Braille Monitor                                                    November 2009

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Understanding Medical Insurance

by Cheryl Echevarria

Cheryl EchevarriaFrom the Editor: Cheryl Echevarria is treasurer of the Greater Long Island chapter of the National Federation of the Blind of New York. She is also a member of the Diabetes Action Network and a medical insurance specialist. This is what she says about paying for diabetic supplies and other durable medical equipment:

As a member of the Diabetic Action Network, I know people have a lot of questions about how to get the Prodigy Voice Meter and the test strips that go with it. Understanding how medical insurance works may give you some ideas about how to get other equipment like walkers, canes, and wheelchairs.

Medical insurance can be very confusing. I went to school to become a medical insurance specialist, and insurance still drives me crazy, not only because there are so many types of insurance and insurance companies, but because all of us have different contracts with our companies. Whether it is Medicare, an employer’s insurance, or private insurance, there is one rule of thumb for durable medical supplies: they are not covered by your general medical policy, but are addressed under a rider or addition to your insurance policy. The insurance terminology for such items is “durable medical equipment” (DME). So, when you are talking about coverage for medical equipment or reading your insurance policy, DME is the term you should be looking for.

Here is an example: Karen wants to get the Prodigy Voice Meter and test strips. She has Medicare. What should she do? If she has Medicare and no other insurance, that is where she must turn. She should go to a medical supply service rather than her pharmacy. Ads for these services are broadcast all the time on TV. Medicare patients can go to any supplier throughout the United States as long as the service takes Medicare; it doesn’t have to be the one in your town or state. If Karen starts the process in January, she must begin by paying her annual deductible, the money paid by the patient before Medicare begins paying for the equipment—remember this is for supplies, not doctors’ visits. After the patient pays the deductible, Medicare pays 80 percent of the retail cost of all recognized supplies. Often medical supply services will provide the equipment at the price Medicare pays. If not, the recipient is responsible for paying the remaining 20 percent. Any medical products that you do not take by mouth or inject (like insulin) in other words, any diabetic supplies (test strips, syringes, lancets, pens, etc.) are covered under durable medical supplies.

If you have insurance through an employer or private insurer, e.g., Blue Cross/Blue Shield, Aetna, United Health Care, etc., you will find that they all have different rules. Determine who your supplier is, either by calling the insurance company or by looking in your insurance handbook. If that supplier doesn’t carry the equipment you need, ask if they can get it for you. Four out of five times they can.

Those who want the Prodigy Voice Glucometer and have only Medicare coverage, for example, should do the following:

A. Go to your doctor and explain what equipment you need to manage your diabetes as a blind person. Most doctors are not familiar with what is available for their blind patients. Medicare will pay for your equipment, even if your doctor does not understand this. Remember that you are the patient and the expert on blindness, and Medicare pays the doctor for taking care of you, so you are on firm ground when you courteously but clearly insist on your rights.

B. You must obtain certification of blindness. This can be a letter from your doctor. In New York we actually have certification of blindness from the state, so that or a similar certification can also be used.

C. If you are dealing with an equipment vendor through a salesperson or even a representative at our national convention, he or she can take care of the paperwork and contacting Medicare. In the case of other insurance carriers, if the medical supplies provider used by your insurance company doesn’t carry what you need, you can tell the carrier what is required and provide the name of the company that makes the product so that your insurer can obtain the necessary equipment. (In the case of the Prodigy Voice this is DDI.) You can also contact DDI directly or let me or a Diabetes Action Network leader know, and we will get in touch with DDI. They can quickly put someone in touch with the supplier. 

If you continue to have trouble getting what you want and need, the insurance company you are dealing with must send you a written document saying that either they can’t or won’t provide the equipment you need. With this denial letter in hand, you can fight the decision. The company must provide what you and your doctor agree is needed, or it will have a fight on its hands.

I hope this information helps a little. If you need additional help or understanding, contact me, Cheryl Echevarria, certified medical insurance specialist, at <cherylandmaxx@hotmail.com> or by phone at (631) 236-5138 from 9:00 a.m. to 3:00 p.m.

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