You can expect one third of your clients to battle diabetes. Are you helping them get coverage for what they need every day?
With almost 30 percent of Americans over age 65 struggling with diabetes, you likely already have clients asking you about coverage for blood sugar medications and supplies. How Medicare covers the cost of diabetes treatment can be confusing given that different Medicare parts cover different aspects and that doctors prescribe a variety of management options.
The average person with diabetes could easily spend between $3,300 and $4,600 dollars a year, even if they have health insurance; therefore, it’s imperative for you to help your clients with diabetes navigate coverage successfully. Here’s how you can help.
Know Medicare Diabetes Coverage Basics
To answer your clients’ questions, you first need to know the basics of how Medicare covers diabetes medication, supplies, and services. The good news is, with either the combination of Original Medicare, a Medicare Supplement (Med Supp), and a Part D prescription drug plan (PDP) or an individual Medicare Advantage Prescription Drug (MAPD) plan, your clients should receive the comprehensive coverage they need.
Know what you can expect your clients to need and how much Medicare Parts B, C, and D will cover. (We aren’t covering Part A since that is hospital care coverage. If your clients receive diabetes care in the hospital, Part A should help cover it.) We’ve divided coverage up by drugs, equipment, and services for clearer organization. We’ll cover how Medicare Supplements can provide further coverage for Part B later.
Medicare Coverage for Diabetes Drugs
| Drug | What Medicare May Cover | What Part of Medicare May Cover It | What Your Client May Pay |
|---|---|---|---|
| Insulin |
| Part D | No deductible; monthly copay capped at $35 (will pay more upfront if getting a 60- or 90-day supply) |
| Insulin |
| Part B or D | No deductible; monthly copay capped at $35 (will pay $70 or $105 if getting a 60- or 90-day supply, respectively) |
| Other anti-diabetic drugs | Depends on the plan’s formulary but could include:
| Part D | Plan deductible, copayments, or coinsurance may apply |
Generally, your clients taking insulin will have very comprehensive coverage at a manageable price, thanks to the Inflation Reduction Act that caps monthly insulin costs under all parts to only $35 a month. If your client takes another anti-diabetic drug, of which there are many, you’ll need to consult plan formularies to see what’s covered.
Here are the supplies your client may need and how Medicare covers them:
Medicare Coverage for Diabetes Supplies
| Supply | What Medicare May Cover | What Part of Medicare May Cover It | What Your Client May Pay |
|---|---|---|---|
| Durable medical equipment (DME) | All prescribed DME sourced from a Medicare-approved supplier accepting assignment including:
| Part B | Part B deductible applies; 20% of the Medicare-approved amount after that Exception: Insulin used with a traditional pump covered as DME is exempt from the Part B deductible and monthly copay is capped at $35. (You’ll pay $70 or $105 if getting a 60- or 90-day supply, respectively.) |
| Non-durable supplies for administration of insulin |
| Part D | Plan deductible, copayments, or coinsurance may apply |
Take note of which parts cover which supplies. For example, if you have a client who takes injectable insulin on Original Medicare with a Med Supp but no drug plan, they’ll have the insulin covered completely (the Med Supp will cover the remaining $35) but owe 100 percent of any supplies needed for its administration, like syringes, needles, and gauze.
To learn more about durable medical equipment and how to help your clients understand and qualify for coverage, read our blog post on the subject, Helping Clients Navigate Medicare’s Durable Medical Equipment Coverage.
Your clients may also ask about whether Medicare covers certain services, like education and screenings. Here’s what Medicare will do:
Medicare Coverage for Diabetes Services
| Service | What Medicare May Cover | What Part of Medicare May Cover It | What Your Client May Pay |
|---|---|---|---|
| Foot exams & treatment | A foot exam every six months if your client has diabetic peripheral neuropathy and loss of protective sensation and they haven’t seen a foot care professional for another reason between visits. | Part B | Part B deductible applies; 20% of the Medicare-approved amount after that |
| Glaucoma tests | A test, performed by a doctor legally authorized by the state, once every 12 months if there is a high risk for glaucoma. | Part B | Part B deductible applies; 20% of the Medicare-approved amount after that |
| Medical nutrition therapy (MNT) services | Medicare may cover MNT and certain related services for those with diabetes or kidney disease if a doctor or other health care provider refers your client for these services. | Part B | If the doctor or health care provider accepts assignment, no copayment, no coinsurance, and Part B deductible does not apply |
| Medicare Diabetes Prevention Program | A once-per-lifetime health behavior change program to help prevent diabetes. | Part B | Nothing, if eligible |
| Screening tests | May be eligible for up to two diabetes screening tests each year if doctor determines a risk for diabetes. | Part B | No coinsurance, no copayment, Part B deductible does not apply |
| Self-management training | For Medicare to cover self-management training services, your client’s doctor or other health care provider must order it and an accredited individual or program must provide the services. | Part B | Part B deductible applies; 20% of the Medicare-approved amount after that |
Once comfortable with the basics, you’ll have a strong foundation of knowledge to inform your next steps.
Fact Find Thoroughly
When your client begins asking questions about diabetes coverage, your first step is to fact find appropriately. Without knowing what your client takes or does to manage their diabetes, you won’t know what plans will work best.
Find out from your diabetic clients:
- When they were diagnosed with diabetes
- What they currently use to manage it:
- Type of insulin taken, if any (injected, inhaled, patch, from a pump)
- Specific names of anti-diabetic drugs taken, if any
- Disposable vs. durable pump, if used
- What supplies they need regularly (syringes, gauze, alcohol swaps, test strips, lancets, etc.)
