Provider Types Affected
Physicians, providers, suppliers, and other health care professionals who furnish or provide referrals for and/or file claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MAC), fiscal intermediaries (FI), and/or Part A/B Medicare Administrative Contractors (A/B MAC)) for Medicare-covered diabetes benefits

Provider Action Needed
This article is informational only and represents no Medicare policy changes.

Background
Diabetes is the sixth leading cause of death in the United States, and approximately 20 million Americans have diabetes with an estimated 20.9 percent of the senior population age 60 and older being affected. Millions of people have diabetes and do not know it. Left undiagnosed, diabetes can lead to severe complications such as heart disease, stroke, blindness, kidney failure, leg, and foot amputations, and death related to pneumonia and flu. Scientific evidence now shows that early detection and treatment of diabetes with diet, physical activity, and new medicines can prevent or delay much of the illness and complications associated with diabetes.

This special edition article presents an overview of the diabetes services and supplies covered by Medicare (Part B and Part D) to assist physicians, providers, suppliers, and other health care professionals who provide diabetic supplies and services to Medicare beneficiaries.

Medicare Part B Covered Diabetic Supplies
Medicare covers certain supplies if a beneficiary has Medicare Part B and has diabetes. These supplies include:

• Blood glucose self-testing equipment and supplies;
• Therapeutic shoes and inserts; and
• Insulin pumps and the insulin used in the pumps.

Blood Glucose Self-testing Equipment and Supplies
Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:

• Blood glucose monitors;
• Blood glucose test strips;
• Lancet devices and lancets; and
• Glucose control solutions for checking the accuracy of testing equipment and test strips.

Medicare Part B covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.
If the beneficiary

• Uses insulin, they may be able to get up to 100 test strips and lancets every month, and one lancet device every six months.
• Does not use insulin, they may be able to get 100 test strips and lancets every three months, and one lancet device every six months.

If a beneficiary’s doctor says it is medically necessary, Medicare will cover additional test strips and lancets for the beneficiary.

Medicare will only cover a beneficiary’s blood glucose self-testing equipment and supplies if they get a prescription from their doctor. Their prescription should include the following information:

• That they have diabetes;
• What kind of blood glucose monitor they need and why they need it (i.e., if they need a special monitor because of vision problems, their doctor must explain that.);
• Whether they use insulin;
• How often they should test their blood glucose; and
• How many test strips and lancets they need for one month.

A beneficiary needing blood glucose testing equipment and/or supplies:

• Can order and pick up their supplies at their pharmacy;
• Can order their supplies from a medical equipment supplier, but they will need a prescription from their doctor to place their order. Their doctor cannot order it for them;
• Must ask for refills for their supplies; and
• Needs a new prescription from their doctor for their lancets and test strips every 12 months.

Note: Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.

All Medicare-enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. A beneficiary cannot submit a claim for blood glucose monitor test strips themselves. The beneficiary should make sure that the pharmacy or supplier accepts assignment for Medicare-covered supplies. If the pharmacy or supplier accepts assignment, Medicare will pay the pharmacy or supplier directly. Beneficiaries should only pay their coinsurance amount when they get their supply from their pharmacy or supplier for assigned claims. If a beneficiary’s pharmacy or supplier does not accept assignment, charges may be higher, and the beneficiary may pay more. They may also have to pay the entire charge at the time of service and wait for Medicare to send them its share of the cost.
Before a beneficiary gets a supply, it is important for them to ask the supplier or pharmacy the following questions:

• Are you enrolled in Medicare?
• Do you accept assignment?

If the answer to either of these two (2) questions is “no,” they should call another supplier or pharmacy in their area who answers “yes” to be sure their purchase is covered by Medicare, and to save them money.

If a beneficiary can not find a supplier or pharmacy in their area that is enrolled in Medicare and accepts assignment, they may want to order their supplies through the mail, which may also save them money.

Therapeutic Shoes and Inserts
If a beneficiary has Medicare Part B, has diabetes, and meets certain conditions (see below), Medicare will cover therapeutic shoes if they need them. The types of shoes that are covered each year include one of the following:

• One pair of depth-inlay shoes and three pairs of inserts; or
• One pair of custom-molded shoes (including inserts) if the beneficiary cannot wear depth-inlay shoes because of a foot deformity and two additional pairs of inserts.

