49-4-159.4. Coverage for continuous glucose monitors.

On and after July 1, 2025, the department shall include coverage for continuous glucose monitors as a benefit under Medicaid via the most cost-effective benefit delivery channel. The criteria for such coverage shall be updated to align with current standards of care and shall include, but shall not be limited to, requirements that:#

1. (1)

   The recipient has been diagnosed with diabetes mellitus by a treating practitioner;#

2. (2)

   The recipient’s treating practitioner has concluded that the recipient or the recipient’s caregiver has had sufficient training in using a continuous glucose monitor as evidenced by the provision of a prescription therefor; and#

3. (3)

   The recipient:#

   1. (A)

      Is treated with at least one daily administration of insulin;#

   2. (B)

      Has gestational diabetes; or#

   3. (C)

      Has a history of problematic hypoglycemia with documentation of at least one of the following:#

      1. (i)

         Recurrent level 2 hypoglycemic events (glucose less than 54 mg/dL (3.0 mmol/L)) that persist despite two or more attempts to adjust medication, modify the diabetes treatment plan, or both; or#

      2. (ii)

         A history of a level 3 hypoglycemic event (glucose less than 54 mg/dL (3.0 mmol/L)) characterized by altered mental or physical state requiring third-party assistance for treatment for hypoglycemia.#

Within six months prior to prescribing a continuous glucose monitor for a recipient, the treating practitioner shall have had an in-person or telehealth visit with the recipient to evaluate the recipient’s diabetes control and shall have concluded that the recipient meets the criteria set forth in subsection (a) of this Code section.#

Every six months following the initial prescription of a continuous glucose monitor, the treating practitioner shall have an in-person or telehealth visit with the recipient to assess adherence to his or her continuous glucose monitor regimen and diabetes treatment plan.#