One Month of Medicare with Type 1 Diabetes

I thought it was going well.

Some of it is great.

I’m learning that maybe not everything is going so great.

I haven’t screamed at a phone menu yet.

I officially started Medicare on April 1. I seem to have figured out how to pay my bills through auto payment. I have received a box of pump supplies and have an order in place for CGM supplies. I have received my insulin at no cost through Medicare Part B and had another prescription covered at no charge through Part D. I belong to a new health club through a program offered by my supplemental insurance. On the surface all of this looks great and some of it is. Unfortunately not everything is going smoothly and Medicare is not approving everything.

What’s Going Great:

Silver&Fit:  This fitness program is a benefit of my BCBS Supplemental policy. It provides a membership at a participating fitness facility, an instructor-led class, or access to Home Fitness kits. I joined a club five minutes from home that has a huge number of work-out machines, weights, a spa, nutrition and fitness programs, locker rooms, and free fitness classes. I have been attending numerous strength and cardio classes and having a great time. No charge at all. My only limitation is that I can only use the club I joined and not the other branches around Minneapolis. I literally walked in the door and was a member 10 minutes later.

Doctor Visits: In April I had two routine doctor appointments. It was easy to provide my Medicare information and as far as I can see, they are being covered with no issues. I feel bad seeing how low the Medicare reimbursement is for my doctors.

Not Perfect but On the Right Track:

Insulin for Pump: As I explained in a previous Medicare blogpost, insulin for an insulin pump is covered under Part B DME. With my supplemental plan coverage that means I get my insulin at no cost. I am not bound by formulary restrictions nor does my insulin require a copay or put me into the Part D donut hole. The new prescription from my endocrinologist contained the required information and I spoke to a pharmacy tech to remind them to file it with Part B. Very quickly I got an email that the prescription was ready; it had been charged to my Part D plan with a charge of $481 for 3 vials.

The next morning I went to Walgreens and fortunately the pharmacist on duty knew how to correct the problem. She told me that it would be referred to the central Walgreens Medicare department and it might take 2 days to set up. That afternoon I got a call from the Medicare department and was asked for information such as my pump brand, model, serial number, purchase date, and whether it was paid for by Medicare or private insurance. That all made sense and was easy to provide. She finished our conversation with two questions. How tall are you? What do you weigh? Huh??? She said that my insulin would be ready for pick-up in an hour and it was.

Pump Supplies: In March I contacted Tandem Diabetes to learn my Medicare supplier for pump supplies. I was told that according to my supplemental insurance, I should use CCS Medical and Tandem would set up the account for me. CCS has been great so far and has contacted me and my endo’s office several times to get the necessary information. One requirement was a C-Peptide test which I had never had before in my diabetes career. As expected, I passed or failed the test depending on your criteria. I failed because I produce minimal to no insulin. I passed because I qualify for a pump and supplies under Medicare.

My pump supplies arrived quickly and were exactly as ordered. Last evening I went into the Medicare site to check my claims and was stunned to see that my pump supplies were denied. I called Medicare this morning and got no good answers as to why. It was suggested that maybe I was using the wrong supplier and I was given the name of another supplier who doesn’t even provide supplies for insulin pumps. I called CCS and the rep indicated that they were already working with Medicare to get it straightened out. She said that it was very common for supplies to be denied on the first go-round for patients new to Medicare. She assured me that everything is OK and I am choosing to believe her.

A Total Mess:

All of us on Medicare were thrilled when the Centers for Medicare and Medicaid Services (CMS) announced in January 2017 that the Dexcom G5 was now covered as a therapeutic CGM under Medicare DME. Soon after that CMS released a document with preliminary coverage criteria and Liberty Medical was identified as the sole Medicare-approved supplier for the G5. Liberty was deluged with calls but managed to start shipping supplies to some customers. One caveat however. In order to receive supplies, you had to sign that you would be responsible for the cost of the supplies if you were not approved by Medicare. Meanwhile it was announced that more specific coverage criteria were still to be released and Medicare was not approving orders filled by Liberty.

Last week it became apparent that Liberty is not going to continue to supply G5 supplies for Medicare beneficiaries. All along Dexcom has indicated that it will not (cannot?) sell G5 supplies out-of-pocket to people covered by Medicare. Please note that the cash price from Liberty is much higher than the previous cash prices from Dexcom. Dexcom will sell G4 supplies to Medicare beneficiaries out-of-pocket. On Monday I received a letter from Liberty officially indicating that they are not going to provide Dexcom supplies after May 28. At this time there is no other supplier.

I placed an order at Liberty about a month ago. I was called last week to indicate that they had everything required to process my order and that it was under medical review. Today I canceled the order because I do not want to be stuck with the responsibility of getting an initial denial by Medicare, having to pay cash for the order, and then filing an appeal. I think I’ll wait to see what happens in coming weeks or months.

Dexcom has been quiet and provided little help to seniors. Today some people received a form letter from Dexcom indicating that they are working on the problem and stating: “If you have an immediate, critical need for Dexcom G5 Mobile CGM supplies, please contact Dexcom at 888-738-3646.” I did not receive the email.

