The Medicare Diabetes Prevention Program and More

Medicare Coverage for Diabetes from Prevention to Treatment

Diabetes is a growing problem in the United States. According to the Centers for Disease Control and Prevention, more than 34.2 million Americans have diabetes and 88 million have pre-diabetes. The number continues to rise and with it the medical complications that come with it.

The American Diabetes Association estimates that people who have diabetes spend 2.3 times more on health care, $237 billion in direct costs, and $90 billion in decreased productivity in 2017 alone.

The disease is costing America and Medicare, not only in health and quality of life but in dollars and cents. To decrease the burden of diabetes on American seniors, Medicare coverage for diabetes includes prevention, screening, and treatment.

Medicare Diabetes Prevention Program MDPP
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Medicare Screening for Diabetes

Medicare covers diabetes screening free of charge for people at risk for the condition. Testing for the condition may include a fasting glucose measurement, a simple blood test that checks how much sugar is in your blood after eight to 12 hours of fasting.

Other options include an oral glucose tolerance test, which measures your blood sugar level before and after a glucose challenge. A hemoglobin A1c test is yet another approach and reflects how much your blood sugars average over the course of three months.

You are eligible for one of these diabetes screening tests every 12 months if you have one of the following:

  • Dyslipidemia (high cholesterol)
  • Glucose intolerance (history of high blood sugar readings)
  • Hypertension (high blood pressure)
  • Obesity (body mass index of 30 or more)

Alternatively, you may be eligible for diabetes screening twice a year if you have at least two of the following criteria:

  • 65 years or older
  • Family history of diabetes in first-degree relatives (parents, brothers, sisters)
  • Gestational diabetes (diabetes during pregnancy) or delivering a baby weighing 9 pounds or more
  • Overweight (body mass index between 25 and 30)

If you have been diagnosed with prediabetes, meaning that your blood sugars are higher than normal but not high enough to be classified as diabetes, Medicare will cover two diabetes screening tests each year.

Medicare Diabetes Prevention Program (MDPP)

The Centers for Medicare and Medicaid Services is making diabetes prevention a priority. An $11.8 million initiative paid for by the Affordable Care Act trialed a pilot program with the National Council of Young Men’s Christian Associations of the United States of America (YMCA) in 2011.

The goal was to promote long-term lifestyle changes that promote healthy eating and regular physical activity. The pilot results were so impressive that they were implemented as the Diabetes Prevention Program nationwide in 2018.

To be eligible for MDPP, you must have a BMI of at least 25 (23 if you identify as Asian) and have no previous diagnosis of diabetes or end-stage renal disease. You must also have an abnormal blood sugar reading within 12 months of your first session that includes one of the following:

  • A hemoglobin A1c test with a value between 5.7 and 6.4%
  • A fasting plasma glucose of 110-125 mg/dL
  • A two-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)

You would then participate in group classes with CDC-approved curricula tailored to decrease your risk for diabetes, eat healthier, increase your activity level, and decrease your weight. There are 16 sessions offered across the first six months and six sessions between seven and 12 months.

If you meet attendance requirements and weight loss goals (5% weight loss or more), you may be able to continue with maintenance sessions for an additional year. These sessions are free for you but it is a benefit offered to you only once in your lifetime.

The pilot study showed a 5% weight loss for Medicare participants at risk for diabetes as well as a decrease in emergency department and inpatient hospitalizations. Health spending for these beneficiaries decreased by $2,650 over a 15-month period.

It is estimated that CMS would have a return on investment of $2.2 for every $1 spent for a first year and $3 for every $1 for the subsequent years for each participant in the program.

Unfortunately, follow-up has shown that there is inadequate access to Medicare Diabetes Prevention Program sites in this country. Only 25% of states have an MDPP site and there are fewer than 1 sites per 100,000 Medicare beneficiaries.