Note: In certain cases, Medicare may also cover separate inserts or shoe modifications instead of inserts.

In order for Medicare to pay for the beneficiary’s therapeutic shoes, the doctor treating their diabetes must certify that they meet all of the following three conditions:

• They have diabetes;
• They have at least one of the following 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; or
  • Deformed foot;
• They are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.

Medicare also requires the following:

• A podiatrist or other qualified doctor must prescribe the shoes, and
• A doctor or other qualified individual like a pedorthist, orthotist, or prosthetist must fit and provide the shoes to the beneficiary.

Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year, and the fitting of the shoes or inserts is covered in the Medicare payment for the shoes.

Insulin Pumps and the Insulin Used in the Pumps
Insulin pumps worn outside the body (external), including the insulin used with the pump may be covered for some people with Medicare Part B who have diabetes and who meet certain conditions. If a beneficiary needs to use an insulin pump, their doctor will need to prescribe it. In the Original Medicare Plan, the beneficiary pays 20 percent of the Medicare-approved amount after the yearly Part B deductible. Medicare will pay 80 percent of the cost of the insulin pump. Medicare will also pay for the insulin that is used with the insulin pump.

Medicare Part B covers the cost of insulin pumps and the insulin used in the pumps. However, if the beneficiary injects their insulin with a needle (syringe), Medicare Part B does not cover the cost of the insulin, but the Medicare prescription drug benefit (Part D) covers the insulin and the supplies necessary to inject it. This includes syringes, needles, alcohol swabs, and gauze. The Medicare Part D plan will cover the insulin and any other medications to treat diabetes at home as long as the beneficiary is on the Medicare Part D plan’s formulary.

Coverage for diabetes-related durable medical equipment (DME) is provided as a Medicare Part B benefit. The Medicare Part B deductible and coinsurance or copayment applies after the yearly Medicare part B deductible has been met. In the Original Medicare Plan, Medicare covers 80 percent of the Medicare-approved amount (after the beneficiary meets their annual Medicare Part B deductible of $131 in 2007), and the beneficiary pays 20 percent of the total payment amount (after the annual Part B deductible of $131 in 2007). This amount can be higher if the beneficiary’s doctor does not accept assignment, and the beneficiary may have to pay the entire amount at the time of service. Medicare will then send the beneficiary its share of the charge.

Medicare Part D Covered Diabetic Supplies and Medications
This section provides information about Medicare prescription drug coverage (Part D) for beneficiaries with Medicare who have or are at risk for diabetes. If a beneficiary wants Medicare prescription drug coverage, they must join a Medicare drug plan. The following diabetic medications and supplies are covered under Medicare drug plans:

• Diabetes supplies;
• Insulin; and
• Anti-diabetic drugs.

Diabetes Supplies
Diabetes supplies associated with the administration of insulin may be covered for all people with Medicare Part D who have diabetes. These medical supplies include the following:

• Syringes;
• Needles;
• Alcohol swabs;
• Gauze; and
• Inhaled insulin devices.

Insulin
Injectable insulin not associated with the use of an insulin infusion pump is covered under Medicare Part D drug plans.

Anti-diabetic Drugs
Blood glucose that is not controlled by insulin may be maintained by anti-diabetic drugs, and Medicare drug plans can cover anti-diabetics drugs such as:

• Sulfonylureas (i.e., Glipizide, Glyburide);
• Biguanides (i.e., metformin);
• Thiazolidinediones (i.e., Starlix® and Prandin®); and
• • Alpha glucosidase inhibitors (i.e., Precose®).

Medicare Part B Covered Diabetic Services
All of the diabetes services listed in this section are covered by Medicare Part B unless otherwise noted. For people with diabetes, Medicare covers certain services. A doctor must write an order or referral for the beneficiary to get these services. These services include the following:

• Diabetes screenings;
• Diabetes self-management training;
• Medical nutrition therapy services;
• Hemoglobin A1c tests; and
• Special eye exams.

