Medicare Advice

[jbowler]

@lichan, the first thing you need is this:

It arrives on our doorsteps (PO Boxes in my case) before October 1, sign-up date. New signees don’t get the printed version before the process of signing up has completed; I didn’t get my first copy until around July, I wish I had. You should find it online (no one told me about it!)

Go to page 79 (start of Section 5). Read the whole section. Regard it as homework with a really stupid multiple choice afterward, “What does it say in bold black print first on page 79?”) Fail the exam and you pay for the remainder of your life.

Then the three other lines in bold black on that page. The table on the next page (page 80) answers your question:

It’s easy; scan down the “F” and “G” columns; the only difference is “Medicare Part B deductible”, which is not known yet; it will not be known until around November, if then. Nevertheless it is not hard to see if an “F” costs around $300 more than a “G” “G” is cheaper next year. Same for “C” and “D”. See the same table.

For those who don’t understand what I just said talk to SHIP (SHIPA, or whatever it is called.)

Bear in mind that those on “F” and “C” might have an interest in the Part B deductible going up as much as is possible, or more; it’s a competition. If you get the “F” you might pay more today and less in 2028. We can change down but we can never change up because we are diabetics.

[lichan]

I have the book and I’m looking for starting on 01/01/2027. This is just data/impression gathering. I’ll have to wait on the 2027 costs to be released before any decisions can be made. I was wondering about whether or not people with F found it a good choice. I guess it depends on the cost of the F, the cost of the G and the size of the part B deductible. Man, I’m not looking forward to doing this year after year! Thanks for all the info and opinions to everyone.

[bostrav59]

@lichan

Man, I’m not looking forward to doing this year after year!

I just got the “Annual Notice of Change for 2027” from my Medicare advantage plan, along with a note from my healthcare consultant that we need to talk. My plan is increasing copays on diabetic supplies (tubing etc) from 20% to 50%. Lots of other things are going up as well.

I can see how this is quite a good business for my hc consultant. Every year she finds me a better deal than the previous year and gets the commission for signing me up. It’s not too bad for me either.

And every year my current insurer hopes that they can shift costs in year 2 because folks can’t easily switch. (and they are probably right)

I’m also not looking forward to doing this year after year, but that’s the way it’s looking right now. It is a huge pain.

[jbowler]

@bostrav59

My plan is increasing copays on diabetic supplies (tubing etc) from 20% to 50%.

That’s a really good example of the difference between original-flavour and MA-flavour Medicare.

The plan	The deductible	The copay	The maximum you can pay
Medicare Part B	about $300	20%	No limits
Medicare Advantage	whatever they say	variable	whatever they say
Part B+Medigap G	about $300	$0	about $300

I didn’t list the “Part A” amounts (hospitals) there but they are broadly similar. Medicare Advantage is simply a bundliing of Part A+Part B+Medigap. So if you are looking at a plan which does not line up with the third line in the table you probably want to look again. This doesn’t apply to people who are 100% healthy and expect to remain so for the rest of their lives; the main point about MA is that the premiums are lower!

Original Medicare does not cover prescription drugs; this is “Part D” which is provided by private insurance. “MA-PD” plans; Medicare Advantage with Prescription Drug coverage, bundle Part D as well.

Go to page 122 on the 2027 booklet (tome?) to start looking at Medicare Advantage plans; there are a whole load in Oregon. Go to the end (page 127 in Oregon) to see the Original Flavour Part D plans. There are precisely 8 in Oregon next year and, having trolled the web site yesterday, three of those (Humana) aren’t available where I live.

Part D is a big deal for those of us on disposable pumps. Everyone should get a tubed pump! Or not. We need to have Part D if we are not using a non-disposable pump (sorry, but the double negative is required here, please remember that a positive is 100%, a double negative is just 25%).

Thanks to @bostrav59 for giving me the missing information about MA; I really did not know it was that bad.

[bostrav59]

@jbowler

Thanks to @bostrav59 for giving me the missing information about MA; I really did not know it was that bad.

I have to look into the other options you discuss. Like Medicare + Medigap. right now it seems like we switch medicare advantage plans every year.

