Diabetes management often requires medications, provider visits, visits with specialists, education, supplies, and equipment - which come with a price tag. If diabetics do not have access to these services, they will suffer complications.
Making an honest and thorough evaluation of your diabetes control can be the best predictor of the intensity of services you will require and what your insurance needs to cover.
Medicare is not a one-size plan that fits all for diabetics. Multiple variables inform which plan will give more bang for the buck.
Never make Medicare decisions without a Medicare agent. There’s much to consider and much at stake.
According to The American Diabetes Foundation (ADF), one in 5 people on Medicare have diabetes. It’s difficult to make sense of Medicare and untangle which plan is best. Medicare is not a one-size plan that fits all. It’s necessary to take stock of your situation and decide which plan makes sense through that lens.
Choosing the best Medicare plan for diabetes: A step-by-step guide
The first step is taking stock of your diabetes control and any recent events or related situations.
Consider these questions:
- Was your last Hgba1c at goal when you last had it checked?
- Am I at a healthy weight? Do I routinely exercise and follow a diabetic diet?
- Do I have high blood pressure and/or high cholesterol? Do I have heart disease?
- What is my engagement level regarding controlling my blood sugar? Do I make an effort every day or am I relaxed about it?
- Has my doctor talked about trying a newer diabetic medication recently on the market, because my current medication is no longer working?
- Has my doctor recently mentioned adding insulin to my regimen?
- Have I suffered a diabetic complication?
- Have I been hospitalized due to uncontrolled diabetes?
- Have I gotten routine dental and eye exams and requested blood work?
- Does my doctor examine my feet at checkups?
- Do I have peripheral neuropathy?
- Am I attached to my current provider(s)?
- Is it a priority for me to choose which provider I will see?
- Do I live in a rural area or a metro/urban area?
Your answers to these questions will give an idea of the intensity of service you will need in the coming year. Write your answers down and keep them handy as you move through the following steps.
The second step is looking at the benefits under Original Medicare.
Original Medicare consists of parts A (hospitalization) and B (medical):
Part A - will provide inpatient treatment for diabetes.
Part B - will provide diabetes self-management training, glucose test strips, lancets, the glucometer, twice-per-year foot exams for people with diabetic peripheral neuropathy, insulin pumps and insulin used in these devices, nutrition counseling, therapeutic shoes and inserts, home health care, durable medical equipment (wheelchair, walker, bed), and many preventative services and annual wellness exams.
Most Americans pay nothing for part A. The cost of Part B is based on your income over the last two years.
There are a lot of gaps in benefits with just parts A and B. For example, they don’t include vision, dental, hearing, medications, routine foot care, and dentures. Medicare Supplement and the Advantage Plan are the two options that were designed to fill in the gaps.
The third step is to learn about Medicare part D.
Part D is associated with the Medicare Supplement plan. Private insurance companies that have been approved by Medicare offer prescription insurance.
Part D covers anti-diabetic drugs, and diabetic supplies such as syringes, needles, gauze, inhaled insulin devices, and insulin. It covers some, but not all, prescription costs.
The fourth step is to consider the premiums or fixed costs of Medicare Supplement and the Advantage plan.
Medicare Supplement is also known as Medigap. It covers Medicare’s deductibles and copays. In addition, there are 10 different plans (including dental and vision). Plans are standardized and organized by a letter of the alphabet.
Each plan offers similar benefits no matter which insurance company you choose or where you live, but the monthly premium may differ. There are monthly premiums associated with each benefit (the plan itself, dental, and vision).
Medicare Advantage (also called Part C) Insurance Plans are offered by private insurance companies and are approved by the federal government. They cover the same benefits as part A and part B and may offer vision, dental, and prescription drugs without an additional premium cost.
If you live in an area with a limited number of healthcare providers, networks can make it
difficult to access care. These plans typically use HMO, PPO, or PFFS networks. It’s important to remember that the network can change yearly, affecting whether or not your doctor accepts your insurance.
Medicare Advantage can offer greater access to specialists. Additional benefits may include over-the-counter supplies such as alcohol swabs, blood glucose supplies, and nutrition therapy.
Some offer additional cost savings for insulin and anti-diabetic medications. The Advantage Plan premium is equal to Part B's cost. According to the Kaiser Family Foundation (KFF), 65% of those using Medicare Advantage have no monthly premiums, and 20% pay less than or equal to $49.00 per month.
The fifth step is to consider the variable costs of Medicare Supplement and Medicare Advantage.
The variable expenses are determined by how much you use the plan and the health care system. Variable costs include:
- Excess charges
- The out-of-pocket maximum
The variable costs are determined by how much you use the plan and the healthcare system.
Supplement Plan G has an average deductible of about $300.00. Under this plan, you pay only the deductible and insurance pays the remainder for all Medicare-approved procedures. There are no co-pays or co-insurance, no excess charges, and no out-of-pocket maximum.
Under the Advantage Plan, there is no deductible. There are copays and coinsurance. The person is confined to a network of providers and hospitals. If you go outside that network, you are responsible for a higher dollar amount or even 100% of the bill. There is an out-of-pocket maximum. The person must pay up to the out-of-pocket maximum which can be $5,500 for in-network services.
The sixth step is to consider that Part D, dental, and vision plans each have their deductible, copay, and coinsurance. There is no out-of-pocket maximum for part D.
The last step is calling a Medicare agent that will take your informed account and plug it into a Medicare plan that meets your goals. Medicare agents cannot charge you for their services.
The agent you choose should represent both supplement and advantage plans.
Choosing the best Medicare plan for a diabetic is challenging to say the least. There’s much to
consider and much at stake.
Conceptualizing where you have been and where you want to be regarding diabetes management, and finances, and choosing your healthcare providers will inform those who can help you meet your goals.
You can find a Medicare representative close to you by dialing the number 1-800-MEDICARE. State health insurance assistance programs (SHIPS) can also provide valuable assistance with Medicare questions.
The American Association of Retired Persons (AARP) provides a worksheet to help decide between original Medicare and Medicare Advantage. The worksheet provides some other topics to consider.
- Centers for Disease Control and Prevention. By the Numbers: Diabetes in America.
- Mayo Clinic. Diabetes care: 10 ways to avoid complications.
- AARP. Your Medicare Decision Worksheet.
- 1 Library. 17 Things Medicare First-timers Need to Know
- AARP. Where can I find answers to my Medicare questions?