So currently the Dexcom G5 is covered by Medicare, but not really. I am choosing to be patient and optimistic that everything will be worked out soon. Many other seniors on Facebook are angry and less optimistic.

Summary:

Some of my diabetes needs are being met through Medicare and other things are being worked out. So far I have had no problem reaching customer service reps at Medicare, CCS Medical, Walgreens, Dexcom and Liberty. Everyone has been polite and helpful to the best of their ability. Unfortunately no one at Dexcom or Liberty really seems to know what is going on and I believe them when they say the delay is with CMS. The Medicare Help Line was answered promptly but they could give me no reason for my supply denial and then nicely gave me inaccurate information. CCS Medical has been very responsive and so has Walgreens.

Right now I have everything that I need, but that won’t be true for the longterm. In the past I have often had problems when switching insurance plans and suppliers. I am hopeful that most of my Medicare problems are in the same category. I expect the pump supply problem to be resolved fairly quickly. I am less optimistic about CGM coverage.

So that’s today’s story about Medicare and Type 1 diabetes. Stay tuned for more. 😀

 

Countdown to Medicare with Type 1 Diabetes:  1 Month / Growing Old with T1D

Laddie_Head SquareI don’t have much to write about this month when it comes to Medicare. I am signed up for Medicare Part A and Part B. I have enrolled in a Supplemental Plan offered by BCBS of MN. I have selected an AARP Walgreen’s Part D drug plan. For better or worse I am ready to tackle Medicare on April 1.

Turning 65 years old and going on Medicare is a milestone in the progression of growing old. It is impossible for me to make this transition without thinking about growing old with Type 1 diabetes. Below you’ll find some of my thoughts.

The idea of “phases of aging” makes sense to me and I am moving into the “young-old” subgroup described in a Lumen Learning sociology course:

The United States’ older adult population can be divided into three life-stage subgroups: the young-old (approximately 65–74), the middle-old (ages 75–84), and the old-old (over age 85). Today’s young-old age group is generally happier, healthier, and financially better off than the young-old of previous generations.

As a young-old person who has lived with Type 1 diabetes for over 40 years, I am the most confident and empowered in relation to my diabetes than I have ever been. That is not going to change on April 1.

When I was diagnosed in 1976, I knew nothing about diabetes and had access to only a few books and magazines. Today the Internet has opened doors to scientific knowledge, professional recommendations, advocacy issues, and the cumulative knowledge of thecountdown-to-medicare-1-month Diabetes Online Community (DOC). Although I don’t blindly follow online diabetes advice and have never consumed okra water, I strongly believe that my fellow people with diabetes (PWD) have taught me almost everything I know about Type 1 and have motivated and empowered me to succeed. Continued learning about diabetes won’t go away just because I get a Medicare card.

I have lived a privileged diabetes life and have never worried about access to care. I understand that I will have a huge learning curve when it comes to getting supplies and medications under Medicare. I am not yet losing sleep over potential roadblocks although I know that it is naive to think that there won’t be any.

There is no doubt that improvements in both insulin formulations and technology have allowed me to reach age 65 in reasonably good health. I can’t envision what my health status would be (or if I would even still be alive) had I continued on my 1976 insulin regimen of one injection a day and no home BG monitoring. Insulin pumps and CGMs have exponentially increased the quality of my life. I can’t even begin to hypothesize on how and if Medicare will cover future diabetes tech such as artificial pancreas systems.

In some ways I am living with a different diabetes than at other stages of my life. Although hormones never completely disappear, they don’t rage as much for me anymore and are usually more predictable than when I was younger. In Figure 5-2 of Think Like a Pancreas, Gary Scheiner shows graphs of “typical basal insulin levels by age group.”

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The thick line is for ages 60 and older and shows a decrease in total basal insulin along with a sharper rise in insulin needs in the early morning hours. I am experiencing both of those changes and they didn’t make sense to me until I saw Gary’s chart. Most of my bolus ratios have remained the same so far.

Hypoglycemia unawareness is a mixed gift bag as I move into my senior years. On one hand, I feel better because I don’t get the sweats, shakiness, blurry vision, and insatiable hunger of my younger years. I also don’t tend to over-treat lows and multiple bowls of Frosted Flakes at 3:00am are a distant memory. At the same time I know that hypoglycemia is a huge problem for seniors with diabetes and my risks for falls, hospitalization, and permanent disability resulting from severe lows will increase. Knowing that Medicare will soon be covering CGMs for seniors is a huge relief, but I won’t consider it a done deal until I am approved under the not-yet-established CMS guidelines.

When I look at my diabetes, I am comfortable believing that I will be in control of my diabetes throughout my “young-old” years and hopefully well into my “middle-old” years. It is likely that I may require help with care at some point in my “old-old” years…. That terrifies me because I don’t trust anyone else to take care of my diabetes and my biggest fear of aging is losing independence.

Aging is a process. My life isn’t going to be much different on April 1 than it was on March 31. I’ll still have type 1 diabetes and will continue to test my blood and take insulin. I’ll still have arthritis and sometimes I worry more about that than diabetes. But one change that will happen is that I will finally start using the red, white, and blue Medicare card stashed in my wallet. Wish me luck.

