Diabetes & Medicare: Everything You Need to Know

If you have diabetes, you may be wondering exactly what Medicare will cover and what it won’t.  Also, you have important decisions to make regarding Original Medicare, Part D, Medicare Supplement Plans & Medicare Advantage. 

Original Medicare

Original Medicare is Medicare Part A, your hospital insurance and Medicare Part B, your outpatient insurance.  Medicare Part B plays a pivotal role in caring for your diabetes.  

Medicare Part B has a monthly premium in addition to a deductible.  Once you’ve met your deductible, you’ll usually be responsible for a 20% coinsurance.

Part B will cover:

  • Diabetes Screening Tests
  • Diabetes Prevention Programs
  • Diabetes Self Management Programs
  • Diabetes Equipment such as blood sugar strips and lancets
  • Foot Exams
  • Glaucoma Tests
  • Insulin Pumps (and the insulin associated with insulin pumps)

Usually you will have to pay a 20% coinsurance for these services and sometimes you will need to meet additional criteria to be considered eligible.  Additionally, you’ll need to work with a doctor or facility that accepts Medicare.  Fortunately, most do!

Medicare Part D

If you are trying to manage diabetes, you will most likely want to enroll in Medicare Part D as well.  Part D is your prescription drug coverage.  Medicare Part D is offered by private carriers.  Although there are certain federal guidelines that all plans must adhere to, carriers can choose to offer better benefits to compete for your business. 

You can enroll in a Medicare Part D plan during your one time open enrollment or during the once yearly annual enrollment.  Your individual open enrollment is the three months before you turn 65, the month of your 65th birthday and the three months thereafter.  The annual enrollment period is every year from Oct. 15-Dec. 7.  

Like Medicare Part B, you’ll need to pay a premium to keep your plan active.  Your premium is determined by the carrier and plan you pick.  You may also be responsible for an out of pocket deductible.  In 2021, the max deductible has been set at $445, but some plans offer lower deductibles or waive them entirely.  Once you’ve met your deductible, your copay will be determined by the tier of your medication.

Part D will cover:

  • Insulin not administered by pumps
  • Medical Supplies to administer insulin such as syringes, gauze, alcohol swabs and inhaled insulin devices 
  • Anti-diabetic drugs 

Remember that as of January 1, 2021, you may be able to get prescription drug plan that offers a 30 day supply of insulin for $35.  So, if you take insulin to manage your diabetes, you may want to look into a Part D plan that participates in the insulin savings model.  

How to Cut Costs

Even though Medicare was designed to be low cost health insurance for seniors, it can still feel cost prohibitive.  There are a few ways to pay less and cut costs.

You can look into a Medicare Savings Program.  There are four different programs with different criteria and benefits. Basically, they are designed to help you pay for Part A, Part B, & Part D premiums.  There are restrictions on income and assets.

There’s also the extra help program designed to assist with Medicare Part D.  You may have access to lower premiums and copays.  This can be extremely helpful in paying for your diabetes related medication.  Again, there are restrictions on income and assets.  

Additionally, there are DSNPs.  Individuals who are eligible for Medicaid and Medicare are known as dually eligible.  If you become eligible for Medicare because of ESRD, you may be eligible for ones of these types of plans.  DSNPs are a type of Medicare Advantage Plan that encapsulate Part A, Part B, Part D, Medicaid and additional benefits at a lower cost.  

Medicare Advantage & Medicare Supplements

If you have significant medical needs, such as diabetes, you may want to look into a Medicare Supplement Plan (Medigap) or a Medicare Advantage Plan (Part C).  These plans can help to limit your out of pocket costs. 

Original Medicare has no out of pocket maximum. If your medical bills become extensive, they can really stack up with no end in sight!  Both Medicare Supplement Plans and Medicare Advantage Plans will help to eliminate that possibility.

Medicare Supplement Plans

Medicare Supplement Plans cover the gaps of Original Medicare.  You’ll still need to pay your Original Medicare premiums plus Medicare Part D because Medigap Plans do not cover RX drugs.  So, you’ll have an additional premium to pay, but your coinsurance will be waived for most plans or at least significantly decreased.  If you are making regular use of medical benefits (and usually those with diabetes do), you’ll end up saving money in the long run. 

Remember, you can enroll in a Medicare Supplement Plan year round but it behooves you to do so during your individual open enrollment period which is six months after you turn 65 and enroll in Medicare Part B.  Plans are standardized, but they are offered by private carriers so make sure to shop around!

Medicare Advantage Plans

Medicare Advantage Plans actually replace Original Medicare entirely.  They must offer at least the same benefits of Original Medicare.  They’ll also cut down on your copays or coinsurance. Very often they also offer prescription drug coverage plus additional benefits such as dental, vision, hearing, and more.  Additionally, they’re usually less expensive than Medicare Supplement plans especially when you take into consideration that you may not need to add Part D. 

BUT, don’t be fooled.  Medicare Advantage plans can be great…but they are not all created equal.  They’re really much more like the health insurance that you’ve had in the past.  You have networks to contend with which can be restrictive, referrals that you may need to deal with and insurance carriers that can change benefits.  Some are great, some are not.  It depends on your plan, your carrier, your location and your needs. 

If you’re going to go this route, please use a broker.  If you have specific health concerns, such as diabetes, your health insurance is paramount.

Your enrollment periods for Part C are the same as Part D.  Your individual open enrollment is the 3 months before you turn 65, the month of your 65th birthday, and the three months thereafter.  The annual enrollment period is every year from Oct. 15-Dec. 7.  

If you have any questions, you can reach us at iHealthBrokers at 888-918-0518.  There is no charge for our services.

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Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.

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