The CMS now will cover more innovative insulin pumps for Medicare beneficiaries with diabetes. The move follows a congressional push for the agency to update its coverage policy.
In an under-the-radar notice issued Jan. 5, the CMS alerted Part D sponsors that they can cover new products on the market that deliver insulin. Older generation devices deliver insulin via a tube, while newer ones deliver the hormone though the skin directly.
Consumers and lawmakers had been frustrated that the CMS had not yet clarified whether the newer, more innovative insulin pumps were covered by Medicare.
"The examples that were previously provided were never intended to be an exhaustive list of products that could be covered under Part D," the CMS said in the notice. "Instead, they represented our understanding of the types of medical supplies associated with the injection of insulin that were available at the time."
Now recognizing that newer insulin-delivery devices are on the market, the agency has clarified that Part D plans can cover these too. However, the agency fell short of mandating that plans do so.
"CMS does not require Part D sponsors to include them on their formularies, and sponsors may apply utilization management criteria if they include such products on their formularies," the agency said.
Despite the caveat, stakeholders rejoiced at the news.
"Most private insurers already cover these proven devices, and it defied common sense that Americans with diabetes would lose this coverage when they qualified for Medicare," Sen. Susan Collins (R-Maine) said in a comment.
Collins and other senators sent a letter last year to CMS Administrator Seema Verma asking her to expand Medicare coverage for new diabetes devices. Verma responded in late November saying she would review the agency's policy.
"Diabetes is one of the most expensive chronic diseases, so it's critical that the federal government advance affordable options to help those impacted better manage the disease so they can live healthy and productive lives," Sen. Jeanne Shaheen (D-N.H.) said after the policy change.
Prior to the CMS notice last week, some seniors complained that they were delaying retirement to continue their employer-sponsored coverage or were being forced to pay thousands out-of-pocket to continue to use more innovative insulin devices they had acquired under private insurance.
Omnipod, one of the new products now covered, can cost as much as $3,000 to $4,000 a month, a senior said in correspondence with Congress.
The proportion of Medicare beneficiaries being treated for diabetes increased from 25.2% in 2006 to 28.2% in 2015 and the CMS projects that the number of U.S. adults with diabetes will double by 2050 if current trends continue.
In 2016, the CMS estimated that it spent $42 billion more on Medicare beneficiaries with diabetes than it would have spent if those beneficiaries did not have the disease.
