CGM bill aims to preserve two-channel option

LITTLE ROCK, Ark. – A new bill in Arkansas is the first on a state level to try and stem the “migration” of coverage for continuous glucose monitors to a pharmacy-only benefit. 

Introduced Jan. 27, HB1255 would amend existing Medicaid coverage of CGMs to allow beneficiaries to obtain CGMs through the DME benefit and would allow DME providers to bill for the devices using a HCPCS code rather than the national drug code number used by pharmacies. 

“We don't oppose expanding access and allowing patients to access equipment and supplies through their pharmacy, but this migration of Medicare Advantage and some state Medicaids has created confusion,” said David Chandler, vice president of payer relations for AAHomecare. “We’ve been working with payers to (help them) understand the benefits of the DME channel and with CMS to shed some light on this, because I don’t think they know what was going on.”  

The bill was scheduled for a Feb. 11 hearing before the House Public Health, Welfare and Labor Committee. 

The Arkansas legislature has already passed legislation moving CGMs from a DME to a pharmacy-only benefit, but the newly formed Arkansas Medical Equipment Providers Association managed to push back implementation while it sought a solution, says Caitlyn Hiland, executive director. 

“We found quite a few DME providers that did a lot of work in the CGM space, especially with Medicaid patients,” she said. “DMEs provide a great benefit to patients, especially in areas where they can't travel and there's not necessarily a pharmacy in close proximity, or those homebound or people that may not be as tech-savvy and need the direct contact (a DME provider can provide).”  

Stakeholders might have their work cut out for them, however, due to a “game” where payers often pay more for equipment and supplies offered through the pharmacy channel and then recoup some of that through manufacturer rebates, says Chandler. 

“That’s the game we’re dealing with, with this hidden rebate going back to the payer that, ultimately, is a disadvantage for the supplier and in a lot of cases the patient,” he said. “We've been told that those rebate dollars are bundled in with all of the pharmaceutical rebates and it's not public information as to how that those rebate dollars are offsetting the higher cost to the plan.”  

But so far, lawmakers have been largely sympathetic, says Hiland. The only pushback will likely be from state Medicaid officials who have previously said it doesn’t have a way reimburse via two different channels, she says. 

“We know of quite a few states that are doing dual-billing, so I don't really buy that,” she said.