Countdown to Medicare with Type 1 Diabetes: 2 Months / A Decision

Laddie_Head SquareI’ve made a decision, but will it matter in the long run?

A month ago I planned to sign up for a Platinum Blue Cost plan offered by Blue Cross Blue Shield of Minnesota. It seemed to promise a relatively easy transition into Medicare with the option of switching to the Senior Gold Supplemental plan within 12 months with no health questions. I believe that longterm Senior Gold is a safer plan for me because it covers all Medicare providers, guarantees no reduction in benefits, and provides better coverage when I am out of state. Unfortunately it is more expensive, mandates the use of Competitive Bidding suppliers, and requires the purchase of a separate drug plan. It should be okay for me to start on Platinum Blue and then switch to Senior Gold for 2018, but the BCBS rep has not been able to give me a link within the policy guaranteeing the ability to switch. I don’t trust anyone in today’s healthcare environment and I’ve decided to dive headfirst into Senior Gold and traditional Medicare.

Like most people living with a chronic medical condition, I am stressed to the max considering the present and future of healthcare in the United States. I am working to stay informed and involved in advocacy while protecting myself from going batshit crazy. I am rationing Facebook time, newspaper reading, and TV news. I am not worried that I willcountdown-to-medicare-2-months ever be in the position of having no access to some level of diabetes care. It may not be a state-of-the-art insulin pump and CGM, but I have to believe that I will always have access to insulin. I worry for other seniors who do not have the resources than I have. I worry for younger people as the protections of the Affordable Care Act (ACA) are repealed without a plan for the future. I worry that some of our elected representatives are more interested in reducing healthcare costs by limiting access to care rather than reining in costs, particularly drug costs.

The future of Medicare is a big unknown and I have read articles that suggest that the repeal of the ACA and changes to Medicaid will precede any major changes to Medicare. At the same time Tom Price, Trump’s cabinet nominee for the Department of Health and Human Services, is in favor of privatizing Medicare and House Speaker Paul Ryan has pledged to reform Medicare in 2017. A recent article in Forbes suggested that Trump might surprise everyone and come out in support of MFA (Medicare for All). So who knows? All I know is that we are in for a wild ride and probably not a ride that will be fun for people with pre-existing health conditions. I will enter Medicare trying to make the best choices I can while knowing that my choices might not matter at all as we move into a crapshoot future.

I haven’t selected a Part D drug plan yet. I currently take three drugs, four if you include insulin. Two have good coverage with any plan. The third is well-covered as a Tier 2 generic drug in the BCBS Platinum Blue formulary. Unfortunately this same drug is non-formulary and/or covered poorly in Part D plans. It’s been a good drug for me but not so great that I won’t be willing to switch to something more affordable.

I have received notification from SSA that I have been accepted into Parts A and B of Medicare. I have not yet received my Medicare card and that is required before I can apply for a supplemental or drug plan.

I am not dreading Medicare as much as when I started this series almost a year ago. I know some people with Type 1 diabetes who are thriving on Medicare and have learned to navigate the system to get the care and supplies they need. I know others who live on a 90-day cycle of frustration and fear as they repeatedly run into roadblocks getting test strips, insulin, and pump supplies. I know that I will go crazy when things don’t happen the way I expect and I will scream at automated phone menus. But I choose to be optimistic that I will get everything figured out. That might be blind, stupid optimism and I reserve the right to change my tune at any point in the future and start cursing and howling at the moon.

Medicare and CGM Coverage: Love Your Receiver!

Laddie_Head SquareI was surprised, thrilled, elated, stunned, relieved, and every other adjective that you can think of when I received Friday’s mass email from Derek App, JDRF President, with the breaking news:

CMS Labels Continuous Glucose Monitors as Durable Medical Equipment

JDRF is pleased to share that the Centers for Medicare & Medicaid Services (CMS) decided today to recognize continuous glucose monitoring (CGM) devices approved for use in making diabetes treatment decisions as durable medical equipment, a significant step toward making them eligible for coverage under Medicare. Today’s decision lays a pathway toward extension of Medicare coverage for the devices that will bring the nation’s largest insurer in line with the vast majority of the country’s private payers. Although the significant benefits of CGM use have been known since 2008, CMS had previously refused to consider covering the devices under Medicare, saying they did not meet the statutory definitions of durable medical equipment or any other category the agency could cover. Today’s decision removes that impediment.

In recent years I have wavered between optimism and pessimism as I advocated, hoped, and prayed for Medicare coverage of continuous glucose monitors. Now it looks as though the day is coming! I don’t know how long it will be before procedures are in place for receiving reimbursement, but it will be soon. Soon may mean later in 2017. Soon may mean 2018. But there is finally a path in sight for Medicare reimbursement of CGM’s.

Today I read through the 15-page CMS Ruling with a yellow highlighter. You will find some of the specifics of the report well-described in Mike Hoskins’ Diabetes Mine article:  NEWSFLASH: Medicare Will Cover Some CGMs Now! Below I will expound on a couple of Mike’s points and then talk more about the specifics of durable medical equipment.

