Medicare and Diabetes – What You Need to Know

Medicare and Diabetes – What You Need to Know

According to the CDC, approximately 37.3 million Americans, or 11.3% of the population, have diabetes as of 2023, according to U.S. News. The prevalence increases significantly with age; more than a quarter (26.8%) of all adults aged 65 years and older have diabetes, equating to 14.3 million seniors affected by the condition (American Diabetes Association, 2020).

Moreover, diabetes is a major cause of blindness, kidney failure, heart attacks, stroke, and lower limb amputation. Adults with diabetes have nearly twice the risk of death at any age compared to those without the disease.

This blog will go over why it’s important to keep your diabetes under control, as well as explore all the resources available under Medicare to help you manage your diabetes and prevent further complications.

The Importance of Treating and Managing Your Diabetes

Managing diabetes in seniors is of paramount importance, not only to control the disease itself but also to prevent or slow the progression of associated complications and to enhance overall health and quality of life.

Diabetes can lead to several complications, some of which are especially severe in seniors. These include heart disease, stroke, kidney disease, vision loss, and nerve damage, among others. Timely and effective management of diabetes can significantly reduce the risk of developing these complications.

For instance, maintaining blood glucose levels within the recommended range can prevent or slow the development of kidney disease and nerve damage, while managing blood pressure and cholesterol levels can lower the risk of heart disease and stroke.

Cognitive Benefits of Controlling Diabetes

Beyond physical health, diabetes management is crucial for cognitive well-being in seniors.

Studies have shown an association between diabetes and increased risk of cognitive decline and dementia, including Alzheimer’s disease. Good diabetes management can potentially decrease this risk, preserving cognitive function and independence for longer.

Managing diabetes effectively also plays a vital role in promoting a good quality of life for seniors. By preventing complications, seniors can maintain their independence and daily life activities. This in turn can contribute to better mental health, preventing or mitigating conditions such as depression, which are more common in people with chronic diseases like diabetes.

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Overview of Medicare for Beneficiaries With Diabetes

Medicare Part A (Hospital Insurance)

Part A provides coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. As it pertains to diabetes, Part A would cover:

Medicare Part B (Medical Insurance)

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. 

Part B Coverage for Diabetes Screening Tests

Part B provides coverage for up to two diabetes screening tests per year if you are determined to be at risk for diabetes.

Your risk of diabetes could be elevated due to several factors:

Additionally, if you exhibit at least two of the following risk factors, you might be considered at risk:

Your doctor will determine the need for a second test following your initial diabetes screening.

Medicare Part B also covers the cost of hemoglobin (a1c) tests as ordered by your doctor. 

Medicare and Foot Exams for People With Diabetes

Medicare Part B helps cover the cost of one foot exam every six months from a podiatrist or other foot care specialist.

Medicare may pay for additional visits if you have had an amputation or injury or if there are signs of disease or necrosis.

Blood Sugar Self-testing Equipment & Supplies

Part B covers blood sugar (also called blood glucose) self-testing equipment and supplies as durable medical equipment.

Self-testing supplies include:

However, the amount of supplies that Part B covers varies.

If your doctor says it’s medically necessary, and you meet other requirements, Medicare will allow you to get additional test strips and lancets. You may need to keep a record that shows how often you’re actually testing yourself.

Medicare may cover a continuous glucose monitor (receiver) and related supplies (sensors and transmitters) if your doctor signs off that your continuous monitoring is medically necessary.

For you to qualify, your doctor must attest that you have a medical need to the requirements include the need to:

The Medicare and Diabetes Prevention Program

Medicare Part B provides coverage for a one-time health behavior modification program designed to assist in the prevention of type 2 diabetes.

The program consists of weekly sessions in a group setting for six months, during which you’ll receive:

Post-Core Session Support: Medicare and Diabetes Prevention Program

Once the primary sessions are completed, you’ll transition into six monthly follow-up sessions.

Eligibility Criteria for the Medicare and Diabetes Prevention Program

To be eligible for this program, you must meet the following criteria:

Understanding Diabetes Self-Management Training

Diabetes self-management training equips you with the necessary skills to effectively control your diabetes.

