certified diabetes educator (CDE); that person could be a nurse, registered dietician, or other healthcare professional. These individuals, if contracted with the health plan, would be listed in a provider directory.
Where you will get self-management training will depend on the contractual relationships that the health benefit plan has established. This information should be disclosed in the member materials received upon enrollment.
If I have a problem with my health benefit plan, what do I do?
You may file a complaint with the carrier (either your HMO or your insurance company), or you may file a complaint at the Department of Insurance.
A complaint form may be accessed electronically at www.tdi.state.tx.us, by calling 1-800-2523439, or by writing to Texas Department of Insurance, P. O Box 149091, Austin, TX, 78714-9091.
Do all states have this coverage?
Only four states do not require coverage for diabetes equipment, supplies, medication, and self-management training: Alabama, Idaho, Ohio and North Dakota.
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Legislation Relating to Coverage for Persons with Diabetes
SB 163 passed in 75th legislative session related to insurance coverage for persons with diabetes. Art. 21.53G of the Texas Insurance Code was amended effective 9/1/97. Bill author was Judith Zaffirini with coauthors Carona, Duncan, Lucio, and Shapleigh . The bill sponsor was Berlanga.
Rules written by Dept. of Insurance and adopted in April, 1999 requiring HMOs, and indemnity carriers* to pay for:
Diabetes equipment & supplies:
A health benefit plan shall provide coverage for equipment and supplies for the treatment of diabetes for which a physician or practitioner has written an order, including:
blood glucose monitors, including those designed to be used by or adapted for the legally blind;
test strips specified for use with a corresponding glucose monitor;
lancets and lancet devices;
visual reading strips and urine testing strips and tablets which test for glucose, ketones and protein;
insulin and insulin analog preparations;
injection aids, including devices used to assist with insulin injection and needleless systems;
insulin syringes;
biohazard disposal containers;
insulin pumps, both external and implantable, and associated appurtenances, which include:
(A) insulin infusion devices;
(B) batteries;
(C) skin preparation items;
(D) adhesive supplies;
(E) infusion sets;
(F) insulin cartridges;
(G) durable and disposable devices to assist in the injection of insulin; and
(H) other required disposable supplies;
repairs and necessary maintenance of insulin pumps not otherwise provided for under a manufacturer's warranty or purchase agreement, and rental fees for pumps during the repair and necessary maintenance of insulin pumps, neither of which shall exceed the purchase price of a similar replacement pump;
prescription medications which bear the legend "Caution: Federal Law prohibits dispensing without a prescription" and medications available without a prescription for controlling the blood sugar level;
podiatric appliances, including up to two pairs of therapeutic footwear per year, for the prevention of complications associated with diabetes; and
glucagon emergency kits.
(b) As new or improved treatment and monitoring equipment or supplies become available and are approved by the United States Food and Drug Administration, such equipment or supplies shall be covered if determined to be medically necessary and appropriate by a treating physician or other practitioner through a written order.
(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.
Source: 28 TAC §21.1605(a)(b)(c)
Diabetes medication:
(c) All supplies, including medications, and equipment for the control of diabetes shall be dispensed as written, including brand name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.
Source: 28 TAC §21.1605(c)
Diabetes education:
(a) A health benefit plan shall provide diabetes self-management training or coverage for diabetes self-management training for which a physician or practitioner has written an order, including a written order of a practitioner practicing under protocols jointly developed with a physician, to each insured or the caretaker of the insured in accordance with the standards contained in Insurance Code Article 21.53G, Sec. 4(b) and (c).
(b) A person may not provide a component of diabetes self-management training under subsection (a) of this section unless the subject matter of the component is within the scope of the person’s practice and the person meets the education requirements as determined by the person’s licensing agency in consultation with the commissioner of health.
(c) Self-management training shall include the development of an individualized management plan that is created for and in collaboration with the insured and that meets the requirements of the minimum standards for benefits in accordance with §21.2604 of this title (relating to Minimum Standards for Benefits for Persons with Diabetes).
(d) Nutrition counseling and instructions on the proper use of diabetes equipment and supplies shall be provided or covered as part of the training.
(e) Diabetes self-management training shall be provided, or coverage for diabetes self-management training shall be provided to an insured or a caretaker, upon the following occurrences relating to an insured, provided that any training involving the administration of medications must comply with the applicable delegation rules from the appropriate licensing agency:
(1) the initial diagnosis of diabetes;
(2) the written order of a physician or practitioner indicating that a significant change in the symptoms or condition of the insured requires changes in the insured's self-management regime;
(3) the written order of a physician or practitioner that periodic or episodic continuing education is warranted by the development of new techniques and treatment for diabetes.
(f) An HMO shall provide oversight of its diabetes self-management training program on an ongoing basis to ensure compliance with this section.
(g) Health benefit plans provided by entities other than HMOs shall disclose in the plan how to access providers or benefits described in subsection (a) of this section.
*Self-funded plans are excluded from the rules, as the Texas Department of Insurance does not regulate self-funded health benefit plans.
Contact Us
by Phone: (512) 458-7111 or 1-888-963-7111 (or view phone list);
Telecommunications Device for the Deaf (TDD) Relay Texas: 1-800-735-2989
by Email: Webmaster
by Mail: Texas Department of State Health Services, PO Box 149347, Austin, Texas 78714-9347
Overnight Mailings (Federal Express, UPS, DHL)
Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199
Physical Addresses: Directions/Addresses/Maps
Regional Offices: Addresses/Maps
Press Officer: Doug McBride (512) 458-7524
Filing Complaints:
by Mail: Customer Service Representative, PO Box 149347, Austin, Texas 78714-9347
by Phone: (512) 458-7111 or 1-888-963-7111; TDD 1-800-735-2989
by Email: Customer Service
For more information about the customer service information and complaints process see Compact with Texans.
Consumer Rights for Mental Health Services:
(800) 252-8154 - Texas Only, 8 - 5 p.m. M - F
(512) 206-5760 - Outside Texas, 8 - 5 p.m. M - F
(800) 735-2988 - Relay Texas, Voice
(800) 735-2989 - Relay Texas, TTY
For more information, visit the Consumer Rights for Mental Health Services web page.
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Last Updated March 19, 2008
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