Understanding Medicare Coverage for Diabetes
November is National Diabetes Month, a time to raise awareness about diabetes and the importance of effective management. With over 38 million Americans living with this condition, it’s crucial to understand the resources available for managing diabetes, particularly for Medicare beneficiaries. Medicare offers a range of coverage options that can help you monitor and manage your diabetes effectively. In this blog, we'll explore what Medicare covers related to diabetes, including screenings, training, preventive programs, and equipment, as well as how having a Medigap or MAPD plan can affect your costs.
Diabetes Screenings
Coverage: Medicare Part B
Details: Medicare Part B covers up to two blood glucose laboratory test screenings for diabetes if you are at risk. Risk factors include high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity, or history of high blood sugar. Medicare will also cover these screenings if two or more of the following conditions applies to you: you’re 65 or older, you’re overweight, you have a family history of diabetes, you have a history of gestational diabetes or delivery of a baby weighing more than nine pounds.
Cost: You pay nothing for these screenings if your doctor or other health care provider “accepts assignment” (meaning they agree to accept Medicare's approved amount as payment in full for Medicare-covered services; most doctors do!)
Diabetes Self-Management Training (DSMT)
Coverage: Medicare Part B
Details: DSMT helps you learn how to manage diabetes effectively, including monitoring blood sugar and meal planning. Your doctor must prescribe this training. Medicare Part B covers 10 hours of outpatient diabetes self-management training in the first year (1 hour of individual training and 9 hours of group training). You may qualify for up to two hours of follow-up training each subsequent calendar year.
Cost: After you meet the Part B deductible ($240 in 2024), you pay 20% of the cost. With a Medigap plan, you may have less or no out-of-pocket expense. In an MAPD plan, check your specific benefits, as some may have reduced or no copays.
Diabetes Prevention Program (DPP)
Coverage: Medicare Part B
Details: The Diabetes Prevention Program focuses on lifestyle changes to prevent type 2 diabetes.Medicare Part B covers this program once per lifetime if all of the following conditions apply to you:
Within 12 months before attending your first core session, you have either a Hemoglobin A1c test result between 5.7% and 6.4%, Fasting plasma glucose of 110-125mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerant test)
You have a body mass index (BMI) of 25 or more (BMI of 23 or more if you’re Asian).
You've never been diagnosed with type 1 or type 2 diabetes or End-Stage Renal Disease (ESRD)
You've never participated in the Medicare DPP.
Cost: Medicare covers 100% of the program for eligible beneficiaries. This benefit remains the same whether you have a Medigap or MAPD plan.
Eye Exams
Coverage: Medicare Part B
Details: Medicare covers eye exams for diabetic retinopathy once per year.
Cost: You pay 20% of the Medicare-approved amount after you meet your Part B deductible. With a Medigap plan, this cost may be covered. For MAPD plans, your costs can vary, but many provide low or no copays for these exams.
Truman’s Tip:
We caught up with Dr. Michelle Barnes, an Optometry in Hollidaysburg, Pennsylvania, to learn more about the importance of eye exams for seniors. Check it out! “Beyond the Prescription: Why Exams are Crucial for Seniors.”
Foot Care
Coverage: Medicare Part B
Details: If you have diabetes-related conditions, Medicare covers certain foot care services.
Cost: After you meet your Part B deductible, you pay 20% of the Medicare-approved amount. A Medigap plan may help cover this cost, while an MAPD plan might offer lower copays.
Blood Sugar Monitors and Test Strips
Coverage: Medicare Part B
Details: Medicare covers blood sugar monitors and test strips as Durable Medical Equipment (DME) with a doctor's prescription.
Cost: You pay 20% of the Medicare-approved amount after you meet your Part B deductible. With Medigap, this cost may be covered. If you have an MAPD plan, your out-of-pocket expense could be lower depending on the specific plan.
Continuous Glucose Monitors (CGMs)
Coverage: Medicare Part B
Details: Medicare covers CGMs and related supplies for those who meet specific criteria. To qualify, you must have diabetes, take insulin or have a history of problems with low blood sugar, have a prescription for testing supplies and instructions on how often to test your blood glucose, have been trained (or had your caregiver trained) to use a CGM as prescribed by your doctor, and make routine in-person or Medicare-approved telehealth visits with your doctor.
Cost: You pay 20% of the Medicare-approved amount after you meet your Part B deductible. A Medigap plan may cover some or all of this cost. With an MAPD plan, check your specific benefits, as many have reduced or no copays for CGMs.
Medical Nutrition Therapy (MNT)
Coverage: Medicare Part B
Details: Medicare covers medical nutrition therapy to manage diabetes. Services may include an initial nutrition and lifestyle assessment, individual and/or group nutritional therapy, assistance managing the lifestyle factors that affect diabetes, and follow up visits to check on progress.
Cost: You pay nothing if you qualify for these services.
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Insulin and Insulin Pumps
Coverage: Medicare Part B and Part D
Details: Medicare Part B covers insulin if you use an insulin pump that’s covered under Part B’s Durable Medical Equipment (DME) benefit. Part B does NOT cover syringes, needles, alcohol swabs or gauze. Medicare Part D covers insulin that isn’t used with a traditional insulin pump, insulin used with a disposable or non-traditional insulin pump, certain medical supplies used to inject insulin (syringes, gauze and alcohol swabs), and insulin that’s inhaled.
Cost: The cost of a one-month supply of each Part D- and Part B-covered insulin product is capped at $35, and the deductible does NOT apply. If you get a 3-month supply of insulin, your costs can't be more than $35 for each month's supply of each covered insulin (this means you'll generally pay no more than $105 for a 3-month supply of covered insulin). A Medigap plan should cover the $35/month (or less) cost for each covered insulin. For insulin-related supplies (like syringes, needles, alcohol swabs and gauze), you'll pay 100% of the cost under Part B (unless you have Part D). With an MAPD plan, your out-of-pocket costs will depend on the specifics of your coverage.
For more info on insulin and insulin pump coverage under Medicare, visit Medicare.gov.
Summary
Medicare provides essential support for managing diabetes, from screenings and training to necessary supplies. Understanding your coverage options, including how Medigap and MAPD plans can impact costs, is crucial in making informed healthcare decisions. If you have questions about your coverage or need assistance navigating your options, reach out to Tara today! Together, we can ensure you have the support you need to manage your diabetes effectively.
Care Compass is an independent insurance agency that helps seniors navigate the complexities of Medicare and other Senior Products. Our services are offered at NO COST! Care Compass is proudly owned and operated in Blair County, Pennsylvania. We provide Medicare insurance assistance to the residents of Altoona, Hollidaysburg, Duncansville and the surrounding region. If you need assistance with Medicare, contact Care Compass today!
