I'm a bit shocked and confused with my insurance coverage as a Wal-Mart employee in Canada. I've been denied an insulin pump.  They will continue to cover my pump supplies but tell me I'm not eligible for an insulin pump - ever!

I've been a pumper for 8 years and am currently trying to get the MiniMed Paradigm with the CGM.  What Manulife is telling me is that Wal-Mart has just made a revision in the last few weeks and took the pump off the eligibility list??  My doc has written the letter already and they still have denied it.

Anyone ever dealt with something like this?  I appreciate any help & advice.
(I did search the forums and I believe my searching skills suck)


Tags: canada, denied, insulin, pump, walmart

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Not all insurers cover insulin pumps.

What the insurer will or will not cover is determined by the insurance contract / plan text that the insurer puts together for the employer. The insurer takes instruction on what to cover or not cover directly from the employer. At times, employers change the specifics of what will or will not be covered at renewal with the insurer. And why? Usually in an effort to keep a lid on healthcare benefit costs.

That being said, if this was a recent revision to the plan text to drop pump coverage that was previously in place, I would seek MimiMed's help to look into the situation in greater detail with your employer. When specifically was the group benefits policy changed? What was the effective date of the change? What allowance can be made for an individual who was in the proceess of applying for pump coverage before the change, etc. Keep in mind that if the coverage existed before, and is now no longer available, this was AN employer driven change, so something to take up with Wal-Mart's H.R. department for reconsideration.

Do you have an employee booklet that indicates coverage for insulin pumps?

Did you receive information from the employer notifying you of the pending change?

You might be able to argue your way to a pump approval if your employee booklet indicated the availability of coverage that has since been taken away, without any notice to you as an employee.

Cheryl
If you have a pump now and the insurance covers supply, you'll probably have that pump for awhile.

Not all insurers cover pumps. They generally have their own internal rules, not written in the contract, about when they'll cover a pump.

Furthermore, getting a new or replacement pump is not the same as continuing with your current pump in "InsuranceLand." There are all kinds of rules governing 'continuation of benefits' when an employer changes insurance plans, but they differ from state to state in the U.S. and I have no idea how it works in Canada. But in "Insurance Land" continuing to pay for your supplies could be continuation of coverage but replacing the pump - not.

I'm sure there is either a labor department or insurance/health care department at the local or provincial level you can contact to get more detailed insight. Don't rely on searching tuDiabetes or the Web. You're going to have to dial the phone and use some shoe leather, I think.

Terry
Thanks for the replies.

This has been a battle for about three months now. Lots of verbals saying that I'm eligible for a new pump (even to Medtronic) and as of recently this week, I am no longer eligble since the policy has changed. Granted, I do blame myself for not getting them to send me something in writing saying I am eligible. I'm hoping Medtronic has something in writing from them at least.

It's been a ton of back-and-forths with A1C requests, doc's letters, manulife telling us they have no records of phone/fax contacts etc.. We never had this before with the last two pumps. It was simple before. We have recently changed our policy with Manulife though in the past 6 months, but regardless it makes no sense anymore.

I have my hubby looking for the old policy book right now to see if it is stated in that since we did not receive a letter from Walmart informing us of a policy change. HR could not answer this question and we've been waiting on them for an answer now for a week. All we received was the new policy book on Wednesday -that is all.

It's very frustrating. I find it odd that they will cover the new pump supplies but not the pump.
Ontario started a pump funding initiative for T1 children about three or four years ago and within the two years added pump funding for T1 adults. This is a provincial initiative and is not Canada wide. Healthcare here in Canada is a bit of a mixed bag. I work in the group insurance industry, yet were it not for my husband's employer (school board), I would not have group insuance myself as my employer is not part of the group plan that we look after.

I have heard parent groups of T1s joke about telling their kids that they need a good, job in the federal government when they finish school to be sure that they have employer paid health insurance. When this discussion went around the table in general conversation at a JDRF meeting, it was discussed, that promoting the federal government as the employer of choice for a T1 is not quite good enough for the long term. You now need to work for the federal government and be married to someone from the federal government and KEEP both sets of benefits in place, as there is a lifetime limit on diabetic supplies that will not carry your just out of school T1'er who goes into federal government as a lifetime career choice, into retirement. He or she will need the benefit of the lifetime maximum from both plans to make it to retirement.

A little bit of sarcasm, with a lot of truth to it, Tom.

