Medicare vs Medicare Advantage plans


#1

I frequently come across all kinds of “savings” for people with diabetes.

Companies making insulin that offer a flat fee of $25 or another amount, for insulin per month. OOPS, not if you have Medicare. Only applies if you are commercially insured.

Dexcom now available under Medicare. OOPS, not if you have a Medicare Advantage plan. Only applies if you have straight Medicare.

So, my question, when does “Medicare” mean straight Medicare, and when does “Medicare” mean anyone of Medicare age, covered under a Medicare Advantage plan? The term is used to mean one thing is some cases and another thing in other cases.

How does one answer the question asked in many cases, do you have Medicare? Do you say YES, if you have a Medicare Advantage Plan? Should you say, NO, if you don’t have straight Medicare, the original, and not an HMO, PPO, etc. Medicare Advantage plan?

The term is not used the same in all situations. How does a person 65 or older know what is meant in each case?

Yes, Dexcom, IS covered by Medicare, but NOT by Medicare Advantage plans.

QUOTE from the Frequently Asked Questions at the Dexcom website.

> "Is Dexcom covered by Medicare?
_> _
> Dexcom is now shipping the Dexcom G5 Continuous Glucose Monitoring (CGM) System to Medicare patients with traditional fee-for-service coverage. Please note that at this time, we are not able to process Medicare Advantage plans."


#2

correct me if I’m wrong, but I believe advantage plans have DME providers that one would need to use to get Dexcom if covered. I think they are referring to directly using Dexcom vs going through a DME like Edgepark or whatevever.


#3

Whether it is Medicare or Medicare advantage or other benefit.
It is up to you to understand if it provides the coverage you need.
No reason to believe otherwise


#4

Correct me if I am wrong, but turning 65 does not mean you are incapable of understanding your health care options.

I just turned 73 and I still seem to function. :slight_smile:


#5

So Medicare is divided into different parts. When one turns the appropriate age they are automatically eligible for Medicare unless they opt out or are not eligible (there still some cases where this applies).

When enrolled a person may select different options. Standard medicare pays 80% of DME coverage. This is typically called part A and B coverage. This includes Dexcom sensors.

One may choose to have an advantage plan, usually these plans cover prescriptions and almost all covered charges with pre specified deductibles and co-pays. But the services received are determined by the advantage plan sponsor. Under standard medicare parts A and B you may see most any docotr at your discretion.

Under an advantgae plan (identified as Part C) one no longer has Part A and B. Again all benefits are determined by the provider, including who needs or receives Dexcom equipment. Each advantage plan sponsor negotiates separately with providers so each promivder may or may not have a contract with Dexcom. again all benefits are determined by the plan sponsor or company.

Now to further confuse the situation Part A and B and some advantage plans do not cover medication. Thus in most cases a person may purchase Part D prescription coverage. Like most of these plans individual providers offer different formularies. So It is important to exam each Part D plan offered to make sure they cover the medications one usually takes.

These are the typical medicare plans. There are also some hybrid plans in other parts of the country that operate on a demonstration basis or as part of regionally specific legislation.

To answer the question you posed. All of these circumstances are Medicare. An advantage plan is a more rare but growing occurrence. Do you have

Medicare? yes

or if signed up (this takes an affirmative selection)

Yes I have a medicare advantage plan with ______ company.

Unless it is my Great Uncle Harry asking. In that case you need to walk away because he is likely trying to marry you and steal you benefits. Just saying.


#6

I previously had Medicare A and B. I also had United Healthcare supplemental to cover a portion (80%) of what Medicare didn’t cover, including my Medtronic CGMS and supplies. In addition, I had a private drug plan to cover my prescriptions. Beginning in 2018, my retirement plan was changed to a United Healthcare Group Medicare Advantage. Under this plan, Medicare A and B is serviced by United Healthcare and I no longer have any coverage for my Medtronic CGM and it’s supplies. My drug plan is now called Silverscript but it is still serviced by Caremark… Though my sensors are not covered ($350 for five), my test strips (Comfort Curve -150 per month) are free.

When I recently called Medtronic to inquire about the future coverage for the sensors, I was advised that the Advantage Plans still need to negotiate with Medicare in order to provide coverage. Several months ago I cAlled Dexcom to inquire about coverage and was advised that the Medicare Advantage Plans did not cover Dexcom sensors.


#7

I have a Medicare advantage plan, which has some limitations as noted. I Don’t use any medications etc for my diabetes, so it works well for me.
Overal the cost seems reasonable and Kaiser, my provider has a large net work.

The original concept for Medicare advantage was a wellness program with controlled access to treatment. It does not work for all. You can choose another Medicare program.


#8

To T2Tom

I am sorry but your smiley face does not excuse your snarkiness.
I still function fine and am very versed in the differences between straight Medicare and Medicare Advantage plans. I read the “Evidence of Coverage” each year from my plan, and I also read the “Medicare and You” published each year.

