I have heard for years that once a diabetic goes on Medicare, he/she must have a doctor’s visit every three months in order to get diabetic supplies. Now that I am actually ON Medicare, I am wondering if that is still true. I have learned that since my insulin pump is an OmniPod (which is covered under Part D), as long as I have a valid prescription for a year, my supplies will come to me. (I am on the SilverScript Allure program, and everything seems to be covered without visit requirements.) I found that the same was true for my insulin. Since I am on OmniPod, my insulin also is covered under Part D. My blood glucose strips are under Part B, but my pharmacy told me that I could get those without a hassle as long as I had both a prescription from my doctor and an exception letter that allows me to have more than 3 a day. My rep at Dexcom told me that if I want a CGM (right now, G5 or earlier), I needed to be checked only once every six months. Yes, I know that Medicare will pay for an A1C test only once every three months plus one day, but other than that, I cannot find anywhere in Medicare’s literature that says diabetics must see their MDs every three months in order to get supplies. Is this true because I use the OmniPod pump rather than a pump covered under PartB? I have looked through Medicare’s entire coverage report online, and no where does it say anything about required MD visits every three months. Does anyone know where this “three month” rule is written?
3 months it is and I believe it must be an endo
I have not looked where the rule is
I am on Medicare and it is every 6 Months (exactly every 180 days) as I am MDI + Dexcom CGM. I have heard that pumpers are every 3 months so you will want to look at rules for pump users.
The 90-day doctor visit requirement is part of Medicare Part B that covers insulin pumps, insulin, pump supplies, and test strips. Here’s a comment that @Laddie posted on this topic in 2016.
This is from my comment on the same thread. I followed Laddie’s Medicare National Determination Letters link and cut and pasted the pertinent section.
Continued coverage of the insulin pump [and related supplies including insulin] would require that the patient be seen and evaluated by the treating physician at least every 3 months.
What are the enforcement mechanisms? What if your doctor only felt it was necessary to see you every 6 months?
When I order my Medtronic pump supplies, Medtronic asks me the date of my last endo visit. If it’s even one day over 90 days, they will not fill my order. Med-T then calls my doctor’s office to verify the date of the last doctor visit.
I suspect that CVS, my supplier of Medicare Part B insulin, also calls my doctor’s office to verify that my last visit was 90 days or less.
If it were left to my preference, I would only see the endo for routine diabetes issues once per year and as needed if something unusual is happening.
There is no way around it - they will find out - this is guaranteed
You cannot get supplies without stating the date of your last visit
That’s outrageous. Guess I’ll plan to pay for my own supplies before I’m Medicare age
So the expectation is that you’re just supposed to die if there was a scheduling conflict that delayed your being seen beyond 90 days? I only try to see my endo about 2x per year and in reality it works out closer to 1.5x: year
Slightly off-topic: Medicare Part B (original Medicare) combined with a supplemental plan provides great benefits. Insulin pumps, insulin, pump supplies, test strips and lancets are fully covered with Part B + a supplemental plan such that it eliminates any out-of-pocket costs. Medicare Part D prescription coverage is not as generous. Some seniors actually switch from MDI to a pump when they get on Medicare once they understand this.
Terry and others, here is where my question lies. Because I use the OmniPod, my PDM controller, my pump supplies (the Pods themselves), and my insulin are all covered under Part D. Medicare considers the OmniPod a drug rather than DME, and the insulin, then, goes under Part D also. The only thing that falls under Part B for me right now is the test strips (which Medicare considers DME); therefore, the only reason I would have to go to my Endocrinologist every 90 days is to get the test strips.
I also am confused about the timing. You are saying that appointments have to be 90 days (or less?), yet my Endo’s office told me that Medicare would only pay for an A1C test if the timing was BEYOND 90-days, so they scheduled my next appointment for one day BEYOND the 90-day limit.
I wonder, financially, if I would be better off skipping the every-90-day Endo appointments and just paying for the test strips out-of-pocket. I am fine seeing my Endo only twice a year because I have access to her office with any questions that I have via phone or email at any time.
Medicare is SO confusing!
