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State mandate for testing strip limit?

Discussion in 'Parents of Children with Type 1' started by rakgyk, Sep 18, 2013.

  1. Haster2004

    Haster2004 New Member

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    3 tests/day limit in Kansas too

    I went to CVS to pick up my test strip prescription yesterday and was told that "because of the new healthcare laws you are only allowed 3 strips per day."

    Huh? I thought the affordable healthcare laws were there to lower the cost for the patients, not the insurance companies. I am so angry about this I can barely type coherently. How can they think this is right? Limiting the amount of times someone with type 1 can test to 3! That is a death wish. How am I suppose to know how much to bolus before meals, or how am i supposed to know if I need a correction bolus, and what happens when I get an error code.... This is the worst thing you can do to a person with type 1, take their test strips away, I mean do these people even have a heart?

    Sorry for that rant, but I am very upset over this new "law" or whatever it is. My pharmacist told me to call my doctor and have them do a pre authorization and then the insurance company may pay for the test strips after that. As if the prescription the doctor wrote wasn't good enough. They told me it could take up to 2-3 weeks for the preauthorization to go through. So in the meantime I am having to by my strips at Glucomart.com again (its like deja vu of when I didn't have insurance).

    I thought about going to a local news station and telling them to broadcast it so people know how the healthcare changes are actually affecting people....and how they are helping the insurance companies get even richer.
     
  2. Megnyc

    Megnyc Approved members

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    Sorry you are having issues but this has absolutely nothing to do with the affordable care act.

    Contact your doctor and get a letter of medical necessity for however many strips a day you need. I have never had preauthorizations (including for cancer drugs a lot more experimental and costly than strips) take more than a few days. Presumably, you can make the 100 strips last the few days it takes to get preauthorization ;)
     
  3. moco89

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    Not true at all. They are using Medicare rules, and this is a major component of the problem.

    If something is only going through pre-authorization, it has not been denied by the insurance company yet. I have experienced prescription appeals, after denial at the pre-authorization stage, taking up to 30 days for "approval".

    http://www.medicare.gov/pubs/pdf/11022.pdf

    Medicare (Part B) covers the same type of blood sugar testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies. If you use insulin, you may be able to get up to 300 test strips and 300 lancets every 3 months.

    Obviously you can even appeal this on Medicare or government insurance but good luck with that. I have a better chance than most as I already basically have an autoimmune autonomic neuropathy, so I can really hold these unscrupulous insurance administrators liable and accountable if things were to get worse.

    You guys better get used to appealing...everything...even bills, which you can do. You just better know what you are doing.

    You can get by with type 1 diabetes, as an expensive to very expensive illness pretty well if you are not insurance savvy and don't know the lingo. If you have multiple very expensive illnesses or even an extremely expensive illness, you need to know the lingo, weird government regulations, laws, etc or you will be screwed. It's called insurance for a reason (Medicare is insurance, too!), and because it's health insurance, it's not administered by need. A bunch of rules and payers dictate what you get and what you don't, and quality of care can depend on the plan itself. Just another example of inequity when certain standards of care and treatment are required.
     
  4. Megnyc

    Megnyc Approved members

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    How exactly does the affordable care act result in insurance companies following medicare guidelines?

    Just for the record, I have no issue with insurance companies limiting test strips to 3 a day without documentation from the patient (electronic meter download) that he/she is actually testing a certain number of times a day.
     
  5. missmakaliasmomma

    missmakaliasmomma Approved members

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    I think I'd really take that with a grain of salt. I doubt there's an actual mandate that limits test strips to that little amount. It just seems absolutely ridiculous. I'm in NY ( I wouldn't think NJ would be much different but i guess you never know) and the insurance only wanted to cover 250 a month but sometimes it's not enough because she gets tested often in school and during the night so all they did was get a letter from my dr and sent me another vial. You probably just need the dr to write a letter of medical necessity.
     
  6. mamattorney

    mamattorney Approved members

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    I think you are being unnecessarily inflammatory on this issue. The same .pdf that you linked to says, one paragraph under your quote -

    "If your doctor says it's medically necessary, Medicare will allow you to get additional test strips and lancets. "Medically Necessary" means that services or supplies are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. You may need to keep a record that shows how often you're actually testing yourself.

    I'm sure the provisions were written with type 2's in mind since they are so much more prevalent than type 1's. With the numbers of strips being sold by consumers for extra cash, I completely understand reducing the base amount and only providing additional strips to those who need them. Strip resale is fraud, plain and simple and if I were the insurance company, I would want it stopped, too.
     
  7. Christopher

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    I agree. Don't just take the Pharmacists word as gospel. Do your own research, talk to your insurance company and your Endo and get the facts.

    As for the number of strips, it is very individual but 250 strips a month works out to about 8 bg tests a day. I would say on average Danielle tests 6-8 times (including me testing her every night), so that is pretty close. I think 300 per month is a good number just to cover all those other circumstances, like increased testing when they are ill, having to retest due to error, etc.
     
  8. rakgyk

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    I sent in an appeal a few weeks ago for the denial of the claim, I'm waiting to hear back fromt he insurance company what is going on.
    There is a statae mandate limitng the strips. I have absolutely no idea why we weren't notified of the limit BEFORE we ordered the strips. We would be ok if they allowed 250 a month, but they want to limit it to 300 for a 3 month supply. I was told we can order more as long as the endo. sends in a letter of medical necessity. The problem is, the endo's office is having trouble reaching someone in the correct dept. by the ins. company to find out exactly where to send the letter, they need a fax number, email address, somewhere to send it. We have a copay if we order the supplies through a regular pharmacist, but the ins. company pays 100% of the supplies if we order it through a mail order pharmacy. I don't know why, but that's how they work.
     
