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February 25, 2002

Insurance/Costs

Question from Monticello, Illinois, USA:

My 14 year old daughter is on an insulin pump, and my husband's insurance for her changed at the beginning of this year. The previous insurance allowed us to see any doctor and get any medication for which a prescription was written, but under the new plan we can only see doctors on a list, and the insurance does not pay for diabetes nurse educators or dietitians. Also, they do not cover glucagon. We must use diabetes supplies from their list to get the best coverage. The most worrisome thing is that they say insulin pump supplies are covered under Durable Medical Equipment with a $15,000 lifetime maximum, and in a few years time, we will have reached the limit. What happens if she needs a new pump in the future? I contacted the Illinois State Insurance Regulators and was told that they could only help us if this was a fully insured plan. However, this plan is self-funded or an employee funded plan and not under State regulations. My husband works for the Canadian National Railroad, and the insurance is the Illinois Central Hospital Association who use a Blue Cross/Blue Shield PPO. We have to get prescriptions by mail order from PCS. Are there any Federal laws that cover the type of plan we are under? Also, we were told my daughter was the first person with type 1 diabetes at the ICHA., so I don't think they understand type 1 diabetes and what the standard of care is.

Answer:

I am sorry to say that I do not see any part of your story that indicates illegal conduct on the part of your insurance plan. Self-funded plans are not subject to minimum coverage requirements set by state. These ERTSA plans are supervised by the US Department of Labor and the rules do not set any type of minimum coverages. The employer establishes the coverages and benefits under this plan.

Perhaps you and your husband could meet with the benefits director to see if you can convince them to provide coverage for a diabetes educator. A letter from one of their participating physicians explaining the medical necessity of diabetes education might also be helpful. The irony here is that the Canadian Railroad provides less comprehensive insurance here in the United States, while the employees in their home country have complete coverage under the government sponsored health plan. Sorry the news is not better.

DSH