So I’m new to Medicare (I’m in my 30s, but disabled). I’ve seen something about a “see an Endo every 3 months” requirement for Medicare…but does that mean I’ve had to see an Endo 3 months prior to starting Medicare to be able to continue my pump supplies/insulin? Or just within 3 months of STARTING Medicare?
I start Medicare September 1 and my next appointment is October 7th. I haven’t seen my Endo since last year because I didn’t have insurance and then COVID happened.
I can’t ask Medicare directly because my plan hasn’t started yet, so I’m not sure where to get more information.
Hi there! I don’t have an answer, but just wanted to express solidarity. I’m trying to navigate the “not yet 67 but getting on Medicare due to disability” track myself. It is utterly baffling, and I understand why most people hire a lawyer to help with SSDI/Medicare/etc. I have a “compassionate allowance” disease, so I don’t have to “fight” the Social Security office, but it is still absolutely impossible to find answers to any reasonable question.
Also, welcome to TUD! It’s a great community, and I’ve found it to be wonderfully supportive and knowledgeable.
Yeah, it was definitely a wild ride. I was approved first time (severe Lupus), but the amount of stress it caused was absolutely ridiculous. Sorry you’re in the same boat!
I’m not on medicare, but have seen discussions mentioning this rule. It seems related to having notes provided in order to get supplies, and need to be faxed to supplier/pharmacy by doctor.
If you are on a pump, medicare requires doctor notes every 90 days (not 3 months). If you are MDI (Multiple Daily Injection) medicare needs doctor notes every 180 days (Not 6 months). So for your initial supplies, due to various possible processing delays of your first order, start the process as soon as you have seen endo to make sure that is taken care of 90/180 days ahead of deadline
I have been on medicare for several years so am familiar with process.
I’m on a pump and a Dexcom, but I haven’t seen my Endo since last year. I’m scheduled to see him this October 2020, but my Medicare starts September 1, 2020.
I won’t be requesting supplies through Medicare prior to seeing him (I have enough pump supplies and insulin until November). Unfortunately the soonest I can see him is after I’ve already begun Medicare…so that’s mainly what I was worried about. If I wait to see him until after Medicare starts is that okay? There’s no way I can get in prior to starting Medicare.
Yup, you can see him anytime. Medicare just checks that your premiums are up to date and that you have visited endo within the last 90/180 days, regardless if you saw endo after or before going on to medicare. My assumption here is that you have previously checked that your endo does accept medicare patients.
You definitely need to see your endo before applying for Medicare. Maybe if you tell the scheduler that you will be going on Medicare she can give you a early appointment.
You need doctor notes from doctor visit to fill certain prescriptions (every 90 or 180 days), but have not heard you need doctor visit before starting medicare.
I assume that you will be on Basic Medicare plus a Supplement. I advise that you call the DME supplier that you plan to use and they can start the process for the info that will be needed. On order to get pump supplies on Medicare you need a qualifying c-peptide test taken at the same time as a Fasting Glucose Test (which must be labeled as Fasting). If you already have this test in your file, it might be accepted but maybe not. As a longtime T1, I had my first c-peptide test ever when I started Medicare. When I was a month or two away from Medicare, I called my pump company (Tandem) and they took care of finding a supplier for me and transferred my info to that company. But if you prefer, you can choose a Medicare DME supplier yourself. I assume that you are not going to be on an Advantage plan. If you are, the requirements for pump and CGM coverage might differ from Basic Medicare.
I actually am going to be on a Medicare Advantage plan in Minnesota (HealthPartners). I didn’t know that Advantage plans might have different criteria than Basic Medicare…I’m assuming I should contact the plan to find out what those criteria are? I’m on Tandem too (and Dexcom). I’ve never had a C-Peptide test.
I definitely can’t see him before I start Medicare, the earliest appointment (that I made back in June) is October. I already signed up for Medicare and did my paperwork? Do you know what paperwork he’s supposed to do for signup? I don’t think I got anything specific that my Endo had to do for me to be approved for Medicare.
