Access to continuous glucose monitors (CGMs) in the U.S. has been limited by high costs and varying coverage policies. In April 2023, the Centers for Medicare & Medicaid Services (CMS) revised its Medicare CGM coverage policy to cover all members with diabetes treated with insulin and those with problematic hypoglycemia. This change, which also permits telehealth visits for CGM initial evaluations and follow-up care, has prompted states to align their Medicaid CGM policies with the updated Medicare coverage.

In February 2024, Texas updated its Medicaid coverage policy to align with the revised Medicare policy and the American Diabetes Association’s 2023 Standards of Care in Diabetes. This profile features Texas’ updated Medicaid CGM policy, as well as its diabetic equipment and supplies policy, which expand access to CGMs and related supplies for Texas Medicaid enrollees.

Broadening Clinical Coverage Requirements for CGMs

In early 2024, Texas updated its clinical eligibility requirements for CGMs under Medicaid. These updates, summarized in the below exhibit, enable more Texans with diabetes to access CGMs through Medicaid.

Exhibit: Texas Medicaid’s Coverage Policy for CGMs

Texas’ previous CGM coverage policy focused on insulin use and low blood sugar, excluding the majority of people with type 2 diabetes not using insulin. The clinical requirements were also challenging for members with type 1 diabetes, potentially requiring ongoing documentation of four or more finger stick blood glucose tests and three or more insulin injections per day to qualify for a CGM. The state’s revised policies in February 2024 simplify clinical criteria for CGM eligibility and expand access to CGMs through Medicaid for members not using insulin including those who have gestational diabetes. The updated CGM policy also includes a provision allowing Medicaid coverage of any CGM device approved by the FDA (already approved or approved in the future), as long as it is prescribed for its intended use, including for gestational diabetes.

Maintaining Valuable Member Experience Provisions and Adding New Flexibilities 

Texas’ prior authorization and provider prescribing policies remain the same under its new CGM policy, but are noteworthy considering how they enhance members’ experience of care:

• One-Time Prior Authorization. Once a member obtains approval for an initial CGM prescription, Texas does not require subsequent renewals of prior authorization for CGM devices or supplies. This differs from many states that require annual renewals of prior authorization for CGM devices and related supplies. Navigating prior authorization requirements is recognized by both patients and providers as a significant barrier to accessing CGMs, making one‑time prior authorization an effective approach for streamlining access to CGMs.
• Broad Prescribing Provider Definition.Texas does not limit CGM prescribing to specialty providers, instead permitting any treating practitioner supporting a patient with glucose monitoring to prescribe. In some states, only endocrinologists or advanced-level providers collaborating with an endocrinologist have the authority to prescribe a CGM. By adopting this approach, Texas ensures broader access to CGMs for Medicaid members, especially given the shortage of specialists and primary care physicians in many communities.

In addition to expanded clinical coverage for CGMs under Texas’ updated policy, the state introduced two new flexibilities that improve the overall member experience for Medicaid enrollees using CGMs:

• Telehealth Follow-Up Care. Like many states, Texas requires follow-up appointments every six months to maintain continued coverage for CGMs. These appointments support members’ ongoing diabetes management. As part of the recent policy change, Texas now allows Medicaid-approved telehealth visits in addition to in-person appointments to fulfill the follow-up care requirement. This change underscores the growing importance of telehealth in expanding access to diabetes care, especially in rural areas.
• Patient-Readiness Assessment. Texas requires that providers ensure that members, or their caregivers, receive adequate training to safely use the CGM device. The recent policy change simplifies this requirement by giving providers greater discretion in determining a patient’s readiness to use a CGM safely.

What’s Next for Texas?

To build on Texas’ recent CGM coverage policy changes, the Texas Health and Human Services Commission’s Vendor Drug Program (VDP), which manages and oversees pharmacy benefits for Medicaid and CHIP in Texas, will soon allow CGM manufacturers to apply for inclusion of their devices on the Medicaid and CHIP formulary. After VDP reviews an application and determines the CGM is eligible for inclusion on the formulary, members will have access to CGMs or related supplies as a pharmacy benefit.