I’m facing the enrollment in Medicare in January and am trying to figure out whether it will be okay to go on Original Medicare or go into a Medicare Advantage plan. My questions relate to how hard/easy it will be to transition my T1 technology usage. Any help/advice will be appreciated from those here who have the knowledge and experience.
My situation is that I will have to get all new doctors in January so I will have to get a new endo clinic that is Medicare oriented where I have no past history with the clinic and staff. I have been T1 for over 50 years and currently use a Tandem Tslim X2 with Dexcom G5. Maintaining the usage of this technology without breaking my budget is the key issue I am trying to solve here.
If I go on original Medicare with a part D drug plan how difficult will it be to get Tandem pump supplies and Dexcom sensors/receivers given that I am currently using all of this stuff. Will I have to start as if have no history with this technology and prove that I need it (as I did a long time ago with private insurance) or is there some adjustment for someone who is already a pumper/cgm’er?
I’ve seen a lot of discussion here about the difficulty of getting pump’ed insulin billed to Medicare part B. Can someone please let me know what exactly is the cost of part B insulin (i.e., all I can find is that the cost is 20% of “something” but I cannot find out what that “something” is to figure out the real cost)? I guess I’m trying to figure out if it is worth the hassle to convince a pharmacy to charge insulin to part B or just let it go onto part D (which I can get a cost estimate for). I use about 5 vials of insulin (either Humalog or Novolog as I have used both in the past) every 3 months.
I can get cost estimates for the Medicare billing of the Tandem and Dexcom supplies. What I cannot get a handle on is how difficult the paperwork will be to start getting my supplies authorized at the beginning of the year. Any advice from anyone out there who has done this would be appreciated.
Finally - I have one last question. In my community it seems like the best Medicare Advantage program is with Aetna. Does anyone have an opinion on how supportive the Aetna insurance company is for a T1 who uses a Tandem pump with Dexcom cgm technology? Ultimately my decision is going to come down to whether or not to go on traditional Medicare or go with a Medicare Advantage plan from Aetna. I am trying to figure out which path would have the least “brain damage” and cost as far as taking care of my diabetic life.
I just received a Medicare Part B explanation of benefits form that includes my last 90-day supply of pump insulin. I got five 10mL vials and the Medicare approved amount is $1190.70. Medicare paid $877.84 and I owe $223.94. The original price the supplier charged was $1590.99 or $318.20/vial.
I am starting a Medicare Supplemental Plan that I expect to pick up my 20% of these insulin purchases starting in 2019.
Your concerns are well founded. It is mess out there. The medicare only covers 80%. After that you have two options. One is join a medicare advantage plan. Other is medicare supplement plan for remaining 20%. Govt had predecided what private insurer will have to do–ie extent of coverage.
The diabetic supply coverage will be identical with both Advantage and Supplement…
I have supplement and I pay about 200 per month in addition to mandatory medicare part B. The big advantage is I can go to any doctor or clinic nationwide-no refferal required no questions asked. You can even see multiple primary care or specialist in the same town. To me this is very important–because all doctors are not alike.
The advantage plan is zero payment in most places. But, you have to go the doctors in the system. In california they have 3-4 major hospital systems and you can not cross their pool of doctors.
I do not know about CGM and other stuff. I think advantage will be lot cheaper. I have separate drug plan and pay 20 per month. Plus I pay 75 for one lantus insulin pen. With hospitals bulk buying–I think it will be lot cheaper.
But, for me it is supplement plan because of flexibility to see many doctors
I have been on original medicare since I was eligible. In addition, I have supplemental insurance that picks up the portion (20%) that medicare does not cover. Every year I shop for the best deal out there for my supplemental coverage. Medicare and my supplemental insurance covers everything. As a result I do not track the actual retail costs of all these items.
Except for medicare and supplemental premiums, I pay nothing for pump, cgm, supplies, insulin, etc. I have been very happy with original medicare although medicare requires I submit written documentation occasionally showing charts for finger sticks, etc. I find that it is not too onerous once you set up a system to track this.
Medicare will often originally deny coverage. Expect that you will have to be persistent in asserting you rights. I would make sure you have an endo that will fight for you and support you. As an example, Medicare paid for my Libre CGM. After 3 motnhs I decided the Libre was way too inaccurate for me and switched to a Dexcom CGM. Medicare ultimately paid for both CGMs although my endo had to get involved to get the Dexcom CGM. I doubt that I would have been successful on my own.
