Updates on Medicare Coverage of OmniPod?

Diabetes Technology Insulin Pumps
1

Although I am not of Medicare age yet (I'll turn 60 in March), I am concerned about the fact that Medicare will not cover the OmniPod. I know that in the past some of you have taken various agencies to court to try to get the government to recognize that an insulin pump is an insulin pump regardless of whether it is tubed or not, so I am just wondering if anyone has made any progress from a legal standpoint.

Having the OmniPod properly "coded" was one of the issues. Has Insulet made any progress on getting the OmniPod the "correct" code to satisfy the government? I know that we have been fighting this battle since at least 2009, and I really would like to see it settled before I AM eligible for Medicare!

Another idea was a class action suit to get Medicare to consider covering the OmniPod. Has any progress been made on that front? I would gladly add my name to that suit along with the thousands of other OmniPod users.

I have had T1 for 47 years, and the OmniPod has given me outstanding control even with recent other medical difficulties. I won't change to a tubed pump, but I certainly would like to be given the same consideration and coverage from Medicare that they give to other Americans who use a tubed pump. A pump is a pump, so why can't we get the same coverage?

2

It's basically going to take a change in the law to re-define what a "durable medical equipment" device is. Omnipod is not a durable medical device. Arguably, the PDM is a durable device and the pod it just a disposable part of the system. So maybe the real fix is to keep the pod out of the equation and have them cover the PDM and it's "disposable" parts differently? Not sure. At least you have an option of using a tubed pump, so it could be worse.

3

I have previously written of my legal efforts to combat this inequity. It has taken several years without any help from Omnipod. I went to the last administrative appeal to argue the prior rulings made no sense. There was one other Omnipod user who was somewhat successful, but he had a different Judge who felt that some small coverage should apply. I tried to argue that made the Omnipod covered, but the Government Appellate Judge wrote a 20 page opinion covering the issues and saying that because the POD gets changed every few days etc, it is not DME.
The coding is an issue. I was told more than a year and a half ago that Omnipod was using some lobbyist to get it changed but that apparently went no where. it is expensive, unfair, and unjustified for this position, but it must make competitors happy and who knows what took place behind the scenes to convince such an irrational decision? Does it make sense for the Medicare "experts" to conclude we only need to test 3 times a day as such is its position?
If Omnipod suddenly received numerous complaints and threats to use another system, perhaps it will realize their pocketbook warrants doing something as the population ages using the Pod.

4

You may have something here. I would like to see them at least cover the PDM, and then see what Medicare does as far as covering the "disposable" part of the system (i.e. the Pods themselves). I wonder what Medicare does about the infusion sets for the tubed pump. Does anyone know how Medicare covers that portion? If they cover the infusion sets, then they should cover the Pods under the same plan.

5

My thanks to you, Richard, for your hard work and efforts on trying to reason with the government. I know that your process has been thorough and terribly frustrating. That happens often when logic and reasoning is met with excuses and irrational replies. On top of everything else, the Medicare people and judges you are dealing with have no idea what diabetes really is, how it can best be controlled (Three tests per day? Seriously??), and what steps must be taken to avoid even more costly complications in the future.

I am all for contacting Insulet to let them know that we Pod users, collectively, are not content to have them do nothing on this issue. If coding needs to be changed, then the requests/actions must start with Insulet. Do I want to change from the OmniPod? Not on your life, but if I cannot afford the system in the future, I may have no other choice. Perhaps the collective voices of the thousands of OmniPod users is what is needed to get Insulet back on this issue.

So where do we go from here? Do we each contact Insulet Corporation one-on-one? Do we start a petition? I know a petition can be done online, and I am more than happy to help write it, but I am not computer savvy enough to actually post it or send it on to Insulet. Any other thoughts or suggestions?

6

I have been on Ommipod for six years and don't want to change but as soon as I'm out of pods (I have about 12 month supply of the old pods) I won't have a choice. I can't afford to spend three+ hundred a month for pods as I am living on social security. Breaks my heart as I do love Omnipod. Makes me mad that they do not do something for us seniors on Medicare to make sure we can keep our device.

