diabetic insulin pumps covered by medicare

Diabetic Insulin Pumps

Does Medicare Cover Insulin Pumps?

Medicare will cover the cost of an insulin pump if you have an honest medical need for it. To ensure that Medicare pays for your pump you must follow the steps below:

  • Only your doctor can prescribe an insulin pump for you, so do not order anything until you have visited your doctor.
  • Your treating doctor must document the need in your medical records and give you a prescription for the pump.
  • The order must be received by the supplier before Medicare is billed and it must be kept on file by the supplier.
  • If you receive your Medicare through a Medicare Medical Advantage Plan (like a HMO, PPO) it is likely you will have to follow the plan's steps for approval and purchase. Make a point of calling your plan's customer service number and ask about their steps for coverage of an insulin pump.

How Do I Qualify for the Coverage for an Insulin Pump?

You must be covered under Part B of Medicare and one of the following conditions must be met:

  • Have Type I insulin-dependent diabetes
  • Have Type 2 insulin-dependent diabetes with blood sugar that is difficult to control
  • Have gestational diabetes with blood sugar that is difficult to control.

You must also have the following:

  • Completed a comprehensive diabetes education program, and
  • Been on a program of multiple daily injections (at least three per day), with frequent adjustments of insulin dose for at least six months, and
  • Documented glucose self-testing four times a day for at least two months

If Covered, Where Do I Buy the Insulin Pump?

You will save money if you order your pump from a Medicare approved provider. Suppliers must meet strict standards to qualify as a Medicare supplier and will have a Medicare supplier number. You may also buy your pump from any store that sells them. However, if the supplier from which you order your pump is not enrolled in Medicare, Medicare will not pay for the pump.

Things you should think about before you choose a supplier:

  • There are two types of Medicare suppliers, participating suppliers and those who are enrolled but have chosen not to participate.
  • A Medicare-certified supplier who does not want to participate can charge more than the Medicare-approved amount. However, they cannot charge more than 15 percent above the Medicare-approved amount. They may also ask you to pay the entire bill when you pick up the pump. In this situation Medicare will send the reimbursement directly to you. However, be prepared to wait; it may take a couple months to receive payment.
  • If you receive your Medicare coverage through a Medicare Advantage Plan (HMO or PPO), it is likely that the plan will have its own steps for insulin pump purchases. In addition, the plan may have restrictions on the supplier from which you can buy. It is important to know that your health plan must supply at least what Medicare covers -- they cannot supply less. Depending on your plan you may actually receive more coverage than you would get with Medicare alone. It is wise to call your Medicare Advantage Plan's customer service and ask about your coverage before you order an insulin pump.

What Will the Insulin Pump Cost Me?

Insulin pumps are in the Capped Rental category for durable medical equipment; that means you may choose to rent or purchase an infusion pump. How much you pay will depend on whether or not you have Part B coverage and where you buy your pump. However, in general, if you are enrolled in Medicare Part B:

  • After you have paid your yearly deductible, you will pay 20 percent of the approved Medicare amount for the cost of the pump.
  • If you have a Medicare supplement plan (MediGap policy) you may owe little to nothing out of pocket.
  • You will pay less if you buy from a supplier who accepts the assignment.
  • If you receive your Medicare through a Medicare Advantage Health Plan, you may owe little to nothing depending on the plan with which you have signed up and your benefits with the plan.
It is important to do your homework. Read about the factors that affect how much coverage you will receive. Make sure all paperwork is completed correctly and that you buy your pump through an approved supplier that accepts assignment. For more information call 1-800-MEDICARE (1-800-633-4227).

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