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Fired Up Friday – Diabetic Supplies vs Durable Medical Equipment

I am sure you all know exactly what I am talking about just from reading the headline of the post.  If you don’t, then I will explain.  The insurance company looks at your different type of supplies in two main categories, prescription and durable medical equipment.  The way your insurance company defines them is most likely very similar, some minor differences I’m sure, but overall the same.  Now, what is the biggest difference to you?  Prescription is usually just a co-pay, for instance, $90 for a 90 day mail order supply.  Durable medical equipment (DME) products must be paid for with your deductible at first and then there is a yearly maximum that the insurance company will cover.

I’ll use my personal insurance numbers as examples for today because I don’t mind disclosing values.  I pay$115 a month for insurance through Cobra since I was fired back in November.  With that, I get my insulin which is a prescription, at $90 for a 90 day supply, which is about 16 vials of insulin.  My testing strips I get at the same rate, $90 for a 90 day supply.  I test about 10 times a day, so that’s 300 strips a month, so 6 boxes a month, which is an order of 18 boxes of strips for $90, can’t beat that. Now, the costly stuff comes in with the insulin pump supplies.  I have a $1,500 deductible, so I will have to pay $1,500 out of pocket before the insurance even begins to cover it.  This is about one 3 motnh supply worth of infusion sets and reservoirs, more on that later.  After that $1,500 is met, then insurance company covers only a maximum of $2,000 for the year, so they will cover only one more 90 day supply.  So that leaves me with 6 months to have to pay for infusion sets and reservoirs myself.

Here is where my problem with the insurance companies comes up.  Why do they consider my infusion sets durable medical equipment and not as a diabetic supply?  Diabetic supplies are covered by your prescription plan which would just be a $90 co-payment.  I understand that people use infusion sets for other things other than diabetes, but if I am using them to manage my diabetes, wouldn’t that be considered a diabetic supply?  This is just another way that the insurance companies can force you into paying extra money in order to survive.

Is there anything that we can do about this?  I really don’t think there is, but I wish that we could.  It is just irritating to know that this is a supply that I need to control my diabetes, so doesn’t that make it a diabetic supply?  Now, I don’t know if you all know how exactly products are billed to the insurance companies, but I will give a little advice on to how this is done.  Your supply company basically charges 3 times the amount of what you would pay to purchase it with cash online.  For instance, if you could buy directly from supplier at $100, they will bill the insurance company $300.  So that eats up your yearly maximum 3 times as fast.

First thing that I would suggest to you, is to find out the policy with your insurance company for reimbursement for submitting invoices.  Some insurance companies will allow you to purchase your insulin pump supplies in cash and then submit the invoice to them for payment.  This could save you a lot of money in the long term because you can get 3 times more in supplies.

Well, like always, I want to hear your feedback.  Leave a comment, hit me up on Twitter, e-mail me, do whatever you want, but I want to hear your opinions.

9 thoughts to “Fired Up Friday – Diabetic Supplies vs Durable Medical Equipment”

  1. I totaly agree with you. I makes no sense. I have searched the online companies. The retail on there product is so much less. I feel that pump supplies would be the same as a syringe. A syringe adminsters insulin. It is covered under pharmacy. Infusion lines are used to administer insulin. It is covered under durable goods. To me they are the same. Also, only recently did I ever hear of a maximum annual durable goods.

    You have to be a rocket scientist to understand the whole insurance thing.

  2. Not sure why you have a maximium of $2,000 after you’re out of pocket the $1,500. Our BC/BS has covered testing strips and pump supplies as DME for the last 7-8 years. We just know we’re going to be ‘out of pocket’ each year the $500 deductable plus the $1,000 in co-insurance. The recent change has BC/BS computer systems confused – especially since our plan doesn’t change until 10/1 (anniversary date).

    Why am I submitting this response? Because treating test supplies and pump supplies as a prescription means we’ll be out 20% of the cost (no maximum) as opposed to the $1,500 flat amount. Unfortunatly, when a months supply of pump supplies cost $900, and test strips are about $1.50 each (daughter tests close to your 10 times/day), you can easily see why we’re out $1,500 per year each year. That is OK w/ me as there is a MAXIMUM. Treating them a prescription where they pay 20% will end up costing us more over the course of a year.

