Medicare and Diabetes
by Danielle Kunkle
(Editor’s Note: Danielle Kunkle is the founder/partner of Boomer Benefits, and on the Forbes Finance Council as a Medicare expert. To read this article online, go to https://boomerbenefits.com/medicare-and-diabetes/.)
Diabetes is a health condition that affects millions of Americans, including many Medicare beneficiaries. It’s also a condition that sometimes requires a lot of monitoring, so coverage is important when it comes to Medicare and diabetes.
Fortunately, Medicare offers robust coverage related to diabetes, especially when paired with a Medigap plan. Most of the treatment related to diabetes falls under Parts B and D, although Part A will provide hospital coverage for any inpatient stays related to diabetes.
In this article, we’ll discuss various aspects of Medicare and diabetes care. Be sure not to miss my comments below about common billing problems regarding diabetes supplies so you can learn how to avoid them.
What Medicare Part B Covers for Diabetes
Part B is your outpatient insurance, and it covers a vast array of services for diagnosing and treating diabetes. Let’s break them into sections to make it easier for you to learn.
Medicare Screenings and Prevention for Diabetes
All people on Medicare get coverage for an initial Welcome to Medicare physical exam. Afterward, they also qualify for an annual wellness visit.
During these visits, Medicare Part B will cover preventive screenings, such as the fasting blood glucose test, to people at risk of developing diabetes. Conditions that put you at high risk for diabetes include older age, high blood pressure or cholesterol, obesity, cardiac disease or history of high blood sugar. A family history of diabetes is also considered a risk factor.
When your doctor orders a screening test for you, Part B will cover up to two screenings per year. These screenings are covered 100% by Part B.
Medicare Part B can also provide screenings for dyslipidemia, impaired glucose tolerance, high fasting glucose, and the very common hemoglobin A1C test.
Medicare and Diabetes Diagnosis
Once diagnosed with diabetes, Medicare Part B will cover up to 10 hours of diabetes self-management training (DSMT). This is important as you will monitor your own blood sugar levels to keep your diabetes in check. DSMT includes information on the benefits and risks of blood sugar control, how to recognize complications and how to adjust emotionally to a diagnosis of diabetes.
With a written doctor’s order, beneficiaries can also get approved for an additional two hours of DSMT annually. This training is often beneficial to people with diabetes when they are changing from no medication to beginner medications, or from oral medications to insulin medications.
Your doctor might also prescribe nutrition therapy so that you can learn to adapt your diet for better control of diabetes. Part B covers this.
A diabetes diagnosis will also qualify you for an annual eye exam for diabetic retinopathy and glaucoma tests every year.
Routine Foot Care
People with Medicare and diabetes also qualify for foot exams every six months if they have diabetic peripheral neuropathy. This benefit is accessible only if you have not seen a foot care specialist for another reason in between visits.
TIP: Over the years we’ve met many diabetics who are not taking advantage of this benefit because they’ve read online or been told by a friend that Medicare doesn’t cover routine foot care. While that may be true for non-diabetics, Medicare does often cover these visits for people with diabetes who are at risk for circulation problems and diabetic neuropathy. If that’s you, don’t miss out! Ask your doctor today.
Shoes and Inserts
Medicare Part B covers the furnishing and fitting of one pair of custom molded or depth-inlay shoes (plus inserts) for people with severe diabetic foot disease. These must be prescribed by a podiatrist or other qualified doctor.
In general, the qualifications are that you:
- Have diabetes;
- Have partial or full amputation, past foot ulcers, calluses that could lead to ulcers, nerve damage because of diabetes, poor circulation, or a deformed foot; and
- Are being treated under a diabetes comprehensive care plan and you need shoes or inserts because of diabetes.
Medicare Diabetic Supplies
Individuals with diabetes often use a lot of medical supplies to monitor their disease. This includes blood glucose monitors, test strips, lancet devices, lancets, and glucose-control solutions whether you use insulin or not.
Your doctor will need to write a prescription for these supplies at least as often as every 12 months.
If you take insulin, you can qualify for up to 300 test strips every 3 months. People who do not need insulin can qualify for 100 test strips every 3 months.
TIP: One of the areas where we commonly see Medicare beneficiaries overspend is on their diabetic supplies. Many people fill their supply orders at local pharmacies, which can often be more expensive than using Medicare’s national mail-order program. This happens because many retail pharmacies do not accept the Medicare-approved amount as payment in full. If the pharmacy does not accept Medicare assignment, you may be charged 15% beyond what Medicare covers, plus the 20% that Part B does not cover. This is called an excess charge.
At Boomer Benefits, we refer our clients with diabetes to Medicare’s national mail-order program. It can save you money while still getting you quality diabetes care products from accredited suppliers. These suppliers offer many common brands that you will be familiar with. The mail-order supply programs also give you the added convenience of supplies delivered right to your home. To learn more, and to find a diabetes mail-order supplier, visit https://tinyurl.com/jqtluc2.