Dexcom Only: This ruling only applies to the Dexcom G5 because it is the only CGM approved by the FDA for insulin dosing. Therefore the G5 is the only system that fits the definition of a “therapeutic CGM.” Currently CGM systems by Medtronic have not been approved for insulin dosing and are considered “non-therapeutic.” They do not fit the definition of Durable Medical Equipment (DME).

No Guarantee of Coverage: This ruling only states that therapeutic CGM systems fall within the scope of Medicare Part B DME. There has not yet been a national coverage determination to guarantee approval if one satisfies still-to-be-determined coverage criteria. Right now MAC’s (Medicare Administrative Contractors) have the option of issuing local CGM coverage determinations or coverage may be obtained on a claim-by-claim basis. What does this mean? We will learn as Medicare beneficiaries begin filing claims for CGM coverage. You can bet that I will apply for coverage as soon as possible after starting Medicare in April.

All Types of Diabetes: Just as people with all types of diabetes are able to receive coverage for home BG monitoring, all PWD will be eligible for CGMs according to this ruling. Don’t get too excited because IMO the coverage criteria will most likely restrict reimbursement to some people with Type 1 diabetes and some insulin-using Type 2’s. Just as it is more difficult for Type 2’s to obtain coverage for insulin pumps, it may be more difficult for them to obtain CGM coverage. But this is still an improvement over the 2015 congressional bills (S.804 and H.R.1427) that specified Type 1 diabetes.

One thing not addressed in Mike’s article is how the Dexcom G5 fits into the Medicare definition of Durable Medical Equipment (DME).

According to the CMS ruling, there are 5 criteria which must be established in order for a device to considered as DME:

  • Can withstand repeated use;
  • Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years;
  • Is primarily and customarily used to serve a medical purpose;
  • Generally is not useful to a person in the absence of an illness or injury; and
  • Is appropriate for use in the home.

Home blood glucose meters and supplies have been in this category for a long time. Technically the meters are “durable” and have an expected life of at least 3 years. For “multicomponent” systems, the other components are covered as long as one component (the meter) is “durable.” Therefore test strips are covered because they are an integral part of the system.

Looking at the Dexcom G5 system, CMS quickly specifies that sensors with an expected life of 1 week are not durable. Neither are transmitters with an expected life of 3 months. So we are left with the receiver. According to CMS, “reliability analysis data from an engineering firm that evaluated the receiver component of the recently approved therapeutic CGM predicts a lifetime of greater than 3 years for the receiver.” CMS goes on to say that the receiver “is the only component of the therapeutic CGM that can be considered durable and satisfy the 3-year MLR criterion of the definition.”

What does this mean? It means Love Your Receiver!!! Without the receiver, the Dexcom G5 system does not satisfy the criteria for DME.

dexcom-love-your-receiver

The FDA approval of the G5 system required the purchase of a receiver and many people complain about that requirement since they use their phones as the receiver. Just know that CMS is never going to classify your phone as a reimbursable medical device, so cherish your receiver even if you never take it out of the box. If you’re not on Medicare, still cherish your receiver so that seniors can receive CGM coverage! Also Medicare coverage of CGM’s is important for everyone because it is a vital component to coverage of artificial pancreas systems.

In the coming weeks and months, we will learn more about the implementation and impact of this CMS ruling. If you’d like to learn more, here are a few links.

Text of CMS Ruling

Diabetes Mine Analysis  

Diatribe’s Preliminary Analysis

Expanded Statement from JDRF

And no matter what, don’t forget to Love Your Receiver!

 

Countdown to Medicare with Type 1 Diabetes: 3 Months / It’s Happening

Laddie_Head SquareOn April 1, 2016 I started writing about my journey to Medicare with the sentence  “A year from today I will be on Medicare.”  With 3 months to go I’m not yet at the finish line. However, on January 1st I entered my “Initial Enrollment Period.” That means that I can finally start doing something about Medicare rather than just talking about it.

Tuesday morning I applied for Medicare benefits online. (I did not apply for monthly retirement cash benefits because as someone born in 1952, my NRA (Normal Retirement Age) to receive full benefits is age 66.) Enrollment in Medicare Part A (Hospital insurance) and Part B (Medical insurance) or Part B only is required before I can apply for a supplemental or cost/advantage plan in my state. Therefore I will need to wait for proof of enrollment and I assume that will be my red, white, and blue Medicare card.

The online enrollment was easy and I immediately received an email confirming my application. About 24 hours later, I received an email from SSA.gov indicating that my application was being processed and I could expect to receive a letter within 30 days.

Thank you for filing your Social Security application online. Our Social Security Office in CHICAGO, IL received your claim and will be working with you to process it. Our goal is to process all applications efficiently.

A representative may call you for more information at the phone number you provided on your application. Please be aware that our representative may call you outside normal business hours, such as on a weekend or during the evening. If we are unable to reach you by phone, we may also contact you by e-mail or U.S. mail.

You should receive a letter in the mail within 30 days with a decision or to request additional information. If you have a future month of entitlement, you should receive a letter in the mail approximately thirty days before your benefits should start. Also, you can check the status of your application at Status of your application or you may call us at (800) 842-0588 with questions. Please wait five days from the time that you filed before checking the status online.

