Getting coverage for a hemoglobin A1c test to screen for diabetes was once a big hassle for patients and physicians.
Many physicians prefer to use this non-fasting test as their regular approach to screen patients, but making sure their patients have insurance coverage for this test has not been easy, according to Kate Kirley, MD, MS, AMA’s director of chronic disease prevention and programs.
“In my previous practice, if I wanted to offer the service to a patient who had Medicare, I had to do additional documentation and fill out a form in my EHR saying I had talked to the patient about how this was going to cost them more money, and that they were OK with it,” Dr. Kirley said.
New regulations lift that barrier. The 2024 Medicare Physician Fee Schedule made several updates to reduce barriers and expand beneficiaries' access for Diabetes screening and treatment services. One important change is that Medicare is now covering the hemoglobin A1C test for screening purposes, noted Dr. Kirley.
In other changes, the Centers for Medicare & Medicaid Services (CMS) expanded coverage of diabetes screening from one test annually to up to two tests annually for all patients at risk for type 2 diabetes. This offers a little more flexibility for a physician to rescreen a patient earlier if they have any clinical reason to think that a patient needs screening again, said Dr. Kirley.
A1c gets an upgrade
Medicare previously covered the hemoglobin A1c test to monitor, not screen, patients with type 2 diabetes.
“But now it can be used to screen for prediabetes and type 2 diabetes, which is great,” said Dr. Kirley.
What physicians and other health professionals like about this test is it gives them an overview of a person’s glucose over a three-month window. Other tests “just tell us what a patient's blood glucose is doing at that moment,” she explained. “So, it gives us a different lens to look at someone's glucose metabolism.”
Fasting can also be a challenge for some patients, particularly if they need to take medications in the morning with food.
“It may be very difficult for them to fast to be able to come to their doctor appointment later in the day,” said Dr. Kirley. If a patient forgets to fast at the time of the appointment, they have to return for another lab visit later.
A huge benefit of the A1c test is patients don’t have to fast.
Medicare’s coverage of this test will make it much easier for physicians to screen their patients consistently, said Dr. Kirley. “It’s really much more aligned with what most commercial payers have done for a long time.”
More screenings and early diagnosis
Covering the A1c test is expected to lead to more screenings and earlier diagnoses. This will lead to more referrals to the Medicare Diabetes Prevention Program (MDPP).
The MDPP is an evidence-based behavioral intervention that aims to prevent or delay the onset of type 2 diabetes for Medicare beneficiaries diagnosed with prediabetes. MDPP uses a National Diabetes Prevention Program curriculum approved by the Centers for Disease Control and Prevention. The program addresses diet, physical activity and weight loss.
Meanwhile, the short-term goal of the program is to help individuals lose at least 5% of their weight, with the longer-term goal of improved health.
In the MDPP, Medicare pays organizations—called MDPP suppliers—to provide up to one year of structured behavioral change sessions facilitated by health coaches. MDPP suppliers can be hospitals, community-based organizations, physician practices, federally qualified health centers, diabetes self-management training providers, YMCAs, churches and other similar types of organizations that meet eligibility requirements.
The MDPP does not require a physician referral and MDPP suppliers can receive up to $768 per MDPP beneficiary. There are no out-of-pocket costs for MDPP for beneficiaries enrolled in fee-for-service Part B Medicare.
Additionally, beneficiaries must have results in the prediabetes range from a blood test conducted within a year of their first MDPP session to be eligible for MDPP. One of the acceptable blood tests to determine MDPP eligibility is the hemoglobin A1C test.
Watch this “AMA Update” interview with Dr. Kirley to learn more about Medicare diabetes screening changes.
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No limit to Medicare DPP sessions
The Medicare Diabetes Prevention Program (MDPP) itself has undergone some important changes. One big update is there’s no limit to how many virtual sessions beneficiaries can participate in. When the program started, patients were required to attend sessions in person. Once the COVID-19 pandemic hit, “CMS became a bit more flexible, recognizing the need for people to be able to attend through distance learning and other approaches,” said Dr. Kirley.
Medicare DPP providers can now deliver as many distance learning sessions to participants as they want.
The new, flexible options will help advance health equity by making this evidence-based intervention more accessible to patients in rural and other underserved areas who have difficulty traveling to an in-person session for any variety of reasons.
“This really should help create better access to this important, preventive intervention,” she said.
Visit AMA Advocacy in Action to find out what’s at stake in diabetes prevention and other advocacy priorities the AMA is actively working on.
What physicians can do
It remains important for physicians to use clinical judgment to determine whether the A1c test is the appropriate one to use in screening patients for type 2 diabetes and prediabetes.
“There might be reasons to use another of the available screening tests to use with a patient,” Dr. Kirley said. But physicians “should be consistently offering some form of diabetes and prediabetes screening to their patients who are at risk for it, and hopefully ordering this test more often for their Medicare beneficiaries.”
Physician practices should also consider building screening protocols into their EHRs to accommodate the newly covered A1c test.
It is important to develop structures and processes to make screening routine, said Dr. Kirley.
Medicare aligning its coverage to clinical guidelines of the U.S. Preventive Services Task Force and various payers will make it lot easier for physicians to put these protocols into place to screen for prediabetes and type 2 diabetes, she said.
Listen to this “AMA STEPS Forward® Podcast” episode about expanded Medicare coverage for screening tests for type 2 diabetes and prediabetes prevention.
The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies.
This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage their risk of developing type 2 diabetes, including referring patients at risk to a National Diabetes Prevention Program lifestyle-change program based on their individual needs.
