According to the Centers for Disease Control, over 11 percent of the US population has diabetes. If you have diabetes, you may require costly equipment and extra visits with physicians and specialists. Understanding what Medicare benefits are available to you and when you will be covered with Medicare is especially important with Diabetes.
Original Medicare Diabetes Coverage
Because diabetes needs to be closely monitored and can lead to other high-risk conditions, it’s beneficial to know what kind of coverage you are able to receive through Medicare. Original Medicare (Parts A and B) does not cover insulin (unless an insulin pump is medically necessary), insulin for a disposable pump, or supplies needed to inject insulin. In order to have these items covered by a prescription drug plan, you will need to enroll in a standalone Medicare Prescription Drug plan alongside your Original Medicare coverage. Medicare Part B does cover some diabetic supplies and services such as the following:
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Lab tests to check for diabetes
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Diabetes screenings (2/year)
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Glucose monitors and corresponding supplies
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Foot exams for those with diabetic peripheral neuropathy (2/year)
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Glaucoma test (1/year)
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Medical Nutrition Therapy
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Some therapeutic shoes or inserts
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Yearly wellness visits (after 1 year of Part B coverage)
It’s important to note that while Medicare Part B may cover these items, you will still be responsible for paying the remaining 20 percent that Original Medicare does not cover. Diabetes supplies and tests can be costly, and the remaining 20 percent of all these costs can build up quickly. It should also be noted that Original Medicare does not cover the cost of prescription drugs.
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Medicare Advantage Diabetes Coverage
Medicare Advantage plans are offered by private insurance companies and offer all of the same coverage as Original Medicare plus additional benefits and savings typically. Medicare Advantage plans may offer included coverage for vision, dental and hearing. Additionally, Medicare Advantage plans often include prescription drug coverage and low to no premiums, deductibles and copays. Those with diabetes may benefit from a plan like this, as it may be more advantageous to your finances and lifestyle.
Part D coverage for diabetics includes:
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Prescription drugs for maintaining blood sugar (glucose)
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Diabetic Supplies for administering insulin
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Insulin that is not administered with a pump.
As of January 1, 2023, insulin covered under Medicare Part D plans are capped at $35 for a one-month supply. Additionally, you can’t be charged a deductible for insulin. This $35 monthly cap for insulin applies whether you are enrolled in a standalone Medicare Part D Prescription Drug plan or a Medicare Advantage Prescription Drug plan. If you get your insulin in 60- or 90-day supplies, you will pay $35 for each month of insulin supply you receive.
Individuals with diabetes may want to consider a Chronic Condition Special Needs Plan (C-SNP), which is a plan that focuses on providing additional support to those who have unique healthcare needs, and often offer coordinated care. Some SNPs are specifically designed with diabetics in mind.
Diabetes Prevention Program
This 6-month program, offered by Original Medicare, centers around preventing type 2 diabetes. The sessions focus on changing behaviors and eating habits to stay healthy and motivated. Medicare offers coverage for the Diabetes Prevention Program once in your life and if you are eligible, the program costs you nothing.
In order to be eligible for the program, you must:
Have never been diagnosed with end-stage renal disease (ESRD) or diabetes type 1 or 2
Never previously participated in the Diabetes Prevention Program
Have a BMI or 25 or more (23 or more if you are of Asian descent)
Blood glucose testing with results indicating prediabetes
Enrollment in Medicare with Diabetes
Generally, you are eligible to enroll in Medicare starting three months before you turn 65. Individuals who have been receiving disability insurance for 24 months are automatically enrolled in Original Medicare (Parts A and B). As an individual with diabetes, you may be eligible for disability insurance through the Social Security Administration (SSA), depending on your situation.
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Frequently Asked Questions
Yes. Medicare Part B will cover diabetic shoes and inserts if you have diabetes and severe diabetic foot disease. In order to be eligible, your physician must sign off on your need for therapeutic shoes and/or inserts, and you must obtain your footwear from a qualified physician, such as a podiatrist or orthotist.
Enrollment Eligibility
Annual Enrollment Period (AEP)
Medicare Annual Enrollment Period runs each year from October 15 to December 7. What is the Annual Enrollment Period vs. Open Enrollment Period?
Initial Enrollment Period (IEP)
Your Initial Enrollment Period generally surrounds your 65th birthday but may occur if you otherwise become eligible for Medicare for the first time.
Special Enrollment Period (SEP)
You may be eligible if you experience a qualifying life event such as moving to a new zip code, losing employer coverage, or change in Medicaid status.
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Further Reading:
Chronic Special Needs Plans | C-SNPs
Original Medicare vs. Medicare Advantage
