Medicare Advantage CGM Coverage vs Original Medicare: Which is Better?

This article provides general information about Medicare coverage for CGM devices. If you’re looking specifically for details about Medicare Advantage CGM coverage, coverage details may vary. Always verify benefits with your specific plan. Consult your healthcare provider for medical advice.

Choosing between Medicare Advantage and Original Medicare for CGM (Continuous Glucose Monitor) coverage can feel overwhelming. As diabetes management experts focused on helping seniors, we’ll break down medicare advantage cgm coverage compared to Original Medicare to help you make the best choice for your health and budget.

Quick Summary: Medicare Advantage vs Original Medicare CGM Coverage

• Original Medicare covers CGMs through Part B with 20% coinsurance
• Medicare Advantage plans must provide at least the same coverage
• Some Advantage plans offer additional benefits or lower costs
• Coverage requirements are identical for both options

Understanding Medicare Advantage CGM Coverage

Medicare Advantage plans are required by law to cover CGMs at least as well as Original Medicare. However, the costs and approval process may differ:

• Some plans have lower copayments than Original Medicare’s 20%
• Prior authorization may be required
• In-network providers may be mandatory
• Additional diabetes management benefits might be included

💡 Pro Tip: Check your Medicare Advantage plan’s formulary and provider network before choosing a CGM. Call 727-831-3729 for personalized guidance.

Original Medicare CGM Coverage Details

Under Original Medicare Part B, CGM coverage includes:

• The CGM device itself (HCPCS code E2103)
• Monthly supplies like sensors (HCPCS code A4239)
• 80% coverage after meeting your deductible
• Freedom to choose any Medicare-accepting provider

Key Differences That Matter for Seniors

Here’s how Medicare Advantage CGM coverage compares to Original Medicare in practical terms:

Cost Comparison

Original Medicare:

Annual deductible: $240 (2025)
You pay: 20% of approved amount
No out-of-pocket maximum
Medigap can cover the 20%

Medicare Advantage:

Plan-specific deductible: $0-$240
Copays: Often $0-$47 per month
Annual out-of-pocket maximum protection
No Medigap allowed

Real Senior Examples

Dorothy with Original Medicare + Medigap: “I pay nothing for my FreeStyle Libre supplies. My Medigap Plan F covers the 20% that Medicare doesn’t. I can see any doctor and get supplies from any Medicare provider.”

James with Medicare Advantage: “My Humana plan charges me $35 monthly for CGM supplies. It’s predictable, and I like knowing my maximum yearly cost is capped at $3,400 for all medical expenses.”

Provider Network Considerations

Original Medicare Freedom

Use any Medicare-enrolled DME supplier
No referrals needed
Switch suppliers anytime
Travel coverage nationwide

Medicare Advantage Networks

Must use in-network suppliers
May need referrals
Limited supplier choices
Check coverage when traveling

Prior Authorization Requirements

Original Medicare Process

Doctor prescribes CGM with proper documentation
DME supplier verifies Medicare criteria
Approval typically within 1-2 weeks
No plan-specific hoops to jump through

Medicare Advantage Process

Doctor submits prior authorization request
Plan reviews medical necessity
May require additional documentation
Timeline varies by plan (3-30 days)

Coverage Requirements (Same for Both)

Whether you have Original Medicare or Medicare Advantage, you must:

✓ Have diabetes (Type 1 or Type 2)
✓ Use insulin OR have problematic hypoglycemia
✓ See your doctor every 6 months
✓ Be willing to use the device daily
✓ Have a prescription from your doctor

Additional Benefits Comparison

Original Medicare Alone

CGM coverage only
No extra diabetes perks
No gym memberships
No nutrition counseling

Medicare Advantage Extras

Diabetes management programs
Gym memberships
Nutrition counseling
Over-the-counter allowances
Diabetic shoe coverage

Cost Analysis: Real Numbers

Monthly CGM Supply Costs (2025 Estimates)

Original Medicare:

