Why wont Medicare pay for the Omnj Pod

I have been a diabetic since I was 2 yrs old. I’ve been followed at Joslin since first diagnosed. Over the years I started with u40 then u80, 100, humalog ,and novolog. Each of these were an improvement on the previous insulins.

The next big thing that came along were insulin pumps another great improvment over having to inject yoursel a number of times a day. Then insulin pumps started coming onto the market. The problem was that the tubing would kink and the pump would jam up.

I am now wearing the insulet Omni Pod. It’s almost like a miracle happened. It’s less expensive than the original pumps. If something happens with the pod you remove it,place another one on immediately,call Omni Pod they send you a fedex envelope and send you a new Pod. You’re never without a Pod.

Medicare calls it disposable. This is only partially true. You don’t discard your meter every time.

I’m sure if appropriate research were done before rejecting tocover it the Medicare People would find out this is much less costly than the other pumps on the market.

My sugars have been much better. My hemaglobin A1c is 6.1. Lets Face it you can’t do much better than that.

The republicans would rather give their donors big tax cuts than help the “average joe.”

Maybe the republicans should learn that a large majority of us aren’t wealthy,but it also doesn’t mean we shouldbe denied products that help us stay out of hospitals.

Jean D Haight

Hi Jean,
I’ve been a diabetic for only 5 years due to pancreatitis. I was only on needles 2 years when I discovered a sample pump on my doctor’s desk and I asked what it was. He didn’t think I’d do well with it but now he’s changed his mind since I’ve been on the OmniPod system for almost 3 yrs.

Congrats on your A1c of 6.1. I’m a little higher than that only because I weaken sometimes with food and don’t calculate my carbs correctly but I’m working on it.

My “new” insurance covers 80% but in just a few short years I’ll be on Medicare which I’m very nervous about because I don’t want to give this up. But for now, I’m enjoying it.

Does the OmniPod not cost ALOT more than normal Insulin pumps? Would that not be the reason to it not being allowed? surley they allow other pumps? I know not as good :frowning: but a pump is better than MDI know the benefits of the Omnipod as I use it myself in the UK, but I have to completely fund it myself :frowning:

Medicare will let you have other pumps WITH tubes. But your like me I have to have my Omni Pod

Medicare pays for standard pumps but not all at once. They pay pump companies monthly like it is a rental payment over a 4 year period. If an elderly person dies before 4 years, the government makes out because then they stop paying. Younger people, like me, on SSA disability getting Medicare still have the same rules as how they pay for elderly on Medicare. Since they consider the OmniPod disposable, I assume it can not be “rented” from the pump company. Medicare pays for meters however, so didn’t they cover the meter portion of the OmniPod system?

I have another insurance through my husband which is primary and they paid 80% for my Animas 1250 5 1/2 years ago. Then secondarily, it was submitted to Medicare. They didn’t end up paying any rental since the portion they would have covered was already paid by my primary insurance. Luckily for me, Animas accepts Medicare assignment in full and so I didn’t have a co-pay. Same with all my supplies.

I would guess that if the OmniPod pods were the price of infusion sets for tubed pumps, they would cover them, but since they are much higher, and since the pods are called pumps individually even though they are tossed every few days, that makes them not covered.

Have you talked to the billing office at OmniPod to make sure they don’t have a way to bill Medicare so it is covered? I live in a community with a huge percentage of elderly people and my primary care doc is always pushing the OmniPod on me. If you get no where with the biling office at OmniPod, I can check next week and see if he has any elderly patients on pods and ask him if they get Medicare to cover it somehow.

Well i will certainly follow this post .I am a 52 yr old woman. I am a nurses aid ,i have diabetes for 23 yrs plus other health problems, thyroid, 3 kinds of arthritis I’m in much pain every day but can’t go on disability in fear i wont get my pods .I have to keep working for my insurance.my sugars have been the best since I’ve been on the Omni pod .I had a minimed for 2 yrs but it just wasn’t user friendly as the Omni pod.i got my A1c down to 7 which has been the best in 23 yrs.
I’m sure its probably the cost of the pods .My insurance gets billed 1350.00 for 3 months of pods .with out insurance I could not afford this.My question is cant we do something to get medicare to cover this cost? ,petitions or something
Karen E La Roche .

I have filed appeals on the denial. Medicare has a regulation that requires payment for pumps, BUT the definition of a pump is a code that is not the Omnipod code. The regulation or rule says that any other pump cannot be medically necessary! Wew how ludicrous this is but because of the rental requirement and the regulation it is not covered. I am in process of appeal and have requested JDRF advocacy people to get involved. They assured me they would look into it… I am waiting. My opinion is that the medicare rule is archaic and may have been placed before Omnipod came into the picture. Medicare fails to consider advances made in treatment, etc. How can another pump, working same way, except for tubes, not be a pump??? That is a question I raised in my appeal along with articles,cost analysis, and the FDA approval for the pod as an insulin pump. Just another example of two different government agencies having different rules. I had prior insurance pay for the PDM and medicare does not have to pay for that. if I switched to a covered pump, medicare would have to pay out more money.

