Thanks for the input. I have been comparing plans and options. I realize I really want the Medicare with Supplement and Part D Drug plan. I found a pretty good supplement plan, for $112.00 Issue age, and a free Drug plan, but looks like my meds would still be around $100.00 per month my costs. Plus, my $174.00 for Medicare. This is much more than I’ve paid for insurance and meds in a long time. Ugh……I have 6 months from my initial enrollment to decide, but that’s my intention now.
Can I use any brand pump supplies with regular Medicare and supplement? Will separate Drug plan cover the supplies? I can’t find anything about pump supplies under Supplement Plan, Drug Plan Or the Advantage Plans. I have to get one that covers Medtronic.
*Has to be FDA approved and no off label use. Also depends on the pump manufacturer, for instance Insulet decided to sell Omnipod via the pharmacy channel instead of DME so they aren’t covered under Part B. When the Tandem Mobi came out this year it took Tandem a few months to get the product registered so Medicare would cover it. Medtronic probably has a whole floor of their office with people that do nothing but Medicare, I think the 780G could be purchased by someone with Part B the first day it was available for sale so you are safe there.
Pump supplies are covered under Medicare Part B so you won’t find them in the drug plan formularies. I looked up pumps in a random Humana MA plan in the Evidence of Coverage document and it said covered as DME. They used the same “infusion pump” language as the Medicare LCD I linked to above.
Do the Medtronic CGMs still require calibration often enough that coverage for test strips is important? While test strips should be covered under Part B there is some wackiness that prevents you from getting them from anyone other than the company that sells the CGM, and those companies usually aren’t selling the good brands of test strips. Look for a Part D plan that covers the brand you need for this year.
Supplement, aka Medigap, plans are pretty simple up front. If Medicare approved the claim for the item, the supplement plan is going to pay a claim for the Part B copay (or the other covered stuff). The big differences between the plans are described by Medicare here: Compare Medigap Plan Benefits | Medicare
Dee @HighHopes, reading and learning is good and exactly what you should be doing. BUT, unless you are “Insurance learned”, I suggest that you try to meet personally with a professional agent/advisor.
The other option after you have narrowed down your choices, that you contact the company, Humana, and discuss specifics such as pump supplies, CGM, insulin, other meds and assure yourself that you have the coverage you want and need; these services are free to you other than the time you spend. As an example, when I was considering buying a Supplemental Gap policy, the company rep showed me my benefit would not justify the additional premium.
I second Dennis’s recommendation. Free independent advisors are provided by each state, in big states like mine they are provided by each county. In addition to Medicare they are also trained on your states Medicaid plans and some SSI benefits that may benefit you. Never assume you don’t qualify. Medicare calls them Statewide Health Insurance Benefits Advisors (SHIBA) and State Health Insurance assistance Program (SHIP). Generally you can google " SHIBA medicare your state " to find them. There’s also https://www.shiphelp.org/
Great ideas! I have a friend who’s worked with SHIIP for many years and an appointment with her next week. And, another friend who used to work with SHIIP in NC for many years. She’s given me lots of links. And, my former insurance agent. Thank you so much.
So, if I get Medigap coverage, I can switch later to Advantage plan, right? But, if I wait past 6 months of initial enrollment I am restricted on Medicap due to approval or pre-existing conditions issue?
Also, I’m not retired. I’ll keep working for a long time yet, as long as able. I doubt I would qualify for Extra Help or Medicaid, but even if I did, I have property (vacation house, not primary residence that would probably disqualify me) that I wouldn’t want to have a lien on for Medicaid medical reimbursement. So, I’d rather pass on that. Hopefully, I have a choice in the matter.
That is a great question for your SHIP appointment. I think that is how it works but I haven’t spent much time looking at MA rules and policies. Please let us know what you find out.
Doubt is okay. Still check during your appointment and maybe be pleasantly surprised. I’ve seen more than a couple healthcare cost assistance programs with income requirements that are 4x the poverty level which is in the $75K/year ballpark. And even if you don’t qualify today you might qualify after you stop working so you can plan ahead.
This is not an official answer, and Medicaid eligibility testing is State influenced, but a Florida Medicaid consultant [a firmer Medicaid officer] told me that the only asset excluded from a person’s net worth is a primary residence.
I got enrolled! Whew! I was really anxious not knowing when my coverage would officially start, but I signed up online12/10 and received confirmation today including my Medicare number. Now to call and get supplement policy tomorrow. And drug plan. It’s such an odd feeling……OH, I got my c-peptide results…… it was .01. My Endo said undetectable. That’s a relief.