Medicare-approved amount: $250
Medicare pays: $200 (80%)
You pay: $50 (20%)
With Medigap: $0-$10

Medicare Advantage Examples:

UnitedHealthcare: $40 copay
Humana: $35 copay
Kaiser: $30 copay
Some plans: $0 copay

Annual Cost Comparison

Original Medicare (without Medigap):

CGM supplies: $600/year
No out-of-pocket maximum
Additional costs for other care

Medicare Advantage:

CGM supplies: $0-$480/year
Out-of-pocket maximum: $3,000-$8,000
Predictable costs

Making the Right Choice

Choose Original Medicare If You:

✓ Want maximum provider flexibility
✓ Travel frequently
✓ Have or can afford Medigap
✓ Prefer minimal prior authorizations
✓ Value provider choice over cost savings

Choose Medicare Advantage If You:

✓ Want predictable costs
✓ Like extra benefits
✓ Don’t mind network restrictions
✓ Want out-of-pocket protection
✓ Prefer lower monthly costs

Special Considerations for CGM Users

Technology Support

Original Medicare: Varies by supplier
Medicare Advantage: Often includes tech support

Supply Delivery

Original Medicare: Choose any method
Medicare Advantage: May require specific delivery

Emergency Supplies

Original Medicare: Any supplier nationwide
Medicare Advantage: Network restrictions apply

Common Pitfalls to Avoid

With Original Medicare:

Forgetting about the 20% coinsurance
Not considering Medigap premiums
Choosing non-Medicare suppliers

With Medicare Advantage:

Not checking network adequacy
Ignoring prior authorization requirements
Forgetting about travel limitations

Questions to Ask Your Plan

For Medicare Advantage:

“What’s my copay for CGM supplies?”
“Which DME suppliers are in-network?”
“Is prior authorization required?”
“What’s covered when I travel?”
“Are there quantity limits?”

For Original Medicare:

“Which Medigap plans cover DME?”
“What suppliers accept Medicare?”
“How long for Medicare approval?”

State-Specific Considerations

Some states have better Medicare Advantage options:

Strong MA Markets:

Florida: Many $0 premium plans
California: Extensive networks
Texas: Competitive benefits

Original Medicare Favorable:

Rural states with limited networks
Areas with few MA plans
States with good Medigap options

Switching Between Coverage Types

You Can Change During:

Annual Enrollment (Oct 15 – Dec 7)
Medicare Advantage Open Enrollment (Jan 1 – Mar 31)
Special circumstances (moving, etc.)

Switching Considerations:

Medigap may require underwriting
CGM approval transfers to new coverage
Suppliers may need to change
Costs will definitely change

The Hybrid Approach

Some seniors use both strategically:

Year 1-2: Medicare Advantage for lower costs
Later: Switch to Original Medicare + Medigap for flexibility

Note: Medigap guaranteed issue rights are limited after initial enrollment.

Getting Help with Your Decision

Free Resources:

SHIP counselors: 1-800-MEDICARE
Medicare.gov Plan Finder
Area Agency on Aging
Senior CGM Support specialists

What to Compare:

Total annual costs
Provider networks
Extra benefits value
Travel needs
Health complexity

Future Considerations

Medicare Advantage Trends:

Expanding CGM coverage
Lower copayments
Better technology support
Integrated care models

Original Medicare Stability:

Consistent coverage rules
No network changes
Predictable benefits
Provider freedom maintained

Making Your Decision

Consider these factors:

Monthly budget constraints
Provider relationships importance
Travel frequency and destinations
Other health conditions needing care
Technology comfort level

Final Recommendations

Best for Most Seniors: Medicare Advantage often provides better value if you:

Stay within network
Have predictable health needs
Want extra benefits

Original Medicare Excels When:

Provider choice is crucial
You travel extensively
You can afford Medigap

References

Need Help Comparing Your Medicare CGM Coverage Options?

Our specialists can analyze your specific situation and help you choose between Medicare Advantage and Original Medicare for CGM coverage.

Call Now: 727-831-3729

Free, unbiased consultation about your Medicare options