Navigating Medicare with Type 1 Diabetes

What is Medicare? 

Simply put, Medicare is federally subsidized health insurance for people in the United States who are 65 years and older, typically after they retire and are no longer eligible for employer-sponsored plans. Established in 1965, it was designed to better ensure that Americans could age with dignity and receive proper medical care without falling into ??poverty, as was common at the time.

This is different from Medicaid, a federal-state partnership that offers health insurance to low-income residents of any age.

What are the different parts of Medicare?

Health policy in the United States is a convoluted web, but Medicare can mostly be broken down into three categories:

• Medicare Part A: offers coverage for inpatient hospital stays, limited care in a skilled nursing facility (SNF), hospice and palliative care, and some home health care services
• Medicare Part B: offers coverage for outpatient care, doctors’ visits, preventive services like physicals and check-ups, and certain medical supplies
• Medicare Part D: offers coverage for shots and regular vaccines, as well as prescription drugs like insulin (interesting to note that the Omnipod DASH insulin delivery system is covered under Part D, rather than Part B, like other insulin pumps)

With Medicare, there are two options for how you’ll receive your coverage. You can either choose:

Original Medicare

This consists of coverage for Part A and Part B. You’ll simply pay for services as you receive them.

You’ll typically first pay a deductible at the beginning of each year, and then pay the Medicare-approved cost for Medicare-approved services. The deductibles and copays vary depending on which Medicare part you’re using.

• For Part B, which covers doctor visits and outpatient care, you’ll pay just 20% of the original Medicare-approved cost. This is called coinsurance.
• For Part A, which covers hospital care, you typically pay a deductible for each time you use the Medicare benefits, which can be more than once a year. After that, the cost depends on how long you stay in the hospital, and daily copays may apply after a set period.

Medicare Advantage (Part C)

This is a good option for people who need regular prescription drugs. These are “bundled” plans that cost a bit more but cover Plans A, B, and D. Sometimes choosing Medicare Advantage is called Medicare Part “C.”

If you live with T1D, you’ll definitely want to opt for a Medicare Advantage plan, as this will be crucial to help you pay for your prescription drugs. Choosing Original Medicare will not include prescription drug coverage.

There are many different Medicare Advantage plans to choose from. They may also offer additional coverage that Original Medicare does not cover, such as vision, hearing, and dental care. Medicare Advantage plans must follow Original Medicare’s coverage guidelines, and they must tell the beneficiary of any changes to their coverage policy before the start of the next enrollment year.

All Medicare benefits are subject to medical necessity. There are also many websites designed specifically for people with diabetes to help them make the best coverage decisions as they age into Medicare.

How does enrollment work? 

Medicare coverage starts when you turn 65 years old. However, you will need to enroll to gain coverage.

All Americans who have been legal residents of the United States for 5 or more years and are 65 and older are eligible.

An initial enrollment period begins 3 months before you turn 65, and lasts until 3 months after you turn 65. Once you’re enrolled, your coverage will start on the first of the following month.

Open enrollment runs Oct. 15 to Dec. 7 every year.

Medicare Advantage has its own Open Enrollment period, from January 1 to March 31 each year, during which you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan).

After your initial enrollment year, if you want to make changes to your Medicare, you’ll have to wait until the open enrollment period, which runs each year from October 15 to December 7, with changes to coverage going into effect January 1 of the subsequent year.

How does Medicare cover diabetes?

Roughly 1 in 3 Medicare beneficiaries have diabetes, and more than 3 million beneficiaries use one or more types of insulin.

That statistic reflects millions of people who likely use an array of devices and supplies, ranging from insulin syringes and pens to administer their insulin, various pumps that may be connected to a glucose-monitoring sensor, and various types of fingerstick meters with different test strips.

No single Medicare part pays for all of a beneficiary’s medical costs. Some costs and services are not covered at all. However, many services may be less costly through the “Extra Help” program.

Coverage on Medicare is similar to private and employer-based health insurance in many ways. To have something covered, you’ll need to contact your primary care physician or doctor to receive a prescription. Then, it’ll process through your Medicare insurance to see how much of the cost it’ll cover.

When it comes to medical devices and supplies, that can be trickier.

Under Medicare, home medical supplies categorized as “durable medical equipment” (DME), such as CGMs and insulin pumps, are covered under Medicare Part B, whereas insulin is covered under Medicare Part D, the prescription drug plan.

However, if you use an insulin delivery device or system, such as an insulin pump, your insulin is also covered at no cost under Part B.

What does insulin cost with Medicare?

In large part due to national advocacy efforts, Medicare coverage for people with diabetes has improved significantly in recent years.

A new Medicare pilot program began in 2021 after years of patient advocacy efforts, resulting in $35 insulin copays under certain plans offered by the Centers for Medicare & Medicaid Services (CMS).

The “Senior Savings Model” initially applied only to Part D prescription drug beneficiaries and affected only a small number of Medicare beneficiaries. It was originally an opt-in that required Medicare beneficiaries to voluntarily enroll in specific plans that offered the $35 insulin benefit.

However, the Inflation Reduction Act made the $35 insulin copay cap permanent in 2023. That $35 insulin copay became a requirement for all Medicare Parts B and D plans, and removed all deductibles for the covered insulin. This meant people no longer needed to know enough to opt in for this lower copay benefit.

However, only certain insulins approved by Medicare vendors are eligible for the discount program. That means people may need to discuss changing their insulin brand to take advantage of the $35 insulin coverage under Medicare.

Seniors may also pay less than $35 on covered insulin.

Does Medicare cover insulin pumps and CGM technology?

Yes, Medicare covers diabetes technology such as insulin pumps and continuous glucose monitors (CGMs).

Of course, there are asterisks attached to that coverage.

Insulin pumps

Medicare will cover a portion of the cost of your insulin pump if you have a doctor’s prescription and meet the following criteria: You complete a comprehensive diabetes education program, inject insulin several times daily for at least 6 months, and meet other eligibility requirements.

Coverage also depends on the type of pump you need and the Medicare part that provides coverage. Medicare Part B covers tubed insulin pumps, while Medicare Part D covers tubeless insulin pumps. Medicare Advantage (Part C) offers the same coverage as Part B, and some Part C plans also offer Part D coverage.

Continuous glucose monitors (CGM)

Medicare may also cover CGM technology, including Dexcom, Abbott Libre, the Medtronic Minimed, and Eversense implantable CGM. Certain requirements may apply:

• you may need to rent or buy the durable medical equipment (DME), from specific Medicare-approved vendors
• your doctor prescribes CGM based on the insulin you take, or a history of low blood sugar (hypoglycemia)
• your doctor has decided that either you or your caregiver has had enough training to use a CGM as prescribed

The takeaway

If you’re approaching Medicare age and living with T1D, you no longer have to fear that you will lose insurance coverage for your CGM or other devices or supplies. But you do have to be careful about the Medicare plan you choose, and be mindful of rules around establishing medical necessity.

As Medicare tends to lag in covering the latest diabetes tools and treatments, lending your voice to advocacy can help ensure that policies are up to date and that no one with diabetes has to fight for coverage individually.