Coverage for CGMs through Healthcare.gov?


#1

Does anyone have any experience getting coverage of CGMs sensors, etc. through healthcare.gov.? I am recently in transition between health insurance (recently divorced) and searching the markets for something comparable to what I had. My previous insurance through my spouse gave me 90% coverage on Dexcom sensors, etc. Have yet to find a policy that even covers Dexcom sensors at all (most seem to have 0% coverage on these products).

Any suggestions or insights would be welcome.


#2

You should be asking about coverage on durable medical equipment. (DME) If you call your cgm company they can give you the code # for the sensors. You can then ask the ins co if they have that item in their system as equipment available with prescription.
I have been on healthcare exchange plans for 2 years. Haven’t found it much different than when we were on a corporate plan. One year I paid a percentage for DME, one year had to hit the deductible to have it fully covered. But if remembering correctly, only 2 of the 3 insurance companies I called covered Dexcom. That definitely affected my choice. Good luck!


#3

Not all insurances cover it as DME though. Mine (Blue Cross Blue Shield) covers it as a pharmacy benefit with a monthly co-pay. In fact, if you try to send it through as DME it will come back as DENIED, and you get told to go through a horrible appeals process rather than them telling you to resubmit it under pharmacy :rage: The truly stupid part was, the “main” insurance customer service people didn’t even seem to KNOW that it was covered under pharmacy benefit. I had to actually call the separate pharmacy benefit line to find out.


#4

. . . and Medicare doesn’t cover CGMs at all. Period. Full stop.


#5

And because Medicare doesn’t cover CGM’s, UHC won’t cover them either, even though they did until January. Even if you had coverage as I did, too bad. Not anymore.


#6

Here’s an excerpt from the “Medical Policy” from my insurer (Providence). Warning: they use this policy to deny coverage for CGM. Many other private insurers have similar policies. If there’s a way to review the “Medical Policy” of the insurer before you sign up, maybe you can find coverage.

"Long-term use of CGM is an expensive technology that may have clinical utility when there is poor control and all other interventions have failed. It is not covered for convenience. CGM may be approved in the following cases when prescribed by a diabetic specialist in a Type One diabetic when:
• Unexplained large fluctuations in daily pre-prandial glucose values
• Unexplained frequent hypoglycemic attacks
• Episodes of Ketoacidosis or hospitalization for glucose out of control
• Pregnancy with insulin dependent diabetes
• An insulin pump regimen, where qid glucose monitoring has failed and lack of control is documented. A pump and CGM device are not approved at the same time.

OHP: CGM may be approved in the following cases when prescribed by a diabetic specialist in a Type One diabetic when:
A. Insulin pump management is being considered, initiated, or utilized and only when the patient has at least one of the following:
• HbA 1c levels greater than 8.0% (despite compliance with treatment), or
• A history of recurrent hypoglycemia
CGM is not covered for;

  1. Patients with compliance issues
  2. Diabetics not on insulin or diabetics taking only basal or bid insulin
  3. Convenience"