7

I hear you, Joy. That is why we must all unite and keep up the fight to get Medicare to recognize that the OmniPod system is NOT just a disposable device. Richard is correct in his reply above that the PDM is "durable medical equipment" just like any other tubed insulin pump, and that the Pods are no different than a tubed pump's infusion sets-- which also need to be "replaced" on a regular basis. Each system has both a permanent DME and a replaceable component, so Medicare's argument really is not sound. How frustrating that they won't listen to logic and reason. It's not fair. At least write to Insulet and let them know that you want them to continue to fight for Medicare approval. They will lose lots of business if all of us Baby Boomers have to leave their system because Medicare will not cover it.

Do you have any supplemental insurance that will allow you to stay on the system? I know that sometimes other insurances will cover something that Medicare will not. My 90 year old mother has Physician's Mutual insurance, and although she is not diabetic, that insurance has been excellent in covering other medical expenses for her.

Don't give up hope, Joy. You are not alone.

8

I am so sad to hear older T1D folks have to deal with such stupidity. My sons are 12 and 20 (both T1D) so they have a long way to go before running into this problem but I am irked to hear of it anyway. I hope your hard work on this issue will not only benefit people in years to come, but will also benefit people it concerns right now!

9

SherryAnn, I am a T1.5 and being on medicare and now tri-care (Jan 2013). I am disabled and retired from the Military last jan 2013 when I turned 60 I have been fighting with Tri-care (Express-Scripts) since the do not cover the pods on their formulary I have to buy my pods through Insulet at full cost and then it goes to medicare and they dont cover it and then it going to Tri-care it only covers 75% of the full cost due to Insulet not having a contract with the Fed Gov. You would think that there are many of us that are tied to the Gov one way or another. Even though Express-Scripts does cover the pods at $13 for 90 days worth Tri-care does not have it on the formulary and I have not found a way to get it covered through them. I have talked with Insulet about this on a number of occasions with no avail. I get nowhere with Tri-care or Express-Scripts. When I was with my work insurance and even when I was force retired from my old job due to my disability that insurance did cover most of the cost along with meds but with only Gov run insurance I am out of luck so far. If anyone that is on Tri-care has found a better way to cover the pods please let me know.

10

Have you contacted any of your legislators or congressmen (women) about this issue? I am frustrated that Insulet does not seem to think the non-coverage by Medicare is an issue. The fact is, as we Baby Boomers age, many of us will be forced financially to either go back to MDI or to change to a tubed pump that Medicare WILL cover. After they lose customers, maybe Insulet will finally take this issue seriously.

My frustration is that Medicare will cover a tubed pump but not a wireless one even though both systems have disposable parts (the infusion sets or the Pods). How can the government favor one company or system over another? Isn't that against the law? That is where my frustration lies.

I recently moved to a different state, so I have to wait now until after elections to see who my new representatives will be. Then I plan to e-mail them to ask them to investigate what can be done to change how Medicare covers these essential medical devices. If everyone were to make noise with their legislators, perhaps our voices would be heard.

11

Thanks for your words of encouragement. Perhaps by the time your sons reach Medicare age (or whatever the government has in place by that time), this will not be an issue. I have been diabetic for 47 years, and the changes in understanding diabetes and how to care for diabetics have been remarkable. I pray that by the time your sons retire, they will be able to say, "I used to have diabetes, but then they found the cure..." Until then, hang in there. We all just do the best that we can do.

12

I am going on medicare in April. I spoke to Insulet regarding any supplemental plans that would maybe cover the omnipod. Doesn't look good, and after 6 years on the omnipod I will have to come off it. Is anyone aware of a way I can avoid this?

Not sure if I will go back to 6 shots a day and ordering both long and fast acting insulin again. Or should I consider a tube pump?

13

SherryAnn, thanks I will talk with them this week I am good friends with mine and His office staff. I let you know how it goes

14

I contacted Rosa Delauro a CT Congress Woman and she turned out to be useless.
She contacted Medicare and forwarded me the turn down letter.
She gave me a story as how she understands since she had had cancer.
I've tried for over 2 years to get in and see her and so far she's refused to grant me an appointment.

