What to Know About Medicare and Insulin Pump Coverage

• Diabetes is a metabolic disorder that affects the way glucose is converted into energy. Sometimes, the use of an insulin pump is medically necessary to manage the condition. 

• Under Medicare Part B (medical insurance), insulin is not covered unless it is used with an insulin pump. This is because Medicare considers an insulin pump to be durable medical equipment (DME).

• Medicare Part D (prescription drugs) will cover insulin without the use of an insulin pump.

• The Part D Senior Savings Model helps drive Medicare costs for insulin even lower. Extra Help may also help with insulin costs.

Diabetes is a metabolic disorder that affects the way glucose is converted into energy. Uncontrolled diabetes is linked to a host of health issues including vision loss, kidney issues, and heart disease. 

Diabetes management is vital to avoiding adverse outcomes. As such, Medicare enrollees with diabetes should educate themselves on what is covered, and what isn’t covered, under Medicare benefits before enrolling in a Medicare plan. 

Everyone with diabetes will have a different treatment plan. This may mean various types of diabetes medications, insulin, lifestyle adjustments, and other diabetic supplies and services that may be needed. Sometimes this means insulin pump therapy, which uses an insulin pump to deliver a steady dose of insulin. Insulin pumps have their own set of coverage rules under Medicare. 

This article will discuss these rules and stipulations of diabetes treatment under the federal Medicare program as it applies to insulin pumps.

Insulin is a hormone created by the pancreas, an organ that sits behind the stomach. The pancreas is made up of two types of glands: exocrine and endocrine. Exocrine glands secrete digestive enzymes while endocrine glands secrete hormones into the bloodstream. 

The pancreas’ endocrine gland secretes insulin and glucagon, hormones that regulate blood glucose. Glucose is the main type of sugar found in the blood. Glucose is derived from the foods someone eats.

Keeping blood sugar stabilized is important for someone’s overall health. The main function of insulin is to allow the body to move glucose into the cells to nourish them. When blood sugar levels are too high, insulin is released into the bloodstream in order to lower levels. When blood sugar levels become too low, glucagon is released into the bloodstream to increase blood sugar. 

Diabetes is a chronic health condition that impacts how food is converted into energy. For those with diabetes, their bodies either do not create enough insulin or cannot utilize the insulin it does produce in the way it needs to. This metabolic malfunctioning can spike blood sugar levels to unhealthy amounts. Over time, this spiking can lead to serious health complications including vision loss, kidney problems, and heart disease. 

Because of the associated risks, managing diabetes and keeping blood glucose within one’s target range is absolutely imperative. That said, management and treatment will vary based on the type of diabetes someone has and other individual factors. There are three main types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes. 

Type 1 Diabetes

Type 1 diabetes is when the pancreas produces little or no insulin. This is due to an autoimmune reaction. While Type 1 diabetes can develop at any age, it is most often diagnosed in children, teens, and young adults. Type 1 diabetes is diagnosed via a simple blood test, a thorough history of illness, and a physical exam.

Type 2 Diabetes

Type 2 diabetes occurs when the body’s cells no longer respond to insulin. This is known as insulin resistance. When this happens, the pancreas overcompensates in response, creating more and more insulin until it eventually cannot keep up. This causes blood sugar levels to rise. Over time, this can lead to prediabetes and eventually type 2 diabetes. Type 2 diabetes is diagnosed via a simple blood test, a thorough history of illness, and a physical exam.

Gestational Diabetes

Gestational diabetes occurs during pregnancy. It usually presents with no symptoms. Pregnant people are often recommended to get a blood test during pregnancy to confirm they don’t have it, or find it and treat it. Gestational diabetes can be damaging to both the mother and the baby if left untreated.

While diabetes has no cure, treatment can help keep the condition under contro and prevent complications. Diabetes treatment usually involves a combination of medical interventions as well as lifestyle changes. Some such treatment options include: 

• Insulin

• Diabetes medications

• Regular exercise

• Healthy diet

• Weight loss

Medicare coverage involving diabetes services and supplies will primarily be handled by Medicare Part B, Medicare’s medical insurance, and Medicare Part D, which covers prescription drugs. That said, there are various rules in place for how this coverage functions under Original Medicare.