Diabetes Screenings
Medicare pays for a beneficiary to get diabetes screening tests if they are at risk for diabetes. These tests are used to detect diabetes early, and some, but not all, of the conditions that may qualify a beneficiary as being at risk for diabetes include:

• High blood pressure;
• Dyslipidemia (history of abnormal cholesterol and triglyceride levels);
• Obesity (with certain conditions);
• Impaired blood glucose tolerance; and
• High fasting blood glucose.

Diabetes screening tests are also covered if a beneficiary answers “yes” to two or more of the following questions:

• Are you age 65 or older?
• Are you overweight?
• Do you have a family history of diabetes (parents, siblings)?
• Do you have a history of gestational diabetes (diabetes during pregnancy); or
• Did you deliver a baby weighing more than nine pounds?

Based on the results of these tests, a beneficiary may be eligible for up to two diabetes screenings every year at no cost (no coinsurance, or copayment or Part B deductible). Medicare will pay for a beneficiary to get two diabetes screening tests in a 12-month period, but not less than six months apart. After the initial diabetes screening test, the beneficiary’s doctor will determine when to do the second test. Diabetes screening tests that are covered include the following:

• Fasting blood glucose tests; and
• Other tests approved by Medicare as appropriate.

Diabetes Self-management Training (DSMT)
Diabetes self-management training helps a beneficiary learn how to successfully manage their diabetes. Their doctor or qualified nonphysician practitioner must prescribe this training for them for Medicare to cover it. A beneficiary can get diabetes self-management training if they met one (1) of the following conditions during the last twelve (12) months:

• They were diagnosed with diabetes;
• They changed from taking no diabetes medication to taking diabetes medication, or from oral diabetes medication to insulin;
• They have diabetes and have recently become eligible for Medicare;
• They are at risk for complications from diabetes. A doctor may consider the beneficiary at increased risk if they have any of the following:
  • They had problems controlling their blood glucose, have been treated in an emergency room, or have stayed overnight in a hospital because of their diabetes;
  • They have been diagnosed with eye disease related to diabetes;
  • They had a lack of feeling in their feet or some other foot problems like ulcers, deformities, or have had an amputation; or
  • Been diagnosed with kidney disease related to diabetes.

A beneficiary must get this training from an accredited diabetes self-management education program as part of a plan of care prepared by their doctor or qualified nonphysician practitioner. These programs are accredited by the American Diabetes Association or the Indian Health Service. Classes are taught by health care providers who have special training in diabetes education.

A beneficiary is covered by Medicare to get a total of ten hours of initial training within a continuous 12-month period. One of the hours can be given on a one-on-one basis. The other nine hours must be training in a group class. The initial training must be completed no more than 12 months from the time the beneficiary starts the training.

A doctor or qualified nonphysician practitioner may prescribe ten hours of individual training if the beneficiary is blind or deaf, has language limitations, or no group classes have been available within two months of the doctor’s order. To be eligible for two more hours of follow-up training each year after the year the beneficiary received initial training, they must get another written order from their doctor. The two hours of follow-up training can be with a group or they may have one-on-one sessions. A doctor or qualified nonphysician practitioner must prescribe the follow-up training each year for Medicare to cover it.

Beneficiaries learn how to successfully manage their diabetes in DSMT classes, and the training includes information on self-care and making lifestyle changes. The first session consists of an individual assessment to help the instructors better understand the beneficiary’s needs. Classroom training includes topics such as the following:

• General information about diabetes, and the benefits and risks of blood glucose control;
• Nutrition and how to manage ones diet;
• Options to manage and improve blood glucose control;
• Exercise and why it is important to ones health;
• How to take ones medications properly;
• Blood glucose testing and how to use the information to improve ones diabetes control;
• How to prevent, recognize, and treat acute and chronic complications from ones diabetes;
• Foot, skin, and dental care;
• How diet, exercise, and medication affect blood glucose;
• How to adjust emotionally to having diabetes;
• Family involvement and support; and
• The use of the health care system and community resources.