Cheryl
Tom -- Not sure if you're teasing or not. But in Canada, basic health care is covered through the public system -- doctor's visits, emergency care, surgeries, those types of things. We have employer-sponsored or individual insurance coverage for all the rest which includes prescriptions and medical supplies, dental care, vision care (seeing the eye doctor and glasses/contacts), and paramedical services (like chiropractics and massage therapy). Our public health coverage is governed by our provinces, so something that is "free" in one province is not in another. To my knowledge, most provinces don't cover for pumps for adults.
I do a lot of third party administration work in group benefits for a large association. As a third party administrator, I am often required to act as a conduit between the employee/member and the insurer for the association that we represent.

It is not unusual for an insurer to cover insulin pump supplies (which by the way, does not extend to CGM's) while not covering the actual pump. The policy I work with, is exactly like that. It does not provide coverage for a pump, but does cover infusion sets and reservoirs for anyone who goes out of pocket to buy a pump. It does not cover anything to do with CGM's. Not the $700 transmitter that needs to be replaced every other year and not the $50 sensors that need to be replaced every three days. My husband's plan is through a different employer and insurer. His plan was going to cover all but $1,000 of the $6,500 needed a few years ago for a MiniMed pump for my son. In the end, the insurer did not have to fund a pump at all, as the Ontario government put initiatives in place to make healthcare funding for pumps available to all T1 children through the assisted devices program of the department of health and long term care.

What I found confusing is that it appears you had pump coverage in the past and now do not. If this was a change made by the employer, change of carrier, or change to policy at renewal, that is fine, the employer is entitled to change carriers or change the policy, but if the change occured while you were doing the back and forth on an approval that would have been granted had the employer not made the change, then you can argue that coverage should be extended and your employer does have the ability to extend coverage as a one-off. Your fight is with your employer, not the insurer and you may get help from your employers H.R. department or group benefits specialist, so find out who that is.

The insurer simply follows the plan design and plan design rules, that your the employer puts in place.

I would definitely address the coverage denial if it is due to a recent change, particularly if a back and forth for approval was underway before the change. Please don't take this personally, but your employer may argue that you have already been extended more than sufficient coverage if your employer paid for your last two pumps in the past 8 years. I can understand wanting to keep up with the most recent technology in an effort to reduce ones A1C, but one can't expect someone else (i.e. employer) or in our case the government (so all Ontario taxpayers) to pay for the newest thing out there.

You will definitely have a fight ahead of you, but one that may result in another employer funded pump. So get cracking. Find the employee handbook. Find what the reconsideration period was on the last approval for a replacement, etc. Find out what changed, when it changed and get documentation of when you started your approval process and push, push, push.

Two years after making pump funding available to all T1 children, Ontario moved forward on making pump funding available to T1 adults as well. This initiative was the result of an in depth study that showed the Ontario government that the cost to society would be less to provide a pump and an annual grant for pump supplies to promote good diabetes control over the cost to society to take care of a T1 with diabetes complications. By the way, the Ontario grant for supplies, requires an annual endo certification that A1C's are less than 10%, DKA has not occurred more than once over the past 12 months, effective pump management has been proven by the patient and appointments (a minimum 3 clinic visits in 12 months) are attended.

You will have to be your own advocate on this pump initiative. Are Wal-Mart employees unionized? If you are, that is another source to go to for help.

Cheryl
Great info! Thanks

Geez, too bad we don't live in Ontario anymore! That is great for Ontarions. I'm happy all that is in place finally.

Yes, it seems like the battle is going to be with Wal-Mart. I totally get the Manulife side of this. We've been with Manulife for almost 10 years and I can only say positive things about them, however we did just recently make a change in the past 6 months (changed employers, hence switched policies) thus this is the reason for the hard time we are facing at getting the new pump.

My current pump is still good and is now 4 years old. I'm a happy gal with it, however we have been planning to have our first child and our Endo is strongly recommending the CGM with the pregnancy. I don't mind spending the extra $1200++ for this new pump, since our insurance did verbally quote that they would cover $6800 - 20% co-pay fee etc...

The Wal-Mart is not unionized. I think, I could be wrong, but there is only two unionized Wal-Marts in Canada that I know of.
I wonder is this would be feasable.( sp?) for you ..... finding out from Medtronic the cost of the Guardian Real Time /CGMS ...or can the endo set you up for 3 day stints over a certain time , till you decide to go for the MM pump ?...just thinking out loud ...yet I maybe totally off .
I like the thinking out loud!

