I am interested in opening a discussion for 2022 as coverage and requirements have changed significantly over the past years. My specific question is concerning what I have heard is a requirement for Diabetics on Part B pumps.
Must we have our pump and insulin prescriptions reviewed/renewed quarterly or the prescription may not be honored at pharmacies? Does this have to be with an Endo or can my PCP do this if willing? Are these quarterly visits paid for by Medicare? (I seldom go to my doctor more than once now so this will be a huge increase in time and possibly money.) I will also be traveling for months at a time, Lord willing, in retirement and I would therefore need to set up virtual appointments. Thanks for any thoughts and experiences!
Your rules will be different depending on what sort of Medicare plan you choose. In almost every post about Medicare, I mention that we all say we have “Medicare,” but in reality may have different types of insurance. I have Basic Medicare along with a Supplement Plan and a Part D drug plan. So I’ll tell you what I know. If you have an Advantage Plan or a retiree plan, you may end up with different benefits and requirements.
Basic Medicare is very strict about the requirement to see a qualifying medical prescriber within the last 90 days to get your pump supplies and Part B insulin. Prior to telehealth, I gamed the system somewhat. I would see my endo in November and get pump supplies and insulin. Then I would see her again in late December before I went to AZ for the winter. The December visit would allow me to get supplies in February because I had been seen in the last 90 days. Then I would see my doctor again in May. CGM only requires a visit every 6 months. With telehealth, I just see my endo quarterly, sometimes in person and sometimes telehealth.
Although the Medicare regulations say that you must see your “prescribing” physician quarterly, some people definitely mix it up with their primary physician and an endo. You have to discuss your diabetes at that visit and all of the medical professionals must be knowledgeable and willing to handle the Medicare requirements on chart notes, etc. Because Medicare suppliers and regulations can be a PITA, I prefer to keep everything with my endo because I know that her office knows how to fill out paperwork.
All of my doctors’ visits, pump supplies, insulin for the pump, Dexcom supplies, etc. are covered by Basic Medicare at 80%. My Supplement Plan pays the remaining 20% of anything that Medicare covers. Medicare Part B covers most of the insulins used in pumps and I know people getting coverage for Humalog, Novolog, Apidra, Fiasp, and some of the generics. I have not yet heard of Medicare covering Lyumjev under Part B but I don’t know. The formulary of your Part D plan does not affect the insulin for your pump (although it might with an Advantage Plan.) If you purchase a long-acting insulin for back-up or for using the untethered regimen, that will come from your Part D drug plan with copays and formularies.
It can occasionally be an adventure dealing with Medicare suppliers for pump and CGM supplies and pharmacies for Part B insulin. (Walgreens will also supply Dexcom but I choose to get it from my pump supplier.) Just know the rules and take responsibility for knowing when to order your needed supplies.
Good luck! Keep asking questions. I’ve learned most of what I know about Medicare from other Type 1’s on Medicare.
Laddie, thanks so much! Appreciate you making it clear that all things are covered at 80% and that sticking with my Endo might be best. I can see where mixing up the schedule of the visits could extend things for times I am away from home. I expect to be on the UHC AARP supplement as it is best coverage here in Virginia and has some overseas coverage as well as Silver Sneakers. Hopefully we can keep this conversation going for input from many.
I was surprised to just learn today that the annual physicals that I have become used to are NOT covered by Medicare, but just a minor review of “the plan”. What have you learned about the best way to have a full physical covered?
My Supplement Plan covers a few things that Medicare doesn’t pay for. For example, when I have my annual eye exam, Medicare will not cover the refraction part of the exam. But my BCBS plan does.
Same with my physical. Medicare pays for part of it and my BCBS plan covers the rest of it so I get a full physical.
There are 4 riders to my supplement plan that I pay extra for and I can’t remember whether the things above are part of those riders and just covered by my plan. One thing I know that I pay extra for is certain providers (like Mayo Clinic) are allowed to charge more than Medicare rates. If I didn’t have this rider I would have to pay those charges above Medicare rates. I have to admit I haven’t had this happen, but I am glad to pay for this in case I got super sick and needed those providers.
Supplement plans technically have to be the same and cover the 20% that Medicare doesn’t pay. But they can provide more things. They can also vary in price. They are the same; but not exactly the same…
I’m not on Medicare yet, but plan to get help from a broker, no cost. Maybe you can find local help even though already signed up.
https://medicareagentfinder.com/how-does-a-medicare-broker-get-paid/#respond
Before I went on Medicare, I wrote a year long series on things to do and think about. I can’t necessarily recommend it because things have changed since then (Medicare coverage of CGM, Cost Plans in Minnesota, etc.).
I spoke with many people in the year prior to going on Medicare: Independent brokers, insurance company reps, etc. Not one person I spoke with understood and knew about Part B insulin. I wouldn’t have known about it with older T1 friends on Medicare advising me.
IMO the whole Medicare decision tree for PWD using diabetes tech is “Buyer Beware!” You will know and need to know more than all of the people you talk with. At the same time, I learned something new from every person I spoke with and every meeting I went to.
Here are some links that may be helpful.
CGM coverage: Medicare regulations still officially say that a DME receiver is required. it is murky whether a Tandem pump suffices for that. But unlike in the first years of CGM coverage, there is no enforcement of the policy and many/most of us have never taken our Dexcom receiver out of the box.
