Florida Medicare Insurance?

Does anyone know of an insurance company in Florida that covers the OmniPod as part of secondary insurance after Medicare? I have four years to go before I reach that point, but I have a diabetic friend who would like to change to the OmniPod, but he has Medicare. Please let me know if you know of a company that will cover the OmniPod in Florida. Thanks!

Yes…I have MEDICARE Blue…(BC/BS)
It covers my pods 100%…Their “care Centrix” does not follow MEDICARE guidelines.
We live in SW Fl.
Dee

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The Omnipods are DME (Durable Medical Equipment) supplies and are covered directly under Medicare Part B. This document explains (sort of):

http://www.medicare.gov/Pubs/pdf/11045.pdf

or this web page which is slightly more helpful if you follow the relevant links:

http://www.medicare.gov/coverage/durable-medical-equipment-coverage.html

The PDM is an "infusion pump", and the pods are supplies for the pump. There is a separate CMS billing code for the Omnipod. (In general insulin pumps are prosthetic devices for type 1 diabetics and medically necessary for type 2, but I believe the CMS classifies them as "infusion pumps" regardless of whether or not they are prosthetic.)

There's more information in the link below, but it's still pretty confusing. As of this moment the CMS hasn't quite got it's ■■■ in gear, but it is getting better; I can see some posterior wobble.

http://www.medicare.gov/coverage/insulin.html

John Bowler

Thanks, Dee. I thought I had remembered that you said that once. You give me hope! I live in Pinellas County, enjoying even the slightly chilly weather here right now. My family lives in the north and are experiencing below zero temperatures this morning. Yikes!

Thanks for the links. I will try to wade through them all to see what I can learn. At least there is some movement in the right direction... even if it is just a wobble rather than a sprint.

Here's my summary of what I *believe* is happening. Most of this isn't medicare specific; it applies to the CMS approved insurance plans we get from the healthcare marketplace as well. Some of it also applies to employer plans and Medicare Advantage plans.

a) If you change insurers, or if you change to a pump from MDI, your doctor may be required to provide a certificate of medical necessity for:
1) The pump. Unlikely if you are just changing insurers, but if you change to a pump
from MDI it's more likely.
2) Test strips. Almost for certain; pump users use way more test strips than MDI users
and the insurance company doesn't distinguish the two. Also test strips are currently
treated as prescription items (Medicare Part D), even though they are clearly DME
supplies for pump users.
3) A CGM. Pretty much a certainty I think.
b) Once your insurance company has the certificates of medical necessity they should
supply both the pump and necessary supplies (pods in the case of Omnipod) at the single
standard DME rate; 20% co-pay for Medicare, variable for marketplace plans (10-30%?).
However test strips will almost certainly be treated as a prescription item and
therefore covered in a different way, or not covered with Medicare.
c) Lots of people don't know what an Omnipod is. These people may not realize that there
is a separate CMS billing code. Insulet does know this.
d) Employer plans and Medicare Advantage plans might be different. Medicare Advantage
works by privatizing the administration of Medicare Part A and B, so you typically pay
the same amount but get restricted benefits. This reduces some extra (copay) costs at
the cost of not getting all the benefits you would get under Medicare; for example you
may have increased copay for DME and you may have restricted access to suppliers.

Safest seems to be to steer clear of Medicare Advantage while ensuring you have Medicare Part D (prescription) coverage. As with marketplace plans, however, if you have the
time for all the phone calls and arithmetic ability to do the math a Medicare Advantage
plan may reduce your costs; but it's essential to find out exactly what coverage levels
the plan has.

It also may be true that obtaining the required certification of medical necessity is easier, or not required, under Medicare (as opposed to Medicare Advantage). The medicare.gov site implies this, here:

http://www.medicare.gov/what-medicare-covers/medicare-health-plans/...

The last paragraph on that page is very helpful, so I'll quote it in full here:

"You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won't pay for a service you think you need, you'll have to pay all of the costs if you didn't ask for an advance coverage decision. Get your plan's contact information from a Personalized Search (under General Search), or search by plan name."

So the process here is formal; before we sign up for a Medicare Advantage plan we have to obtain "written advance coverage decision(s)" for everything we might need (pumps, test strips, CGMs.)

