Brief Diabetes State Mandates and Insulin Copayment Caps

In 2018, 34.2 million Americans—or 10.5% of the population—had diabetes, with an additional 1.5 million Americans diagnosed every year. Beyond the sheer prevalence of the disease across the country, the costs of diagnosed diabetes have increased from $245 billion in 2012 to $327 billion in 2017, according to the American Diabetes Association.

Given the significance of diabetes in the U.S., many federal and state policymakers have pursued intervention strategies to improve access and coverage for diabetes-related services and treatments. This web page provides an overview of these strategies, including state health insurance mandates, federal mandates and caps on insulin copayments.

Diabetes Overview

Diabetes is characterized by a condition where the body does not produce or properly use insulin. Insulin is necessary to covert sugar, starches and other foods into energy for living. Among the types of diabetes:

• Type 1 diabetes is a chronic autoimmune condition where the body produces little or no insulin. Previously known as juvenile diabetes, type 1 is usually diagnosed in children and young adults and requires insulin to keep blood glucose levels down. Approximately 5-10% of people with diabetes have type 1.
• Type 2 diabetes causes the body to not produce enough insulin or causes the cells to ignore the insulin. Type 2 is the most common form of diabetes—90-95% of people with diabetes have type 2—and is more common in older adults.
• Gestational diabetes develops during pregnancy in women who do not already have diabetes. Every year, 2-10% of pregnancies in the U.S. are affected by gestational diabetes.

Additionally, approximately 88 million adults—or more than 1 in 3—have prediabetes. This is when blood sugar levels are higher than normal, but not high enough to be considered type 2 diabetes.

While state diabetes mandates vary greatly, state laws often require coverage for:

• Diabetes-related equipment and supplies, such as blood glucose monitors, visual reading and urine strips, insulin syringes or insulin pumps.
• Diabetes services, such as diabetes self-management training.
• Diabetes medication, such as insulin.
• Diabetes education, such as medical nutritional therapy.
• Prosthetic or artificial limbs.

For specifics on state diabetes mandates, see here for NCSL’s 2016 report “State Insurance and Medicaid Coverage Requirements and Programs.”

Federal Mandates and EHB Benchmark Plans

The 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 patients for abnormal blood glucose levels and type 2 diabetes.

Additionally, health insurance plans sold in the ACA’s individual and small group marketplace must provide coverage for the 10 essential health benefits (EHBs) without 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 state-to-state. Additionally, state EHB benchmark plans must meet coverage requirements for diabetes-related services and supplies established through state-level insurance mandates.

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 for all diabetics. This includes insulin pumps, home blood glucose monitors and outpatient self-management training and education.

The Centers for Medicare and Medicaid Services (CMS) maintains a list of EHB benchmark plans for all 50 states and the District of Columbia.