Diabetes is one of the most common chronic conditions we face as we grow older.
Nearly 27 percent of Americans age 65 and older are living with diabetes, according to the American Diabetes Association. That’s over 14.3 million seniors. Nearly $300 billion is spent each year on medical costs associated with diabetes. So, if you’re living with diabetes or are pre-diabetic, it’s important to have health insurance that will cover the services and supplies you need.
If you have Original Medicare, some diabetes services and supplies are covered by Medicare Part B (medical insurance) and others are covered by Part D (prescription drug coverage). Understanding Medicare diabetes coverage, especially what is and isn’t covered and at what cost, can help ensure you get what you need to stay healthy.
Medicare Part B covered services
Typically, Medicare Part B covers the services that may be needed by people who have diabetes, as well as preventive services for people who may be at risk for diabetes or are pre-diabetic.. Medicare also covers some diabetes education services. These services include:
These screening tests are used to help detect diabetes early. Medicare may pay for up to two diabetes screening tests in a 12-month period. After you have one test done, your doctor will help determine if you need a second one. The tests may include a fasting blood sugar test, or another test approved by Medicare.
These lab tests are covered if you are at risk for diabetes, with risk factors such as high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity or a history of high blood sugar. You may also be covered if you’re age 65 or older, are overweight, have a family history of diabetes, or have a history of gestational diabetes.
Typically, there is no coinsurance, copayment, or Part B deductible for screenings, but you will have to pay 20 percent of the Medicare-approved amount after the Part B deductible for the visit to your primary care provider.
Medicare Diabetes Prevention Program
This program was designed to help you change your health behaviors to prevent diabetes. There are 16 core sessions over a 6-month period. In these sessions, you’ll receive training to help you make behavior changes around your diet and exercise, learn tips on how to exercise more, and practice strategies for controlling your weight. You’ll also get a coach to help you, as well as support from other group members.
Once you complete the 16 core sessions, you’ll receive an additional six months of follow-up sessions and 12 months of maintenance sessions (if you meet certain criteria).
If you’re eligible for these services, there is no out-of-pocket cost to you. To be eligible, you must have:
- Medicare Part B.
- A hemoglobin A1c test result between 5.7-6.4 percent, a fasting plasma glucose of 110-125mb/dL, or a 2-hour plasma glucose of 140-199mg/dL within 12 months prior to the first session.
- A body mass index (BMI) of 25 or more.
- Never been diagnosed with type 1 or type 2 diabetes.
- Not currently diagnosed with End-Stage Renal Disease (ESRD).
- Never participated in this program before.
Diabetes Self-Management Training
This training is an outpatient program that helps you learn to cope with and manage diabetes. It may include tips for healthy nutrition and exercise and information on how to monitor your blood sugar, take medication, and reduce other risk factors. You’ll also better understand foot, skin and dental care, how to prevent, recognize and treat complications from your diabetes, and how to adjust emotionally to your diagnosis.
You’ll receive up to 10 hours of initial training, and two hours of follow-up training if you need it and it’s prescribed by your doctor. Once you begin the training, you must complete it within 12 months.
In order to qualify, you must have a diabetes diagnosis and a written order from your doctor. For the training to be covered, you must get it from an approved individual or program, who your doctor can help you find.
You must pay 20 percent of the Medicare-approved amount (after the Part B deductible).
Medical Nutrition Therapy (MNT) Services
If you have diabetes or kidney disease, you may qualify for nutrition therapy services covered by Part B. To be eligible, your fasting blood sugar must meet certain criteria and your doctor must prescribe this service.
You will receive nutrition counseling, as well as information to manage lifestyle factors that affect your diabetes, from a registered dietitian or nutrition professional. They will help you understand what foods to eat, as well as how to follow an individualized diabetic meal plan.
You will pay no copayment, coinsurance or Part B deductible if your doctor or health care provider accepts assignment, which means they will accept the Medicare-approved amount as full payment for services.
Foot Exams and Treatment
Part B covers a foot exam every six months for people with nerve damage in their feet, including diabetes peripheral neuropathy and loss of protective sensation. The exam must be completed by a Medicare-approved podiatrist or other foot care specialist.
You must pay 20 percent of the Medicare-approved amount after the annual Part B deductible.
Hemoglobin A1c Tests
This lab test, covered by Part B if ordered by your doctor, measures how well your blood sugar has been controlled over the past three months. These tests are often ordered to help understand whether or not your diabetes is under control so appropriate actions can be taken if necessary.
If you’re at risk, Part B will cover a glaucoma test once every 12 months. You’re considered high risk if you have diabetes, a family history of glaucoma, are African Americana and 50 or older, or are Hispanic and 65 and older. To be covered, the test must be done by an eye doctor who’s legally allowed to give this service in your state.
“Welcome to Medicare” preventive visit
You’re eligible for this service within the first 12 months you have Part B. This review of your health, as well as education and counseling about preventive services, includes information about screenings, vaccines and referrals for care. Your doctor will help you understand which preventive services you may need, such as a diabetes screening test.
