Understanding Insurance and Why Staying Insured Is so Important

Insurance can be complicated. To find help, call the customer service phone number on your insurance card and ask to be assigned a case manager. A case manager will be able to help you understand and manage your insurance coverage.

What is an insurance card?

Your insurance card contains all the information you need to be able to make appointments, fill prescriptions, get bloodwork done and be admitted to the hospital if necessary. You should have this card on you at all times. Note: some insurance companies issue two cards: one for appointments and one for prescriptions. 

What are all the numbers and letters on the card?

  • The Member ID is your unique identification number that identifies you as the insured person. You will be asked for this number when making an appointment.
  • The Group # is also a number you may need when making an appointment or calling the insurance company to discuss your healthcare needs.
  • The Effective Date identifies the date in which your insurance became active or started.
  • Copays list the different amounts you will be expected to pay when visiting your doctor or specialist, or when filling prescriptions.
  • Prescription coverage gives information on how much you will need to pay for your medications.

I have two insurances (a primary and a secondary). How does that work?

  • There are two basic levels of insurances (PRIMARY and SECONDARY):
    • If you have insurance you pay through work or if you pay for an individual plan, this is known as “Commercial” or “Private” insurance. This is your PRIMARY insurance.
    • If you have a chronic illness you may also qualify for Medicaid insurance, which is offered through a state or federal program, this is your SECONDARY insurance.
    • Your benefits are submitted to your PRIMARY insurance benefits FIRST.
    • What your PRIMARY insurance does not cover may be paid for by Medicaid or your SECONDARY insurance.

How do my primary and secondary insurance companies talk to each other?

  • If you get prescriptions through your local pharmacy, using a primary and secondary insurance, your pharmacist must request a “coordination of benefits” from your secondary insurance company.
  • Mail order pharmacies have different ways of working with secondary insurance. If you use a mail order pharmacy:
    • Contact the mail order pharmacy and tell them you have secondary insurance.
    • Ask the mail order pharmacy how to get reimbursed for your co-pay. They may be able to bill the secondary insurance directly. If not, you will have to pay the co-pay up front and get reimbursed from the secondary insurance.
    • Contact your secondary insurance and explain that you must use mail order through your primary insurance.
      • Explain the reimbursement process outlined by your primary insurance.
      • The secondary insurance may require additional paperwork to be completed before you can be reimbursed.

How do I get insurance once I am 18 years old?

You have several options for health insurance:

  • If you are on your parent’s insurance, you can remain on their insurance until you are age 26 years old.
  • If you are going to college, you may be eligible for a college health insurance program.
  • If you are starting a job, you can enroll in your employer’s health insurance program. Check to see when the coverage will become effective. Insurance coverage often doesn’t start until after you have worked for a company for 90 days.
  • You can purchase private insurance plans through the Affordable Care Act at www.healthcare.gov or by calling 1-800-318-2596 (24 hours a day/7 days a week).
  • If you need additional assistance, please contact CHOP’s Family Health Coverage Program at 1-800-974-2125. You may be eligible for Medicaid depending on the state where you live.

Other insurance resources

The Juvenile Diabetes Research Foundation (JDRF) website has a very comprehensive guide to insurance issues specific to type 1 diabetes. Visit typeonenation.org to find help with:

  • Understanding common insurance terminology
  • Diabetes prescription and insulin costs
  • Denials/appeals: what to do when your insurance company denies coverage
  • Applying for an insurance exception for type 1 diabetes
  • Common issues around insulin, insulin pumps, CGMS and test strips
  • Obtaining prior authorizations
  • Choosing the best health insurance plan for type 1 diabetes, including key questions to ask