2015 National Training Program Medicare Coverage of Diabetes Services and Supplies For Those Who Counsel People With Medicare July 2015.

2015 National Training Program

Medicare Coverage of

Diabetes Services and Supplies

For Those Who Counsel People With Medicare

July 2015

What is Diabetes?

Chronic disease in which your body can’t make or effectively use it’s own insulin to regulate blood sugar

Type 1 and Type 2 Diabetes Diabetes is the 7th leading cause of death in the U.S.• Approximately 29.1 million Americans have diabetes

26.9% are 65 and older

• Estimated 8.1 million are undiagnosed

• 1 in 3 people will develop diabetes in their lifetime07/01/2015 2Medicare Diabetic Services and Supplies

Generally, Medicare Part B covers • Diabetes screenings• Diabetes self-management

training• Medical nutrition therapy services• Hemoglobin A1c tests • Foot exams & treatment• Therapeutic shoes or inserts• Glaucoma testing• Blood sugar self-testing

equipment and supplies • Insulin pumps and insulin used

with them

Generally Medicare Part D covers • Insulin • Anti-diabetic drugs • Certain diabetes supplies

Medicare Coverage of Diabetes Services and Supplies

07/01/2015 Medicare Diabetic Services and Supplies 3

Diabetes Screening

Part B covers these screenings if your doctor determines you’re at risk for diabetes • You may be eligible for up to 2 diabetes screenings each

year • You pay nothing for the test if your doctor or other

qualified health care provider accepts assignment Assignment—an agreement by your doctor, provider,

or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.

07/01/2015 Medicare Diabetic Services and Supplies 4

Diabetes Self-Management Training

Part B covers diabetes outpatient self-management training to teach you to cope with and manage your diabetes• May include tips for eating healthy, being active,

monitoring blood sugar, taking medication, and reducing risks

• You must have diabetes and a written order from your doctor or other health care provider

• You pay 20% of the Medicare-approved amount, and the Part B deductible applies

07/01/2015 Medicare Diabetic Services and Supplies 5

Medical Nutrition Therapy Services

Part B may cover medical nutrition therapy and certain related services if you have diabetes (or kidney disease)• A registered dietician or nutrition professional who

meets certain requirements can provide these services May include nutritional assessment, 1-on-1

counseling, and therapy services, either in person or through an interactive telecommunications system

• You pay nothing for these services if the doctor or other qualified health care provider accepts assignment

07/01/2015 Medicare Diabetic Services and Supplies 6

Hemoglobin A1c Test

Is a blood test ordered by your doctor• To measure your average blood sugar (also called

glucose) over the past 2-3 months It helps your doctor gauge how well you’re

managing your blood sugar It is ordered twice a year, but can be ordered

quarterly, for people having trouble managing their blood sugar

07/01/2015 Medicare Diabetic Services and Supplies 7

Foot Exam

Part B covers a foot exam every 6 months for people with diabetic peripheral neuropathy and loss of protective sensation• As long as you haven’t seen a foot care

professional for another reason between visits• You pay 20% of the Medicare-approved amount

after the yearly Part B deductible

07/01/2015 Medicare Diabetic Services and Supplies 8

Therapeutic Shoes and Inserts

Medicare will pay for one pair of therapeutic shoes and inserts per calendar year if your doctor certifies that you have diabetes and you Have at least one of these conditions in one or both feet• Partial or complete foot amputation • Past foot ulcers • Calluses that could lead to foot ulcers • Nerve damage because of diabetes with signs of problems with calluses • Poor circulation • A deformed foot

Are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.

Medicare also requires A podiatrist or other qualified doctor prescribes the shoes, and a doctor or

other qualified individual fits and provides the shoes07/01/2015 Medicare Diabetic Services and Supplies 9

Eye Exams for People With Diabetes

Diabetes increases susceptibility to diabetic retinopathy and glaucoma Part B covers• Yearly eye exam for diabetic retinopathy • A glaucoma test once every 12 months for people at high risk

for glaucoma These tests must be done or supervised by an eye doctor who's

legally allowed to do this test in your state You pay 20% of the Medicare-approved amount and the Part B

deductible applies In a hospital outpatient setting, you also pay a copayment

07/01/2015 Medicare Diabetic Services and Supplies 10

Blood Sugar Self-testing Equipment & Supplies

Blood sugar (also called blood glucose) self-testing equipment and supplies are covered as durable medical equipment for all people with Medicare Part B who have diabetes, even if you don’t use insulin• Self-testing supplies include:

