Does Medicare Cover CGM Devices For Type 2 Diabetes?

Nearly half of Americans over 65 develop type 2 diabetes, according to the American Diabetes Association.

For people managing this condition, a continuous glucose monitor (CGM) can be a valuable tool. These devices track blood glucose levels in real time, helping people better manage their type 2 diabetes and prevent complications.

The good news? Medicare covers CGM devices when they're medically necessary. Here's what you need to know.

What is a CGM for Diabetes?

A Continuous Glucose Monitor (CGM) is a small device worn on the body to continuously measure glucose levels. It provides real-time blood sugar readings, allowing people with diabetes mellitus to:

• Track trends: See how their blood sugar levels change throughout the day and night.

• Make adjustments: Make informed decisions about food intake, exercise, and medication.

• Reduce hypoglycemia risk: Minimize the risk of severe low blood sugar events.

If you or a caregiver can insert the sensor under your skin, your doctor can prescribe a CGM device. You can use it with any type of insulin treatment (including injections and pumps).

Your doctor may include a CGM as part of your diabetes treatment plan. If Medicare covers your CGM, you'll need to have a check-up with your doctor every six months. This visit can be in person or via a Medicare-approved telehealth visit. During these visits, your doctor will make sure you're using the device correctly and that your treatment plan is working well.

Can CGMs be used for both Type 1 and Type 2 diabetes?

While CGMs were first created for people with type 1 diabetes, they're now widely used for many people managing both type 1 and type 2 diabetes. A CGM eliminates the need for frequent finger pricks and shows your glucose levels in real time. This means you can instantly know when you need insulin.

Do Type 2 diabetes patients qualify for a CGM on Medicare?

As type 2 diabetes diagnoses continue to rise in the US, the Centers for Medicare and Medicaid Services announced a policy change in April 2023 to expand approval of continuous glucose monitors for type 2 diabetics.

Medicare covers Continuous Glucose Monitors (CGMs) if you:

• Have  diabetes mellitus

• Take insulin or have a history of issues with low blood sugar

• Have a prescription for testing supplies and instructions for how often to test your blood glucose levels

• Have been trained to use a CGM

• Have routine visits with your doctor

You are also eligible for CGM coverage if you are treated with insulin or have hypoglycemia and have had one of the following:

• Two or more level 2 hypoglycemic events (glucose <54 mg/dL) despite treatment adjustments.

• One level 3 hypoglycemic event (glucose <54 mg/dL) requiring assistance.

Why was expanded coverage authorized?

Medicare's expanded CGM coverage is a significant step forward in improving diabetes care for individuals with type 2 diabetes. A CGM makes people aware of their blood sugar levels so that when levels rise or fall, they can adjust their medication, diet, and activity level to get things under control. Prompt treatment can prevent permanent damage to the eyes, nerves, kidneys, blood vessels, and other parts of the body.

How does Medicare cover CGMs?

CGMs are covered under Medicare Part B as durable medical equipment (DME). Once you've met the Part B deductible, Medicare pays for 80% of the cost of most covered items and services. This leaves you responsible for about 20% of healthcare costs (this is your coinsurance). A Medicare Supplement (Medigap) plan will help reduce your out-of-pocket costs, including coinsurance.

Medicare Advantage plans must cover CGMs the same way Original Medicare does. That said, Medicare Advantage plans may require prior authorization and have their own deductibles and coinsurance. This could make a CGM more expensive under certain plans. 

How often will Medicare cover CGM replacements?

Medicare typically covers replacements for CGM sensors in accordance with the manufacturer’s guidelines for each device. For example, Dexcom G7 sensors tend to last up to 10 days, and Freestyle Libre sensors every 14 days

Transmitters are usually covered every 90 days for systems that require them. If a beneficiary uses a separate receiver instead of a smartphone app, Medicare covers a replacement if the existing receiver is malfunctioning and cannot be repaired, rather than on a routine annual basis.

Does Medicare coverage apply to all brands of CGM?

Medicare covers CGMs approved by the FDA. The health insurance provider will only cover products your doctor thinks will provide the best diabetes management for your specific health condition. 

Eligible devices include the FreeStyle Libre 2 and Freestyle Libre 3 systems by Abbott Labs and the Dexcom G6 and Dexcom G7.

Recently, both manufacturers of these devices released an over-the-counter CGM that requires no prescription. Dexcom's Stelo and Abbot Labs' Libre Rio system are FDA-approved, but not covered by Medicare. That said, some Medicare Advantage plans may cover these devices. If you have a Medicare Advantage plan with an OTC card benefit, you could also use this benefit to purchase your OTC CGM. 

The over-the-counter devices are primarily for people with type 2 diabetes who do not take insulin or those who have prediabetes (blood sugar levels are high but not at type 2 levels). Finger sticks were the only way this group could test blood glucose levels until the over-the-counter CGM models became available.

How much do CGMs cost?

The cost of CGMs is much higher than traditional blood sugar testing through finger sticks and blood glucose meters.

A basic finger-stick glucose meter kit costs around $35 or less, including everything you need: the monitor, test strips, and lancets (the needles that prick your finger). 

According to Good RX, CGM systems range in price from less than $2,000 to about $7,000 per year before insurance or discount.

CGMs include:

• Replaceable sensors, which cost $50-100 each

• A transmitter, unless it's part of the disposable sensor

• A yearly receiver or reader, if needed

Many people use their cell phone as the receiver, which reduces the cost to an average of $100 to $300 a month ($1,200 to $3,600 annually).

Should you consider getting a CGM?

If you have diabetes, though more expensive than the finger stick method, a CGM could help you better manage your condition. Medicare’s recent expanded coverage also made these devices more accessible.

Talk with your doctor about whether a CGM is right for you, and check with your Medicare plan to understand your specific coverage and costs.

Want to learn more about Medicare CGM coverage? Our Medicare Advisors are eager to help you understand your coverage and how to get the most out of Medicare. Get in touch by calling us at (855) 900-2427 or picking a time to chat.