As mentioned by CJ114 the key requirement are the "doctor notes – how often depending on the treatment. If they are 1 day late, Medicare will not approve and the pharmacy will not ship. My endo’s office is good about scheduling appointments in the proper window and sending the doctor notes to Medicare on time. Given I am on Dexcom G6, during the pandemic I just upload my data 2 weeks before my next appointment, and the appointment itself is virtual (web). She reviews the data and talks with me, same as a periodic office visit. Key is she gets those doctor notes to medicare on time.
That is Key 1
Key 2 is to make sure that your current provider has a prescription that has not expired.
Key 3 is to make sure that all of your Medicare A/B/D where applicable are paid up to date.
Key 4 is to be proactive as stuff falls through the cracks but if the above items are taken care of and followed up with all parties involved BEFORE YOU RUN OUT OF OR ARE DUE TO SHIP MEDICATIONS OR SUPPLIES, you will be a lot happier and less stressed.
I am from Minnesota also and chose to go with Basic Medicare and a Supplement when I started Medicare in 2017. I assume that you “did the Math” before choosing a Health Partners Advantage Plan. Health Partners is a good company but on an Advantage Plan, you may be responsible for 20% of your DME costs. And likely the insulin for your pump will be covered through pharmacy benefits not DME Part B. The problem with insulin being covered under pharmacy is that you have co-pays, have formulary restrictions, and run into donut hole issues.
Although you have the option to switch to Basic Medicare at any point in the future, Supplement Plans can reject you for pre-existing conditions after your “initial benefit period.” I am not sure whether that is 3 or 6 months after you start Medicare. If a year from now you do the math and find out that Medicare and a supplement is a better deal, you likely will not have the option to switch. So I don’t want to scare you. I want you to do the math and make sure that you are making the correct decision because it is not too late to change. You will always have the option to switch to an Advantage Plan. You lose the option to get Supplemental plan coverage after your initial benefit period.
I probably pay more in premiums than you do, but my pump supplies, CGM supplies, and insulin are provided through DME at no out-of-pocket cost to me. Medicare pays 80% and my BCBS Supplement plan pays the remaining 20%. I have no donut hole issues because my insulin is not supplied from my Part D pharmacy plan.
With an Advantage plan, you are likely to have easier requirements for getting your pump and CGM supplies. I have no idea whether you will need a c-peptide test and I suspect that you will not need to see your endo every 90 days in order to receive pump supplies. I think if you call Health Partners they will tell you what DME supplier you will be using. This supplier should be good at telling you want is required to get set up for your supplies and they may likely do the legwork for you. An Advantage Plan is an “all-in-one” plan and it can be easier for navigating Medicare. The question is whether it is financially the best choice. It may be; it may not be. When I did my homework before starting Medicare, I spoke with an independent rep, someone from Health Partners, and someone from BCBS. I also attended multiple group sessions. The big issue is that none of these people understood the specifics of Type 1 diabetes and using a pump, insulin, and a CGM.
I go to Arizona in the winters and that is another reason that I chose Basic Medicare and a Supplement. Although Advantage Plans offer out-of-state coverage, it is more reliable/easier to get care through Basic Medicare.
I was part of a panel of seniors who consulted with JDRF to create this document and maybe it will give you info.
Anyone with diabetes who is considering selecting a Traditional Medicare Supplement plan should read Laddies’s above quote carefully. While Oregon and California permit switching Medicare Supplement plans each year without medical underwriting under the “birthday rule,” people living in the other 48 states are not eligible.
I signed up with a Medicare Supplement Plan two years ago at my initial opportunity and then discovered better-priced plans. When my birthday arrived this year, I switched to the exact same plan (Plan G) and saved over $20/month.
It’s my understanding that without Oregon’s Medicare Supplement birthday rule, I would not have been able to make that switch without underwriting. Underwriting, as I understand it, would allow the prospective insurance company to increase rates to reflect my medical health and even allow the company to refuse to insure me.