Blood sugar monitors Blood sugar test strips Lancet devices and lancets Glucose control solutions for checking the accuracy of

testing equipment and test strips

07/01/2015 Medicare Diabetic Services and Supplies 11

Insulin Pumps and the Insulin Used in the Pumps

Covered for people with Medicare Part B who have diabetes and meet certain conditions

Medicare covers the cost of insulin pumps and the insulin used in the pumps when medically necessary• Injectable insulin not associated with the

use of an insulin infusion pump and inhaled insulin are covered under Medicare Part D drug plans

07/01/2015 Medicare Diabetic Services and Supplies 12

Part D Coverage for Insulin and Supplies

Covered for all people with Medicare Part D • Medical supplies include the following:

Syringes, needles, alcohol swabs, gauze, and inhaled insulin devices

• Injectable insulin not associated with the use of an insulin infusion pump

• Anti-diabetic drugs

Insulin Pen

Insulin Vials & Syringe

07/01/2015 Medicare Diabetic Services and Supplies 13

What Do I Need From My Doctor to Get Supplies?

Medicare will only cover your blood sugar self-testing equipment and supplies if you get a prescription from your doctor. The prescription should include Whether you have diabetes What kind of blood sugar monitor you need and why you

need it• If you need a special monitor because of vision problems,

your doctor must provide an explanation Whether you use insulin How often you should test your blood sugar How many test strips and lancets you need for one month

07/01/2015 Medicare Diabetic Services and Supplies 14

Two Ways to Get Diabetic Testing Supplies

If you have Original Medicare there are 2 ways to get diabetic testing supplies1. Delivered directly to your home by a national

mail-order contract supplier (mail-order)2. Picked up in person from any Medicare-enrolled

supplier of diabetic testing supplies (non-mail-order) which could be a pharmacy

07/01/2015 Medicare Diabetic Services and Supplies 15

Home Delivery of Diabetic Testing Supplies

You can use the Medicare National Mail Order Program• No matter where you live, you’ll need to use a

Medicare national mail-order contract supplier for Medicare to pay for diabetic testing supplies that are delivered to your home

• The National Mail-Order Program doesn't require you to change your testing monitor. If you're happy with your current monitor, look for a mail-order contract supplier or local store that can provide the supplies you need

07/01/2015 Medicare Diabetic Services and Supplies 16

Medicare.gov Supplier Directory

07/01/2015 Medicare Diabetic Services and Supplies 17

Pharmacy Choice May Affect Cost

Ask the supplier or pharmacy if they are enrolled in Medicare and if they accept Medicare assignment• If yes to both, Medicare will pay the pharmacy or supplier directly• People pay just their coinsurance amount when they get supplies

from a pharmacy or supplier for assigned claims • If the pharmacy or supplier doesn’t accept assignment,

prescription costs may be higher• People may have to pay the entire charge at the time of service,

and wait for Medicare to send its share of the cost If there are no local suppliers or pharmacies enrolled in Medicare

that accept assignment, you may want use the mail order option • This may save you money

07/01/2015 Medicare Diabetic Services and Supplies 18

What’s Not Covered?

Original Medicare and Medicare drug plans don’t cover everything.

Diabetes supplies and services not covered include • Continuous glucose monitors• Eye exams for glasses (called refraction)• Orthopedic shoes (shoes for people whose feet

are impaired, but intact)• Cosmetic surgery

07/01/2015 Medicare Diabetic Services and Supplies 19

What If I Have a Medicare Advantage Plan?

