Type 1 diabetes: the monitor, 150 monthly strips and the pump your plan must cover

It is the coverage mandate for type 1 diabetes control equipment and supplies in Puerto Rico. Unlike the bill of rights for people with diabetes — which we cover separately and is written in terms of principles — this law carries concrete quantities and frequencies, which is what you can cite to a health plan when it rations strips or denies equipment.

Patients diagnosed with type I diabetes mellitus by a pediatric endocrinology or endocrinology specialist. Also protected, by express provision of the law, are patients for whom the endocrinology specialist orders the use of the glucose monitor with its accessories because they present a clinical picture of predisposition or a greater number of risk factors for developing the condition.

• A type I diabetes mellitus diagnosis made by a pediatric endocrinology or endocrinology specialist.Verified against the official source
• For the infusion pump: also meeting the qualification criteria established by the Centers for Medicare & Medicaid Services for that use.Verified against the official source

• The diagnosis certification by the endocrinologist or pediatric endocrinologist: the law ties the benefit to that specialist.
• For the pump, the laboratory results supporting the qualification criteria, as the law defines them by reference to CMS.

1. 1

   Step 1: Know the exact quantities before calling the plan

   Basic coverage must include the supply of a glucose monitor every three (3) years with replacement of damaged equipment; the supply of one (1) glucagon injection and its replacement if used or expired; and a minimum of one hundred fifty (150) test strips and one hundred fifty (150) lancets each month. Note the word "minimum": 150 is the floor, not the ceiling.

2. 2

   Step 2: Confirm who made the diagnosis

   The law ties the benefit to a diagnosis made by a specialist: for patients diagnosed with type I diabetes mellitus by a pediatric endocrinology or endocrinology specialist. If your diagnosis comes from another professional, that is the first point to address before claiming coverage.

3. 3

   Step 3: Claim the infusion pump if you qualify

   The law requires including in the coverage the portable insulin infusion pump as therapy for patients diagnosed with Type I Diabetes Mellitus. To receive that benefit, in addition to the diagnosis by a pediatric endocrinologist or endocrinologist, one must meet the qualification criteria for using that pump as established by the Centers for Medicare & Medicaid Services — criteria centered on the patient being insulinopenic per the C-peptide test result, or alternatively being a patient positive for beta-cell autoantibodies.

4. 4

   Step 4: If you are at high risk, the endocrinologist may order it anyway

   It is the least known part of the law: the endocrinology specialist may also order the use of the glucose monitor with its accessories for patients presenting a clinical picture of predisposition or a greater number of risk factors for developing type I diabetes mellitus. And the law closes: these patients shall also be protected by all the provisions of this Act.

5. 5

   Step 5: Know who oversees by type of entity

   The duty reaches every insurer and health service organization under the Insurance Code, plans providing services in Puerto Rico and any other entity contracted to offer health benefits. And the law adds that this provision shall also apply to entities excluded under Article 1.070 of the Insurance Code, which shall be overseen by the Department of Health. That is: for most, the Insurance Commissioner; for those excluded entities, Health.

Coverage is claimed first with your health plan, with the endocrinologist’s order. For complaints against insurers, the Office of the Insurance Commissioner; for entities excluded under Article 1.070 of the Insurance Code, the law itself places oversight with the Department of Health. If the matter concerns the Government Health Plan, the Health Insurance Administration contracts those plans.

• Accepting fewer than 150 strips or 150 lancets a month: the law sets that number as a minimum, not a quota.
• Not claiming replacement of a damaged monitor: the coverage includes replacement of damaged equipment, in addition to the three-year supply.
• Forgetting glucagon: the coverage includes one injection and its replacement if used or expired.
• Believing the insulin pump is not covered: the law includes it for type I diabetes, subject to CMS criteria.
• Not knowing the at-risk patient is also protected when the endocrinologist orders the monitor.
• Claiming with a diagnosis not made by endocrinology or pediatric endocrinology.
• Confusing this law with the bill of rights for people with diabetes: that one sets principles, this one sets quantities.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov