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Will Medicare Cover My Diabetes?

A guide to getting the diabetes care you need when on Medicare

Do you have diabetes and are hoping to use Medicare benefits to help manage your related costs? Different needs are met by various plan options. Let’s take a closer look to see what will best suit your lifestyle and health concerns.

What you’ll learn:


Original Medicare and Diabetes Care

Diabetic services covered by original medicare

If you’re hospitalized or require surgery relating to your diabetes, part A will cover your inpatient stays and the care in a skilled nursing facility. You’ll be required to pay a deductible before the coverage kicks in. Part B will cover diabetic supplies with a prescription, including blood sugar self-testing supplies, insulin pumps, and therapeutic shoes or inserts. Part B also covers 80% of covered medically necessary outpatient services after you meet your deductible.

Part A

Part A (hospital care) covers inpatient hospital stays and skilled nursing facilities. In 2018, more than 8 million U.S. hospitalizations were due to Type 1 and Type 2 diabetes. Given that there were just more than 19 million stays not involving diabetes, that translates to one diabetes-related hospitalization for every 2.3 non-diabetes-related hospitalizations.i

The great majority of these were for patient with Type 2 diabetes. Most stays related to Type 1 diabetes involved patients between 18 and 34 years of age, while most involving Type 2 diabetes were for patients between 65 and 84 years of age.ii

If you have an inpatient medical procedure owing to your diabetes, Part A benefits address this. Expect to pay a deductible of $1,556iii (in 2022), but no coinsurance for an inpatient stay of less than 60 days.

Part B

Part B (medical care) covers consultations with doctors and other providers, as well as services like annual wellness checks, outpatient care, lab tests, and preventative services.

Part B also covers diabetes supplies (with a prescription), including:

  • Blood sugar self-testing equipment and supplies such as monitors, test strips, lancets and associated devices, and glucose control solutions
    • If you use insulin, you may be eligible for up to 300 strips and 300 lancets every three months
    • If you don’t use insulin, you may be eligible for up to 100 test strips and 100 lancets every three months
  • Insulin pumps, including insulin used with the pump for certain diabetes sufferers with Part B who meet certain conditions
  • Therapeutic shoes or inserts including:
    • One pair of depth-inlay shoes and three pairs of inserts
    • One pair of custom-molded shoes (including inserts) if you can’t wear depth-inlay shoes plus two additional pairs of inserts

Living with more than one chronic condition?

If you suffer from another chronic condition in addition to diabetes, you may also qualify to use Part B benefits for chronic care management.

Living with multiple chronic conditions.

If you’re living with multiple chronic conditions, you may qualify for medicare part B chronic care management. Chronic care management services include around the clock access, a care plan crafted just for you, 20 minutes of related services per month, and regular check-ins with your doctor. These services are covered when provided by physician assistants, nurse specialists, midwives, or nurse practitioners. Please note that you might also qualify for a medicare advantage special needs plan, offering these services and more.

As part of this management, your provider will draft a plan with your health concerns, goals, medications, other providers, community services that you have or will need, and other relevant health information.

In addition to the care plan, you’ll get medication management assistance, 24-7 emergency care access, and other necessary help.


Medicare Advantage and Diabetes Care

Medicare-approved, these private insurer-provided plans (also known as Part C) cover everything from Parts A and B. However, while Original Medicare covers basic supplies, you may still be subject to a copay and/or not get full coverage for what you need.

Diabetic services covered by medicare advantage

Medicare Advantage covers all part A and B services, including diabetic supplies with a prescription, blood sugar self-testing supplies, insulin pumps, and therapeutic shoes or inserts. It also covers medically necessary outpatient services, inpatient hospital stays, and skilled nursing facility care. Extra benefits include podiatry services, vision and dental services, insulin and injections supplies, and certain medications for diabetes. Special needs plans may offer even more benefits if you live with a qualifying diabetic condition.

If this is the case, you may want to consider Medicare Advantage. These plans tend to offer benefits that don’t come along with Original Medicare, including:

  • Dental care
  • Higher-level foot or eye care
  • Prescription drug coverage for diabetes and insulin injection supplies
  • Alternative or complementary diabetes care

Some Medicare Advantage plans also offer Special Needs Plans for those with chronic conditions like diabetes. These are called Chronic Condition Special Needs Plans (C-SNP). Network benefits, providers, and medications are tailored to meet your needs as a diabetic.

You’ll probably have to choose a primary care doctor and get referrals for most specialists. In addition, while, some Special Needs Plans cover out-of-network providers, others don’t, so check with your preferred plan to make sure you’ll be able to see the right doctors.