Thanks to all who replied with some information. Every bit is helpful.
After researching this for quite a while I have concluded that an optimal Medicare alternative from the perspective of a T1 diabetic is not obvious or apparent (and probably never will be). I suppose the best thing one can do is to take a chance on what seems like a reasonable alternative and hope for the best while preparing to advocate for your T1D drug and technology needs as best you can.
One good thing I learned is that in 2019 you can try out a Medicare Advantage plan and if you find out it is not working for you in the first three months of 2019 you can try switching to a new plan (or traditional Medicare). If I make a bad choice I can at least try to improve the situation by switching to something else early on. I suppose that means I have to get established with an endo clinic quickly in January and start working on getting supplies reordered as soon as possible after that.
Original Medicare should allow you to use your current Endo. Your insulin and sensors will be covered for 80% of the Medicare approved price. Depending on the Medicare supplement you choose a portion or all of the remaining 20% will be covered. I do not know about your Tandem pump supplies. I have the Minimed pump and supplies are covered.
IMO a person with diabetes who uses a pump and CGM will almost always be better off on Original Medicare with a Supplement rather than an Advantage plan. Some reasons:
Medicare pays 80% of Durable Medical Equipment (DME) under Part B and that includes your pump, pump supplies, insulin used in your pump, and all Dexcom G5 CGM supplies. Your Supplement will pay the remaining 20% and therefore you will have no out-of-pocket cost. With an Advantage plan, you are normally responsible for the 20% but it can vary according to plan.
If you do not select a Supplement (Medigap) policy in your initial benefit period, they are allowed to use underwriting and deny you coverage or charge higher rates based on pre-existing conditions. However, you can always switch from a Basic Medicare/Supplement/Part D situation to an Advantage plan. It is kind of a one-way street.
With Basic Medicare and a Supplement, you can see any doctor who accepts Medicare. No worry about Network restrictions or future changes in networks. Although Advantage plans talk about travel benefits, healthcare away from home is definitely easier with Basic Medicare and Supplement.
Other things to consider: Currently only tubed pumps (Tandem and Medtronic) are covered under Part B. The Omnipod has recently received Medicare coverage but only under Part D. The insulin therefore is reimbursed under Part D and much more expensive. Some Advantage plans may covered the Omnipod under DME so you would have to check your plan. Sometimes Advantage plans approve things sooner than Basic Medicare and some people are getting Dexcom G6 systems now.
You have to pull out your calculator and compare the finances. Most Advantage plans have cheaper premiums but you may pay a lot more for your pump, pump supplies, CGM, and insulin.
I currently use a Tandem X2 and a Dexcom G5. I pay no out-of-pocket cost for any supplies. It was a PITA to initially get set up with Dexcom and Medicare, but it has gone smoothly for me since then. Dexcom is required to send supplies monthly rather than every 3 months, but I can set up the order online. Getting my pump supplies seems to have different rules every 3 months but I do get what I need. Because I change infusion sets every 2 days rather than 3, my endo had to do a lot of paperwork to justify that. I have gotten used to the hassle.
When you switch to Basic Medicare, you are required to meet their rules for pump coverage. I don’t have the link handy, but I had to take a c-peptide test (my first ever!) along with a fasting BG. Usually longterm T1’s have no problem meeting the c-peptide target number, but some people with T2 can struggle to have it low enough. It is good to contact your supplier a month or two before Medicare and start getting set up.
For me it was only a minor hassle getting set up with Walgreens for my Part B insulin. They have a national Medicare department that can coordinate that. Others have success with CVS and other pharmacies, but I have always heard that Walgreens is the best at this. One advantage of getting insulin through Part B is that you do not have a formulary unlike most Part D plans. For sure you can get Humalog, Novolog, Fiasp, and Apidra at this time.
One good place to ask questions about Medicare and diabetes (especially Type 1) is this Facebook group. It was originally started as an advocacy group for CGM coverage by Medicare. Now is lots of topics related to navigating Medicare with diabetes and technology.
That’s all for now. If you have more questions, just ask.
