Does Medicare Cover Continuous Glucose Monitors?

Continuous Glucose Monitors (CGMs) represent a significant advancement in the management of diabetes, providing real-time glucose readings throughout the day and night. These devices consist of a small sensor inserted under the skin, a transmitter, and a receiver or smartphone app that displays glucose levels, trends, and alerts. This continuous flow of data enables individuals with diabetes and their healthcare providers to make more informed decisions regarding diet, exercise, and medication dosages. Medicare, the federal health insurance program for people aged 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease, covers these devices.

Original Medicare Coverage for Continuous Glucose Monitors

Original Medicare, primarily through its Part B component, provides coverage for Continuous Glucose Monitors (CGMs) and their associated supplies when certain medical criteria are met. Part B covers medically necessary durable medical equipment (DME), which includes therapeutic CGMs. For a CGM to be considered medically necessary, a beneficiary must be diagnosed with diabetes and be receiving insulin treatment. This includes individuals with Type 1 or Type 2 diabetes, or other types requiring insulin.

Individuals must also be performing at least four fingerstick blood glucose tests per day, be on a multiple daily injection (MDI) insulin regimen, or use an insulin pump. A treating physician must determine that the CGM will help improve the management of the individual’s diabetes. This determination often involves an assessment of the individual’s history, including documented episodes of problematic hypoglycemia or hyperglycemia. The physician must also confirm that the individual or their caregiver is capable of using the CGM and interpreting its data.

Non-adjunctive CGMs are generally covered, meaning the device can be used to make diabetes treatment decisions, such as insulin dosing, without the need for a confirmatory fingerstick blood glucose test. Adjunctive CGMs, which require a confirmatory fingerstick before making treatment decisions, are typically not covered under Medicare Part B. This distinction is based on the device’s capability to provide sufficient accuracy for immediate treatment adjustments.

To obtain coverage, a Medicare-enrolled physician must prescribe the CGM and its supplies. This prescription should detail the medical necessity and the specific type of CGM system required. The CGM device and all necessary supplies, such as sensors and transmitters, must be procured from a supplier that is also enrolled in Medicare. This ensures that the equipment meets Medicare’s quality standards and that the supplier adheres to Medicare’s billing rules.

The initial prescription for a CGM often requires an in-person visit with the prescribing physician to establish the medical need and to educate the patient on proper usage. Subsequent follow-up visits are also typically required to monitor the patient’s progress and to ensure the continued medical necessity of the device.

Understanding Costs with Original Medicare

When a CGM is covered under Medicare Part B as durable medical equipment (DME), standard Part B cost-sharing rules apply. After the annual Medicare Part B deductible is satisfied, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount for the CGM and its associated supplies. The Part B deductible is a fixed annual amount that beneficiaries must pay out-of-pocket before Medicare begins to pay its share.

For example, if the Medicare-approved amount for a CGM system and its initial supplies is $1,000, and the deductible has been met, Medicare would pay $800, and the beneficiary would be responsible for the remaining $200. This 20% coinsurance applies to the device itself, as well as recurring supplies like sensors and transmitters, which are typically needed on an ongoing basis.

The concept of Medicare assignment also significantly impacts out-of-pocket costs. A supplier that “accepts assignment” agrees to accept the Medicare-approved amount as full payment for services and supplies. If a supplier accepts assignment, beneficiaries are only responsible for the 20% coinsurance after the deductible. Many DME suppliers accept assignment, which helps to limit beneficiary financial responsibility.

Conversely, if a supplier does not accept Medicare assignment, they can charge more than the Medicare-approved amount, up to a certain limit known as the “limiting charge.” In such cases, the beneficiary would be responsible for the 20% coinsurance of the Medicare-approved amount, plus the difference between the supplier’s charge and the Medicare-approved amount. This can result in significantly higher out-of-pocket expenses. Beneficiaries should confirm the supplier’s assignment status before obtaining a CGM to prevent unexpected costs.

Medicare Advantage and Part D Coverage

Medicare Advantage plans, also known as Medicare Part C, are offered by private companies approved by Medicare and must cover at least everything that Original Medicare (Parts A and B) covers. Medicare Advantage plans often have different cost-sharing structures, such as varying copayments, coinsurance rates, or deductibles, compared to Original Medicare. These plans may also operate with specific networks of healthcare providers and durable medical equipment (DME) suppliers. Beneficiaries enrolled in a Medicare Advantage plan might be required to obtain their CGM and supplies from a supplier within the plan’s network to receive full coverage. Additionally, some Medicare Advantage plans may require prior authorization for CGMs, meaning the plan must approve the device before it is dispensed for coverage to apply. It is important for individuals with Medicare Advantage to review their specific plan’s benefits and rules regarding DME coverage.

Medicare Part D plans, which cover prescription drugs, generally do not cover Continuous Glucose Monitors or their supplies. CGMs are typically classified as durable medical equipment (DME) and are therefore covered under Medicare Part B, not Part D. Part D plans are designed to cover medications dispensed at a pharmacy for self-administration.

While some diabetes supplies, like insulin or syringes, are covered under Part D, the CGM device and its sensors and transmitters fall under the DME category. The core CGM system, including the reader/transmitter and the disposable sensors, is consistently covered as DME under Part B or through a Medicare Advantage plan’s equivalent benefit. Beneficiaries should confirm with their Part D plan if they have any questions about specific diabetes-related supplies, but they should generally expect CGM coverage to fall under Part B or their Medicare Advantage plan.