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Analysts project that the updated Medicare policy will expand access to continuous glucose monitors (CGMs) for 1.5 million beneficiaries. Additionally, a proposed change in statewide Medicaid makes CGM coverage more transparent.
Last Update May 30, 2023
Originally posted March 15, 2023
Medicare: Striking out the 3 times daily insulin requirement
A March 3 policy update from the Centers for Medicare and Medicaid Services (CMS) removes key restrictions to CGM coverage for Medicare beneficiaries as of April 16, 2023. Individuals with type 2 diabetes will no longer need to meet the “three times daily insulin administration” requirement, opening up coverage for all who are “insulin treated.” Even further, coverage will be expanded to those with non-insulin treated diabetes who have “a history of problematic hypoglycemia.”
According to analyst projections from JP Morgan and BTIG, this change could increase CGM access for approximately 1.5 million Medicare beneficiaries using basal (once daily) insulin only.
Of interest to collaborative members, Medicare defines problematic hypoglycemia as follows:
EITHER 1.) AT LEAST TWO Level 2 hypoglycemic events (glucose <54mg/dL), with at least two previous medication adjustments and/or modifications to the treatment plan prior to the most recent Level 2 event (glucose <54mg/dL)OR 2.) AT LEAST ONE Level 3 hypoglycemic event (glucose <54mg/dL associated with altered mental and/or physical state), with documentation in the medical record that the patient required third party assistance for treatment.
Additionally, in order to get CGMs covered, clinicians must also now document:
1.) “the beneficiary (or the beneficiary's caregiver) has received appropriate training in the use of the device as evidenced by a prescription,” and2.) “the CGM is being prescribed in accordance with FDA indications for use”
MCT2D content expert, professor of endocrinology, and member of the American Diabetes Association Board of Directors, Dr. Rodica Pop-Busui, MD, PhD, stated, “As a clinician and President for Medicine and Science of the ADA, I would like to applaud CMS for this major victory for Americans with diabetes on Medicare who could benefit from this technology.”
Dr. Pop-Busui also notes, “Additionally, the final rule allows the required six-month follow-up visit with the beneficiary’s healthcare provider, to happen via telehealth. Easing criteria for coverage of these devices could prove life saving for many people with diabetes.”
Michigan Medicaid: Greater Transparency
As of June 1, 2023: The Michigan Department of Health and Human Services issued this Michigan Medicaid Policy Bulletin (#23-31) providing an overview of CGM coverage criteria for Michigan Medicaid beneficiaries, effective June 1, 2023. The final policy reflects changes from the March 2023 proposed policy, including the removal of the 2x a day blood glucose testing requirement and a more inclusive description of diabetes educational training in conjunction with CGM.
First posted March 15, 2023: Until now, clinicians across Michigan have struggled to access clear and consistent guidelines for Medicaid coverage for CGMs. A proposed update makes clearer the criteria for CGM coverage for Medicaid beneficiaries. The comment period for the proposed revision is open until March 30th. We encourage MCT2D members to review the proposed policy and make their voices heard by contacting Lisa Trumbell, MDHHS trumbelll@michigan.gov.
If approved, effective May 1, 2023, CGMs could be authorized with the following criteria:
1.) The beneficiary is under the care of an endocrinologist, a physician, or a non-physician practitioner (nurse practitioner, physician assistant, or clinical nurse specialist) who is managing their type 2 diabetes.2.) Provider must document that beneficiary completed a DSME training within 1 year of CGM order3.) The beneficiary is prescribed and uses insulin or an insulin pump4.) The beneficiary tests blood glucose 2x or more per day5.) The beneficiary is educated on the use of the device and willing and able to use CGMs
This process will still require prior authorization for patients with type 2 diabetes.
Michigan clinicians, policy and health equity experts, and professional collectives like the Michigan Collaborative for Type 2 Diabetes, have come together to advocate for improved clarity and access in Medicare coverage guidelines.
MCT2 Program Co-Director and assistant professor of pharmacy, Dr. Heidi Diez, PharmD, makes it clear: “Defining prior authorization criteria for type 2 diabetes and CGMs will increase access, prevent disappointment on the part of patients and clinicians, and will save everyone time. Clear criteria for prior auths will allow clinicians to be confident in prescribing CGMs, rather than subject to assumptions about coverage.”
Dr. Diez is a clinical pharmacist specialist at Domino’s Farms Family Medicine. She adds, “Primary care is experiencing limitations in staff resources. Having defined prior authorization criteria saves on unnecessary staff utilization. For patients, having transparency will provide more equitable coverage opportunities and foster hope.”
Our members know their patients with Medicaid face an interlocking system of challenges: social determinants of health such as limited income, limited access to healthy foods, housing instability, and structural racism, that result in disparate health outcomes. In a 2020 Diabetes Care commentary, Johns Hopkins internal medicine physician S. Michelle Ogunwole, MD, and endocrinologist Sherita H. Golden, MD, MHS make it clear, “Historically marginalized groups such as racial and ethnic minorities, as well as those with lower socioeconomic status, bear a disproportionate burden of diabetes and its associated complications: blindness, neuropathy, limb amputations, chronic kidney disease, cardiovascular disease, and death.”
“These proposed policy changes are a step forward for Medicaid patients in Michigan. With more transparent criteria, our practices will have a better understanding of which Medicaid patients would qualify for a CGM,” stated MCT2D Program Manager Jackie Rau, MHSA, PMP.
“This has been a challenge for practices in the past, who were not clear on coverage criteria for Medicaid patients and wary to prescribe a device without that clarity. We anticipate the number of Medicaid patients with Type 2 Diabetes receiving CGM prescriptions to increase with this policy change, aligning with MCT2D's goals not only of higher CGM use, but of increasing health equity and reducing disparities in care."
Related CGM Coverage Support Tools
Abbott Diabetes Sales Team Contact List
Dexcom Diabetes Sales Team Contact List
Medication and CGM Coverage Guide - Updated March 2023
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Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.