- 1 So What is Diabetes?
- 2 Does Medicare Cover Diabetes?
- 3 Breakdown of Part B and Part D and What They Cover
- 4 Diabetes Medicare Insurance Coverage
- 5 Medical Treatments for Diabetes
- 6 How Much Do I Pay for Medicare Covered Services and Supplies?
- 7 Part D and the Donut Hole
- 8 What Doesn’t Medicare Cover?
- 9 Medicare Advantage Plan Options
- 10 Medicare Supplement Plans
- 11 Tips for Choosing the Right Plan
- 12 Appealing Coverage Decisions
Diabetes is a disease where the body struggles to produce insulin causing high levels of blood glucose. Diabetes affects more than 30 million Americans. Of that 30 million, 25% are age 65 and older. So, approximately 12 million seniors are affected by diabetes in America.
As the seventh leading cause of death in the United States, diabetes can also lead to blindness, kidney and/or heart failure, amputations, and stroke. There are two main levels of diabetes.
Type 1 Diabetes
The most severe type of diabetes is Type 1 Diabetes (T1D). T1D is most common in children, giving it the name “juvenile diabetes”. However, T1D can affect any age. Type 1 diabetes is when the pancreas either doesn’t produce enough insulin or doesn’t produce any insulin at all. This happens because the immune system doesn’t recognize the insulin-producing cells in the pancreas and attacks them. The lack of insulin causes the glucose to build up in the blood instead of being distributed out to the body’s cells. This causes a high level of blood sugar.
Type 2 Diabetes
Unlike T1D, Type 2 Diabetes (T2D) patients are able to produce insulin. Unfortunately, it isn’t enough. Without the right amount of insulin, the body’s cells won’t allow glucose to enter, leading to insulin resistance. T2D is the most common form of diabetes. It is often diagnosed in adults 35 and older, giving this type its name, “adult-onset diabetes”.
Type 2 diabetes is usually easier to manage than type 1. Normally an adjustment in diet and exercise can help to control the blood sugar levels.
Does Medicare Cover Diabetes?
People living with diabetes often need supplies and services to help better manage their disease. Medicare has developed certain coverage rules for the items needed.
Part A of Original Medicare covers the medically necessary inpatient stays you might eventually incur while living with diabetes. It also covers skilled nursing care and hospice care.
However, the main two parts of Medicare that will cover your diabetes treatment are Part B and Part D.
Part B will be responsible for your outpatient services and durable medical equipment while Part D is a voluntary program you can enroll in to help with outpatient prescription costs.
There are many supplies and services one might need when battling diabetes. Knowing which part of Medicare covers them can help you plan ahead for any costs you may share in.
What Part B Covers for Diabetics
As mentioned above, Part B covers your outpatient services and durable medical equipment (DME). Some pieces of equipment that Part B covers for diabetes are
- Blood Sugar Testing Monitors
- Blood Sugar Test Strips
- Lancet Devices and Lancets
- Insulin (if an insulin pump is needed)
- Insulin Pump
- Blood Sugar Control Solutions
- Therapeutic Shoes or Inserts
It’s important to note that not all durable medical equipment is covered the same way. For instance, certain equipment may need to be rented, purchased, or you may have an option between the two.
Your doctor and the supplier of your DME must be enrolled in Medicare in order for Medicare to cover the equipment. You will also need to make sure your supplier accepts Medicare assignment. If a provider does not accept Medicare assignment, they can charge you an excess charge of up to 15% beyond Medicare’s allowed rate in many states.
If you need certain supplies for your durable medical equipment and you’d like to order them through a pharmacy, make sure the pharmacy bills your Part B and not your Part D drug plan. Be aware that purchasing these items through Medicare’s approved vendor list will often mean the items are less expensive than if you fill them at your local pharmacy.
Some services for diabetes that Part B covers are
- Diabetes Screenings
- Diabetes Self-Management Training (DSMT)
- Yearly Eye Exam for Diabetic Retinopathy
- Foot Exam
- Glaucoma Tests
- Medical Nutrition Therapy (MNT)
- Doctor’s visits
- Lab testing
When it comes to covering diabetic services, Medicare enacts specific rules and limits. For example, you can receive a foot exam once every six months, but you can’t have had seen a foot care professional for any other reason between each exam.
An example of limits set by Medicare is the time limit for DSMT. Only the first ten hours of your training are covered. Medicare might also cover an additional two hours of training once a year after your initial training. Also, in order for your DSMT to be covered, your doctor must provide a written order. Without this, you will pay for the training yourself.
