Insulin Pump Coverage: Summary of Alberta Health Insulin Pump Program
UPDATE May 12, 2022:
Alberta Health "pauses" the plan to end Insulin Pump Program on August 1. Theoretically, the diabetes community in Alberta will now be consulted.
This is a developing situation – stay tuned for updates.
UPDATE May 10, 2022
Diabetes Canada sent a letter to Minister Copping, urgently requesting a meeting.
UPDATE May 8, 2022
The people are rising up!
Diabetes Canada’s advocacy for the diabetes community has kicked in. They issued a statement of concern about the proposed changes.
UPDATE May 4, 2022:
The Alberta Insulin Pump Therapy Program has provided government-funded financial coverage of insulin pumps and supplies (including pumps, infusion sets, cartridges, insulin, test strips, but NOT including CGM sensors or transmitters) since 2013. Alberta Health is planning to end the IPT Program, with an associated transition of coverage to Alberta Blue Cross. The main differences?
The IPT Program covers pump and glucose meter supplies for any Albertan with Type 1 Diabetes, regardless of age, with no user premiums. However, it does not cover test strips if you’re not also on an insulin pump (those who inject insulin are out of luck), nor does it cover CGM for anyone.
Under the proposed move to AB Blue Cross, users would have to pay a monthly premium to participate in Blue Cross; pumps and supplies would still be covered for those with diabetes; test strips would now be covered (with an annual maximum); CGM would now also be covered, but only for those under 18 years of age. Both programs have coverage maximums.
Where’s the balance for all Albertans with diabetes? A major flaw of the IPT Program is inequity: basic supplies like test strips are not covered for non-pumpers, so many families have been unable to provide even a minimum standard of care for their children, while other families have received a greater standard of care at next to no cost. Another major flaw is that the funding provided by the IPT Program allowed some private insurers to de-list pumps and supplies, so public money (from us, the tax-payers) paid for what previously had been paid for by private companies (who have received premiums for such). Finally, according to Alberta Health, the funding for the program was not sustainable, which would eventually lead to no government-funded coverage at all. Everyone loses.
However, there are also flaws with the new program. Now there are premiums; the majority of families will have to pay more, possibly for less. (I’m still trying to figure out which coverage maximums apply – it could be pretty lean.) And the income threshold for subsided premiums, if my research is correct, is about $39K for a family with children. If you make $40,000 a year and live in Calgary like I do, I highly doubt that you can afford a home and food, let alone $118/month for Blue Cross premiums. So, you won’t be able to enroll in the program, and you STILL won’t have coverage for test strips or CGM. At the same time, everyone else is paying more. But the Blue Cross program will be sustainable for longer, so that’s a win.
I’ll keep you posted.
Alberta Insulin Pump Therapy Program
Under the Alberta Government’s Insulin Pump Therapy (IPT) Program (implemented June 1, 2013), the full cost of insulin pumps and basic supplies are covered for Albertans who meet eligibility and clinical criteria. Here we provide an overview of eligibility criteria, pre-requisite and ongoing clinical skills, details about what supplies are covered, and links to help you find more information and to start the process to receive financial support for your insulin pump therapy program.
Summary of Eligibility Criteria:
- diagnosed with type 1 diabetes (there are no age restrictions)
- under the care of doctor/nurse
- resident of Alberta, eligible for Alberta Health Care coverage
Summary of Clinical Criteria:
- A minimum of four blood glucose checks per day (before meals and at bedtime)
- Regular attendance at diabetes appointments
- Adequate blood glucose control is required for continued participation in the program (A1C of 9.0% or less; 9.5% or less for 6 years of age and under) – for details talk to your child’s diabetes health care provider.
- Carbohydrate counting skills
- Adjusts insulin to prevent hypoglycemia and hyperglycemia
- For patients under the age of 18 and adult patients with legal guardian(s):
- Parent/legal guardian provides ongoing support for the patient’s diabetes management.
(This would be tough for kids to do on their own!)
- Parent/legal guardian knows they are responsible for a pump management plan while in the care of other individuals, schools or treatment centres.
