By Leila Sullivan and Amy Killelea
For many people with complex or chronic health conditions, figuring out whether a health insurance plan will actually meet their needs can be a difficult task. Coverage on paper does not always translate into timely, affordable care, particularly when health plans rely on utilization management tools that shape how and when services are delivered.
Over the past two years, Georgetown University’s Center on Health Insurance Reforms (CHIR) has examined these dynamics through the lens of people living with insulin-requiring diabetes (IRD). Through a multi-state research project, a series of issue briefs, and several webinars, CHIR explored how private insurance coverage rules and utilization management policies align with clinical standards of care, and how misalignment can limit access to essential diabetes services.
Early findings on coverage gaps and access barriers
In May 2025, CHIR published a series of issue briefs examining barriers to coverage, affordability, and access for people with insulin-requiring diabetes in state-regulated private insurance markets. Drawing on findings from a multi-state research project, the briefs identify policy approaches states can use to strengthen coverage of essential diabetes services and supplies, reduce patient cost sharing, and limit prior authorization practices that interfere with timely access to care.
A central takeaway from this work is that coverage alone does not guarantee meaningful access. Even when services are technically covered, plan design and utilization management requirements can delay or restrict access in ways that are inconsistent with clinical needs.
A closer look at coverage policies and prior authorization
CHIR’s initial findings informed the second phase of CHIR’s research. Using continuous glucose monitors (CGMs) as a case study, CHIR looked under the hood of plan coverage and utilization management policies and how (and whether) CGM coverage criteria and CGM utilization management policies align with diabetes clinical standards of care.
As CHIR explored in its November webinar and blog post on translating standards of care into insurance coverage, clinical practice guidelines play an important role in articulating an evidence-based standard of care for the management of specific conditions, including diabetes. For example major diabetes medical societies – including the American Diabetes Association (ADA) Standards of Care and the American Association of Clinical Endocrinologists (AACE) Clinical Practice – publish and regularly update diabetes care guidelines to reflect the evolving evidence base, including for CGMs. These standards support high-quality clinical practice, and insurers often look to these guidelines when developing coverage criteria.
However, CHIR’s CGM research found that there was not always alignment between the coverage criteria plans used for CGMs and up-to-date clinical evidence, particularly as diabetes technology continues to evolve. Coverage policies analyzed by the research team sometimes reflected outdated evidence, lagging behind current standards of care or imposed requirements that are more restrictive than clinical recommendations. Some plans CHIR reviewed, for example, required providers to demonstrate that a patient is unable to meet glycemic targets or has experienced specific complications before approving CGM coverage, which contradict the ADA’s standards of care recommending that people with diabetes have access to a CGM as soon as possible after diagnosis. As CHIR examined in its December webinar, in practice these requirements can delay access, add administrative burden, and restrict coverage to individuals on intensive insulin regimens or those with demonstrated poor glycemic control, even when clinical standards support earlier use
Conclusion
These findings illustrate a broad challenge for people with insulin-requiring diabetes, and likely for others with complex or chronic conditions: Coverage on paper does not always translate into meaningful access to care. Even with the ACA’s consumer protections, utilization management practices such as prior authorization can create barriers to essential services and technologies that are central to effective diabetes management. When coverage policies are not aligned with current clinical standards, administrative hurdles can disrupt continuity of care and limit the real-world benefits of advances such as CGMs.
As states pursue reforms to improve transparency, timeliness, and clinical alignment in prior authorization, understanding how these policies operate in practice is especially important. Examining how insurers interpret clinical evidence and translate it into coverage and utilization management decisions helps clarify where and why gaps emerge. While this analysis focuses on IRD and CGMs, the patterns observed reflect broader dynamics in private insurance coverage, highlighting how benefit design and utilization management shape access to care across conditions and services.
For additional analysis, see our recently released CGM report and related webinar recordings, along with other relevant resources, here. To receive updates on our ongoing research and diabetes policy updates, sign up here.