Diabetes Medicare Insurance Coverage
Your outpatient prescriptions and syringes to administer your prescriptions are covered under Medicare Part D. You can choose to get your drug coverage through a stand-alone drug plan or inside a Medicare Advantage plan.
Medicare Part D covers injectable insulin. If your insulin doesn’t control your blood sugar well enough, you may need anti-diabetic drugs. A few types of anti-diabetic drugs that Part D can cover are
- Alpha-Glucosidase Inhibitors
Every Part D drug plan has its own specific drug formulary. A formulary is a list of medications covered by the plan. The formulary will also show you the tiers into each medication falls so that you can look up what your copay for each medication will be. Not every drug plan covers the same medications, so it’s imperative that you double check the plan’s formulary prior to enrolling.
You might need medical supplies to administer your prescriptions, especially if you receive injectable insulin. A few supplies that may be covered are
- Alcohol Swabs
- Inhaled Insulin Devices
Although these supplies aren’t medications, you will need a prescription in order to receive these items through a pharmacy or a DME supplier. Also, Medicare has specific approved brands that they cover. Not all manufacturers are covered by Medicare.
Insulin is meant to regulate the amount of glucose within our bloodstream. This very common form of treatment can be administered in several ways. You can receive insulin through a pump, as single injections, from an inhaler device, or even intranasally.
We mentioned that Part D also covers antidiabetic medications. Even though insulin is the main method for treating diabetes, your doctor may prescribe one or multiple anti-diabetic drugs from the classes listed below. These anti-diabetic drugs are usually used to treat people with type 2 diabetes
Alpha-Glucosidase Inhibitors: These oral drugs delay the absorption of the carbohydrates. Thus, they can lower blood sugar levels.
Biguanides: This class of drug is used to prevent the liver from producing glucose. That allows your intestines to not absorb as much sugar.
Meglitinides: These are meant to assist the insulin-producing cells in the pancreas with releasing insulin as you eat. These drugs are usually meant to be taken before each meal.
Sulfonylureas: These were the first drugs created to treat diabetes. Very similar to meglitinides, sulfonylureas help your pancreas to produce insulin. However, sulfonylureas allow your cells within your pancreas to produce insulin throughout the day, instead of for just part of the day.
Thiazolidinediones: The purpose of these drugs is to increase the secretion of insulin within the body. They also help to lower blood pressure.
Diet and Exercise
Monitoring your diet, exercise, and general health is a big factor in managing your diabetes. Your diet and exercise vary each and every day. Therefore, your insulin intake will vary as well.
Diet and exercise are helpful because you should try to maintain a healthy weight when living with diabetes. This will allow you to better control your blood sugar levels.
How Much Do I Pay for Medicare Covered Services and Supplies?
Diabetes is an expensive disease to manage. In 2017 alone, Americans with diagnosed diabetes spent $327 billion. Looking at that number may lead you to think that Medicare must not cover much of the expense. However, Medicare usually covers the majority of the bill. After a small annual deductible, Medicare Part B pays 80% of medically necessary services and supplies, leaving you to pay only the other 20%.
That 20%, however, has no annual cap. If you have a lot of treatment for diabetes, that percentage can really add up unless you enrolled in a Medicare Supplement plan, which we talk about below.
Diabetes medications are also very expensive even with a Part D drug plan in place. This is partly due to the fact that many brand-name medications for diabetes can cause you to fall into the donut hole.
Part D and the Donut Hole
Medicare Part D drug plans have basic minimum guidelines. Most plans have a deductible that you satisfy up front and then you go into your initial coverage phase during which you pay copays for your medications.
Each Part D drug plan has set copayments for each tier of medication. After you have spent a certain amount out-of-pocket ($3,750 as of 2018) within your Part D drug plan, you move into the coverage gap, also known as the donut hole.
During this stage of your drug plan, you are expected to pay a higher percentage of your drug costs. This percentage can sometimes be considerably higher than your copay in the initial coverage stage of your drug plan. This stage causes the price of brand-name insulins to skyrocket, adding to the overall cost of spending for diabetes.
Once you have spent $5,000 out-of-pocket in one calendar year, you move to the catastrophic coverage stage of your plan. While in catastrophic coverage, you pay no more than 5% of the cost of the medication. Bear in mind that these amounts are set by Medicare and can change each year.
What Doesn’t Medicare Cover?
