Do I Need Continuous Health Insurance Coverage
Why Won't My Insurance Cover a Continuous Glucose Monitor?
2022-03-25
Many people with diabetes not only depend on their insulin but important technology like continuous glucose monitors (CGMs) to manage their diabetes successfully. Navigating insurance can be exhausting, and when it comes to life-saving diabetes medications and supplies, the need to figure it all out is critical!
You're not alone. Start here if you are having trouble figuring out whether your insurance covers a CGM.
How do I know if my insurance covers a CGM?
Figuring out if your insurance covers a CGM can be tricky, especially if you are navigating insurance independently for the first time, new changes have occurred with your current insurance, or you've recently switched insurance providers. If you get health insurance through your employer, you may have access to an internal benefits manager who can give you more information about getting a CGM covered. (Your internal benefits manager may be your human resources manager or a third party that works with your company.)
Internal employee resources aren't an option for everyone, and internal benefits managers don't always know everything about CGM coverage. However, they may at least be able to point you in the right direction.
You have a few choices when it comes to figuring out if your insurance covers a CGM. The two most common ways you can get the answer you're looking for are by hopping on the phone with a customer service rep from your insurance plan or using your insurance's online self-service portal.
Reach out to your insurance directly to determine coverage:
Reaching out to your insurance directly may be the most efficient approach. Most insurance cards and websites list their customer service phone numbers.
Block out at least 30 minutes of your time to chat with an insurance rep. Likely, you won't get the type of representative you need on the first try because different agents have different insurance knowledge focuses. You may also be able to work with your healthcare team to get connected with their insurance verifiers and get the answers you need. (Ask your healthcare provider if this is an option.)
Some CGM manufacturers also have forms on their websites to help you determine coverage without filling an order. They may be able to tell you whether you need prior authorization. When filling a CGM order through a direct medical supplier, they will know to automatically fill it through your durable medical equipment benefit, just like a pharmacist knows how to charge through your pharmacy benefits.
Use your insurance's self-service portal to determine coverage:
When using your insurance's self-service portal, it's important to know what you are looking for. You can spend a couple of hours frustratingly browsing through your insurance's pharmacy portal, but a CGM may be covered under the durable medical equipment benefit instead. If you use a pharmacy search tool within your insurance portal and the CGM isn't coming up, or the CGM is coming up but saying "not covered," don't rule it out yet! This alert is only telling you it isn't covered under the pharmacy benefit so far.
Most insurance plans do not cover current CGM technology under pharmacy benefits. Pharmacy benefits are a part of health insurance plans that cover select drugs, but not all pharmacy benefits are created equal. As a person with diabetes, medications you fill under pharmacy benefits may include blood glucose meter (BGM) test strips, insulin, blood-sugar-lowering medicines, etc.
Depending on your insurance, you may find that you have to pay a "A copay is a fixed out-of-pocket amount paid by an insured for covered services. It is a standard part of many health insurance plans." (Investopedia.com)copay pay the entire bill until you meet your The amount you pay for covered healthcare services, supplies and medications under your health insurance plan until insurance starts to pay.deductible , or you may get special full coverage for certain medications. Durable medical equipment (DME) benefits may cover select diabetes supplies like CGMs and insulin pumps.
When navigating your insurance portal, you may find a webpage or downloadable PDF attachment that includes a list of durable medical equipment covered by your insurance and where you can get your supplies filled. The list may also stipulate whether you need prior authorization before getting your supplies filled. If you have any questions about the list, reach out to your insurance rep via the phone or your insurance's internal messaging portal to get answers.
Note: Insurance portals are different than the patient portals you use with your healthcare provider.
How do I get prior authorization for a CGM?
Prior authorization is a process among insurance plans where they evaluate the medical necessity of the equipment, supplies, services or medications you are requesting before agreeing to cover it. This process may be done online or via the mail. The prior authorization process can take a few weeks (or even months in some cases), so it's always best to start as early as possible. Though it's exciting to request coverage of a CGM, don't go through the steps too fast, or you may miss some and elongate the approval process.