Now my job is to reply to any requests for further information from a SSA representative and then to wait.

countdown-to-medicare-3-monthsUnless something happens in the next month to change my mind, I have decided to enroll in a Platinum Blue Cost plan offered by BlueCross BlueShield for 2017. I will write more about the decision in a future blogpost, but this plan essentially “cushions” my entrance into Medicare. It allows me to use BCBS DME suppliers and not deal with Competitive Bidding. It exempts me from several other Medicare regulations such as seeing my pump-prescribing physician every 3 months and extensive record keeping to justify more than 3 test strips per day. It includes prescription coverage and for the most part functions like the commercial insurance I currently use.

With any Cost plan in Minnesota I would have 6 months to switch to a Supplemental/Medigap plan with no questions about pre-existing health conditions. However, by going with the BCBS Cost plan, I am allowed 12 months to switch to Senior Gold, the supplemental plan offered by BCBS. I am still not sure about the best Medicare plan longterm, but this strategy buys me time to consider that choice again for 2018.

So now I wait.

Countdown to Medicare with Type 1 Diabetes:  4 Months / No Decision

Laddie_Head SquareI thought that I would have made a decision about Medicare by now and I haven’t. I don’t feel that I am much closer to a “right” decision than I was a few months ago. I have narrowed my choices to 3 plans: 2 Cost plans and 1 Supplemental plan. Each plan has definite pluses and minuses.

About 6 weeks ago I was close to making the decision to go with one of the Cost plans offered by BCBS of MN. The advantages of this plan are reasonable cost, excellent coverage for pump supplies, formulary inclusion for all of my drugs, and a preferred test strip brand that I am satisfied with. It allows me to use BCBS DME suppliers without dealing with the Competitive Bidding suppliers of Basic Medicare. With this plan I will have 12 months to change my mind and switch to the BCBS Supplemental plan with no consideration of pre-existing medical conditions. Therefore I can stay on this plan for all of 2017 and have all Medicare options available in 2018. The major disadvantages of this plan are no CGM coverage and that starting in 2017, Walgreen’s is not a preferred pharmacy. I have always had great service with Walgreen’s and my first choice is to stay with them.

A couple of weeks ago it was announced that Fairview, one of the major health systems in Minnesota, has not come to a network agreement with BCBS for 2017. Therefore many of my health providers will be out-of-network if I choose a BCBS Cost plan. I believe that an agreement will eventually be reached, but….

The second Cost plan that I am considering is offered by HealthPartners. The main advantage of this plan is that it provides CGM coverage. It should be a no-brainer to go with this plan, but co-pays for pump supplies and test strips cost substantially more than on the BCBS plan and the total cost of the two plans is about the same. Plus the preferred brand of test strips for HealthPartners is one that I have not had good success with. I will only have 6 months to revert to Basic Medicare and a Supplemental plan and I will need tocountdown-to-medicare-4-months re-evaluate my options partway through 2017.

The Supplemental plan that I am considering is BCBS Senior Gold. The advantages of Senior Gold are that benefits will never be reduced in the future and I can take the plan with me if I move out of Minnesota. With this plan I will experience few or no out-of-pocket costs. There are no network restrictions and I can see any provider who accepts Medicare. I can always choose to switch to a Cost or Advantage plan in the future. The downside is that Supplemental plans follow Medicare guidelines and there is no CGM coverage. Also I will be forced to use Competitive Bidding suppliers for mail order test strips and pump supplies. I will be required to see my endocrinologist every 90 days in order to receive pump supplies. Although this plan allows the most flexibility for future coverage, it is substantially more expensive than the two Cost plans I am considering.

I don’t know what I am going to choose. I have a list of questions that I will present to an insurance broker I have been in contact with and to a representative from my local SHIP agency. Because I do not need to make my decision until February, I have avoided recent contact with these consultants until the Medicare Open Enrollment period ends today.

Last month I wrote about the anxiety I was experiencing as I thought about Medicare. Today I am not worrying about it. Frankly there are so many unknowns that I am beginning to think that it may not matter what I decide. I have written that Medicare Cost plans are unique to Minnesota, Wisconsin, and a few other states. I was told by a representative from BCBS of MN that these plans will probably be disappearing in the next year or two due to pressure from Medicare. They will be replaced by Advantage plans with different guidelines and network restrictions but more similar to plans offered in other states. The plan I select now may possibly not exist in two years. I know people with diabetes who are using Supplemental plans. I know people with diabetes who are using Cost or Advantage plans. Whatever I select, I will be part of a population of people with diabetes who are in the same boat as I am.

Meanwhile a Trump presidency along with a Republican-controlled legislature is an indication that we may see substantial changes to Medicare in the coming years. Will current Medicare beneficiaries be exempt from future changes or will we all move into a new unproven system? What will happen to people with pre-existing conditions and serious illnesses?

I don’t know the answers to these questions. The only thing I know is that there may not be a “correct” decision for me to right now. There are different decisions. There is Plan A, Plan B, and Plan C. Maybe my choice will make a difference. Maybe it won’t.

I just don’t know.

