{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T19:31:14Z","timestamp":1786390274384,"version":"build-2736575974"},"reference-count":45,"publisher":"American Diabetes Association","issue":"4","license":[{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"vor","delay-in-days":7,"URL":"https:\/\/www.diabetesjournals.org\/journals\/pages\/license"}],"funder":[{"DOI":"10.13039\/100000062","name":"National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"publisher","award":["R01DK141666"],"award-info":[{"award-number":["R01DK141666"]}],"id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["P30AG028747"],"award-info":[{"award-number":["P30AG028747"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["P30AG097158"],"award-info":[{"award-number":["P30AG097158"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["diabetesjournals.org"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,7,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>To provide primary care professionals with practical strategies for navigating Medicare coverage across all domains of diabetes management to reduce financial and administrative barriers while optimizing treatment access.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESEARCH DESIGN AND METHODS<\/jats:title>\n                    <jats:p>This comprehensive guide examines Medicare coverage policies for diabetes care across Parts A, B, C (Medicare Advantage), and D. We analyze coverage requirements for clinical services, pharmacotherapy, diabetes technologies, and preventive care, with particular attention to recent legislative reforms including the Inflation Reduction Act of 2022. We present actionable protocols for coverage verification, clinical documentation, prior authorization management, and patient education, incorporating team-based workflow approaches that distribute navigation responsibilities according to staff expertise.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>More than one in four Medicare beneficiaries have diabetes, yet health care professionals receive minimal training in insurance navigation despite its direct impact on treatment access and clinical outcomes. Medicare\u2019s fragmented benefit structure creates substantial barriers: patients face complex coverage pathways for medications, diabetes technologies, specialist consultations, and diabetes self-management education, while health care teams navigate burdensome prior authorization processes consuming 13 h per physician weekly. Recent reforms have transformed coverage: the Inflation Reduction Act established a $35 monthly insulin cap, implemented a $2,000 annual out-of-pocket spending limit (effective 2025), and authorized drug price negotiations yielding 66%\u201379% reductions for four diabetes medications in 2026.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>By implementing systematic Medicare navigation strategies and team-based workflows that protect clinician time for direct patient care, primary care teams can reduce financial and administrative barriers, optimize treatment access, and improve health outcomes for millions of Medicare beneficiaries living with diabetes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.2337\/doc26-0016","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T14:30:12Z","timestamp":1783521012000},"page":"714-724","update-policy":"https:\/\/doi.org\/10.2337\/ada-journal-policies","source":"Crossref","is-referenced-by-count":0,"title":["Medicare Coverage for Diabetes Management: A Primary Care Professional\u2019s Guide to Advocacy and Navigation"],"prefix":"10.2337","volume":"1","author":[{"given":"Umailla","family":"Naeem","sequence":"first","affiliation":[{"name":"University of Maryland School of Medicine 1 , Baltimore, MD"},{"name":"University of Maryland Institute for Health Computing 2 , North Bethesda, MD"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0348-742X","authenticated-orcid":false,"given":"Kasia J.","family":"Lipska","sequence":"additional","affiliation":[{"name":"Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale School of Medicine 3 , New Haven, CT"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2289-3183","authenticated-orcid":false,"given":"Rozalina G.","family":"McCoy","sequence":"additional","affiliation":[{"name":"University of Maryland Institute for Health Computing 2 , North Bethesda, MD"},{"name":"Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine 4 , Baltimore, MD"},{"name":"Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine 5 , Baltimore, MD"},{"name":"Department of Health Policy and Management, School of Public Health, University of Maryland 6 , College Park, MD"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1167","published-online":{"date-parts":[[2026,7,8]]},"reference":[{"key":"2026081014514011500_B1","unstructured":"Chronic Conditions Data Warehouse.