@Maggie4 Same here…the Medigap policy supplementing Medicare Part B is a great way to go to get coverage of the 20% copay for Dexcom or anything DME. I will be (hopefully) starting Tandem Mobi pump sometime this year and believe/hope the Medigap policy will provide great coverage for that too.
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@Maggie4 A Medigap policy is usually the best bet in our world because we use so much tech. Pumps, cgm’s etc. The cost of those at 20% can be significant. Plus 20% of visits, tests, x rays, MRI’s or ??? etc. Getting a Medigap policy after you’ve had Medicare 6 months isn’t guaranteed except for certain circumstances. So deciding later isn’t the best option. But it does add on cost, for us it usually is worth it. But everyone’s circumstances are different.
The first 2 are Medicare government sites, the boxed third is just an article that nicely explains it
https://www.medicare.gov/health-drug-plans/medigap/basics
https://www.medicare.gov/health-drug-plans/medigap/basics/coverage
The way I see it, if you have a stricter budget, Medicare Advantage Plans can cost you $0, so are the cheapest route. But with Medicare Advantage Plans they severely limit who you can see, where you can get treatment, pre authorizations for all sorts of stuff etc. They even limit which/if medications and tech choices like pumps and even CGM’s and other equipment you can get. That is after all how they cut down costs. But definitely the cheapest route.
It’s worth pointing out that this is not true universally, and everyone should examine the options available to them. I have an excellent Advantage plan which covers basically every physician in town, both hospitals, and is super easy to deal with – even the doctor’s office staffs like dealing with them. Others have pointed out valid reasons that Medigap + Part D is a good choice for many, but it depends on both individual situations and regional options.
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If you are healthy at age 65 and little history of needing doctors, it can seem like good sense to commit to a Medicare Advantage plan. You’ll likely enjoy $0 monthly premiums and some added perks like a gym membership or vision plan.
What if you or a loved one at age 75 receive, for example, a cancer diagnosis? You now must deal with the world of prior authorization or PA in addition to the emotional burden of the diagnosis. PAs are simply a practice to delay and deny access. In the stress of life-threatening health consequences to you or a loved one, how likely are you to be comforted by perks you received at age 65?
You can still switch back to standard Medicare but the ability to qualify (when given a serious medical diagnosis) for a Medigap policy is forever off the table. Paying 20% of chemotherapy costs, for instance, can break the bank for many.
When you choose standard Medicare along with a Medicare Supplement policy (Medigap), you get a permanent (provided you pay the monthly premiums) policy that you may keep the rest of your life. Alternately, when you decide on Medicare Advantage, you embark on a series of annual or temporary agreements whose benefits (and doctors, hospitals, and other providers) can and likely will change as the years roll by.
I never liked a business person making key health access decisions; I much prefer that important health decisions be made between me, my family, and my doctor.
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In our case ( hubby is on .10k a month chemo pillls), we have been getting better benefits with Part A, B and then Extra Help d and QMB Medicare Savings program for me. Everything is vastly different place to place and often confusing. I now understand why my quite elderly mom used to hand me her enrollment stuff and tell me she had no idea what to do.
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@Terry4 An excellent post. Most Advantage Plans are very limiting. I just read an article about many Americans are feeling trapped in an Advantage Plan because of the issues they face when they try to switch back to regular Medicare.
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Or as soon as they need to spend time out of town due to family, job, travel or other circumstances.
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Laura’s. Thank you for your service.
1st my Dexcom presently come from a vender in Arizona.
They bill MediCare directly. Twice a year I get a STATEMENT from MediCare, as to what and to who they have paid.
NOW FOR THE IMPORTANT QUESTION. You mentioned that you are a veteran, do you get care/treatment of any type at a V.A. Hospital. I am not service connected for anything but somehow fell under their care. I just found that the V.A. Can provide G6 And G7 sensors and the is NO Pharmacy copay. Which for me means I won’t any longer have my Dexcom’s deducted from my social security.
