In the U.S., diabetes affects more than 38 million people and accounts for one in four health care dollars spent. Medicaid beneficiaries with diabetes, in particular, experience worse glycemic control, more complications, and greater barriers to care compared to those with private insurance. Innovations in health technology, such as continuous glucose monitors (CGMs), offer powerful solutions to close these gaps, improve health outcomes, and lower costs.

CGMs are wearable devices that provide real-time tracking of blood glucose levels, enabling individuals with diabetes to make informed decisions about their care. These devices have been shown to improve glycemic control, reduce the risk of severe hypoglycemia, and enhance overall quality of life. Yet, despite their proven benefits, many Medicaid beneficiaries lack access to these tools. Targeted efforts, informed by state successes, can bridge this gap.

The Center for Health Care Strategies (CHCS) recently convened seven state Medicaid agencies and their partners in Austin, Texas, to discuss opportunities to promote CGM access for enrollees with diabetes. These states are participants in the CGM Access Accelerator initiative, made possible with support from The Leona M. and Harry B. Helmsley Charitable Trust and led by CHCS. Following are key strategies identified by participants to advance CGM access: 

1. Update Medicaid Policies to Promote Access

During the convening, states discussed and shared actions they are taking to implement policy changes that remove barriers and simplify access to CGMs:

• Shifting CGMs from durable medical equipment to a pharmacy benefit. This modification can streamline the prescribing and dispensing process by reducing paperwork, shortening approval timelines, and simplifying workflows for both providers and patients.
• Reducing or removing CGM prior authorization requirements. This change can both improve patient access to CGMs and alleviate administrative burden for providers, allowing them to focus more on patient care.
• Expanding CGM eligibility to include people with type 2 diabetes and gestational diabetes. By closing this coverage gap, states can extend the benefits of this proven diabetes management tool to a broader population, improving glycemic control for individuals with type 2 diabetes and reducing complications in pregnant individuals with gestational diabetes.

2. Align Managed Care Organization Coverage to Streamline Access

Strengthening oversight and aligning managed care organization (MCO) coverage policies can improve CGM access, streamline administrative processes, and enhance patient outcomes. Opportunities for alignment include:

• Setting standardized CGM requirements across MCOs. By aligning MCOs around Medicare guidelines and American Diabetes Association recommendations, states can reduce variability in CGM eligibility and prevent administrative hurdles, such as prior authorization delays and additional documentation requirements, that often slow patient access to CGMs.
• Expanding CGM access and improving device procurement timeliness. States can promote CGM utilization at the MCO level by incorporating medical necessity criteria, utilization management standards, and other contract requirements to support timely access and reduce preventable complications.
• Using CGM-related quality measures in MCO contracts. This strategy can improve access and drive better diabetes outcomes by encouraging both providers and MCOs to prioritize CGM adoption, ultimately reducing avoidable, costly care, like emergency department visits.

3. Educate Patients and Providers

Diabetes experts at the convening shared insights about the obstacles patients face while attempting to access and use CGMs, including mistrust of the health care system, language barriers, non-intuitive device manuals, and more. Potential state solutions to these challenges include:

• Incorporating CGM education into diabetes self-management programs. These efforts can improve patients’ health literacy and ability to interpret CGM data, such as historical time in range and glycemic variability, and apply them to daily decision-making, with the goal of improving diabetes management and long-term health outcomes. Programs might also include multicultural guides to support patients in effectively using CGMs.
• Strengthening awareness and education of CGMs across provider types. Rather than solely relying on endocrinologists for CGM prescriptions, states can improve CGM education for primary care providers. These providers can significantly increase access to these devices through their role as a first point of contact for patients. Several states participating in the CGM Access Accelerator initiative are developing provider surveys aimed at identifying challenges primary care providers face when prescribing CGMs. These states are also working to use existing CGM provider education training modules with their broader provider networks.

4. Use Data to Address Disparities

Experts presented evidence on how a broad array of factors, including clinical decision-making, administrative hurdles, and Medicaid policies, contribute to uneven access to CGMs and disparities in outcomes. Variations in prescribing practices — influenced by factors like insurance type and nonclinical considerations, like race and ethnicity  — can lead to differing assumptions about who may benefit from CGMs. Prior authorization requirements, variable coverage policies, and provider knowledge gaps can also promote unequal access to CGMs. To address these barriers, states are implementing a range of approaches:

• Using data to identify disparities in CGM access. By tracking CGM prescription rates, A1C outcomes, and utilization trends according to demographics and geography, states can identify gaps and develop targeted interventions that improve access among underserved populations.
• Incorporating population-specific performance measures into MCO contracts. Based on gaps in care and outcomes identified through data tracking, states can require MCOs to monitor and address CGM adoption disparities among underserved populations and geographic areas.
• Directing support to high-Medicaid volume, under-resourced clinics. By expanding CGM education and training among primary care providers in underserved communities, states can ensure that providers consistently recommend CGMs to all eligible patients, regardless of background.

Next Steps for Accelerating CGM Adoption in Medicaid

CHCS’ recent CGM Access Accelerator convening provided opportunities for state Medicaid programs to share the substantial progress they are making to broaden access for CGMs, as well as build relationships with other states and experts in the field to aid them in their continuing efforts. These strategies can help continue to shape practical approaches to make CGMs an essential part of diabetes management within Medicaid programs across the country.