Diabetes and Understanding Medicare Special Enrollment Periods

Medicare Benefits Solutions
Jun 1, 2022

Having the healthcare coverage that’s right for you is even more important when you are living with diabetes. Getting the care, services, and supplies you need at a price you can afford can be affected by which Medicare plan you have.

Your health needs may change if you have diabetes, so your coverage may need to evolve too. If you have been diagnosed with diabetes and are new to Medicare, or you’re already enrolled but want to consider your options, understanding Special Enrollment Periods may help.

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“For all seniors, it is so important to be aware of any changes in their life that can trigger a special enrollment period (SEP) that may allow them to enter a plan better suited for their current life situation. For anyone managing diabetes, or another chronic health condition, it is even more important to know about these SEPs because they need access to insulin or other supplies critical to their quality of life and medical care.”

David Taylor
Medicare Benefits Advisor

Medicare and Diabetes

If you are newly eligible for Medicare and either have diabetes or are at risk for diabetes, your health condition will likely influence any decisions you make while shopping for health insurance coverage. If you are already a Medicare beneficiary and have diabetes, you might want to comparison shop for a plan that is favorable for minimizing diabetes-related medical expenses.

Before you start shopping for a Medicare plan, learn how the different parts help cover the cost of diabetes screenings, testing, training, treatment and medical equipment. As you sort out the overall benefits of Original Medicare and diabetes coverage specifically, you can weigh the pros and cons of other ways to get Part A and Part B coverage. If you want to change your Medicare health coverage to better meet your needs, determine if you may be able to take advantage of a Special Enrollment Period.

Medicare and Diabetes Coverage Under Part B

For most services under Part B, using a Medicare-participating provider limits your out-of-pocket cost to 80% of Medicare-approved charges after you meet your deductible. For beneficiaries with diabetes, these services include:

  • Training to help you cope with the struggles of managing the disease
  • Annual foot exams if you have nerve damage that raises your risk of losing a limb
  • Testing for glaucoma every 12 months

For preventive services, you pay nothing if your healthcare provider accepts assignment from Medicare. Providers who accept assignment will bill Medicare directly and accept Medicare’s direct payment. If you are at high risk for diabetes, these services include two diabetes screening tests per year. If you have been diagnosed with diabetes, you may be eligible for medical nutrition counseling from a nutrition professional like a registered dietitian.

People with diabetes who need diabetes-related equipment and supplies to monitor glucose levels or need custom-made shoes and shoe inserts can find these benefits under Part B. If you use an insulin pump, Part B covers insulin, tubing and insertion sets. Assuming your supplier accepts assignment, your out-of-pocket cost after the deductible should not exceed 20% of the Medicare-approved charges.

Medicare Part D Diabetes Coverage

Part D is Medicare-approved prescription drug coverage you get from a private insurance company. These plans vary in the drugs covered, premiums and cost-sharing.

You have two choices in how to get Medicare drug coverage: Sign up for a Medicare Prescription Drug Plan that you add to Original Medicare, or join a Medicare Advantage (MA) plan that covers Part A, Part B and includes Part D benefits. Medicare Advantage is an alternative way to get all three parts of Medicare under one umbrella.

Part D diabetes coverage includes:

  • Injectable insulin (for people who do not use an insulin infusion pump or inhaled insulin)
  • Anti-diabetic drugs for people whose blood sugar is not managed with insulin
  • Supplies that you use to inject insulin, such as syringes, and other devices and supplies

Medicare Initial Enrollment Period

If you are new to Medicare, you can register for Part A and/or Part B as you approach your 65th birthday. This is a seven-month time frame that begins three months before your birthday month and ends three months after your birthday month. Once enrolled in Part A and Part B, you can sign up for Part D. You may also enroll in Medicare Advantage.

Medicare Annual Enrollment: Oct 15 to Dec 7

During the Annual Enrollment Period, you can change your Medicare plan or drug coverage for the following calendar year. This includes joining an MA plan, switching to another MA plan, and leaving an MA plan and returning to Original Medicare. You can also join, change or leave a Medicare drug plan.

MA Open Enrollment: Jan 1 to March 31

During the Medicare Advantage Open Enrollment Period, MA plan members can switch one time to another MA plan or leave an MA plan and revert to Original Medicare. You can’t change from Original Medicare to an MA plan during the MA-OEP.

Medicare Special Enrollment Period

If you do not sign up during the Initial Enrollment Period, you may have an opportunity to enroll in Medicare during a designated window known as the Special Enrollment Period (SEP).

What is the Medicare Special Enrollment Period?

The best time to enroll in Part A and Part B is during the Initial Enrollment Period to avoid a late enrollment penalty. If a penalty is imposed, your premiums will be higher for Part B. If you don’t have premium-free Part A, your premiums will be higher for Part A as well. However, special circumstances may make you eligible for a Special Enrollment Period. In that case, you can usually sign up during your SEP without a penalty.

The following are examples of special circumstances when people with diabetes may qualify for an SEP:

  • Loss of employer health insurance coverage
  • Relocating to a new area
  • Enrollment in the Program All-inclusive Care for the Elderly (PACE) plan
  • Loss of coverage due to the termination of your plan’s contractual agreement with Medicare
  • Moving into or out of an institution, such as a long-term hospital or skilled nursing facility

How Long is the Medicare Special Enrollment Period

If you did not enroll in Part A and/or Part B when you first became eligible because you were already covered under an employee group plan, then your SEP spans an eight-month window. This window begins on the month after employment ends or your coverage ends, whichever comes first.

When is Medicare SEP for MA and Medicare Drug Plans?

Rules for the Special Enrollment Periods are driven by the special circumstances that determine your eligibility, regardless of whether you have Medicare Advantage or a Prescription Drug plan.

For example, let’s say you move to an area that is still in your plan’s service area, but new choices are available in your destination. If you advise your plan before you move, you have from the month prior to the moving month through two months after relocation to switch to a new MA or Part D plan.

If you enrolled in a PACE plan, you can terminate your MA or prescription drug plan anytime. If Medicare ends your plan’s contract, your SEP begins two months before and ends one month after the contract termination date.

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Applying for Medicare Special Enrollment Period

If you qualify for a Special Enrollment Period for Medicare Part B, submit your application to Social Security either by mail, in person or online. For guidance, refer to “How to Apply for Medicare Part B During Your Special Enrollment Period“. You can also get help by calling Social Security at 1-800-772-1213 or finding answers on the Social Security website.

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