Other Durable Medical Equipment for Diabetes
Some people with severe diabetic disease will qualify for an external insulin pump. When your doctor prescribes an insulin pump, Part B will cover the pump and the pump supplies, including the insulin used in the pump.
This is an important distinction because people with Medigap plans that pay 20% can get this insulin at no cost. Medicare covers 80%, and your Medigap plan pays the other 20%. This can sometimes be very cost-effective compared to insulin you inject yourself, which you must purchase under your Part D coverage.
What Medicare Part D Covers for Diabetes
Medicare Part D covers many different anti-diabetic drugs for maintaining sugar levels. This is perhaps the most important coverage to many diabetics, especially if they are insulin-dependent.
Part D covers both oral diabetes medications and insulins. For some people, the medications can still be quite expensive. Many diabetes medications are still under patent, which means there is no generic drug available. If a medication has a retail cost of $600+, it will usually fall under Tier 5 for specialty drugs. Your coinsurance for these medications is usually 25% or more, so while Part D covers the larger share, the meds are still costly to you.
Medications like Lantus, Victoza, Novolog, Trulicity and others, especially in pen form, may cause you to spend more than you like. However, it’s important to remember that just 10 years ago, there was no coverage at all for retail prescription drugs. At least with Part D, you pay less now than you would have back then.
Donut Hole Expenses for Diabetes Meds
In recent years, the high cost of these drugs has put people into the donut hole as well. During this part of the year, you will pay 40% of the cost of your brand name drugs in 2017. Working with your doctor to identify any generic drugs that may be alternatives will help.
Although some medications cost more in the donut hole, you can look forward to the coverage gap going away in 2020. Medicare is phasing it out. This is welcome news for many diabetics on insulin.
While currently there are no generic insulin medications on the market, diaTribe.com reported that several drug manufacturers were actively working as early as 2010 to produce biosimilar insulin products that could be brought to the marketplace less expensively in the future.
Lastly, be aware that Part D also covers syringes, needles, alcohol swabs and gauze. A Part D plan will help you to manage costs and protect you from catastrophic drug spending on all of these items.
Diabetes and Medicare Supplement Open Enrollment
When you are first eligible for Medicare, you will have a 6-month window to join any Medigap plan without health questions. During this window, the insurance company cannot turn you down for coverage due to diabetes. If you have diabetes, this may be an important window for you.
Here’s why: Once you are past your initial six-month window, you must answer health questions and go through medical underwriting to qualify for a Medigap plan. The severity of your diabetes could affect your eligibility.
For example, it’s relatively easy to pass underwriting if you simply take oral medications. However, if you take medications and/or insulin and have risk factors such as obesity, neuropathy, cholesterol or high blood pressure meds, Medigap companies may turn you down.
You can easily avoid this possibility by signing up for Medigap during the first six months after your Part B effective date.
TIP: Every insurance company asks their questions a little differently. If you have missed your open enrollment window, our team can help you evaluate if you have a better chance of approval with one over the another.
BONUS TIP: Some people are unaware that their medical records include a diabetes diagnosis. Their doctor may have used the word “pre-diabetes.” However, if he noted in your medical record that you have diabetes, this can affect your eligibility for Medigap. Be sure to ask your doctor if you are unsure of your diagnosis.
Diabetes and Medicare Advantage Plans
If Medigap carriers decline to cover you, don’t panic. You can still qualify for Medicare Advantage plans. Also called Part C, Medicare Advantage plans have only one health question. If you do not have end-stage renal (kidney) failure, you can qualify for Medicare Advantage coverage.
Medicare Advantage plans cover all the same services that Original Medicare Parts A and B cover. However, your cost-sharing may be different. Be sure to review the plan’s summary of benefits to learn what your copay or coinsurance percentage will be for your Medicare diabetic supplies and durable medical equipment.
You can only join or leave Medicare Advantage plans at certain times of the year. Once enrolled, you cannot change mid-year unless you have a special circumstance like moving out of state.
Medicare Advantage Special Needs Plans for Diabetes
In many areas of the country, insurance companies offer Medicare Advantage Special Needs Plans for people with diabetes. Special Needs Plans (SNPs) are a type of Medicare Advantage plan that limits enrollment to specific chronic or disabling conditions.
Medicare Advantage SNPs for people with diabetes will have comprehensive diabetic care. This care is specifically tailored to meet the needs of people who have diabetes. This may include richer benefits, provider choices or medication formularies. It might also offer comprehensive care management of your condition. Care management involves a care coordinator and/or a group of doctors work together to provide you the best possible care.
All special needs plans come with a built-in Part D drug plan. You can check the plan’s formulary to see if it covers the medications you need.
SNPs also have a unique feature which allows people with the qualifying health condition to be able to enroll mid-year. This means you can join if you have the qualifying condition even if it is not during the annual election period.
If this sounds like a suitable plan for you, contact us. We’ll be happy to search your county for any qualifying plans.
There are lots of great coverage options for people with Medicare and diabetes. We’d be happy to help you with your questions so that we can find you the right plan. Give us a call at 1-855-732-9055.