No Coverage for Insulin Supplies

Diabetes Advocacy Public Advocacy
1

As a T-1 Diabetic for 30 years who has had support and fully took advantage of Diabetes Technology I now find myself at a cross road where all technology is being taken away from me by Alignment Health Sutter Advantage HMO health plan. I received a week ago a letter from Sutter Medical who state that they will not provide or authorize Insulin Supplies. Insulin Supplues include syringes, glucose meters and test strips, insulin pumps and continuous glucose monitors. I am retired and the health insurance I mentioned above is my Medicare Advantage plan. As a result of coverage being refused I’ve now been off my Dexcom CGM for almost a month and have been using finger sticks with my glucose meter. It’s been hard stepping back over 20 years in my diabetes adventure to be managing my disease in a fashion that made it so much easier using 21st Century technology, But I’m doing it … at least in monitoring my glucose levels by using finger sticks. I am waking up every 2 hours or so at night to test and monitor glucose trends. Not impossible but hard, in about three months I will run out if my Tandem Insulin Pump supplies and will start using syringes. I’ve been using a pump since the mid 1990’s. I will be speaking with a Diabetes Educator to get training on how I tried to manage my diabetes 30 years ago and will hopefully be able to handle that backwards transition. Just to preempt the question that will obviously be asked … yes I’m fighting this issue with Medicare and Sutter Health but as yet I’m precluded from any coverage for my Tandem Punp and Dexcom CGM. I have to manage my T-1 Diabetes and doing so the best I can. I live California and have reached out to everyone and anyone who can help. Thankfully at my age I still have a relatively clear mind, and although I go into panic mode occasionally, I don’t want to give up and have been working to try and work with the cards that have been dealt to me.

Has anyone here had a similar experience and how have you coped with the change? Any pointers on better managing Diabetes while not using a pump or CGM? Thanks fir any and all feedback.

2

Do you still have the option to go back to traditional Medicare? I’ve never heard of any recent insurance of any kind that can refuse a T1D pump therapy or CGM…

2 Likes
3

It’s possible that I could return to traditional Medicare especially since we’re coming up to the annual election period. It’s done thing I am thinking about dnd will need to research further. However, the big challenge with that is finding primary care and specialists who will take me on as a patient. I’ve already sought out both snd couldn’t find any within driving distance who would take me on as a patient. They all only accepted PPO or HMO Advantage plans as medical insurance for me as a patient. It seems a real Catch-22 for me at this point.

4

It’s my understanding that returning to traditional Medicare from a Medicare Advantage (MA) plan requires successfully going through medical underwriting. (Correction: It is the switching from MA to traditional Medicare with a supplemental plan requires medical underwriting.) T1D, as far as I know, will assuredly disqualify you. That’s a tough break and completely unfair to you.

I know of one path you could take: using a low carb way of eating combined with a multiple daily injection program featuring three insulins: Regular, a long acting basal, and a rapid insulin for corrections. Dr. Richard Berstein’s book, Diabetes Solution, has all the details and it works!

For you to adopt this protocol and make it work would require a large adjustment and commitment from you but it seems a fair trade by me. Here is an interview of a young college student who was brought up using this method and he has made it work for him and his family. Dr. Bernstein, by the way, has been a T1D for 78 years and is now 89 years old.

I’m sorry if my suggestion seems unattainable to you but many, including many seniors, have found this path doable and life-changing. I wish you luck in whatever you choose to do!

1 Like
5

It looks like you can switch Medicare Advantage Plans during the annual open Advantage Plan period from January 1 through March 31. United Health/Walgreens offer Medicare Advantage Plans and other national firms probably offer them as well.

If you can switch to a better plan early next year then you only have to self-finance for a few months. The Freestyle Libre is cheaper than a Dexcom and might be easier to deal with than 12 finger sticks a day. A few months of pump supplies might be something you can handle. It’s an emergency just like car breaking down.

Again if the problem is only short term, you might be able to get help through a charity or even a Go Fund Me campaign.

Hope this is at least a little helpful,

Maurie

2 Likes
6

Are you saying they are changing the plan coverage or is the letter a claim denial?

7

Something sounds wrong here. I don’t think any medicare plan can refuse to cover items that medicare approves of. Is it possible your advantage plan simply isn’t a distributor of these supplies and wants you to get them elsewhere? With the “elsewhere” billing medicare and then turning it over to your advantage plan for the remaining payment?

Like…I’m on Medicare, with a BCBS Medex supplemental plan. My pump and pump supplies come from a company called CCS medical. They bill medicare, who pays what medicare is going to pay, and then medicare automatically submits it to BCBS, who then pay their share. Likewise, I get my insulin and test strips from CVS Caremark, who bill directly to BCBS.

It might be a good idea to call your advantage plan and ask for clarification. BTW, because I never wanted to deal with it, I still get my insulin as a “drug” rather than as an adjunct to durable medical equipment. If I did the dme route, the insulin would be free but this way I have a bit more control and since I get a 90 day supply with only a $15 copay, it only costs me $60 a year.

Good luck and let us know what happens.

1 Like
8

It costs you $60 a year plus the premiums of your part D prescription drug plan. Some, depending on other medication, requirements pay very low premiums for part D but their preferred insulin is not on their formulary, while others pay much higher monthly premium payments and get insulin with low copays. There is no free lunch when it comes to medicine.

