Free Guide to Medicare Part B and Continuous Glucose Monitors

Understanding Medicare Part B Coverage and How It Works

Medicare Part B is one of the main parts of Original Medicare, a federal health insurance program run by the Centers for Medicare & Medicaid Services (CMS). Part B covers doctor visits, outpatient hospital services, medical equipment, and preventive care. Unlike Part A, which primarily covers hospital stays, Part B is the portion of Medicare that pays for services you receive outside of a hospital setting.

To understand how Part B works, it helps to know about its cost structure. Part B has a monthly premium that most people pay directly. In 2024, the standard Part B premium is $174.70 per month for individuals with higher incomes, though lower-income individuals may pay less. Beyond the premium, you also pay a yearly deductible (currently $240 in 2024) before Part B begins to pay its share. After you meet the deductible, Medicare typically covers 80% of approved services, and you pay the remaining 20%.

Part B covers a range of services including:

• Doctor office visits and consultations
• Diagnostic tests and lab work
• Imaging services like X-rays and ultrasounds
• Outpatient surgery and procedures
• Mental health services and counseling
• Physical therapy and occupational therapy
• Home health services in certain circumstances
• Durable medical equipment such as wheelchairs, walkers, and oxygen equipment

An important aspect of Part B is that doctors and providers must be enrolled in Medicare and accept Medicare payment. Not all providers participate in Medicare, so it's useful to verify that your doctor accepts Medicare before scheduling appointments. Providers who accept Medicare assignment agree to accept Medicare's approved amount as payment in full for covered services.

Practical takeaway: Review your Part B coverage details annually, verify that your current doctors accept Medicare, and understand your premium amount and deductible to plan for healthcare expenses.

What Continuous Glucose Monitors Are and Why They Matter

A continuous glucose monitor (CGM) is a small device worn on the skin that automatically measures blood sugar levels throughout the day and night. Unlike traditional fingerstick testing, which provides only a single reading at one moment, a CGM takes readings every few minutes—typically every 5 to 15 minutes depending on the device—and shows patterns in how blood sugar changes over time. For people with diabetes, understanding these patterns can be crucial for managing their condition and preventing serious complications.

CGMs work through a tiny sensor inserted just under the skin, usually on the abdomen or arm. The sensor measures glucose levels in the fluid between cells and transmits this information to a receiver or smartphone app. Users can check their current glucose level at any time and see trends showing whether their blood sugar is rising, falling, or staying stable. Many CGMs also send alerts when blood sugar goes too high or too low, which can help prevent dangerous situations.

The three major CGM systems available in the United States are:

• Dexcom G6 and G7: Worn on the abdomen or back of the arm, with readings sent to a smartphone or receiver every 5 minutes
• FreeStyle Libre: Worn on the back of the arm, scanned with a reader or smartphone to check glucose levels
• Medtronic Guardian: A system that integrates with insulin pumps and sends readings every 5 minutes

Research shows that people using CGMs often see improvements in their diabetes management. A study published in the journal Diabetes Care found that adults using CGMs had lower average blood sugar levels and reduced episodes of high blood sugar compared to those using traditional testing methods. For people with type 1 diabetes or those taking insulin, CGMs can reduce the time spent in dangerous low blood sugar situations, which is particularly important because severe low blood sugar can cause confusion, loss of consciousness, or seizures.

CGM devices typically last between 10 and 14 days before needing replacement, depending on the brand. This means users go through approximately 26 devices per year, making the cost of CGMs a significant consideration for many people with diabetes.

Practical takeaway: If you have diabetes and use insulin or struggle with unpredictable blood sugar patterns, ask your doctor about whether a CGM might help you understand your glucose trends and improve your management strategy.

Medicare Part B Coverage of Continuous Glucose Monitors

Medicare Part B covers continuous glucose monitors for people who meet certain medical criteria. The coverage policy reflects CMS's determination that CGMs provide medical benefit for specific groups of people with diabetes. Understanding these coverage rules helps explain what Medicare may pay for and what out-of-pocket costs patients might face.

For Medicare to cover a CGM, a person generally must have a diagnosis of diabetes and meet at least one of these conditions:

• Type 1 diabetes (insulin-dependent diabetes that typically begins in childhood or young adulthood)
• Type 2 diabetes managed with insulin injections multiple times daily
• A history of severe low blood sugar episodes
• Hypoglycemia unawareness (a condition where a person doesn't feel warning signs of dangerously low blood sugar)

When Medicare Part B covers a CGM, the specific coverage includes the sensor, the transmitter that sends readings, and the receiver device. Medicare typically covers one CGM system per person. The beneficiary pays their normal Part B cost-sharing—meaning you pay 20% of the approved amount after meeting your yearly deductible, and Medicare covers the remaining 80%.

An important consideration is that CGM supplies must be obtained from a Medicare-enrolled supplier. Not all medical supply companies are enrolled in Medicare, so patients need to order their CGM through approved suppliers. Additionally, the prescription must come from a physician who specializes in diabetes care or endocrinology, though in some cases a primary care doctor can prescribe if they have established protocols for CGM use.

The approval process typically involves submitting documentation of your diabetes diagnosis and evidence that you meet one of the medical criteria outlined above. This documentation comes from your doctor's office. There is typically a waiting period while Medicare reviews the request, which can range from a few days to a couple of weeks depending on the specific circumstances.

It's worth noting that coverage policies can change over time. CMS periodically reviews evidence and may expand or modify which patients can receive CGM coverage. Staying informed about your coverage through your Medicare documents or your healthcare provider helps you understand what may be available to you.

Practical takeaway: If you have diabetes and use insulin, discuss with your doctor whether you meet Medicare's criteria for CGM coverage, and ask for a referral to a Medicare-enrolled CGM supplier if your doctor determines a CGM would benefit your care.

How to Work With Your Doctor to Obtain a CGM Prescription

Getting a continuous glucose monitor through Medicare starts with a conversation with your healthcare provider. Your doctor needs to determine whether a CGM is medically necessary for your specific situation and whether you meet Medicare's coverage criteria. This process typically involves several steps, and understanding what to expect can make the process go more smoothly.

Begin by scheduling an appointment with your primary care doctor or, preferably, a diabetes specialist like an endocrinologist if you see one. During this visit, discuss your current blood sugar management and any challenges you're experiencing. If you have frequent low blood sugar episodes, unpredictable blood sugar patterns, or difficulty recognizing when your blood sugar is low, be specific about these concerns. Bring records of your recent blood sugar readings if you've been monitoring at home, as this information helps your doctor understand your patterns.

Your doctor will review your medical history, including your diabetes diagnosis, current medications, and past treatment responses. They'll examine your records to see if you meet one of Medicare's qualifying conditions. This review is an important medical decision—the goal is to ensure that a CGM would genuinely help you manage your diabetes better and reduce your health risks.

If your doctor determines that a CGM may help, they'll prepare a prescription or referral. The prescription needs to be specific about the CGM type being recommended. At this point, it's useful to ask your doctor:

• Which CGM system are they recommending and why