11 Responses

  1. Mike Ratrie
    Mike Ratrie October 15, 2013 at 10:17 am | | Reply

    Amy, one of the biggest questions regarding diabetes and the Marketplace/Exchange is what does the coverage look like for pumps, pump supplies, meters, test strips and CGMs. Some are considered DME, some are not, but I haven’t seen anyone like AADE, ADA, etc, address this important area.

    1. Stevie B
      Stevie B October 15, 2013 at 2:54 pm | | Reply

      Here, here! Exactly what I would like to hear more about.

      I suspect that not much will change and that even slightly more costs will be thrown upon the insured so that the insurance carriers might make even more profits!

  2. Jay Kauffman
    Jay Kauffman October 15, 2013 at 10:53 am | | Reply

    Yes, that’s my biggest question too….how to find out if a plan is going to cover my Omnipod, for instance.

  3. StephenS
    StephenS October 15, 2013 at 11:40 am | | Reply

    Amy, you and the commenters here make very good points. For the record, my state (Maryland) has the exchange open (state exchange– not going to the federal exchange), with some delays, but it seems to be working. The premiums are among the lowest of any of the exchanges (

    I haven’t been able to find out what each plan will cover yet, mostly because I don’t want to set up a user account to get in. But like any legislation of this nature, what it looks like today is likely not what it will look like in five years. Hopefully, any changes will be positive ones.

  4. Stevie B
    Stevie B October 15, 2013 at 2:26 pm | | Reply

    In your second to last paragraph you point to the “Health Affairs blog” article which basically states not much is expected to change in coverage of illnesses, which feeling I also share. But here in my state of Californie-ya it seems fairly clear so far that my “out of pocket” expenses will be going up (and up and probably continue to go up)!

    My wife are both self employed and have to cover our own health insurance costs in whole. We have a good plan but it is expensive even with the high deductible our premiums are still outrageous and within the exchange we will be paying close to what we already do but with even more costs diverted to us. (of course, the insurance companies really need to continue to make more and more profit from our afflictions. Being one of the most profitable industries in the world just should not be good enough, more, more and more – they have shareholders they are accountable to you know!)

    The Affordable Care Act is a good thing, a very, very small beginning but a good thing. But, it is in fact only good for those that are currently uninsured who want or need health insurance and (profitable for) the insurance companies – which of course they consider good.

    It will take much more to make “health care” a reality in the US and I’m afraid that might be a long time in coming. Either way, hopefully it is coming….


    1. Jessica
      Jessica October 16, 2013 at 9:07 am | | Reply

      I, too, am in California. We are fortunate that my husband’s company is keeping their current benefits for at least the next benefit year (Nov-Oct). Out of curiosity I went on the CoveredCalifnia site to use the premium estimator and for coverage similar to what we have through his employer (HMO – no deductible, excellent/low copays for most services. And most importantly – 100% DME coverage) which is essentially the Platinum Plan through the exchange, our premiums would about triple in cost if we wanted to keep that similar coverage if his employer stopped offering insurance. The only thing I am not sure on, as mentioned in the article, is the coverage amounts for DME through the exchange offerings.

      As far as the insurance companies making a larger profit – remember that part of the ACA rules is that the companies have to refund to subscribers any amount that falls over that 20% (or is it 15%?) line. I have a feeling that this first year of the plan people that have been living without insurance but have now chosen (or have been forced) to purchase healthcare may use it a LOT to get things taken care of that they’ve been putting off. However, I would imagine after the initial shine wears off people will go back to avoiding the dr’s office unless absolutely necessary. Hopefully our emergency depts will be less overrun with the uninsured who use it like a dr’s office. I am hopeful that once the hype wears off that things will settle into a more normal pattern and we may even see a decrease in premiums and health care costs as more people are paying into the health care system and insurance companies are required to refund any excess amounts that don’t go directly to reimbursing healthcare costs.