Countdown to Medicare with Type 1 Diabetes:  5 Months / Anxiety

Laddie_Head SquareThere are frequent online discussions about addressing mental health issues along with physical concerns when living with diabetes. I am lucky to be mostly immune from things like diabetes burnout and depression. I don’t like diabetes but it doesn’t haunt or slow me down much. I come from a family with a history of depression but its dark clouds have never settled over me for very long. Still…

I have a tendency towards anxiety. The kind of worry that radiates in my chest and aches in my belly. It has never been so crippling that I have felt the need for professional help and I have been helped by progressive relaxation tools I learned from a book many years ago. Deep breathing and exercise also help.

I am very in tune with my anxiety. It surfaces when I need to make a decision or address a problem and I don’t feel in control. Sometimes the issues are trivial or at least very fixable, but my rational brain can’t convince my gut that I shouldn’t be stressed. I won’t call them silly, but my anxiety worries are not life-or-death. Maybe it is a leaky roof. Maybe it is a grandchild getting her feelings hurt. Maybe it is Christmas. Maybe it is thinking about what needs to be done to sell our house and we don’t even plan on selling the house.

Maybe it is Medicare.

I have been trying to get a handle on Medicare options for several months. I haven’t decided whether I know too much or not enough. I wake up many nights at 2:00AM and start thinking about Supplemental versus Cost* plans. I walk the dog and my stomach cramps thinking of Competitive Bidding. Part B insulin and test strip brands are a constant concern. This stuff is important, but not so important that I should be losing sleep.

But anxiety does not always make sense.

I finally have premium costs and plan information for 2017 and I am making worksheets to compare my options. I have only one decision that could have an impact beyond my first year on Medicare and that is the Supplemental versus Cost plan decision. Supplemental (Medigap) policies are only required to accept me (a person with pre-existing conditions)countdown-to-medicare-5-months during the first 6 months that I am on Medicare. After that I can be denied coverage or charged higher rates. At the same time there are guidelines about having guaranteed Medigap rights and some of those scenarios will grant me needed flexibility in the future.

The things that stress me are discrepancies like one plan agreeing that insulin for a pump will be covered under Part B and a similar plan saying it won’t. (That can be a big deal because Part B insulin does not go into donut hole calculations.) I think the plan saying no is wrong, but what do I do about it and do I dare risk signing up with that company? I need to consider that company because it happens to offer CGM coverage. Yes, I am lucky to have the option of CGM coverage with one plan! But I need to consider the whole package, not just one thing. More homework to do.

Another thing that is stressful is trying to figure out what pump and testing supplies cost. For the most part I have been using the negotiated prices from my current BCBS policy. But one friend shared his test strip cost info with me and it looks as though he is paying 20% of what I consider a high retail price compared to what a negotiated price should be. Am I right? Right or wrong it certainly makes me wonder what prices I should be using to figure out my anticipated costs.

Another thing that kicks me in the gut is competitive bidding. This is only relevant if I choose a Supplemental plan because Cost plans use their own suppliers. DPAC has published a couple of blogposts recently that scare the bejesus out of me. One post was written by a person with diabetes on Medicare and the other was written by someone who owns a durable medical equipment company. These are great articles to spur advocacy, but frightening for those of us anticipating Medicare.

One benefit of participating in the DOC is that I have support from other people affected by diabetes. A downside is that I read stories of people having nightmare experiences with Medicare. As a blogger, I get emails from readers sharing their stories and problems. At the same time I know many people with Type 1 who are doing fine on Medicare but those people don’t write much about their experiences. I mostly hear the bad stuff.

anxiety

I have anxiety. Some of it is unreasonable. I live in Minnesota and have several good (not perfect) options for Medicare. My husband still works and his income will provide a buffer from the shortcomings of Medicare. At the same time some anxiety might be reasonable because healthcare reimbursement at all levels in the United States is under siege and people with diabetes are getting hit particularly hard.

I expect that my next Countdown to Medicare post in December will outline some specifics of my choices. Obviously cost is a major concern, but so are things like drug formularies, test strip brands, and requirements for getting pump supplies. I have already eliminated choices that do not network my current doctors and I am looking at the plans of two different companies. It is likely that I will choose a plan that allows me to avoid competitive bidding because anyone with a tendency towards anxiety might not survive that disaster.

More to come. 😀

*

**Minnesota is one of very few states that offers Cost plans. These plans are hybrids that combine features of traditional Medicare and Advantage plans. Most people reading this post will not encounter Cost plans in their Medicare journey.

Countdown to Medicare with Type 1 Diabetes: 6 Months / The Journey

Laddie_Head SquareI occasionally have readers who contact me by email rather than leave comments on my blogposts. Kathy K from New York is one of those readers. She and I have an amazingly number of things in common. She was diagnosed with Type 1 diabetes in 1974 at age 23 after recently graduating from school and getting married. I was diagnosed in 1976 at age 24 after recently graduating from school and getting married. She has 2 children and 5 grandchildren. I have 2 children and 5 grandchildren. Do you see a pattern here?

Kathy is a few steps ahead of me in the Medicare process. Today she has written about some of her experiences as a newcomer to Medicare. There is no doubt that she knows “diabetes.” In addition to living with Type 1, she is a retired RN and BSN Certified Diabetes Educator.

Welcome, Kathy K from New York, and I hope that this is the first of many guest posts!

