Chances are you or someone you know is affected by diabetes. About 38.4 million Americans, or 11.6% of the population, have diabetes, according to the American Diabetes Association. The percentage of Americans ages 65 and older is notably higher, at 29.2%, or 16.5 million seniors.
Since diabetes affects seniors at such a high rate, it is critical that people who qualify for Medicare understand the benefits available and what is — and isn’t — covered under the federal program.
What Is Diabetes?
Diabetes is a chronic medical condition that affects how your body processes blood glucose, or blood sugar. Glucose is a vital energy source for your body’s cells, and its regulation is primarily managed by the hormone insulin.
For some, lifestyle changes — such as healthier eating and exercise — can help manage the condition, but many others need more help through insulin or other anti-diabetes medications.
Without proper diabetes management, people with the disease can develop heart disease, kidney disease, nerve damage, blindness and can require amputation of feet or legs.
[SEE The Best Foods to Help Manage Diabetes]
What Does Medicare Cover?
Different parts of Medicare cover different areas of diabetes care. Medicare Parts B (medical insurance), C (Medicare Advantage) and D (prescription drug coverage) each play a role in covering diabetes-related services and supplies. If you have a Medigap plan, it can help cover out-of-pocket costs associated with diabetes treatment under original Medicare but does not apply to Medicare Advantage plans.
The Inflation Reduction Act (IRA) introduced a cap on insulin costs for Medicare beneficiaries, improving affordability. Under the IRA, in effect from 2023, Medicare members pay no more than $35 per month for insulin. This cost-sharing limit applies regardless of the number of insulin doses required each month and aims to alleviate the financial burden on individuals managing diabetes.
[READ: Prediabetes: Prevention, Screening and Corrections]
Medicare Part B Coverage
Medicare Part B covers several aspects of diabetes care, including:
Blood glucose self-testing equipment and supplies:
— Blood glucose monitors
— Blood glucose test strips
— Insulin user: Up to 300 test strips per three months
— Non-insulin user: Up to 100 test strips per three months
— Continuous blood glucose monitors (CGMs)
— Glucose control solutions to check accuracy of test equipment and strips
— Lancet devices and lancets
— Insulin user: up to 300 lancets per 3 months and 1 lancet device every 6 months
— Non-insulin user: up to 100 lancets per 3 months and 1 lancet device every 6 months
— Supply allowance for a therapeutic continuous glucose monitor including supplies and accessories
— Part B will also cover additional test strips and lancets if the patient’s doctor documents the medical necessity.
Durable insulin pumps
External durable insulin pumps
are covered by Part B, including the insulin used with the pump. If a durable insulin infusion pump is necessary, the doctor must prescribe it. Medicare limits the coinsurance for insulin to $35 per month.
Part B will not cover disposable pumps such as OmniPod or V-Go or the insulin used in these pumps. While Part B does not cover this, some Part D drug plans may provide coverage, so check with your plan to see what options you have.
Therapeutic shoes and inserts
If basic coverage criteria are met, Part B will cover therapeutic shoes. The criteria are:
— It is prescribed by a qualified doctor or podiatrist.
— The doctor fits and provides the shoes to the patient.
— The patient has at least one of the following in either one or both feet:
— Calluses that could lead to foot ulcers
— Deformed foot
— Nerve damage related to diabetes
— Partial or complete foot amputation
— Past foot ulcers
Types of shoes and inserts covered each year include:
— One pair of depth shoes and three pairs of inserts
— One pair of custom-molded shoes, including provided insert plus two more pairs of inserts
[READ: How Meditation and Mindfulness Can Help Manage Diabetes.]
Available Diabetes Education
Medicare beneficiaries under Part B with a diagnosis of diabetes qualify for free outpatient diabetes self-management training.
“Medicare offers 10 hours of initial diabetes self-management education and support services and two hours per year after the initial training,” says Barbara Eichorst, vice president of health care programs at the American Diabetes Association in Arlington, Virginia. “The 10 hours of diabetes self-management education and support is a one-time benefit. The American Diabetes Association encourages beneficiaries living with diabetes to utilize all of those initial hours within the year allotted.”
