Medicaid and CF

Medicaid is a health care program funded jointly by the federal government and state governments. It provides free or low-cost health care coverage for low-income individuals and people meeting certain eligibility requirements, such as individuals with disabilities. For people with cystic fibrosis, Medicaid helps with the affordability of the treatments, medications, and inpatient and outpatient care needed to live a healthy life.

Medicaid is administered by states according to federal requirements and overseen by the Centers for Medicare & Medicaid Services (CMS). Each state sets its own eligibility requirements, so income and resource limits will vary by state.

What Services Does Medicaid Cover?

Federal law requires states to cover certain groups of people, called mandatory eligibility groups, based on their household size, age, disabilities, and income. States are required to cover the following services for mandatory eligibility groups:

• Limited inpatient and outpatient hospital services
• Physician, midwife, and nurse practitioner services
• Nursing home services for people age 21 years and older
• Home health services for people who qualify for nursing home care
• Pregnancy-related services
• Family planning services and supplies
• Laboratory and X-ray services
• Federally qualified health center and rural health clinic services
• Emergency services for non-U.S. citizens
• Screening, diagnosis, and treatment services for individuals aged younger than 21 years

States can also receive federal funding to cover optional services, such as:

• Prescription medications
• Eyeglasses and eye exams
• Hearing aids
• Durable medical equipment
• Clinic services
• Nursing home services for people aged younger than 21 years
• Home and community-based services
• Targeted case management
• Hospice or respite care
• Dental, optometry, prosthetic, and tuberculosis services
• Rehabilitative services provided by a home health aide

Medicaid and CF

In most cases, individuals with cystic fibrosis who are on Medicaid can get their covered medications and services at no cost. However, some states may impose limits on the number of medications or brand-name medications that they will cover. In addition, your service provider must be contracted with Medicaid. Some states may contract their Medicaid plans out to private insurance companies that must follow Medicaid’s coverage standards. These plans are called Medicaid managed care organizations (MCOs). It is also important to make sure your service provider accepts that MCO. 

Although Medicaid eligibility requirements differ by state, there are some general factors that will always qualify you for coverage. By understanding what the rules are, you can find which options may be available for you.

The exact rules for Medicaid eligibility vary by state, but individuals must generally meet at least one of the following criteria to qualify for Medicaid:

• Individuals must satisfy federal and state requirements regarding residency, immigration status, and documentation of citizenship.
• Individuals must meet federal and state financial need requirements.
• Individuals may qualify based on disability (e.g., blindness).

In states that have chosen to expand their Medicaid programs, all individuals with incomes up to 138 percent of the Federal Poverty Level (FPL) will qualify for coverage. Some states offer Medicaid coverage to individuals with a higher income limit.

Qualifying for Medicaid

The general qualifications for Medicaid can be divided into the following groups:

• Financial eligibility: Medicaid is related to resources, means, and income. Therefore, the individual must meet requirements for limited income and resources.
• Categorical eligibility: Medicaid eligibility is limited to individuals who fall into specified categories of low-income individuals.
• Immigration status: Medicaid requires you to be a U.S. citizen or an immigrant who has legally lived in the United States for five or more years.
• Residency: Medicaid is run by states, so an individual must be a resident of the state in which he or she is applying.

Federal law requires states to cover certain groups of people (called mandatory eligibility groups) based on income level, age, and pregnancy status. However, the federal government also allows states to cover other population groups (called optional eligibility groups) and expand Medicaid coverage to people with higher levels of income.

Mandatory Eligibility and Optional Eligibility Groups

Mandatory groups include:

• Children
• Individuals between ages 19 and 64 years (including parents and adults with dependent children) ≤138 percent of the federal poverty level in expansion states
• Parents or caretakers of dependent children (median = 42 percent of the federal poverty level) in non-expansion states
• Pregnant women ≤133 percent of the federal poverty level
• People who are blind or disabled
• Individuals receiving Supplemental Security Income
• People ages 65 or older
• Children in foster care and children aging out of foster care

Optional groups include:

• Children ages 19 and 20, in non-expansion states
• Breast or cervical cancer program
• Individuals receiving home- and community-based services
• Individuals receiving hospice care
• Medically needy
• Medicaid waivers -- HIV/AIDS, autism, and other chronic diseases

Applying for Medicaid

The first step in applying for Medicaid is to get an application from your state Medicaid office. You can apply online your state's Medicaid website. In some states you can apply for other state benefits, such as Supplemental Nutrition Assistance Program (SNAP) benefits (also known as food stamps) at the same time.

Before you apply, you will need to gather all necessary information, documents, and forms. Your state may require proof of:

• Age
• Citizenship or alien status
• Income
• Assets and other resources
• Disability
• Residence or homeownership
• Insurance

Because Medicaid eligibility differs by state, you may want to connect with your local Medicaid office, your cystic fibrosis care team, or a team member at Cystic Fibrosis Foundation Compass to ensure you are meeting the proper requirements for a successful application. Including all necessary information in your application is key to getting the coverage you need.

People who qualify for both Medicare and Medicaid are known as dual eligible. While enrolling in both plans means you will likely have more comprehensive coverage, it is important to understand the basics of dual eligibility.

Some people are “dual eligible,” which means they are eligible for both Medicare and Medicaid at the same time. For Medicare-eligible individuals with limited incomes, dual eligibility allows for more comprehensive coverage and typically applies to those with significant medical needs.

What Services Are Covered?

Dual eligible individuals receive all benefits included in Medicare Part A, Part B, and Part D. In addition, Medicaid may also cover some medications and other benefits that Medicare does not cover, such as hearing, vision, dental, and transportation.

Coordinating Benefits With Medicaid

Medicaid does not pay first for services covered under Medicare. Medicaid covers only after Medicare, employer plans, or Medigap plans have been applied. It's important to make sure your benefits are coordinated when planning for medical services and treatments to ensure you get the most out of your benefits.

For help assessing your eligibility or troubleshooting Medicaid problems, contact CF Foundation Compass at 844-COMPASS (844-266-7277).

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