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MEDICARE COVERAGE FOR DIABETES

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Diabetes is a condition where your body does not make enough insulin or does not respond to insulin as it should. Insulin is a hormone that changes sugar, starches and other food into the energy you need to live. If you do not have enough insulin, your blood sugar will be too high and a high blood sugar level is bad for your health. Over 34 million Americans were diagnosed with diabetes in 2018. Approximately 26% of individuals age 65 and older have diabetes. Diabetes is the seventh leading cause of death in the United States.

Diabetes management is a burdensome expense for many. The American Diabetes Association has noted that the average diabetes diagnosis creates medical expenses that are 2.3 times as high as they would be in the absence of diabetes. If you have diabetes, you know it’s a day-to-day reality that needs to be attended to. Fortunately, Medicare covers various diabetes medications, supplies and services to help treat diabetes and keep your blood glucose in a healthy range.

MEDICARE COVERAGE FOR DIABETES

If you have diabetes or are at risk for it, Medicare can help. Medicare covers:

  • Tests to tell if you have diabetes
  • Drugs and supplies you will need if you have diabetes
  • Services that can help you manage your diabetes and stay healthy

Medicare Part B covers up to two diabetes screenings each year if you are at risk for diabetes. It also covers many of the supplies and services you may need to control your diabetes.

Medicare Part D covers insulin, diabetes drugs, and certain supplies. However, there are times when Medicare Part D does not cover insulin, diabetes drugs, or supplies. For example, Medicare Part B covers external insulin pumps and the insulin used in them, not Part D.
Here’s a rundown of the diabetes supplies and services that Medicare covers. Some require a prescription or recommendation from your doctor. Coverage limits may include the amount of some supplies you can get or how often some services are covered. 

Medicare Part B coverage for diabetes

  • Blood glucose testing supplies and needed equipment (meters, test strips, etc)
  • Insulin pumps with insulin for use in them
  • Diabetes self-management training
  • Medical nutrition therapy, including diet counseling
  • Hemoglobin A1C test to monitor blood glucose control
  • Foot exams and treatment for nerve damage related to diabetes
  • Therapeutic shoes or inserts
  • Eye test for glaucoma

Medicare Part D coverage for diabetes

  • Medications used for managing blood glucose
  • Insulin injections
  • Supplies for taking insulin by injection (syringes, needles, alcohol swabs and gauze)
  • Inhaled insulin

In general, Medicare pays 80% and you pay 20% of the Medicare-approved amount for diabetes supplies and services covered by Part B after the yearly deductible is met. You may pay a coinsurance amount or a copayment for items covered by Part D. What you pay depends on the terms of your specific Part D plan. Some services, such as medical nutrition therapy and A1C tests, may be provided at no additional cost to you.

Medicare Advantage plans (Part C) cover diabetes supplies and services, too, and often additional services such as vision, dental and hearing care. The costs and items covered will depend on the specific plan you have. Here is a breakdown of Medicare Advantage coverage for diabetes treatment.

MEDICARE ADVANTAGE COVERAGE FOR DIABETES

There are multiple types of Medicare Advantage (Part C) plans, with some plans better suited for people with specific healthcare needs and other plans with a preferred network of medical professionals. Your Medicare Advantage options will vary according to your region. Many Medicare Advantage plans include medications, generally known as Medicare Advantage Prescription Drug (MAPD) plans.

Oral medications and insulin are covered under MAPD plans. Examples of oral medication for diabetes include:

  • Acarbose, which prevents your blood sugar from rising
  • Alogliptin, which increases insulin levels when blood sugars are too high
  • Chlorpropamide, which lowers blood sugar by having the pancreas release more insulin into the body

Even though insulin is necessary for effective diabetes treatment, there is no universal standard for insulin coverage in Medicare Advantage plans. Patients’ biggest issue with Medicare Advantage Prescription Drug plans is the cost of their insulin on different plans because certain carriers have preferred pricing on insulin. If a patient gets put into the wrong Medicare Advantage Prescription Drug, their insulin could cost them a few hundred or thousands of dollars a month.

Many Medicare Advantage plans will also cover other helpful supplies for someone living with diabetes. Durable medical equipment (DME) is also covered under Medicare Advantage. Things like test strips, diabetic shoes, and glucose monitors are classified as DME and are covered. Diabetic shoes are designed with soft materials and protective inserts for people with diabetes. These shoes help manage foot conditions that typically occur in someone with diabetes, like numbness or ulcers.

WHAT IS NOT COVERED UNDER MEDICARE?

Medicare does not cover everything. Here are some services people with diabetes commonly need that Medicare does not cover:

  • Eye exam for glasses – but, There is a special type of eye exam that Medicare will cover for people with diabetes. This exam, called a dilated exam, checks for damage to your eyes. If not controlled, diabetes can cause serious problems to your vision. Medicare will cover this exam once every 12 months.
  • Routine physical exams – these are beyond the Annual Wellness visit every 12 months that are covered under Medicare.

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