[squidsdc]

@jbowler I have a question for you…(I’m on a tubed pump) I understand that my Part B will pay for the insulin and pump/CGM supplies. But will Part B cover all brands of insulin, or is it still tied to the Part D formulary? Does Part B cover all brands of insulin, tubed pumps and CGM supplies? I am choosing a basic throwaway plan for Dec for Part D, because I am squirreling away hopefully enough supplies to not need to use it. But I do need to know for the upcoming 2027 sign up for Part D…TIA.

[jbowler]

@squidsdc

But will Part B cover all brands of insulin, or is it still tied to the Part D formulary?

Part B is not related to Part D; if you have no Part D your insulin supplies are still the same. Part B only covers insulins approved for use with the pump. I use Lyumjev in my Omnipod Dash (a Part D pump) and I can do that; my endo writes the prescriptions. However only Fiasp is actually approved with the Dash (or that was the case last year) so Part B would not, I think, cover it.

If you have a pump on Part B and, therefore, Medicare pays for your supplies you may have difficulty getting them. It may be that, if you also have Part D, your supplier, e.g. Walmart, ends up billing Part D and you end up paying more. I don’t know - my insulin, like my pump, is on Part D.

Non-disposable pump users (not Omnipod, not twiist) who are on “Original” can tell from their Medicare statements whether Part B is paying for the insulin, so they should comment.

Suck it and see, then tell us! We can change Part D every year. I’m doing exactly what you do except that I always use the stuff I accumulate for the fracas that starts happening on Jan 1.

I’m also going to “downgrade” my Part D from the UHC $185.50/month plan that I would otherwise have in 2027, a plan which pays for both Omnipod and Lyumjev, to a plan which pays for the Omnipod (probably not as much as the current one) and another ultra-fast insulin like Humalog or Novolog but only costs $9.30 (max) per month.

I know all my diabetic supplies apart from the 4x a year endo appointments (which itself blows away the deductible and, therefore, all my costs) are on Part D. So I’ll change from Lyumjev (which my endo likes, in my case) to something else; not Fiasp, that isn’t covered either.

Your situation is different; with a diabetic-appropriate Medigap you should just be paying around $300/year in addition and, of course, the Medigap premia (which will be significant; $211.11 a month until April when they will go up an unpredictable amount in my case.)

If you get reamed by your insulin supplier you still won’t pay more than $2400 in 2027 for insulin and, in practice, $35x12; $420, if you choose the appropriate Part D insulin. You can also claim fraudulent billing (billing Part D for insulin covered under Part B) and you would be absolutely right (@mohe0001 might care to comment). But I wouldn’t because I know what stress does to my BG; they stab us in the back on the way in then, lazy buggers, stab us in the stomach on the way out.

[squidsdc]

Thanks for all the info…sadly, Lyumjev did not work for me and gave me insulin resistance. I was told by Tandem I could use Fiasp but since then they have walked that back. So from what I understand you are saying, Part B will not cover my Fiasp since I use the X2 and it is not an approved insulin with Tandem, is that correct? But if I choose a plan D that has Fiasp on the formulary, I should be able to pay the $35 per month limited insulin amount. Not terrible, but worth it if I can get Fiasp! I wonder if I have my dr do a preauth or contest it, or whatever they call it, if it may be covered. Probably not, with my luck. Novolog was my choice prior, but when that was discontinued by most insurance, that is when I had to try Lispro, and then Lyumjev. Lispro was like water, and Lyumjev I had terrible reactions which created the insulin resistance. So basically, I’m screwed (or stabbed in the back/stomach as you say!) I’ve already signed up for the Medigap plan, and did so as soon as I was able to, in June. Because we get the discount for my husband being on the same plan AND I signed up before the July increases, my rate is set through my anniversary date. Any other recs on what to look out for regarding Part D plans? I’ve done the math and find it amazing the differences in total yearly amounts, whether paying a higher deductible, lower monthly costs, and the cost of the actual meds. One plan has a total cost of $763 vs another topping out at just over $2k

[jbowler]

Even if Part B does not cover the insulin because it’s not approved for the pump I believe you might be able to get it with endo authorization, however I don’t know and it’s a lot of work to go through that process.