What I was referring to was the ambiguity and vagueness used by others. For example: If one calls their Advantage plan, they will tell you different things depending upon the representative that answers the call. I have called for clarification about something that was generalized in the “Evidence of Coverage” and told by one person, that a particular item was NOT covered. I called back about 15 minutes later and was told by a different rep that the same item WAS covered and my portion would be X dollars. A third call, same item, was told it was covered but my portion would be Y dollars, not X as previously quoted.

So, Tom, you tell me how I am suppose to know MORE than the people that administer the plan?

Again, I thought this forum was to HELP other diabetics, not a put down. Your comments were of NO help and insulting.


#9

Thank you, BradP.

It may just be a matter of time when Dexcom negotiates with the various DME suppliers.


#10

To Rphil2

Thank you for your very detailed explanation. That was kind of you but unnecessary. I am fully aware of the ins and outs of Medicare, Advantage Plans, supplemental plans, and drug plans. I spent months studying and researching ALL options a few years ago.

When someone has opted to go with an Advantage plan instead of straight Medicare, they do NOT show their Medicare card when seeking medical services. They show their insurance card from the advantage plan.

My question related to the ambiguous use of the word “Medicare”.

If someone has a Medicare Advantage Plan, they technically do NOT have Medicare. The word Medicare is used in many instances to encompass not only Medicare, but also other options to Medicare, such as advantage plans.

Some people have only Part A of Medicare.
Some have Parts A and B.
Some have Parts A, B, and D.
Some have Part C, which is the combination of A and B administered by an advantage plan, which may or may not include Part D.

Where my confusion comes in is the broad use of the word Medicare. Are they referring to straight Medicare, those with Parts A and B?
Does the term ALWAYS include Part C or is Part C excluded at times from the generalized term “Medicare”?

When someone makes a doctor appointment, when asked about coverage, does someone say they have Medicare if they actually have Aetna, Blue Cross, Humana, etc.? Not usually. They state the insurer name on the card they provide. People with advantage plans do NOT present their Medicare card, they provide the card from the plan.

What prompted me to post my question was seeing all the ads on television for diabetic drugs and supplies with great discounts and offerings. Then, when you investigate, you find that “Medicare” patients are prohibited from participation in the discounts.


#11

Thank you Don1942.

Sounds like you had great coverage and now are at a big disadvantage.

Sorry to hear about the change in your coverage.


#12

I am very happy to hear that do not need medications for your diabetes control.

Some of us on the forum DO need medications and supplies. I would hope that you would show a little more empathy for us and the financial burdens we face.


#13

It was not meant to be snarking, sorry, but you did say how anyone over 65 understand this. So not sure what that meant. I thought that was demeaning.

I still do not see that things are confusing


#14

We obviously have a communication problem. I am glad you have such clarity when terms are used ambiguously.

Medicare has 4 different “parts”, so if someone simply states “Medicare”, . . . . . does that ALWAYS refer to ALL 4 parts? Or do differences exist?

When a statement is made that Medicare now covers Dexcom G5, does that mean all 4 parts cover it? NO. Some parts of that is an obvious NO.

My question is when does Medicare mean ANY part of “Medicare”, including Part C, and when does Medicare mean only Part B?

I don’t know how I can be any clearer in my question.

If the ads stated the Dexcom G5 is now covered under Part B of Medicare, then, my question would null and void.


#15

Insulin is covered under Medicare. BUT, it is my understanding that HOW the insulin is administered makes a difference of whether it is covered under Part D or under Part B.

Things are not as cut and dry as you portray them.


#16

Sorry again babs it seems I am not on you good side. I mentioned that I was not on medication just to point Out i was not having issues about medication for diabetes because I’d don’t use them.

I consider my LC way of eating and my exercise program to be my treatment for my T2

I have Medicare coverage as administered under the Kaiser Permanente Medicare Advantage plan. Which means I mostly need to use in plan services.

I did see AARP has a Medicare Complete plan which they say is an advantage planWhich is a new plan to me.


#17

Dear T2Tom,

I was sincere when I said I was happy for you that you are able to manage your diabetes without the aid of medications.

I know you are very active on this forum and I know I am not the only person that has been perplexed at times about all the red tape involved and have voiced that on this forum.

Since my first day on the forum, you seem to attack me frequently when I post. I don’t know why we can’t communicate with each other. Maybe we can get along better from here.


#18

At least for my Medicare advantage Plan through Kaiser (largest in Medicare group in Sam Francisco) one of the advantages is that since they administer the entire program down to eyeglasses. If you have any problems or questions you just call them. They may not give you the answer you want, but there will be an. Answer and explanation.


#19

I hope to get along also, I don’t mean to attack anyone on purpose.
But we each have our own style which might not work the best. I will more careful with my comments.


#20

Consider yourself very fortunate. When I call MY plan, I get a different response to the same question with each call. I have even been told an item was NOT covered after they have been covering it for me for months. That is when I know I need to call back and get someone else on the phone that knows what they are talking about.

Wishing you the best. Keep up the great work you do with controlling your diabetes.