Managing Insurance Issues
Frequently asked questions
My son cannot get an A1C done at CHOP. How do I get the A1C done so we have the results for our diabetes visit?
- The CHOP lab may be out-of-network.
- Ask your primary care doctor (PMD) if he can make a referral to CHOP’s lab.
- If you can’t get a referral to CHOP’s lab, ask your primary care doctor to do an A1C a week before your diabetes visit.
- Make sure your PMD forwards your A1C results to your diabetes nurse or bring the results with you to your visit.
I went to pick up blood sugar test strips at the pharmacy. My pharmacist said that my insurance company would not cover them. I had to pay full price. What should I do?
- Call the “Member Services” phone number on your insurance card. Ask how test strips are covered. They may be covered under a “Durable Medical Equipment (DME)” benefit, not a pharmacy benefit. You need to get your strips, lancets and syringes through a Durable Medical Equipment supplier. Ask “Member Services” for DME suppliers. (You may have to make a mail order request).
- If you do have to pay for strips out of pocket, save your receipts. Call Member Services for help to submit them for reimbursement.
My daughter’s insulin pens are no longer covered? What should I do?
- Your insurance may not cover insulin pens. Insulin pens are more expensive than syringes. Many insurance companies cover the cheapest medication or device to keep costs down.
- Contact your diabetes nurse. She will make a request for prior authorization. She gives reasons why the insurance should cover expensive insulin pens for your child. When this works, you get a 3-6 month approval for pens.
- Call the insurance company yourself. Advocate for your child. Ask for a case manager to be assigned to your case so that you are talking to the same person every time.
My insurance company will only pay for 100 test strips a month — even when I have a prescription for my child to test 10 times a day. What should I do?
- Your nurse needs to get prior authorization to get more test strips. She may have to get prior authorization every time you get strips. You may have to prove you are using the strips. Some insurance companies require computer downloads of your meter or blood sugar logs to justify the extra test strips.
My child needs a bottle of insulin at school. Insurance won’t pay for it. They say one bottle of insulin is enough. What should I do?
- Talk to your diabetes nurse. She will contact your insurance company to request an extra bottle of insulin through a prior authorization.
I just lost my job. I cannot afford the COBRA payments to keep my child with diabetes insured. What should I do?
- Contact your diabetes social worker at 215-590-3174. She will refer you to CHOP’s Family Health Coverage Program (FHCP). FHCP staff will help you apply for state health insurance for your child. They will inform you if you are eligible for other programs that can assist you with the costs of prescriptions and diabetes visits.
Since I was laid off over a year ago, my family has been uninsured. I recently started a new job. For health benefits, I was told my son’s diabetes medical needs would not be covered. Can the insurance company do this?
- If your child with diabetes has not been covered for the past 63 days, the insurance provider can claim diabetes as a “pre-existing condition.”
- A pre-existing condition is any illness that is treated or diagnosed in the past 6 months.
- Insurance companies may impose only one 12 month waiting period for pre-existing conditions. During this waiting period, you have to pay for diabetes supplies.
What if I switch jobs? Will my child’s diabetes be considered a “pre-existing condition” again?
- The new plan cannot impose another pre-existing condition exclusion period as long as:
- you have had insurance for one year.
- you do not have a break in coverage for more than 63 days.
My insurance claim (for coverage for a pump, insulin pens, extra strips, extra insulin etc.) has been denied despite the diabetes team’s intervention. What can I do?
- Review your insurance policy or employee benefits to find out your appeals rights. Make the appeal. You may need to file a written appeal and provide information from your doctor supporting your dispute.
- If you are dissatisfied after appeals through your insurance policy, contact your State Insurance Department. Below is contact information for the tri-state insurance departments:
Tips for contacting your insurance company
- Make sure you have enough time to make the call. You will have to explain your situation to a number of people.
- Before calling, make sure you have the following:
- Paper and pen
- Insurance card
- Insurance Identification number for your child
- Group Identification number (on insurance card)
- See our Glossary of Insurance Terms - it may be helpful to you
- Take notes of what is said.
- Write down the name of the person you speak to. Ask for their direct phone number. If there is only one general customer service number, ask to talk to the same person. They may not remember all the details but at least they would be familiar with your case.
- Request a case manager. Some insurance companies assign a case manager to patients with chronic conditions. The case manager helps you navigate the insurance system. Sometimes they can alert you to benefits you didn’t know you were eligible for.
For more information or questions about managing insurance issues, please call 267-426-0271 or email us at firstname.lastname@example.org.