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Continuous Glucose Monitors (CGMs), the small devices that many people with diabetes wear on their bodies, are incredible tools for improving diabetes management without requiring the user to do as much.
In contrast to constant manual blood sugar checks, a CGM will automatically monitor the interstitial fluid (fluid found in the spaces around cells) that will approximate a blood sugar reading within 10% (extremely accurate) up to 288 times per day (about every 5 minutes).
Additionally, a CGM offers the user trend lines, allowing users to predict future blood sugars, plan meals and exercise accordingly, and notice patterns. Users can set low and high blood sugar alarms, waking them up even in the middle of the night to avoid severe hypo- or hyperglycemia.
CGM technology has been revolutionary for so many people, improving not only blood sugars but quality of life as well. Thankfully, most private insurance companies along with Medicare now cover this life saving device. Medicaid coverage, on the other hand, has been a bit spottier.
This article will explain the Medicaid program, discuss how CGMs are covered under certain Medicaid programs, and clarify how that coverage differs by state.
What is Medicaid?
Unlike most other industrialized nations that have universal health coverage for their citizens, the United States operates mostly under the private health insurance industry.
Nearly half of all Americans receive their health insurance coverage through their employer.
Populations that are outliers are older Americans (65+) who receive Medicare coverage, military veterans who receive health coverage through Veteran’s Affairs (VA), individuals who do not qualify for employer-based health insurance and buy their health plans on the individual health insurance exchange (either state or federal), and lower income Americans who qualify for Medicaid.
Medicaid is a blended federal and state program that provides health insurance to over 72.5 million Americans, which includes children, pregnant people, seniors, and individuals with disabilities (including diabetes). Medicaid is the single largest source of health coverage in the United States.
Under the 2010 Patient Protection and Affordable Care Act, 38 states (plus the District of Columbia) have expanded income eligibility for individuals to qualify for Medicaid, although those levels vary by state.
One would think that CGM coverage under such a large program would be a no-brainer, but many states do not cover CGMs in their Medicaid programs.
This is a battle being fought by policymakers on a state-by-state basis, with victories being hard-won for people who need this technology most.
Which state Medicaid programs cover CGMs?
It’s important to note that under the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program all children in the United States under the age of 21 on any Medicaid program can access a CGM.
This will, of course, also depend on a state’s Medicaid expansion status, to determine just how many people are actually covered.
Coverage changes drastically after individuals turn 21, however. The list below describes CGM coverage for all 50 states:
Comprehensive Coverage (type 1, type 2 adults)
- Arkansas (effective in 2022)
- North Dakota
- New Mexico
- West Virginia
Coverage for type 1 adults only
- New Hampshire
- New York
- North Carolina
- Rhode Island
- South Carolina
- South Dakota
It’s important to note that most state Medicaid programs will require a prior authorization from a physician to receive CGM coverage. Some examples of eligibility criteria to qualify for coverage include proving a diagnosis of diabetes, proof of regular visits with an endocrinologist, the need for frequent self-monitoring of blood sugars throughout the day, and any other eligibility criteria that the Medicaid agency may choose (for example, a history of hypo unawareness or a higher HbA1c may be required for coverage).
Check with your state’s Medicaid program for specific eligibility criteria.
No Published CGM coverage
While there may be loopholes to gain coverage in these states (such as getting an appeal from a physician, pregnancy, or petitioning the Medicaid agency), they do not have published benefit criteria online:
- New Jersey
Remember that even if a state does not have a published benefit or benefit criteria, all children under 21 on a state’s Medicaid program are eligible for CGM coverage under the federal EPSDT program.
The need for continued advocacy
While advocates and policymakers have come a long way to ensure access to this lifesaving technology, there is still a long way to go until all people with diabetes have the access to the continuous glucose monitoring that they deserve.
All people with diabetes in the 7 states that currently have no published coverage (and frankly the 12 states that have yet to expand Medicaid) depend on it.
But all hope is not lost! We need people like you to get involved, raise your voice, and make the needs of our community known. Here’s how to get involved:
- Call your local elected officials (representatives and senators) to educate them about what it’s like to live with diabetes, and how important access to CGMs is for people living with diabetes.
- Write a letter to your Governor, asking for a budget allocation in your state’s budget for Medicaid coverage of CGMs (since Medicaid is partly funded by the state, coverage for new benefits often comes from the state budget)
- Seek out your members of Congress and ask them to help! Members of Congress have a lot of clout in their states and having them onboard can a huge help.
- Gather with other people who have diabetes, and plan an advocacy day at your state Capitol, meeting with elected officials and policymakers, urging them to support CGM access for all people on Medicaid.
- Get involved in the diabetes online community via Facebook, Twitter, and Instagram to meet like-minded advocates and amplify your voice.
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A Guide to CGMs and Medicaid Coverage Differences by State
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