Preparing for Medicare - any advice?

I will be reaching Medicare age sooner rather than later, so I’m looking for any information tailored to T1 diabetics (I’ve had it for close to 50 years). I tried a search in the forum, but see mostly specific topics, like whether G6 is covered, and don’t see any general advice, though it may be there. So any referral to other threads or websites that talk about the overall process and which options are best for long term T1 would be great.

I currently use a G6, own a receiver (though I use my phone and watch instead). Moderate carb with MDI, my doctors and I don’t see any reason to go to a pump, though I am open to doing that in the future so wouldn’t want to lock into any choices that precludes that.

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Unfortunately, medicare doesn’t directly address Type 1 diabetics. there are a few publications but they aren’t all that helpful. Best bet is to go on medicare.gov and create an account if you haven’t already. From there you should be able to find a local insurance broker knowledgable in the ins & outs of medicare and the plans available in your area. There are many, many ways to skin the medicare cat and what works best for someone else may not work best for you. That’s where the broker comes in very handy.
One thing to note is that if you are using a pump insulin is covered under medicare part B as durable medical equipment. It is much cheaper than under any part D prescription plan or part C advantage plan.
I just went through this a a year and a half ago so I know what you’re going through.

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You can change plans once each year, so with terms and conditions that keep changing, even if your situation changes during the year, you just have to sweat it out to the end of that year to change. I am in MA and have BCBS and BCBS Medex bronze as that covers pretty much everything including the 20% copay on the Dexcom G6. Then I use a cheap Wellcare part D plan for the small stuff like statin (about $200/year). For insulin, I am MDI and copays, insurance premiums, donut hole, hassles, etc are a killer price wise so I just mail-order or pick up my insulin in Canada at 1/10th of the cost identical insulin is in the US. My cost to order from Canada is less than a copay on any insurance in the US let alone the additional premium.

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Not on medicare yet, but have been following discussions.

One key decision is going with standard Medicare or Advantage plan. It can get more complicated if you move or travel between states, and have Advantage plans, which may have limited access to providers. @Laddie has written some details on this.

TV commercials make it seem like Advantage plans are better, lower cost, extra benefits. But you may have limited access to providers accepting standard MC, but may not be on Advantage plan.

At least that’s my understanding!! I get to worry about in a few more years.

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Oh boy, Jag. Its a good question. I’ll research. Medicare | ADA

Hi, Jag1, I have been on Medicare for 6 years now, 7 the end of March. I am not type 1 DM but type 2 that recently started MDI Jan 2021. The Dexcom is covered under durable medical equipment Medicare part B. Pumps are a bit more tricky. It would be best if your doctor got you on a pump before you hit 65. That gives you the best chance of Medicare covering it. Pumps such as Tandem and Medtronic and the insulin are covered under DME part B, while the OmniPod is under the drug benefit part D. This makes a difference in the cost. How much I can’t say.

CGMs are covered if you inject insulin 3 or more times per day and test 4 or more times. The latter has been relaxed a bit, but I don’’t think that’s an issue for you.

Link to medicare pump coverage:
https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=109

To save you time, here’s the criterium:
1. Glycosylated hemoglobin level (HbAlc) > 7.0 percent - NO
2. History of recurring hypoglycemia - Seldom
3. Wide fluctuations in blood glucose before mealtime - NO
4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl - Never let that happen
5. History of severe glycemic excursions - NO, if I understand correctly.

Criterion b

  1. The patient with diabetes has been on a pump prior to enrollment in Medicare and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment .

That part I bonded is suspect. Does one have to test with a finger stick 4 times daily or is a CGM good enough? Probably depends upon the clerk’s interpretation. Good luck.

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  1. While this is true, it is important to note that the copay for Dexcom varies depending on your plan under part B anywhere from no copay to 20% so check the cost of the plan and then factor in the copay to choose the best plan for you. I believe the 20% copay is currently $44.64 per month.
  2. Another consideration is that if you remain on MDI, Medicare will only require 2 endocrinologist visits each year while the pumpers need to go 4 times a year. Visits are 100 miles away for me and not convenient which is one of the reasons I stay on MDI.
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I just got on medicare this past month. I think I hate it. I’m on an Advantage plan, but there was a mixup getting my sensors approved through where i get my care, because they had the insurance information wrong. What does MDI stand for?

It’s helpful to know this about the Dexcom. Thank you Luis3. 1. While this is true, it is important to note that the copay for Dexcom varies depending on your plan under part B anywhere from no copay to 20% so check the cost of the plan and then factor in the copay to choose the best plan for you. I believe the 20% copay is currently $44.64 per month.

I may switch over to what CJ14 is doing. Sounds cheaper to me. Just found out I wasn’t eligible. Oh, well.

Thank you!

Ame E.

Multiple Daily injection, via syringe or pen.
Not using insulin pump.

that’s me too! thank you!

A.

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First word of advice: Apply as early as you can. It takes time for the application to be processed and you want it to start on the first day you are eligible. Don’t hesitate to follow up with Social Security if you are not seeing action or results, especially as offices are still closed to the public.

Tubed insulin pumps and insulin for tubed pumps are covered under Medicare Part B. Non-tubed pumps like Omnipod are not. Insulin for non-pump use is also not covered by Part B so you will need a supplemental plan to pick that up. CGM are covered, generally, and if you are already using one you shouldn’t really have a problem getting it transferred.

