Does anyone know about Omnipod coverage in New York under Affordable Care Act?

Diabetes Technology Insulin Pumps
#1

Anyone from New York, I'm doing research to try to get the best coverage under Affordable Care Act. It's such a labyrinth. I feel like I'm playing coverage roulette.

Lost my previous insurance, which covered Omnipod. It was good, but RIDICULOUSLY expensive, so I'm glad to move on in that way.

I'm currently signed up for a policy with Empire BlueCross, and they don't cover the Omnipod test strips, but possibly the pod, if they accept the application from my doctor.

Don't know if they will.

2 Questions:

1. Has anyone been successful getting coverage for the pod with an ACA policy? If so, I'd love to find out, I have until the 15th to switch to whatever plan is most likely to cover it.

2. My family is paying for this coverage. But as a musician (i.e. freelance, low income, etc) with a chronic disease, I qualify for Medicaid. Does anyone know if the omnipod is covered by Medicaid in NY?

I'm trying to decide whether to just switch to Medicaid, save my family some money and if there's a possibility of getting omnipod or at the very least, a decent pump coverage with medicaid, I might go for that.

Thanks in advance for any reply. If you have information, suggestions, leads, it's all appreciated..

Jay

#2

Here's one part of your question: Medicaid will cover a pump, but most likely not the Omnipod. I understand that Medicaid and Medicare both follow the same guidelines for "durable medical equipment" and Omnipod does not fit that description. There may be loopholes though so keep looking... Another place to ask is from Insulet, as they have a very good staff with knowledge of insurance. Call their 800 and start there.

#3

Thanks Scott...
That's generally what I've heard.
I'm wondering if anyone knows if there's any limit (other than tubeless) what kinds of pumps Medicaid covers, or if they just cover any pump that has tubes (which I hate:(

#4

Hi I live in CT and had to go to war to get the pod but I have the state insurance which is husky c I think its the same as medicaid... But what ended up doing it is to have your current pump malfunction and pester them saying its urgent... Good luck

#5

There's a different code for Omnipod as opposed to tubed pumps. Medicare documents this. So far as I can see Omnipod is covered under exactly the same rules as pumps - I couldn't find any difference in the documents I found on-line. Under Medicare both the pods *and* the test strips (and, for that matter the insulin) are treated as supplies for durable medical equipment - so they get paid under medicare, *not* the prescription benefit.

Whether Medicaid really is the same is anyone's guess.

The rules here are logical but different to the insurance industry behavior. Insurance companies handle pods as DME and test strips and insulin as prescription items; so where and when copays and deductibles apply can differ a lot.

#6

I think the answers aren't specific to New York. In fact if you go the ACA route the plan you end up isn't determined by the *state* you live in, rather it is determined by your zip code - insurance companies don't have to cover the whole state.

If you are eligible for Medicaid you can still get an ACA plan but you won't get any subsidy, at least in NY. (In states that didn't participate in the Medicaid expansion you can get a subsidy at lower income levels.)

The only way I found of being sure about ACA coverage is to ask the insurance company. I was lucky, the first one I tried (which is also the cheapest) were able to confirm that they covered Abbott test strips (as a preferred brand). I don't imagine that there should be a problem with the pods though in my case my insurance company didn't need pre-approval because I was already on the pods.

The issue with the pods was that the request had to come from the supplier - not me and not my doctor. So I had to contact Insulet, get them to check if they were a supplier (they were) and, as soon as the policy became active (Jan 1) verify coverage.

If you are looking at a new insurance company it will only become active on March 1, therefore I don't think you have time to do the check, since you won't be able to swap back unless you could have the two policies overlap in March.

I'd say it's less risk and almost certainly cheaper and easier to look at the Medicaid option so long as the Omnipod is the only health issue of concern.

John Bowler

#7

Hi Jay,
I’m in CA and have Anthem Blue Cross. You may run into a problem with them covering the Freestyle test strips as one of the other comments stated as they are not preferred. However, Abbot had a special discount card for OmniPod users where you only will have to pay a $15 co-pay for the strips. Fortunately I have great endos and pharmacists because they had to jump through a lot of hoops to get me in the program. What we found is its best to go straight to Abbot and skip your insurer. Abbot then coordinated of all the details with the insurer and pharmacy and endo. Lot of effort but worth it. Without this the charge was over $400 for 300 test strips and I test 8-10 times a day. Too bad insurance companies make just trying to stay healthy and out of the emergency room so much work!

#8

Thanks everyone, this is all very helpful

I'm signed up for an ACA plan and have until the 15th to change it. I thought it was one of the better plans but evidently, since so many people signed up, they're overwhelmed---it took a two months after signing up just to finally receive my card and membership info. Just paying the premium took several days of 2 hr waits on the phone only to have things not work out because of their computer system. (this is Empire BlueCross. Can't say I recommend them.

I'm going to look really carefully at the Medicaid programs available to me, talk to my endo to see what she recommends and which networks she's part of.

If there's a possibility that a medicaid version of one of these plans can cover the pod, then I'm in. If not, then perhaps I'll go on a pump vacation while I look for further options. Another possibility: find one that does cover Abbot in their formulary, and then just buy the pods myself. Still cheaper than the coverage I have now, by 300 a month.

#9

I am on Medicare and Tricare (Tricare for Life) and they are not covered by Medicare even Insulet says the same thing. That is why it cost me 5 times what they cost me before I went on Tricare (I am also retired from IBM) they were covered by both CVS caremark and Express-Scripts (if not tied to Tricare).
If you know of a way that both Insulet and Tricare have said.

#10

See the discussion here:

https://forum.tudiabetes.org/topics/medicare-part-b-guidelines-f...

I.e. you have to meet one of the criteria for getting an insulin pump (not specifically the Omnipod).

I suspect Jay meets both criteria but he must meet Criterion B (I can't imagine only testing 4 times a day ;-)

Nevertheless this is still Medicare, not Medicaid, and the criteria may be different

John Bowler

#11

I live in NYC, and just started using Omnipod 2 weeks ago. I have Blue Cross, and when I was notified that they would no longer cover the Freestyle strips, my pharmacist suggested I have my doc call the insurance company to override it due to medical necessity, and they did. Now I no longer have that problem.
Email me anytime if your in the city and wanna chat :-)
Jess.keats842@gmail.com