Thanks for all that good information. Unfortunately for me I cannot qualify for a Medicare supplement plan in my state because I could never get past the underwriting requirements (I passed up the original enrollment opportunity years ago). My only available choice is bare bones Medicare or a Medicare Advantage program.
It would be really nice if there was a resource somewhere that could help one figure out the approximate cost of things on bare bones original Medicare. Just knowing that everything has a 20% copay doesn’t tell you much when you don’t know what the cost (or Medicare approved amount) of the thing (e.g., doctor visit, specialist visit, A1C test, part B insulin) is in the first place. Does anyone out there know if there is an official site of these items that is available to the public or at least some sort of list of commonly known estimates for these Medicare approved amounts?
Bob-I didn’t realize that you no longer have the option of a supplement plan. I was recently part of a group of seniors who had a conference call with JDRF as they prepare a document to help seniors with transition to Medicare. Everyone of us felt the most important thing that T1 seniors needed to understand was the importance of considering Basic Medicare with a supplement. Or maybe the most important thing is understanding one’s options and how they might change once you’re on Medicare.
My guess is that an Advantage plan might now be your best bet because you can be very vulnerable if you only have Basic Medicare. My understanding is that there is no maximum out-of-pocket on Basic Medicare and if you have a major medical event, you could really be vulnerable. I think many Advantage Plans have an annual maximum OOP. It is definitely something to check out.
If our national government remains Republican, we may quickly see a scenario where Advantage plans are the only option with seniors being responsible for more of the costs of their healthcare. But who knows? But I sometimes think that the decisions I make today may have little relevance to the senior healthcare landscape in the future.
Thanks again Laddie - I have been studying the Medicare landscape intensely over the past few weeks and have come to the conclusion (as you suggest) that traditional Medicare for a T1D w/o a supplement backup is too risky. In my community I’ve narrowed my options down to two choices of a Medicare Advantage program. Either Kaiser or Aetna’s best platinum PPO.
Kaiser has excellent endocrinology support for pumps, cgms and all the supplies and insulin - it is overall a very cost effective way to go. On the other hand they do a lot of cost cutting in other areas that can be a problem (e.g., it is very difficult to get an ophthalmologist appointment as you must always see an optometrist first and they will decide if you can get a referral to a real eye doctor - not a great scenario for a T1D such as myself with a long history of eye issues). And of course with Kaiser you are severely limited to the in-network set of doctors and have absolutely no option of going out of network.
Aetna’s platinum plan is pricey but you get access to the best set of doctors and clinics available in my community. I am told that the paperwork to get access to pump and cgm supplies is not too onerous but not nearly as efficient as Kaiser. The prescription drugs will be more expensive compared to Kaiser.
I’m not sure which way I am going to go at the moment. If anyone reading this can offer any anecdotes from their own experience or words of wisdom regarding these options for a Medicare Advantage choice I would be extremely grateful. I am going to continue to research these choices for at least another month or so.
thanks again,
…bob…
p.s. I personally was delighted when the ACA (Obamacare) was passed as I was one of those T1Ds who was (in earlier years) told by insurance companies to “just go away” when attempting to get access to health care. I suspect that the outcome of the election next month will determine the future health and status of a lot of us reading this forum.
Maybe if things get really bad one or two individual states will deal with the health care problem and lead the way to an eventual national solution. I believe that Canada’s national health care system started in one province initially…
p.p.s. in the context of all the complaints and issues with Medicare - I cannot imagine what the health care scenario would be like if we didn’t have anything like Medicare. All in all I am very grateful for the ability to be on Medicare - it truly is a lifesaver!
Great summary and review, @Laddie. Your writing inspired me to pick up the phone and buy a plan to supplement my Original Medicare benefit. I had been researching for some time and knew which lettered plan I wanted. I switch over on 1-1-2019.
I turned 65 a few months ago so I decided to switch from the work provided “supplement” that I received from a former employer. It wasn’t very good but it has covered my Dexcom supplies for several years, long before Medicare made the G5 a covered item.
I’m still using the G4 and have a few spare to last me until I switch to the G5 or G6 as covered by Medicare.
Thanks for your clear and informative writing, putting things in plain English. I follow the Seniors with Sensors group on Facebook and see your info posted there.
So this probably makes it the desert southwest time of year for you. I hope you are doing well
