Does Medicare Cover Continuous Glucose Monitors (CGMs)?

Continuous glucose monitors (CGMs) can be life-saving to people with diabetes who use them to track and manage blood sugar levels, improve their A1Cs over time and their overall quality of life. CGMS help track and manage blood-sugar levels over time and improve time in range, A1C, and quality of life. In the past, most CGMs in the U.S. were covered by private health insurance. In recent years, coverage has significantly expanded but people with diabetes want to know—Does Medicare cover CGMs?

This is important because, as people with diabetes age, they may experience reduced sensitivity to low blood sugar (hypoglycemia) warning signs. Long-term diabetes can lead to hypoglycemia unawareness, where the usual symptoms like shakiness or dizziness become less noticeable. This decreased sensitivity makes it harder to detect and manage low blood sugar before it becomes serious.

What is a CGM?

• CGMs are worn devices that are used instead of manual blood-sugar testing for many people with diabetes.
• CGMs are built with alerts and alarms that let people with diabetes know when their blood sugar levels are high, low, rising or falling.
• CGMs test the interstitial fluid around cells to estimate blood-sugar levels every one to five minutes throughout the day.
• CGMs also show trend lines, helping you:
  • Predict future blood sugars
  • Plan meals, and
  • Exercise accordingly.
• Once you notice patterns, you can adjust your insulin doses and medications to help improve your quality of life even more.
• Some CGM systems are integrated with insulin pumps, called automated insulin delivery (AID) systems, which can make insulin dosing adjustments based on blood-sugar readings without input from people with diabetes at all.

What is Medicare?

• As of 2022, Medicare covered 65 million Americans.
• The Medicare program was established in 1965 under Title XVIII of the Social Security Act, and signed into law by President Lyndon B. Johnson.
• Medicare ensures that Americans could age with dignity and receive proper medical care without facing devastating poverty

Medicare coverage categories can mostly be broken down into these three buckets:

Medicare Part A: This offers coverage for:

• Inpatient hospital stays
• Care in a skilled nursing facility
• Hospice and palliative care, and
• Some home healthcare services

Medicare Part B: This offers coverage for:

• Outpatient care
• Doctor’s visits
• Preventive services like physicals and check-ups, and
• Certain medical supplies—like CGMs

Medicare Part D: This offers coverage for:

• Shots and regular vaccines
• Prescription drugs like insulin.

With Medicare, there are two options for how you’ll receive your coverage. You can either choose:

Original Medicare: 

• This consists of coverage for Part A and Part B.
• You’ll pay for services as you receive them.
• You’ll first pay a deductible each year, and then for Medicare-approved services under Part A or Part B, you’ll pay 20% of the original cost—this is called coinsurance.
• If you need prescription drugs, you’ll have to add a separate drug plan (Part D).
  • Choosing Original Medicare will not cover prescription drugs.

Medicare Advantage: 

• This is a good option for people who need regular prescription drugs.
• These are “bundled” plans that cost a bit more money but offer coverage for Plans A, B, and D.
• Sometimes choosing Medicare Advantage is known as Medicare Part “C.”

There are many different Medicare Advantage plans from which to choose. They may also offer additional coverage that Original Medicare does not cover, such as vision, hearing, and dental care.

Medicare Advantage plans must follow Original Medicare’s coverage guidelines.

If you choose Original Medicare but want extra coverage, you can purchase a Medigap plan to help supplement your coverage. It can help cover the extra costs of things like coinsurance, co-payments, and deductibles to make your coverage more affordable and accessible.

All Medicare benefits are subject to medical necessity from a prescribing physician.

Does Medicare Cover CGMs?

Since 2017, Medicare has covered CGMs under their Part B category.

CGMs are covered by a wide range of health insurance plans, including:

• Most private health insurance plans
• State Medicaid programs
• Medicare, which provides coverage for:
  • Americans who are 65 years and older
  • Individuals with qualifying disabilities
  • People with End-Stage Renal Disease
  • Those with Amyotrophic Lateral Sclerosis (ALS)

In mid-2023, Medicare expanded coverage eligibility for CGMs for even more people with diabetes.

CGM services are now covered for people with any type of diabetes who are treated with insulin or have hypoglycemia and meet at least one of the following criteria:

• Two or more level 2 hypoglycemic events (glucose <54 mg/dL) that persist despite multiple modifications to the treatment or medication plan,
• One level 3 hypoglycemic event (glucose <54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance for treatment.

An in-person or telehealth visit with the prescribing physician is required within six months of starting CGM for Medicare recipients. The coverage requirement for frequent insulin regimen adjustments based on CGM or blood-glucose monitor results has also been removed.

Previously, Medicare required the beneficiary to be insulin-treated with multiple (three or more) daily administrations of insulin or an insulin pump.

What Are the Steps to Get a CGM Covered by Medicare?

Medicare covers CGMs as durable medical equipment under Part B coverage with a 20 percent copayment.

If you also have a private Medigap plan that supplements your Medicare coverage, they may cover your 20-percent copayment.

To have something covered by Medicare—similar to private or employer-based health insurance—you will need to visit your physician to obtain a prescription.The prescription will be run through your Medicare insurance to see how much of the cost they will cover.

To qualify for coverage, you need a diabetes diagnosis and either be using insulin or meet the criteria for medical necessity due to frequent low blood-sugar episodes.

In addition, your doctor must:

• Prescribe a CGM and confirm that you have sufficient training using the monitor.
• Prescribe the CGM according to the Food and Drug Administration rules for use.
• Have a follow-up visit (either in-person or virtual) within six months of receiving a CGM.

Remember, the CGM device must be FDA-approved and purchased from a Medicare-approved supplier.

Common Questions about Medicare and CGMs

Centers for Medicare and Medicaid Services (CMS) announced expanded CGM coverage in mid-2023.

Here are some of the most frequently asked questions about this change:

What type of insulin do I need to be on to get a CGM? 
There is no specific type of insulin requirement; you just have to be prescribed insulin for your diabetes management.

Does it matter what brand CGM I use?
No. Medicare will cover any CGM as long as it is FDA-approved and prescribed by your doctor.

I don’t currently use a CGM, but I am interested in getting one, and I’m on Medicare. Where should I start? 
Talk with your doctor about your interest in getting a CGM to see if this is a good treatment option for you.

Talk with Your Doctor About Getting CGM

• Talk with your doctor if you’re interested in adding a CGM to your diabetes therapy toolkit!
• You can find out more information about Medicare’s CGM and coverage here.
• You can also get involved in patient groups like the Center for Medicare Advocacy, AARP, or Patients for Affordable Drugs.
  • They often organize fundraising events, marches, and rallies to make their voices heard on behalf of older Americans with chronic health conditions like diabetes.

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