Medical nutrition therapy services are also available with a referral from your doctor. This includes a nutrition and lifestyle assessment, help managing lifestyle factors that affect your diabetes and follow-up visits with a registered dietitian.
Specialist Exams
Part B covers eye exams for diabetes retinopathy once each year with a diabetes diagnosis. You must get the exam from a Medicare-approved eye doctor. It does not cover eye exams for glasses or contacts.
Foot exams are covered if you have diabetes?related lower leg nerve damage that can increase the risk of limb loss. You can get a foot exam once a year, as long as you haven’t seen a footcare professional for another reason between your yearly visits.
Medicare Part C Coverage
Medicare Part C, also known as Medicare Advantage, by law must offer everything that original Medicare (Parts A and B) cover, but may offer other benefits, limitations or out-of-pocket costs. Some extra benefits that may be included are gym memberships, nutrition counseling, telehealth consultations and diabetes management programs. Many Advantage plans require using in-network doctors and pharmacies, so check with your plan. Most have drug benefits, but to find out what your plan specifically covers, check the plan’s formulary.
Some Advantage companies offer Special Needs Plans (SNPs), which provide additional or specific support for chronic conditions, including diabetes. Check Medicare.gov or contact the State Health Insurance Assistance Program (SHIP) to find out more. SHIP is a free, federally funded program that helps Medicare-eligible individuals and their families make informed decisions about their care and benefits. You can find your local office by going to shiphelp.org or calling (877) 839-2675.
Medicare Part D Coverage
Part D (drug insurance) covers insulin, certain diabetes supplies and diabetes medications. Keep in mind, Part D is only available with original Medicare, not with Advantage plans, which usually include some drug coverage.
Anti-diabetes medications
Drug plans cover different anti-diabetes medications, such as:
— Alpha glucosidase inhibitors, such as Precose (acarbose)
— Biguanides, such as Glucophage (metformin)
— GLP-1 receptor agonists, such as Ozempic (semaglutide) and Mounjaro (tirzepatide)
— Sulfonylureas, such as Glucotrol (glipizide)
— Thiazolidinediones, such as Actos (pioglitazone) and Avandia (rosiglitazone)
Before getting too excited about GLP-1 receptor agonists, such as Ozempic and Mounjaro, being covered by some Part D plans, know that there are several steps that need to be followed before the medication is approved.
“GLP-1 medications require prior authorization and documentation that the patient has tried and failed at least Metformin. You must also have a diagnosis of Type 2 diabetes or cardiovascular disease,” says Tammie Payne, a family nurse practitioner and diabetes care and education specialist in Everett, Pennsylvania.
You must check your particular plan’s formulary to find out what it specifically covers since Part D plans and their coverage varies.
“There were more than 700 Part D plans available to Medicare beneficiaries so it can be difficult to generalize what each plan allows for in practice,” says Lisa Murdock, chief advocacy officer at the American Diabetes Association in Arlington, Virginia.
Diabetes supplies
Diabetes supplies are considered items needed for the administration of insulin. These include:
— Alcohol swabs
— Gauze
— Inhaled insulin devices
— Needles
— Syringes
Insulin
Medicare Part D plans cover injectable insulin not associated with the use of durable insulin pumps, which are covered under Part B.
Bottom Line
Considering nearly 30% of adults ages 65 and older have diabetes, it’s important to understand what Medicare covers and what it does not cover.
Knowing what benefits a beneficiary is entitled to is key in effective diabetes management.
More from U.S. News
Questions to Ask Your Doctor About Diabetes
What Foods Are Good for Diabetes?
A Patient’s Guide to Type 1 Diabetes: Causes, Symptoms and Treatments
Does Medicare Cover Insulin and Supplies for Diabetes? originally appeared on usnews.com
