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Introduction
Diabetes is the sixth leading cause of death in the United States. Seventeen million Americans have diabetes, and over 200,000 individuals die each year of related complications.
Millions of people have diabetes and do not know it. However, with early detection and treatment the more likely it is that the serious health consequences of diabetes can be prevented or delayed. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes. This benefit will help to improve the quality of life for Medicare beneficiaries by preventing more severe conditions that can occur without proper treatment from undiagnosed or untreated diabetes.
Risk Factors
To be eligible for the diabetes screening tests beneficiaries must have any of the following risk factors or at least two of the following characteristics: Individuals are considered at risk for diabetes if they have any of the following risk factors: - Hypertension
- Dyslipidemia
- Obesity (a body mass index greater than or equal to 30kg/m2)
- Previous identification of an elevated impaired fasting glucose or glucose intolerance
OR Individuals who have a risk factor consisting of at least 2 of the following characteristics:
- Overweight (a body mass index greater than 25 but less than 30kg/m2
- Family history of diabetes
- Age 65 or older
- A history of gestational diabetes mellitus, or delivery of a baby weighing greater than 9 pounds
Effective with services provided on or after January 1, 2005, Medicare provides coverage of diabetes screening tests for individuals in the risk groups previously listed or those diagnosed with pre-diabetes. This new benefit will allow for earlier diagnosis for Medicare beneficiaries, which will assist in treatment and management of the disease.
Pre-diabetes is a condition of abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100-125 mg/dL or a 2-hour post-glucose challenge of 140-199 mg/dL. The term "pre-diabetes" includes impaired fasting glucose and impaired glucose tolerance.
What Medicare Covers
- A fasting blood glucose test
AND - A post-glucose challenge test; not limited to an oral glucose tolerance test with a glucose challenge of 75 glucose for non- allenge of 75 glucose for non- pregnant adults
OR - A 2-hour post-glucose challenge test alone
- For those with pre-diabetes Medicare covers a maximum of two diabetes screening tests within a 12 month period (but not less than 6 months apart)
For those who are not diabetics or have not previously been diagnosed as pre-diabetics, Medicare covers on diabetes screening test within a 12 month period (or that at least 11 months have passed following the month in which the last Medicare covered diabetes screening test was performed) What the Physician Must Do
Provide a referral for an individual at risk for diabetes. What the Beneficiary Pays
There is no coinsurance, copayment or deductible for this benefit.
Page Last Modified: 07/03/2007 8:26:04 AM
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