Continuous glucose monitoring coverage varies widely by state Medicaid program – check out our guide on who’s covered and where.
California is the most recent state to expand access to continuous glucose monitors (CGMs) under its Medicaid program, Medi-Cal. While Medi-Cal originally limited CGM coverage to children with diabetes, it has expanded to now cover all people with type 1 diabetes. In California, 25% of the population is covered under Medi-Cal and the Children’s Health Insurance Program (CHIP), which are programs for low-income Americans supported by federal and state government. We estimate that at least half of these beneficiaries have diabetes, prediabetes, or undiagnosed diabetes. For these individuals, coverage of diabetes drugs and technology dramatically increases their chances of living a life free of complications.
Despite these advancements, California and 27 other states still do not cover CGMs for all people with diabetes who need them. CGMs are essential to providing regular blood glucose readings to track time spent in range, identifying patterns in behaviors and blood glucose, and anticipating hypo and hyperglycemia. These devices nearly eliminate the need for finger sticks and have been shown to be superior to self-monitoring of blood glucose in lowering A1C, reducing hypoglycemia, and increasing time in range in both people with type 1 diabetes and people with type 2 diabetes using insulin. In turn, these improved glycemic outcomes and increased time-in-range lead to fewer hospitalizations and long-term complications, generating substantial savings for the healthcare system.
CGMs are covered by most private insurance and also under Part B of Medicare, a federal health insurance program that covers those who are 65 or older, or who are disabled. Such CGM benefits should be made available to everyone on Medicaid, and many in the advocacy community are working to ensure progress is made on this front.
Who is covered by Medicaid?
While Medicare benefits are the same throughout the country, Medicaid, which covers mainly low-income adults, children, pregnant women, and some parents, varies from state to state. In states that have chosen to expand Medicaid under the Affordable Care Act (ACA), people can qualify for Medicaid if their income level is below 133% of the federal poverty level. Therefore, in states that have expanded Medicaid, a higher percentage of people are covered and insured. In states without expansion, many people in need of care neither qualify for Medicaid nor are able to afford a subsidized private health plan through the Health Insurance Marketplace.
To find out if you qualify for Medicaid in your state, click here.
Does my state’s Medicaid program cover CGM?
It depends. In states that have expanded Medicaid, a higher percentage of people with diabetes are able to access Medicaid coverage benefits, which may include CGM access depending on the state. But even if CGM is covered under your state’s policy, each state has its own criteria for which individuals qualify to receive it. For example, some states only cover CGM for type 1 diabetes, and other states have differing policies for short-term and long-term CGM use. To find out more about your specific state’s policy, see the map below:
This map is the general landscape of Medicaid coverage for CGM. The 7 states shown in red (Alabama, Arizona, Florida, Georgia, Hawaii, Kansas, New Jersey) and DC offer no coverage of CGM for Medicaid recipients, while the other states offer some degree of coverage, as shown in the legend.
22 states’ Medicaid programs provide CGM for people with both type 1 and type 2 diabetes: Alaska, Colorado, Connecticut, Delaware, Idaho, Illinois, Iowa, Indiana, Maine, Massachusetts, Minnesota, Montana, New Mexico, Ohio, Oklahoma, Texas, Utah, Virginia, Washington, and West Virginia.
21 states’ Medicaid programs provide CGM for people with type 1 diabetes only: California, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Wisconsin, and Wyoming.
Almost all of these states require at least a diagnosis of diabetes, regular visits with an endocrinologist or other healthcare provider, and self-monitoring of blood glucose at least three times per day. To get a definitive answer about whether you are covered, please consult your healthcare provider or your insurance plan benefits document.
What do states that cover CGM under Medicaid have in common?
Diabetes prevalence: While it might be expected that states with the highest diabetes prevalence would also have the greatest investment in diabetes tools, this is not the case. Among the 14 states where at least 12% of adults have diabetes, only six of them (AR, NM, IN, OH,TX, and WV) cover CGM under Medicaid for people with both type 1 and type 2 diabetes.
Medicaid spending: Five of the top 10 states with the highest Medicaid spending (above $15 billion in total) do not cover CGMs for both people with type 1 and people with type 2 diabetes. This approach is not cost-effective because CGMs account for only 1.1% of the total cost of diabetes, while the costs of treating complications and lost productivity -- both expenses that would be reduced with widespread CGM use -- account for 73.1% of total diabetes costs. In addition, using a CGM has been shown to be cost-effective for individuals with diabetes.
Should my state’s Medicaid program cover CGM?
We believe that all people with diabetes who receive healthcare from state Medicaid programs should have access to CGMs in order to improve daily management of diabetes, reduce healthcare spending on hospitalizations and long-term complications, and enhance quality of life. All people with diabetes, regardless of type 1 or type 2 diabetes, can benefit from using intermittent or real-time CGM.
Eligibility requirements for obtaining CGM through Medicaid should be subject to only reasonable out-of-pocket costs and minimal processing delays. Medicare has recently adjusted their eligibility requirements to make CGMs more accessible but many Medicaid programs still require 3-4 blood glucose tests per day. In Alabama, Arizona, Florida, Georgia, Hawaii, Kansas, New Jersey, and DC, Medicaid recipients with diabetes do not have any CGM coverage.
The recent expansion of CGM coverage in California will help many people with type 1 diabetes access these valuable devices, but millions of people with type 2 who could also benefit from CGM if the coverage was further expanded. We urge California and the 21 other states to expand Medicaid coverage of CGM for all people with diabetes. We hope to see more states advance CGM access under their Medicaid programs. diaTribe will continue to advocate for CGM access for people with diabetes.