Medicare requires insulin used with a pump to be obtained on Part B; if it is used with a Part B pump it cannot be obtained under Part D. However Medicare may not know or check. I have a prescription for Lantus pens, on Part D, in case my pump fails; I don’t see a problem with that.

The Medicare price for insulin on Part B is the same as on Part D; $35/month for each type of insulin. There’s no limit on the amount; it’s whatever the doc prescribes.

Lyumjev and lispro are Humalog; they are all the same. Lyumjev has added chemicals that are intended to speed up adsorption through the skin. Those chemicals may produce an adverse reaction; if you are resistant to lyumjev and not lispro that would strongly suggest an adverse reaction to the additives. On the other hand you seem to say you have the same problem, insulin resistance, with lispro. I’d say the safest thing is to stick to aspart.

Fiasp is Novolog and Novolog is aspart and Merilog is too; they are all the same. Fiasp has added nicotinamide, which is a skin irritant and is intended to speed up adsorption through the skin. A number of people here and on TUD have reported bad skin reactions with Fiasp and I and, indeed, my endo’s PA found that any speed-up effect stopped happening after a while.

You can change Medigap plans in some states on your birthday. I haven’t tried that (yet) but I think it would mean double the deductibles etc. This is certainly what happened when I went from an ACA plan to Medicare in 2025; our medical expense (me and my wife) jumped to $35,000 for the year up $10,000 from 2024 almost entirely because I had to have two insurance plans in the year. A Medigap Plan G plan change should, however, be safe because there are no deductibles or copays.

Look for Merilog if Novolog isn’t available and always check for asparte, though that normally isn’t available or costs more. That said given you have a pump I really don’t think you should have any problem getting insulin on Part B but I’ve never seen a comment by anyone on Original with a pump about the Part B supply of insulin.

[mohe0001]

News from today, Bowler, is that FTC is sending out warning letters to the largest hospitals. FTC Issues Letters Warning Hospitals Against Deceptive Pricing Practices | Federal Trade Commission

@jbowler

fraudulent billing (billing Part D for insulin covered under Part B) and you would be absolutely right

Burried in the previous press release, you will find reference to “…The FTC has prioritized investigating and prosecuting deceptive and unfair practices in the healthcare industry, including through Chairman Ferguson’s creation of the Healthcare Task Force earlier this year,”
and how to, “…report fraud, scams, and bad business practices at ReportFraud.ftc.gov.”

@jbowler

But I wouldn’t because I know what stress does to my BG;

I am always in favor of reporting everything to the authorities. It used to make me mad, but now I have learned to enjoy it.

[squidsdc]

@jbowler thanks for all the info!

[Marie]

Regular Medicare has been pretty liberal in what they cover in our equipment. Insulin is considered a needed necessity of your pump if you get it through Part B (DME). However there are some caveats. They expect you to use vials of insulin for your pump, since the insulin is through your pump a pen is not accepted. So you won’t get a pen source approved through Medicare Part B. Lyumjev, Humalog 200 only come in pens and there is no code for a pharmacy to bill Medicare for them. Feasibly since Omnipod is a pump but because they got it approved through Part D, your insulin is not covered under Part B. You have to get your insulin through Part D.

(You can never completely tell when a policy has changed or what might slip by)

[Marie]

If you have been on an Advantage Plan, you will have trouble finding a Medicare with a Medigap policy later.

This is in the Medicare book.

"The best time to get a policy is during your Medigap Open Enrollment Period. It’s the 6-month period that starts the month you turn 65 and you first have Medicare Part A and Part B. During this time, you can buy any Medigap policy sold in your state, even if you have health problems.

1. The best time to get a policy is during your Medigap Open Enrollment Period. It’s the 6-month period that starts the month you turn 65 and you first have Medicare Part A and Part B. During this time, you can buy any Medigap policy sold in your state, even if you have health problems.

   If you’re under 65, you may not be able to buy a Medigap policy, or you may have to pay more.

2. After your Medigap Open Enrollment Period ends, you may not be able to buy a policy. If you’re able to buy one or want to switch policies later, it may cost more."