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Sometimes it can be hard to determine what’s covered under Medicare Part B vs Part D. Attached is a helpful guide. Below is an example of a tricky situation with the new disposable and wearable insulin pumps.

Insulin

Medicare Part B (Medical Insurance) covers insulin if you use an insulin pump that's covered under Part B's durable medical equipment benefit. Part B doesn’t cover insulin pens or insulin-related supplies like:

Syringes
Needles
Alcohol swabs
Gauze

Part D covers these:

Injectable insulin that isn’t used with a traditional insulin pump
Insulin used with a disposable insulin pump
Certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs
Insulin that's inhaled

Your costs in Original Medicare

The cost of a one-month supply of each Part D- and Part B-covered insulin is capped at $35, and you don’t have to pay a deductible for insulin. If you get a 3-month supply of insulin, your costs can't be more than $35 for each month's supply of each covered insulin. This means you'll generally pay no more than $105 for a 3-month supply of covered insulin.
Under Part D, the $35 cap applies to everyone who takes insulin, even if you get Extra Help.
If you have Part B and Medicare supplement Insurance (Medigap) that pays your Part B coinsurance, your plan should cover the $35/month (or less) cost for each covered insulin.
For insulin-related supplies (like syringes, needles, alcohol swabs and gauze), you'll pay 100% of the cost under Part B (unless you have Part D).

Other questions about insulin coverage under Part D?

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Dual Special Needs Plans (D-SNPs) are network-based. These plans require members to get care and services from doctors or hospitals in their Medicare SNP network.

If someone is full dual, meaning they are eligible for full Medicaid and Medicare, they are eligible for a Dual Special Needs Plan. Most DSNPs are HMOs, in other words it’s very important to check the doctors and hospitals that the beneficiary would be using. When selecting a DSNP, they specifically ask for your Primary Care Physician on the application to make sure they are in-network. Medicaid will NOT automatically step in and pick up if you go outside your plans network. However, if the same carrier manages the Medicare Advantage Plan and the CHC Medicaid portion there may be a chance for coordination of benefits.

Coordination of benefits (COB) applies to people who have coverage under more than one health plan. COB refers to which plan is the primary (first) payer and which plan is the secondary payer. The primary payer coordinates the delivery of all health plan benefits. The secondary payer covers what the primary payer doesn't cover on costs and benefits.

Resources:

Learn more: https://www.uhc.com/communityplan/dual-special-needs-plans/faq

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If I change Medicare Advantage plans during the year, will the amount that I have already spent out-of-pocket for Medicare Part A and Part B coverage transfer to the max out of pocket (MOOP) of my new plan?

MOOP transfers are possible only if your new Medicare Advantage plan is offered by the same insurance carrier or Medicare plan sponsor -- and you are moving into the same type of Medicare Advantage plan (for example, HMO to HMO or PPO to PPO) -- or your Medicare Advantage plan sponsor allows you to transfer your MOOP even though you have moved to one of the company's different type of Medicare Advantage plan (for example, you were enrolled in Company ABC's Medicare Advantage HMO and you use a Special Enrollment Period to move to ABC's Medicare Advantage PPO).

Learn more: https://q1medicare.com/faq/FAQ.php?faq=Will-MOOP-transfer-if-I-switch-Medicare-Advantage&faq_id=609

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Typically losing Medicaid is a special enrollment period to pick up a Medicare Advantage or Part D Plan. Your chance to change lasts for 3 months from either the date you’re no longer eligible for Medicaid or from when you were notified, whichever is longer.

Previously, this occurrence did not give you a guaranteed issue right to purchase a Medicare Supplement plan. However, due to COVID delays and the Medicaid Redetermination Act many people are losing Medicaid. They have issued a temporary Medigap GI Enrollment.

Learn more: https://www.phlp.org/en/news/new-medigap-guaranteed-issue-enrollment-opportunity-for-pennsylvanians-losing-medicaid-during-unwinding

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When you have other insurance and Medicare, who pays first and when?

If your client is 65 or older and has group health plan coverage based on their or their spouse's current employment status:

If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second. If the group health plan didn't pay all of your bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn't cover.
Employers with 20 or more employees must offer current employees 65 and older the same health benefits under the same conditions that they offer employees under 65. If the employer offers coverage to spouses, it must offer the same coverage to spouses 65 and older that they offer to spouses under 65.
If the employer has less than 20 employees and isn't part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan pays second.
If the employer has less than 20 employees, the group health plan pays first, and Medicare pays second if both of these conditions apply:
- The employer is part of a multi-employer or multiple employer group health plan
- At least one of the other employers has 20 or more employees

Check with their plan first and ask if it will pay first or second. If your group health plan or retiree coverage is the secondary payer, you'll likely need to enroll in Medicare Part B before they'll pay.

Learn more: