Medicare CGM Coverage for Diabetes Care

Continuous glucose monitors (CGMs) can be lifesavers for people with diabetes, helping them track blood sugar levels, improve A1Cs, and boost their quality of life. Thanks to expanded Medicare CGM coverage and private insurance plans, more people than ever now have access to this life-changing technology.

Why CGMs are crucial

Expanded Medicare CGM coverage is key.

As people with diabetes age, they may lose sensitivity to low blood sugar symptoms, also known as hypoglycemia warning signs.

Long-term diabetes can lead to hypoglycemia unawareness, where symptoms like shakiness or dizziness are harder to notice.

What is a CGM?

CGMs are wearable devices that replace the need for manual blood sugar testing for many people with diabetes. These gadgets offer real-time data and alerts for highs, lows, or sudden shifts in blood sugar levels.

Here’s how CGMs make life easier:

• Track blood sugar every 1–5 minutes.
• Predict future blood sugar trends for meal or activity planning.
• Show patterns to adjust insulin doses and improve overall health.

Some CGMs are integrated into automated insulin delivery (AID) systems, which make adjustments without user input—a true game-changer.

What Is Medicare?

Medicare, established in 1965, covers over 65 million Americans, ensuring older adults have access to vital healthcare services. Its coverage breaks down into:

• Part A: Inpatient hospital care, skilled nursing, hospice, and home healthcare.
• Part B: Outpatient care, preventive services, and medical supplies like CGMs.
• Part D: Prescription drugs like insulin and vaccines.

Medicare offers two main coverage options:

1. Original Medicare: Covers Parts A and B with separate drug coverage under Part D. Beneficiaries pay for services as received, including deductibles and a 20% coinsurance rate.
2. Medicare Advantage: Includes bundled plans covering Parts A, B, and D, often with added perks like dental or vision care.

For added support, Medigap plans help cover deductibles and coinsurance costs.

Does Medicare cover CGMs?

Yes! Since 2017, Medicare has covered CGMs under Part B. Coverage is available for:

• Americans aged 65+
• Those with qualifying disabilities
• People with End-Stage Renal Disease or ALS

In 2023, Medicare expanded eligibility to include people with any type of diabetes treated with insulin or experiencing hypoglycemia. Coverage now extends to:

• Two or more severe low blood sugar events (<54 mg/dL) despite treatment adjustments.
• One critical low (<54 mg/dL) requiring third-party help.

Recipients must have an in-person or telehealth doctor visit within six months of starting CGM use.

Getting a CGM through Medicare

Medicare covers CGMs as durable medical equipment with a 20% copayment. If you have a Medigap plan, it may cover this copayment.

Steps to get a CGM:

1. Visit Your Doctor: Get a prescription confirming medical necessity.
2. FDA Approval: Ensure the CGM is an approved device.
3. Supplier Check: Buy from a Medicare-approved provider.
4. Training: Confirm you have proper training to use the device.
5. Follow-Up: Schedule a check-in with your doctor within six months of starting.

Common questions about CGM coverage

Medicare’s expanded CGM coverage has raised a few FAQs:

• Do I need a specific type of insulin for CGM coverage? No. Any prescribed insulin will qualify.
• Does Medicare cover all CGM brands? Yes, as long as they’re FDA-approved.
• How do I start using a CGM under Medicare? Talk with your doctor to explore if it’s right for your care plan.

Advocate for CGM access

If you’re interested in CGMs, discuss options with your doctor. You can find out more information about Medicare’s CGM and coverage here.

To raise awareness, you can join patient groups like Center for Medicare Advocacy, AARP or Patients for Affordable Drugs. These organizations often rally for better access and affordability for older Americans.

CGMs empower people with diabetes to live healthier lives—and Medicare makes it easier to access this cutting-edge technology. So take charge and enjoy the benefits!

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