Federal Mandates and EHB Benchmark Plans
The Affordable Care Act (ACA) includes various provisions affecting coverage requirements for individuals with diabetes. For example, all health insurance plans (including employer-sponsored plans) must provide coverage for certain preventive services without imposing cost-sharing on health plans enrollees. This includes screening adults aged 35 to 70 years for abnormal blood glucose levels and type 2 diabetes which is recommended by the United States Preventative Services Task Force (USPSTF). USPSTF recommendations receiving a B or higher are considered high value and coverage by health insurers is required.
Additionally, health insurance plans sold in the ACA’s individual and small group marketplace must provide coverage for 10 essential health benefits (EHBs). Furthermore, plan enrollees are not subject to annual or lifetime limits. Each state sets standards for EHB coverage through their benchmark plan, so coverage requirements for specific services and treatments (e.g., diabetes-related services) vary from state-to-state. State EHB plans must meet coverage requirements for diabetes-related services and supplies established through state-level insurance mandates. States may update their EHB plans annually, but are not required to. The Centers for Medicare and Medicaid Services (CMS) maintains a list of EHB benchmark plans for all 50 states and the District of Columbia.
States may include coverage requirements specific to diabetes in their EHB benchmark plans. For example:
- Alabama covers blood glucose regulators and disease management services for diabetes.
- New York covers diabetic equipment, supplies and self-management education if recommended or prescribed by a physician or other authorized health provider.
- Tennessee covers diabetes education, nutritional counseling for diabetes treatment and blood glucose regulators.
- Virginia covers medical supplies, equipment and education for diabetes care. This includes insulin pumps, home blood glucose monitors and outpatient self-management training and education.
Insulin Access and Affordability
Insulin is the most common of the many types of prescription drugs used in the treatment of diabetes. Unlike people diagnosed with type 2 diabetes who may be able to control their condition without insulin, people living with type 1 diabetes must have insulin to survive.
Research shows that the list price of insulin increased 184% between 2008-2017 for commercial payers. Although rebates and other discounts have also increased, some consumers’ out-of-pocket costs are tied to the list price. With the implementation of the Inflation Reduction Act, the monthly copayment of insulin for Medicare beneficiaries is capped at $35. However, this provision only applies to the Medicare market. Recent studies point to a growing number of people without Medicare coverage citing affordability as a major challenge to insulin adherence.
Manufacturers have addressed this issue by offering programs for discounted insulin. For example, eligible consumers may receive a 30-day supply of insulin between $35-$99. In addition, consumers may also qualify for patient assistance programs offered through some manufacturers.
Policymakers in at least 25 states and the District of Columbia have passed legislation to cap the monthly copayment for insulin. However, these limitations only apply to state regulated plans.
In addition to insulin, some states have pursued copayment limitations on diabetic supplies.
- Delaware caps the amount an insured person is required to pay for diabetes equipment and supplies at no more than $35 per month, regardless of the amount or types of diabetes supplies needed.
- New Mexico requires insurers to provide enrollees adequate networks of suppliers for diabetic equipment and to maintain that network throughout the contract.
- West Virginia caps the copayment for certain diabetic devices, such as continuous glucose monitors, at $100 per month.
Some states have established insulin urgent need programs for qualified individuals.
- Illinois established a program that allows participants to purchase insulin at a discounted, post-rebate price.
- Maine and Minnesota created safety net programs for eligible residents supported by manufacturers.
Other states are exploring public-private partnerships to manufacture insulin.
- California has entered into a partnership to provide low-cost insulin to Californians living with diabetes.
- Maine formed a commission to assess the feasibility of producing insulin through the University of Maine system and a manufacturer.
- Although not specific to insulin, the Texas Pharmaceutical Initiative establishes a board which has the authority to explore partnerships to launch a manufacturing facility for generic or biosimilar drugs. Texas also passed legislation in 2023 directing insulin manufacturers to report to the state Health and Human Services Commission if a generic or biosimilar equivalent is unavailable due to a pay-for-delay contract.