Annual Wellness Visit
As long as you’ve had Part B for more than 12 months, you’re eligible for an annual wellness visit each year. When you meet with your doctor, you will work to develop or update a personalized prevention plan based on your health and risk factors. You may review your medical and family history, discuss current medications, develop a screening schedule for applicable preventive services, and share risk factors and treatment options for you.
Medicare Part B covered supplies
Medicare Part B also covers a number of diabetes supplies you may need to treat or control your diabetes. These include:
Blood Sugar Self-Testing Equipment and Supplies
Considered durable medical equipment (DME), many diabetic supplies are covered by Part B if you have diabetes. Self-testing supplies include:
- Blood sugar monitors
- Blood sugar test strips
- Lancet devices and lancets
- Glucose control solutions (for checking accuracy of testing equipment)
These supplies are covered whether you use insulin or not, though the amount of supplies that are covered varies. For example, if you use insulin, you may be able to get up to 300 test strips and 300 lancets every three months, but if you don’t use insulin you may only be able to get up to 100. As long as your doctor says it’s medically necessary, Medicare will cover additional test strips and lancets. You may need to keep a record that shows how often you’re testing yourself, so talk to your doctor about what your specific needs may be.
You can order and pick up these supplies at your pharmacy, or from a medical equipment supplier who is enrolled in Medicare and accepts Medicare assignment. If you get supplies from a supplier, you must place the order yourself, though you’ll need a prescription from your doctor to place the order.
Keep in mind that you must ask for refills for your supplies yourself, and you’ll need a new prescription from your doctor every 12 months for lancets and test strips.
You’ll be required to pay 20 percent of the Medicare-approved amount after the Part B deductible.
If you have diabetes and meet certain conditions, insulin pumps may be covered by Part B. This includes pumps worn outside the body (external) as well as the insulin used with the pump. Certain pumps are considered DME, and must be prescribed by your doctor for use in the home.
You will pay 20 percent of the Medicare-approved amount after the Part B deductible. Medicare will pay the other 80 percent.
Therapeutic Shoes or Inserts
If you meet certain criteria, therapeutic shoes will be covered if you need them. This includes either:
- One pair of depth-inlay shoes and three pairs of inserts
- One pair of custom-molded shoes (and inserts) and two additional pairs of inserts
In order to qualify, you must:
- Have diabetes.
- Have at least one of these conditions in one or both feet:
- You’re being treated under a diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.
A podiatrist or other health care provider must prescribe the shoes, and a qualified doctor must fit and provide the shoes.
How to get diabetic supplies through Part B
In order to receive coverage for diabetic supplies under Part B, you must have a prescription from your doctor. To ensure coverage, the prescription must include:
- That you’ve been diagnosed with diabetes.
- What type of blood glucose monitor and test strips you need.
- How often you should test your blood sugar.
- Whether or not you use insulin.
- How many test strips and lancets you need each month.
Medicare Part D diabetes coverage
Medicare Part D (prescription drug coverage) covers a number of medical supplies you may need to help treat or control your diabetes. Coinsurance or copayments may apply to these supplies, as well as a Part D deductible.
Covered supplies may include:
Part D covers injectable insulin, not insulin used with an insulin infusion pump or inhaled insulin (covered by Part B).
Sometimes, blood sugar isn’t controlled by insulin but instead maintained by an anti-diabetic drug. Examples of covered drugs include:
- Sulfonylureas (Glipizide, Glyburide)
- Biguanides (metformin)
- Thiazolidinediones (Actos, Avandia, Rezulin)
- Meglitinides (Starlix, Prandin)
- Alpha glucosidase inhibitors (Precose)
While Medicare Part B covers some diabetic supplies, Part D covers additional supplies including:
- Alcohol swabs
- Inhaled insulin devices
What is not covered by Medicare?
While Original Medicare covers most of the services and supplies you may need if you have diabetes or are pre-diabetic, there are a few things that are not covered. Examples of items not covered include:
- Eyeglasses and eye exams for glasses, except after cataract surgery
- Orthopedic shoes (shoes for people whose feet are impaired, but intact)
- Cosmetic surgery
- Weight loss programs
Does Medicare Advantage cover diabetes?
Medicare Advantage (MA) plans (Part C) cover diabetes services and supplies you may need. Because MA plans must cover everything Original Medicare does, all of the above services and supplies will be covered with your MA plan as well. MA plans may then offer additional services such as vision, dental and hearing care. Costs for supplies, services and prescription drugs may also differ compared to Original Medicare.
Contact your MA plan to learn what is available to you and at what cost.
What if I’m sent supplies I didn’t order?
You are responsible for re-ordering any supplies you may need in coordination with your doctor and pharmacy or DME supplier. However, there may be an occasion where you receive supplies you have not requested. For example, perhaps you were automatically sent supplies from a supplier. In this case, Medicare will not pay for these supplies and they will not reimburse you for any costs. You will also not receive coverage if you accept, purchase or order supplies that were not prescribed by your doctor or are not medically necessary.
If you are receiving unwanted supplies or advertisements that are misleading, or suspect fraud relating to your diabetes supplies, call Medicare immediately.
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