Does Insurance Cover CGM? What To Know

With a Continuous Glucose Monitor (CGM), diabetes patients avoid needing to prick their fingers regularly. Since these devices display sugar levels 24/7, they help diabetes care become easier and more accurate.

Many worry that CGMs are costly and are unsure if their health insurance helps with the payment. Learning what insurance offers for CGMs helps you avoid any surprises and is best done before you decide to get one.

This guide gives information on how insurance handles coverage for CGMs. It provides details on possible insurance for them, the guidelines for being eligible, the application process, what you may still be responsible for and helpful tips. Although you may have private coverage, Medicare, Medicaid or nothing, this article explains the basic information about CGM insurance for you.

Types of Insurance Plans That May Cover CGMs

Not all insurance plans treat CGMs the same way. The coverage you get depends on which insurance type you have. These are the main categories:

Private Health Insurance

Private insurance is either given by your employer or bought on your own. Many private insurers include CGM coverage, but what they pay for and how much can differ.

• Employer-Sponsored Plans: If you work for a large company, your plan may include CGM coverage, especially if your doctor says it’s medically necessary.
• Marketplace Plans: Plans bought through the ACA (Affordable Care Act) usually help pay for CGMs when your condition requires it.

Medicare Coverage

Medicare is a federal insurance program mostly for people over 65 or younger people with certain disabilities. It has specific CGM rules.

Medicare Part B may pay for CGMs for people with diabetes who meet their rules.

Only CGMs approved by Medicare as durable medical equipment (DME) are covered. This limits your choice of brands.

Medicaid Coverage

Medicaid is a government program for people with low income. Each state manages its own rules, so CGM coverage under Medicaid depends on where you live.

• Some states give full CGM coverage to people who qualify.
• Others may have tight limits or not offer coverage at all.
• What’s covered and who qualifies can vary a lot by state.

Other Public Insurance Programs

Other government programs like Tricare (for military families) and the VA (for veterans) also may cover CGMs, but the rules are different for each one.

 

Eligibility Criteria for Insurance CGM Coverage

Even if your plan covers CGMs, there are often rules you must follow to qualify for insurance to pay.

Medical Necessity

Your doctor must explain why a CGM is needed to manage your condition. This proof of medical need is key for insurance to approve coverage.

• Most often approved for people with Type 1 diabetes or people with Type 2 who use insulin daily.
• If you often have low blood sugar or don’t notice when your sugar drops, your case is stronger.
• Insurance may want to see records showing that regular testing isn’t enough to manage your blood sugar well.

Insulin Use

• Many insurance companies only cover CGMs for people using insulin often.
• This is to make sure CGMs go to people who need them most.
• Some newer plans are starting to allow CGMs for patients not using insulin, but this isn’t yet common.

Doctor’s Prescription

• You need a prescription from a licensed doctor to get a CGM through insurance.
• The prescription must say why the CGM is needed and which model is recommended.
• Some insurance companies also ask for pre-approval before they agree to pay for the device.

How to Get Insurance Coverage for a CGM

To avoid delays and costs, follow these steps to apply for CGM coverage through your insurance.

Step 1: Consult Your Healthcare Provider

• Talk with your diabetes doctor or care team about whether a CGM is right for you.
• They will look at your current diabetes control and decide if a CGM is a good fit.
• If they agree, they will write a prescription and note the medical reasons for needing the CGM.

Step 2: Check Your Insurance Policy

• Read your plan’s rules or speak to a customer service rep.
• Find out if your plan covers CGMs.
• Ask if you need to get pre-approval or if your plan only covers certain brands or pharmacies.

Step 3: Obtain Prior Authorization

• Some plans want to review your case before saying yes to coverage.
• Your doctor or the CGM supplier will usually send in the needed paperwork.
• This includes medical history and proof that you meet the insurance company’s rules.

Step 4: Choose a Supplier or Pharmacy

• Pick a pharmacy or medical supplier that works with your insurance.
• Your copay amount and what’s covered may depend on where you get the device.
• Some suppliers also teach you how to use the CGM and offer help with setup.

Step 5: Receive Your CGM and Begin Use

• Following approval of your paperwork, the supplier will either deliver your device or you can pick it up.
• Familiarize yourself with services that are part of the agreement, when they end and how to replace, repair or extend them.
• Always keep your care team updated when there are issues or changes so they can fix them for the next review.

Costs to Expect Even with Insurance

Even with insurance, you may still have some out-of-pocket costs for your CGM.

Deductibles and Copays

• Many insurance plans require you to pay a certain amount first.
• You might need to meet a yearly deductible before coverage begins.
• After that, you may owe copays for parts like sensors and transmitters. These vary by plan.

Coverage Limits

• Plans often limit how many CGM parts you can get in a certain time.
• There may be rules on how many sensors or transmitters are allowed each month.
• Some parts may not be covered at the same rate as others.

Non-Covered Items

• Some CGM-related items may not be part of your insurance benefits.
• Extra items like skin adhesive patches or smartphone apps might not be paid for.
• Using suppliers not in your plan’s network can increase your costs.

 

What to Do If Your Insurance Denies CGM Coverage

It’s possible your insurance may say no to CGM coverage, but you can fight that decision.

Understand the Reason for Denial

• Find out why your coverage request was turned down.
• Reasons include missing medical documents or requesting a brand not on your plan’s list.

File an Appeal

• You can ask your insurance to review their decision.
• Ask your doctor to send extra information to support your need.
• Be sure to explain your daily struggles with diabetes in your appeal letter.

Seek Help from Patient Advocacy Groups

• Some organizations help patients deal with insurance problems.
• Groups like the American Diabetes Association can guide you through the appeal process.

The Role of Manufacturer Assistance Programs

• If you don’t have insurance or if your insurance doesn’t help much, CGM makers may offer help.
• You’ll need to show proof of your income or financial need.
• Some programs provide sensors and transmitters at a lower cost or even free.
• These programs can also assist you with paperwork for insurance approval.

Recent Trends in Insurance Coverage for CGMs

• In recent years, insurance has gotten better at covering CGMs.
• More people use CGMs because studies show they help improve health.
• Insurance companies are starting to view CGMs as a normal part of diabetes treatment.
• Telehealth services and remote care rules now also support CGM use.
• Some plans are testing CGM coverage for people who don’t have diabetes yet, but may in the future.

Conclusion

It is now more achievable to get your CGM covered by insurance than before, but you still have to work on it. Talk with your doctor, research what your insurance plan will provide, and expect to fill out forms like prior authorizations and appeals. Review whether the manufacturer is involved in any programs created to reduce the cost of prescription drugs.

Looking to get a CGM and want help with insurance? Healify Now is here to assist you. Our care team explains insurance rules, helps with paperwork, and finds the right CGM for your situation. Contact Healify Now for a free session and see how a CGM can change your diabetes care.

Frequently Asked Questions (FAQs)

Does Private Insurance Usually Cover CGMs?

Private insurance plans are likely to pay for CGM devices if a doctor has prescribed them for medical use, especially in Type 1 diabetes or frequent insulin use.

Will Medicare Cover My CGM?

Medicare Part B will pay for some CGM devices if you use insulin and meet other set conditions.

Are CGMs Covered By Medicaid?

It depends on where you live. Some states offer full coverage, while others don’t cover CGMs or only cover certain parts.

What If My Insurance Denies CGM Coverage?

You can appeal the decision by sending extra documents from your doctor and asking patient support groups for help.

Can I Get Financial Assistance For CGMs If I Have No Insurance?

Yes. Many CGM brands have programs to help people without insurance afford the device and supplies.

Evelyn Brown