Get the Medicare Coverage You Need for a Chronic Condition

What to look for if you have diabetes, kidney failure, cancer or heart failure

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If you have a chronic condition, you have special needs to consider when making Medicare decisions.

You may want original Medicare, which covers any doctor or hospital that participates in the Medicare program and has very few prior authorization requirements. Or you may be attracted to a private Medicare Advantage plan that has special coverage for people with chronic conditions – such as transportation to doctor’s appointments, meal benefits, some in-home support and care coordination – even though it has a limited provider network.

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Some Medicare Advantage special needs plans (SNPs) also may be available in your area that focus on your specific condition.

Whether you choose original Medicare and a Part D prescription drug plan or a private Medicare Advantage plan for your health and drug coverage, it’s important to review your options during open enrollment every year to make sure you have the best coverage for your chronic condition. Consider the following when choosing a plan and making the most of your Medicare coverage if you have diabetes, kidney failure, cancer or heart disease.

Medicare and diabetes

• Prediabetes programs
• Diabetes care
• Insulin costs
• Continuous glucose monitors
• Weight loss drugs
• Chronic condition coverage

Diabetes

• If you use insulin, find out whether Medicare Advantage or Part D covers the insulin you use. The Inflation Reduction Act capped insulin copays at $35 per month starting in 2023. But not all plans cover all types of insulin. Also compare the cost of your other medications.

• Choose a pharmacy or medical supply company that accepts payment from Medicare for supplies like glucose monitors and test strips. “That will save you money in the long term,” says Laura Friedman, vice president of regulatory affairs at the American Diabetes Association. If a pharmacy or company accepts payment from Medicare, Part B will cover 80 percent of the cost of your supplies and you’ll have a 20 percent copayment that Medigap or a retiree plan will cover. You can search for medical equipment and suppliers by zip code at Medicare.gov. Medicare expanded coverage for continuous glucose monitors to more people with diabetes in 2023.

• Make sure your endocrinologist and other doctorsare covered if you’re considering a Medicare Advantage plan. Some plans provide special benefits for people with diabetes, such as low- or no-cost sharing for visits to an endocrinologist, over-the-counter drug benefits, and additional podiatry visits and vision screenings, says Christine Leo, vice president of Medicare products at Cigna.

• Find out if there’s a diabetes SNP available in your area. These plans, which aren’t available everywhere, may offer additional specialized benefits, such as blood glucose and insulin management tools, nutritional counseling, a fitness program and routine podiatry and wound care. Your primary care doctor may work with your endocrinologist to coordinate care.

• Find out about otherMedicare coverage for diabetes. For example, Medicare offers a prediabetes prevention program for people at high risk of developing type 2 diabetes. It also covers nutrition therapy, a diabetes self-management program, and eye exams and foot exams for people with diabetes, which generally aren’t covered under original Medicare.

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Kidney failure

• If you have kidney failure — also known as end-stage renal disease (ESRD) — and you need regular dialysis or have had a recent kidney transplant, you may qualify for Medicare before you turn 65. Currently, 17 states won’t guarantee access to Medigap supplemental insurance for people who have kidney failure and are under age 65. If that’s the case for you, consider enrolling in a Medicare Advantage plan. “These plans have an annual out-of-pocket maximum,” says Holly Bode, vice president of government affairs at the American Kidney Fund. “This cap on out-of-pocket expenses is particularly important for patients who don’t have guaranteed access to Medigap.”

• Medicare Advantage plans may offer additional benefits, such as a care coordinator and transportation to and from dialysis appointments. A Medicare Advantage SNP for people with end-stage renal disease may include education, self-training, services and supplies to support dialysis and manage care, transportation, nutritional counseling, and a dedicated kidney care team that works with your primary care doctor and nephrologist to coordinate your care, says Neil Steffens, president of Elevance Health’s Medicare East Region.

• If you’re interested in a Medicare Advantage plan, make sure your nephrologist and dialysis provider are covered. Also, find out which kidney transplant centers are included in the plan’s network.

• Find out how dialysis is covered. Original Medicare covers outpatient dialysis under Part B, which has a 20 percent copayment that can be covered by a Medigap policy or retiree coverage. If you have Medicare Advantage and travel frequently to a second home or to visit family members, find out how dialysis providers would be covered in the other location.

Cancer

• Cancer SNPs are rare, but some standard Medicare Advantage plans offer extra coverage that can help, such as transportation to chemotherapy or radiation therapy appointments. “You’re often asked not to drive to those appointments, so transportation may be an important benefit for people who have cancer,” says Leo.​​ The type of transportation service, number of trips and distance you can travel varies from plan to plan, says Anna Howard of the American Cancer Society’s Cancer Action Network.

• Make sure your oncologist, other doctors and hospitals you want to use are covered by your plan. Having the flexibility to choose your own doctor can be particularly important to consider when deciding between original Medicare and Medicare Advantage. “Cancer is not just one disease, and oncologists may have different subspecialties,” says Howard. “Cancer treatment can vary and can consist of surgery, chemotherapy and/or radiation. Each of these treatments may be handled by different providers.”

• Some academic medical centers that offer advanced treatments may not be included in a Medicare Advantage plan’s network. Check on the hospitals in your area, as well as other hospitals where you may want to go for special treatment. For example, the MD Anderson Cancer Center, which is headquartered in Houston, with hospitals in a few other states and contracted with Blue Cross Blue Shield plans in several states, has working relationships with some other Medicare Advantage plans. They recommend contacting your plan to find out if it will cover services provided by MD Anderson. Original Medicare, on the other hand, covers all hospitals that accept Medicare.

• Find out about any prior authorization requirements. Some Medicare Advantage plans require you to obtain approval before you have surgery or imaging procedures, says Howard.

• Understand coverage for chemotherapy. If you have original Medicare, it’s covered by Part B. You’ll have a 20 percent copayment that can be covered by Medigap, a retiree plan or other supplemental coverage.

• Compare out-of-pocket costs for your prescription drugs under the Part D or Medicare Advantage plans available in your area. Cancer drugs are among the most expensive drugs covered by Part D.