For Medicare Part B to cover this training, it must be prescribed by your doctor or another healthcare provider.

Eligibility for Diabetes Self-Management Training

You’re eligible for diabetes self-management training under one of the following circumstances:

Your healthcare provider may deem you to be at higher risk if:

Your healthcare provider will typically provide you with information about where you can access diabetes self-management training. This training must come from an accredited individual or program, forming part of a care plan prepared by your healthcare provider. These programs and individuals are accredited by organizations like the American Diabetes Association or the American Association of Diabetes Educators.

Medicare Coverage Details for Diabetes Self-Management Training

Medicare provides coverage for up to 10 hours of initial training and an additional two hours of follow-up training if needed.

The initial training must be completed within 12 months of commencement. This initial phase includes one hour of individualized training and nine hours of group training.

Medicare covers up to two hours of follow-up training each year.  if your doctor decides it’s medically necessary.

This follow-up training can be in a group or one-on-one sessions. It can also happen via telehealth. 

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Medical Nutrition Therapy 

Besides diabetes self-management training, Medicare Part B also provides coverage for medical nutrition therapy services from a certified nutritionist.

These services are available if you’re diagnosed with diabetes or renal disease and fulfill certain criteria. They must be prescribed by your doctor.

What Does Nutrition Therapy Include?

Medical nutrition therapy services encompass:

Additional Diabetes Benefits Under Medicare Part B

Part B also covers therapeutic shoes or inserts, as well as costs related to diabetes education and training on how to manage your disease. 

Glaucoma Screenings

People with diabetes are at increased risk of glaucoma – a condition of the eye that can lead to blindness.

If you have diabetes mellitus, Medicare Part B will cover the cost of one glaucoma exam every 12 months. 

Cost Cap on Part B-Covered Insulin

Beginning from July 1, 2023, the maximum cost you will have to bear for a month’s supply of Part B-covered insulin for your durable medical equipment (DME) pump will be capped at $35.

The Part B deductible will not be applied in this instance.

Insulin Pump Coverage

Non-Disposable External Insulin Pump

In cases where you utilize an external, non-disposable insulin pump, Medicare Part B may extend coverage to include insulin used with the pump and even the pump itself as it qualifies as DME.

Regional Restrictions on Suppliers

Please note that if you reside in certain parts of the country, you may be required to use specific insulin pump suppliers for Medicare to provide coverage for a durable insulin pump.

Therapeutic Shoes or Inserts

Under Part B, you’re eligible annually for one of the following options:

Eligibility for Therapeutic Shoe/Insert Medicare Benefit

To qualify for this benefit, you must meet the following criteria. 

Additional Medicare Requirements

Apart from these basic conditions, Medicare also mandates the following:

Part B Costs

Note: This 20% coinsurance under Part B has no upper limit. Without additional protection from Medigap, the Medi-Share 65+ healthsharing plan, or Medicare Advantage, your 20% share of doctors and surgeon’s fees, anesthesiologist fees, durable medical equipment, lab fees, and other Part B expenses can amount to thousands of dollars in out-of-pocket exposure.

Especially if you have diabetes.

Without the additional protections of Medigap insurance, the Medi-Share 65+ health-sharing plan, or Medicare Advantage, your Part B co-insurance costs can quickly become financially devastating.

It’s important to think through your possible total costs for medical care out of pocket, and line up the additional insurance or health sharing protection that you need.

The best time to enroll in these plans is when you are first eligible for Medicare. You can possibly sign up later, but you could be required to pay more, and possibly be declined altogether, depending on your medical history. 

Medicare Part C (Medicare Advantage Plans)

Part C is an “all in one” alternative to Original Medicare (Parts A & B).

These “bundled” plans include your benefits under Part A and Part B (Original Medicare) and usually prescription drug benefits under Medicare Part D. 

Medicare Advantage plans are offered by private companies approved by Medicare.

These plans require you to access care via their own network of authorized providers, unless there is a medical emergency that makes that impractical or dangerous.

