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Author Topic: Pumps, CGMs and Medicare  (Read 591 times)

Offline Tamagno

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Pumps, CGMs and Medicare
« on: April 22, 2016, 04:04:29 AM »
For my U.S. friends dealing with advancing age, type 1 diabetes and government health care:

What a train wreck this all is!

I've discovered that Medicare will indeed cover my beloved Omnipod. This is only true, however, if you're already using it when you go on Medicare.

Medicare still only covers 80% unless you buy the "gap" insurance. Sounds all right, but around here costs nearly $500/month, plus the cost of Part B ($122/month for 2016). You'll have to run the numbers for yourself to see if it's worth it.

Still no coverage for CGMs. A disaster for those of us with hypo insensitivity, but CGMs appear to have fallen through the cracks in the category of durable medical devices.

I haven't actually checked, but suspect these things may be fully covered if you manage to have some more newsworthy disorder - I'm restraining my characterological sarcasm only with the greatest effort...

Offline Shanny

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Re: Pumps, CGMs and Medicare
« Reply #1 on: April 22, 2016, 05:59:48 AM »
Gosh! I'm appalled at the difference in price for gap policies across the country! My BH is quite a bit older than you, John, and his policy costs us $198/mo. My own is $147/mo. Our policies aren't full coverage, but they've paid everything we've needed so far, except for a 60-mile trip by ambulance a few years ago.


And the business with CGMs is just plain scandalous.

Offline Grammabear

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Re: Pumps, CGMs and Medicare
« Reply #2 on: April 22, 2016, 07:23:13 AM »
For my U.S. friends dealing with advancing age, type 1 diabetes and government health care:

What a train wreck this all is!

I've discovered that Medicare will indeed cover my beloved Omnipod. This is only true, however, if you're already using it when you go on Medicare.

Medicare still only covers 80% unless you buy the "gap" insurance. Sounds all right, but around here costs nearly $500/month, plus the cost of Part B ($122/month for 2016). You'll have to run the numbers for yourself to see if it's worth it.

Still no coverage for CGMs. A disaster for those of us with hypo insensitivity, but CGMs appear to have fallen through the cracks in the category of durable medical devices.

I haven't actually checked, but suspect these things may be fully covered if you manage to have some more newsworthy disorder - I'm restraining my characterological sarcasm only with the greatest effort...

Medicare must have changed their rules about covering the cost of OmniPod.  Back in 2010 I had been on OmniPod for 3-1/2 yrs when I turned 65 and was going on Medicare.  I was told that absolutely 'NO' - they did not cover the Pod and I switched to Medtronic 723 Revel which is a tubed pump.  Again in 2015 when my pump warranty expired, I was told that they don't cover OmniPod.  Maybe it is different considering what part of the country you live in.

Medicare does cover 80% of the pump and my secondary insurance covers the other 20% of the cost of pump and pump supplies.  However they cover nothing for the cost of a CGM system unless you have a good lawyer.
Type 1, April 2003
Dexcom CGM Sep 2007
Tslim pump Oct 2015
A1C 6.5% - March 2018
"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."  ~Maya Angelou

Offline skb

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Re: Pumps, CGMs and Medicare
« Reply #3 on: April 22, 2016, 06:57:34 PM »
Not a T1 so I wouldn't wander into the part about pumps & CGMs. Insurance is a different game on different continents IMO. Locally, people buy insurance to cover for serious procedures & hospitalisation and I don't think daily consumables or drugs are covered. My own policy has a coverage of about $ 8000/- and I pay roughly $ 325/- premium annually. One of our enrolled member is an expert in the field & im going to ask him to post for us here. Would love to have a global perspective on insurance.
No meds since June 2011
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Offline Tamagno

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Re: Pumps, CGMs and Medicare
« Reply #4 on: April 23, 2016, 04:02:19 AM »
Interesting!

Grammabear, I was specifically told by one insurer the coverage information about Omnipod, however, I've gotten conflicting advice other places, including Medicare itself. I'll be checking with both Insulet and my endocrinologist.

One question about Medtronics is whether or not it's integrated CGM is also covered; also, albeit unrelated to Medicare, is the usual question of its accuracy.

Shanny, your response regarding cost raises a new question about locale that also bears investigation. Keep in mind that I'm also looking for fairly "premium" coverage that has some hope of paying for my bi-monthly IVIG. At a cost of some $30,000/month, I still couldn't afford to pay 20%/month even if it's covered which, so far as I can tell, it's not. I'll be talking to my neurologist about treatment options and coverage Monday.

It would be truly great to find someone who's expert at all these issues. As it stands, finding the right coverage is a nightmare of phone calls, conflicting information, spread sheets and cost/benefit analyses. AARP has thus far proven useless as its really just an insurance company incognito. Similar deal with web sites claiming expertise.

As things stand, I'm still mostly in my right mind and reasonably intelligent. Whatever becomes of people who are not?

Offline Grammabear

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Re: Pumps, CGMs and Medicare
« Reply #5 on: April 23, 2016, 12:02:23 PM »
Tamagno ~

I was on OmniPod for 3-1/2 yrs before I started Medicare.  It did not matter, they still said 'No'.  However I've heard from Facebook people that with the right set of circumstances, whatever they may be, that people have had their Pods covered but not their CGM.  And then again, I've also read on FB where people have had good lawyers who have gotten their CGMs covered through Medicare.  Go figure. 

Type 1, April 2003
Dexcom CGM Sep 2007
Tslim pump Oct 2015
A1C 6.5% - March 2018
"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."  ~Maya Angelou

Offline gattupatel

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Re: Pumps, CGMs and Medicare
« Reply #6 on: April 23, 2016, 08:36:26 PM »
Hi,
on the subject of insurance , SKB is right that globally each country has different rules . In India , medical insurance normally only covers inpatient hospitalisation . regular medicare costs of drugs and home testing kits / appliances are not paid for at all.
if anyone has any specific queries then let me know .
US is a complex market , unlike NHS in UK where free kits and meds are provided to citizens .
Regards,

Offline Tamagno

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Re: Pumps, CGMs and Medicare
« Reply #7 on: April 24, 2016, 03:15:48 AM »
Many thanks, Gattupatel!

I'll be dining this evening with a close friend who's very highly placed in a major pharmaceutical company that distributes its wares globally. While I'm aware of the hurdles in place for various country's regulatory agencies, I've not asked about him about insurance or formularies.

Tonight may be a good night to inquire...