Medicare and CF

What is Medicare?

Medicare, a federal health insurance program, is a coverage option for some people with cystic fibrosis, especially adults who are receiving Social Security Disability Insurance (SSDI) payments. If you are no longer able to work due to treatment burdens or other health-related issues, SSDI might be an option for you.

After two years of receiving SSDI benefits, you will be eligible for Medicare. Medicare Part A is premium free for most people who receive SSDI (sometimes called “premium-free Part A”).

In addition, Medicare could be an option for:

  • People 65 years and older who qualify for benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB)
  • People younger than 65 years who are receiving SSDI or people receiving certain disability benefits from the RRB
  • People with end-stage renal disease (ESRD), which is permanent kidney failure that requires dialysis or a transplant

Medicare is broken down into four “parts” that help cover specific services:

  • Original Medicare Part A (Hospital Insurance)
  • Original Medicare Part B (Medical Insurance)
  • Medicare Part C (Medicare Advantage Plan)
  • Medicare Part D (Medicare Prescription Drug Plan)

Learning how each of these parts works and what services they cover can help you choose the right Medicare plan for you.

Medicare Part A (Hospital Insurance)

The first component of Original Medicare (Medicare Part A) focuses on inpatient care. Services typically covered under Medicare Part A include: 

  • Inpatient hospital care
  • Skilled nursing facility care (not custodial or long-term care)
  • Hospice care
  • Home health care

To see the full list of services covered under Medicare Part A, visit Medicare.gov.

Most people do not pay a monthly premium for Part A. Each type of Part A services comes with its own set of out-of-pocket expenses and may require you to pay various deductibles, coinsurance, and co-payments.   

  • Inpatient hospital deductible for each benefit period: $1,600 
  • Days 1-60: $0
  • Days 61-90: $400
  • Days 90 and beyond (for lifetime reserve days): $800

Skilled Nursing Facility coinsurance 

  • Days 1-20: $0
  • Days 21-100: $200

Medicare Part B (Medical Insurance)

Medicare Part B, the next component of Original Medicare, focuses on medical services provided outside of hospitals and medical facilities. This includes doctor visits, outpatient services, some preventive care, and other medically necessary services. Medicare Part B typically covers:

  • Services from doctors and other health care providers
  • Outpatient care
  • Diagnostic tests (blood work) and imaging (X-rays, CT, PET scans, MRIs)
  • Home health care when homebound
  • Durable medical equipment
  • Some preventive services
  • Ambulance services
  • Emergency department services
  • Some prescription drugs (most nebulized CF medications are covered under Part B)

To see the full list of services covered under Medicare Part B, visit Medicare.gov.

To receive Medicare Part B, you are required to pay a monthly insurance premium. Most people pay the standard premium amount ($164.90 per month in 2023), which is automatically deducted from your Social Security check each month. If you don’t sign up for Part B when first eligible, you may be subject to penalties. 

Out-of-pocket costs for Medicare Part B services vary. Generally, you will pay a deductible annually ($226 in 2023 and then 20 percent of the Medicare-approved amount for covered services, if you use providers who accept Medicare assignments. The Medicare Part B deductible and coinsurance do not apply to some screening and preventive services.

Medicare Advantage Plan (Part C)

Medicare Part C, also known as Medicare Advantage, is provided by Medicare-approved private insurance companies. The companies offering Advantage plans varies by geographical area (zip code and county). Medicare Advantage plans:

  • Include all benefits and services covered under Medicare Parts A and B
  • Cap Medicare Part A and B out-of-pocket costs in the calendar year
  • Usually include Medicare Part D — or Medicare prescription drug coverage
  • May include additional benefits and services, such as dental, vision, food, wellness programs, non-emergency transportation, or home modification

While Medicare Advantage Plans are required to follow Medicare guidelines, the amount paid for deductibles, co-payments, and/or coinsurance varies by plan. These plans usually have network restrictions, limiting which doctors and hospitals you can use. These rules can change each year, and the Medicare Advantage plan must notify the enrollee about any changes before the start of the next enrollment year.

