Questions and Answers
1. How do I know whether my plan has a coverage policy?
a. Medicare, Medicaid, and many commercial and health exchange plans list their coverage policies publicly on their websites. Some plans make them available to members or participating physicians by request. If you are unable to find your plan’s coverage policies online, contact the plan by phone and ask the customer services representative for a copy of the policy. If they cannot provide you with a copy of the policy, ask them about their plan’s coverage of the item or service you’re interested in (e.g., CGM, insulin pump, CGM and pump combinations (sometimes referred to as sensor-augmented pumps or artificial pancreas device systems). You may also ask your physician or their staff to inquire on your behalf.
2. Where do I look on the plan website to find coverage policies?
a. Coverage policies are usually listed in the “Coverage” or “Medical Policy” section of plans’ websites. For certain plans, you may need to establish a user name and password and then sign into the Members Section to view these pages.
3. After locating my plan’s listing of coverage policies online, how do I find the specific policy that discusses the item or service I’m interested in?
a. Once in the coverage or medical policy section of the site, use the search feature to locate a specific policy. Useful search terms to locate policies may be: “diabetes supplies”, “CGM”, “continuous glucose monitoring”, “blood glucose monitoring/testing”, “insulin pumps”, “insulin delivery”, “artificial pancreas”, “APDS”, and “durable medical equipment”. Some polices may include the actual name of a product. In some cases, the policy containing CGM or insulin pump coverage information is named something similar to “Diabetes Tests, Programs and Supplies.” NOTE: A policy like this will likely include coverage information on ALL diabetes supplies, so you will need to search within the policy itself to find the item or service you are interested in.
4. Once I locate a medical or coverage policy, how do I figure out what it means?
a. Medical policies from commercial insurers, health exchanges, Medicare Advantage, and Managed Medicaid plans differ by company. Policies that provide coverage will most likely contain the phrase “medically necessary for” or “covered for.” Coverage will also likely be subject to specific patient criteria, such as having type 1 diabetes (T1D) or documented history of hypoglycemia. It is important to understand these criteria and work with your physician to ensure you have the necessary documentation demonstrating that you meeting the criteria for coverage. In addition, keep an eye out for the phrase “experimental and investigational,” which is often a rationale for non-coverage. In addition, as new products come to market with enhanced features (e.g., low-glucose suspend systems, CGM with predictive alerts, etc.), insurers may refine their policies to be more specific about what options are or are not covered. Be sure to read carefully for any distinctions between products that the policy may include.
b. Medicaid policies vary by state, and some may vary further by specific plan within a state. Similar to commercial insurers, policies that provide coverage will most likely contain the phrase “medically necessary for” or “covered for.” Coverage will also likely be subject to specific patient criteria, such as having T1D or documented history of hypoglycemia. It is important to understand these criteria and ensure you have the necessary documentation from your physician to demonstrate meeting the criteria for coverage. In addition, keep an eye out for the phrase “experimental and investigational,” which is often a rationale for non-coverage.
c. Medicare policies are fairly standard nationwide. Medicare’s insulin pump policy includes several criteria to qualify for coverage, including laboratory tests to detect beta cell autoantibodies and C-peptide levels, indicators of overall diabetes management (e.g., A1c >7%), and participation in diabetes education. Medicare’s detailed requirements for insulin pump coverage can be found here. Medicare does not currently cover CGM.
5. What if I can not find a coverage policy?
a. It is possible that your insurer may not have a policy specific to the item or service you are interested in.
6. If my insurer does not have a coverage policy, is there any way I can still obtain coverage?
a. A formal coverage policy is not required for coverage. Some plans may readily provide coverage for items and services but do not have a formal written policy. Others provide case-by-case coverage through the appeals process for certain members that demonstrate a need for items such as CGMs and insulin pumps. A thorough guide to obtaining case-by-case coverage can be found here.
7. If my insurer offers coverage for a diabetes product I need, what are my next steps?
a. If you haven’t done so already, you’ll need to talk to your physician about what specific product is right for you and make sure they are willing to fill out the necessary prescription and paper work to help you obtain a CGM and/or insulin pump. You will then need to talk to the device company who will help you get started and answer questions that you may have. If your doctor does not have a representative from the device company that they work with regularly, you may wish to call the manufacturer directly.
8. How will my insurer reimburse me for the cost of the CGM or insulin?
a. The manufacturer of your CGM and/or insulin pump will work directly with your insurance company. The device company will then contact you if you are required to pay any portion of the item’s cost (e.g., co-payment or coinsurance charge).
9. If my CGM or insulin pump is covered by my insurance company, will they pay the entire cost of the device?
a. The amount paid by the insurer varies among plans based upon their individual coverage and payment policies for diabetes supplies or durable medical equipment. You will need to speak with your plan directly to determine the amount they cover.
10. How do I ensure that my insurer will continue to pay for supplies related to my CGM or insulin?
a. Coverage of supplies, such as the sensor, infusion sets, and insulin reservoirs will likely also be addressed in the coverage policy for CGM, insulin pumps, and/or diabetes supplies. If your plan does not have a coverage policy or you cannot find the payment and coverage information, contact your plan’s customer service representative for clarification (if your manufacturer has not already done so).