Medicare disappointment

#1

Hi its been a while since I have posted. I recently started getting medicare. After working many many years I get medicare to find out it pays for so little. How is it that medicaid pays for everything yet medicare pays for so much less. One of the things cut out has been my dexcom. Dexcom is not covered by my plan. After years of using it im going to have to go without. Meanwhile my neighbor who hasnt had a job in decades has all the new tech. What is going on here?

#2

Dexcom G5 is currently approved by medicare. G6 will start shipping later this year.

Can you provide more details? Who told you it was not covered.

Do you have an Advantage plan?

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#3

I agree. What type of Medicare plan are you on? I have been on Medicare for 5 years and on Dexcom since approved by Medicare. If you are on an advantage plan that doesn’t cover Dexcom, “hie thee to another plan”at next open enrollment! (FYI I am on original Medicare with supplemental if that makes any difference)

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#4

Traditional Medicare combined with a supplement plan under Part B features Dexcom G5 coverage with no out of pocket cost once the annual deductible is paid.

As others have already mentioned, coverage under Medicare Advantage plans vary and do not necessarily cover CGMs.

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#5

You have to have a supplemental plan (Plan F is the most popular plan and so is AARP). I have UHC thru AARP and don’t pay squat for surgeries, testing, doc appts, hospital stays…all I pay for is for medications. My diabetic supplies are 100% covered: strips, sensors, sets, insulin (part B–because I pump). Not being nickled and dimed constantly is a blessing.

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#6

I was surprised when I first learned this. I wonder if those “selling” the plan make that clear. Or is it a clever way for those plans to discourage PWDs from signing up, or they end up switching the next year.

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#7

What I learned when I signed up with a traditional Medicare supplement plan when I turned 65 last year was that if I chose an Advantage plan and later wanted to switch to traditional Medicare, then I would have go through medical underwriting and likely pay a higher price for the supplemental or even be refused.

I know the Advantage plans have some benefit sweeteners but that trip through the underwriting process if I chose an Advantage plan and wanted to switch back to regular Medicare seemed financially risky to me. I also didn’t like the fact that Advantage plans could change access to providers and some benefits at their whim. As a taxpayer, I don’t like that the Advantage plans cost the system more per person than traditional Medicare.

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#8

I agree! Thanks for the heads up.

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#9

It’s a transfer of risk. Medicare Advantage plans transfer the risk from the federal government to an insurance company. In return, the government pays that insurance company a premium. The insurance company has to provide a certain level of coverage, but not necessarily the same level as an enrollee would receive under the traditional FFS Medicare coverage. The insurance company tries to manage the costs of the Medicare Advantage plan by using a restricted network or formulary as well as other methods. Managing the costs effectively enables them to make a profit off of their work. Conversely, if costs are not effectively managed, then they incur a loss.

In a traditional FFS Medicare arrangement, the federal government holds all the risk. In some cases, this saves them money, and in some cases it doesn’t. If costs are not being effectively managed, then it does not save them money. A Medicare Supplement does not transfer risk to another entity but simply wraps around the traditional FFS Medicare coverage.

I’m not saying one is better than the other. An effective Medicare Advantage plan might enable a more holistic approach to managing the conditions of an individual, and there’s definitely a benefit there. Better management of conditions saves the insurance company money and can give the enrollee better health.

I prefer having more access to medications and doctors though, so if I were to retire in the near future I would probably opt for a supplement instead. It’s unlikely Medicare will still be around by the time I retire.

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#10

yes I have aetna coventry an advantage plan

#11

I don’t know which AARP plan I have? But just got a new 90 day supply of Humalog. I am on pump and Dexcom 5. After many discussions with supplier and insurance my co-pay was over $432.00. What am I doing wrong?I am not familiar with Plan F.
c

#12

Congrats on joining the joining the discussion at TuD, @spjwt. Medicare recipients must do several things to get their insulin covered at 100% following payment of the annual deductible:

  • Subscribe to traditional Medicare, not Medicare Advantage.

  • Buy a Medicare Supplement plan. These plans are designated by letters like F and G. AARP sells all kinds of insurance plans, not all of them are the lettered Medicare Supplement plans. You are not eligible to purchase a lettered Supplement plan unless you have already subscribed to a traditional Medicare plan.

  • Use an insulin pump.

  • Make sure the pharmacy submits the Medicare claim under Part B, not Part D. Pharmacies are not all familiar and experienced with Part B; they’re more experienced with Part D claims. Sometimes you will say “Part B” and they will hear “Part D.” I often say, “Part B as in bravo, not Part D as in delta.” Part B is also known as DME or durable medical equipment coverage whereas Part D is a pharmacy drug benefit.

Once Medicare pays their 80% of their negotiated share, the claim is automatically submitted to the Supplement plan leading to eliminating your out of pocket cost.

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#13

Thank you so much for needed info. I see that my mistake is being enrolled in a Medicare advantage plan. Will call UHC Monday and see if it is possible to switch. 0

#14

You may find this info helpful. There are rules for different time periods.

leaving medicare advantage

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#15

So in a couple years to get best Medicare benefits I would need to go on a pump?? I hate the idea of something else STUCK inside my body!!!

#16

Yes, it would be a trade off for someone who doesn’t like devices attached to his body. That’s a decision that only you can make. It’s not fair and I hope that Medicare’s policy evolves to paying for all insulin. For the time being, we must live with this inequity.

Have you ever tried to wear a pump? With wearing one for almost all of the last 32 years, it’s become embedded in how I move through my day. In fact, when I’ve taken a few pump breaks, I find myself reaching for my “pump tail” when I get out of bed in the middle of the night.

Like many things, we can often adjust and adapt to habits that at first irritate us. Not always but we humans are remarkably adaptable.

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#17

After many years of MDI and chasing affordable insulin, including insulin from Canada, I did go on a pump and found that the attachment issue was not an issue at all.

My fear is that instead of paying for ALL insulin, Medicare would decide to pay for none, a much more likely event.

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#18

The sets aren’t “stuck” in your body. LOL! You can remove them at any time. Normally, they get replaced every 2-4 days. It’s great to have awesome control, which relates directly to a longer, less stressful life. Are you opposed to that??

You’d probably get used to having a pump in a week or so. It’s not bad. It’s actually liberating because you can get such better control over your bg’s, take care of any DP you might have, reduce your basals for activity…the pros FAR outweigh any cons that you can dream up.

#19

I’m totally with @JJM1 on this one. I suppose you can’t knock it until you’ve tried it.

I’ve tried it, and I can knock it. I hope I never have to go on a pump again.

I’d probably price out buying insulin from Canada before doing a pump again.

You can get insulin through Part D, it’s just not covered in full like it is under Part B (with a pump). Maybe some supplement or Medicare Advantage plans have benefits that cover the Part D donuthole?

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#20

Quite well aware that they are readily removable. So in a month I could expect to STICK stuff in my body 8 to 14 times PLUS the 3 or 4 times for CGM.
No, I have not tried a pump and at some point I might be convinced to try, particularly when artificial pancreas is proven infallible and totally automatic.
Not meant to knock all those who love their pumps.