By Leila Sullivan and Amy Killelea
For many individuals with advanced or power well being circumstances, determining whether or not a medical insurance plan will really meet their wants could be a troublesome activity. Protection on paper doesn’t at all times translate into well timed, inexpensive care, notably 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 Middle on Well being Insurance coverage Reforms (CHIR) has examined these dynamics by way of the lens of individuals residing with insulin-requiring diabetes (IRD). By means of a multi-state analysis venture, a sequence of challenge briefsand a number of webinarsCHIR explored how personal insurance coverage protection guidelines and utilization administration insurance policies align with medical requirements of care, and the way misalignment can restrict entry to important diabetes companies.
Early findings on protection gaps and entry boundaries
In Might 2025, CHIR revealed a sequence of challenge briefs analyzing boundaries to protection, affordability, and entry for individuals with insulin-requiring diabetes in state-regulated personal 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, cut 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 lined, plan design and utilization administration necessities can delay or prohibit entry in methods which can be inconsistent with medical wants.
A better take a look at protection insurance policies and prior authorization
CHIR’s preliminary findings knowledgeable the second part of CHIR’s analysis. Utilizing steady glucose screens (CGMs) as a case research, CHIR appeared below 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 medical requirements of care.
As CHIR explored in its November webinar and weblog submit on translating requirements of care into insurance coverage protection, medical observe tips play an vital position in articulating an evidence-based normal of look after the administration of particular circumstances, together with diabetes. For instance main diabetes medical societies – together with the American Diabetes Affiliation (ADA) Requirements of Care and the American Affiliation of Scientific Endocrinologists (AACE) Scientific Apply – publish and frequently replace diabetes care tips to mirror the evolving proof base, together with for CGMs. These requirements assist high-quality medical 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 medical proof, notably as diabetes know-how continues to evolve. Protection insurance policies analyzed by the analysis crew generally mirrored outdated proof, lagging behind present requirements of care or imposed necessities which can be extra restrictive than medical suggestions. Some plans CHIR reviewed, for instance, required suppliers to show {that a} affected person is unable to fulfill glycemic targets or has skilled particular issues 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 analysis. 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 medical requirements assist earlier use
Conclusion
These findings illustrate a broad problem for individuals with insulin-requiring diabetes, and sure for others with advanced or power circumstances: Protection on paper doesn’t at all times translate into significant entry to care. Even with the ACA’s shopper protections, utilization administration practices comparable to prior authorization can create boundaries to important companies and applied sciences which can be central to efficient diabetes administration. When protection insurance policies will not be aligned with present medical requirements, administrative hurdles can disrupt continuity of care and restrict the real-world advantages of advances comparable to CGMs.
As states pursue reforms to enhance transparency, timeliness, and medical alignment in prior authorization, understanding how these insurance policies function in observe is particularly vital. Inspecting how insurers interpret medical proof and translate it into protection and utilization administration choices helps make clear the place and why gaps emerge. Whereas this evaluation focuses on IRD and CGMs, the patterns noticed mirror broader dynamics in personal insurance coverage protection, highlighting how profit design and utilization administration form entry to care throughout circumstances and companies.
For added evaluation, see our 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.
