Great news!!!
Dexcom now covered under Medicare & Medicaid (CMS)
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Is this for real? Am I dreaming?
Fantastic! Now, if we can get the Omnipod approved, I can get to 65!
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This is definitely a surprise to the industry. A CMS decision was not expected for at least a year.
Yep on a case-by-case basis.
The prevailing thought is still late 2017 or very early 2018 for a full, national coverage determination. Currently, this is only on a case-by-case basis and itâs limited to the Dexcom G5 (since that is what has the dosing claim from FDA). And itâs not a retroactive decision, meaning it only applies to those who get a G5 and seek coverage after Jan. 12, 2017. Hopefully, more will come on this before long.
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Medicare coverage of the G5 CGM made DexCom more valuable today.
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diaTribe published more information on the Medicare decision to classify the DexCom G5 system as durable medical equipment (DME). As of today, Medicare did not make a blanket determination but will consider coverage on a case-by-case basis. Itâs expected that Medicare will make a national policy to cover all people that need this device. This means that the Dex G5 receiver as well as the necessary accessories, sensors and transmitters, will soon (2018?) be covered under Medicare Part B.
Hereâs diaTribeâs take on what will be reimbursed by Medicare:
Hereâs a link to the actual ruling by Medicare.
Thatâs fantastic! $600 a year plus the initial cost could be difficult for many seniors, but it is certainly going to make the technology available to far more patients than are currently able to pay out of pocket!
Do any supplemental plans cover DME or however the sensors and transmitters are classified? Or is it just for pharmaceuticals, which this now doesnât qualify as?
For those who are interested, here is a link to the January 12 ruling by CMS:
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Just got off phone with Dexcom. Here is what Iâve learned. Dexcom management have advised that all orders for Medicare patients (we are all cash pay) have been stopped immediately. Dexcom will do what they can to fill that pending order at a no charge for this time.
No details were given to staffers from upper management for the halt of Medicare patient orders. Staffers say that Medicare has approved and should cover ⌠but no one knows how long it will take Medicare to trickle down the paperwork that we will all have to go through to âget approvedâ for CGM and coverage by Medicare. I recall having to jump through hoops to get my insulin pump approved when I went on Medicare two years ago. Iâve worn pumps for 25+ years!!
Iâm guessing there are politics at play here and Iâm not sure if Medicare is pushing Dexcom to halt supply of CGM to us on Medicare or is Dexcom doing this to stir the flames to get Medicare to get their ducks in order. A few too many moving targets to get a good handle on just exactly what has happened.
It could come to a point where Dexcom may not even âcompâ the sensors, transmitters, etc., etc⌠Just depends upon how long the bureaucracy wheel takes to make its turns.
Iâm on a recurring monthly sensor order and got e-mails late last week that it was in process and when I talked with Dexcom this afternoon they said they had been told to cancel the order. He did request a variance for a âcompâ for the box of sensors, but he wonât know for 24-48 hours and it may only be a âone-timeâ such event. So ⌠when my transmitters time out in 3-months (if Medicare has not got things underway) I could be out of luck with my CGM as even being âcash payâ wonât work.
Interesting to say the least.
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This is interesting, but doesnât make sense to me. You are currently covered by Medicare but Dexcom will not even allow you to pay cash for sensors or transmitters. Do I understand you correctly?
That is correct. Dexcom management told their cust. svc folks effective today that all CGM users on Medicare where covered by âMedicareâ and we could not âcash payâ. As noted ⌠Medicare has not yet figured out routines to get CGM coverage or which distribution centers will be authorized to supply the product.
I just can grasp why I could not continue with âcash payâ until all the Medicare minutia was worked out.
It is beyond me for sure.
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Another Update: I had another chat with Dexcom (along with confirming e-mails from Dex local territory manager).
Dexcom will provide supplies on an âas neededâ basis until CMS/Medicare gets their ducks in order for those of us on Medicare. It wonât be automatic and Iâm sure we will have to process paperwork along with our endoâs seeking Medicare CGM approval.
Part of reason for the stopping the product charges to us on Medicare is CMS/Medicareâs concern that us CGM users might demand historical reimbursement back to 01/12/17 ⌠even though that individual user was not approved for CGM usage by Medicare. That is a liability and financial concern on CMS/Medicare for sure.
Dexcom and CMS/Medicare appear to be hoping that the ducks will all be lined up sometime in April.
It would be at that time we would likely be able to start the CGM/Medicare application process for consideration of coverage.
Those items are best guesses, and things can change for sure.
Wow!!! thanks for all the infi I am going to retire in july and will be on medicare this is a lot to process between now and then. I used the mini Med Pump for 18+ years and just switched to the Pod and G5 did I make a mistake.
So I understand, while Dex is supplying on as âas neededâ basis until April or so, who is paying for the supplies? Is it cash pay (as before) or are they free?
LeapFrog,
Dexcom must be absorbing the cost for the products (as needed) until Medicare gets their ducks in order for us Medicare patients to apply for CGM coverage and (hopefully) approval by Medicare for same.
I was on a âcash payâ basis for the past two years and they will not and/or cannot accept âcash payâ from us Medicare participants.
You do have to talk directly to Dexcom Cust. Svc. for your product needs and they will step you through the process.
Cheers,
Nolan K.
TCOYD (www.tcoyd.org) has help for people to get through the process. Just got o their website, and on the right side of the home page is where you click. Thanks to Steve Edelman et al
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Do you know if this TCOYD service is still needed in light of the recent Medicare policy change (January 12, 2017) to recognize the Dexcom G5 system as durable medical equipment and will immediately consider coverage on a case-by-case basis until a national determination is published?
I donât know. I can imagine there are healthplans that will not cover it - like mine. And there are Endoâs like one I had - who refuse to believe CGM is of any value (you know the type - the I know Everything kinda HCP)
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