What you need to know about navigating Medicare and diabetes

What are the different parts of Medicare?

Like any insurance plan, the best way to have a satisfactory experience with Medicare is to understand the plan coverage and advocate for your needs when necessary. With several "parts" to Medicare, it's important to learn how each aspect will meet your healthcare needs and where to find coverage information about specific items or services.

Original Medicare includes Parts A and B and is offered directly from the federal government.

Medicare Part A includes hospital coverage for things like inpatient stays, some home health care, and care in skilled nursing facilities. For example, if you were to be hospitalized with diabetic ketoacidosis (DKA), Part A would provide coverage for your stay and treatment.

Medicare Part B is general medical coverage for things like preventative screenings, specialist visits, outpatient services, imaging, and laboratory testing. When you see your endocrinologist and go to the lab to get your A1C drawn, they are both covered under Part B. It is also where your glucose meter, test strips, durable insulin pump (and insulin used in that pump) will be covered.

Medicare Part C (Also known as "Medicare Advantage") is offered by private health insurers and takes the place of Parts A and B. These plans are required to provide the same coverage as Original Medicare and may also offer extra benefits, with some plans including health and wellness support and incentives. If you are eligible for Medicare because of a disability, you have the option to purchase a Medicare Advantage Special Needs Plan which is tailored to your medical condition(s), like ESRD.

Medicare Part D provides separate coverage for prescription drugs and is only offered by private health insurers. You may purchase Part D separately or it may come as part of a Medicare Advantage plan. For example, if you are on multiple daily injections (MDI) and not a pump (see Part B), your insulin is covered under Part D, along with your other medications.

If you're enrolled with a Medigap plan (also known as a Medicare supplement plan) or a Medicare Advantage plan, you can reach out to the broker with questions that may come up along the way. Additionally, the Medicare website provides comprehensible information to help guide you through.

Understanding Medicare and diabetes

Dealing with a chronic condition often means lengthy phone calls with insurance companies, filing appeals, and patiently scanning over documents to find the supporting language you need to get what you're asking for from your insurance coverage. The costs associated with managing diabetes can sometimes feel overwhelming, making it that much more important to understand your coverage. After all, if you know how your policy works, you can get the most out of it.

Navigating insurance and diabetes can be challenging enough with commercial insurance, but Medicare often adds new twists and turns. As a person living with diabetes, you may have more concerns about navigating Medicare than others. Reading diabetes-specific information about Medicare can help you get some clarity in figuring out information gaps you may have.

If you find yourself wanting more guidance, the American Diabetes Association provides insight on coverage for Medicare and diabetes, and JDRF offers a guide specifically about Medicare and type 1 diabetes.

Overcoming setbacks

When navigating Medicare, you may run into the occasional setback, but most obstacles can be solved with your drive and determination. For instance, denials and nonmedical switching can be a problem for patients with all types of insurance. The good news is, there are often ways to work around these issues.

In the case of Medicare, keep in mind what you may already know from previous experience with commercial insurance or any other type of health coverage — you and your doctor know what's best for your diabetes care. If you experience a denial or nonmedical switching, you and your doctor can work through the Medicare appeal process.

Keeping up with the latest developments

Health policies are liable to change over time, so staying up to date on evolving Medicare additions and revisions can be key. Keeping an ear out for changes out of CMS can help you stay ahead of shifts and get more out of your coverage.

For example, a significant change which went into effect January 1, 2021 is the Part D Senior Savings Model. The Part D Senior Savings Model allows some Medicare beneficiaries to receive Medicare drug coverage offering access to many types of insulin for no more than $35 for a 30-day supply. Medicare drug plans and Medicare Advantage plans with drug coverage can provide insulin cost savings as part of this model. The Part D Senior Savings Model allows the patient to choose among drug plans that offer insulin at a predictable and affordable cost.

Navigating Medicare and diabetes can feel daunting at times, but you can be encouraged that many of the principles of getting what you need from your insurance learned from years of private insurance apply here as well. Your local healthcare system may offer Medicare basics classes or videos to help support your journey. As questions arise, continue reaching out to community resources and Medicare representatives to get the care you need and deserve.

With health insurance and employment often intertwined, losing a job can cause stress about accessing diabetes care. Read about the need-to-knows of handling health insurance and job loss (while keeping hope at heart) on the Edgepark Health Insights blog.