Andy

15

Well, I WAS covered under the medicaid side right up until Feb 1st of this year, now all bets are off as I have been notified that my coverage never should have been allowed and they are hinting that they may go back and deny previously paid items etc... meaning I may end up owing the government some 30k in coverages since last October.

Medicare has already told me that I will NOT have coverage no matter how I gain it through the feds. I am physically disabled now, was already covered by state medicaid, but since I asked questions about it all, both are now denying me coverage for the omni-pod. Of course no one will offer any sort of help with the issue, and my state is rapidly changing what is allowed and what is not etc. The new American Health Care Act (or Obahma care as named by the media) is also refusing to cover things, even AFTER you meet the $6 thousand out of pocket deductibles.

Worked over 40 years, paid taxes I didn't owe since I was 10. They only took the Social Security taxes, but even that was not legally theirs, I just didn't know it back then and paid into the system anyway. Now, comes time to collect and you get a 2 year ineligibility waiting period, and denial of coverage for life saving requirements... The only answer I get is "sorry, that is the way it is..." when I asked what I was supposed to do to survive for that 2 year waiting period, they told me they had no idea but there was nothing they could or would do to help me out. So, I borrowed money from friends and family and had just under 1k in the bank, and of course, that was too much so again I had to wait an additional 6 months to prove that I was completely broke (and hopefully dead) before I could re-apply.

Finally get the coverage, use it for a year, got the pod, insulin etc, year runs out, auto-renewal comes along, fill out the paper work, it gets approved, moved into a new county so that I could afford to live and the new county re-ran all the numbers without taking into account all the expenses I had already paid out to them and denies me again.... another year to wait with them, while obahma care (which doesn't) refuses to cover basic life sustaining medication.

Makes me truly wonder why anyone would wish to move to America. Health care, is better every where else from what folks are telling me from various countries. Of course, I would not be able to move there to attain that coverage.

Ugghh... I sure wish I could find someone to give me work that I can do from a desk, preferably my own home desk, but even at their facility if necessary... everything seems to have a requirement to be able to move 50lbs, which I can't do on crutches, and I can't get coverage for a prosthetic at all....

16

You can give them all the reasons you want they won't listen if you want to get it done is that somting has to happen to your current pump even then you got to keep bothering them stressing the urgency

17

Check into all of the Medicare supplemental plans in your state, some are supposed to be covering it. My daughter is double insured right now but soon will only be on Medicaid. We are changing her to the Tslim. She is ready for a change anyway, and the Tslim offers some advantages. She has used tubed pumps before and would never go back to shots just to avoid tubing. It really isn't that big a deal to most people.

18

SherryAnn,
Hi, I have been on medicare for 5 years. When the new PDM and PODS came out out last year, mine was old so I needed to pay for it. Medicare paid their portion of the PDM and Tri-CAre for life our insurance picked up the rest. I was told about 7 years ago that Insulet would be in Washington talking to the Medicare people in Feb 04 2009, I was told my Insulet that it would be probably be approved by Medicare, well we know that didn't happen. I still use my POD as I really do love being tubeless, Medicare turns down the clain and then TRI-Care for life picks up some of the cost, it cost us around $300 when new shipment comes in.
Nice talking with you, have a great day. CArolyn

19

Medicare does cover the PDM because it is also a glucose monitor. However the case of the POD being disposable has not been argued correctly. The infusion sets, and the syringe for all other pump systems is also “disposable.” The PODs are not “disposed” of. They can be recycled. Every piece of the pods are recycled and not turned into trash like the infusion sets and syringes for the other pump systems. Also the PODs and the PDM are more cost effective than the other systems. Look at the numbers and you will see what I mean.

20

I would like to know where I can recycle my used Pods. Insulet USED TO have
a program that allowed users to collect and then submit their used Pods for
recycling, but that program has been discontinued. As far as I know, the
Pods are now just a part of the growing waste that continues to fill our
landfills. Please let me know how I can continue to recycle my used Pods.

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