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Make sure your diabetic health needs are covered.
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Medicare Diabetes Coverage
Does Medicare cover the healthcare costs associated with diabetes?
In simple terms, yes. Diabetes is a health condition impacting millions of Americans, many of whom are Medicare beneficiaries. Here are some important facts to know about Medicare and what it covers:
Medicare-eligible individuals have two options when it comes to coverage:
- Original Medicare (Medicare Part B) – This option for most people is $148.50/month (2021 pricing) and you must meet a deductible of $203 (2021 pricing) before Part B benefits kick in. You can also add prescription coverage (Medicare Part D) as well as a Medicare Supplement Insurance plan (Medigap) to take care of expenses beyond what Original Medicare covers.
- Medicare Advantage plans – These plans offer the same Medicare diabetic coverage as Part B and many of the plans also include prescription benefits, all for one monthly premium or in many cases, a $0 monthly premium.
IMPORTANT: You must be enrolled in Medicare Part B for Medicare to cover your diabetic services or supplies. If you have a Medicare Advantage plan, you’re required to be enrolled in both Medicare Part A and Part B, so as long as you continue paying your Part B monthly premium, you should be covered.
How each of these options covers diabetic care:
- If you have Original Medicare Part B (medical coverage) or a Medicare Advantage plan, both will generally cover the services, screenings and tests you require, as well as covering in large part the important supplies used in diabetes care.
- If you have a Medicare Part D (prescription coverage) or a Medicare Advantage plan with prescription benefits, you are generally covered in larger part for oral and injectable medications, such as insulin, as well as the diabetic supplies needed to self-administer these medications.
- The Medicare Advantage option is not available to individuals with End-Stage Renal (kidney) failure.
- You must choose either Original Medicare or a Medicare Advantage plan.
- If you choose a Medicare Advantage plan, you cannot also get a Medicare Supplement Insurance plan.
Medicare Diabetic Coverage for Outpatient Services
Your Medicare Part B benefits include the following diabetic services and supplies as long as they are ordered by a Medicare-participating physician. Take note that if you have a Medicare Advantage plan, the same services and supplies are covered, but the amount of Medicare diabetic coverage could vary.
Screenings & Tests:
These are generally covered at 100% if you have qualifying risk factors including high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity (with certain conditions), high blood sugar and impaired glucose tolerance.
- Diabetic screening
- Diabetes self-management training (DSMT)
- Hemoglobin A1c testing
- Certain diabetic blood screenings
- Annual eye exam for diabetic retinopathy
- Annual glaucoma screening
- Medical nutrition therapy
- Foot exam (6-month intervals) for diabetic peripheral neuropathy
These are generally covered at 80% and vary depending on whether you use insulin or not as part of the diabetes treatment.
- Blood glucose monitors (with a doctor’s prescription)
- Self-testing supplies such as lancets, lancet devices, diabetic test strips, etc.
- Therapeutic shoes & inserts (based upon certain conditions)
- Medically necessary external insulin pump & pump supplies (including insulin)
IMPORTANT: Beneficiaries with diabetes who use insulin may be able to get up to 300 test strips and 300 lancets every three months. Beneficiaries with diabetes who don’t use insulin may be able to get up to 100 test strips and 100 lancets every three months. If your doctor says it is medically necessary, you can get additional quantities of testing supplies.
Diabetic Prescription Drug Needs
Your Medicare Part D benefits include self-administered diabetes drugs as long as they are ordered by a Medicare-participating physician. Take note that if you have a Medicare Advantage plan, the same services and supplies are covered, but the amount of Medicare diabetic coverage will vary depending on the plan you choose.
You are covered (generally at 80%) for:
- Many types of oral diabetes medications
- Anti-diabetic drugs
- Diabetes supplies such as syringes, needles, alcohol swabs, gauze, inhaled insulin devices
If a medication has a retail cost of $600+, it will usually fall under Tier 5 for specialty drugs. Your coinsurance for these medications is usually 25% or more, so while Part D covers the larger share, you may still pay a significant amount.
How can you pay for diabetes expenses not covered by Medicare?
If you have Original Medicare Part B and Part D, you are responsible for 20% of the cost of many of your diabetic services, drugs and supplies after your yearly Medicare Part B deductible is met.
Knowing this, many diabetic patients covered by Original Medicare choose to add one of the standardized Medicare Supplement Insurance plans (also known as Medigap policies) identified in most states by letter plans A through N. Medigap plans have a monthly premium, in addition to the monthly premium you pay for Part B.
These plans are sold by private insurance companies and can help pay some of the healthcare costs that Original Medicare doesn’t cover such as copayments, coinsurance and/or deductibles. Some plans also cover medical care when you travel outside the United States.
Note: In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. Check with your state Medicare office or the private insurer selling the Medicare Supplement plans you’re considering.
Medicare Advantage Special Needs Plans
In many areas of the country, insurance companies offer Medicare Advantage Special Needs Plans for people with diabetes. Special Needs Plans (SNPs) are a type of Medicare Advantage plan that limits enrollment to specific chronic or disabling conditions. Medicare Advantage SNPs for people with diabetes will have comprehensive diabetic care.
This care is specifically tailored to meet the needs of people who have diabetes and may include richer benefits, provider choices or medication formularies. It might also offer comprehensive care management, including a care coordinator and/or a group of doctors working together to provide you the best possible care.
All Special Needs Plans come with a built-in Part D drug plan. You can check the plan’s formulary to see if it covers the medications you need. SNPs also have a unique feature that allows people with qualifying health conditions to enroll mid-year. This means you can join if you have a qualifying condition, even if it is not during the annual election period.
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