Expanded CGM Coverage for Medicare Beneficiaries
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Jules Guito is a Policy Manager, where she works closely with product, data, and other teams to embed policy into technology. She previously worked at Palantir Technologies, Doctors Without Borders, and the United Nations Population Fund (UNFPA).
Health plans have limited time to update policies and processes to comply with new CMS guidelines for Continuous Glucose Monitors (CGMs).
The changes are expected to have an immediate impact on Medicare Advantage health plans by increasing access to glucose monitors for members who may have not qualified previously. By some estimates, up to 2 million Medicare beneficiaries living with type 2 diabetes who frequently use insulin will gain coverage for CGM devices due to these recent policy changes1. As a result, Medicare Advantage plans can expect utilization and spending for CGM therapy to increase.
At Tomorrow Health, our dedicated policy experts support health plans’ payment integrity teams by keeping up with the latest home-based care policy changes. This research creates clinical and regulatory rules enforced by our technology to automatically verify order requirements and reduce fraud, waste, and abuse.
Read on to learn more about one of the latest updates -- the expansion of CGM coverage.
Latest policy changes
Last month, Centers for Medicare & Medicaid Services (CMS) made changes to further eliminate barriers to accessing continuous glucose monitors (CGMs) for Medicare beneficiaries, particularly those diagnosed with type 2 diabetes (diabetes mellitus). CMS updated the Local Coverage Determination (LCD) for Glucose Monitors (DL33822) so that patients with a diabetes mellitus diagnosis who either use insulin as part of their treatment or have a documented history of problematic hypoglycemia may qualify2.
Key changes to the LCD are summarized below:
- Loosened clinical criteria and expanded conditions (e.g. insulin-treated, or, non-insulin treated with problematic hypoglycemic events – recurrent level 2 or at least one level 3).
- Beneficiaries can be evaluated for initial or continued coverage through a Medicare-approved telehealth visit, increasing access to those who may be receiving care at home or unable to visit a facility in-person.
| PATIENT GROUP |
2022 LCD |
2023 LCD |
| Diabetes mellitus |
Diagnosis with documentation of three or more daily administrations of insulin or a CSII pump. Frequently adjusts insulin based on testing results. |
Diagnosis with insulin therapy |
| Diabetes mellitus with problematic hypoglycemia |
Diagnosis with documentation of three or more daily administrations of insulin or a CSII pump. Frequently adjusts insulin based on testing results. |
Diagnoses and documentation of problematic hypoglycemia, regardless of insulin therapy (e.g. recurrent level 2 or at least one level 3). |
This latest expansion of eligibility comes on the heels of a string of recent policy changes related to CGMs:
- July 2021: CMS eliminates the four-time-daily fingerstick requirement in order to qualify for coverage of a CGM.
- January 2022: CMS expands the Medicare Part B benefit for DME to include adjunctive (non-therapeutic) CGMs that had not previously been covered, creating a new group of HCPCS codes for billing
- January 2023: CMS further updates its coding guidelines to adopt a second new group of HCPCS codes for the billing of non-adjunctive (therapeutic) CGM devices
The CDC estimates there are 16 million Americans over the age of 65 living with diabetes3. These policy changes have continued to increase access for the Medicare population to a variety of glucose monitors on the market, allowing them to better manage their condition.
What it means for health plans
The updated LCD takes effect on April 16, 2023, giving health plans limited time to update their policies and processes in order to comply with CMS guidelines and manage the projected increases to utilization and spend related to CGMs.
Health plans may need to take the following actions:
- Update benefit policies, coding guidelines and clinical rules
- Disseminate and enforce policy changes to provider networks
- Maintain or re-negotiate rates with suppliers for CGM devices
- Increase the capacity of processes for ordering, billing, and troubleshooting DME orders
- Monitor utilization and manage any anticipated increase in spend
- Educate members about the benefits of CGMs and how to use them to effectively manage their condition
Is your health plan prepared for policy changes?
Our policy team maintains custom clinical policies and rules through our proprietary Clinical Rules Engine, meaning changes to policies and rules can be implemented automatically on behalf of health plans. For example, CGM orders that are submitted through Tomorrow Health’s e-prescribe workflow are validated against clinical rules at the point-of-referral, resulting in members receiving their orders 4 days faster on average than orders submitted by fax.
About Us: Tomorrow Health, is a healthcare technology company enabling more efficient and reliable home-based care. We guarantee 15%+ savings for health plan partners while maintaining 90%+ member satisfaction for our health plan partners.
To learn more about how Tomorrow Health can help your health plan maintain and automate clinical rules to ensure your members get the right level of treatment while managing utilization and spend, email partnerships@tomorrowhealth.com.
2 CMS LCD for Glucose Monitors, https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33822. Accessed May 23, 2023.
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