Services

Does the health care plan have a special program to treat diabetes (often called a diabetes or disease management program)? If yes, how do members access this program - by self-referral or referral from a health care provider?

A diabetes management program allows the plan to better serve its members with diabetes by anticipating their needs, coordinating and tracking member services, and evaluating the outcomes of the program. If the plan includes member self-referral to its diabetes program, check to see that members can sign up using a toll-free number or Web site. If a health care provider referral is necessary, you need to know the specific referral criteria, required procedures for the referral, and site to which the health care provider refers you.

Does the plan offer members with diabetes lifestyle and behavior education programs on nutrition, exercise, quitting smoking, and blood sugar monitoring and screening? If so, is there an additional cost for the classes? Are the education programs offered on an ongoing basis and also available to family members?

Since most diabetes care takes place between office visits, patient self-management education and training are critical. The diabetes-related services and lifestyle classes offered by different plans vary greatly. Some plans offer members the materials for self-management education programs while others offer comprehensive education programs with counselors. Education program formats range from one-on-one telephone counseling to group counseling to online education. It is important for you to have a full understanding of all of the options available to you.

How does the plan decide who receives case management services? How is case management customized?

Some plans offer members with diabetes the voluntary opportunity to work with case managers who help the members monitor their own diabetes care. When evaluating the case management services of a health plan, inquire whether meetings with case managers are available and, if so, what the eligibility criteria are. Eligibility criteria for such services vary among plans but usually depend on the severity of a member's diabetes.

How does the plan manage pregnancies complicated by diabetes?

In order to ensure a safe and healthy pregnancy, health plans should offer members with diabetes (types 1 and 2, and gestational diabetes) access to special disease management programs, including preconception counseling and risk awareness. Ask the health plan to provide you with information about any special health management programs for expectant mothers with higher risk pregnancies. These programs should include coverage of supplies, education, special monitoring, and health screenings for both mother and child, as needed.