Will Medicare Cover My Diabetes?

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.

Original Medicare and Diabetes Care

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.¹

The great majority of these were for patients 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.²

If you have an inpatient medical procedure owing to your diabetes, Part A benefits address this. Expect to pay a deductible of $1,556³ (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.

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. While you may be subject to a monthly fee, if you have Medicare Supplemental Insurance or both Medicare and Medicaid, these may be able to help cover the cost.

The Part B deductible ($233 in 2022)⁴ and 20 percent coinsurance for provider visits both apply to chronic care management.

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.

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, other don’t, so check with your preferred plan to make sure you’ll be able to see the right doctors.

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 braod access to many types of isnulin and can charge no more than $35 for 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.

Learn more about the Medigap enrollment periods here.

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
  • Pre-diabetes
  • Age – you’re more likely to get it if you’re 45 or older
  • Lack of physical activity
  • If you have pre-diabetes 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.