Whats going to happen when all the other patch pumps come out? and you are no longer able to get a pump with tubes and infusion sets?

hope your appeal goes through ok

Then insulin pumps will only be for the rich and famous. :frowning:

I am not rich or famous and I have a pump via insurance and Medicare. I don’t have a pod or a patch, but I do have a pump and it’s covered. Medicare and many private insurers do not cover new technology and drugs. After pods become mainstream and there is an appropriate billing code, they will adjust. When I got my first pump (16 1/2 yrs ago) and second pump (10 yrs ago), Medicare didn’t pay for pumps at all. I was very happy when they did when I got my third pump a little over 5 years ago. By then, they were more mainstream apparently. They aren’t where I live, but overall they must be.

I hope when I’m ready to retire and go on Medicare they’ll cover the OmniPod. I certainly won’t be able to afford it when I’m on Social Security but whatever happens I’ll always need insulin so if I’m back to the needles, so be it.

I don’t think the Republicans want you to be denied for healthcare you need. They are trying to get the economy back in order by giving tax cuts to business’s who hire employees so we in turn can have jobs and stimulate the economy. The only reason there is Medicare is because of large companies paying into it. Forget Republican and Democrat, just think about fueling the growth of the economy so we have Medicare in the future because Government can afford it.

P.S I have Anthem Blue Cross HMA and they cover 100% of my pods. Who would have thought HMO would do that in California.

I am going on Medicare on 4/1. I have been on the Pod for 2 yrs plus. It works great for me because I’m very active. I get involved in Triathlons etc. I have requested from my supplier if the Pod’s are covered and everyone says no. I have contacted Insulet and wrote a letter to Medicare with no response. So I guess I’m going to have to go back to Mini Med. My Dr advised me that Medtronic and other groups are trying to introduce a tubeless pump. I hope they do and Medicare does the right thing!

Richard

Since you brought it up, the large corporations aren’t the reason we have Medicare. We pay for it with every paycheck and then we pay premiums out of the SSA checks when we become eligible for Medicare coverage. Yes, republican do want to deny health care you need. Just today, one stated that shutting the government down was what needed to be done to un-fund Obama’s health care law. Putting hundreds of thousands of people out of work to keep insurance companies from having to provide coverage for pre-existing conditions doesn’t sound like they don’t want to deny needed healthcare to me! And corporations are sitting on HUGE profits right now and not hiring and they are getting the same tax cuts they got under Bush. They never expired. Didn’t cause them to hire, so the republican tax cuts have nothing to do with stimulating the economy by increasing hiring. The rich get richer and the sick get sicker.

What are you talking about? The question was why does,t Medicare reimburse Omni Pod replacements? Has nothing to do with Obama Care or large corp’s.

The Rich get richer and the sick get sicker is the most pathetic phrase I have ever heard in my life. The rich are rich because they work harder and smarter than broke people. I work with many people that were born in other countries and they thank God for America and its Free Markets systems. They say its only lazy Americans with an Entitlement attitude that complain about it.

Its not the Republicans or the democrats is us who determine our future and our health. God bless you but your Republican trip is only going to waste your energy.

Karen

I certainly feel for your situation. If I were working, I’d feel exactly like you regarding not wanting to give up the pod.

My understanding is that it’s cheaper to start up on the pod but over the course of 4-5 years, the cost is approximately the same as with the traditional pump.

Janet,

I’m hoping along with you! I’ve got 18 yrs to go so hopefully pods or some other tubeless type pump will be standard by then.

Fighting to keep from having our rights and benefits trampled on is not a waste of energy. Lazy Americans? Entitlement attitude? Really? My husband couldn’t work any harder and still get 6-7 hours sleep a night. I worked that hard too until diabetes and complications left me unable. We have a 17 year old daughter finishing her 2nd year of college and holding down a job. We pay $1400 a month in medical co-pays for our family of three in addition to paying insurance premiums and that is with me having Medicare as my secondary payer. I guess I do feel I am “entitled” to medical coverage.

The people you work with from other countries must not come from the civilized countries with universal healthcare if they prefer the system we have. My husband’s family in Finland pays something like $20 a month for the whole family and that includes medical, dental and prescriptions for all of them. They don’t have care denied or prescriptions not covered. I doubt they’d prefer to come here and pay what we do to not have things covered.

“Harder and smarter than broke people.” Now THAT’S the MOST PATHETIC phrase I have ever heard in my life!!! Your thinking is absurd. Wake up!!!