The CMS guidelines make for an interesting and infuriating read. Based on a literal interpretation, the fasting glucose requirement (IV.A.3) yields an A1c over 9, so it looks like some extremely uninformed, antiquated bias on the part of CMS. For example, according to Article - Response to Comments: External Infusion Pumps - DL33794 (A58802) CGM does not satisfy the requirement for multiple dialy finger-prick BG tests.
Who is the currently in charge of BreakthroughT1D advocacy?
LCD - External Infusion Pumps (L33794)
IV. Administration of continuous subcutaneous insulin for the treatment of diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.) if criterion A or B is met and if criterion C or D is met:
A. C-peptide testing requirement – must meet criterion 1 or 2 and criterion 3:
3. A fasting blood sugar obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl.
IV.A.3 just defines a condition for the C-Peptide test, not something you an turn into an A1C.
The medicare documents are like a great novel, your understanding of the text increases each time you re-read them because you start paying attention to other information that is related. For instance I know I saw somewhere that CGM readings do count for the testing requirements these days. Feel free to create a new topic with questions about the docs. It’ll be like book club.
Two commenters suggested modifying the coverage criteria for an insulin infusion pump to no longer require glucose self-testing an average of 4 times a day as a pre-requisite for coverage to align with the CGM
One commenter requested a pathway to coverage for all 3 components of an interoperable closed-loop system (the CGM, insulin pump, and software)
The standard response: “Out of scope” despite the fact that as of the June 2021 publication date, both Tandem and Medtronic had 4+ years market availability of automated insulin delivery systems that combined an insulin infusion pump and CGM.
Using the novel analogy, CMS’ style and content are antiquated and out-of-touch?
Coverage of an external infusion pump for the administration of continuous subcutaneous insulin as outlined in the related LCD’s “Coverage Indications, Limitations, and/or Medical” section under criteria IV. C. and D. requires a frequency of glucose self-testing an average of at least 4 times per day. A beneficiary using a continuous glucose monitor (CGM) is inherently testing more than the 4 times per day glucose monitoring requirement. Documentation of the use of a CGM device in the beneficiary’s medical records would meet the testing requirement in the External Infusion Pump LCD.
I went back though some of the previous versions of the LCD and PA and at no time did I find “testing” with a CGM excluded. Interesting that Medicare felt the need to state the obvious.
Where do you order the insulin pump supplies when on Medicare? Can you order directly from the company or can you use places like Edgepark Supplies? Or, do you look to who the Supplement plan requires?
I turn 65 in a few months and am preparing to do my own deep dive, so I appreciate these discussions. A couple of questions:
As I understand it, a c-peptide test is required to confirm Type1. Is there a certain number of weeks before or after starting on Medicare, to submit the results?
How has the changeover been with getting supplies - any delays with new pre-auths or that kind of thing?
Thanks.
@wadawabbit My transfer to Medicare/Tricare for Life went very smoothly (yes, I was surprised after hearing various horror stories). I was dx’d T1 prior to being Medicare eligible, so I was Tricare Prime (military retired) and as such I didn’t need to submit anything special to Medicare, the T1 dx and meds just transferred over from my Tricare (military retired) system to Medicare (primary with Tricare for Life (secondary). It may be a function of what pump/CGM you use and whether it’s a pharmacy or DME benefit. I used to get Dash pods from military pharmacy and Dexcom G6 from Wellstart Medical. When I switched to G7 from G6, I started getting both from a DOD pharmacy.
My wife is in the midst of moving from Tricare Prime (primary and sole) to Medicare (primary) and Tricare for Life (secondary). She’s not going on Social Security (playing the delay and get more game) and she’s having a devil of a time getting SSA or Medicare to fess up what she needs to do to pay for Medicare from her federal government retirement (OPM), neither is responsive to the question and phone calls result in frustration of non-understanding by both of their customer service reps. I find it difficult to believe she’s the first with this question. If anyone “knows” please respond!
Since you said supplement plan I assume you signed up for Medicare Part B. You can buy from any company that can bill Part B for the supplies. Picking one that can bill your supplement plan directly for the copay is nice but you can always submit a claim yourself. Usually these are DME companies like Edgepark. Does Medtronic still sell direct to patients? If so they’d work too. My local independent pharmacy used to have a person who could bill Part B so you can also ask pharmacies if you prefer them.
