It can sometimes be confusing to know what exactly is covered under the U.S. Government’s Medicare program when it comes to diabetes. The Center for Medicare and Medicaid Services provides some details.

MEDICARE – PART B

Medicare covers certain supplies if a beneficiary has Medicare Part B and has diabetes. These supplies include:

• Blood glucose self-testing equipment and supplies;
• Therapeutic shoes and inserts; and
• Insulin pumps and the insulin used in the pumps

Blood Glucose Self-testing Equipment and Supplies

Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:

• Blood glucose monitors;
• Blood glucose test strips;
• Lancet devices and lancets; and
• Glucose control solutions for checking the accuracy of testing equipment and test strips.

Medicare Part B covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.

If the beneficiary

• Uses insulin, they may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months.
• Does not use insulin, they may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months.

If a beneficiary’s doctor documents why it is medically necessary, Medicare will cover additional test strips and lancets for the beneficiary.

Medicare will only cover a beneficiary’s blood glucose self-testing equipment and supplies if they get a prescription from their doctor.

Their prescription should include the following information:

• That they have diabetes;
• What kind of blood glucose monitor they need and why they need it (i.e., if they need a special monitor because of vision problems, their doctor must explain that.);
• Whether they use insulin; and
• How often they should test their blood glucose.

A beneficiary needing blood glucose testing equipment and/or supplies:

• Can order and pick up their supplies at their pharmacy;
• Can order their supplies from a medical equipment supplier, but they will need a prescription from their doctor to place their order; and
• Must ask for refills for their supplies.

Note: Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.

All Medicare-enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. A beneficiary cannot submit a claim for blood glucose monitor test strips themselves. The beneficiary should make sure that the pharmacy or supplier accepts assignment for Medicare-covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. Beneficiaries should only pay their coinsurance amount when they get their supply from their pharmacy or supplier for assigned claims. If a beneficiary’s pharmacy or supplier does not accept assignment, charges may be higher, and the beneficiary may pay more. They may also have to pay the entire charge at the time of service and wait for Medicare to send them its share of the cost. (Source: cms.gov)

There is a greater cost involved in treating diabetes than preventing it. The U.S. Government realizes this so they have included prevention programs in their Medicare plan.

While this list isn’t complete it does take a look at prevention programs related very specifically to diabetes and related illnesses for those who participate in Medicare.

Cardiovascular Screenings
Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.

Diabetes Screenings
Checks for diabetes. These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests are also covered if you answer yes to two or more of the following questions:

• Are you age 65 or older?
• Are you overweight?
• Do you have a family history of diabetes (parents, siblings)?
• Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds?

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.
Diabetes Self-Management Training

For people with diabetes. Your doctor or other health care provider must provide a written order. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

EKG Screening
Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time “Welcome to Medicare” physical exam. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test.
Flu Shots

Helps prevent influenza or flu virus. Covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor accepts assignment for giving the shot.

Glaucoma Tests
Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Medical Nutrition Therapy Services
Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Welcome to Medicare Physical Exam (one-time physical exam)
A one-time review of your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. You pay 20% of the Medicare-approved amount. When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare” physical exam.

More information about these and other services can be found at the Medicare website

The idea of paying for high performing health care providers seems like a good idea, but new laws spelled out in the Health Care overhaul could mean that some diabetics on Medicare could find even limited services cut.

According to a press release in ScienceDaily.com, “The planned nationwide implementation of institutional bonuses mandated under federal health care reform threatens to … [cause] hospitals in less-advantaged regions to lose funds to health care facilities in more affluent areas of the country, according to a study published in the academic journal PLoS Medicine.”

Researchers from New York University, Cornell University, and Harvard University say, “Pay-for-performance assumes that providers have adequate economic and human resources to perform, or improve their performance, within a short time frame. Yet the prevailing distribution of resources in the U.S. health care system makes it difficult for some providers to operate effectively as it is. Payment based on performance may worsen inequalities, as hospitals in under-resourced areas lose funds to their better-off counterparts, with the government acting as a sort of ‘reverse Robin Hood.’ ”

In essence what this policy does is potentially penalize rural health care centers because they don’t have the staff or patient volume to fairly compete with larger medical centers. When they can’t match performance the already struggling rural counterpart is penalized as extra Medicare funds are shifted to the high performance medical centers. The end result would appear to be a lack of quality care for rural residents – unless they are willing to travel to larger clinics in more urban areas. Often this is inconvenient and impractical.