Ok, mind my noobness, but is this CGM a stand-alone? like the dexcom? I only ask, since I have a Animas pump right now. It would be nice to have it all in one system, but if that can't happen, than I'm game for two devices sitting on my belt.
Googling Guardian Real -Time will get you there ; yes it is a stand-alone ...the " gadget " for lack of better word at this moment looks simelar to the MM pump .
Desdemona,

I agree, a change in employer, so subsequent change in policy is probably the source of your current problem, even if both employers had insurance through Manulife, it is the policy itself that dictates what the employer will or will not cover under the group plan contract. It seems though that the coverage was being considered though subsequent to the employment change, so I would still be asking a lot of questions.

Have you looked at MiniMeds site for information on the transmitter/sensor. The transmitter is small, about quarter size round, and about three quarters high, but definitely a separate unit, with a sensor that has somewhat of a big ass needle to put under your skin. The advantage is that with calibration (BG testing) it does talk to the pump and sends readings every five minutes. IT DOES NOT adjust your insulin dosage. You receive feedback and need to adjust yourself. I can understand for planning parenthood why you would want a CGM, but if you have to go out of pocket to replace a good, working pump at the same time you may want to do a lot more research. You might find a CGM that will work well with your existing pump. I would consider asking Marps how her dexcom performs as I believe she uses a dexcom together with MDI. I have no idea what a dexcom transmitter or sensor costs. This site does have alot of discussions on CGM's so there is definitely a whole host of people to go to with questions.

We spent the money less than two years back for a transmitter and sensors for my sons MiniMed pump. He wore one CGM for three days. Thats it, thats all. There is a considerable time delay on the upward and downward trends and it seems that his transmitter did little more than "alarm" almost the entire time he wore it. It was such a frustrating experience for him that he never even used the other three sensors that were purchased. They have since expired and the transmitter itself, that has a "guaranteed" life of six months has expired as well. So based on pricing at the time, about $1,200 out the window.

I was hoping that we would at least get a three day reading every quarter to include with our other data for diabetes clinic visits. No such luck as you can't talk a 16 year old into anything that they have tried and been severly frustrated with. His situation though is likely very different from yours. He was between 15/16 at the time and growing like a weed, so eating almost continuously.

You would not likely have the same "alarm" all day, frustrations. Time changes and young son is now training for a 10K run as part of his high school athletic program. I was ready to rush out and purchase another transmitter and sensor pack so that he would have this tool available for training until I read several peoples posts about the time delay being so significant that they were only looking at fast upward or downward trends for a proactive response to highs or lows while doing this sort of training and paying little attention to the CGM beyond that as each quick response to trends was going to require another finger poke for verification before adding or reducing insulin.

When the time comes that we do decide to invest in another CGM, we will be looking at the various alternatives that are available. Comparing costs and may or may not use the CGM that will automaticaly talk to his pump if the alternatives prove to be more cost efficient to accomplish the same task. I may go to Marps at some point myself to get more info on her dexcom.

Cheryl
Cheryl ,
I did see your posting on DTC on other discussion ...thanks for reminding me ...have you read some of the recent responses ? Don't give up yet, please .Record keeping of utmost importance . Alan P. also mentioned somewhere: ...he will have to re-apply in 2015 .

Regarding CGMS ...Medtronic is the only brand av. in Canada ...I read, that Tu member Alan P.from BC was going to look into Dexcom ..not sure if he can purchase , since Health Canada sets the rules , not MM or any other company ?? Would be interesting to find out .
It took me more than 3 days to " learn" the GCMS ( NO spring chicken and am still learning !!) set -up, calibration , how to insert , insert at night and add transmitter in the morning , do not over calibrate etc before "I got it " .Reading the postings here have certainly been a great education tool .Removed a sensor today with 10 days of use. I have used outdated sensors , I know of others , who have as well ; my transmitter was upgraded in Aug. 31, 2007 ... 2 1/2 years of age ! ( from the bulkier size ) . Have you tried the transmitter ...are lights flashing; have you changed the battery ? MM states a 6 month warranty ( is this the same meaning as guaranteed life ? ) One can set the alarms at one's preference , one setting I use for instance : lo and hi . I have between 4.6 - 8.5 . I use the vibrate ..everyone but I and Hubby could here the " ding dong " !! 20 plus minutes for the sensor to respond to interstional readings . I still finger poke regularly and I understand that a lot of folks do . My end result is not a lower A1C ...BUT : fewer lows ! ( 27 plus years with diabetes and no complications )

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