Thank you for your interest in CCO content. As a guest, please complete the following information fields. These data help ensure our continued delivery of impactful education.
Become a member (or login)? Member benefits include accreditation certificates, downloadable slides, and decision support tools.
University Physicians Group
Elyse Marriner, BSN, RN, CDCES, has no relevant conflicts of interest to report.
Many people with diabetes are receiving Medicare coverage for their healthcare. However, navigating the requirements for Medicare coverage of the technology and supplies needed to manage diabetes in 2021 can be challenging for both patients and healthcare professionals.
Medicare Requirements for Finger Sticks
Medicare requirements make it challenging to establish people on technology, as they maintain very strict qualifications for who is eligible for diabetes technology. For example, Medicare requires patients to demonstrate that they are completing 4 finger sticks per day for a minimum of 60 days, but for people on insulin, they will only pay for 3 test strips per day. That leaves a gap. How can individuals get to those 4 finger sticks? Do they have to pay for test strips out of pocket? Are we giving them sample strips? Are we putting them on a Libre Pro to cover 14 of those days? There are many ways to try to address this, but trying to obtain extra test strips can often create unnecessary financial burden and stress to a patient who has Medicare.
Another barrier is that for people not on insulin, Medicare only covers 1 test strip per day, which can be very limiting. Many times, people with diabetes are transitioning between medications, or they might have low blood sugars with certain medications, such as glipizide, even if insulin is not causing the lows. These patients need extra test strips in case they find themselves in those situations, so that they can test and treat a low blood sugar safely and appropriately. It can be challenging to navigate the Medicare coverage to make sure people have enough supplies within those insurance requirements.
Medicare Requirements for A1C
Another challenge with Medicare is meeting certain requirements for A1C testing. To maintain Medicare coverage, people who are on an insulin pump must have a clinic visit every 90 days, but Medicare will only pay for an A1C evaluation every 91 days. That can create a gap in care if the person with diabetes cannot get his or her A1C level drawn in office without paying out of pocket for the test. Not every person with diabetes is required to get an A1C test every 3 months, although this can provide valuable clinical information about overall blood glucose control.
Pump and Sensor Coverage Under Medicare Part B
For people in need of a pump or continuous glucose monitoring (CGM), those supplies are covered under medical equipment as part of Medicare Part B, which covers medical needs (Part A is for hospital coverage). All persons on Medicare are enrolled in Medicare Parts A and B (the red, white, and blue card). Although many people with commercial insurance are able to get their supplies from a pharmacy, people with Medicare must go through supply companies, which can often lead to delays and difficulties with obtaining their supplies appropriately. Medicare Part B will pay for 80% of the cost of a CGM, pump, or supplies, but the other 20% often falls to the individual. If they have supplemental insurance, frequently the supplement will pick up the remaining 20%, but it can differ by supplemental insurers. Medicare Part D is supplemental drug coverage, and there are additional supplements, including Parts G and J—suffice it to say, there are a lot of letters that can quickly become confusing.
More coverage is not always better and that goes for all insurance in general. In some cases where people have multiple supplementals, one prefers this brand of something and the other prefers that brand and they will not cover the opposite. Often this creates a situation where both insurance companies will not agree to cover a brand that the second insurance plan prefers. Then you must determine which is primary, and which covers more, and many people still end up paying a lot of money out of pocket. We are often asked about the cost breakdown when you compare different pieces of technology. However, obtaining a straightforward cost estimate for devices is nearly impossible unless you submit it, so we often do not get to see the pricing side of things unless the patient lets us know that a requested device is too expensive. We send in documentation for an insulin pump and then the company is doing the workup and has to find a supplier that can work with that specific person’s insurance. Often, that 20% is too expensive for someone on a fixed income. Even $50 per month can be too much for a lot of our patients. Navigating these barriers can be very challenging because the person has been working hard to accomplish 4 finger sticks per day for 60 days—they may have had to buy test strips out of pocket to get to this point—and then we do the whole workup and often the device that the person wants is not affordable for him or her.
Advocating for the Patient Within the Rules of Medicare
With commercial insurance, we can call the plan and advocate for why a patient needs something. With Medicare, they will not give you any information if you are not the plan member. I try to be upfront and tell my patients on Medicare, “This is going to be an uphill battle. This is life‑changing technology and I want you to get it, but I want you to also be prepared for what the process is going to look like. You have to advocate for yourself. If there is a problem, you have to let me know.” Many times, I do not find out about barriers to technology until a patient comes in for a follow-up visit. For example, Medicare will only let the person get 1 month’s supply at a time. Most commercial plans allow for a 3-month supply. When you order from a medical equipment company, your eligibility is based on your last reorder date. So, if you last ordered on May 12, you can place your next order on June 12. Then you must account for extra time for things such as delayed mail, if the medical equipment company needs to request a prescription, the time it takes to get a provider signature and turn the prescription around, if the medical equipment company has to submit the request for authorization to insurance, and all of this does not include any insurance delays. In my practice, when people on Medicare are approved for life‑changing technology, I advise them to wait 2 or 3 weeks to use it, so that they can build a buffer of time and are less likely to run short on supplies.
It is a huge gap in care, and in my opinion, it is often an uphill battle. It is important to have these conversations upfront to set people with diabetes up for success as much as we can.
Steps Forward in Coverage
The requirement that a Medicare patient must complete 4 finger sticks per day will be permanently removed starting July 18, 2021. This will make CGM technology and insulin pumps much more accessible to more people with diabetes, as some people previously ineligible for these devices may now qualify with this requirement eliminated.
Medicare also expanded coverage of an inhalable insulin. These are significant measures in the battle to increase the accessibility of medications and technology to people with diabetes. Although these are incredible steps forward, we must continue striving to examine policies and implement change to address barriers and increase access to healthcare.
What are your thoughts on the how to optimize a visit with a person with diabetes who is using CGM under Medicare coverage? Answer the polling question and share your thoughts in the comments box below.