By Leila Sullivan and Amy Killelea
For many individuals with advanced or continual well being situations, determining whether or not a medical insurance plan will really meet their wants is usually a troublesome activity. Protection on paper doesn’t at all times translate into well timed, inexpensive care, significantly when well being plans depend on utilization administration instruments that form how and when companies are delivered.
Over the previous two years, Georgetown College’s Heart on Well being Insurance coverage Reforms (CHIR) has examined these dynamics by way of the lens of individuals dwelling with insulin-requiring diabetes (IRD). By way of a multi-state analysis venture, a collection of concern briefs, and a number of webinars, CHIR explored how non-public insurance coverage protection guidelines and utilization administration insurance policies align with scientific requirements of care, and the way misalignment can restrict entry to important diabetes companies.
Early findings on protection gaps and entry limitations
In Could 2025, CHIR revealed a collection of concern briefs inspecting limitations to protection, affordability, and entry for individuals with insulin-requiring diabetes in state-regulated non-public insurance coverage markets. Drawing on findings from a multi-state analysis venture, the briefs determine coverage approaches states can use to strengthen protection of important diabetes companies and provides, scale back affected person price sharing, and restrict prior authorization practices that intervene with well timed entry to care.
A central takeaway from this work is that protection alone doesn’t assure significant entry. Even when companies are technically coated, plan design and utilization administration necessities can delay or prohibit entry in methods which might be inconsistent with scientific wants.
A more in-depth take a look at protection insurance policies and prior authorization
CHIR’s preliminary findings knowledgeable the second section of CHIR’s analysis. Utilizing steady glucose displays (CGMs) as a case examine, CHIR appeared beneath the hood of plan protection and utilization administration insurance policies and the way (and whether or not) CGM protection standards and CGM utilization administration insurance policies align with diabetes scientific requirements of care.
As CHIR explored in its November webinar and weblog put up on translating requirements of care into insurance coverage protection, scientific observe tips play an vital function in articulating an evidence-based customary of look after the administration of particular situations, together with diabetes. For instance main diabetes medical societies – together with the American Diabetes Affiliation (ADA) Requirements of Care and the American Affiliation of Medical Endocrinologists (AACE) Medical Observe – publish and repeatedly replace diabetes care tips to replicate the evolving proof base, together with for CGMs. These requirements help high-quality scientific observe, and insurers typically look to those tips when creating protection standards.
Nevertheless, CHIR’s CGM analysis discovered that there was not at all times alignment between the protection standards plans used for CGMs and up-to-date scientific proof, significantly as diabetes know-how continues to evolve. Protection insurance policies analyzed by the analysis crew typically mirrored outdated proof, lagging behind present requirements of care or imposed necessities which might be extra restrictive than scientific suggestions. Some plans CHIR reviewed, for instance, required suppliers to exhibit {that a} affected person is unable to satisfy glycemic targets or has skilled particular problems earlier than approving CGM protection, which contradict the ADA’s requirements of care recommending that folks with diabetes have entry to a CGM as quickly as attainable after prognosis. As CHIR examined in its December webinar, in observe these necessities can delay entry, add administrative burden, and prohibit protection to people on intensive insulin regimens or these with demonstrated poor glycemic management, even when scientific requirements help earlier use
Conclusion
These findings illustrate a broad problem for individuals with insulin-requiring diabetes, and sure for others with advanced or continual situations: Protection on paper doesn’t at all times translate into significant entry to care. Even with the ACA’s client protections, utilization administration practices resembling prior authorization can create limitations to important companies and applied sciences which might be central to efficient diabetes administration. When protection insurance policies should not aligned with present scientific requirements, administrative hurdles can disrupt continuity of care and restrict the real-world advantages of advances resembling CGMs.
As states pursue reforms to enhance transparency, timeliness, and scientific alignment in prior authorization, understanding how these insurance policies function in observe is very vital. Inspecting how insurers interpret scientific proof and translate it into protection and utilization administration selections helps make clear the place and why gaps emerge. Whereas this evaluation focuses on IRD and CGMs, the patterns noticed replicate broader dynamics in non-public insurance coverage protection, highlighting how profit design and utilization administration form entry to care throughout situations and companies.
For extra evaluation, see our just lately launched CGM report and associated webinar recordings, together with different related assets, right here. To obtain updates on our ongoing analysis and diabetes coverage updates, enroll right here.