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 post, 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

Medicare offers a number of preventive screenings 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, for 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 a 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 ten 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.

Diabetic Shoes Medicare (and inserts)

Lots of beneficiaries ask us: Does Medicare cover diabetic shoes? Fortunately, it does. Congress passed the Therapeutic Shoe Bill in the early 1990s.

Medicare Part B covers the furnishing and fitting of one pair of custom molded or depth-inlay diabetic shoes (plus inserts) for people with severe diabetic foot disease. These diabetic shoes must be prescribed by a Medicare podiatrist or other qualified doctor.

In general, the qualifications to get diabetic shoes covered by Medicare 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
• Are being treated under a diabetes comprehensive care plan, and you need shoes or inserts because of diabetes.

Type of Diabetic Shoes Medicare Covers

If a beneficiary qualifies, he or she is limited to one of the following categories of footwear in a calendar year:

• one pair of depth-inlay diabetic shoes and three pairs of inserts
• one pair of custom-molded shoes (this includes inserts) and 2 extra pairs of inserts

Sometimes separate inserts could be covered if certain criteria are met. Modification of existing diabetic shoes may also be covered as a substitute instead of an insert. Custom-molded shoes are also covered when a beneficiary has a deformity of the foot (when a depth shoe won’t work)

Since diabetic shoes fall under Medicare Part B, you can expect that Medicare will cover 80% after you have met your deductible.

Medicare Diabetic Supplies

Medicare Part B covers 80% of the cost for supplies like lancets, test strips and glucose monitors.

Individuals with diabetes often use a lot of medical supplies to monitor their disease. This includes blood glucose monitors, test strips, lancet devices, and lancets to name a few.

What Medicare Part D Covers for Diabetes

Diabetes drugs that you administer to yourself fall under Medicare Part D.

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 does cover both oral diabetes medications and insulins. For some people though, 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 ten 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, which can sometimes be quite expensive in the Medicare donut hole.

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 its 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 other.

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 a Medicare Advantage plan. Advantage plans do not ask any health questions when you apply for a plan. Additionally, these 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

Medicare Advantage Special Needs plans offer comprehensive care from a team of medical professionals who work together.

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 working together to provide you with 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 that allows people with qualifying health conditions 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.