    And, seems like each time she has key-tones, the ER will admit her for a day or two. That’s always been covered under major medical – – so no extra out of pocket. Separating pump supplies and test strips to require them to be treated as a prescription will cost us more than the $1,500 per year – – as one hospital stay will eat up that first $1,500.

    My understanding is some law (state or federal??) changed that required insurance companies to cover ‘diabetic supplies’ as prescription – – – without adequately defining ‘diabetic supplies’. While this probably benefits the majority (type 2 diabetics who normally don’t test 10 times per day nor have an insulin pump), it does not benefit the Type 1 diabetic as it takes away our ‘maximum’ when getting supplies.

    I vote they change it back. . . let me pay the $1,500 out of pocket each year . . then they take care of 100% of the rest (except for insulin, which they separated out 12 years ago!).

    Unless you have had experience with insurance company maximums and the splitting out of prescriptions, testing supplies, DME, major medical, etc., I agree it is very difficult to understand (or to explain). I believe what happened is the state or Federal government made a change they thought would be a benefit . . . but it will not be to us if it remains this way. For us, the best change would be to keep the test strips and pump supplies as DME and process it as a major medical item. Of course, I don’t have that $2,000 maximum after your deductable is met either – – that sounds like a pretty cheap policy. If you’re COBRA is only costing you $140/mo, the coverage probably wasn’t too good to begin with. If we went on COBRA, our monthly premiums would be $1300/mo. Maybe that’s why we don’t have that $2,000 ceiling??

  3. Having same issue! Have you had any success in getting this changed? I’m writing American Diabetes Assoc and the ADA. This is ridiculous!

  4. I have been a diabetic for the last 16 years. I have experienced almost all the side effects that you can and currently have early onset of diabetic neuropathy in my legs. After getting diagnosed I had the ketoacidosis almost regularly. I managed to graduate from HS and went on to college and that is when the problems started with and learning the insurance system. Had a diabetic attack my sophomore year and ended up missing finals week because of being in a coma for 2 days. Well then I couldn’t continue my classes and subsequently got canceled from my parents insurance. Now I was forced to provide for myself and with no college degree. I had A1C’s when I was a kid up until my 19th birthday between 5 – 7 % which is kind of unheard of for a child but when I was testing 5-8 times a day I was not paying for the strips so I wasn’t worried. Well had no problems once I found a job that covered my diabetic supplies but to make a long story short I was paying out almost my entire paycheck in just diabetic supplies. Now I find myself unemployed and have had to really fight long and hard to get assistance. I have found that you need to deal directly with the manufacturer. I have an insulin pump which I have had for 4 years now. Only issue is that my one touch meter (made by Johnson & Johnson) does not offer any discounts on their products and at roughly 50 cents to $1.50 per test depending upon where you buy your test strips you are looking at forking out $300 a month IN JUST THOSE. Funny thing is that I applied for social security and well if you make more than $1000 a month GROSS you are not disabled, even if the cost of your prescriptions cost more than that out of pocket. I even took it upon my self to contact the ADA… Unfortunately they don’t assist people in taking care of the diabetes here in Oregon. So I called the Headquarters in Virginia… SAME STORY… They strictly do research and education… They are the MOST USELESS organization I have ever dealt with… Even did the walk and it is all about the money… I used to do the American Cancer Society walk and even served on the committee… We brought in over $200,000 and we got BITCHED about because they like the ADA strictly worry about education… NO assistance of any kind… Basically they are a non-profit who is non-helpful… Your best way of trying to get assistance is contacting your doctor (namely an endocrinologist) and checking to see if they are associated with a group that deals in low-cost to free discounts… The one that got me was that I recently got approved for assistance and they are able to give me 100 strips a month because the guidelines is that you only need to test 3 times a day whereas the pump company states you need a minimum of 4 times a day… In my opinion for tight control you need to test on the regiment that I have been on for years even before the pump… Every 2 hours when well and when ill every 90 minutes… If you have any other questions just ask… I am currently working in Oregon as an advocate trying to hopefully get Congress to get their HEADS OUT OF THEIR *** and see diabetes is a problem in the USA as well as worldwide… Type 1 diabetes is growing in the world and until they find out what the cause of the problem is then their is no way to fix it… And if Congress does not see that then they can go ***** themselves…