John Bowler

John:
I use Omnipod and appealed Medicare's denial to the highest level on appeal and it took more than 2 years, but Medicare continued to deny Omnipod because it did not fit the alleged definition of DME. I have spoken at length with Insulet and know it is trying to correct this wrong, but unless federal law is changed, I believe it is unlikely.
I have basic medicare and in Pa. use AARP supplemental United Healthcare. Most, perhaps with exceptions you note. follow guidelines of medicare and say they are required to do so.
I would be interested in knowing how Fla. differs , either in policy or regulations because we many of us could use that precedent in fighting with our insurers.
Richard Meltzer

So far as I know CMS does not maintain any particular point of view with regard to Omnipod vs any other insulin pump; is Medicare currently covering an insulin pump for you?

I'm asking because I've heard (on tudiabetes) of people covered by Medicare for pumps including the Omnipod, and the CMS rules are explicit that this is allowed, but I've yet to hear of someone covered by Medicare for a pump who was refused a swap to Omnipod. They (insulin pumps in general vs Omnipod) do have different CMS codes, so I guess it might happen.

John Bowler

Does Medicare purposely make this difficult just so the ordinary person gives up before trying to wade through all of the verbiage? I know insurance is a complex topic, but the wording makes me think that the lawyers who wrote all of this did so in a way so they always have "loopholes" through which they can deny coverage. I dread having to face all of this in a few years.

I wonder how long getting written advance coverage decisions would take. Since this is insurance and government combined, I could see waiting eons before they send an answer.

Thank you, though, for all of your research and insight into this whole insurance issue.

SherryAnn,

To answer your question, Yes Medicare makes this difficult so the ordinary person will give up and just go away. However, I'm not one who will go away without a fight. I fought the VA and won a disability after waiting over 40 years because of Agent Orange exposure in Vietnam and the VA too hoped I would go away or die.

We (my wife & I) recently lost an appeal before an ALJ (third level appeal process) just like Richard above said happened to him. We also live in PA. I am now in the process of going to the next level of appeal before a Medicare Panel Board with the help of a very bright lady attorney who knows and understands Medicare and fights for those that have been wronged. She believes that both Insulet(Omnipod) and CMS along with their three appeal levels regarding the Pods are not being coded properly as "Supplies" just like tube type insulin pumps are, and tubing is paid for under Medicare as supplies for tube type pumps.

And Mr. Bowler sorry sir, but you are incorrect regarding CMS not maintaining a particular view with regard to the Omnipod versus any other insulin pump. CMS has a BULL HEADED opinion and is under the impression that the PODs are an independent device of the PDM. Well if you don't fill the POD with insulin via a syringe it will not function and deliver the proper insulin levels to your body. CMS currently would pay for an Omnipod-PDM because it has a useful life of of 3-4 years. BUT in the case of the Plastic PODs they are a disposable item, and CMS considers the PODs disposable Non-DME items, thus no coverage according to CMS and they(CMS) also refer to the PODs as a "Convenience Item? So then, are insulin syringes and tubing for tube type pumps convenience items as well? Here is what's wrong, and as I said previously the PODs are "Supplies for the PDM" and should be coded as such under HCPCS with a Code: K0552 and NOT coded as a Code: A9274 as they are presently being coded by Insulet Corp. when they are submitted to Medicare for reimbursement.


Its sad to say, but Insulet Corp moves VERY SLOWLY with regard to this matter, and as long as the Medicare patients keep paying for these PODs out of their own pocket Insulet doesn't really care one way or the other how they are getting their money from the consumer versus waiting for CMS to reimburse them which takes months because of our fast moving Government. Why do you think some Doctors don't like dealing with Medicare? Its because they have to wait over three months or more for reimbursements from CMS.


For three and half years these PODs were paid for under our Blue Cross/Blue Shield until we turned 65 then you are shoved onto Medicare, and CMS will deny payment for these PODs because they are not properly coded and are referred to as Non-DME. Then who suffers after making life long payments into Medicare? Well its us poor peons! Its a sad state of affairs that elderly seniors have to fight the Government for something they paid into most of their working lives!


James Bill

I stand corrected. I couldn't find that code when I searched for it and I had naively assumed that the coding would be covered; somehow I had found it before and interpreted it as a "supply" code.

You are right; the code suggests that the *pod* is a complete system on its own so is not covered, just as syringes used to inject insulin for those on MDI are not covered. This is clearly wrong because the pod is part of a larger system and does not work without a PDM, which is clearly not disposable.

