Medicare Coverage for Diabetes

Roughly 1.5 million Americans are diagnosed with diabetes every year, according to the American Diabetes Association. The organization estimates nearly 29% of Americans age 65 and older — about 14.3 million people — have diabetes, either diagnosed or undiagnosed.

A report in the association’s journal, Diabetes Care, estimated that diabetes cost Americans $237 billion in direct medical costs in 2017, and that the condition was a major contributor to rising Medicare costs.

Medicare covers some diabetes treatments and supplies, which can be expensive since diabetes is a long-term medical condition for which there is no cure.

It disrupts how the body converts food to energy. It interferes with how and when your body produces insulin — a hormone that regulates the amount of sugar in your blood.

Without enough insulin, sugar builds up in your bloodstream. This can lead to kidney disease, heart disease and vision loss among other serious health conditions.

Medicare covers a wide selection of services aimed at preventing and managing diabetes. Medicare Advantage plans are required to cover everything that Part B covers, but may offer more services.

These begin with your “Welcome to Medicare” preventive visit covered by Medicare Part B. The visit is a one-time review of your health that also provides education and services for all Medicare coverage.

If you are new to Medicare, you must schedule the visit in your first 12 months after enrolling.

It’s a good opportunity to talk with your doctor about the conditions you have and what services you need now that you have Medicare coverage.

Beyond that, Medicare also covers yearly wellness visits. These review and update your health prevention plans since your last visit. It will review your medical and family history, a list of your current doctors and prescription drugs and look at your risk factors.

Medicare also covers other services to prevent and treat diabetes.

In January 2023, Medicare is expanding coverage with a new $35 monthly cap on injectable insulin. This benefit will last until 2025, then insulin copays will be $35 or 25% of the drug’s negotiated price (whichever is less) in 2026. This new benefit was the result of the 2022 Inflation Reduction Act, which will provide relief to many older diabetic Americans in 2023.

According to the U.S. Centers for Medicare & Medicaid Services, there will also be a monthly $35 price cap on traditional insulin pumps starting on July 1, 2023. This benefit is covered under Medicare’s durable medical equipment benefit, and the deductible won’t apply.

Medicare covers some of the costs of several diabetic supplies. But that coverage is split between Medicare Part B and Part D.

Medicare Advantage plans must cover whatever Part B covers and may include Part D prescription drug coverage. Premiums and cost-sharing in Medicare Advantage plans can vary.

Medicare Part B may also cover therapeutic shoes or inserts if you need them for your diabetes, but you have to meet certain conditions. You may qualify for one pair of depth-inlay shoes and three pairs of inserts per year.

If you can’t wear depth-inlay shoes, Medicare may pay for one pair of custom-molded shoes and two pairs of inserts.

You have to meet certain conditions, including being diagnosed with diabetes, are in a comprehensive treatment plan and require the shoes and inserts.

You will also need a podiatrist or other qualified health care professional to prescribe the shoes and to fit and provide them.

Not all insulin and diabetic supplies are covered by Original Medicare. Much of it is covered under Part D prescription drug plans. Most Medicare Advantage plans include Part D coverage. For example, the $35 monthly cap on injectable insulin is included with most Part D and Medicare Advantage plans.

If you are enrolled in Original Medicare, you will have to pay 100% for insulin not used in an insulin pump. You will also have to pay all the costs of syringes and needles.

You will pay 20% of the Medicare-approved prices for insulin used in an insulin pump under Original Medicare.

But if you are enrolled in Medicare Part D prescription drug coverage or a Medicare Advantage plan that incorporates Part D coverage, much of these costs may be covered.

As of 2020, people with diabetes who have Part D coverage may pay a maximum $35 copay for a month’s supply of insulin. But you have to select from certain sets of insulin Medicare has approved for the low copay.