Wednesday, March 4, 2009

More Questions?

I've had way too much time on my hands being snowed in the last few days. I'm thankful I had time to do some "homework" and save us money for Kacey's insulin but now I have another question.

As I shared in an earlier post, we got the pump approval and we will have to pay a balance of $1060. The more I thought about this....the more I started to stress (and I'm probably stressing over nothing...but don't want to wonder about it). We have United Healthcare insurance and we have a cap for Durable Medical Equipment of $3500 a year. Since it is the beginning of a new year and we are using that $3500 toward a pump, what happens with the pump supplies? Are they covered under DME or are they covered under the prescription plan? Is there a way to have that cap removed or increased since the pump is what is using it and we only upgrade every 3-4 years? I'm worried that her pump supplies are not going to be covered now. I tried talking to the UHC rep on the phone and it was obvious he didn't know diddly-squat about what I was talking about and insisted that I should "RENT" her pump and supplies. Whattttttttttt? Rent something that is going to be attached to her 24/7 and parts of it are disposable? I don't think so! I asked the UHC rep about having the cap removed and he said there is no way they can do that. He told me I had to call the person who sold my husband's company the insurance and ask them. So I called the lady at my husband's work that handles the insurance stuff and asked her and she told me that they get the insurance stuff sent down from corporate and she has no clue who the UHC rep is or how I would go about getting my questions answered. Ugh! So I'm stuck!

Is there anyone experienced with insurance questions? Can anyone help me with these questions or tell me how I'd go about finding out the answers?

I'm sitting here stressing because once she gets this pump, I don't want to be stuck not being able to afford the supplies for it.


Rachel said...


I am not an expert but I don't think that the supplies for the pump fall under the category of Durable Medical Equipment. They are not durable, they are used and then tossed in the trash. I believe they will be under the prescription part of your plan.

Hope this helps, but again, I'm not an expert.

type1mom said...

Well, honestly Jill, that isn't good. I have been a medical claims specialist my entire working life and have learned even more lately about DME because of our pump supplies as well. $3500 max means exactly what you think it means, and I am SO SORRY! BUT, you can look deeper into your policy and see if by some miracle "diabetes supplies" is an exclusion to the DME max.

Perhaps after the $3500 max they pay at a lower level? I have seen that as well. It is all in the fine print of your policy and all coverages are decided by the employer as far as how much/little they are going to cover.

The amount that your insurance pays will actually be an "allowed" amount per the contract they have with your chosen pump company. In our case, the pump cost $5,000 per Medtronic but allowed was only $2240.00..SO, our policy paid 80% of the allowed $2240....which was $1792.00 so we were fine for pump supplies for the year. Hopefully you will be too! Email me if you need anymore help!

type1mom said...

Also, to the other comment....Rachel is right that supplies are DISPOSABLE Medical supplies...BUT, insurance companies can be as dirty as they want to be so they choose to define pump supplies as DME, which is SO WRONG by definition! I had UHC and they consider supplies DME unfortunatley. They consider things like syringes and bandages "disposable medical supplies"......check your policy for what defines "disposable medical supplies. The RX part of your plan wont cover anything that is a necessity for use of a DME. Insurance sucks! I know!

Wendy said...

All of our pump supplies are DME...and I think you're concerns are correct. The $3500 cap will probably only cover the pump for the rest of this year. When does your insurance year begin? Ours is, maybe it's not as long as you might think it is before that $3500 resets itself.

Please e-mail me with your home address. I might be able to help get you guys through the rest of this year.

*Kendyl* said...

Well when I was on the pump my insurance covered all of my supplies under the prescription plan, but I also know how much an insurance company can jerk you around. I have looked at other pumps since I have gone off my pump, but I still just don't trust them. I also have way better control taking shots. On the pump my A1C was in the 9 range and now on the shots I am between 5-6. If you use the silloette(sp) infusion sets I have a couple boxes if you would like them