Navigating health insurance with a chronic condition like type 1 diabetes can be challenging. Many myT1Dteam members have shared their frustrations and confusion about insurance coverage. “I think what we all face every day with type 1 diabetes is first managing our disease, but then we also have to deal with the constantly changing insurance policies (if we’re lucky enough to have insurance),” a member wrote.

Understanding how health insurance policies function and what you should look out for can help you get coverage for the diabetes care you need. It’s also essential to reach out to your insurance company if you have any questions about your health insurance policy.

Here are some tips about finding an insurance plan that’s right for you or a loved one with type 1 diabetes, and how to be sure you understand how your insurance plan works.

1. Know When You Can Enroll in an Insurance Plan

Health insurance plans generally have open enrollment months when you can sign up for health insurance or make changes to your health insurance policy. If you have health insurance through an employer and want to make changes to your policy, they can advise you about open enrollment for the policies they support, which can be different in every state.

Health insurance programs through HealthCare.gov — including the Health Insurance Marketplace for individuals, and Medicaid and Children’s Health Insurance Program (CHIP) for people with a low income — have open enrollment dates from November 1 until January 15.

If you have Medicare, there are also specific months for enrolling in or changing plans, depending on which plan you have.

Certain life events can allow you to enroll in a health insurance plan outside of open enrollment dates and may vary depending on the particular health insurance policy. Qualifying life events usually include:

• Loss of an existing health insurance plan
• Marriage, divorce, having a child, or death
• Some changes in residence
• Changes in income that affect eligibility for some types of insurance coverage
• New U.S. citizenship
• Release from prison

2. Understand the Costs of a Health Insurance Plan Before Enrolling

Health insurance plans have different types of costs and coverage options. Most plans will require you to pay a monthly premium, which is a fixed cost per month for the year. In addition to a monthly premium, other out-of-pocket costs — costs that you are personally responsible for — may be associated with a health insurance plan, including:

• Copays — Extra costs for prescription drugs, in-person doctor visits, blood tests, or other medical services
• Deductibles — The amount you pay before insurance starts covering costs
• Coinsurance — The percentage of costs you pay after you meet your deductible

“I’m on Medicare plus insurance supplement. I pay a little over $100 per month out of pocket for my Omnipod,” a myT1Dteam member shared.

Some health insurance policies have an out-of-pocket maximum, and the insurance company will pay 100 percent after you reach that amount. This doesn’t include payment of premiums.

Some policies may offer low monthly premiums but will have higher out-of-pocket costs. When choosing a health insurance plan, it’s important to consider which type of plan is best for you in terms of your overall health care costs.

Some people who use medical services more frequently may prefer to pay more for monthly premiums if that means their out-of-pocket costs are lower for medications and doctor visits. Others may prefer a lower premium with higher out-of-pocket costs if they generally need medical care less frequently, with the understanding that the need for medical care can always change.

It’s also important to check the in-network and out-of-network costs as they can vary substantially, and the out-of-network costs can be very expensive. Also, if you are told to see a specialist for your care, check if your insurance needs your primary care provider to send a referral to the insurance company before you go to your appointment with the specialist.

3. Find Out Which Supplies Your Health Insurance Covers

Ask your doctor what services and supplies you’ll need to manage your diabetes. For example, you’ll need to know which types of insulin, pumps, and continuous glucose monitors are covered. While choosing the health plan, check carefully what they cover and at what cost. Depending on your health insurance policy, it may only cover certain brands of insulin, or it may only cover generic insulin. Health insurance policies have a list of medications they cover, which is called a formulary. A formulary will also give you information about any restrictions on which pharmacies you use or if medications are covered by mail order.

It’s essential to review your policy’s formulary to avoid unnecessary out-of-pocket costs. Likewise with insulin pumps, continuous glucose monitors, and other diabetes supplies such as test strips, each health insurance company has specific guidelines for what they cover.

One myT1Dteam member shared their experience: “My pharmacy just filled my 90-day script for Novolog and when I went to pick it up, I was told my insurance doesn’t cover my prescription. No explanation, just NO. I’m on Medicare and I have a gap plan and a pharmacy plan. So I had to call each place to figure out that they changed their formulary to Lispro insulin.”

Talk to your health care provider or endocrinologist (doctor who specializes in treating hormone-related conditions) if you think you need a type of insulin or device that isn’t covered by your health insurance company. If your doctor determines that you need something for your diabetes management, treatment of your blood glucose levels, or another related health condition that your insurance isn’t covering, you can work with your doctor’s office to submit an exception request to your health insurance company. If an exception is granted, the insurance company will cover the costs.

4. Check if You Need Prior Authorization for Some Types of Coverage

Some health insurance companies require prior authorization (also called preauthorization). This means they will only cover something if it’s been approved beforehand. Each insurance company has guidelines for when prior authorization is needed and how to submit a request for prior authorization. You’ll need to work with your doctor to submit a form provided by the insurance company. Many prior authorization forms can be submitted online.

You can find out if something you need for your diabetes treatment needs prior authorization by reviewing your policy guidelines or by calling your insurance company.

5. Consider Appealing if Coverage Is Denied

It can be upsetting if a health insurance claim is denied and you are asked to pay a medical bill that you thought would be covered by health insurance. Fortunately, you have the legal right to appeal when an insurance company denies coverage. It’s encouraging to know that more than 50 percent of appeals for health insurance coverage are successful.

If your coverage is denied, contact your insurance company about the process for filing an appeal. Talk to your doctor's office as well because your appeal will be stronger with support from your doctor.

6. Look Into Resources if You Need Health Insurance

If you don’t have health insurance or have health insurance and need help with costs associated with your diabetes care, you may be eligible for certain programs. The National Institute for Diabetes and Digestive and Kidney Diseases has numerous resources to help manage health care costs for people with type 1 and type 2 diabetes.

Find Your Team

On myT1Dteam, the social network for people with type 1 diabetes and their loved ones, more than 3,500 members come together to ask questions, give advice, and share their stories with others who understand life with type 1 diabetes.

Do you have tips on health insurance for people with T1D? Have you had a problem with your health insurance that you were able to resolve? Share your experience in the comments below, or start a conversation by posting on your Activities page.