Medicare - After Part B

I’ve been told it is possible to have zero dollar out of pocket if I have the right medigap policy. I don’t have a pump yet but am investigating the possibility.

I haven’t retired yet but I understand that Part B covers the pump, infusion sets and 80% of the insulin (ideally) Does the typical medigap plans cover everything else involved in pumping?

@Gabriel1 Welcome Vance, to the JDRF TypeOneNation Community Forum!

I waited until I reached 70 to retire, and and the first of the following month I began using a UHC Medicare Advantage Choice PPO; during the 12 years on this plan; during these 12 years, I’ve had very good coverage for diabetes supplies - pump, CGM - and minimum out-of-pocket co-pay for a half dozen specialist doctors of my choice. The “Choice Plan” has changed slightly over the years and become a little better; I do pay upfront [by Social Security withholding] the highest monthly premium, which a UHC agent calculated is less costly than a Medicare GAP plan.

I suggest that you visit medicare.gov and use the search to find plans available where you live and then enter your health needs, including prescriptions, and let it calculate your actual expenditures. I was surprised at how well the government site and calculator work. Your location is important, not all plans are available universally, and I was told by the agent that “Gap Plans” are most expensive in Florida where I live.

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Dennis, thank you.

I have worked Medicare.gov from every angle, including using a couple of agents.

You already know this however When entering information into Medicare’s plan finder, they do not permit one to enter an insulin pump as a cost consideration. I know that a pump is a Part B DME device but part B doesn’t cover it all and I wanted to see the numbers for what remains and if Medigap or part D will cover the rest.

EvenMedicare.gov folks said it cannot be done on their site, no surprise. I asked them if there was a criteria that would indicate whether a plan would cover pump related 20%. They said no, it was up to the plan.

I also reached out to Humana - it keeps coming up as my best option on the plan finder. They were not sure but said I’d have to sign up to find out. Must have been how the ancient humans figure out what plants were poisonous.

I asked here because I thought people like yourself could share their experience. Thank you very much.

You did the right thing Vance @Gabriel1, in getting in touch with the insurance company for direct and specific questions. Last fall when reviewing plans before the December “change date”, I found a Cigna plan that “appeared” to be as cost effective - I don’t say “cheaper” overall than my UHC plan. The company spokesperson did assure me that Tandem supplies would be covered and could NOT confirm that Dexcom G6 would also be $0.00 co-pay every quarterly refill and without deductible. Needless to say, I continued with United for another year.

The autumn “before corona virus” I consulted an independent agent [who would earn commission] about my choice of coverage; after he explored all possible options, including Medicare GAP", he told me to stay just where I am. He is trustworthy and respected in this County.

As far as Agents, we’re still looking.

I found the SHIP people in my area. Very helpful but also very slow to respond. They really don’t have ideas or direction, just the ability to explain baseline items in detail, ie nothing specific like Diabetic needs. Turnaround time on an email is about a month.

My Home & Auto lady sent me to a medicare specialist. He delegated to one of his staff and their first comeback was Part D alone would be $18K for me, not including my wife. Stunned, I asked them to double check. Then it was $9K and then $3k and then back to $10K.

So I went looking and found another internet advertising agent. Very nice folks but then they delegated me to the trainee agent. You can guess where this is going…

I’ve also spoken to Medicare directly. Very nice people but they are reading scripts and don’t have fundamental knowledge or the ability to go too far off script.

So we’re still looking for guidance. My goal is to have the numbers make sense and to find someone that knows more about Medicare than I have had to learn. I can’t believe I have to educate the agents to whom I am talking about basic things.

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Hi @Gabriel1 I don’t have anything to add as I am on company insurance right now. What is your location? Perhaps a JDRF online support volunteer may have something for you? I can make the connection if you give me your state or zip. You can DM me if you don’t want it public.

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I always like to follow these threads so maybe I’ll be prepared in a few years when its my turn…Please come back and let us know how the search turned out.

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When I retired at 65, I was on an advantage plan for 6 months. I was not happy with it because of the amt of money out of pocket. I switched to a gap plan, part G, and now pay a monthly amt. But I do not pay anything out of pocket for insulin or my pump and dexcom supplies.
Of course, every January, I have to pay part B deductible for supplies or procedure or Dr appt, depending on what gets billed first that year.
The payment for my gap policy has gone up every year, but at least I know how much I pay. Plus, my supplies are covered, as are emergency visits, Dr appts, and procedures.

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Thank you, that is valuable information.

For all the research I have done, and professional advice I have been given, they have universally deprecated Advantage plans. As I understand it, if one is basically healthy they are attractive. If health matters go south Advantage plans get very expensive. I’ve also been told it can be difficult to switch from an Advantage Plan to a Medigap plan once problems have started to occur.

Thank you again.

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Yes, once you reach 65, there is a 5–6-month window to sign up for a gap plan. Not sure of the exact timing but would be wise to check on it. When you sign up for a gap plan in the time interval, after turning 65, the gap plan can’t deny you, no matter how many health issues you have. With a gap plan, you will always have a monthly amt to pay the gap company you go with. The amt will increase, sometimes twice a year. But you will be covered for your supplies, emergencies, etc. For me, it has been well worth it. Even if you are relatively healthy, the body does break down with age. Just like a car. The older you get, the more things break down.

Just adding my hubby’s 2 cents. We have Medicare Advantage through BCBS, the highest plan they sell which in our state is $162 per month. He just started on a Tandem pump in March; used to be Medtronic. His Dexcom supplies are covered at 100%. His pump has a “rental” fee for one year and its monthly DME is $58. He pays $18.xx for the infusion sets. After the year is up, we will just pay for the infusion sets’ DME cost. Our DME deductible is 15% until he hits the $2900 yearly out of pocket, which won’t happen. We pay nothing for insulin. In our state, Minnesota, traditional Medicare medigap policies have a very high premium of about $250-$275 per month. It’s cheaper to pay the Advantage DME cost because the Advantage plan covers other things like drugs, vision, hearing and dental at a lower premium. Also he has no Part B deductible because BCBS pays for it in the premium. Like the others said, you have to weight upfront costs versus premiums to determine the best outcome. Hope this helps.

I’m on Medicare and expect my tandem pump shortly. Cost to me is $900. Not sure what the CGM will be. Insulin is $40/ month. I have Aetna PPO advantage plan.

I went with Medicare B and medigap part g thru CIGNA. They have been outstanding when any glitch occurs and I am covered 100% for pump and supplies, Dexcom CGM and supplies and all insulin. No out of pocket except beginning of each year for Plan B. All labs are covered and doctors visits with my choice of doctors. If they are available in your area, I do recommend. Earlier this year I needed to replace my pump and switched to T Slim from Medtronic. No out of pocket and love my new pump

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@Gabriel1 , you have been informed correctly. I have traditional Medicare A & B and was fortunate to keep insurance from my employer as “secondary”. It is important to have SECONDARY, not supplemental according to some of my providers. Except for premiums, my OOP is zero.