[IP] Re: (IP) Pam Brown - Another Part B insulin question
Boy, now the pressure is really on me to answer you since my name is in the
subject line :)B I'm happy to try to help.
Anyway, first, Medicare Cost plans are not Advantage plans. So, whatever rules
govern Advantage plans, such as insulin in a pump being under Part B, don't
govern Cost plans. Cost plans are very rare, only about 30 in the country, but
we happen to have one in our County, so I'm somewhat familiar with them. While
they are network plans like HMOs, unlike Advantage plans, they allow you to go
outside the network and use Original Medicare and just pay the regular
Medicare coinsurance. That's their great benefit. You have more flexibility -
kind of a hybrid between Original Medicare and the Advantage path. With
Advantage plans if you go outside the network you pay the full cost yourself.
That being said, I'm only familiar with our one Cost plan and I can't speak to
yours or all the rules and regulations governing Cost plans in general. Ours
charges 20% for all DME items including test strips and Part B drugs, which
would include insulin in a pump. But that's not to say that some Cost plans
might not waive the 20% just as some Advantage plans do. Ours does not include
Part D so you must get a separate Part D plan. However, according to this link
on the medicare website
lth-plans/other-medicare-health-plans.html, some Cost plans do include Part
I can say with authority that unless you have coverage through the VA, under
Medicare you're only allowed one prescription drug plan at a time. So if your
Cost plan (or anyone's Advantage plan) includes Part D, then you can't get
another separate drug plan from them or any other company. So what the rep
told you about that is true. As far as how they bill insulin, as the above
citation says, each Cost plan can have its own rules and exceptions and you
need to check with the particular plan. So if the one plan is saying that they
treat insulin in a pump as Part D, I suppose that could be true. For people
with Advantage plans, however, it's different and they must treat insulin in a
pump as Part B, not D. (That's not to say that they don't sometimes get it
wrong and you might have to fight with them).
You are correct that if you go the Original Medicare with a supplement route
instead of the above, then the supplement will pick up the 20% for insulin in
a pump and it should not be billed to your Part D plan. So cost-wise you might
come out ahead going that route unless you can get your CGM covered under the
one Cost plan you mentioned. In that case it could tilt the other way as
Original Medicare does not cover CGMs. You're wise to be doing your research
early and to crunch the numbers for all the scenarios.
By the way, although supplements are standardized across the US, three states,
Minnesota being one of them, have their own rules and own standardization for
supplements. Therefore what I say about supplements in general for the other
47 states could be different in your state. For all I know, some Minnesota
supplements might not cover the 20%.
Keep notes of the date, time and names of what any plan reps or anyone at
Medicare tells you. If it turns out that they told you the wrong thing and you
enrolled in a plan on that basis, you could file a complaint with Medicare and
they would likely grant you a special opportunity to switch plans later.
Documentation is the key.
I hope this helps. Welcome to the ridiculously confusing world of Medicare!
<I live in Minnesota and will be starting Medicare in April 2017. My biggest
choice is going to be whether to choose a Supplemental Plan or a Cost Plan.
Cost plans are much more common in MN than other states, but from what I can
tell go by Advantage plan rules.
I have one cost plan saying that Part B drugs are covered at 80/20 under
medical Benefits and that makes sense to me since the plan does not pay the
20% that supplemental plans might cover. I would need to confirm that it does
not enter in to Donut Hole calculations, but since it is listed separately
from Rx benefits, I think that is so.
A rep from another cost plan (the one that covers CGMS!) says that insulin is
covered as a Part D prescription drug benefitbmeaning Tier 3 and goes into
Donut Hole calculations. In order to get the 80/20 medical benefit, I am not
allowed to have a drug plan with them or another company.
Are Advantage (Cost) plans allowed to not cover insulin for pumps as Part B
and able to include it under Part D? Or do you think they are mistaken? The
rep I met with bdid her homeworkb and asked for specialized help to get
the answer to some of my questions. Not one rep I have spoken to at any
company has been familiar with insulin for pumps being handled differently
than insulin for injections.>
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