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Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
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Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
Nancy Klobassa Davidson and Peggy Moreland
Nancy Klobassa Davidson, R.N., B.S.N, C.D.E
Nancy Klobassa Davidson is a registered nurse who has worked in diabetes education for 17 years. She is a certified diabetes educator (C.D.E.) and is currently in graduate school working on a Master of Science in nursing (M.S.N.) and health care education.Nancy works with adults who have type 1, type 2 and other forms of diabetes. Nancy is coordinator of the Diabetes Unit's intensive insulin therapy program within the Division of Endocrinology, Diabetes, Metabolism, & Nutrition at Mayo Clinic in Rochester, Minn. Nancy has worked extensively with insulin pump therapy and continuous interstitial glucose sensing.
Peggy Moreland, R.N., M.S.N.
Peggy Moreland is a certified diabetes educator (C.D.E.) in the Division of Endocrinology, Diabetes, Metabolism, & Nutrition at Mayo Clinic in Rochester, Minn.Peggy graduated with a Master of Science in Nursing and Health Care Education from the University of Phoenix and is a member of the American Association of Diabetes Educators and the American Diabetes Association. A certified diabetes educator (C.D.E.), Peggy enjoys working with patients to set and achieve diabetes self-management goals.
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Living with diabetes blog
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Oct. 19, 2011
Insulin pumps: Medicare coverage?
By Nancy Klobassa Davidson, R.N., and Peggy Moreland, R.N.
This blog is the third in a three-part series in which we discuss Medicare coverage for diabetes supplies.
Medicare Part B covers insulin pumps worn outside the body — including the insulin used with the pump — for some people with Medicare Part B who have diabetes and meet certain conditions.
What are those conditions? You must meet either criteria A or B.
Criteria A
Criteria A states that you must:
- Meet C- peptide or beta cell autoantibody lab test results requirement (blood test results that show that you make little or none of your own body insulin)
- Complete a comprehensive diabetes education program
- Have been on a multiple daily injection (MDI) program for six months, using at least three insulin injections a day
- Provide documentation of blood glucose testing an average of four times per day
- Meet one of the following: 1. Have an A1C greater than 7 percent, 2. Have a history of recurring hypoglycemia, 3. Experience wide fluctuations in blood glucose levels before meals or dawn phenomenon — an early morning rise in blood glucose or hormone levels
- Experience severe swings in blood glucose levels
Criteria B
Criteria B states that you must have been using an insulin pump prior to enrollment in Medicare, and that you have documentation of testing your blood glucose four times a day during the month prior to Medicare enrollment.
Important details
In addition, it's important to note:
- Coverage amount. If approved, you pay 20 percent of the Medicare approved amount after the yearly Part B deductible.
- Provider requirements. The insulin pump must be ordered by a medical provider who manages multiple patients on insulin pumps, and you must be seen by this provider every three months.
- Timing of prescription renewal. Before your yearly prescription has run out, you must be seen by your insulin pump provider in order for Medicare to continue paying for pump supplies. I have seen cases in which my patients didn't have an appointment with their provider, or the appointment got delayed or missed. Medicare wouldn't cover the supplies until that individual was seen by the provider. Meanwhile, the patient was stuck without supplies and was unable to use his or her insulin pump.
What are your experiences with insulin pumps and Medicare?
Have a good week.
Regards,
Nancy
14 comments posted
April 22, 2013 11:24 a.m.
for the person who thinks medicare patients are stupid to think their meds will be paid for...we pay our own way. we pay a premium for medicare just like and more then private insurance. I also pay (besides the 130 to medicare) $170 for a supplement and another $80 for meds insurance. Now they are backing out of the deal and not paying insulin???? All this on my social security payment of $1200. even though I worked my life and put into social security...how about they give me my money back and I'll pay full price for all???
- carole
April 22, 2013 11:19 a.m.
In the last year, medicare will not cover insulin for pumps anymore. I have changed supplies three times and cannot find one to supply insulin for insulin pumps anymore so have to pay for the insulin instead of it being paid under durable goods. horrible...
- Carole
January 10, 2013 10:39 p.m.
Medicare insulin guidelines question. If you are insulin dependent non-type 1, what are you to use if your doctor prescribes insulin therapy? If it is not covered are you they suggesting that you not treat your diabetes? I have never been on oral agents with the exception of Metformin as an adjunct therapy only. Who is prescribing; my doctors or Medicare? -Rebecca RN and LADA-fully insulin dependent
- Rebecca
January 10, 2013 10:31 p.m.