\n          \n          Medicare Chronic Condition Charts. Accessed 30 November 2025. Available from https:\/\/www2.ccwdata.org\/medicare-charts\/medicare-chronic-condition-charts"},{"key":"2026081014514011500_B2","article-title":"Medicare & You Handbook 2026"},{"key":"2026081014514011500_B3","volume-title":"Diabetes in America.","author":"Hirsch","year":"2023"},{"key":"2026081014514011500_B4","doi-asserted-by":"crossref","first-page":"26","DOI":"10.2337\/dci23-0085","article-title":"Economic costs of diabetes in the U.S. in 2022","volume":"47","author":"Parker","year":"2024","journal-title":"Diabetes Care"},{"key":"2026081014514011500_B5","volume-title":"Diabetes in America.","author":"Casagrande","year":"2023"},{"key":"2026081014514011500_B6","unstructured":"Fuglesten Biniek\n              J\n            , SroczynskiN, FreedM, NeumanT. Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. KFF, 2025. Accessed 15 October 2025. Available from https:\/\/www.kff.org\/medicare\/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023\/"},{"key":"2026081014514011500_B7","unstructured":"The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds\n          . 2025 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC, Centers for Medicare & Medicaid Services, 2025. Accessed 15 October 2025. Available from https:\/\/www.cms.gov\/oact\/tr\/2025"},{"key":"2026081014514011500_B8","unstructured":"Ochiend\n              N\n            , FreedM, Fuglesten BiniekJ, DamicoA, NeumanT. Medicare Advantage in 2025: enrollment update and key trends. KFF, 2025. Accessed 15 October 2025. 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Available from https:\/\/www.ama-assn.org\/system\/files\/prior-authorization-survey.pdf"},{"key":"2026081014514011500_B15","unstructured":"Yarmuth\n              JA\n            \n          . Summary: H.R.5376 \u2014 117th Congress (2021\u20132022). Congress.gov, 2022. Accessed 15 October 2025. Available from https:\/\/www.congress.gov\/bill\/117th-congress\/house-bill\/5376"},{"key":"2026081014514011500_B16","unstructured":"KFF. The facts about Medicare spending. 2025. Accessed 30 November 2025. Available from https:\/\/www.kff.org\/interactive\/the-facts-about-medicare-spending\/"},{"key":"2026081014514011500_B17","first-page":"qxaf042","article-title":"Medicare Part D insulin coverage: formulary strategies amid policy headwinds","volume":"3","author":"Buttorff","year":"2025","journal-title":"Health Aff Sch"},{"key":"2026081014514011500_B18","unstructured":"Cass\n              A\n            \n          . Nearly half of health systems are considering dropping Medicare Advantage plans. Becker\u2019s Hospital Review; 22 March 2024. Accessed 26 January 2026. Available from https:\/\/www.beckershospitalreview.com\/finance\/nearly-half-of-health-systems-are-considering-dropping-ma-plans\/"},{"key":"2026081014514011500_B19","unstructured":"March 2025 Report to the Congress: Medicare Payment Policy, 2025. Accessed 26 January 2026. Available from https:\/\/www.medpac.gov\/document\/march-2025-report-to-the-congress-medicare-payment-policy\/"},{"key":"2026081014514011500_B20","unstructured":"KFF. Medicare Advantage plans denied a larger share of prior authorization requests in 2022 than in prior years. 2024. Accessed 30 November 2025. Available from https:\/\/www.kff.org\/medicare\/medicare-advantage-plans-denied-a-larger-share-of-prior-authorization-requests-in-2022-than-in-prior-years\/"},{"key":"2026081014514011500_B21","unstructured":"Office of Inspector General\n          . 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FAQs on CGM coverage criteria changes in Medicare"},{"key":"2026081014514011500_B32","article-title":"American Academy of Family Physicians. Resources for Continuous Glucose Monitoring (CGM)","year":"2024"},{"key":"2026081014514011500_B33","first-page":"17","article-title":"Medicare coverage of continuous glucose monitoring\u20142023 updates","volume":"31","author":"Oser","year":"2024","journal-title":"Fam Pract Manag"},{"key":"2026081014514011500_B34","unstructured":"Pollitz\n              K\n            , PestainaK, LopesL, WallaceR, LoJ. Consumer problems with prior authorization: evidence from KFF survey. KFF, 2023. Accessed 15 October 2025. Available from https:\/\/www.kff.org\/affordable-care-act\/consumer-problems-with-prior-authorization-evidence-from-kff-survey\/"},{"key":"2026081014514011500_B35","unstructured":"American Diabetes Association. American Diabetes Association (ADA) Advocacy Resources. Accessed 30 November 2025. 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