John Bowler

Well folks as I said previously, we and our lawyer will be appealing this action to the fourth level of Medicare appeals to the Medicare Appeals Council(MAC)in the next few weeks after I obtain some more coding information from Insulet Corp for our original PDM purchased back in 2010, and prior to my wife going on Medicare last year.

All this could not have happened without the immense help of our very bright lawyer who has been diligently consulting with Insulet Corp on this matter and moving forward towards providing a very good aggressive argument to the MAC Board that the PODs should be considered as "Supplies" for the OmniPod PDM just like tubing and cannulas are reimbursed by CMS for tube type insulin pumps.

Our lawyer has asked Insulet why they have abandoned the Medicare user community in support of the OmniPod system, and they have finally agreed that they have dropped the ball on this matter, and will move forward in support of our efforts to help those of us on Medicare that have been denied payment for the PODs because the CMS incorrectly considers these "POD supplies" as Non-DME which we hope to get changed after our 4th level of appeal, but we will still need to keep our fingers crossed regarding accomplishing this wrongful deed.

James Bill

The best of luck to you and the best of judges too; it really shouldn't be a matter of luck. You are working for the benefit of all the T1Ds in the country; we all hope to get to that age when we will be on Medicare.

John Bowler

UPDATE…after over 5 yrs of omni pod coverage, I was suddenly told they (care CENTRIX) made a mistake. No more coverage. This was in Dec, 2015.
Dee

So if I take Medicare in Florida and look for supplemental insurance to cover diabetic supplies – i.e. my Pods – I am just SOL. So sad that a medical condition that affects millions of people worldwide is still so terribly misunderstood. I know already that Medicare only covers THREE test strips a day, and that they will not cover anything but a tubed pump.

Sometimes I feel like I am living back in the dark ages or in a third-world country. The insurance industry cries, “Use preventative steps to avoid health problems,” but it fails to provide the tools necessary to take the steps we need to stay in control. This makes me SO angry that my blood sugar is probably rising as I type!

I will be out of pods in a few months. If nothing changes with Medicare, I will have to make a big decision! I am very stressed about this!!! Of course, that stress sends my numbers up!

Now I know why I see so many far-past-retirement-age people working in Florida. They are just trying to keep some type of insurance that will pay for medical supplies. My husband and I will be forced to take Medicare from Florida since we are legally Florida residents, but we continue to look for supplemental insurance that will cover at least some of the diabetic supplies. He turns 65 next year. I have a few years left on my former employer’s insurance plan, but by 2019 I need to find something. I am sorry that you will probably have to change from the OmniPod system. This whole insurance industry is a rigged fraud, and we all are the victims. At least you are among friends and have good company, Dee. I wish you the best and hope that we can get the Pods covered someday soon.

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what happened in your case? Please let us know.

Hi Richard,

Sorry for the late response, but the bad news is that our Medicare appeals were DENIED at every level. We took our appeal to the board level which is the next to the last level of Medicare appeals (level 4). The last level, (level 5) of Medicare appeals is taking your case to the Federal Appeals Court system, which as you know by being an attorney will cost some big bucks, and you’ll need a good lawyer to go before the Federal Court. Therefore, we decided that we spent enough time, and money on this appeal process, so we caved to the powers to be at Medicare. We told our lawyer that we were not going to pursue our case any further because we feel this is simply a lost cause. Medicare’s answer to us is listed below in a referenced case that they reversed a previous ruling made by an Administrative Law Judge (level 3 in the appeals process), and this what Medicare is now hanging their hats on!

Reference this case as it is very similar to ours:

You know who I blame, I blame the executives at Insulet/Omnipod for NOT going before Congress to have the Omnipod Pods PROPERLY RE-CODED. Because if they were properly coded in the beginning just like tubing for tubed pumps, the users of Omnipod when they become Medicare eligible would NOT have to be fighting these battles like you, and we did along with some others.

TWO WORDS: MEDICARE SUCKS.
Best Regards,
James Bill

You have fought a good fight, James, and for that we all thank you. I agree that Medicare Sucks, and I am not even on it yet!

Let us all hope that SOME other pump company out there is working on a wireless pump, and that they will do a better job at coding their device than Insulet did with the OmniPod. If something else was wireless, I would seriously consider it.

On a side note, I wonder if Medicare pays for the Pod when it is used by cancer patients to deliver Nulasta after their chemo treatments.