The Insurance company that handles my Medicare PPO approved my CGM no problem, and I received it yesterday, Friday 9/9/2016. It is under DME at an 80/20 reimbursement, The Insurance Company, (I will not name it), that handles my Medicare PPO doesn’t go by Medicare Guidelines, they have their own guidelines and policies they observe, I was told. So if you can find a Medicare Insurance Company that uses their own guidelines and NOT Medicares you could probably get a CGM.
24 hours in and I’m Loving it!!! Doctor put me on it because of me complaining that I sometimes wake up in the Middle of the nite Drenched in Sweat and confused…He surmised Nocturnal Hypo unawareness…Sure enough last nite, the first nite with the CGM, it caught 2, yes TWO Hypos before they got really bad…I was able to correct and didn’t have any more problems…I did notice this morning some Dawn Phenomenon when I uploaded to Carelink. That MIGHT be though from what I used to correct earlier…we’ll see tonight when I goto bed what happens over nite.
This is interesting, but there has to be more to it. Medicare’s blanket policy is not to cover CGMs, which is why there are two bills pending in Congress to get that rule changed. If your carrier decided unilaterally to cover your CGM (and good on them!), presumably they are footing the entire bill and not just the difference between Medicare’s reimbursement and the total cost. If that’s the case then it suggests that they are an unusually enlightened insurance company. We could use more of them, to put it mildly.
Is your insurance termed a “Medicare Advantage” program? Medicare Advantage is not technically Medicare but the insurance companies, to participate in the program must cover everything Medicare does. I’ve read other comments like this one in the past. Perhaps exceeding Medicare coverage in a Medicare Advantage program is OK with Medicare.
I’m happy to read that you’ve received the CGM through your insurance. I would be worried about the company not fully appreciating what this means financially and then changing their mind on this policy.
Medicare should not discriminate against people with diabetes. Let’s hope the FDA expert panel’s finding that dosing off of CGMs is OK (a ruling in the Dexcom package insert language) and that the full FDA votes to change that policy.
By the way, we taxpayers pay more per capita to cover people in the Medicare Advantage programs versus traditional Medicare. Another fantasy of the free marketeers.
Preferred Provider Organization (PPO) Plans
How PPO Plans Work
A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network . You pay more if you use doctors, hospitals, and providers outside of the network. [emphasis added]
I followed a few links listed when I googled “medicare advantage dme coverage.” Nothing specific offered there. I think you probably have to sign up and go through all the motions to find out if CGMs are covered or not. This prevents due diligence on the prospective customer’s behalf. I’m sure that’s a feature, not a bug.
I have a Medicare advantage plan through UHC. They covered me for two and a half years. Then they changed their minds and decided to follow Medicare rules and stoped my coverage. I’m still trying to get coverage resumed. Waiting on my ALJ hearing. Glad they are covering you. Enjoy the CGM. They are lifesavers.
Dave, I had the Medicare Advantage Plan through UHC When I tried to get my pump the first time…they Literally on phone laughed at me and said “good luck with that, we WON’T cover it.”…Needless to say I changed my Medicare Advantage plan to another Company and was approved almost Immediately for my Pump. I was approved the same day they received the information from Medtronics for my CGM…What you need to do is change your Medicare Advantage Plan company away from UHC or whom ever will not cover you…call the other companies and ask if they go by Medicare Guidelines or use their own for “Prior Authorizations”…If they use their own then switch to that company at the Open enrollment in October…Also, You can do a Google search for a particular Companies Medical Policies to find out if they will cover you and what their guidelines/requirements are to get that coverage.
That’s what I have been considering. If I can find coverage, I have to weigh the cost of that against my former employer reimbursing me my Medicare premium. Would probably still be to my advantage. Thanks for the reply.
Yeah, Medicare doesn’t have any problems covering pumps if you meet their criteria. But they don’t cover CGMs at all, and while I am not a fan of pumping, I would kill for a CGM. Figures.
Also, I don’t have a Medicare Advantage plan but rather a Part F supplement. My broker and I crunched a lot of numbers and this penciled out way way out front. Not close.
There are some, but very few, Medicare Advantage and Cost plans that cover CGM. Supplemental (Medigap) plans do not cover CGMS because they follow Medicare guidelines. Sometimes people who have Medicare plans through retiree insurance also end up with CGM coverage and coverage for things like the Omnipod that Medicare does not cover,
One of the Cost plans I am looking at in Minnesota does cover CGMS for some patients, but that is only one factor for me to consider as I choose a plan. If I do not choose a Supplemental (Medigap) plan in my 6-month eligibility period when I first start Medicsre, they can refuse me or charge me higher rates due to pre-existing health conditions in the future. Longterm there are benefits for me for having a Supplemental plan and I need to weigh those benefits against the short-run benefits of CGM coverage.
