Have you had the opportunity to hear, read or view the fairy tale of Cinderella? Watching children in a group, listening to the reader of such a tale can bring insights to all of us. Adults included.
In story-land there is a condition set down by the Fairy Godmother of Cinderella. For Cinderella it was to be home by midnight! If not, everything would revert to its original status after midnight. There was one specific condition for Cinderella.
Congress is debating new healthcare proposal options for the private sector. The President desires that the Veterans Administration initiate changes to improve coverage for members who have served our country. It is my position that there is another, a very large population, which has not been entered into the discussion of the health and the healthcare of America. It is the senior population under Medicare.
I turned 65 years young in May 1964. My healthcare was transitioned from a non-Medicare plan to a Medicare Advantage Plan. It has proved to be an antiquated rules based system. Change is only brought forward by a new or revised rule. It would be a good question to ask how I came to this conclusion.
Almost, all Americans including Medicare Advantage Plans are required to make a choice of plans and coverage during a period from October – December, and for this set of examples in calendar year 2016. Now, just what the #$*!?% is going on. Starting in January 1, 2017, the flood of changes began.
Yes, I received a healthcare card. Oh, it had the name of a different primary physician when compared to 2016. My 2016 physician is now considered to be an out-of-service physician in 2017. Most physicians are linked with a local hospital(s). What is the status of the local hospital? Is the doctor and hospital In-network or Out-of-network? Should you need emergency services, this becomes an important question should one need to stay at the hospital. Oh, be sure to check on the emergency room physicians’ assignment if you are checked into the hospital. The wrong coding can lead to a sizeable personal bill. Coding is critical for your hospital stay. Who made the decision? How did the hospital staff consult with the patient and were they able to have a lucid conversation with the patient? This is another question that will potentially impact one’s personal financial obligations related to coverage. Now, what about the back room questions.
Should one ever attempt to visit the local pharmacy between January 2-5 you will view lines due to two different facts. Did the prescription(s) from 2016 carry forward into 2017 and where is your new healthcare card?
Oh, the healthcare changed my doctor and I need a new prescription. A new physician, new forms, a new appointment in a timely manner while I am running out of medication. The pharmacy needs a copy of our new healthcare card for coverage information. It is interesting to note that holiday bills from 2016 come due in January of 2017, at the same time that healthcare deductibles start!
As a type 1 diabetic, there are supplies which may be covered as a durable medical equipment, DME, and can include equipment components such as blood glucose meters and pumps. Maybe??!
Oh, guess what, the medical supply organization from the prior year 2016 is no longer an In-service provider for specific durable medical equipment (DME) under my 2017 Medicare Advantage Plan. Finding out in late February 2017 that a component from a prior year’s approved supplier, with an extended prescription/order, with the necessary information from the physician are not covered means the senior is on the hook for the cost of certain DME components. Your blood glucose meter and your insulin pump are defined as a DME. How did Medicate get out of covering what used to be considered as DME appropriate components? They have an annual bidding process with a focus on the cheapest price. Do you always buy the cheapest without any consideration for quality and need? There is only one winner chosen! How did three different fast acting insulins with separate Food and Drug Administration approvals become identical. Chemically they are different and they each have their own characteristics. With three fast acting insulins for a pump, only one will be covered as a DME supply item. Welcome to the deductible pharmacy item category and donut-hole issues. If the insulin for your pump was not the single winner you lose. How do you feel about being told, directed, etc., to change the insulin in your pump? Oh, Medicare changed the warranty period established by the Food and Drug Administration from four years to five years before one is able to upgrade your current model pump. Are you ready to re-calibrate your insulin pump for new insulin to carb ratios, insulin sensitivity, and etc. with only four endocrinologist appointments for the year? What happens if the fast acting insulin is changed again in 2018 to a different brand? Have you ever seen an Annual Formulary List?
The prior approved and now a non-covered vendor needs to be paid, the patient is in need of DME component supplies and the only option for the patient is to start a Medicare appeal. Really! I have filed an appeal for a January order for Dexcom sensors for my Dexcom G4. The February order of sensors, again denied and was forced to file a new appeal again. Oh, add finding a new medical supplier, who is an In-service provider and having the physician’s office re-send another set of clinical documents to another medical supplier of DME components. Oh, add in a request to upgrade my Dexcom G 4 CGM to a Dexcom G 5 on March 27, 2017. It was summarily denied, due to the use of the old billing codes. Billing codes! That is really an interesting position for a denial. Currently, there are three appeals with my healthcare provider. In March of 2017, my G 4 sensors needed to be replaced and I needed a new transmitter. I am currently running on empty concerning my Dexcom G 4 CGM components with no consideration from the healthcare provider. My Dexcom G 4 CGM has been covered from the beginning of my Medicare enrollment through December 2016 due to favorable ruling in a Medicare Appeal process. This is the link to the successful appeal: http://www.ajmc.com/journals/evidence-based-diabetes-management/2016/may-2016/a-medicare-appeal-for-cgm-coverage-one-patients-never-ending-story
The last hassle is the lack to medical support by Medicare. Medicare has been fighting the introduction of a personal continuous glucose monitoring system, pCGM, for at least five years since 2012. Have any of you ever viewed the clinical reports and references which Medicare uses to make their decisions?
Medicare issued a new CMS Ruling on January 12, 2017, with approval of just the Dexcom G 5 CGM. Medicare has started to lay down a new set of revised restrictions. The most onerous is to deny the use of the ability of an approved Dexcom G 5 for a Medicare senior. What is the issue? It is interesting to note that a type 1 child as young as five years and individuals through the age of 64 plus years can be approved in two steps for a Dexcom G 5. What is the point of restricting the communication ability of the Dexcom G 5 information to other family members for seniors and approving this communication link to the parents of young children? Are you telling me that adult children of type 1 diabetic parents do not need any help with parents living with diabetes?
Medicare by their actions regarding the approval of the “therapeutic Dexcom G 5 demonstrate that Medicare does not have the ability to initiate the introduction of new medical technology for the senior population of American. The Food and Drug Administration has a better transparency concerning their approval process. What is the approval process for Medicare? They are proving to be very opaque with their processes. Why were the Medicare Advisory Contractors, MAC, responsible for writing the operational rules for billing and processing requests for Medicare Advantage Plan seniors? Will these new set of rules be extended by healthcare providers to non-Medicare plans?
Going through a Medicare Appeal Process for Part A and Part B is another process that needs to be changed. An individual started a Medicare Appeal process for coverage of a Dexcom G 4 unit. The process was started in early 2012 and was not settled until late 2016. This particular case when through the entire five appeal steps and seven separate hearings. Now here is the real kicker. When one proceeds through a Medicare Appeal process and is successful, how long is that particular ruling effective?
Reading the approval process steps for a Dexcom G 5 CGM in a Medicare Contractor notification dated March 23, 2017 does not demonstrate a very open process for the seniors of American. There are too many conditions and it takes too long. Seniors with Diabetes need Congress and the President to step forward to reduce and minimize the arcane, opaque, and untimely rules which have grown over the years in the delivery of complex Medicare rulings and decisions in the name of the federal government. This is a disservice to the seniors of American.
Cinderella had a person willing to find her. The only criterion involved the ability to be able to wear the glass slipper. All type 1 diabetics wear a glass slipper, our diabetes. Diabetes is a very delicate matter to control. We need your help! We do not all wear the SAME glass shoe size. There is no sense in trying to wear each others’ glass shoe. We all need our own unique shoe.