1 Like
9

So true, CJ, but my premiums are quite low, thank goodness, and I have no copays for doctor visits or hospitals or tests. I was very lucky to have worked for a hospital for 3 years, and when I retired, I was grandfathered into a program that no one can get any more. Admittedly, I am very blessed.

2 Likes
10

I was always told that diabetics should never get a Medicare Advantage Plan. Please try to switch to traditional Medicare with a medigap supplement.

2 Likes
11

I think you can switch to another MA plan anytime if it has a 5 star rating. Maybe you can find a 5 star that will provide supplies. I switched outside the window to a 5 star.

1 Like
12

There is a few tricks/hoops I believe going back to traditional Medicare from an advantage plan. I could be wrong here, I’m no expert. I think advantage plans can follow their own rules as long as they cover certain basics. I think it is more of a should cover versus have to cover when it comes to especially their formulary list. That’s how they cut down on costs. While I might have the choice of 10 insulins, or any doctor, an Advantage plan will limit which/what ones you can get. Usually the pump choices are limited and maybe what qualifies, although I’ve never heard of them stopping all choices altogether. But I am not surprised either. All the ads of no monthly cost and they will pay for other things, the costs have to come from somewhere. And costs have gone up. I never recommend an advantage plan unless you are really limited in being able to pay any costs. But traditional Medicare Type D has it’s own costs and without Medigap insurance you could have some costs with it you need to be prepared for.

But… you might want to really investigate the choices of switching back to traditional or just switching to another Advantage Plan. I think it’s odd they changed coverage mid year. But I don’t think they are actual laws to say they can’t. I did find where they are supposed to give you a 60 grace period of coverage.

I am no expert though and you really need to dig into looking it all up, probably on the Medicare sight. They have a lot of useful information.

https://www.medicareinteractive.org/get-answers/medicare-health-coverage-options/medicare-advantage-plan-overview/notices-that-medicare-advantage-and-part-d-plans-must-send-if-they-make-changes-during-the-year

Medigap and Part D Coverage insurance after you’ve been in an advantage plan.

2 Likes
13

Here is a question, why did you ever cancel medicare part b. Part B covers a pump tslim, minimed ect. They also cover cgm supplies Dexcom. they cover infusion sets all these items are a 90 day supply. Medicare covers insulin if you are on a pump, I get 3 bottles every month for 35.00 dollars. This is without bc/bs involved this is my secondary ins. You should have never ever have let part b lapse. ( might have repercussion to get it back). To sum it up part b covers all your cgm and pumping supplies at no cost to you.Best of luck Al

1 Like
14

This doesn’t sound right. Did you stop paying your Part B premiums? No insurance advisor would have ever suggested that you do that unless you were destitute - in which case you apply for financial assistance and Medicaid. If you were to drop Part B you’d no longer qualify for a Part C (Advantage) Plan.

I wonder if your supplies were mistakenly not being filled under “Part B” and you are misunderstanding the situation. If you had been on a pump with private insurance and transitioned to Medicare Advantage without going through the Medicare qualification process for a pump, this could have caused your situation.

It is up to your doctor to get you qualified under Medicare B for pump and CGM, to work with A pharmacy and AN authorized Medicare B supplier. These need not be (probably won’t be) the pharmacy selected by your HMO Advantage Plan for formulary supplies.

Under Medicare guidelines the prescribing doctor has to have an active practice managing multiple persons using such equipment and you must “visit” them every 3 months to continue verifying your condition. If your PCP isn’t a diabetes specialist, you have the right to demand that they refer you to one. It’s possible that with the shortage of endocrinologists, that might require your HMO sending you outside their network to a specialty group.

btw, My pump, CGM, and associated supplies come from different providers than my insulin. I can get my Medicare Part B insulin from many pharmacies, including all the national chains, regardless of any network or plan I’m in. Any plan that covers Medicare Part B copay for durable equipment covers the 20% copay. (If your new pump model requires calibration, then BGM strips for calibration would also be covered.)

Insurance companies can’t change coverage without advanced notice. You should receive a packet every year from your Medicare Part C Advantage Plan describing all the changes that they propose to make in advance of the renewal date. You are responsible for making sure you receive it, for reading it, and for choosing your plan each year.

"If your (HMO Advantage) plan gives you prior approval for a treatment, the approval must be valid for as long as the treatment’s medically necessary. Also, your plan can’t ask you to get additional approvals for that treatment. " https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/HMO

While Medicare Advantage plans are provided by private companies, they are contacted with Medicare and are required to cover things that are medically necessary and are explicitly covered by Medicare. Pumps, CGMs and insulin for pumps for persons with type 1 diabetes are specifically included under Part B - they aren’t under a formulary chosen by the insurance company.

" Most plans include Medicare Drug Coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. In 2023, the standard Part B premium amount is $164.90 (or higher depending on your income). If you need a service that the plan says isn’t medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal."

As far as economically surviving without a CGM or pump, I did well without both (and without insurance for most of it) for 45 years. I bought insulin over the counter from Walmart for more than 10 years. It’s still available for roughly $25 a vial. Relion BGMs and strips are available OTC, cheaper ones that are Medicare mail order supplier overstocks are available on Ebay for $0.20/strip.

1 Like
15

As a t1 diabetic, a Canadian one to boot, this just sounds wrong. So sorry you are going through this.

1 Like
16

I think that you should call your state attorney general.

1 Like