- What other equipment they need, if any (therapeutic shoes)
- Their primary care provider and pharmacy of choice
- If and what screenings and tests they receive
- If and what educational resources or trainings they utilize
- If and what other complications or chronic illnesses they have resulting from diabetes
- If not receiving screenings, tests, or education, if they’d like to
If your client comes to you with questions about coverage in the first place, they’ll likely be prepared to provide this information without any awkwardness, but as always, we encourage agents to be sensitive to your client’s personality and comfort level when fact finding. Preface questions with a statement about how the answers are imperative to helping you recommend the best plan.
Recommend the Best Plan
What you learn from fact-finding will determine what plan or configuration of plans will work best for your diabetic clients. Since an MAPD plan and the combination of Original Medicare, a Med Supp, and a Part D plan will offer similar coverage for diabetic medications, supplies, and services, your recommendation might come down to other factors, like complications due to diabetes, drug formularies, budget, priorities, etc.
Know the Formulary
As a rule, whenever a plan has a drug formulary (Part D and MAPD plans), consult it diligently! If your client has been taking a certain anti-diabetic drug for years and wants to continue, it’s imperative you find a plan that covers it.
Whenever a plan has a drug formulary (Part D and MAPD plans), consult it diligently!
Imagine the frustration your client would feel going to the pharmacy to pick up their usual covered prescription only to receive a hefty bill after switching to a plan you suggested. Sometimes, clients are willing to switch drugs; sometimes, they aren’t. But that’s something they need to decide with their doctor. You simply do your formulary homework and inform your client of their options.
MAPD Plans
With the combination of Part B-equivalent and drug coverage, MAPD plans can be a very attractive option for your diabetic clients, especially since some carriers offer plans without copays or coinsurance for diabetes supplies. Consult the summaries of benefits and coverage of the different MAPD plans you offer. If you don’t offer any plans with $0 copays and/or low or no coinsurance for diabetes supplies, we recommend expanding your portfolio to offer one that does.
C-SNPs
A type of Medicare Advantage (MA) Special Needs Plan, Chronic Condition Special Needs Plans (C-SNPs) can be a wonderful choice for your client, since some are designed especially for people with diabetes. C-SNPs could offer additional coverage and services on top of traditional MAPD plans, including customized prescription benefits, coordinated care management, educational resources, and complementary benefits.
If you don’t currently offer C-SNPs as part of your portfolio, we highly recommend adding some! Read our blog post, The Beginner’s Guide to C-SNPs, to get started.
A C-SNP could be the best choice for your diabetic clients, especially those with severe cases or complications. Although there’s not much research comparing outcomes for beneficiaries in C-SNPs vs. non-specialized MA plans, preliminary research shows that those beneficiaries with diabetes in C-SNPs experience better outcomes than those in generic MAPD plans.
C-SNPs can be a wonderful choice for your client, since some are designed especially for people with diabetes.
Note: C-SNP availability and competitive pricing can vary by market. Speak with your sales specialist to see what’s available.
Med Supp and Part D
Pairing a Med Supp and Part D plan with Original Medicare will offer the same general coverage as an MAPD plan and, perhaps, even better coverage. A Med Supp can be especially useful for covering the remaining 20 percent Part B coinsurance for diabetes durable medical equipment, like pumps. If your client relies on an insulin pump, a Med Supp might be the best fit.
We don’t recommend leaving off the Part D plan to save on premiums, since your diabetic client could benefit from all a drug plan would help cover, including different types of insulin, other anti-diabetic drugs, and supplies like syringes, needles, and gauze.
Remember, if your client wants a Med Supp but they’ve missed guaranteed issue periods, they’ll need to pass underwriting to join one.
Remember, if your client wants a Med Supp but they’ve missed guaranteed issue periods, they’ll need to pass underwriting to join one. Luckily, carriers recognize the prevalence of diabetes and don’t usually deny enrollees automatically because of it (although they will have parameters).
Want to learn more about Med Supps and underwriting for diabetes? Grab your free copy of A Comprehensive Guide to Medicare Supplement Underwriting!
Encourage Annual Screenings & Additional Services
Your clients may not be aware of the full breadth of tests and services that Medicare will cover for diabetic beneficiaries. Notify them of the possibilities and encourage them to receive their “Welcome to Medicare” visit, annual wellness checkups, and any covered foot exams, glaucoma tests, and annual screenings, as instructed by their doctor.
Your clients may not be aware of the full breadth of tests and services that Medicare will cover for diabetic beneficiaries. Notify them of the possibilities.
Additionally, point out covered nutritional and self-management services that may be available to them. Mention the Medicare Diabetes Prevention Program for any of your clients with pre-diabetes.
Provide More Resources
You and your clients will inevitably have more questions. Will Medicare cover supplies automatically sent by a supplier? Does your client need to ask for refills? How many test strips and lancets can your client get?
For the answers, investigate and provide these additional resources from the Centers for Medicare & Medicaid Services (CMS):
- Medicare Coverage of Diabetes Supplies, Services, & Prevention Programs booklet
- Medicare Coverage of Diabetes Supplies fact sheet
- 5 Things to Know about Medicare Insulin Costs fact sheet
If you still can’t find the answers you need, reach out directly to Medicare at 1-800-MEDICARE or contact the plan provider.
Give your diabetic clients confidence that their essential supplies will be covered. Guide them through Medicare coverage by knowing the basics yourself, fact finding, and researching drug formularies thoroughly, educating clients, and recommending the best fitting plans.
Ritter is here with a diverse array of plans for your portfolio, including excellent options for your diabetic clients. Register for free with us and speak to your sales specialist to unlock easy online contracting through Contract Now.
Not affiliated with or endorsed by Medicare or any government agency.
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