July 9, 2006
Question from Marlborough, Massachusetts, USA:
When insurance coverage changes due to what is offered by an employer, isn't it also important to check your legislation in your state, as most states have something? For example, Massachusetts has the Diabetes Cost Reduction Act that says that private, HMOs, and State insurance, etc. have to cover diabetes supplies and even gives an extensive list. Am I mistaken, as you did not mention this in your answer to a recent question today, July 3, when someone's new insurance was not going to cover insulin? I had private insurance that was out of state and they tried to tell me that pregnancy wasn't covered where I am in Massachusetts. I was protected by active legislation that says that if they cover a Massachusetts resident, they had to cover pregnancy like any other illness so to speak. When I disclosed this to them, they covered me with no problem. They weren't going to do so if I hadn't brought up the legislation though, so am I want to be sure I understand that at least in Massachusetts, insurers have to cover diabetes supplies (at whatever rates are typical for other covered things) because of the Diabetes Cost Reduction Act. Other states have similar legislation and we should at least be aware of how it can help protect coverage for diabetes.
The Florida resident who wrote to inquire about her family’s coverage was a participant in a employer group contract that was not subject to state mandated coverage requirements. One must be careful when evaluating group health insurance benefits against state established baseline coverage requirements because the size and the characteristics of the employer group plan will result in the group’s benefits being subject to less generous Federal requirements. In addition, many states have authorized the offering of stripped down benefit plans for some small employer groups. Employer group plans offered by employers with 50 or more employees, that have work locations in more than one state, or are self-funded or self-insured as well as union sponsored health and welfare benefit programs are not subject to state mandated coverage requirements. This leaves approximately 40% of all insurance contracts, primarily individual coverage and small group contracts (and most HMO contracts) with the protections afforded by state mandated coverage provisions.
I am quite familiar with the state coverage requirements for diabetes care. A little history–In 1993, I was Assemblyman Bob Sweeney’s legislative counsel responsible for drafting and negotiating passage for the bellwether New York state legislation establishing the national model for health insurance coverage for diabetes education, equipment and supplies. (Mr. Sweeney still proudly serves the people of Lindenhurst, West Babylon and Amityville, New York). Much sweat, tears and toil was shed by the diabetes community to establish diabetes health insurance coverage requirements in over 40 states by the year 2000. That is why the chronic disease community, including advocates for people with diabetes, oppose the legislation in the U.S. House and the Senate to establish “association health plans” which would be exempt from the benefits of state mandated coverage laws.