  5. Pam
    Pam October 17, 2013 at 10:03 pm | | Reply

    I am in Calif. and am planning on purchasing one of the Exchange plans. Even the most expensive platinum plan will save me money over my current HIPAA guaranteed issue plan, which is all I could get when my employer plan and then Cobra ended. The most expensive platinum PPO will cost the same premium, but copays will amount to far less than the current $4000 deductible I now have.

    I did call one of the plans directly yesterday to ask about diabetes supplies. Pumps, pump supplies and CGMS are all treated as a DME benefit, meaning on the platinum plans there is 10% coinsurance. Test strips, syringes and insulin are under the diabetes benefits under the prescription drug benefit. The copays follow the regular drug copays for generic, preferred brand, non-preferred brand, specialty. Each plan has it’s own formulary. The one I called, Health Net, considers Humalog as Tier 2 ($15), Novolog as a Tier 3 ($25) and Symlin as speciality 10%. They couldn’t tell me which brands of test strips were on their formulary.

  6. Ann B
    Ann B October 18, 2013 at 6:52 am | | Reply

    The site issue is really a struggle. My husband is a health insurance broker and has been told by the insurance companies that he will have to take paper applications and fax them, until they can work through all the glitches.

    Also, people should realize that it may be more advantageous to work through a broker, then to wait for the exchange. The benefit of the exchange is if you qualify for the tax credit ( ), you should go through the exchange. If you don’t qualify, then the exchange kicks you out to the marketplace, where you have to find a broker anyway. Also, not all the companies have listed their programs and pricing listed yet. Working with a broker is free to the individual shopping for a policy and, at this point, may be the only way to get it done.

  7. Lucia Maya
    Lucia Maya October 18, 2013 at 1:45 pm | | Reply

    I am thrilled to be able to get coverage at all, as a self-employed person with Type 1. I’ve had no insurance for this past year, and the last plan I was able to get was $1,000/month with a $3,000 deductible, and that one is not even available anymore. From what I’ve seen, I’ll be paying much less, with greater benefits with the Affordable Care Act.

    I’m almost all the way through the application process (the federal site, as I live in Arizona), but the final piece hasn’t been working still. I’m trying to go on in early am and late pm when fewer are on, but hard to remember!

    As for what will be covered, it seems it’s not very different from the past, where different companies and different plans provide different coverage. You just need to do the research, though it is frustrating at times, but that’s nothing new! Thanks for the article.

  8. Dave
    Dave November 5, 2013 at 11:18 pm | | Reply

    Still not sold on Obamacare. Seems like a ticking time bomb to me. Hopefully it works out in the long run.

  9. Evin
    Evin June 16, 2014 at 1:37 pm | | Reply

    Attention Omnipod Users: if you are shopping around for a plan to cover your pods under the state or federal Health Insurance Marketplace, please call Insulet directly when you are shopping. They have developed lists of plans that are direct about repayment and coverage and lists of plans that are not.

    From what I understand, many of the plans up to Gold level may claim coverage but not actually provide it. Say, for example, you purchase a plan through, expecting to pay 50% of the Omnipod costs. Insulet will send you a box of 30 pods and then submit to the new plan for coverage, but most of the time, many of these plans are only paying for one or two pods, or none at all. I sincerely hope this is not the case and if it is, all Omnipod users are in big trouble if we are looking for a plan.

    The best thing to do is call Insulet to find out who is actually paying for pods before choosing a plan. Insulet said Gold and Platinum are good, but the rest may provide zero coverage. This is of course, in a constant state of flux, and I expect and hope things will get better.

    So far, after speaking with two representatives from the Health Insurance Marketplace, as well as Insulet, it looks like if I purchase the plan with the highest premium in my state of VA, then I will have 80-100% of Omnipod costs covered. This will actually save me money over the former insurance through an employer!!

    Please give your pump company a call for details on these different plans!

    I will be making the switch in a few days and will probably blog about my experiences at so check back if you need some info.


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