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Does Medicare offer coverage for prediabetes?


Medicare has its own yearlong diabetes prevention program, consisting of weekly group sessions and periodic screenings to help people with prediabetes avoid or delay developing the disease. To be eligible, you must meet specific conditions.

Almost half of U.S. adults 65 and older have prediabetes, according to the Centers for Disease Control and Prevention (CDC). Those diagnosed have higher than normal blood sugar levels, but they’re not high enough to be diagnosed with type 2 diabetes. Having prediabetes increases your chance of developing type 2 diabetes, but you can take steps to prevent the progression, which is where Medicare’s prediabetes coverage comes in.

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You can quickly assess your risk of having prediabetes with the CDC’s one-minute prediabetes risk test. It takes your height, weight, activity level, family history of diabetes, age and other factors into account.

The only way to know for sure whether you have prediabetes is through a blood test. If you have certain risk factors, the Medicare Diabetes Prevention Program covers your participation.

How do I qualify for diabetes prevention under Medicare?

The Medicare Diabetes Prevention Program covers group sessions with a trained coach who will work with you to identify diet and behavioral changes to increase your activity level and set goals. Diet and exercise are known to help decrease the risk of developing diabetes.

The program has shown to lower the risk of developing type 2 diabetes by more than 70 percent for people 60 and older, the Centers for Medicare & Medicaid Services says.

To qualify, you must have:

body mass index (BMI) of 25 or higher; for someone of Asian descent, it’s 23 or higher.

Received one of the following blood sugar test results within a year of your first group session: 

  • Fasting plasma glucose of 110 to 125 milligrams per deciliter (mg/dL) of blood. A milligram is one-thousandth of a gram. A deciliter is one-tenth of a liter.
  • Oral glucose tolerance results of 140 to 199 mg/dL.
  • Hemoglobin A1C of 5.7 percent to 6.4 percent.

No history of type 1 or type 2 diabetes, not including gestational diabetes.

No diagnosis of end-stage kidney disease.

Not participated previously in Medicare’s diabetes prevention program.

What benefits does the diabetes prevention program offer?

The program begins with six months of intensive weekly group sessions. A trained lifestyle coach will work with you to increase your level of exercise, change your diet and help you control your weight. You’ll work alongside others with prediabetes risk factors to motivate one another and reach goals.

After you complete the first six months, you’ll get six monthly follow-up sessions to help you maintain your healthy habits. If you started the program in 2021 or earlier, you can receive 12 additional monthly sessions by meeting predetermined weight loss goals. 

How much does the diabetes prevention program cost?

Medicare Part B covers the program as a free preventive service without any deductibles or copayments. But an approved Medicare diabetes prevention provider must administer the program.

This could be a health care provider or a program through a local community center or faith-based organization. You can find an eligible provider near you in Medicare’s database of diabetes prevention providers.

The Medicare Diabetes Prevention Program is available to eligible Medicare beneficiaries who participate in either original Medicare or a Medicare Advantage plan.

Does Medicare cover prediabetes screening?

Medicare covers up to two diabetes screenings a year if your doctor determines you’re in danger of developing diabetes and have any of the following risk factors:

  • High blood pressure.
  • History of abnormal cholesterol or triglyceride levels.
  • History of high blood sugar.
  • Obesity, which is defined as a BMI of 30 or higher.

You may also be eligible for a free screening if two or more of the following apply to you:

  • Age 65 or older.
  • Gestational diabetes during pregnancy or delivered a baby weighing more than 9 pounds.
  • Overweight with a BMI of 25 to 29.9.
  • Parents or siblings with diabetes.

If you meet the criteria, Medicare Part B covers these screenings as a free preventive service without deductibles or copayments, but only if your doctor accepts assignment.

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Video: Daily Habits That Could Raise Your Diabetes Risk

Keep in mind

If you develop diabetes, Medicare covers insulin, a diabetes self-management program, diabetes supplies, and several other diabetes-related tests and services. Medicare Part D can cover antidiabetic drugs to help with blood sugar, such as Ozempic, when prescribed for type 2 diabetes but not for weight loss.

Some Medicare Advantage special needs plans focus on covering certain chronic conditions, including diabetes. These plans may help coordinate care among providers and have special coverage for diabetes medicine and supplies. However, they often come with a provider network.

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