*****

The Journey that is Medicare

kathy-krieg-headshotThank goodness that I found Laddie. I was fuming with frustration trying to get my first prescriptions, pump supplies and strips through Medicare. Even though Laddie is not quite there yet, her blog regarding her journey toward Medicare eligibility sounded exactly like mine.

The  psychological profile of most persons with Type 1 diabetes who use an insulin pump probably include such traits as independence, controlling, problem solving and motivated. (well maybe that’s just me!) I have lived with Type 1 diabetes for 42 years and thankfully had excellent health insurance and a wonderful physician willing to let me “run the show”

What a shock to realize that Medicare regulations takes all that away. You all know how we make sure we have enough pump supplies on hand, strips to cover frequent testing and insulin. I am here to tell you to be sure to have enough on hand to withstand ins and outs of new insurance rules.

Some of the biggies are Medicare does not cover CGM. Only 100 test strips are allowed if you take insulin and calculating your individual costs for medications is an accounting nightmare! But wait, there’s more to share. Do not take any of those restrictions at face value. My motto “Never take NO for an answer.” As many people that you call looking for help, that’s as many different answers you can get for the very same question.

Here is what I found out along my journey.  I am now knee deep in the muddy waters of Medicare coverage. Medicare has been approving some CGMs. A very specific appeal process needs to be followed but even courts have directed Medicare to approve of these devices. With that said, contact your supplier for help. They will probably offer you a decreased price for persons who have to pay out of pocket. My experience with Medtroniccountdown-to-medicare-6-months is that before you order supplies, you have to sign a disclaimer that states:  1) bill Medicare the full price and you will proceed with the appeals process to get the bill for $473.00 for a box of 5 sensors. If the appeal fails, you are responsible for the entire amount. Or 2) I want the sensors but will pay a decreased price up front now and cannot then bill Medicare and go through the appeals process. This price is about 45% off or approximately $260.

Another fact to keep in mind for those on an insulin pump, the insulin used in the infusion device is covered under Part B of your Medicare health insurance. Do not back down on this one. Find a pharmacy that has experience billing this way and use them. For me that was Walgreens. My Walmart pharmacist looked at me like I had two heads when when I was trying to explain this. I have a Medicare supplement policy that picks up all costs that are not paid by Medicare. So my cost $0!! Yep, that’s right—$0 for my Humalog insulin. My infusion sets and reservoirs are also covered under this same policy. That is one of my biggest successes in this journey. A new order for pump supplies, for me reservoirs and infusion sets, cannot be started until you only have 5 sets left!!! or 81 days from the previous order.

Another change I encountered is that I can no longer get my test strips from the pump company. There is a bidding process for providers in some areas and whomever Medicare chooses as the winner of the bid is the type of strips and the place where you need get them. Additionally, you will only be allowed 100 strips per month. Not nearly enough for me and probably you too! Once again Medicare also known as CMS, has a process for appeal. You need to supply a log of your tests and a physician note documenting the need. I have yet to submit for strips. I am not due to reorder yet.

Lastly, at least for now, is drug coverage. This is the biggest stumbling block for me. I tried the mail order supplier the insurance company suggested. I am quite dissatisfied with this company and that is another long story. I am finding it difficult to follow how much each of my medications cost and how far down the line to the donut hole I am. Hopefully, that’s a learning curve I will master soon.

DISCLAIMER:  Please do your own research into your specific state and insurance companies regulations. This is just my experience in the journey that is Medicare.

ONE MORE THING:  I have an additional psychological trait. I am so stubborn with a 2 year-old’s “ME DO IT!” attitude. Hummmm… A 2 year-old battles Medicare! Stay tuned.

Congrats to Medtronic!

Laddie_Head SquareUnless you are living in an underground bunker, you know that Medtronic Diabetes announced yesterday that the MiniMed 670G hybrid closed loop system has been approved by the FDA with anticipated shipping in the spring of 2017. Here’s a link to the press release if you haven’t read it yet.

Am I excited about this? Absolutely yes!!! Will I purchase it? Absolutely not!!!

You may think that I won’t purchase this because I am currently a Dexcom and Animas user. You may think that I won’t purchase this because I’m mad about the United Healthcare/Medtronic agreement. You may think that I won’t purchase this because “The Cure” will be here in five years. No, those are not the reasons. What is preventing me from pursuing this device is my next pump and CGM is ⚡️⚡️⚡️⚡️

Those lightening bolts are supposed to grab your attention and make you sit on the edge of your seat as I explain my predicament.

My issue is that I am going on Medicare in April 2017 after having my current pump go out of warranty in December 2016. I long ago satisfied my deductible for 2016 and if I purchase a pump before the end of the year, it will be at no cost. The individual health insurance market in Minnesota is in chaos and I plan to purchase the cheapest insurance plan possible for January through March 2017. It will be expensive despite a high deductible. No way can I purchase a new pump in that time frame.

So my choice is to purchase a pump in early December or enter 2017 with an out-of-110089warranty pump and wait until Medicare. A naive advisor might suggest that I buy the Medtronic 630G in December knowing that those buyers will be the first in line for the 670G pump when it is released in the spring. But guess what! Once you get on Medicare, it is against Medicare law for beneficiaries to participate in upgrade programs. So if I purchase a 630G, that will be my pump for the next 4-5 years because I will not be allowed to upgrade to the 670G.

