Medicare covers diabetic supplies, medications, and screenings. Additionally, Medicare beneficiaries can receive assistance with daily testing equipment, specialized tools, and certain drugs, such as insulin. However, your coverage may vary depending on which Medicare programs you’re enrolled in.
Some supplies are covered under Medicare Part B, which is included in Original Medicare and Medicare Advantage plans. Other medications and supplies fall under Medicare Part D, a prescription drug plan that can be purchased in addition to Original Medicare. Medicare Part D is also commonly included in Medicare Advantage plans.
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Understanding Medicare Coverage for Diabetic Supplies
Original Medicare is divided into two main parts: Medicare Part A and Medicare Part B. The bulk of diabetes-related services and supplies fall under Medicare Part B, including blood sugar self-testing supplies like glucose monitors and glucose test strips, insulin pumps, and therapeutic shoes or inserts for those with severe diabetic foot disease. Part B coverage aims to provide patients with comprehensive support in managing and monitoring their diabetes, reducing potential complications.
General Eligibility Criteria
To be eligible for Original Medicare, you must be 65 years or older, have a qualifying disability, or suffer from End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
For diabetes-specific expenses to be covered under Medicare, patients must be diagnosed with diabetes and follow their doctor’s prescribed plan of care, which typically includes the regular use of necessary diabetic supplies. The patient’s suppliers and healthcare providers must also participate in Medicare.
Blood Sugar Testing
Blood sugar testing involves monitoring glucose levels in the blood, which is essential for diabetes management. Medicare covers blood sugar testing supplies, including glucose meters, test strips, lancet devices, and the lancets themselves. Beneficiaries can obtain these supplies through Medicare-approved suppliers. If you need additional supplies beyond the standard provision, you can consult with your healthcare provider to request documentation to justify the expense for Medicare.
Continuous Glucose Monitors
Continuous Glucose Monitors (CGMs) provide real-time glucose readings, offering valuable data on glucose fluctuations. Medicare Part B covers CGMs, including the receiver and associated supplies like sensors and transmitters. To be eligible for coverage, your doctor must deem the device medically necessary, and you must meet the following conditions:
- You test your blood sugar at least four times a day.
- You either use an insulin pump or receive three or more insulin injections daily.
Keep in mind that regular in-person doctor visits are also a prerequisite for coverage.
An insulin pump is a device that delivers precise doses of insulin 24/7, replacing the need for multiple daily injections. Medicare Part B covers external durable insulin pumps and the insulin used in the pump for beneficiaries who meet specific criteria, as long as a physician certifies that the use of the pump is medically necessary.
Foot care can be crucial for diabetics. Therapeutic footwear, which includes shoes and inserts, can prevent complications like ulcers and amputations. Medicare covers therapeutic footwear for beneficiaries with severe diabetic foot disease. Generally, one pair of shoes and three sets of inserts are covered each year. However, certain conditions may apply.
Insulin and Diabetic Drug Supplies: Part D Required
While Original Medicare offers coverage for many diabetes-related services and supplies, it does not extend its coverage to prescription drugs, including insulin that is injected or inhaled.
For such coverage, individuals must enroll in Medicare Part D, a separate plan explicitly designed to provide prescription drug coverage. In addition to insulin, Medicare Part D covers diabetic supplies needed to administer the drug, such as needles, syringes, gauze, and alcohol swabs. Some Part D plans also cover inhaled insulin devices. Anti-diabetic drugs that are used when blood sugar is not controlled by insulin also fall under Part D coverage.
How Medicare Advantage Covers Diabetic Supplies
A significant advantage of many Medicare Advantage plans is that they commonly include Part D prescription drug coverage. Therefore, beneficiaries with these plans not only get their diabetic supplies but also insulin and other diabetic medications without needing a separate Part D plan.
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. Part C plans typically provide broader benefits. While they must cover the same things Original Medicare does, many Medicare Advantage plans go above and beyond, offering more extensive coverage for diabetic supplies. Medicare Advantage plans may have more relaxed eligibility requirements, more frequent supply delivery, or additional tools and resources for diabetes management.
How Much Do Diabetic Supplies Cost With Medicare?
For supplies covered under Medicare Part B, covered individuals must first meet their annual deductible ($226 in 2023), and then the out-of-pocket cost is typically 20% of the Medicare-approved amount. However, costs can vary based on the supplier’s agreement with Medicare. Medicare Advantage plans may have unique cost structures, including different deductibles, copays, or coinsurance rates.
For individuals using insulin covered under Medicare Part D, the cost of a one-month supply is capped at $35, with no deductible required. The cost of anti-diabetic drugs can vary depending on several factors, including the plan’s formulary (list of covered drugs), the drug’s tier, and the pharmacy used.
For individuals without Medicare coverage, the costs can be substantially more. For example, a box of 100 syringes typically costs between $15 and $20, while the cost of insulin can range from $25 to $325 per vial. A box of 5 insulin pens costs between $300 and $600.
Without insurance, a new insulin pump costs around $6,000 out of pocket, plus, on average, $3,000 to $6,000 per year for necessary supplies, such as sensors and batteries. In addition, patients must pay separately for the insulin that is delivered via the pump, making it a costly solution for those without insurance coverage.
What This Means for You
Medicare Part B provides vital coverage for a range of diabetic supplies, from testing equipment to therapeutic footwear. Medicare Advantage plans may offer more extensive coverage and frequently include Medicare Part D, which covers both insulin and the supplies needed to administer it. Individuals covered by Medicare Part D, either separately or through a Medicare Advantage plan, can take advantage of the $35 monthly cost cap for insulin, resulting in significant savings over the retail price.
Medicare Part B also covers a once-per-lifetime Diabetes Prevention Program, Diabetes Self-Management Training, and Medical Nutrition Therapy Services. If you think you may benefit from these services, you can speak to your healthcare provider or a qualified Medicare representative to learn more about how to access them.