Medicare Coverage of Diabetes
This article was updated on: 04/04/2019
According to the Centers for Disease Control and Prevention (CDC), about 29 million Americans suffer from diabetes, or approximately 9.3% of the population (all ages in 2012). The Centers for Medicare & Medicaid Services (CMS) says that diabetes is a disease where blood glucose levels are higher than normal. There are many people who don’t know they have diabetes, and Medicare covers screening tests to check if you do.
If you have been diagnosed with diabetes and are enrolled in Original Medicare (Part A and Part B), you may have questions about Medicare coverage of diabetes treatment, tests, and supplies. Here’s what you need to know.
What diabetes screenings and exams does Medicare cover?
Medicare Part B (medical insurance) will cover lab tests to check for diabetes if you have one of the following risk factors:
- High blood pressure
- History of abnormal cholesterol and triglyceride levels
- History of high blood sugar
Also, Part B will cover the diabetes screenings if two or more of the following apply to you:
- Age 65 or older
- Family history of diabetes
- History of gestational diabetes (diabetes during pregnancy), or delivery of a baby who weighs more than nine pounds
If your doctor orders a screening test, Medicare Part B will pay for up to two diabetes screenings in a 12-month period and you won’t have to pay anything for these tests.
If you’ve been newly diagnosed with diabetes, you may want to consider attending diabetes self-management training, which Medicare Part B helps to cover, to help you manage and cope with diabetes.
If you have already been diagnosed with diabetes and have Medicare Part B, Part B covers certain screenings, listed below. You’ll generally need to pay a copayment and for 20% of the Medicare-approved amount for the doctor’s services after the yearly Part B deductible.
- An annual eye exam for diabetic retinopathy by a Medicare-approved eye doctor
- An annual glaucoma test
- Semiannual foot exams & treatment (as long as you haven’t seen a foot-care provider for another reason between visits)
What diabetes supplies and equipment does Medicare cover?
Medicare Part B coverage of diabetes includes certain blood sugar self-testing equipment and supplies such as:
- Blood sugar (glucose) testing monitors
- Blood sugar (glucose) test strips
- Finger-prick devices and lancets
- Glucose control solution for calibrating monitors
- Therapeutic shoes or inserts
Diabetes equipment and supplies that are used at home (like blood sugar test strips and lancets) are considered durable medical equipment (DME) for the purposes of Medicare coverage and subject to certain restrictions. In order to get payment for these products, both your doctor and the company must be Medicare-approved. You are generally responsible for 20% of any allowable charges plus any of the unpaid Part B deductible amount. Medicare Part B may also pay for external insulin pumps and the insulin the devices need (under durable medical equipment) if your doctor believes it is medically necessary to treat your condition.
Recently, Medicare implemented the Competitive Bidding Program, which works with specially contracted equipment suppliers to help lower health-care costs. If you live in a part of the country where the Competitive Bidding Program is in force, you must use a supplier who is contracted with Medicare to provide the equipment.
Is there Medicare coverage of diabetes prescription drugs, medical supplies, and insulin?
If you receive your Medicare benefits through Original Medicare, there is limited coverage for prescription drugs (including prescription drugs for diabetes treatment) under Medicare Part B. Insulin is typically not covered except in very narrow circumstances, such as the insulin used in external insulin pumps (as mentioned above).
If you would like help with insulin and prescription drug costs, you will need to enroll in a Medicare plan with prescription drug coverage–either a stand-alone Medicare Part D Prescription Drug Plan if you remain with Original Medicare, or a Medicare Advantage Prescription Drug plan. Keep in mind that every Medicare plan with prescription drug coverage uses a formulary, which is a list of approved medications that are covered under the plan. To avoid high out-of-pocket costs, be sure to ask your doctor if the medication he or she is prescribing is included in your prescription drug plan’s formulary. Also, please note that the formulary may change at any time and that the plan will notify you when necessary.
Medicare Advantage (Part C) offers an alternative way to get your Original Medicare benefits. Medicare Advantage plans, which must offer all the same benefits as Original Medicare at a minimum (except for hospice care, which is still covered under Part A), may also help you manage your out-of-pocket costs. That’s because most of them include coverage for prescription drugs, and may include additional benefits like routine vision, hearing, and dental care. You still continue paying your Medicare Part B premium, as well as any premium the Medicare Advantage plan may charge.
You may be concerned about out-of-pocket expenses related to your diabetes treatment. If you decide to stay with Original Medicare, another option you may have is to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance and deductibles.
If you’d like more information about Medicare plan options and possible coverage of diabetes treatment, I’d be happy to answer your questions. You can request a phone call or an email with information by clicking the appropriate link below. To see a list of plans in your area you may qualify for, click the Compare Plans button below.