Medicaid and Cystic Fibrosis

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 people meeting certain criteria — such as income or disability status — or participating in state-specific programs. 

Medicaid is a crucial source of insurance for people living with cystic fibrosis; half of all children and a third of adults rely on Medicaid for some or all their health care coverage. Many people with CF use Medicaid to supplement employer or marketplace insurance. Others may receive Medicaid and Medicare benefits simultaneously.

Each state administers Medicaid based on regulations set by the Centers for Medicare and Medicaid Services (CMS). However, each state may administer the program differently, so income or program limits will be different depending on where you live.

What Services Does Medicaid Cover?

States are required to cover certain groups of people based on their household size, age, disabilities, and income. States must provide certain health services to these groups, including:

• Limited inpatient and outpatient hospital services
• Physician, midwife, and nurse practitioner services
• Nursing home services for people aged 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 generic or brand-name medications that they will cover. In addition, your physician 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 important to make sure your service provider accepts that MCO. 

Medicaid rules can be different depending on the state you live in. However, there are some general guidelines that can help you figure out if you qualify. 

To be eligible for Medicaid, you usually need to meet at least one of these requirements:

• You live in the state and meet the rules about citizenship or immigration status.
• You have a low income and limited resources.
• You have a disability, such as blindness.

In states that have expanded their Medicaid programs, anyone earning up to 138% of the Federal Poverty Level (FPL) can apply for coverage. Some states may allow people with higher incomes to qualify as well. 

Qualifying for Medicaid

To qualify for Medicaid, you need to meet one of these requirements: 

• Money and income: Medicaid helps people with low income and few resources. You must meet limits on how much money you make and what you own.
• Group eligibility: Medicaid is for certain groups of people, like children, pregnant women, older adults, and people with disabilities.
• Immigration status: You must be a U.S. citizen or have lived legally in the U.S. for at least five years.
• State residency: You must live in the state where you apply for Medicaid.

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 by shifting eligibility from a categorical basis (disability or parenting status) to income-based.

Mandatory Eligibility and Optional Eligibility Groups

Mandatory groups include:

• Children
• Adults ages 19 and 64 years (including parents and adults with dependent children) with low income, especially in states that have expanded Medicaid
• Parents or caretakers of dependent children with low income in states that did not expand Medicaid
• Pregnant women with low income
• People who are blind or disabled
• People receiving Supplemental Security Income
• Adults ages 65 or older
• Children in foster care and children aging out of foster care

Optional groups include:

• Young adults 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 and disorders 

Applying for Medicaid

Eligibility individuals can apply for Medicaid at any time during the year. Unlike other insurance options, there is no open enrollment for Medicaid. 

They may be many circumstances that could result in an individual applying for Medicaid. Some such circumstances could include (but are not limited to): 

• Job loss
• Decrease in income
• Loss of coverage
• Change in citizenship status

The first step in applying for Medicaid is to get an application from your state Medicaid office. You can apply online on your state's Medicaid website. In some states, you can apply for other state benefits, such as Supplemental Nutrition Assistance Program (SNAP) benefits 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
• Information about your savings and property
• Disability
• Residence or homeownership
• Insurance

Because Medicaid rules can be different in each state, it's a good idea to talk to your local Medicaid office, your cystic fibrosis care team, or a team member at Cystic Fibrosis Foundation Compass. They can help make sure your application is complete and meets all the requirements. 

Some people can get both Medicare and Medicaid. This is called being dual eligible. If you qualify for both, you may get more complete health coverage. Dual eligibility usually applies to people with low income and serious health needs. 

What Services Are Covered?

Being eligible for both Medicare and Medicaid means you receive broad health coverage at a much lower cost. Many expenses — like premiums, deductibles, and copays — are reduced or even eliminated.

Coordinating Benefits With Medicaid

Medicaid helps cover services that Medicare doesn’t, such as long-term nursing care, transportation, and often dental, vision, and over-the-counter benefits. These benefits are often combined into special plans called Dual Eligible Special Needs Plans (D-SNPs), which bundle services together for easier access.

However, 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).

• Insurance Basics
• Get Help with CF Foundation Compass
• Choosing Insurance Coverage
• Protecting Access to Medicaid
• 2026 Changes to Marketplace and Medicaid