Medicare and Tpe one

Hello
I just reodered my CGMS supplies and Insulin. Both the CGMS supplier and the pharmacy for my insulin for the first time asked about if I had a receiver for my CGMS and how I received my insulin. After 5 days of back and forth they managed to record that I was on a Tandem Pump with a built in receiver and that my insulin was delivered via a pump, for the pharmacy. I do not understand why for a prescription of insulin they now after 55 years need to know how it is delivered nor do I know why the DME provider needs to know what I use as a receiver, pump, phone, or stand alone receiver??? What is this.

Medicare Part B and Medicare Advantage providers require DME companies and pharmacies to keep sufficient records to support every claim. They will be audited at some point. Or they were audited and have learned their lesson. :grin:

I have no idea how MA plans work. Part B requirements are public documents so I, and you can, know how it works. If you have Part B I recommend checking them once a year. They explain a lot of what seems crazy.

So for the CGM, checking that you have a receiver or are using a pump is normal. Should be in Standard Written Order (SWO) from your doc but DME companies are notorious for not reading the documentation they held up your order for. For the insulin… does the prescription contain the phrase “use in pump” or similar? If it does then either the person asking can’t read or you’re using Edgepark/ADS and they are asking because if you tell them they can add that to their marketing database. If the 'script doesn’t say “pump” make your life easier by asking the doc to change the instructions for use next time you see them.

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In short, those answers tell them how to bill you.
Depending on your answers it might be part B or part D.
It also indicates if you are eligible for things like cgm.
So be careful that your answers are correct

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To, I hope, summarise what @spdif and @Timothy said when we go on to medicare the rules change. The pharmacy has to either bill the insulin against Part B, if you have a tubed pump, or Part D if you have no pump or an Omnipod. That’s the law.

For the CGM if you use a pump the provider of the CGM has to verify that you have a Medicare approved receiver. The T:slim is an approved receiver, the Omnipod O5 is too but the Omnipod Dash is not; Medicare requires us to have an appropriate receiver and use it. That’s the law.

Beyond the summary

So far as I can tell Part C plans (aka Medicare Advantage) do all this under the cover; they do all the checks, so it’s a one-place shop, a supermarket but they will ask the same questions.

I assume you are not using Part C, good choice; Part C costs a lot just to do all that work. My best estimate is that DIY halves the cost for me and for you, on a T:slim (I use Omnipod) you will come out at much lower cost if you have Medigap and may come out ahead even without it.

The cost is the DIY and, for me, spending months working this out; thanks to @spdif for the help on that front. Still I paid no actual money, just time and stress and high BGs. Worth saving a few thousand a year while still having health coverage for other issues.