Note: If a patient lives in a rural area, they may be able to get DSMT in a Federally Qualified Health Center (FQHC). For more information about FQHCs, visit http://www.cms.hhs.gov/center/fqhc.asp on the CMS Web site. FQHCs are special health centers, usually located in urban or rural areas, and they can give routine health care at a lower cost. Some FQHCs are Community Health Centers, Tribal FQHC Clinics, Certified Rural Health Clinics, Migrant Health Centers, and Health Care for the Homeless Programs.

Medical Nutrition Therapy (MNT) Services
In addition to DSMT, medical nutrition therapy services are also covered for people with diabetes or renal disease. To be eligible for this service, a beneficiary’s fasting blood glucose has to meet certain criteria. Also, their doctor must prescribe these services for them. These services can be given by a registered dietitian or certain nutrition professionals, and the services include the following:

• An initial nutrition and lifestyle assessment;
• Nutrition counseling (what foods to eat and how to follow an individualized diabetic meal plan);
• How to manage lifestyle factors that affect diabetics; and
• Follow-up visits to check on progress in managing diet.

Medicare covers three hours of one-on-one medical nutrition therapy services the first year the service is provided, and two hours each year after that. Additional MNT hours of service may be obtained if the beneficiary's doctor determines there is a change in their diagnosis, medical condition, or treatment regimen related to diabetes or renal disease and orders additional MNT hours during that episode of care.

Foot Exams and Treatment
If a beneficiary has diabetes-related nerve damage in either of their feet, Medicare will cover one foot exam every six months by a podiatrist or other foot care specialist, unless they have seen a foot care specialist for some other foot problem during the past six months. Medicare may cover more frequent visits to a foot care specialist if a beneficiary has had a non-traumatic (not because of an injury) amputation of all or part of their foot or their feet have changed in appearance which may indicate they have serious foot disease.

Hemoglobin A1c Tests
A hemoglobin A1c test is a lab test ordered by the beneficiary’s doctor. It measures how well a beneficiary’s blood glucose has been controlled over the past three months. Anyone with diabetes is covered for this test if it is ordered by their doctor. Medicare may cover this test when a beneficiary’s doctor orders it.

Glaucoma Tests
Medicare will pay for a beneficiary to have their eyes checked for glaucoma once every 12 months. This test must be done or supervised by an eye doctor who is legally allowed to give this service in their state.

Special Eye Exam
People with Medicare who have diabetes can get special eye exams to check for eye disease (called a dilated eye exam). These exams must be done by an eye doctor who is legally allowed to provide this service in their state. The dilated eye exam is recommended once a year and must be performed by an eye doctor who is legally allowed to provide this service in the beneficiary’s state.

Diabetes Supplies and Services Not Covered by Medicare
The Original Medicare Plan and Medicare drug plans (Part D) do not cover everything. Diabetes supplies and services not covered by Medicare include:

• Eye exams for glasses (eye refraction);
• Orthopedic shoes (shoes for people whose feet are impaired, but intact);
• Routine or yearly physical exams (Medicare will cover a one-time initial preventive physical exam (the ”Welcome to Medicare” physical exam) within the first six months of the beneficiary enrolling in Part B—coinsurance and Part B deductible applies.); and
• Weight loss programs.

Additional Information
The Centers for Medicare & Medicaid Services (CMS) has developed a variety of educational resources for use by health care professionals and their staff as part of a broad outreach campaign to promote awareness and increase utilization of preventive services covered by Medicare. For more information about coverage, coding, billing, and reimbursement of Medicare-covered preventive services and screenings, visit http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage on the CMS Web site.

• Medicare Learning Network - The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s Web page at http://www.cms.hhs.gov/MLNGenInfo on the CMS Web site.
• Patient Resources - For literature to share with Medicare patients, please visit http://www.medicare.gov on the Internet.
• The National Diabetes Education Program - NDEP (http://ndep.nih.gov/) provides a wealth of resources for health care professionals, educators, business professionals, and patients about diabetes, its complications, and self-management.

If you have any questions, please contact your Medicare contractor (carrier, DME MAC, FI, and/or A/B MACs) at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications web page. To download and view, please go to http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS Web site.

Posted: 11/27/2007