  5. I can understand the PDM for the omni pod being considered DME and the Receiver for the Dexcom CGM being considered DME. How on this green earth is a Pod that is filled, used, and disposed of at the end of 72 hours considered DME? How is a transmitter for the Dexcom that is used for 7 days and disposed of considered DME? I am at a loss here. I have insurance but it only pays 80% of the cost of my DME. My 20% copay equals $350.00 each month with a 3000 catastrophic cap for the year. When do I reach my cap? Three months before the cap resets for the year…NEVER. I am at a loss as to how to afford living expenses since I live on a fixed income and now have to pay the $350 to manage my diabetes. My alternative…do not use the pump, go back to using 156 units of Novolog a day plus 150 units of lantus. Both covered by my insurance with a $ 27.00 co pay for a 90 day supply of each. The down side of that is the uncontrolled glucose levels, progressing kidney diffculties, vision problems, and the risk of heart disease. My A1C was 6.6 for the last three months, the lowest that my A1C was in 15 years prior to the use of the pump was 10.8. You would think that to reclassify the pump supplies to prescription rather than DME would save the insurance compainies an enormous amount of money in the long run. I wonder how many of us would be willing to join together and get some support to lobby for a change in the definition of DMEs? Does anyone know of any type of supplemental insurance that would cover the copay? This is eating my lunch!

  6. Same problem with Horizon BCBS of NJ. Last year they put a rider at the end of my contract (pg 110 of 115 pgs) that DME caps at $2500. (never had that before!) This yr I had to make sure that was NOT in my contract and found another plan through them that did not have a cap. Weird that I pay less for this plan too. I cannot have prescription coverage b/c the costs are too high, so my supplies are under medical, and prescriptions I pay up front and they are typically reimbursed 80 to 100%. I hate this game, but you have to play it to afford it. Although I have out-of-network benefits, they will only cover my supplies in-network readily. I am still fighting $7000 worth of costs paid to my previous pharmacy. I spend an hour minimum a day calling them to find out why my claims are denied or partially covered. Last time I submitted my insulin receipts they coded them in error as tape! I am contacting NJ’s Health & Senior Services because they do have a diabetes advocate that has helped me before. I suggest the same be done if you are in another state. The public doesn’t like govt involvement, but being diabetic for over 35 years, I have found this to be the best way to get what we need to survive. It started over 40 years ago when my mother fought to have my sister’s disposable syringes covered by our insurance. 2 steps forward, once step back in this battle. Insurance companies are not there to care for you – they are a company to make money. I think people will have to wake up to realize that to get care, we might just have to look toward the govt to do the right thing. BTW, I worked at a very large pharma company who professed to “care” and left yrs later because I just couldn’t stand the hypocrisy. I’m a small business owner and struggle, but wouldn’t trade it! Thanks for letting me rant! 🙂

  7. in the end, the supplier and your doctor have to help you with this. You will not convince the health insurance industry by yourself. involve the pump manufacturer, and you physician.

  8. We have BC/BS of TN. ALL of our diabetes supplies are covered under Durable Medical and this includes insulin, strips ect… The plan I originally bought for my then 5 year old son, had almost no pharmacy coverage. Cap of $150 a quarter. I think this is why we get everything under DME. They are required to cover these supplies. Because of this requirement, I have a hard time understanding how any insurance company can set a DME cap that will not cover the supplies. We have not been hit by one and hope we don’t. It is hard enough to pay our 1500 deductible plus 20% co-pay each year.

  9. I wonder why no one has filed a lawsuit against insurance for this. According to at least one gov website a piece of DME must be reusable and be able to be, say, rented from one person to another. Obviously the pump qualifies but like the insulin (or syringes for that matter) these other parts do not. American Diabetes Association should be fighting this IMO.

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