It is with great sadness that I must leave you all: finally it was firmly established that Insulet was in error saying that my Medicare Advantage insurance would cover this system, Edgepark also confirmed my coverage and accepted money for equipment for two months, my insurance sent me to another vendor who also 'qualified' me and now everyone is ducking responsibility and I can't afford pods anymore. I have taken ther c-peptide test and based on results, may go to t:slim. As for now, it's MDI AT 5 ADY, HIGHER Aic, eight gain, and horrible site injection reactions (:
Who was the insurance with?
Went through the same thing…
Would you email me.
Sunflwr126@aol.com
Dee
PS…I know I had told you about MY advantage plan. Medicare Blue.
I am paying $67 for 3 mos supply…next year…NO copayment I’ve been told.
Again…please email me.
This will be an issue for me next year at this time also. Please continue to post to keep us informed.
Medicare Part B (which is included in a Medicare Advantage plan) includes "durable medical equipment" and *supplies* for the equipment. "Durable medical equipment" includes medical equipment that has a life of 5 years or more and was prescribed for you by a physician or other qualified person in a face-to-face encounter (the physician has to have seen you) within the last 6 months.
Insulin pumps are covered, and so are supplies for pumps. (For that matter blood glucose meters and test strips are coved). Coverage for the pump is at 70% (i.e. you pay 30%), for the supplies the Medicare rules aren't totally clear - they could be covered as prescriptions (which Part B also covers) or just at 70% as for the basic device.
I believe the problem with the Omnipod stems from the fact that Medicare does not cover supplies in general; so, for example, syringes to inject insulin aren't covered! Because Part B is administered by a health insurance company ("contractor" in Medicare terms) some contractors apparently believe that the supplies for an Omnipod PDM (i.e. the Omnipods themselves) are not covered. This is clearly wrong.
As Dee has pointed out some contractors (well, specifically Medicare Blue; Blue Cross Blue Shield?) have sorted this out and got the right answer. Unfortunately the contractors are separate private companies who don't talk to each other and probably talk to the government (CMS) as little as possible.
This is why it is important to build a list of the contractors (insurance companies) who have this *wrong* because we don't want to have to fight them on an individual basis; it's much better to use the market and simply avoid insurers who have a problem.
The insurance companies don't (or rather, shouldn't) get any choice about what they cover:
Below is a link to the CMS determination of coverage for insulin pumps. I also searched the national coverage database for "Omnipod" and for "Insulet" and nothing came up, indicating that there has been no separate determination about the Omnipod (and why should there be - it's an insulin pump!) *Implanted* insulin pumps are not covered (see the end of the document below), but the Omnipod is clearly external.
Ok, some of you say that SOME Medicare policies cover Omnipod PDMs, yet don't cover the Pods themselves. It's clear to me that my Medicare Advantage Physician's Health Choice (a United Health plan by another name) used in Hays County, Texas is not one who will fight for coverage for the Pods. Judging from the bills from Edgepark, they aren't claiming monies for the PDM, just all the pods they supplied (less their requested 20% Part B co-pay of $60 per box)I am appealing the charges as I have emails verifying my coverage and co-pays and did what in the Law is called 'due dilligence' as far as establishing costs. I guess my next project will be to search out plans for 2014 either Advantage or Supplemental for my area that will cover the Pods. Please note that I am currently awaiting the results of a C-peptide test to determine if I would qualify under Medicare criteria for a tubed (approved) pump. I will not know the results until 12 November and will have to wait until 2014 to purchase a pump and have to change to a Supplemental plan: they will pay all co-pays and co-insurances. Please note that according to a person at Medicare: all insulin used in a pump MUST USE PART B for costing, and it is illegal to use Part D funds for this insulin. It makes a costly per month basis compared to using up the Part D until hitting the 'hole' and then 'switching' to the Part B for the remainder of the year. It also appears that Insulet never tries to qualify you for Medicare coverage (c-peptide) as they know it's not covered: never was qualified via c-peptide and was never advised that Medicare didn't cover the system.