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Not me, I’m not a veteran
Interesting they want A1C.
What if your A1C is in non-diabetic range?? Do they think you don’t qualify? I start MC in May. With estimated A1C in xDrip, I can see my est A1C every day.
I went looking for a cms.gov doc that had the A1C requirement and found Medicare removed the requirement last year. Oops and yea!
CMS Glucose Monitor Policy Article
Lots of people post with questions about getting on Medicare. I’d like to know how the process goes for you, what decisions you have to make and when, etc if you are willing to share. Policy docs are great but don’t always match the real world.
This might be worth a listen. It’s got a lot more than just A+B vs C. I’m looking forward to part 2.
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I was aware they required C-peptide test, which would indicate insulin is produced by pancreas. This was criteria for insulin pump coverage.
When I had a marketplace HC plan, and was getting pump, they required c-peptide and once again it was 0. They followed MC policy.
Come May 1st, I will start MC, with an out of warranty Tandem X2. That will be fun.
Medicare policy document
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That document is a real mouthful! Just an FYI, when I started Medicare while already using Omnipod there were no testing requirements for A1c or c-pep. Probably because it comes via Part D, refills seemed to sail through with no red tape.
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I think you want NCD - Infusion Pumps (280.14) Note this one has the “have to see a doc every 3 months” requirement in addition to the C-Pep.
Since you have a May 1 date have you already signed up? Seen your endo or scheduled an appt to say hey I’m on medicare, please re-prescribe everything and do the paperwork so medicare will pay for it? Maybe checked the costs of a new pump on your current insurance vs medicare?
As an example of real life not matching the docs earlier this year I saw on another diabetes forum a person whose doc or DME company messed up the initial paperwork and she had to file an appeal to get her pump supplies covered after months of denials. The appeal process required she dig up her old insurance’s EOB from when she got the pump.
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A few weeks ago that how it would have worked. But she decided to move to hospital setting, and treating those newly diagnosed, or other related endo things. My April appt will likely be interesting with replacement, if they fill it quickly.
My X2 pump warranty is up end of June. So hopefully can get things started in May and approved for order in late June.
My understanding with MC is that you “rent” a pump for 5 years.
Didn’t need Peptide test. That’s an old policy. Part D has my pods and B’s got the Dex. Only lousy thing is I had to take an Aetna Plus part D plan and am paying $65 a month because pods are Tier 3. Meanwhile my husband who is on very very expensive chemo pills for life, has Part D plan that was only $21 for the year. Makes no sense.
C-peptide tests are still required for tubed pump coverage under Medicare Part B. It is not “old policy.”
Omnipod is covered under Part D prescription benefits by some plans. Although some plans might require a prior authorization, Omnipod is not subject to Medicare pump coverage rules. Thus you don’t have to provide a c-peptide test to get an Omnipod.
@MM1 Medicare rents the pump for the first year or actually I think 13 months.
Just a reminder to everyone, Part D plans and Advantage plans are plans offered by private companies not the government-run Medicare. They have rules they have to follow and certain benefits they have to provide. But they have some leeway to set requirements for coverage and can operate with formularies and doctor networks. We can all say we have “Medicare”, but for sure we don’t all have the same “Medicare.”
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OK, so they need it for tubed pumps (rentals technically) but not CGM. Sorry, I didn’t know that.
I don’t think I ever had one in 53 years of being type I.
Glad for my Omnipod.
I was diagnosed with T1 in 1976. I got my first c peptide test when I went on Medicare in 2017. I received the lowest possible number which was a win for getting Medicare pump coverage but a loss that I produce no insulin.
Stupid regulation that I have to see my endo (or another medical professional willing to talk diabetes and fill out the forms) every 90 days for pump supplies and Part B insulin. CGM coverage under Part B requires an endo (medical professional) visit every 180 days which makes more sense than 90 days.
Another reason I stick with MDI as MDI only requires visits every 180 days. Then of course there is the annual Medicare wellness visit and the annual eye exam.