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Bill

S 4003

Requires Medicaid coverage for continuous glucose monitors and related supplies for individuals diagnosed with diabetes who meet certain coverage eligibility criteria.

2026-2027 Regular Session Introduced by Joe Vitale

Medicaid in NJ would cover glucose monitors and related supplies for diabetics on insulin or with severe hypoglycemia, with required follow-up care.

Introduced in the Senate, Referred to Senate Health, Human Services and Senior Citizens Committee
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Bill Summary · S 4003

Summary of Bill S 4003 (New Jersey, Session 222)

Title

Requires Medicaid coverage for continuous glucose monitors (CGMs) and related supplies for individuals diagnosed with diabetes who meet specified coverage eligibility criteria.

Purpose and Intent

  • Ensure Medicaid-covered access to continuous glucose monitors and related supplies for Medicaid recipients diagnosed with diabetes who are treated with insulin or have a history of problematic hypoglycemia meeting defined thresholds.
  • Align Medicaid benefits with diabetes management best practices by covering CGMs, repairs, and replacement parts, subject to federal participation and state plan requirements.
  • Establish criteria and oversight to determine eligibility, prescribing practices, and ongoing follow-up to maintain coverage.

Key Provisions and Changes

CGM Coverage (Section 6.a.(22) and related)

  • The Medicaid program shall cover CGMs and the cost of necessary repairs or replacement parts.
  • Eligibility criteria for CGM coverage include:
    • Diagnosed with diabetes by an authorized clinician.
    • Receiving insulin or having a history of problematic hypoglycemia, demonstrated by:
    • Two or more level 2 hypoglycemic events (glucose < 54 mg/dL) despite treatment Plan adjustments, or
    • A history of one level 3 hypoglycemic event (severe hypoglycemia requiring third-party assistance).
    • Prescription of the CGM per FDA indications.
    • Treatment team determines that the recipient or caregiver has sufficient CGM training.
    • Additional criteria may be set by the Commissioner based on evidence-based standards.

Ongoing Coverage and Follow-Up

  • To qualify for continued coverage, Medicaid recipients must:
    • Participate in follow-up care with their treating health care practitioner at least once every six months for the first 18 months after initial CGM receipt.
    • Then participate at least once every 12 months thereafter.

State Plan and Regulation

  • The Commissioner of Human Services must apply for State plan amendments or waivers to implement these provisions and secure federal financial participation.
  • The Commissioner shall adopt rules and regulations under the Administrative Procedure Act to implement the act, with an authorization to issue interim regulations that are effective for up to six months upon filing, after which standard rulemaking applies.

Miscellaneous Provisions

  • The bill expands Medicaid authorized services consistent with federal law and state regulations, and preserves cost-certainty for providers by requiring written certification that no additional charges will be imposed on eligible recipients.
  • General Medicaid provisions remain subject to federal participation, waivers, and approvals as necessary.

Affected Parties and Scope

  • Primary: Medicaid recipients in New Jersey diagnosed with diabetes who meet the insulin use or hypoglycemia criteria.
  • Providers: Physicians, diabetes educators, and other licensed professionals who diagnose, prescribe CGMs, and provide training.
  • State administration: New Jersey Department of Human Services (Division of Medical Assistance and Health Services) responsible for implementing amendments, applying for waivers, and issuing regulations.

Timeline and Implementation

  • Effective date: Immediate (per bill text).
  • Implementation steps:
    • Seek federal approvals/participation via state plan amendments or waivers.
    • Develop and publish interim regulations (up to six months) followed by standard regulatory adoption.
    • Begin CGM coverage and follow-up requirements upon plan amendments and regulatory implementation.

Practical Implications

  • Potentially expands access to CGMs for many Medicaid enrollees with diabetes, improving glycemic control and hypoglycemia management.
  • Introduces structured follow-up to ensure effective use and ongoing clinical benefit.
  • Requires coordination between clinicians, Medicaid, and state regulatory bodies to align with federal Medicaid guidelines.

Compiled from official sources — confirm details with the bill’s official record.

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