My grandson was diagnosed with Type 1 diabetes four days ago.
His parents were advised to sign up for an ACA Plan for 2025 that was better suited to address the needs of a T1D child. They have little time to research this since 12/15/2025 is the deadline for signing up for 1/1/2025 coverage.
Does anyone have any insight or recommendations as to ACA Plans in Union County North Carolina that are best suited for T1D coverage?
Thanks.
It was my understanding that health plans were based on state, not county - but I am not in NC and I could be mistaken. Hopefully you will get some replies from forum members in the State but one thing but if I might share my experience: - I’ve had many of my doctors for a number of years and would rather not switch: so if I am thinking about changing plans when open enrollment rolls around, I check to see if they participate. Since your family is new to diabetes they might want to select a plan that has a large number (relatively speaking) of pediatric endocrinologists to choose from. There’s nothing wrong with “shopping around” until they find one who is a good fit for them and their son. It might also be good to look at group practices rather than individual practitioners - the odds of finding someone might be better, and if their chosen doctor is out when they need them, it may be quicker to get a reply since another doctor from the same office may be covering. Hope that makes sense.
Thank you very much for your response, and all good points.
For most plans, it seems fairly straightforward to see the providers and how they will be covered. But for someone new to this situation, it seems more daunting to learn how insulin and diabetic supplies will be covered. That’s part of the challenge in choosing an ACA plan that is most appropriate for my grandson’s new T1D journey.
Another aspect of any plan is which level of coverage: they are often labeled Gold, Silver and Bronze, with each having its own deductible, co-pay, % reimbursement and maximum annual out of pocket expense. An insurance broker might be able to help you navigate things and decide which you think is best.
A suggestion - some people start on a pump almost right away. They are wonderful but they are expensive and require commitment. Some people are excited about using them, others don’t want one at all, and many people do fine on injections. There are people who cannot keep their numbers from going to extremes without one no matter how hard they try, but that is more the exception than the rule. It may take some time to determine the right doses and timing for injections - it does take some tweaking - but that’s normal.
All of that is to say, if pumps come up in conversation don’t feel pressured to say yes - be sure to ask if that is something he really needs. If it’s not, and he’s not willing to use one, taking that off the table will keep your costs down.
Again, an insurance broker might be able to help you.
On a side note, I highly recommend you check out the book Think Like a Pancreas by Gary Scheiner. He has Type1 diabetes and works in the field so has a unique personal perspective that is particularly helpful.
@hrdjfb James, Welcome to Breakthrough T1D Community Forum!
I don’t know anything about ACA in NC, but here is a likk to the Breakthrough insurance guide - it is a lot on reading but it will help your family to ask the necessary questions.
Type 1 Diabetes Health Insurance Guide - Breakthrough T1D
Hi James @hrdjfb since selecting a plan is balancing premiums, deductibles, costs and risks constrained by the family budget we can’t recommend a plan. I can try to list some things to look for. First thing to consider is the old 3 things to survive is now 4 things and insulin comes before food shelter and housing. Second thing to consider is a phone screen is really too small for what we’re about to look at, I hope they have a computer they can use.
Thanks for giving a county name, I used zip 28112 in Monroe to search for ACA plans to see what y’all are looking at. This isn’t a recommendation, just as an example I started with “Cigna Healthcare Connect Bronze CMS Standard”. Go to Plan Details, Plan Documents then Summary of Benefits.
After the usual deductibles etc. there’s health care providers. Copays with fixed dollar amounts are great and this plan charges copays for his pediatrician, endocrinologist, and 2-4 other specialists before the deductible is met, also great. Plan to see the endo 3-4 times a year forever. Next is lab tests, 50% copay isn’t great (Gold pan has 25% copay, still not great). Labs will need to be done at least 4 times a year.
Prescriptions, again $ instead of % is great. We’ll come back to this when we finish the summary. Note the ER costs. The tech we have today means ER visits for diabetes shouldn’t happen but the risk is there.
On page for is an item called Durable Medical Equipment 50% coinsurance. Some diabetes supplies are DME. Next we need to find out what is DME and what is under the pharmacy benefits by looking in the Evidence of Coverage document. (so far the three NC plans I’ve perused all use a different name for this doc, inside it’ll say EOC or certificate or contract.) Back on Page 1 of the summary at the top is a link to Plan Documents | Cigna Healthcare At the bottom of that page is Find Plan Documents. Pick the options Medical, 2025, NC then scroll down to the plan name click the arrow then click on the policy doc. Do a find and search for diabetes. Forth result gets us to the paragraph for “Diabetic Equipment” and “Diabetic Pharmaceuticals and Supplies”. The items in equipment are covered under the Durable Medical Equipment (DME) benefit. Most things are on the pharmacy list.
Next lets look at the Formulary to see what specific items are covered. Back on the page with the policy doc link near the bottom is a section called " Member Guide Quick Links" with a link to “prescription drug lists”. Scroll down and click the 4 tier NC list. Search for the rapid acting insulin, I searched Novolog first, its tier 2, turns out all the insulins on this plan are tier 2, but there are Quantity Limits and Step Therapy for Novolog. The QL isn’t defined, another minus against the plan but a minor one, ST for an insulin means they don’t want you to use it. Humalog doesn’t have the ST so its only a problem if he’s on Novolog. Repeat for the long acting insulin, glucagon, etc. Then search for Omnipod, that is the one pump that is sold via the pharmacy and not as DME. This plan has it so that’ll be an option in the future,. Search Dexcom, find its Tier 2 which would be cheaper than a 50% DME copay so that a positive for this plan. Even with a Dexcom CGM he’ll need a BGM and test strips, Contour isn’t covered but One Touch strips are, minor downside. Also look up lancets and pen needles. Pump infusion sets (Medtronic, iLet, Autosoft) for the common pumps are all Tier 2.
Use the info to guestimate a yearly cost, compare it to the premium then do it all again for the next plan. Health insurance induced headaches is one of the many complications from diabetes we all suffer from. Holler (PM me) if your grandsons parents have any specific questions they need answered.