I'm an insulin dependent type 2, probably an LADA diabetic, who has only been on insulin since diagnosis. I switched to an insulin pump approx. 10 months ago and it has been no less than life changing. I feel better. More energy. I have been able to lose weight since I am no longer "chasing" yesterdays does of long acting insulin, which is said to not have a peak.Based on what I feel & my testing results I do not agree. My control has always been excellent due to my behavior. I have still had complications of DM.I feel the Medicare 2001-2004 criteria for pump therapy for non-type 1 diabetics is more and more outdated.Other countries have documented benefits. Patients are reporting benefits. The criteria is punitive for patients taking excellent care to control their DM vs patients who are out of control, that in itself does not make any sense.I thought using a pump would ultimately be more expensive than multiple daily injections (I was doing up to 6 a day).After 10 months the costs are break even with the added cost of long acting.It is time to re-evaluate pump therapy and join the modern age and use the excellent and continuely improving technological tools available to us to make DM treatment with intensive insulin therapy more palatable, comfortable, available and help those of us desperately trying to prevent complications by trying to maintaining excellent control. Thank you, Rebecca RN
- Rebecca
December 12, 2012 7:48 a.m.
I'm a type 1 diabetic and have been for roughly 30 years. In addition I've been on Medtronic MiniMed insulin pumps (several different upgraded models over time) for approximately 15 years. I'm being told by my supplier of reservoirs and infusion sets, Medtronic, that it is a Medicare requirement that I must see my physician every 3 months (they claim this to be a Medicare requirement) in order for them to refill my prescription. I meet the Medicare criteria for pump use and haven't been able to locate any information on the Medicare site that I must visit my physician this often (4 times per year). Can anyone enlighten me? Thanks!
- David
December 3, 2012 4:52 p.m.
Pumps and Medicare are not compatible...unless you have $INCOME$ With a job, I paid $0 out of pocket and my pump, insulin and infusion sets/resevoirs were covered and cost me $5 - $15 per month...now that Im on Medicare, I pay $100 part B premium...anohter $160/mo in MedAdvantage fees, and pump supplies cost me approx $200/mo on top of all of that. So, after 10+ years of pumping...and 30+ years of Type 1 diabetes, I am now back on a sliding scale and 7 shots a day. yay!
- Adam
September 13, 2012 11:11 a.m.
You are correct, A C-peptide test and a conncurrent fasting glucose are required by Medicare. Nice catch.
- Nancy and Peggy
September 12, 2012 9:25 a.m.
This information that is given here is not correct. For one thing, you need a c-peptide test with concurrent glucose >= 225 in addition to criteria a or b.
- John
August 29, 2012 10:43 a.m.
How stupid are these people in Medicare to think that they will not pay for injections of insulin???Lots of people cannot afford a pump or insurance will not cover it so this is why you pay $100 a month for???
- Insulin and Medicare
August 29, 2012 10:40 a.m.
Liberty Medical is my supplier for pump supplies and they told me that I would have a fasting blood sugar and a C-Ppeptide test doine at the same time.I didi this, had a bad infusion set so my FBS was 338 that day and now they refuse to send me supplies saying that Medicare will not approve them. Is this true?Also, M<edicare has the dumb rule that they will not pay for Insulin UNLESS it is used in a pump!!!How dumb is that for the people who cannot afford a pump????
- BILL
February 20, 2012 7:28 p.m.
I don't think this is right. A C-peptide test and Fasting Glucose is required in order to have Medicare pay under part B. So, if you know for sure and can document this criteria B please post it. I'm type 2 and been on a pump since June 2011 and will turn 65 in April and not able to qualify under part B. The c-pep test is to "weed out" the type 2 diabetic. Any info you have please post... Dave
- Dave
February 10, 2012 12:16 p.m.
My mother has been a practicing Type 1 for the past 25+ years and a new Medicare recipient. She recently found out that although Medicare covers her insulin pump, they DO NOT cover the sensors and AGM Transmitter necessary to use it, the cost of which is upwards of $80 a week. How can Medicare expect Type 1 patients to pay for these out-of-pocket?? Is she the only one encountering this problem with Medicare coverage??
- Kevin
November 3, 2011 1:43 p.m.
Can you tell me how to find a Medicare contracted provider that will supply the insulin used in pumps.
- Suzanne
October 27, 2011 7:02 p.m.
Iam a practicing Type 1 for the past 44 years. I was diagnosed in 1967 at age 30. My Medicare HMO Blue provided me with an Animas Pump 3 years ago but now I could use a Dexcom CGMs to help with hypoglycemia unawareness and the dangerous unsafe conditions that very often occurs. How can I get my health insurance provider pay for a CGMs when they say that my health is important to them?
- Florian
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