Medigap plans and the Medi-Share 65+ plan, in contrast, allow you to choose any doctor who accepts Medicare patients.

The coverage for diabetes care would include everything covered by Parts A and B and usually prescription drugs covered by Part D.

You can choose a Medicare Advantage plan that does not include Part D. If you do, it’s important to enroll in a standalone Part D plan, alongside your Medicare Part C plan.

Do not attempt to enroll in a Medigap plan and a Medicare Advantage plan at the same time. You only need one or the other. 

Medicare Part D (Prescription Drug Coverage)

Part D adds prescription drug coverage to Original Medicare and is offered by insurance companies and other private companies approved by Medicare. Part D plays a crucial role in diabetes management, covering:

Medicare Part D and Insulin Costs

As of 2023, insulin costs under Part D are capped at $35 per month for each type of insulin – with no deductible.

This rule applies to all individuals who use insulin, as well as those in the  Extra Help program.

Note that Medicare Part D covers self-injected insulin, while Part B covers the cost of insulin pumps and other hardware under the durable medical expenses heading.

Not every insulin product is covered under every Part D plan. So once you and your doctor have decided what specific form and brand of insulin will work best for you, be sure to check the formulary of any Plan D policy you are considering.

If you aren’t sure how to check, contact one of our expert Personal Benefits Managers for free help.

Cost Caps for Extended Supplies

If you decide to acquire a 60- or 90-day insulin supply, the cost restriction still applies at $35 for each month’s supply of each covered insulin. For instance, a 60-day supply of a Part D-covered insulin would generally not exceed $70.

Medicare and Long-Term Care

Many diabetics eventually require long term care, such as assisted living facilities or skilled nursing homes. This is because of amputations, wound care concerns, and cognitive declines, among other issues.

Medicare does not cover long-term care, except in very limited circumstances, immediately following a hospitalization. And that’s only for up to 100 days.

Medigap does not cover long-term care, either, except for the limited out of pocket costs of your Part A and Part B deductibles and coinsurance.

If you want protection against the high cost of long term care, especially for chronic conditions, you should speak with your Personal Benefits Manager about buying Long Term Care insurance protection, in addition to your Medicare and Medigap or Medicare Advantage.

Continuous Glucose Monitor (CGM) Coverage

Medicare may also extend coverage to include a continuous glucose monitor (receiver) and related supplies (sensors and transmitters) if your doctor certifies that you met the requirements.

As of Jan. 1, 2023, all Medicare Part D plans must cap out-of-pocket costs for covered insulin at no more than $35 a month. But not every Part D plan covers every insulin, so make sure the plan you’re considering covers the type of insulin you take.

For Medicare Part B, a similar cap takes effect July 1, 2023. Part B covers insulin that is administered through insulin pumps that aren’t disposable.

Medicare and Diabetes Conclusion

Let’s review some of the key points:

Individuals with diabetes have access to various programs under Medicare, Medicare Advantage, and Medigap that provide essential coverage and support.

Medicare Part A covers hospitalization charges, including limited coverage in skilled nursing and rehab facilities following a qualified hospitalization. However, without additional protection, Medicare Part A leaves Medicare beneficiaries with significant potential out-of-pocket charges for hospitalizations.

Medicare Part B offers significant benefits to help with diabetes management. These include coverage for doctor visits, diabetes self-management training, durable medical equipment, and supplies such as glucose monitors and test strips.

Again, without additional protection, such as Medi-Share 65+, Medigap, or Medicare Advantage,  Medicare Part B’s 20% copayment means Medicare beneficiaries may face significant out-of-pocket charges.

Medicare Part D covers prescription drugs. However, you can qualify for the $35/month price cap on certain insulin products for Medicare beneficiaries even if you are not enrolled in a Part D plan.

Medicare Advantage, provides an alternative to traditional Medicare and often includes additional benefits beyond what original Medicare covers.

Many Medicare Advantage plans offer specialized programs for diabetes care, such as diabetic supplies, preventive services, and disease management programs. These programs may involve personalized care coordination, nutritional counseling, and exercise programs to help individuals manage their condition effectively.