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Diabetic Supplies and Drugs Covered through Part D

Original Medicare doesn’t include prescription drug coverage; you need to add this on. That’s where Medicare Part D (prescription drug coverage) comes in. These privately sold plans can sometimes vary in terms of what diabetes drugs they’ll cover, so make sure to check your plan’s formulary to ensure that your medications are listed.

Medicare Part D covers the following for diabetes sufferers:

  • Insulin
  • Anti-diabetic drugs including:
    • Sulfonylureas (such as Glipizide and Glyburide)
    • Biguanides (such as metformin)
    • Thiazolidinediones (such as Actos)
    • Alpha glucosidase inhibitors (such as Precose)
    • Meglitinides (like Starlix)
  • Diabetes supplies including:
    • Needles
    • Alcohol swabs
    • Syringes
    • Insulin pens, with or without included insulin
    • Gauze
    • Inhaled insulin devices, with or without included insulin

If you have a specific question about diabetes drug coverage, contact a licensed Ensurem agent at the phone number on this page.

Insulin savings through the Part D Senior Savings Model

Different stages of diabetes require different treatments, medications and supplies. For insulin-dependent diabetics, never running out of insulin is a top priority. Most Part D Plans, as well as Medicare Advantage Plans that include Part D, will cover some insulin costs.

As of 2021, Medicare plans can choose to participate in Part D Senior Savings Models including those for insulin savings. Plans that participate in this model offer broad access to many types of insulin and can charge no more than $35 for a one-month supply.

Part D coverage may include coverage for supplies you need to administer the insulin, including:

  • Insulin pens
  • Syringes
  • Needles
  • Alcohol swabs
  • Gauze

Medicare Supplemental Coverage

These privately offered plans are also known as Medigap. They’re a way to bridge the gap between your Medicare coverage and your health needs. Specifically, they can help you afford coinsurance, copays, deductibles and other fees related to diabetes.

While you can still get a Medigap policy if you have diabetes, you may find that the underwriters will screen you a little more carefully. For example, you’ll be asked how much insulin you take (most carriers have a 50-unit daily limit) or how many total medications you need (many carriers have a medication limit as well). Other considerations include other conditions and body weight.

If you’re concerned with being accepted into a Medigap plan, it’s best to enroll during your Medicare Initial Enrollment Period. During this time, you won’t be required to complete underwriting and can’t be denied or charged extra because of your diabetes.

The Medigap open enrollment period

The medigap open enrollment period is a one-time, six-month window starting on your medicare part B effective date. No medical underwriting is required and policies are never denied. It’s the period when you can qualify for the lowest rates.

What are the Different Types of Diabetes?

It’s important to understand the type of diabetes that you have so that you can better understand the type of coverage you’ll need from Medicare. There are three different main types:

  • Type 1, which is caused by an autoimmune reaction stopping your body from manufacturing insulin. Between 5% and 10% of diabetes sufferers have type 1.
  • Type 2, where your body cannot regulate insulin and blood sugar. Between 90% and 95% of diabetes sufferers have type 2.
  • Gestational, which develops in pregnant women who have never had diabetes.

What are the Risk Factors for Diabetes?

  • Type 1:
    • Family history
    • Age – it’s more likely to develop when you’re younger
  • Type 2:
    • Obesity
    • Prediabetes
    • Age – you’re more likely to get it if you’re 45 or older
    • Lack of physical activity
    • If you have prediabetes or have ever had gestational diabetes
    • If you are African-American, Hispanic/Latino American, American Indian, or Alaska Native.

Conclusion

According to the U.S. Centers for Disease Control and Prevention, more than 37 million Americans have diabetes. That’s about 1 in 10 people.

If you’re living with diabetes and need help choosing the right Medicare solutions to support your condition, we can help. Give us a call to talk to a licensed agent specializing in Medicare plans in your area.

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Ensurem Trusted Expertise

Education is crucial in finding the right Medicare solution for you. With so many Medicare resources out there, it can be difficult finding a source you can trust. That’s why Ensurem has a Compliance Program dedicated to ensuring our Medicare content meets Centers for Medicare & Medicaid Services (CMS) regulations. So, you can rest assured you’re getting the information you need to make the right coverage decisions.

Learn More Here

i Agency for Healthcare Research and Quality, “Diabetes-Related Inpatient Stays, 2018.” Accessed February 11, 2022.

ii Agency for Healthcare Research and Quality, “Diabetes-Related Inpatient Stays, 2018.” Accessed February 11, 2022.

iii Centers for Medicare and Medicaid Services, “2022 Parts A and B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.” Accessed February 10, 2022.

iv Centers for Medicare and Medicaid Services, “2022 Parts A and B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.” Accessed February 10, 2022.

Denise Austin, 65, Ensurem Ambassador

Best-Selling Author, Creator of Fit Over 50 Magazine

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