(Agreed. We can’t just drop our kids off at school, for example, and expect school staff to know what to do – we need to provide training and support, so our kids have a safety net while they are out of our care.)
- Parent/legal guardian provides ongoing support for the patient’s diabetes management.
- Once approved for coverage, your child’s participation in the program can be discontinued if clinical criteria are no longer met, at the discretion of the doctor/nurse practitioner.
- Some clinics also include discontinuation criteria such as:
- more than 1 hospitalization for DKA in the last year
- infusion sites are not being rotated and/or are not being changed every 2-3 days
- boluses are not being given for food intake
- not setting basal rates to meet your child’s insulin needs
- ketones are not being checked during illness or for unexplained high blood glucose readings
- insufficient number or spacing of A1C tests
Tips from the Trenches
Basically, the government and clinicians want to make sure that pump users have the skills required for safe and successful use of the pump. Makes sense to me. This does, however, mean that the funder (the government) looks to health care professionals to determine whether clinical criteria are being met in an individual case, and, therefore, whether funding will be provided/continued. In most cases, this will not likely be a problem – if my child and I (as a team) check blood glucose frequently enough, count carbs, make necessary insulin adjustments, and visit our diabetes clinic regularly (see provincial funding criteria), then we are doing what we need to do to be safe and succeed on a pump, and so would likely have the support of the diabetes health care provider. If we did not have this support, however, and disagreed with that decision, I would first discuss this with my child’s doctor/nurse to understand their perspective. Then, if I still disagreed with their assessment of the situation, or felt the “red light” was related more to a resistance to pumping than to an assessment of our family’s readiness, I would seek a second opinion. ~Michelle
Summary of Coverage:
The IPT Program covers the complete costs of a pump and basic supplies that are essential to pump use (less any amounts covered through government-sponsored agencies and patients’ employer-sponsored or private insurance programs), as follows:
- Insulin pumps
- Infusion Sets
- Insulin Cartridges / Reservoirs
- IPT skin preparation (dressings and/or skin adhesives and/or adhesive removers)
- Blood glucose test strips
- Blood ketone meters and test-strips
- Syringes or pen tip needles
Interesting to note that although “essential to pump use”, insulin is not covered (perhaps because it is “medication” rather than “supplies”).
Things to note about coverage:
- Five is the magic number: once approved, coverage is provided for five years.If you already have a pump before enrollment in the program, the cost of the pump will not be covered retroactively, but supplies will be covered from the date of enrollment and for five years following. Further, the program will not cover the cost of a new pump until the current pump is five years old (although you should begin the application process well in advance of this).It’s interesting to note that most pump companies provide a 4-year warranty, and yet a new pump is only covered under the government program every five years. Theoretically, if your pump still works for a year after the warranty period is up, all is good, no reason to worry. But if your pump malfunctions after the warranty expires, most pump companies have an agreement with the government to provide warranty coverage for 5 years for IPTP-funded pumps. The government website says that if your pump breaks down you should first contact the pump company; if the company “refuses to provide a replacement insulin pump or repair a defective insulin pump” then there is a process to request coverage for a new replacement pump.
- You don’t pay out-of-pocket for covered supplies/pumps – they are direct-billed to the IPT Program from a pharmacy or pump company. In fact, there is no reimbursement if you pay for the supplies yourself. Following from this, there is no retroactive reimbursement for pumps and supplies bought before an individual is enrolled in the IPT Program.
Go Back to the Source:
We have provided a summary and commentary here for your convenience, however, we are not the final authority on this program. According to Insulin Pump Therapy Program – Eligibility Criteria on the ministry of Alberta Health website, “the IPTP is delivered by AHS through an authorized AHS Adult or Pediatric Insulin Pump Therapy Clinic (Clinic), with claims administration by Alberta Blue
Cross (ABC) and administrative support from Alberta Health.”
As such, complete information on the Insulin Pump Therapy (IPT) Program can be accessed at both of the following websites:
- Alberta Health Services (the provincial health authority responsible for planning and delivering health supports and services)
- Alberta Health (the provincial government ministry responsible for health policy and standards)
The above information was reviewed for content accuracy by clinical staff of the Alberta Children’s Hospital Diabetes Clinic.
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