Diabetes and Medicare: What is Covered and How?

By Elie Harriett

One of the most expensive diseases affecting older Americans today is diabetes.  According to the American Diabetes Association, in 2012, approximately 29.1 million Americans, or 9.3% of the population have diabetes.  And 1.4 million Americans are being diagnoses with diabetes every year.  At least one quarter of people afflicted with diabetes are seniors.  With such a high population of seniors in this country diagnosed with diabetes, it is important to understand Medicare’s coverage of diabetes and how to access that coverage.

Many of the basic services a diabetic will utilize are covered by Medicare and the insurance that goes with it.  Part B, the medical insurance portion of Medicare covers:

• Diabetic risk assessment
• Self-management training
• Equipment and supplies (more on that below)
• Podiatry
• Glaucoma testing
• Insulin going into a pump (more below)
• Medical nutrition therapy
• Therapeutic shoes and inserts

Most of these services are covered at 80% of the cost after Medicare B’s annual deductible.  Your insurance will pay its applicable portions beyond that.  For those with Medicare Advantage, be sure to consult your plan’s summary of benefits to find out your cost sharing before seeking service.

Medicare Part D, the prescription drug portion of Medicare covers many supplies and drugs.  Your co-pays will be based on your plan for that year.  It is important when annually deciding whether to keep or change your part D plan, to see if your plan will cover your diabetic medications and what your cost will be for it both before and in the coverage gap.

Equipment and supplies: Medicare allows diabetics to receive up to 300 test strips and lancets every 3 months, if you use insulin, and 100 every 3 months if you do not.  These limits can be lifted if your doctor orders more due to medical necessity.  As with most Medicare Part B services, 80% of the cost is covered by Medicare with insurance covering its share beyond that (Medicare Advantage users must check with their plan to find out their coverage).  In 2013, a national mail-order program began requiring you to use specific vendors to get Medicare-approved testing supplies if you want them mailed to your home.  Contact Medicare at (800) 633-4227 for the most updated list.  Medicare Part D will usually cover syringes or any other supply used in the injection of insulin that does not go into a pump.

Insulin: An external insulin pump might be covered by Medicare Part B as durable medical equipment under certain circumstances.  To find out if Medicare will cover a pump for you, be sure to consult your doctor.  If Medicare does cover your insulin pump, then the insulin which goes into the pump will also be covered by Medicare Part B.  If either Medicare Part B will not cover the pump or you do not have an insulin pump, then insulin will be covered by Medicare Part D.  As with all other prescriptions covered by Medicare Part D, be sure to check your plan’s formulary, costs, and coverage gap cost to plan your expenses going forward.

One of the most common causes of frustration diabetics experience when dealing with Medicare payments is knowing which part of Medicare covers what item.  For all diabetics, Part B covers most testing supplies.  For diabetics with a pump that Medicare approves, the insulin is covered by Part B, while other drugs are covered by D.  It is important to make sure your pharmacy files claims for the proper portion of Medicare based on your situation.  Usually this process goes through smoothly, but if you see a sudden cost jump in your bill, it is worthwhile to go over these costs with your pharmacist or insurance representative to make sure the right part of Medicare gets billed for the right item.

Diabetic coverage of Medicare is complicated.  For help and guidance with this and all other aspects of Medicare-related insurance, contact us or a knowledgeable insurance advisor today. 

For more information on the American Diabetes Association, click here.

To download a copy of Medicare’s booklet on Medicare’s Coverage of Diabetic Supplies and Medications, click here.