  9. moco89

    moco89 Approved members

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    I do get worked up over nothing. I have no shame in admitting that.

    There is no law or mandate that requires private insurance (even plans governed by Obamacare) to adopt Medicare guidelines. But, Medicare sets standards for the industry, and private insurance typically adopts these guidelines to a certain degree. Obviously, guidelines are not laws.

    I am well aware that selling test strips that were reimbursed via insurance in insurance fraud, and this has to stop, one way or another.

    I guess I have been put through the ringer too many times recently with insurance issues with my other, rare, autoimmune disease. I am just saying that it is not going to be a bed of roses with any sort of health insurance. With a rare disease, I can have more leverage and at the same time less leverage with insurance issues. There have been no double-blinded clinical trials whatsoever (including for medication efficacy) for my rare disease, to date, so there really are no true standards of care, and all treatment is essentially experimental. But, this disease can be treated like other rare autoimmune diseases.

    But, most importantly, I do get worked up over nothing.
     
    Last edited: Oct 23, 2013
  10. missmakaliasmomma

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    Or of course retesting to make sure that high number is an actual high number and not dirty fingers lol
     
  11. missmakaliasmomma

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    Our insurance card has the number on the back of it. When we go through edgepark, they just send a request (I believe) to the endo.
     
  12. missmakaliasmomma

    missmakaliasmomma Approved members

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    In the beginning, we had so many "this is not covered anymore, now you need this" it was ridiculous. The insurance company kept changing what and how many they covered. We had to switch from accuchek to freestyle to one touch because they stopped covering those specific strips. I'm starting to think though the her first endo didn't care about sending a letter of medical necessity. Now that I think about it, her endo now, for some reason receives the denials ( I think, or maybe the pharmacy just takes a proactive approach and calls her to get auth.) and lets me know afterward that they tried to deny it but she sent in the letter. She called me one day telling me that they tried to give me cheaper strips (which I honestly don't care, they probably work the same) instead of the one touch. I didn't even know there was an issue until she called. Insurance didn't want to cover apidra, got a letter for that too. One touch strips were approved for lifetime, apidra- one year.
     
  13. sincity2003

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    I'm not sure who is responsible for the "3 test strips a day" rule or not, but when we switched our script from Express Scripts to DME through Anthem BCBS, our endo wrote it for 10 times a day and when the company called to verify the prescription before they shipped it the guy said "I have here an RX for testing 3 times per day, for a 90 day supply.". I told him no, the RX was for 10 times per day and he told me he would call Care Centrix (who is the third-party handling all the billing) because that's how THEY sent it over. Ten minutes later he called me back and said, "Yep, it's 10 times a day, so we will be sending 900 strips out tomorrow."
    So, the RX was written for 10 times, yet Care Centrix sent it over as 3 times. Nice. Having said that, right now, DS is averaging 11 times a day checking, but we're still getting this pump thing down. He goes on Dex next Wednesday, so I'm hoping to cut down on that and then we'll back off the RX a little bit.
     
  14. rakgyk

    rakgyk Approved members

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    I think we're finally getting somewhere. A letter of medical necessity must be sent to the insurance company before anything is done with Liberty Medical. After being on the phone for an hour with the insurance company, I finally got an answer where to endo's office needs to send the letter to. I just hate getting a different answer from everyone I speak to, it's rediculous.
     
  15. Amy C.

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    What state are you in? It might be a warning to others who live in your state.
     
  16. TheFormerLantusFiend

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    Private insurance is required to do AT LEAST as much as medicare does (with some exceptions). They are not required to do no more than medicare does.
     
  17. meganmac

    meganmac Approved members

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    I get worked up easily about insurance as well. And when I want to vent, or complain about our situation, people with "good" insurance through an employer always make it sound so easy and simple to override denials. We purchase private insurance because our employers don't offer health insurance. What was originally $600/month for my family of 5 is now $1200/month 5 years later. This is with a huge deductible, little to no DME coverage and lots of denials. We sold our house and had to downsize after my son was diagnosed because Type 1 diabetes is a huge financial burden for our family. After the first 2 years with hours on the phone every month and lots of doctor authorization letters, things seemed to go pretty smoothly. Until this year when suddenly our 3 month supply of strips (normally 900) turned into 300, just like the OP stated. I live in Texas. Our prescription had not changed. It took more than a month to figure out and countless hours on the phone.

    It should NOT be this difficult. For many of you out there, it isn't difficult. You have a large company negotiating on your behalf. You have an HR department to go to and get help from. But many of us are on our own. Please have compassion and understand that not everyone's policy is the same. There are real problems and real denials for many of us. Please do not minimize this or make us feel like we are stupid and doing things wrong just because it goes smoothly for you.
     
  18. manda81

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    We have group coverage, in Texas, through my husband's employer. We were declined filling our rx for the same reason, we were over limit, and Freestyle wasn't their "choice" of strips. I called our endo, they sent a fax to the insurance co, we had our strips within 24 hours.

    It had nothing to do with our employer or their HR department, neither were contacted, and I can't imagine why they would be... It was solely between our endo and the insurance co.
     
  19. Sarah Maddie's Mom

    Sarah Maddie's Mom Approved members

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    Funny how the OP hasn't been back - after making a first ever post about going to the media to report these changes the he/she attributes to the ACA. :rolleyes:
     
  20. meganmac

    meganmac Approved members

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    She just posted this morning...
     

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