The ScienceDaily.com release explains more about how the new system would work, “Offering bonuses to doctors when they reach pre-determined targets, such as for the regularity of blood sugar checks for patients with diabetes, is a practice that has been adopted widely over the past decade by countries with rapidly aging populations and rising health costs, among them the UK, Australia and Taiwan. Pay-for-performance has also been used in the United States, albeit in a piecemeal fashion. Now, however, the U.S. is poised to evaluate hospitals in Medicare’s “Value Based Purchasing” (VBP) program, and, based on results, to reward those that improve, and reduce reimbursements for those that fail to show progress toward performance targets. The first wave of nationwide evaluation under this federally mandated effort, slated to begin in 2012, will focus on hospital performance on process-of-care measures for common conditions such as heart attack and pneumonia. Later, VBP will likely be extended to other metrics such as risk-adjusted patient death rates.”

This report does point out that there is a window of opportunity “to modify and improve upon the current version” of the new mandate before implementation in 2012. The study concludes, “”Holding providers accountable is not an unreasonable approach to quality improvement, but it must be done in a way that attends to the profound inequalities in local circumstances that shape life in the twenty-first century.”

Critics indicate that this plan could lead to health care rationing while others suggest the language should be addressed and will likely be changed. Those who view this as detrimental to Medicare patients in rural or under-served areas find the prospect less than ideal for patients who have come to rely on local care in familiar surroundings.

Health care remains a critical topic to all Americans, but the notion of decreased services for under-performing medical centers could potentially create significant gaps in care for Medicare patients struggling with diabetes.

In past articles we have covered the first three parts of Medicare coverage. This represents the final part in this government-based program.

Medicare prescription drug coverage (Part D) is available to everyone with Medicare. To get Medicare drug coverage, you must join a Medicare drug plan. Plans vary in cost and drugs covered.

Two plans offer Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”

Who Can Get Medicare Drug Coverage?

To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B. To get prescription drug coverage through a Medicare Advantage Plan, you must have Part A and Part B.

How to Join a Medicare drug plan

Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, enrolling on the plan’s Web site, or through the MPDPF LINK. You can also enroll by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Contact the specific plan you’re interested in to find out how to join. Medicare drug plans aren’t allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this. (Source: Medicare.gov)

The first year for Medicare Part D was 2006. That year 11 million people were expected to sign up to use this program. The actual number was 24 million.

According to government reports, “As of the end of year 2008, the average annual per beneficiary cost spending for Part D, reported by the Department of Health and Human Services, was $1,517, making the total expenditures of the program for 2008 $49.3 (billions). Projected net expenditures from 2009 through 2018 are estimated to be $727.3 billion.”

Interestingly statistics seem to suggest that since the implementation of Part D Medicare users have improved their willingness to follow their physician’s directions in taking medication. The usefulness of Medicare Part D has statistically proven that if an individual can afford to take the medication they will in fact take it.

According to Wikipedia, “As of 2008 there were 1,824 stand-alone Part D plans available. The number of available plans varied by region. The lowest was 27 (Alaska) and the highest was 63 (Pennsylvania & West Virginia). This allows participants to choose a plan that best meets their individual needs. Plans can choose to cover different drugs, or classes of drugs, at various co-pays, or choose not to cover some drugs at all. Medicare has made available an interactive online tool called the Prescription Drug Plan Finder that allows for comparison of drug availability and costs for all plans in a geographic area. The Prescription Drug Plan Finder can be used to perform a personalized or general search for plans; in either case, the tool allows one to enter a list of medications along with pharmacy preferences. The Plan Finder output includes the beneficiary’s total annual costs for each plan, along with a detailed breakdown of the plans’ monthly premiums, deductibles, and prices for each drug during each phase of the benefit design (initial coverage period, coverage gap, and catastrophic-coverage period).”