There are a few things that Original Medicare doesn’t cover at all. A few things that Part A and Part B do not provide coverage for are
- Eye exams for prescribing eyeglasses (except after cataract surgery)
- Cosmetic Surgery
- Dental Care
- Hearing Aids
- Long-Term Care
Although they are not covered under Original Medicare, you still may be able to receive coverage for these items inside a Medicare Advantage plan.
Also called Part C plans, Medicare Advantage plans are a type of plan you can enroll in to receive your benefits from a private insurance company instead of Original Medicare itself. Part C combines your Part A, Part B, and usually Part D coverage into one plan. Extra benefits such as dental, vision, and hearing benefits are sometimes included as well.
Medicare Advantage plans typically have very affordable monthly premiums. Some Medicare Advantage plans even have $0 premiums. However, you will need to receive your care from providers who are contracted with the plan and you will pay copays for your services as you go along. Some plans require you to choose a primary care doctor who will coordinate your care and write a referral for you if you need to see a specialist.
This type of coverage differs from a traditional Medicare supplement or Medigap plan.
Medicare Supplement Plans
Medicare Supplement plans, better known as Medigap plans, are add-on plans to your Original Medicare. These plans offer additional coverage for the gaps in Original Medicare. For instance, most plans, including the very popular Medigap Plan G, pay the 20% we mentioned earlier that you would normally have to pay.
These plans help pay for your Part A out-of-pocket expenses as well. In addition to paying your Part B copayments, Plan G also pays your Part A copayments and deductible.
The best time to enroll in a Medigap plan is during your Open Enrollment Period (OEP). This is a six-month period following your Medicare Part B effective date where you can enroll in a Medigap plan without answering any health questions. If you apply during this period, you can’t be turned away due to health conditions.
Tips for Choosing the Right Plan
Choosing the right plan to work with your Original Medicare is an important part of living with diabetes past 65.
There are many things you need to check before enrolling in a plan. When enrolling in a Medicare Advantage plan, you need to check to see what plans your doctors are in network with. When enrolling in a Part D plan, you should check the plan’s formulary to ensure that all of your drugs are covered under that plan. You should also check the set copays for each tier under that plan to make sure you can afford them.
When choosing a Medigap plan, be aware that each plan is the same no matter which insurance carrier you get your plan from. The only difference between Plan G from Carrier A and Carrier B is the price of the monthly premium.
Our agency can do all of this and more for you. We are able to compare plans and premiums from 30 different insurance companies, guaranteeing that we will find you the most cost-effective plan for you in your area.
Instances happen where Medicare will deny coverage for a particular supply or service. Six common reasons Medicare denies coverage are
- Incorrect Coding: Each item a doctor’s office puts on a bill has a code. This code shows the insurance company what service was provided at the time of the visit. Sometimes, this code is wrong and require an adjustment.
- Incorrect Billing: Doctor’s offices don’t always have up to date insurance information for every patient. If you enrolled in Medicare since last seeing your doctor, they might not have that information. The office may still have your employer plan as your primary insurance. Then they will bill your employer plan and your old plan won’t pay anything since you are no longer covered by them.
- Not Medically Necessary: Medicare only covers that of which is medically necessary. If they receive a bill from your doctor’s office and they feel that it was not medically necessary, they can deny coverage.
- Uncovered Item: Medicare will deny a bill if they are sent a claim for uncovered items such as cosmetic surgery.
- Non-Referral: If you have a Medicare Advantage plan that requires referrals from your primary care physician to see a specialist, Medicare will deny the claim if you see a specialist with a referral or pre-authorization.
- Out-Of-Network: If you are enrolled in an HMO Medicare Advantage plan and go out-of-network to receive medical treatment, Medicare may deny the claim.
How a Medicare Broker Can Help
When denial of coverage occurs, you have the right to file an appeal for the decision. To file an appeal, you’ll need a few important documents to make your case. Documents such as medical claims and a letter of medical necessity prove to be beneficial when filing an appeal.
You will need to write a Medicare Appeal letter explaining your doctor’s orders along with dates of service and other facts as to why you are filing your appeal. From there, a claims examiner will read your letter, investigate the situation and come to a decision.
Assisting clients with filing appeals is one of the main things our customer service team here. The appeals process typically involves multiple phone calls and a lot of paperwork. Having a Medicare broker to help with the heavy lifting can be very valuable.
Would you like free help with choosing the right supplemental coverage? Reach out to us today so we can help.