A Medtronic representative told me on Saturday that the 630G is now being reimbursed by Medicare. The sensors are not Medicare-eligible, but at least the pump is covered. If I wait hoping to purchase a 670G after April 1, the most likely possibility is that it will not be covered by Medicare for quite a while. Hopefully I am wrong on that.

I am excited that the FDA has approved the MiniMed 670G. Medtronic is not calling it an  artificial pancreas, but it is an important step on the journey to complete insulin automation. That is good for all of us excited about the future of diabetes technology.

But for me, it is not in the game. My reimbursement scenarios just don’t fit the timing of this release. Anyone who reads my blog regularly knows that I currently use Dexcom after several unhappy years with Medtronic SofSensors. The Guardian Sensor 3 that is part of the 670G is many generations removed from that nightmare and I would be open to trying them. But it would be too big a leap of faith to move back to Medtronic without a trial run. Maybe that will be possible in the future when hopefully, hopefully, hopefully CGM/pump systems will be reimbursable under Medicare.

Today my options are too tangled and uncertain to make the MiniMed 670G part of my plans. But I will still camp out in the grandstands with other diabetes advocates yelling “Congrats!” to Medtronic. We live in a golden age of diabetes tech. Unfortunately we also live in a stone age of diabetes reimbursement for those of us who are approaching age 65 and older.

Countdown to Medicare with Type 1 Diabetes: 7 Months / Ducks in a Row

Laddie_Head SquareI went to court last month. Was I nabbed by the diabetes police? Nope. How about the regular police? Not them either. Was I dragged into the legal system for breaking the rules by dosing insulin off my CGM? Nothing like that. So what was I doing?

I was getting my ducks in a row.

What does that have to do with Social Security and Medicare? The answer to that is a lot.

As you approach your initial sign-up date for retirement benefits under Social Security, you need to be sure that you have the required documentation for your claim. According to the Social Security Administration (SSA) website, in most circumstances you will need the following documents:

•your Social Security card (or a record of your number);

•your original birth certificate or other proof of birth (You may also submit a copy of your birth certificate certified by the issuing agency);

•proof of U.S. citizenship or lawful alien status if you were not born in the U.S. [More Info];

•a copy of your U.S. military service paper(s) (e.g., DD-214 – Certificate of Release or Discharge from Active Duty) if you had military service before 1968; and

•a copy of your W-2 form(s) and/or self-employment tax return for last year.

My advice is to consider this list at least 3 months before signing up for Social Security so Countdown to Medicare 7 Monthsthat you will have time to obtain any missing documents. Although I had a copy of my birth certificate, I chose to get a certified copy just to be safe. It took about 3 weeks to get the official document from the vital records department of my birth state.

Fortunately if you have any gaps in documentation, you can and should sign up for Social Security on time. From the Social Security Administration (SSA) website:

“Even if you don’t have all the documents you need, don’t delay signing up for Social Security. You can submit any documents you do have. You can provide the missing documents later or we may be able to help you get them.

In many cases, your local Social Security office can contact your state Bureau of Vital Statistics and verify your information online at no cost to you. If we can’t verify your information online, we can still help you get the information you need.

If you delay signing up, you could lose some benefits you may be due.”

So why did I have to go to court?

I had to get a court order for an official name change. Since 1976 I have had a discrepancy between the middle name on my driver’s license and the middle name on my Social Security card. When I got married I chose to keep my maiden name as my middle name and abandoned my previous middle name. Or so I thought. I went to Social Security and had a card issued in my new name. When we moved to Minnesota, the DMV required me to use the old middle name on my driver’s license. I don’t remember how my passport was handled, but it has always matched my driver’s license. So my two main forms of ID for the last forty years have not matched my tax information, bank accounts, and everything else that we own.

I should have fixed this discrepancy years ago, but it amazingly has never been a problem. Thinking of approaching Social Security and handling our assets in our senior years, I finally determined that it was time to resolve the issue.

Changing your name is not difficult. I didn’t need to use an attorney, but did so because a good friend was willing to help me. I filled out a lot of paperwork, seemingly the same thing over and over again. I signed a form allowing for a criminal background check by the FBI. I completed another form for a background check by the MN BCA (Bureau of Criminal Apprehension). More than once I signed that I was not changing my name for fraudulent reasons or to hide assets. On my scheduled court date, I went before a judge with two witnesses and received an official court order for a name change.

With the certified copy of my court order, I have applied for a new driver’s license and will apply for a new passport once the DL arrives.

It is possible that my name discrepancy might not have been noticed with my Social Security application. However in our increasingly ID-conscious society, it seemed to be an unnecessary risk to be a citizen with two aliases. Two aliases sounds so criminal compared to two middle names….

I don’t know everything about Social Security and Medicare yet, but at least I have my ducks in a row. Most of you won’t have to go to court to get ready for Medicare. However, you may have other things that should be taken care of as you enter this new stage of your life.

Now is as good a time as any to get your ducks in a row.

Ducks in a Row