Diabetes: What does health insurance pay?
If you have type 1 or type 2 diabetes, you need medication and certain aids to treat it. These are, for example, blood sugar meters and lancing devices for blood sugar control. For treatment with insulin, people with type 1 or type 2 diabetes need syringes, insulin pens, needles or insulin pumps and accessories.
But when does health insurance cover the costs for blood glucose meters or test strips? What about insulin pens or insulin pumps? Where do I have to pay? These questions cannot be answered in general terms. If in doubt, it is worth asking your own health insurance company.
In principle, those with statutory health insurance are entitled to a wide range of benefits. This means that the statutory health insurance (GKV) covers the costs for the treatment of diabetes, including diagnostic measures, medication, aids and remedies, preventive and aftercare, sick pay and much more. This service catalog of the statutory health insurance companies is regulated in the Social Code Book V. It applies that all measures must be “sufficient, appropriate and economical” and “must not exceed what is necessary”.
The Federal Joint Committee (GBA) regulates which examination and treatment methods are included in the catalog of services. It is a body of impartial members, representatives of the medical and dental profession, statutory health insurance companies and hospitals.
About 95 percent of the services are identical for all statutory health insurance companies. So if medicines and aids are prescribed by a doctor, the health insurance company pays. However, there are limitations. The insurance company only pays for blood sugar test strips for people with type 2 diabetes under certain conditions. Some health insurance companies only hesitantly approve an insulin pump . There are also differences in terms of offers and cost coverage for training courses for patients. In many cases it is worth asking the health insurance company.
Good to know:
The Independent Patient Advice Service Germany (UPD) helps free of charge, among other things, with questions about cost bearers and cost assumption.
For privately insured persons, what is written in the insurance contract applies, i.e. whether a corresponding obligation to provide benefits has been agreed. Often only certain tools are included in a final list. Reimbursement can be difficult if, for example, an insulin pump or a continuous glucose monitoring (CGM) system is not listed.
People with type 1 or type 2 diabetes who require insulin are entitled to blood glucose meters as an aid and the test strips are paid for by the health insurance company. They have to take insulin several times a day and keep an eye on their blood sugar levels.
At least 4 blood glucose measurements per day are usually required. In certain situations, for example when the patient no longer notices hypoglycemia properly , further measurements are necessary.
People with type 1 diabetes who are on intensive insulin therapy or insulin pump therapy are usually prescribed 400 to 600 blood glucose test strips every quarter. However, there is no upper limit for the regulation. For people with type 2 diabetes who inject insulin, 50 to 200 test strips per quarter can be prescribed. The medical specialist decides how many test strips are required. However, she may only prescribe the amount that is sufficient and necessary from a medical point of view to fulfill the purpose of the treatment.
For women who develop gestational diabetes (gestational diabetes) during pregnancy , which is treated with insulin, the health insurance company also covers the costs for a measuring device including test strips. However, the assumption of costs for blood glucose meters and test strips in the case of gestational diabetes, which is treated through a change in diet, has not yet been bindingly regulated.
In people with type 2 diabetes who are not insulin dependent and are being treated with pills, the effectiveness of self-monitoring of blood glucose levels to improve glycemic management has not been clearly established. You will therefore not be reimbursed for any measuring device or test strips (urine and blood sugar test strips). The costs will only be covered in certain of the following exceptional cases. The medical specialist can then generally prescribe 50 test strips per treatment situation. For example, this is displayed:
- When a type 2 diabetes is diagnosed for the first time.
- If there are indications of increased hypoglycaemia and hyperglycaemia or hypoglycaemia perception disorders.
- In the event of additional illnesses or interventions, such as severe infections or planned operations.
- When long-term blood glucose (HbA1c) is significantly outside of the treatment goal.
- When first starting or changing tablets to a diabetes medication that increases the risk of hypoglycaemia (sulfonylureas, glinides).
- For foreseeable events that can lead to an unstable metabolic situation, such as air travel to a different time zone or Ramadan.
Participants of diabetes training courses as part of a disease management program (DMP) may be reimbursed for test strips.