The basics on private insurance coverage for diabetes supplies in Canada

The CIM community is like an amazing source of information with experts across a diverse range of topics joining us at our events across the country. This year, we’re working to distill many of the tips and things we’ve learned into digestible chunks. Throughout the year, expect to see recaps from some of our favourite Slipstream sessions, how-to guides based on things we’ve learned during Hot Topics sessions, and information we just couldn’t keep to ourselves.

If you have questions or something you’d like crowd-sourced and answered, share your question with us by sending us an email at: info@connectedinmotion.ca

Disclaimer: Please check out CIM’s Partners Page to learn more about the companies we work with. This post was not paid for and does not represent sponsored content, but it’s important to recognize that we may be biased based on the fact that some companies highlighted below support CIM in different ways. We still thought this info was important for you to know about.

Navigating the insurance landscape is one of the necessary evils of life with Type 1 diabetes. It is never fun. We’ve done some digging to put together an Insurance Primer for adults with Type 1 diabetes in Canada to help you advocate for yourself and get access to the technology that may make life with diabetes just a little bit easier. Part one of this blog will focus specifically on the basics of insurance in the Type 1 world. We’ll then move on to share device-specific resources to help you get your hands on the technology that matters to you.

If you’re living in Canada, you probably have a pretty good understanding of how our healthcare system works. You probably access it on the daily. But for those readers who are new to Canada, new to diabetes, or not so familiar with the ins and outs, this is for you.

Without getting too much into it, the Canadian Healthcare System is funded both provincially and federally but is administered and delivered on a provincial level. This is why you see differences in coverage for certain things (including insulin pumps) from province-to-province. Canada has one of the only universal healthcare programs that does not cover prescription drugs (other than in Quebec). Seeing a doctor is free. Hospital visits are free. Drugs are not. Because of this, approximately 30% of healthcare costs are covered by the private sector.

A large number of people with diabetes rely on private insurance to access insulin pumps (in provinces without coverage, or with only limited coverage), glucose monitoring devices, and insulin. Most often, private insurance is funded by an employer, union or association through a pooled healthcare plan. Below are some of the most common questions we hear about private insurance answered. As always, if you have your own experiences that may help the community out, please share!

This is the one we see the most often. People who are frustrated with their insurance companies because they’ve had an important medical device or drug denied, only to find out that Joe in Saskatoon got coverage for his CGM from said insurance company, no questions asked. To date, about 85% of insurance providers in Canada offer CGM coverage for the majority of their plans. So why do we see so many denials?

The most important information we can pass on is that, more often than not, and especially with larger providers, it is, in fact, your employer, union or association who holds the power to give you access to your device/drug. Insurance companies provide offerings and packages to employers. Each package is different – an employer selects one and a premium is paid, per employee, for said plan. The more expensive plans include better benefits (vision, dental… CGM!). Employers, unions, and associations hold the key to include or opt out of certain coverage.

You’re right.  Several of the major insurance providers in Canada (Sunlife, Greenshield, Manulife, Great West Life, etc) announced that they would begin covering CGM for people with Type 1 for most of their plans. There was one caveat. If your employer, union or association explicitly-opted out, then… they opted out. That means they decided NO, we do not want to include this coverage for our employees (and that can be for any number of reasons). Bummer. BUT, that doesn’t mean the end of the road for you. What it does mean is that CGM is at least a familiar term to your company’s HR department or benefits administrator. Someone there had to distinctly make the decision to opt out of coverage. Perhaps they don’t understand the value of CGM. Maybe it’s due to cost constraints, union contracts or other factors. Perhaps they have just never had an employee interested in CGM. Your next step – Talk to your HR department or benefits administrator. (Resources to follow!)

Each insurance company sets criteria for who they will cover and why. Since covering a CGM is not inexpensive, the insurance company wants to be sure that CGM is used by those that will really benefit. And in the end – insurance companies are always out to make money, not to lose it.  But people get frustrated when barriers are put in place that doesn’t make sense. In this case, you need to write an appeal letter to your insurance provider. At the same time, you need to go to your HR department or benefits administrator and tell them the criteria does not make sense.

Change never happens with insurance coverage until there is an ask for it.  You may be out of luck in the short term, but you absolutely have the power to influence change.  The first step in gaining access to the devices and medications you need with insurance companies is getting in touch with them. You also need to get your HR department or benefits administrator involved to request coverage – and to ask the question why the criteria is what it is, as you are being denied coverage for something you really need.

Do you have questions we haven’t answered? Submit them in the comments below or send to info@connectedinmotion.ca

And stay tuned for more info: Up next, getting coverage for Dexcom G5 in Canada.