You will need new prescriptions once you start on Medicare for your equipment and supplies so try to make sure you have some extras in reserve before you start Medicare (if you can) so you can weather any delays.

You will need to prove you are type 1 by having a fasting C-Peptide test done AND a blood glucose test done at the same time. It is important that the test states it was done fasting even if the doctor has to write that information in him/herself.

Make sure you give all of your providers your new Medicare number when you get it. Medicare doesn’t notify anyone; you do.

It looks like everyone else has covered the other important stuff. Look closely at any supplemental/Advantage plan you choose to make sure it meets your actual needs rather than provides glitzy extras that may not be worth doing without what you really do need for provider coverage wise.

Again, the most important part - apply as soon as you can because it may take the whole 3 to 4 months to get it done. (I had to have a phone appointment - it was scheduled for 6 weeks later. I then had to do a follow up phone appointment after co-ordinating with my supplemental insurance - another 6 week wait, and it was literally approved the last day before I would have had no coverage.)

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I was just about to post the same topic—spouse (kinda suddenly, long story) retiring, so we’re about to lose her excellent private insurance and go to Medicare. Really feeling at sea. BIGGEST worry is this business of c-peptide test to qualify for pump coverage. I’ve had T1 since 1983, never had a c-pep test until a couple of years ago, and it turns out I still produce some endogenous insulin, which plays hob with my results. Am I really going to have to jump some freaking bureaucratic hurdle to prove I’m type 1 and entitled to keep using the same therapy I’ve been on for ten years???

Multiple Daily Injections, i.e., not a pump but a manual injector or hypodermic.

Many type 1s do still produce a small or minute amount of native insulin, especially earlier on. As you age, native insulin production generally drops and as you age you produce less and less insulin. I believe if you are on a pump for ten years your level is going to still be in the ‘qualifying’ range. Why not have a C-Peptide test done now while you still have good coverage so you can see what you are dealing with? You may also be able to use that test if it is no more than 6 months ‘old’ when you actually apply.

I suggest the same, although they may ask for it again.

I recently had to do c-peptide test when getting my last pump last year, on non-medicare plan, but required same as medicare. It had to be fasting with bg test at same draw.

As a “juvenile diabetic” (age 5), I still had to do the test, 55+ years later.
I had also previously had the antibody tests done too, just in case !! You may want to do that now too.

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This is one of the better articles on Medicare with Type 1 diabetes.

The biggest decision to make is whether to go with Basic Medicare and a Supplement Plan versus an Advantage Plan. That decision is basically a one-way street. If you choose an Advantage Plan initially, you can always go back to Basic Medicare. But Supplement Plans can use underwriting after your initial benefit period (first 6 months of Medicare) and will likely refuse to give you coverage because of Type 1. So you can start with Basic Medicare and a Supplement and switch to an Advantage Plan in the future. If you start with an Advantage Plan, you will quickly lose the option to get a Supplement unless you live in one of the few states that doesn’t allow Supplement underwriting.

In general Basic Medicare pays 80% of my medical expenses including my pump, pump supplies, Dexcom, and the insulin used in my pump. Plus the same for doctor appointments, labwork, etc. My Supplement pays the remaining 20% so I have virtually no out-of-pocket expenses. I have to purchase a Part D drug plan also. In general premiums for Basic Medicare plus a Supplement plus a Part D plan are more expensive than an Advantage Plan. But the coverage in most cases is better and you can see any doctor who accepts Medicare rather than dealing with network restrictions.

It is good that you are trying to learn about your options. An independent agent can help you or your local SHIP agency. https://www.shiphelp.org/

Ultimately you need to do the math for what works for you. At the same time you need to consider the math for future years when your health status might change. Or your choice of Diabetes tech. CGM is covered by Basic Medicare although not Medtronic. Advantage Plans cover CGM but they can have CGM formularies. A friend of mine switched Advantage plans for 2021 because his previous plan was going to start only covering Libre.

Good luck!

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A virtual doctor visit should be enough to fulfill the requirements.

I recommend you see if your jurisdiction has a SHIIP (Senior Health Insurance Information Program). It is supposed to be active in every state and helps you navigate the cumbersome Medicare process. They can also direct you to websites that will allow you to enter the medications you use routinely and see what your costs will be. You can get a good feel for your costs with Medicare only, or Medicare Advantage or supplements through SHIIP or your own navigation through the cost calculator websites. Personally, I cannot imagine not having a supplement to help with the costs.

If your BG is well controlled with MDI then continuing that therapy is great. For me, transition to a pump helped lower my A1c over 2 points in less than a year. There is some inconvenience to it, but it has been well worth it to me.

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The State Health Insurance Assistance program, or SHIP, is a great asset to help make important Medicare decisions.

In Oregon, we have an agency called SHIBA, Senior Health Insurance Benefits Assistance, which seems to cover the same mission as SHIP.

I’ve used SHIP/SHIBA counseling three times in two different states to help make Medicare choices. They are staffed with volunteers, often Medicare beneficiaries themselves, and are without any conflict of interest in their recommendations. This is a wonderful resource for seniors.

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@MM1 …. Out of curiosity, what did your C-Peptide and antibody results show?

Are you still making any insulin, and do you continue to have antibodies?