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.
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…
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.
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!
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.
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.
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.
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.
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.
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.
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
Years ago I went on Medicare for every thing. No advantage plans. Medicare pays 100% for my CGM. My wife’s Medical insurance pays the co pay for my meds.
