How Health Care Reform Affects Your Diabetes Care

Health plans cannot deny coverage to people with diabetes. And they must offer a range of benefits that help you manage your illness.

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 (doughnut) hole.

The donut hole occurs after you and your health plan have spent a combined amount of $2,960 in 2015 and $3,310 in 2016. 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 $4,700 in 2015 and $4,850 in 2016.

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 2016 you will pay 45% of the cost for a brand-name medicine. This will steadily decrease to 25% in 2020. After 2020, 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..

Savings on Drug Costs for Seniors continued...

For generic medicine, you pay 58% of the cost in 2016 and 51% in 2017. This will steadily decrease to 25% in 2020. Again, after 2020, the donut hole will disappear.

Get out of the donut hole faster. You pay only part of a medicine's cost, but its full price counts toward your out-of-pocket costs. 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 2016, you pay 45% of $100, which is $45. However, the total amount of the medicine, $98, is added to your out-of-pocket costs, instead of just the $45 you paid. This benefit puts you much closer to the amount you need to get out of the donut hole -- $4,850 (in 2016).

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:

Type 2 diabetes screening
Obesity screening and counseling
Nutrition counseling
Blood pressure screening
Gestational diabetes screening for pregnant women

If you are enrolled in a plan that existed before March 2010 and hasn't changed substantially, you are grandfathered and exempt from this part of the law. 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 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.

Children With Diabetes Must Be Covered

The new law no longer allows health plans to turn away children under age 19, including those with chronic conditions such as diabetes. All plans must allow families with children who have diabetes to enroll. Young adults, including those with diabetes, can stay on their parents' plan until age 26.

Insurance Benefits

Health care reform has brought benefits to some people, such as those with diabetes.

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 a yearly 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.