Some insurance plans may require you or your doctor to submit a log of your blood sugar levels over a period of time to determine the medical necessity of a CGM, for example. Though insurance may not always tell you to do this before submitting your prior authorization, it's good to be proactive and can only help speed up the process of CGM approval!
You can also give your doctor less complicated, practical reasons you need a CGM like hypoglycemia . Your doctor should be able to submit this reasoning for prior authorization for you. They are likely to have experienced this process before with other patients, so they can advise and get you that much closer to approval.
If you have more questions about the prior authorization process for your specific insurance plan, don't be afraid to revisit your insurance website or hop back on the phone with a rep. Just because you and your care team submit a prior authorization does not guarantee coverage.
How to file an appeal with your insurance if they deny CGM coverage:
If you've gone through all of the steps in this post and insurance still won't approve your CGM, you can submit an appeal and ask for coverage again. The appeal process will take some time, but it is worth it when you need your medication and supplies, and your medication and supply alternatives are not as effective or qualitative.
Your insurance has to tell you why they've denied your claim or ended your coverage whenever you go through this process. They also have to let you know how you can dispute their decision(s) , which should give you a better chance of turning it over. Though, submitting an appeal also does not guarantee coverage.
Appeals may be reviewed internally with your insurance or externally with a third party. You can request a "full and fair" internal review from your insurance. If the medical need is urgent and insurance is reviewing the decision internally, they must be quick. If the decision is not critical and can be reviewed externally, insurance no longer has the final say. You can request any of these appeal review methods.
A 2019 report from KFF found that "about 40 percent of denials that enrollees appealed internally to their health plans were overturned" and "…the overturn rate ranged from less than 15 percent to over 90 percent." Overturn (also known as decision reversal) rates varied among insurance providers.
Your insurance should have directions for filing appeals on their website. Your insurance may let you submit an appeal online or via the mail. An appeal can't be filed over the phone as insurance requires official documentation—you should save the documents too.
What to do when you've tried everything and still can't get a CGM approved:
If you've exhausted all of your options for getting CGM coverage, it's not over yet! Though CGMs can cost anywhere from a couple of hundred to a couple of thousand dollars out-of-pocket for a 30 to 90 day supply, there are still some saving strategies you can try to get this cost down.
First, you may be eligible for CGM manufacturers' patient assistance programs if they have them. Patient assistance programs can lower the cost of diabetes supplies and medications for low-income households.
Second, several websites offer people with diabetes cost-savings options on old or refurbished supplies for filling BGM and CGM orders like Save Rite , Lifeline Direct and Diabetic Warehouse . Though it's not ideal, older and refurbished CGMs are better than no CGMs to most people with diabetes who benefit from and love them!
Finally, you may also find that some CGMs cost less without insurance than CGMs with insurance! Before ordering your supplies, you should be able to get a quote from a direct medical supplier. This will give you the most transparency before you fill your prescription.
Getting a CGM approved and filled is bound to take time, so hang in there and don't get too discouraged on your path to getting one.
Educational content related to type 1 diabetes is made possible with support from Abbott Freestyle, the makers of the Freestyle Libre 2. Beyond Type 2 maintains full editorial control of all content published on our platforms.
This content mentions Abbott, an active partner of Beyond Type 1.
News coverage by the Beyond Type 1 team is operated independently from any content partnerships. Beyond Type 1 maintains full editorial control of all content published on our platforms.
WRITTEN BY Julia Flaherty, POSTED 03/25/22, UPDATED 10/11/22
Julia Flaherty is a published children's book author, writer and editor, award-winning digital marketer, content creator and type 1 diabetes advocate. Find Julia's first book, "Rosie Becomes a Warrior." Julia finds therapy in building connections within the diabetes community. Being able to contribute to its progress brings her joy. She loves connecting with the diabetes communities, being creative and storytelling. You will find Julia hiking, traveling, working on her next book, or diving into a new art project in her free time. Connect with Julia on LinkedIn or Twitter.
Source: https://beyondtype2.org/cgm-insurance-coverage-faqs/
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