Medicare Insurance Guide

Of that 30 million, 25% are age 65 and older. This means that approximately 12 million seniors are affected by diabetes in America today.

As the seventh leading cause of death in the United States, diabetes can also lead to blindness, kidney and/or heart failure, amputations, and stroke. Because there are different severity levels of diabetes, the disease is broken down into types.

Type 1 Diabetes

The most severe type of diabetes is Type 1 Diabetes (T1D). T1D is most common in children, giving it the name “juvenile diabetes”. However, T1D can affect any age. Type 1 diabetes is when the pancreas either doesn’t produce enough insulin or doesn’t produce any insulin at all. This happens because the immune system doesn’t recognize the insulin-producing cells in the pancreas and attacks them. The lack of insulin causes the glucose to build up in the blood instead of being distributed out to the body’s cells. This causes a high level of blood sugar.

Type 2 Diabetes

Unlike T1D, Type 2 Diabetes (T2D) patients are able to produce insulin. Unfortunately, it isn’t enough. Without the right amount of insulin, the body’s cells won’t allow glucose to enter, leading to insulin resistance. T2D is the most common form of diabetes. It is often diagnosed in adults 35 and older, giving this type its name, “adult-onset diabetes”.

Type 2 diabetes is usually easier to manage than type 1. Normally an adjustment in diet and exercise can help to control the blood sugar levels.

Does Medicare Cover Diabetes?

People living with diabetes often need supplies and services to help better manage their disease, long term medicaid services has developed certain coverage rules for the items needed.

Part A of Original Medicare covers the medically necessary inpatient stays you might eventually incur while living with diabetes. It also covers skilled nursing care and hospice care.

However, the main two parts of Medicare that will cover your diabetes treatment are Part B and Part D.

Part B will be responsible for your outpatient services and durable medical equipment while Part D is a voluntary program you can enroll in to help with outpatient prescription costs.

Breakdown of Part B and Part D and What They Cover

There are many supplies and services one might need when battling diabetes. Knowing which part of Medicare covers them can help you plan ahead for any costs you may share in.

What Part B Covers for Diabetics

As mentioned above, Part B covers your outpatient services and durable medical equipment (DME). Some pieces of equipment that Part B covers for diabetes are

  • Blood Sugar Testing Monitors
  • Blood Sugar Test Strips
  • Lancet Devices and Lancets
  • Insulin (if an insulin pump is needed)
  • Insulin Pump
  • Blood Sugar Control Solutions
  • Therapeutic Shoes or Inserts

It’s important to note that not all durable medical equipment is covered the same way. For instance, certain equipment may need to be rented, purchased, or you may have an option between the two.

Your doctor and the supplier of your DME must be enrolled in Medicare in order for Medicare to cover the equipment. You will also need to make sure your supplier “participates” in Medicare. Even though they are enrolled in Medicare, they are not required to accept Medicare assignment rates. This means that if a provider does not participate, they can charge you an excess charge of up to 15% beyond Medicare’s allowed rate in many states.

If you need certain supplies for your durable medical equipment and you’d like to order them through a pharmacy, make sure the pharmacy bills your Part B and not your Part D drug plan. Be aware that purchasing these items through Medicare’s approved vendor list will often mean the items are less expensive than if you fill them at your local pharmacy.

 

Appealing Coverage Decisions

Instances happen where Medicare will deny coverage for a particular supply or service. Six common reasons Medicare denies coverage are

  1. Incorrect Coding: Medical Coding Solutions hеlр ensure the medical соdеѕ аrе аррlіеd ассurаtеlу during the mеdісаl bіllіng process, each item a doctor’s office puts on a bill has a code. This code shows the insurance company what service was provided at the time of the visit. Sometimes, this code is wrong and require an adjustment, in other words, coding should only be performed by those who have gotten proper Medical Coding Education, those are the ones that will truly understand a 99212 code.
  2. Incorrect Billing:Doctor’s offices don’t always have up to date insurance information for every patient. If you enrolled in Medicare since last seeing your doctor, they might not have that information. The office may still have your employer plan as your primary insurance. Therefore, they will bill your employer plan and your old plan won’t pay anything since you are no longer covered by them.

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