If you’re diabetic, you’re likely no stranger to dealing with complexities related to health insurance. Although Medicare provides comprehensive coverage for many conditions, understanding coverage related to diabetes management and hypoglycemia can be confusing. Part of the reason is that much of the coverage relates to equipment and prescription drugs, both of which are a bit complex under Medicare.

We’ll discuss some of the background concepts you should understand when you think about Medicare and diabetes, and then go over some specific guidelines for understanding how Medicare covers insulin pumps.

The Basics of Diabetes and Medicare

For the most part, Medicare covers diabetes in the same way that it covers any other medical conditions. Certain healthcare needs will be determined to fall under medical necessity and will be covered by the proper part of Medicare (more on parts of Medicare later!)

Diabetes can be especially complicated because it involves equipment, such as monitors and insulin pumps. Durable medical equipment has its own category under Medicare and can be covered much of the time. However, there is some variety to coverage, and this can apply to diabetes coverage as well.

In general, Medicare provides some form of coverage for blood sugar monitors, test strips, lancet devices, and equipment related to glucose control. But, the levels of coverage can vary depending on the details of the devices and solutions in question.

Understanding the Parts of Medicare

Medicare is divided into four parts, and each one is relevant for understanding Diabetes care.

Medicare Part A covers inpatient care, such as hospital care, skilled nursing facility care, and sometimes in-home care. Although Part A may be relevant for diabetes care if you are hospitalized, we’ll mostly focus on other parts of Medicare here. Part A won’t cover any equipment or prescription drugs that are self-administered.

Medicare Part B will be relevant for a lot of your needs related to diabetes. Part B covers medically necessary outpatient care, such as doctor visits and tests. It also covers durable medical equipment or DME. There are restrictions regarding which equipment can be covered.

Medicare Part C, or Medicare Advantage, doesn’t cover a specific type of healthcare need. Rather, this part of Medicare allows you to receive your Part A and Part B coverage through a private insurance company. Medicare Advantage plans are also commonly bundled with prescription drug coverage, which isn’t covered by Original Medicare. Enrollment for Part C isn't available to those enrolled in Original Medicare, and vice versa.

Medicare Part D covers prescription drugs only. Like Part C, it is offered by private health insurance companies. If you have diabetes, you should make sure to find a Part D plan that covers your required medications at a level you’re comfortable with, because Original Medicare doesn't cover any prescription medication.

When it comes to diabetes care and equipment, Part B and Part D are the most relevant parts of Medicare. However, Part C can also stand in for Part B and may stand in for Part D as well if your Part C plan covers prescription drugs.

Part B & DME: General Guidelines

Generally speaking, Part B will cover medical supplies that are necessary for the treatment of your health condition. This can include things like oxygen tanks, wheelchairs, and hospital beds. It will also apply to other diabetes equipment like continuous glucose monitor (CGM), equipment related to Continuous Subcutaneous Insulin Infusion (CSII) therapy, and blood sugar/blood glucose level monitoring equipment. However, there are some restrictions here.

First, the equipment in question must be directly related to the treatment of your condition. And, there are restrictions on the type of equipment that is covered. For example, hospital beds are covered in some cases, but electronic hospital beds will almost never be covered by Part B.

In addition to this, equipment must be purchased from Medicare-approved sellers. Otherwise, the price can be very high, and coverage will be limited.

Make sure to seek information related to the equipment you need in detail before you make any purchases.

Insulin Pumps and Part B Coverage

The Centers for Medicare & Medicaid Services (CMS) considers Insulin pumps to be DME, which means that you’ll be able to get one covered if you need it. Note that the Medicare cost-sharing guidelines apply. This means that you’ll still pay 20 percent of the cost of the equipment after you’ve reached your yearly deductible. Other forms of insulin delivery may be covered in different ways.

Tubed vs. Tubeless Insulin Pumps

Insulin devices can be covered by Medicare in different ways, even when both qualify as insulin pumps. A major distinction is between tubed and tubeless insulin pumps.

Tubed pumps will be covered by Part B of Medicare as durable medical equipment. In most cases, the insulin used in these pumps will be covered as well.

Tubeless pumps will be covered by Part D of Medicare instead. Basically, they are considered to simply be a form of medication, rather than a form of equipment.

Because Part D plans can vary, make sure you check how much tubeless insulin pump coverage your plan offers. Part D coverage also comes into play for those who receive insulin via daily injections versus insulin pumps.

How Medigap Plans Can Help

Unlike normal Medicare health insurance, Medigap plans (also called Medicare Supplement Plans) offer coverage related to out-of-pocket costs. Basically, you will pay a monthly premium, and the plan will pay things like your deductible, coinsurance, and copayment for you.

As we mentioned above, Medicare coverage for most forms of diabetes care still requires you to pay a 20 percent coinsurance fee. Although Medigap plans can’t help you get more coverage for diabetes, they can help financially if your coinsurance fees are high. This will vary from person to person, and you should look at more details about Medigap plan comparison before making any choices.

Additional Coverage Under Medicare Advantage

As mentioned above, Medicare Advantage plans are another way of getting coverage related to diabetes care. Basically, these are private health insurance plans available to Medicare beneficiaries, which are required by law to offer the same coverage that Original Medicare (Parts A and B) provides.

Although Medicare Advantage plans are required to cover at least this amount of coverage, some plans also cover more. This will tend to vary a lot from plan to plan, so you should make sure to investigate the details of every plan you look into.

Medigap plans may cover DME at a different rate than Part B, or offer coverage for additional services that are related to diabetes care but aren’t considered medically necessary by Original Medicare. The process of comparing Original Medicare to Medicare Advantage can get complicated, so make sure you don’t make any decisions without consulting additional information.

Key Things to Remember about Medicare and Insulin Pumps

Although understanding DME guidelines can be complex, you should expect some form of coverage for insulin and insulin pumps under Medicare. This includes a combination of Medicare Part B and Part D, Part C and Part D, or just Part C if your plan covers prescription drugs.