Answers to Diabetes Questions: Does Medicare Cover Insulin?
If you have recently been diagnosed with diabetes, the learning curve may seem a bit daunting. Understanding the important role insulin plays in managing the disease and how Medicare can help cover the costs of insulin can help.
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Medicare Benefits Solutions
May 11, 2022
Is Insulin Covered by Medicare?
Diabetes is a disease where your body either does not manufacture or effectively use insulin, a hormone critical to the process of transforming food into energy. If your doctor prescribes insulin therapy as part of your diabetes treatment, and you qualify for Medicare benefits, you may be wondering, “Is insulin covered by Medicare?”
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Does Medicare Cover Insulin?
To understand how insulin coverage works, it’s important to understand the different parts of Medicare with respect to diabetes.
- Part A is hospital insurance, which generally covers drugs while you are formally admitted as an inpatient in a hospital or skilled nursing facility.
- Part B is medical insurance, which covers many preventive services for people at risk for diabetes, and includes coverage for medically necessary services and supplies for people with a diabetes diagnosis.
- Part D covers prescribed medications and certain supplies.
Is Insulin Covered by Medicare Part B?
Part B covers equipment and supplies to perform blood sugar self-testing, covered as part of durable medical equipment (DME). Even if you don’t take insulin, you are eligible for blood sugar monitors, test strips, lancets and lancet holders. Benefits also include a liquid known as a glucose control solution that checks if your equipment and test strips are generating accurate readings.
External insulin pumps, and equipment worn outside the body, are covered. Part B will cover insulin if you use an insulin pump, your doctor documents that the pump is medically necessary, and you meet specific conditions.
Coverage of therapeutic custom shoes and shoe inserts is a benefit available each year. If you have foot problems related to diabetes, you can get one pair of depth-inlay shoes and three pairs of inserts. If these shoes are not suitable due to a foot deformity, Part B covers one pair of custom-made shoes plus two additional pairs of inserts.
Part B does not cover insulin pens, syringes, needles, alcohol swabs or gauze. Unless use of an insulin pump is medically necessary, Part B will not cover insulin.
Does Medicare Part D Cover Insulin?
Part D is a Medicare-approved prescription drug plan you purchase from a private insurer. If you enroll in Part D and have diabetes, Part D covers insulin, anti-diabetic drugs and some supplies.
Part D covers insulin that you inject. If you inhale insulin or use an infusion pump, Part D does not cover insulin. Covered supplies you use with injected or inhaled insulin may be covered, such as syringes, needles, alcohol swabs and inhaled insulin devices.
Managing the Cost of Insulin
You can apply for Part D as a stand-alone Medicare Prescription Drug Plan (PDP), or you can join a Medicare Advantage plan that includes prescription drug coverage (MA-PDP). Some Part D plans offer an insulin savings program.
If your plan participates in the Senior Savings Model, you may be able to get supplemental benefits developed especially for insulin. The maximum copay is $35 for one month’s supply, not applicable to the catastrophic phase.
Members of Congress have introduced bills that would make this cap a requirement. According to Peterson-KFF, “Under both the Affordable Insulin Now Act and Build Back Better, insurers, including private plans and Medicare Part D plans, would be required to charge no more than $35 per month for insulin products.”
Extra Help is a program for people with limited financial means. Qualifications are based on annual income, other financial resources and marital status. Under the Senior Savings Model, the copayment for beneficiaries eligible for the full Extra Help program will pay less than $35 per month. If you receive partial Extra Help in 2022, you pay a deductible amount of up to $99 and coinsurance equal to 15% of the Medicare-approved amount.
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Other Medicare Coverage for Diabetes
If you have Original Medicare and are at risk for diabetes, Medicare covers up to two glucose lab tests as a preventive measure. If you use a Medicare-participating healthcare provider who accepts assignment, there should be no out-of-pocket charges for these tests.
If you have a diabetes diagnosis, you are eligible for educational training to learn how to manage your condition. Some beneficiaries are also eligible for medical nutrition therapy training. Your responsibility for the cost of these services is the Part B deductible ($233 in 2022) and the 20% coinsurance payment.
Part B covers diabetes-related foot care or treatment in the following cases: You have nerve damage in your lower leg, which may lead to limb loss, or you need treatment for an injury or disease in your foot. The Part B deductible and coinsurance applies.
What Medicare Plans Cover Diabetes?
If you have Medicare Advantage (MA), you may have benefits that extend beyond Original Medicare, but all Medicare Advantage plans “must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers.” Because MA plans are offered by private insurance companies that contract with Medicare, costs and additional benefits can vary. Medicare Advantage plans furnish members with an Evidence of Coverage (EOC) each year. Refer to your EOC to check if any benefit provisions vary from Original Medicare.
If you have Original Medicare and have purchased a Medicare Supplement plan (Medigap), you may get help paying for some of the costs that Part A and Part B do not. Although Medigap is standardized across the country, each of the plans available offer a different level of coverage, so check to see what your specific plan covers.
How Medicare Helps Cover Diabetes Expenses
Your Medicare coverage will help cover the costs of many medically necessary services and supplies you may need when you’re diagnosed with diabetes. Depending on your individual needs, your doctor may create a care plan that includes insulin.
While Part A and Part B include standard benefits for care related to diabetes, your Medicare Advantage plan may offer additional coverage. Check with your MA plan directly if you have questions regarding specific coverage.