Diabetes Medicare Coverage: What is and isn’t covered

Diabetes medicare

Patients assume their doctors are fully aware of how Medicare works in terms of coverage for diabetes, but where do you as a healthcare provider turn to in order to navigate the often labyrinthine parts of Medicare? This right here may be of a little help. For starters, diabetes supplies and services are covered by part B, and diabetes drugs (and supplies needed for their administration) are covered by Medicare part D.

Medicare coverage of diabetes

Part B

Part D



Drugs and drug supplies

·         Blood sugar self-testing equipment and supplies

·         Insulin pumps

·         Therapeutic shoes or inserts

·         Screenings

·         Self-management training

·         Nutrition therapy

·         Hemoglobin A1 c tests

·         Foot exams and treatment

·         Glaucoma tests

·         Flu and pneumococcal shots

·         Preventive visits

·         Insulin

·         Anti-diabetic drugs

·         Syringes

·         Needles

·         Alcohol swabs

·         Gauze

·         Inhaled insulin devices


Part B: Supplies

All people who are enrolled in Medicare, have part B, and have been diagnosed with diabetes are eligible for coverage of durable medical equipment (DME) used to test and monitor blood sugar (glucose) levels, including:

In order to grant access to these supplies you must write a prescription stating that your patient has diabetes, what type of monitor they need and why (for example if they have vision problems that require a special monitor), if they use insulin or not, how often they test their blood glucose, and the amount of strips and lancets they need for one month. The same testing supplies are covered regardless of whether patients use insulin or not, but insulin users may get up to 300 strips and lancets every three months, as opposed to 100 strips and lancets every three months for non-insulin users. Extra strips and lancets may be available if you believe they are medically necessary. A new prescription for strips and lancets is needed every 12 months, and your patients must request refills.

Insulin pumps are also DME supplies available to Medicare part B beneficiaries with a prescription. Medicare pays for 80% of the cost of the pump, including the insulin. The remaining 20% of the approved amount after the yearly deductible is covered by the patient.

In addition to diabetes, your Medicare-enrolled patients who need diabetic shoes or inserts must have you vouch that they have one of the following conditions in at least one foot:

-        Partial or complete foot amputation

-        Past foot ulcers

-        Calluses that could lead to foot ulcers

-        Nerve damage because of diabetes with signs of problems with calluses

-        Poor circulation

-        A deformed foot

Patients also need to be in a comprehensive diabetes care plan. Though the need for shoes and inserts must be a direct consequence of having diabetes, these supplies must be prescribed by a podiatrist or other qualified doctor, and fit and furnished by a pedorthist, orthotist, prosthetist, or other qualified individual. Part B covers either one pair of depth-inlay shoes and 3 pairs of inserts or, if a deformity prevents you from wearing inlay shoes, one pair of custom-molded shoes -inserts included- each year.

Part B: Services

People with high blood pressure, dyslipidemia, obesity, impaired glucose tolerance, or high fasting glucose are at risk of developing diabetes. Medicare covers two diabetes screening tests (including but not limited to fasting blood sugar tests) in a period of 12 months. As a physician it is up to you to determine the timing of the second test after you have conducted the first one. On the other hand, people who already have diabetes may avail themselves as well of Medicare self-management training services. You may recommend training if your patient has experienced the following in the past year:

-        A diabetes diagnosis

-        Switching from no diabetes medication to diabetes medication, or from oral diabetes medication to insulin

-        Are at risk for diabetes complications

A patient of yours may be at risk for such complications if they:

-        Have difficulty controlling blood glucose

-        Have been admitted to a hospital or treated in an E.R. due to diabetes

-        Have been diagnosed with diabetes-related eye disease

-        Have a lack of sensation in the feet, feet ulcers or deformities, or have hand an amputation

-        Have been diagnosed with diabetes-related kidney disease

Medicare covers a total of 10 hours of initial training (additional hours may be prescribed if necessary) provided by healthcare providers who specialize in diabetes education, during which patients learn about:

-        Diabetes

-        Benefits of blood sugar control and risks of poor blood sugar control

-        Nutrition and diet management

-        Managing and improving  blood sugar control

-        Exercise and its importance for health

-        How to take medications properly

-        Blood sugar testing and how to use the information to improve diabetes control

-        How to prevent, recognize, and treat acute and chronic complications from diabetes

-        Foot, skin, and dental care

-        The effects of diet, exercise, and medication on blood sugar

-        Behavior changes, goal setting, risk reduction, and problem solving

-        How to adjust emotionally to having diabetes

-        Family involvement and support

-        The use of the healthcare system and community resources

Similarly, you may prescribe nutrition therapy services such as nutrition and lifestyle assessment, nutrition counseling, lifestyle factor management, and follow-up visits each year, and they are covered by Medicare. Additionally, certain services may be available without a written order or referral, including:

-        Foot exams and treatment for diabetes –related nerve damage every six months

-        Hemoglobin A1 c tests to measure how well blood glucose has been controlled in the previous three months

-        Glaucoma tests performed by an eye doctor every 12 months

-        Flu shots every flu season in the fall or winter and pneumococcal shots at least once in the patient’s lifetime

-        Welcome to Medicare preventive review of the patient’s health, as well as education and counseling on preventive services which include but are not limited to diabetes.

Part D: Drugs and Drug Supplies

In addition to insulin, Medicare part D covers anti-diabetic drugs like sulfonylureas (glipizide, glyburide), biguanides (metformin), thiazolidinediones (actos, avandia, rezulin), meglitinides (starlix, prandin), and alpha glucosidase inhibitors (precose). Moreover, supplies used to administer insulin are also covered, for instance syringes and needles, as well as swabs, gauze, and inhaled insulin services. Your patient pays coinsurance or copayment for most part D-covered items. Part D deductible may also apply. Conversely, Medicare pays for 80% of most part B-covered services and supplies, with the beneficiary paying 20% of the Medicare-approved amount after the yearly part B deductible.

Diabetes supplies and services not covered

Medicare does not cover eye exams for glasses, orthopedic shoes, or cosmetic surgery.