Some Medicare Advantage plans include prescription drug coverage, while others don’t. It’s important to determine whether your Medicare Advantage plan includes prescription drugs when you sign up.

Medigap plans, also called Medicare Supplement Insurance, can be purchased to fill in the gaps left by original Medicare. While Medigap plans do not typically offer specific diabetes programs, they do help cover out-of-pocket costs, including deductibles, copayments, and coinsurance.

Overall, Medicare, Medicare Advantage, and Medigap programs play vital roles in supporting individuals with diabetes. These programs offer a range of benefits and services that help individuals manage their condition, promote preventive care, and minimize financial burdens. It is essential for individuals with diabetes to review their options, understand the coverage available, and choose the program that best suits their healthcare needs and preferences.

Here are some additional blogs on the topic: What To Do if Medicare Denies Your Prescription Drug | Medicare and Alzheimer’s Disease/Dementia: What You Need to Know

Here are some additional pages related to this article: Medi-Share 65+ | Medicare Advantage Plans

Frequently Asked Questions About Medicare and Diabetes

Q: What does Medicare Part B cover in relation to diabetes?

A: Medicare Part B covers diabetes screenings, self-management training, medical nutrition therapy services, blood sugar testing equipment and supplies, insulin pumps, and therapeutic shoes for individuals with diabetes.

Q: How does Medigap help Medicare beneficiaries with diabetes?

A: Medigap, or Medicare Supplement Insurance, helps cover some of the healthcare costs that Medicare doesn’t cover, such as copayments, coinsurance, and deductibles. This can be especially beneficial for people with diabetes, who often have higher medical costs.

Q: Does Medicare cover insulin for diabetics?

A: Yes, insulin is covered under Medicare Part D (prescription drug coverage) or under Part B if an insulin pump is necessary.

Q: Is diabetic self-management training covered by Medicare?

A: Yes, Medicare Part B covers diabetic self-management training if prescribed by your doctor.

Q: What services does Medicare provide for diabetes prevention?

A: Medicare covers a one-time lifestyle modification program to help prevent type 2 diabetes. This includes training in dietary changes and exercise, weight control strategies, and motivational coaching.

Q: Does Medicare cover glucose monitors for diabetics?

A: Yes, Medicare Part B covers blood sugar self-testing equipment, including glucose monitors.

Q: What is the coverage limit for diabetes test strips under Medicare?

A: If you use insulin, you may be able to get up to 300 test strips and 300 lancets every 3 months. If you don’t use insulin, you may be able to get 100 test strips and 100 lancets every 3 months.

Q: Does Medigap cover the costs of prescription drugs like insulin?

A: No, as of 2023, Medigap plans sold to new people with Medicare aren’t allowed to cover prescription drugs. You would need to get Medicare Part D to get help with drug costs.

Q: Does Medicare cover the cost of therapeutic shoes for diabetics?

A: Yes, Medicare Part B covers one pair of therapeutic shoes and inserts per year for those with diabetes when prescribed by a doctor.

Q: How does Medicare help with the costs of diabetes-related kidney disease?

A: Medicare covers kidney dialysis and kidney transplant services under Part A and Part B. It also covers an annual kidney function test for people with Medicare Part B who have diabetes.

Q: Can Medigap help cover the out-of-pocket costs of diabetes supplies?

A: Yes, Medigap can help cover the costs of copayments, coinsurance, and deductibles related to covered diabetes supplies and services.

Q: Are diabetes screenings covered by Medicare?

A: Yes, Medicare Part B covers up to two diabetes screenings per year if you’re at risk for diabetes.

Q: Does Medicare cover diabetes education programs?

A: Yes, Medicare Part B covers diabetes self-management training, which includes education on diet, exercise, and lifestyle changes.

Q: Are diabetes-related eye exams covered by Medicare?

A: Yes, if you have diabetes, Medicare Part B covers an annual eye exam for diabetic retinopathy.

Q: Does Medicare cover the cost of a continuous glucose monitor (CGM)?

A: Yes, if your doctor determines it’s medically necessary, Medicare Part B can cover the cost of a continuous glucose monitor and related supplies.