OVERVIEW
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.
Does the health plan promote and make available to its members health risk assessments, such as patient surveys, and routine health screenings such as those for depression and blood pressure?
Diabetes can increase the risk for such medical conditions as high blood pressure and depression. It is important for people with diabetes to have routine health screenings and to know if their health plans offer such preventive screenings at no charge or a minimal charge. Check to see if the health plan informs members of these benefits. Health plans that promote routine health screenings can help members to identify potential health problems before they become dangerous.
Are the benefits easy to understand? Which benefits will the plan cover?
Ask the health plan for a booklet that reviews all the services the plan offers its members. People with diabetes should check to see that the plan covers diabetes medications, syringes, blood glucose monitoring monitors and supplies (such as strips), eye and foot exams, required lab tests such as those for A1C or glycosylated hemoglobin (HbA1c) and microalbuminuria (protein in the urine), immunizations (for flu and pneumonia), routine medical exams, and self-management education. If you are unsure about the coverage, ask a customer service representative from your health plan to explain. If the benefit literature is not easy to read and understand, you may have difficulty tracking your current coverage and/or changes in your coverage. Easy-to-read benefit materials can mean that the health plan wants to keep its members informed and to have them actively use its services. In addition, look for member satisfaction surveys and other information from the health plan that indicates its desire for member feedback on its services.