If you have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, your plan must give you at least the same coverage as Original Medicare, but it may have different rules• Your costs, rights, protections, and choices for where

you get your care might be different if you’re in one of these plans

• You might also get extra benefits • Read your plan materials, or call your benefits

administrator for more information about your benefits

07/01/2015 Medicare Diabetic Services and Supplies 20

Rights and Protections

All Medicare beneficiaries including those covered by the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program have certain rights and protections

You can find more information about your rights and protections in the following:• Supplier

Quality Standards and Beneficiary Protections Fact Sheet [PDF, 327KB]

• Your Guide to Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program [PDF, 720KB]

07/01/2015 Medicare Diabetic Services and Supplies 21

Problems With Service And Supplies

If you have a problem getting needed DMEPOS items or services, or if you are concerned about the quality of the supplies and services you’re getting• Contact your supplier• Call 1-800-MEDICARE (1-800-633-4227) to get

help TTY users should call 1-877-486-2048

07/01/2015 Medicare Diabetic Services and Supplies 22

Competitive Acquisition Ombudsman (CAO)

If you have contacted the supplier and 1-800 MEDICARE, but still need help• Ask the 1-800-MEDICARE representative to submit

your issue to the CAO The CAO • Helps to ensure that DMEPOS issues are resolved• Provides CMS with data that can be used to improve

the Competitive Bidding Program• Identifies systemic issues to help CMS ensure that

people have access to high-quality DMEPOS07/01/2015 Medicare Diabetic Services and Supplies 23

Diabetic Testing Supplies Fraud Schemes

It may be a scam if• The pharmacy bills diabetic supplies only, no

medications• You get unsolicited telemarketing calls from a pharmacy• You’re asked to purchase products you didn’t order• Your contacted and told to call your doctor for an order

when you don’t need supplies• Your physician is asked to sign orders he didn’t authorize• You’re billed for supplies that you didn’t request or

receive

07/01/2015 Medicare Diabetic Services and Supplies 24

Check Your Knowledge–Question 1

Which part of Medicare covers diabetic testing supplies?a. Part Ab. Part Bc. Part Cd. Part D

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 25

Casework Discussion Scenario 1

Agnes was just diagnosed with diabetes. How would you explain her options for getting supplies? She has Medicare Parts A, B, and D.

07/01/2015 Medicare Diabetic Services and Supplies 26

Casework Scenario 1—Question 1

What part of Medicare will cover her insulin?a. Part Ab. Part Bc. Part Dd. Depends on whether

she has an insulin pump

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 27

Casework Scenario 1—Question 2

Agnes received lancets and syringes in the mail that she didn’t order. What part of Medicare should pay for them?a. Medicare won’t pay for

supplies she didn’t order and her doctor didn’t prescribe

b. Part Dc. Part B lancets and Part D

syringesd. Part B

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 28

Casework Scenario 1—Question 3

All mail-order deliveries of diabetic supplies are fraudulent?a. Trueb. False

a. b.

0%0%

07/01/2015 Medicare Diabetic Services and Supplies 29

Casework Scenario 1—Question 4

Agnes tells you she saw a large box of diabetic test strips for sale “cheap online” from a woman who found them in a closet at her late mother’s house. What would you say to Agnes?a. Great, you got a deal.b. This isn’t a good idea.c. Just be sure they match your

meter.

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 30

Casework Scenario 2

Sandy is enrolled in Medicare Parts A and B

She has insulin dependent diabetes and tests 3 times daily

Recently, Sandy’s doctor determined it was medically necessary for Sandy to test more frequently

07/01/2015 Medicare Diabetic Services and Supplies 31

Casework Scenario 2—Question1

Sandy’s supplier said Medicare won’t pay for additional testing supplies even if it’s medically necessary. a. Trueb. False

a. b.

0%0%

07/01/2015 Medicare Diabetic Services and Supplies 32

Casework Scenario 3

Anton has insulin dependent diabetes and has some nerve related symptoms in his feet. He asks you for information about what Medicare might cover. He has Medicare Parts A, B, and D.

07/01/2015 Medicare Diabetic Services and Supplies 33

Casework Scenario 3—Question 1

Anton may be eligible for a. Part B diabetes self-

management trainingb. Part B foot exams and

treatment c. Therapeutic shoes and

insertsd. All of the above

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 34

Casework Scenario 4

Bill has Medicare Parts A, B and D. He uses an insulin pump.His doctor has just prescribed an insulin pen with long-acting insulin for Bill to use when he’s off his pump for an extended time.