Medicare Part B 

Medicare Part B is commonly known as medical insurance as it covers some services that may affect someone who has diabetes. Medicare Part B may also cover preventive services such as an insulin infusion to help those manage their condition. 

Medicare Part D 

Medicare Part D is Medicare’s prescription drug coverage. Medicare Part D covers diabetes supplies, such as an insulin infusion pump, used to inject or inhale insulin and other antidiabetic drugs. Someone must be enrolled in a Medicare prescription drug plan in order to receive Medicare Part D benefits. 

Note: Learn more about Medicare coverage for diabetes services and supplies at this resource.

Medicare Coverage for Diabetes Self-Management Training

Diabetes self-management training is a Medicare-approved cost and is covered under Medicare Part B. 

Medicare will cover up to 10 hours of outpatient diabetes self-management training if a patient has recently been diagnosed with diabetes. This training helps patients learn how to manage and cope with their new diagnosis as diabetic. The training is covered by Medicare Part B and allots 1 hour for individual training and 9 hours for group training. 2 hours of training each following year will also be covered to make sure patients know fresh ways to manage their condition.

After meeting the Part B deductible, Medicare will cover 80%, leaving the patient to cover 20% in copayments or coinsurance.

Note: To learn more about Medicare coverage and diabetes self-management training, visit this source.

Original Medicare does not include coverage for insulin. Under Medicare Part B, the following are not covered:

• Insulin

• Insulin pens

• Syringes

• Needles

• Alcohol swabs

• Gauze

However, if a Medicare beneficiary needs to use an insulin pump in order to control their diabetes, Medicare pays for both the insulin pump as well as the insulin used with the device. This is because an insulin pump is considered to be durable medical equipment (DME).

Note: Learn more about insulin coverage and Medicare at this resource.

Medicare Coverage for Insulin Pumps

Medicare Part B may cover insulin and the insulin pump it is used with as durable medical equipment (DME). If this is the case, Medicare beneficiaries pay 20% of the Medicare-approved amount. In this scenario, the Medicare Part B deductible also applies. That said, an insulin pump must be deemed medically necessary in order for it to be covered by Medicare.

What is Durable Medical Equipment?

Medicare covers durable medical equipment. Durable medical equipment consists of certain medical equipment ordered by a doctor for at-home use.

What Is An Insulin Pump?

An insulin pump is a medical device that supplies those with diabetes with a constant, small amount of insulin to keep blood sugar levels in an individual’s target range.

Medicare Advantage and Insulin Pump Coverage

Medicare Advantage plans, also known as Medicare Part C or MA plans, are Medicare plans provided by private insurance companies that are contractually Medicare-approved. Medicare Part C is considered a supplementary Medicare plan as it consists of the standard Medicare Part A (hospital insurance) and Medicare Part B coverage, in addition to other benefits including vision, hearing, and Medicare Part D. 

Because MA plans include standard Medicare coverage, a Medicare Advantage plan would cover a medically-necessary insulin pump under Medicare Part B. However, to ensure costs, be sure to contact your private insurance company for more details on your healthcare coverage and benefits.

Insulin pumps are not medically necessary for all patients with diabetes. Other glucose control solutions may include injecting insulin or taking oral medications. 

Since Medicare Part B does not cover insulin and associated supplies, Medicare beneficiaries will need to seek out other ways to pay for their insulin. Some options include:

• Medicare Part D 

• Medicare supplement insurance plans (Medigap)

• Dual Eligibles

• Extra Help

• Senior Savings Model

What are the new changes to Medicare’s coverage for insulin in 2023?

As of 2023, Medicare cannoy charge more than $35 for a one-month supply of covered insulin. A deductible also does not have to be met before insulin is covered. For more information about recent 2023 changes to insulin coverage, visit this source.