How Medicare Cares for Those With Diabetes

Doctor watching woman test for diabetes
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Diabetes is a growing problem in the United States. According to the Centers for Disease Control and Prevention, more than 29 million Americans had diabetes and 86 million had pre-diabetes in 2012. The number continues to rise and with it the medical complications that come with it.

Diabetes is associated with eye disease (retinopathy), heart disease (coronary artery disease), kidney disease (nephropathy), and nerve disease (neuropathy).

Hospitalization rates for heart attack and stroke are 1.8 and 1.5 times higher for people with diabetes than those without the condition.

The disease is costing America, and Medicare, not only in health and quality of life but in dollars and cents. It is estimated that direct medical costs for the condition amounted to $176 billion and decreased productivity as much as $69 billion in 2013 alone.

How much is diabetes costing you?

Medicare Screening for Diabetes

Medicare covers diabetes screening free of charge for people at risk for the condition. Testing for the condition may include a fasting glucose measurement, a simple blood test that checks how much sugar is in your blood after 8 to 12 hours of fasting. Other options include an oral glucose tolerance test, which measures your blood sugar level before and after a glucose challenge. A hemoglobin A1c test is yet another approach and reflects how much your blood sugars average over the course of three months.

You are eligible for one of these diabetes screening tests every 12 months if you have one of the following:

  • Dyslipidemia (high cholesterol)
  • Glucose intolerance (history of high blood sugar readings)
  • Hypertension (high blood pressure)
  • Obesity (body mass index of 30 or more)

Alternatively, you may be eligible for diabetes screening twice a year if you have at least two of the following criteria:

  • 65 years or older
  • Family history of diabetes in first-degree relatives (parents, brothers, sisters)
  • Gestational diabetes (diabetes during pregnancy) or delivering a baby weighing 9 pounds or more
  • Overweight (body mass index between 25 and 30)

If you have been diagnosed with pre-diabetes, meaning that your blood sugars are higher than normal but not high enough to be classified as diabetes, Medicare will cover two diabetes screening tests each year.

Medicare Coverage of Diabetic Supplies

Your healthcare provider may want you to monitor your blood sugar if you are diagnosed with diabetes. This may be the case whether you take oral medications or insulin to manage your blood sugar. The following supplies are covered by the Medicare Part B benefit and will allow you to test your blood sugars properly. You will pay a 20 percent co-insurance for these supplies though oftentimes, glucometers may be offered free of charge.

  • Glucose monitors
  • Control solutions
  • Lancets
  • Test strips

Special therapeutic shoes and inserts may be covered once per year by Medicare Part B for those who have diabetic neuropathy and related foot disease. These shoes cost a 20 percent co-insurance and require a prescription from a Medicare-approved doctor.

Not only that but the medical supplier of those shoes must have a contract with the Medicare program. To assure best results, Medicare also pays for proper fitting of these shoes and/or inserts.

For those who require insulin, further equipment and supplies are needed to administer the drug. This includes:

With the exception of the insulin pump, which is covered as durable medical equipment under Medicare Part B, these supplies should be covered by your Part D drug plan. Your Medicare Part D drug plan will cover the medications, including insulin, to treat your diabetes as long as they are on your plan’s medication formulary.

A co-pay or co-insurance will apply.

Medicare's Management of Diabetes

If you have diabetes, your healthcare provider will want to take any steps necessary to stop complications from developing. Beyond monitoring your blood sugar, prescribing medication, and performing routine examinations, they may need to refer you to see certain specialists.

  • Nephrologist (kidney doctor): People with diabetes-related kidney problems may be monitored by a nephrologist to hopefully slow or prevent progression of the disease. The frequency of evaluations will depend on the severity of the nephropathy and will cost you a 20 percent co-insurance per visit.
  • Nutritionist: Everyone with diabetes should be offered one-on-one medical nutrition counseling with a nutrition specialist. The initial visit and follow-up evaluations are free of charge if your doctor accepts the assignment.
  • Ophthalmologist (eye doctor): The longer someone has diabetes, the higher the risk of developing retinopathy. Retinopathy puts you at risk for decreased vision and in severe cases, blindness. Expect to pay a 20 percent co-insurance for Medicare to cover the recommended once annual dilated eye exam.
  • Podiatrist (foot doctor): People with diabetes but especially those with diabetes-related nerve damage to their feet qualify for evaluations by a podiatrist or other qualified professionals twice a year. The foot doctor will monitor for sensory changes as well as decreased blood flow to the feet that could put you at risk for skin ulcerations and other complications.

Group classes may also be offered for diabetes self-management training and education. These self-management services are covered for someone who is newly diagnosed with diabetes but are also available to anyone at risk of complications from the disease. In the first year of services, Medicare will cover up to 10 hours of self-management training (1 hour in a one-on-one session and 9 hours in group sessions). In subsequent years (starting at least one calendar year after your initial training), Medicare will cover two extra hours of training per year as long as the training is conducted in group sessions of at least 30-minute duration and including 2 to 20 people each. Out of pocket, each session will cost a 20 percent co-insurance.

Medicare Aims to Prevent Diabetes

The Centers for Medicare and Medicaid Services is making diabetes prevention a priority. An $11.8 million initiative paid for by the Affordable Care Act trialed a pilot program with the National Council of Young Men’s Christian Associations of the United States of America (YMCA) in 2011. The goal was to promote long-term lifestyle changes that promote healthy eating and regular physical activity. The pilot results were so impressive that they are now being implemented as the Diabetes Prevention Program nationwide in 2018.

The pilot study showed a 5 percent weight loss for Medicare participants at risk for diabetes and decreased the health spending for these beneficiaries by $2,650 over a 15-month period. The short-term savings show that the program will pay for itself. Better yet, it could save substantial dollars for Medicare in the long run. The health of a nation may benefit from this simple preventive approach.

Sources:

2014 National Diabetes Statistics Report. Centers for Disease Control and Prevention website.  http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html.

Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017. Centers for Disease Control and Prevention website. https://www.federalregister.gov/documents/2016/11/15/2016-26668/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.

An Overview of Medicare Covered Diabetes Supplies and Services. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0738.pdf.

Statistics about Diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/.

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