Unlocking CGM Insurance Coverage for Diabetics

Continuous glucose monitors (CGMs) are crucial for managing diabetes. Instead of pricking your finger multiple times a day to test your blood glucose, they do it for you, painlessly and automatically. They’re a total game-changer for anyone with diabetes.

But insurance coverage for diabetes supplies like this can be dicey. You have to navigate a maze filled with insurance hurdles and jargon, and if you’re doing that on your own, you might feel like giving up.

But you’re not alone. The experts at TMS are ready to help you jump those hurdles and start living your healthiest life with diabetes. Here’s an overview of some of those obstacles and how we help you overcome them.

What’s Covered?

Let’s start by discussing what’s usually covered when it comes to CGMs. Of course, it will depend on the kind of insurance you have.

Medicare: Usually covers a CGM at 80% after a deductible has been met.

Medicare replacements: If your plan has a deductible, it usually covers a CGM at 80% if it has been met. If there isn’t a deductible, it usually covers a CGM at 80%. Some Medicare replacement plans have different tiers of coverage. A patient who chose one tier may get coverage at 90% with no deductible, while a patient at another tier might get coverage at 70% after a $500 deductible has been met.

Medicaid: As Medicaid varies state-to-state, your coverage for CGMs will depend on the state under which you’re covered. The requirements you’ll need to follow to be covered will vary as well. To learn more about the coverage for CGM in your state, read this article by our friends at DiaTribe.

Private insurance: Your private insurance guidelines could vary greatly depending on the company, where you live, and the plan you chose. It’s best to check with your insurance company about what they cover. And if you’re considering a new insurance plan, ask them about their coverage for your diabetes supplies before officially selecting them.

Compliance

Your insurance will probably have certain guidelines you’ll need to meet to get your CGM covered. For Medicare and its replacement programs, you’ll need to be:

• Insulin treated
• Diagnosed with diabetes
• Educated on how to use the CGM (either the patient or a caregiver)

If you have private insurance, their compliance guidelines will vary. Check with your insurance provider for their exact requirements.

Common Issues

When you work with TMS, we do the hard work for you. You may not understand everything that goes into coverage or what your insurance plans actually cover when it comes to a CGM. You may have gotten denied before.

No matter where you are in the process, TMS is here to make the process easy and stress-free. If you’re just starting out or if you’ve already been denied, we’ll do the heavy lifting so you can start enjoying your CGM as soon as possible with as little out-of-pocket cost as possible.

Here are some common issues and how we fix them:

High deductible/low coverage: If a CGM is prohibitively expensive through your medical coverage, we’ll show you where it could be in your pharmaceutical coverage. If that’s a better option, we might also look at pharmaceutical discount cards, like GoodRX, to further defray the cost.

Your insurance requires preauthorization/documentation: No need to handle this yourself. We’ll contact your doctor and get the authorization needed to move forward with the CGM process. If your insurance requires proof that your blood sugar has dropped below certain levels, you’ve had a hypoglycemic event, or your doctor has made changes to your diabetes care plan, we’ll contact your doctor to get the necessary documentation.

You’ve already been denied: Fighting with an insurance company is no one’s idea of a great time. So, if you’ve been denied, we’ll appeal it on your behalf. There are many reasons why you might have been denied. We’ve seen them all. If you need a physician’s approval, we’ll work with your physician to get that approval. If the insurance says your diagnosis isn’t in the medical records, we’ll point out where it is. Our job is to jump over any barricades the insurance company has put up so you can start living a better life with your CGM. Though it’s sometimes faster, overturning a denial can take 30 to 90 days.

We’re not in your network: We don’t want you to pay more just to work with us. So, if we’re out of network for your insurance, we’ll refer you to a provider that’s in your network.

Co-Pays and Deductibles

Your insurance plan might come with co-pays or deductibles. A co-pay is an amount you will pay alongside your insurance provider for a service, usually as a percentage of the total cost. A deductible is a set amount you have to pay out of pocket before your insurance starts covering anything. Medicare has an annual deductible (in 2023, it was $233, but it usually goes up every year), while Medicaid does not. Most private insurance policies have some sort of deductible. It’s best to start the process of getting your CGM after your deductible has already been met. If it hasn’t, we can explore other options, like moving up an annual doctor’s appointment or other service so the deductible is met.

Confusion About Your Coverage

One of the biggest problems we come across is that people don’t understand their own insurance coverage. It’s common for a patient to tell us they have Medicare when they have a Medicare replacement plan, or to be confused about their deductible. And that’s OK. You’re not expected to be an insurance expert. We have those on our staff, and they’re ready to help you get the most out of your insurance. But we can’t change what your insurance will or won’t cover, so be sure to ask those questions before signing up for any specific insurance plan. And remember, your health care team can’t speak intelligently to what your plan will cover. For that, you’ll have to go straight to the insurance provider or work with a company, like TMS, who does that for you.

Our Process

Now that you know some of the common roadblocks to getting a CGM, let’s discuss what we do behind the scenes to help you jump those hurdles.

What to Do

For you, the to-do list is short. Just select the type of CGM you’re interested in from our website, and then, give us a call. As long as you have your first and last name, date of birth, and insurance information, we can start gathering the necessary information and documentation to get the process going.

Need help choosing the right CGM for you? We’ve got a guide to help make it easy.

What We’ll Do

Leave everything else up to us. You’ll be assigned a case manager who will reach out to you to ask for additional information and keep you posted on the progress of your request. Behind the scenes, they’ll be looking through paperwork, contacting doctors, talking with your insurance, and doing everything else necessary to get your supplies to you.

Navigating the complexities of insurance coverage for continuous glucose monitors can be a daunting task. Between understanding what your insurance covers and making sure you have the right paperwork to meet your insurance’s coverage regulations, it can feel like you’re doomed to a life of fingerstick tests. But with the right experts in your corner, it’s easier than ever. At TMS, we knock down obstacles to help you get the CGM you need to live your best life with diabetes. Just give us a call, and we’ll do all the hard work for you.