This is a long and actually very old Medicare document about pump coverage. About halfway down is the criteria for pump coverage. Although not officially stated, I think CGM use can substitute for BG testing and I haven’t submitted meter results in at least two years.
This is the section: Medicare NCD Manual 280.14 (formerly CIM 60-14) Section A.5
This is the document: NCA - Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092R) - Decision Memo
You will need a c-peptide test taken at the same time as a fasting BG. The test must specify that the BG test is fasting. As a longtime T1 I had no issues satisfying the c-peptide required result, but some people with Type 2 do. My Medicare c-peptide was my first ever in 40+ years of diabetes.
I have a non-medicare plan, but it follows same rules. Same thing, first c-peptide test, after 40+ years T1D. Glad I know that now. Hoping Medicare will accept that test result in a couple years.
Technically that c-peptide should be good enough as long as it is accompanied by a fasting BG. But it may be up to your supplier. I know someone who has had to get a new c-peptide test with every new Medtronic pump since she has been on Medicare. Some DME suppliers may want a new test because they don’t want to run the risk of Medicare denying the pump. I got a new Tandem pump over a year ago and did not need to repeat the test.
Well said, Laddie! My Medicare experience echos yours. I now just see my PCP nurse practitioner quarterly via telemed to keep my pump coverage. Had an Endo but stayed with my PCP after my Endo went on maternity leave. Am in a rural are with one Endo. Have had no trouble continuing my pump and Part B insulin coverage.
How do you folks on telehealth visits get your A1c done for the visit? Mine is done in the office and the result is ready when the Endo comes in.
My Dr.s office sends me a lab requisition through the mail and I get my labs drawn the week before my appointment so the results are sent to my Dr. before hand. My local clinic does the draw and sends it on.
Thanks. I know of one commercial clinic but I am so used to the endo’s clinic and my experience is that it’s best to use one lab consistently. But I will talk to him next time I go in because I’m so stable I don’t really need an in person visit. But with the mail system what it is…my local mail goes to another state for sorting and then back to my town for delivery!
My doctor has not required an A1c with every visit, whether telehealth or in-person. He sends the chart notes for every visit to my insulin, pump supply, test strip and CGM supply vendors when I request an Rx refill.
I don’t think that payers, whether private insurance or Medicare, require an A1c to make a doctor’s visit eligible for payment. My doctor, however, has a much better picture of my glycemia since I wear a CGM. That provides a superior view of my glucose experience and management than an A1c test.
The CGM time-in-range (TIR) report is slowly replacing the need for an A1c for patients who use CGM. Think about it. An A1c is a single data point that only reflects the average glucose and doesn’t report on variability or glucose extremes. The CGM gives the doctor up to 288 data points every day and 25,920 data points every 90 days.
In your case, the need for an A1c may be a requirement of your doctor.
The a1c may be an endo requirement but I also like to track it over time. I agree th cgm is better for trends and they do my cgm printout and give me a copy of that sheet also. Even tho I can get it myself at home. But we look at it together in the office. And sometimes they recommend a basal adjustment. I may agree or at other times tell them no that was my poor eating choices in those times which I can change!
I’m not sure if this has been brought up or not. My hubby is on a pump and Dexcom. He has Medicare and a supplemental policy. The pump supplies and insulin are ALL covered under Medicare Part B. It took a long time to train our pharmacy and the technicians how to bill so that everything is covered. Also, not every pharmacy works with Part B. We have had good results with Walgreen’s (in Idaho) even though it took several months and several phone calls to get them used to billing Part B. Their system is kind of whacky and they MUST put in your last dr visit date, and it must be every 3 months. He trades off between the PCP and the specialist.
If you have trouble you can call Medicare, but even some of them do not know these items are considered DME (durable medical equipment). If you are persistent your pharmacy will eventually learn how to do it. But like I said, it took a few months for the Walgreen’s to figure it out.
The rule for pumpers is not every 3 months, it is every 90 days. I am on MDI so it is every 180 days. A few years back my appointments due to endo scheduling conflicts ended up at 182 days (yes within 6 months) and my CGM supplies were delayed for several days, I believe 2 weeks to get that mess straightened out.
WOW! this has been so helpful to me as I approach beginning Medicare and switching from OmniPod to primarily Tandem pump. I see I should likely first work with my Endo but then can also work with my PCP as long as they both understand how to work with a Pharmacy well to provide them a letter each 90 days. I will provide my Dexcom CGM Clarity reports to my doctor as evidence of my HgA1c and TIR. Thanks again all!
There is an easy way to do this automatically if you wish as well and save the hassle of printing out your clarity report. Additionally, doctors have access to a professional version of Clarity which gives them a much greater ability to deep dive into your numbers which they may or may not want to do.
- Sign into your Clarity Dexcom Report
- Click on the Settings Tab
- Scroll to the bottom right of the settings page
- Click on +Share Data With A New Clinic
- Ask your Endo for a Sharing Code
- Enter the Sharing Code and your Date of Birth and you are set to go.
This also saves time and hassles when you arrive for your appointment because you don’t have to go through the “give me your receiver to download your data dance” You just tell them that information is shared with them and online. Dexcom allows for more than 1 clinic to be added so you can do this for both your Endo as well as your PCP.