Medicare Part B: Insulin pump coverage
Individuals type 1 diabetes or other insulin-dependent conditions may qualify for an insulin pump under Medicare Part B. Medicare covers insulin pumps deemed medically necessary as part of the Durable Medical Equipment benefit (DME), which covers certain medical equipment used at home.
Qualifying for insulin pump and insulin coverage
To qualify under the Medicare Part B DME benefit, insulin pumps must be worn externally and must be deemed medically necessary by a physician. Individuals with diabetes are eligible for coverage if their glucose is difficult to control. For the most part, qualified patients suffer from type 1 diabetes, but some type 2 and gestational diabetes patients may be eligible as well. Most patients must complete a diabetes education program before qualifying for coverage.
To get coverage for an insulin pump, follow these steps:
- Visit a physician. The doctor will evaluate a patient's glucose levels and current blood glucose maintenance regimen to determine whether she qualifies for an insulin pump. Patients must typically document a history of daily glucose testing and frequent adjustments to insulin doses to qualify.
- Verify medical necessity. The doctor must submit a Certificate of Medical Necessity to Medicare.
- Get a prescription. The doctor writes a prescription for the insulin pump and insulin. This prescription must be renewed annually for continuing eligibility.
Choose a Medicare-approved supplier
To ensure coverage, patients must take care to choose a Medicare-approved supplier. Medicare advises patients to ask insulin pump suppliers two questions:
- Are they enrolled in Medicare?
- Are they a participating supplier in the Medicare Program?
Patients should seek a supplier that meets both qualifications. If the supplier is not enrolled, Medicare will not pay the claim at all. If the equipment provider is not a participating supplier, the provider may not accept Medicare's reimbursement structure, known as 'assignment.' This means that the patient is liable for all costs in excess of the Medicare-approved amount.
As of January 2011, Medicare may require patients in some states to use a particular supplier. The new program uses competitive bidding to help Medicare get the best deal on equipment. This requirement is in effect in parts of California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina and Texas.
To find a Medicare supplier, select 'Find Suppliers of Medical Equipment in Your Area' on the Medicare website. Patients without local access to a qualified supplier may order products online or by mail order.
Medicare and paying for insulin pumps
A prescription for an insulin pump entitles the patient to 80 percent coverage of the equipment from a Medicare-approved supplier. The patient pays 20 percent of the Medicare-approved cost as well as the Medicare Part B deductible, if applicable. Patients whose insulin pumps are covered under Medicare Part B can also receive coverage for insulin under Part B benefits. The same payment structure and deductibles apply to insulin as to insulin pumps.