June 2, 2006
DIABETES SUPPLIES INSURANCE AND MEDICARE COVERAGE
By: Helga Niesz, Principal Analyst
Janet L. Kaminski, Associate Legislative Attorney
You asked whether diabetic supplies must be covered (1) under the private group and individual medical insurance policies issued in this state, (2) by Medicare and whether this type of coverage is involved in the new Medicare Part D program, (3) by ConnPACE, and (4) by Medicaid.
Connecticut law requires group and individual medical insurance policies to cover diabetic supplies. Medicare Part B also provides such coverage for seniors, including blood glucose testing monitors, test strips, lancet devices, lancets, and glucose control solutions. The new Medicare Part D prescription plans cover the prescription drugs themselves, including insulin and only those supplies needed to inject insulin, including syringes, needles, alcohol swabs, and gauze. The state's Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) program covers prescription drugs, insulin and insulin syringes; but it does not cover other diabetic supplies. The Medicaid program covers diabetic supplies; it also still covers prescription drugs and insulin for those who are only eligible for Medicaid and not Medicare.
PRIVATE GROUP AND INDIVIDUAL INSURANCE COVERAGE
State insurance law requires health insurance policies to cover medically necessary laboratory and diagnostic tests for all types of diabetes, including insulin-dependent, insulin- and non-insulin-using, and gestational diabetes. It requires coverage for medically necessary equipment specified in the insured's treatment plan and drugs and supplies prescribed by a licensed health care professional authorized to issue prescriptions. The law applies to group policies (CGS § 38a-518d) and individual policies (CGS § 38a-492d). For diabetic supplies, the insurance companies can impose the same copays they have for durable medical equipment (CGS § 38a-518e(c)).
Medicare Part B already covered and continues to cover diabetes supplies, including blood glucose testing monitors, blood glucose test strips, lancet devices, lancets, and glucose control solutions. Some beneficiaries can also qualify for coverage of therapeutic shoes and diabetes self-management training. (Medicare Part A generally covers hospitalization costs and Part B covers doctor visits and other services, including the diabetes supplies.) After the overall annual deductible is paid, Medicare covers 80% of the approved cost and the patient covers 20%. If the patient has Medicare supplement insurance, that policy may pay the patient's portion.
The new Medicare Part D-approved private prescription plans cover diabetes-related prescription drugs and only those supplies needed to inject insulin, including syringes, needles, alcohol swabs, and gauze.
More information is available at the Medicare Diabetes Health Information website at:
CONNECTICUT PHARMACEUTICAL ASSISTANCE CONTRACT TO THE ELDERLY AND DISABLED
ConnPACE covers prescription drugs, insulin and insulin syringes. It does not cover any other diabetic supplies, such as the monitors or test strips. But since ConnPACE serves people who are age 65 and older and younger disabled people, most ConnPACE participants are also eligible for Medicare and would be covered through Part B. ConnPACE participants who enroll in a Medicare Part D plan do not pay more than their usual maximum $16.25 per-prescription ConnPACE copay.
The Medicaid program, which serves very poor families (mainly through HUSKY A managed care), and elderly and disabled people (through fee-for-service), also covers diabetic supplies, insulin, and prescriptions. But poor elderly or disabled people who are eligible for both Medicare and Medicaid receive these benefits first through Medicare Part B and D and then Medicaid pays the remainder.