I definitely would consider that option since it appears you prefer the Omnipod. Omnipod’s inclusion in the Part D coverage just happened in the last few years. Before that, Medicare did not cover Omnipods, a silly policy.
I know that Medicare just started covering the OmniPod under Part D. I also know that under Part D, I must pay $573.18 for a three-month supply whereas if I chose to go to a tubed pump, I could get my pump supplies free through Part B. Part B is covered 100% between Medicare and my supplemental insurance. I LOVE the freedom and the control I get with the OmniPod, though. I have used them for over a decade and guess I will just have to find a way to continue to pay for them. You know what REALLY is silly? My Pods are not considered a “pump” and thus covered under Part B because the Pods themselves are disposable after three days of use, yet test strips – which also are disposable after one use! – are considered DME and covered under Part B. Medicare makes no sense.
I totally agree. Medicare should treat pods just like any other pump. It is silly.
I think there are a couple of mis-conceptions about the every 3 months/6 months 90 Days/180 Days for medicare coverage.
The timing is always in days, not months. So like when a CGM company talks about 6 months doctor notes, they mean 180 days. You will not get your supplies past day 100. For pump manufacturers it is 90 days.
Should your doctor notes be delayed, that does not mean that your coverage has been stopped. It has just been delayed until your doctor notes are received by the entity supplying your DME. In other words if you are a pumper and your visit needed to be delayed 10 days and or your doctor notes arrived on day 100, you would be 10 days without supplies. Some individuals seem to believe that if they miss their 90 day appointment, they will no longer get supplies on medicare.
I am on MDI and CGM and therefore only need a visit every 180 days and yes, doctor’s notes were once delayed by 1 week and Dexcom refused to make any accommodations beyond making a note on my record that notes were on the way and the day they received the doctor notes, they sent out my medicare supplies. For decades I was on 1 visit/year and it worked fine but Medicare insisted that in order for them to save money I need to go every 180 days or they would not cover cgm. I tried fighting, getting waivers, etc. due to my heavy travel schedule and my endo’s tight schedule but nothing doing, Medicare insists I go for additional costly unnecessary visits so they can save money.
I was told when I inquired recently that it did not have to be an endo. as long as a doctor gives the prescriptions and writes out the reports that are necessary, you are golden. If you are on Medicare, pump supplies necessitate 90-day visits
So once again, Medicare rules seem to contradict themselves. I must go to my Endo or MD WITHIN 90 days to get diabetic supplies. Yet Medicare will not pay for an A1C unless the time lapse has been 90 days plus 1, thus, not WITHIN 90 days. My Endo wants to do an A1C with each visit to assess my long-term control, and I think that is a reasonable action. I am not bashing Medicare. They pay well for many procedures, and thousands of people would be totally lost without the program. I wish I could afford not to use them, but I cannot. What frustrates me is that I am a fairly logical person, and their requirements seem to defy logic!
Thanks, CJ114, for the clarifications. I am starting to understand (somewhat) how Medicare works. Their rules still contradict one another. I will have to have a discussion with my Endo about appointment timing the next time I see her. Although I do not travel often, I spend winters in Florida and summers in Wisconsin, so I have the struggle of trying to juggle prescriptions and appointments with two Endos in two different locations.
I have a long way to go yet but I am now so excited that I am moving away from every 3-4 months and moving to 6-8 months due to the new technology. It will be kinda sad going backwards. But hopefully by the time I get there (and of course could be longer because i’m Sure the age requirement will go up!), they will realize how silly this rule can be for many people. Like all things diabetes, everyone is different and like all things government we are all the same🙁
The rules are enforced by the people that supply your DME equipment and medication(s) under whatever Medicare part you fall under so you need to make peace and get a great understanding of what your provider in Wisconsin requires to get reimbursement and what your provider in Florida requires to get Medicare reimbursement. In theory it will be the same but in this game, theory does not always prevail. The endo’s will then prescribe in each location what your provider insists is what they need and then keep fingers crossed that your provider in each location did not give you bad information.
Starting two years ago, My endo started increasing the time between visits from 90 days to 120 days. I guess I now need to remember to order my supplies at least 30 days before my next visits. My visits, including blood tests, cost $7.90 under Medicare Advantage.