07/01/2015 Medicare Diabetic Services and Supplies 35

Casework Scenario 4—Question 1

Which part(s) of Medicare will cover Bill’s insulin?a. Part B covers the insulin used in the

insulin pump and in the insulin penb. Part D covers the insulin used in the

insulin pump and in the insulin penc. Part D covers the insulin used in the

insulin pump and Part B covers the insulin in the insulin pen

d. Part B covers the insulin used in the insulin pump, and Part D covers the insulin in the insulin pen

a. b. c. d.

0% 0%0%0%

07/01/2015 Medicare Diabetic Services and Supplies 36

Resources

American Diabetes Association diabetes.org/ MedlinePlus nlm.nih.gov/medlineplus/ Call 1-800-MEDICARE (1-800-633-4227). TTY

users should call 1-877-486-2048. State Health Insurance Assistance Programs

(SHIPs) Medicare.gov/contacts/ If you live in a rural area contact a • Federally Qualified Health Center (FQHC), visit

CMS.hhs.gov/center/fqhc.asp

07/01/2015 37Medicare Diabetic Services and Supplies

Publication Resource

Medicare’s Coverage of Diabetes Supplies & ServicesCMS Product No. 11022

07/01/2015 Medicare Diabetic Services and Supplies 38

CMS National Training Program

To view all available NTP training materials, or to subscribe to our email list, visit

CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html

For questions about training products email [email protected]

Appendix 1Supply/service What’s covered What you pay

Anti-diabetic drugs Part D covers anti-diabetic drugs for maintaining blood sugar (glucose).

Coinsurance or copayment;Part D deductible may also apply

Diabetes screenings Hemoglobin A1c Tests

Part B covers these screenings if your doctor determines you’re at risk for diabetes. You may be eligible for up to 2 diabetes screenings each year.

No coinsurance, copayment, or Part B deductible;Generally, 20% of the Medicare-approved amount for the doctor’s visit

Diabetes self-management training

Part B covers outpatient training for people at risk for complications from diabetes or recently diagnosed with diabetes to teach them to manage their diabetes, with a written order to a certified diabetes self-management education program.

20% of the Medicare-approved amount after the yearly Part B deductible

Medicare Diabetic Services and Supplies 4007/01/2015

Appendix 1.2Supply/service What’s covered What you pay

Diabetes equipment & supplies Uses insulin, they may be able to get up to 300 test strips and lancets every month, and 1 lancet device every 6 months. Doesn’t use insulin, they may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months.

Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. These supplies include:•Blood glucose monitors;•Blood glucose test strips;•Lancet devices and lancets; •Glucose control solutions for checking the accuracy of testing equipment and test strips.

20% of the Medicare-approved amount after the yearly Part B deductible

If your doctor says it’s medically necessary, Medicare will allow you to get additional test strips and lancets.

Diabetes supplies Part D covers certain medical supplies for administration of insulin (like syringes, needles, alcohol swabs, gauze, and inhaled insulin devices).

Coinsurance or copayment Part D deductible may also apply

07/01/2015 41Medicare Diabetic Services and Supplies

Appendix 1.3Supply/service What’s covered What you pay

Foot exams & treatment Part B covers a foot exam every 6 months for people with diabetic peripheral neuropathy and loss of protective sensation, as long as they haven’t seen a foot care professional for another reason between visits.

20% of the Medicare-approved amount after the yearly Part B deductible

Therapeutic shoes or inserts Part B covers therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease. The doctor must certify your need for therapeutic shoes or inserts. The shoes and inserts must be prescribed and provided by a qualified doctor .

20% of the Medicare-approved amount after the yearly Part B deductible

07/01/2015 42Medicare Diabetic Services and Supplies

Appendix 1.4Supply/service What’s covered What you pay

Insulin Medicare Part D covers insulin that isn’t administered with an insulin pump.

Coinsurance or copayment Part D deductible may also apply

Insulin pumps Medicare Part B covers external insulin pumps and the insulin that the device uses under durable medical equipment for people who meet certain conditions.

20% of the Medicare-approved amount after the yearly Part B deductible

Medical Nutrition Therapy Part B may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, and your doctor refers you for the service.

No copayment, coinsurance, or Part B deductible if your doctor or health care provider accepts assignment

4307/01/2015 Medicare Diabetic Services and Supplies