Managing diabetes effectively requires regular screenings, medications, and a variety of medical supplies and services. This chronic condition affects millions of Americans, many of whom depend on Medicare to cover their critical diabetes services and supplies.
If you’re a diabetes patient who has turned or is about to turn 65, understanding your Medicare eligibility and coverage options for the medications, supplies, and services you need can help you choose the best plan for your best health.
Medicare Parts and What They Cover
Medicare is the federal health insurance program designed to provide medical coverage to individuals that are aged 65 and older, as well as to those with certain disabilities. During your Medicare enrollment period, you’ll choose which Medicare “parts” (or benefits) you want and the type of plan to administer those benefits—a privately administered Medicare Advantage Plan (also known as Part C) or federally administered Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance). You’ll also have the opportunity to enroll in a Part D prescription drug plan.
To ensure you have the needed diabetes care and coverage, you want to focus on these three parts of Medicare:
Medicare Part B: Medical Insurance covers typical healthcare services (like preventive care and screenings, doctor visits, lab work, and certain medical equipment and supplies) with any clinic, doctor, or healthcare provider within the U.S. who accepts Medicare. Your Part B coverage pays 80% of healthcare costs and you pay 20%, with the Part B premium, deductible, and coinsurance rates set annually, based on income according to the Social Security Act.
Medicare Part C: Medicare Advantage Plans are managed by private insurance companies approved by Medicare to administer your benefits and coordinate your healthcare services. Medicare Advantage Plans provide Part A and B coverage, but usually also include prescription drug coverage (Medicare Part D), as well as additional benefits. These private plans often have a set network of providers you choose from, with higher rates for out-of-network providers, and can also have different cost-sharing requirements and premiums (beyond the Medicare Part B premium) based on the coverage and features of the plan.
Medicare Part D: Prescription Drug Coverage meets your prescription medication needs. All Medicare Part D plans are offered by private insurance companies and supplemented by Medicare. Prescription drug coverage is included if you choose a Medicare Advantage Plan, or you can choose to add Part D if you enroll in Original Medicare.
Diabetes Services and Supplies Covered by Medicare Part B
As your medical insurance plan, Medicare Part B covers a range of preventative services and screenings for diabetes and the management care and supplies for those with diabetes.
Diabetes Screenings: Medicare covers up to two diabetes screenings (fasting glucose blood tests and hemoglobin A1C tests) per year if your doctor deems you at high risk for developing diabetes. These high-risk factors include hypertension, dyslipidemia, obesity, or a history of high blood sugar.
Diabetes Prevention Program: Based on your risk factors and the results of your diabetes screening, Medicare offers a Medicare Diabetes Prevention Program, “a proven health behavior change program to help prevent type 2 diabetes.” The program includes six months of weekly group sessions and six months of follow-up sessions, completely covered by Medicare.
Diabetes Self-Management Training (DSMT): If you are diagnosed with diabetes, you can be eligible for Medicare’s diabetes self-management training, an educational program designed to help individuals maintain their health by learning how to effectively manage the disease. You need a referral from your healthcare provider to participate in DSMT. Medicare then fully covers up to 10 hours of training and two hours of follow-up training if necessary.
Medical Nutrition Therapy Services: While proper nutrition and diet management are part of Medicare’s diabetes self-management training, you may also be eligible for fully covered medical nutrition therapy if your doctor prescribes it. You’ll receive an initial nutrition and lifestyle assessment, nutrition counseling, diet and lifestyle management tips, and progress check-ups, all with a registered dietitian.
Diabetes-Associated Diseases: Diabetes can put you at risk for developing other health issues and diseases. Medicare covers screenings and treatments for many of these, including yearly glaucoma screenings and a foot exam every six months for severe diabetic foot disease and diabetic peripheral neuropathy, along with related treatments. With these services and treatments, you’re responsible for 20% of the Medicare-approved cost after meeting the yearly Part B deductible.
Diabetes-Related Supplies: Medicare Part B’s durable medical equipment coverage (80% of costs) includes many of the supplies and devices diabetes patients need to use on a daily basis. This covers blood sugar monitors and their related supplies, including test strips, lancets and lancet devices, and glucose control solutions. If you’re prescribed intensive insulin therapy, the external insulin pump and the insulin medication used with that pump are covered under Part B. It also covers therapeutic shoes or inserts if you have severe diabetic foot disease.
Diabetes Services and Supplies Covered by Medicare Part C
A Medicare Advantage plan, also known as Part C, provides all the same coverage for diabetes-related care, services, and supplies as Medicare Part B. The difference is these private plans bundle all the Medicare “parts” and additional benefits, like dental and vision coverage.
These additional benefits can also include enhanced coverage for preventative wellness programs, diabetes management, over-the-counter drugs, and nutrition services. Medicare Advantage plans offer you the lowest rates through their in-network doctors, pharmacies, and medical suppliers, many of which may offer financial discounts or additional supplies (like test streps or lancets) with a regular order. Medicare Advantage plans coordinate care through their network of providers, providing a more holistic and integrated care approach to diabetes, which can simplify the management of the disease for patients.
While every Medicare Advantage plan must provide the same diabetes-related benefits as Medicare Part B, when it comes to enhanced or additional benefits offered, every plan is different. If you’re considering a Medicare Advantage plan you’ll want to compare the benefits offered to ensure you choose a plan with the most comprehensive diabetes coverage.
Diabetes Medications Covered by Medicare Part D
Medicare Part D covers the prescription drugs and medications you need to help control your diabetes and maintain your health. All the private Part D plans have formularies listing the drugs covered and at what tier, determining your out-of-pocket costs. Before enrolling in a Part D prescription drug plan or Medicare Advantage plan with Part D included, you’ll want to compare costs and review the formularies and tier structures to ensure your diabetes medications are covered at the lowest cost to you.
While which drugs are covered at what tier can be different with each plan, all Medicare Part D prescription drug plans cover the below diabetes-related medications in some capacity:
Insulin: While Medicare Part B covers insulin administered through an insulin pump, Part D covers insulin not used with an insulin pump, including insulin pens and vials. Part D also covers the supplies needed for injecting insulin, like syringes, needles, alcohol swabs, and gauze. Medicare coverage caps the out-of-pocket cost for insulin at $35 for a month’s supply, whether covered under Part B or Part D and neither deductible applies.
Anti-Diabetic Drugs: For diabetes patients whose glucose isn’t controlled by insulin, they rely on a variety of anti-diabetic drugs to manage their blood sugar levels. Part D covers these other injectable diabetes medications (not administered via an insulin pump) and many oral diabetes medications, such as metformin, sulfonylureas, and DPP-4 inhibitors.
Medicare offers robust coverage of diabetes services, supplies, and medications through its many parts. The Wandacare Team can help you navigate and compare all the parts, benefits, and coverage options to ensure you have a Medicare plan that provides optimal diabetes management.
