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Diabetes At Work: The Patient’s Rights and Benefits

A person cannot be denied health care coverage and benefits because they have diabetes prior to employment.

In the U.S., most people who are employed have health insurance coverage provided by their employer directly from their own job or through family members such as a spouse or parent. However, not all employers offer health insurance to their employees. Small companies are not required to provide insurance to their employees but medium size and large companies that have 50 or more full-time employees must provide their employees with affordable health care coverage, failure of which will attract heavy fines. Health insurance plans offered by the employer involve both employer and employee premium contributions with the employee’s contribution being paid on a pre-tax basis.

Understanding insurance is challenging but also very crucial especially for people living with diabetes. Companies offer different options of healthcare coverage plans and are required to provide a summary of benefits and coverage (SBC). This summary lists information on coverage and costs such as deductibles, out-of-pocket limits, co-pays, and co-insurance. Health insurance providers are required to give their employees an SBC during their first enrollment and at the beginning of each plan year, but employees can request an SBC from their provider at any time from which they have seven days to provide it.

Although an SBC is useful, it does not show if specific products are covered. However, one can always call the health insurance helpline to determine which medications and devices are covered by specific insurance coverage and which ones are not. The insurance company can also provide their prescription drug formulary, which lists all prescription drugs under each plan. It is important for patients with diabetes to discuss this with their healthcare provider and know how their diabetes management will look because SBCs do not take the complexity of a patient’s condition management into account, which can significantly increase their insurance co-pays and other out-of-pocket costs.

Some employers provide their employees with access to Diabetes Prevention Programs (DPPs). This is a proven lifestyle change program that can help delay or prevent prediabetes and those who are at risk of developing T2D. DPP can either be included in the health insurance cover or it can be offered separately in the form of a health benefit offered by the employer such as fitness, healthy food options, health screenings, and workplace wellness programs.

People living with diabetes in employment-based health insurance plans have rights and it is illegal under federal law to deny them or members of their family eligibility or benefits or even impose discriminatory charges because of their condition. However, employer-based workplace wellness programs can discriminate and offer rewards based on achievement of set goals or milestones. The Affordable Care Act requires job-based plans to include coverage for pre-existing conditions and one cannot be denied health care coverage and benefits because they have diabetes prior to employment. If the rights of an employee living with diabetes are violated based on their diabetes, they can file a charge either by mail or in person against their employer for discrimination with the US Equal Employment Opportunity Commission (EEOC).

Most employers set up a specific sign-up period (annual open enrollment window) during the year for all employees that need health insurance coverage. Once this period passes, no new enrollment is accepted for existing employees except in certain life events like marriage, birth, adoption, or loss of another coverage. In such cases, individuals are required to request a special enrollment opportunity within 30 days from the date of the triggering event.

Employees and their families can stay on the employee’s health insurance plan for a limited time after losing coverage through COBRA (Consolidated Omnibus Budget Reconciliation Act). COBRA is costlier than an employment-based health plan because enrollees pay a full monthly premium, including employer’s contribution in addition to a 2% administrative charge. Choosing COBRA continuation coverage can exclude a person from the special enrollment opportunity offered through the Marketplace whereby they will have to wait till the next Marketplace open enrollment period.

Practice Pearls:

  • Companies offer different options of healthcare coverage plans and are required to provide a summary of benefits and coverage (SBC) to their employees.
  • It is illegal under federal law to deny people living with diabetes or members of their family eligibility or benefits based on their condition.
  • If the rights of an employee living with diabetes are violated based on their diabetes, they can file a charge either by mail or in person against their employer for discrimination with the US Equal Employment Opportunity Commission (EEOC).

References:

Chin I. Kennedy, L. Kwon J. Diabetes at Work: Your Rights and Benefits. diatribe.org/diabetes. Accessed August 2, 2017

American Diabetes Association. Available at: http://www.dol.gov/ebsa/consumer. Accessed August 2, 2017

Josephat Macharia, PharmD candidate, Lecom School of Pharmacy class of 2018