Services for Diabetes

If you have diabetes, your healthcare provider will want to take any steps necessary to stop complications from developing. Beyond monitoring your blood sugar, prescribing medication, and performing routine examinations, they may need to refer you to see certain specialists.

  • Nephrologist (kidney doctor): People with diabetes-related kidney problems may be monitored by a nephrologist to hopefully slow or prevent the progression of the disease. The frequency of evaluations will depend on the severity of the nephropathy and will cost you a 20% coinsurance per visit.
  • Nutritionist: Everyone with diabetes should be offered one-on-one medical nutrition counseling with a nutrition specialist. The initial visit and follow-up evaluations are free of charge if your doctor accepts the assignment.
  • Ophthalmologist (eye doctor): The longer someone has diabetes, the higher the risk of developing retinopathy. Retinopathy puts you at risk for decreased vision and in severe cases, blindness. Expect to pay a 20% coinsurance for Medicare to cover the recommended once annual dilated eye exam.
  • Podiatrist (foot doctor): People with diabetes but especially those with diabetes-related nerve damage to their feet qualify for evaluations by a podiatrist or other qualified professionals twice a year. The foot doctor will monitor for sensory changes as well as decreased blood flow to the feet that could put you at risk for skin ulcerations and other complications.

Group classes may also be offered for diabetes self-management training and education. These self-management services are covered for someone who is newly diagnosed with diabetes but are also available to anyone at risk of complications from the disease.

In the first year of services, Medicare will cover up to 10 hours of self-management training (one hour in a one-on-one session and nine hours in group sessions).

In subsequent years (starting at least one calendar year after your initial training), Medicare will cover two extra hours of training per year as long as the training is conducted in group sessions of at least a 30-minute duration and including two to 20 people each. Out of pocket, each session will cost a 20% coinsurance.

Diabetic Supplies and Treatments

Your healthcare provider may want you to monitor your blood sugar if you are diagnosed with diabetes. This may be the case whether you take oral medications or insulin to manage your blood sugar.

The following supplies are covered by the Medicare Part B benefit and will allow you to test your blood sugars properly. You will pay a 20% coinsurance for these supplies though oftentimes, glucometers may be offered free of charge:

  • Glucose monitors
  • Control solutions
  • Lancets
  • Test strips

Special therapeutic shoes and inserts may be covered once per year by Medicare Part B for those who have diabetic neuropathy and related foot disease. These shoes cost 20% coinsurance and require a prescription from a Medicare-approved doctor.

Not only that but the medical supplier of those shoes must have a contract with the Medicare program. To assure the best results, Medicare also pays for proper fitting of these shoes and/or inserts.

For those who require insulin, further equipment and supplies are needed to administer the drug. This includes:

Insulin pumps and insulin that is administered through these pumps are covered under Medicare Part B. Otherwise, insulin and the above listed supplies are covered by your Part D drug plan. Your Medicare Part D drug plan will cover other medications to treat your diabetes as long as they are on your plan’s medication formulary.

A Word From Verywell

The Medicare Diabetes Prevention Program decreases your risk of getting the disease. If you are diagnosed with diabetes at any time, Medicare also offers resources to treat the condition and decrease its complications. Knowing how to best treat diabetes, what Medicare covers, and how much it will cost are important as you move forward.

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Article Sources
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  1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. August 7, 2020.

  2. American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018 Mar;dci180007. doi:10.2337/dci18-0007

  3. Alva ML, Hoerher TJ, Jeyaraman R, Amico P, Rojas-Smith L. Impact of the YMCA of the USA Diabetes Prevention Program on Medicare spending and utilization. Health Aff (Millwood). 2017;36(3):417-424. doi:10.1377/hlthaff.2016.1307

  4. Ritchie ND, Sauder KA, Gritz RM. Medicare Diabetes Prevention Program: Where Are the Suppliers? Am J Manag Care. 2020;26(6):e198-e201. doi:10.37765/ajmc.2020.43496