Medicare Part D (Medicare Prescription Drug Plan)

Medicare Part D, or the Medicare Prescription Drug Plan, is an optional benefit administered by Medicare-approved private insurance companies to help cover prescription drug costs. Those who wish to add standalone Part D coverage to Medicare Parts A or B are usually required to pay a monthly premium, which varies by the plan, household income, and the geographical area (zip code and state) of residence.

No Medicare Part D plan can have a deductible more than $505 in 2023. Some Medicare drug plans do not have a deductible at all. And in some plans that do have a deductible, drugs on certain tiers are covered before the deductible is met.  

In 2023, once you and your plan spend $4,660, you’ll pay no more than 25% of the cost of prescription drugs until your out-of-pocket spending is $7,400 under the standard drug benefit. At this stage, you will move out of the coverage gap and into “catastrophic coverage.” In this “catastrophic coverage” phase you will pay a minimum of $10.35 for brand drugs or $4.15 for generics, or 5% of retail cost, whichever is higher.

If you take insulin, you may be able to get Part D that offers savings on your insulin. You could pay no more than $35 for a month's supply. 

Medicare Extra Help

Medicare Extra Help is offered through the Social Security Administration to help people with limited income and resources with costs related to a Medicare prescription drug plan. To qualify for Extra Help, your income and resources must be below a certain limit. You also won't have to pay a Part D late enrollment penalty while you get Extra Help and enroll. If you receive Extra Help, you may qualify for an exemption to make changes to your Part D plan outside of the annual open enrollment period. Extra Help can lower drug co-pays and may help lower premiums and deductibles as well. You are automatically eligible for Medicare Extra Help if you:

  • Are eligible to receive both Medicare and Medicaid (referred to as full dual eligibility)
  • Have a Medicare Savings Program that assists with Medicare premiums and cost-sharing
  • Receive need-based Supplemental Security Income (SSI) benefits but not Medicaid.

Medicare Supplemental Plans (Medigap)

Medigap is supplemental insurance to cover Original Medicare deductibles and coinsurance. Medigap plans are offered by Medicare-approved private insurance companies and have several requirements:

  • You must have Original Medicare Part A and Part B
  • You cannot have a Medicare Advantage and a Medigap plan at the same time
  • You must pay a separate premium for a Medigap plan, in addition to your monthly Part B and Part D premium
  • Medigap plans cover only one person. Your spouse must have a separate individual policy.

Because there is no annual enrollment period for these plans, you can drop your supplement at any time.

Medigap plans strictly follow Medicare guidelines, which means they will cover your Medicare costs for Medicare Part A- and B-covered services only. These plans pay after Medicare pays.

Some things to remember:

  • If you already have a Medicare Advantage Plan (Part C), you will not be able to purchase a Medigap plan unless you switch back to Original Medicare.
  • Medigap plans do not include prescription drug coverage, so you’ll want to purchase a stand-alone Part D drug plan to cover your medications.
  • Medigap plans are available in all 50 states, but in some states Medigap policies may not be available or may have higher monthly premiums for individuals younger than 65. 

Medigap plans are standardized and identified by letters A-N. Each plan follows the same structure for what costs it will cover. To get a quote for a Medigap plan, you must contact an insurance company or an insurance broker offering the plan in your area. You can search for the policies offered in your area on medicare.gov.

Comparing Medicare Options

To explore specific Medicare Advantage plans or Medicare prescription drug plans available in your area, visit the Medicare Plan Finder. For more information about Medicare, download the Medicare & You official handbook.

Medicare Eligibility and Enrollment

Knowing eligibility requirements and when you can enroll in Medicare will ensure you get the benefits you need when you need them.

Medicare is a federally funded health insurance option typically for individuals age 65 years or older. However, many people with certain disabilities or conditions, like cystic fibrosis, may qualify for the program without reaching the age requirement. Groups eligible for Medicare benefits include:

  • Individuals age 65 years or older
  • Individuals younger than 65 years who receive Social Security Disability Insurance (SSDI)
  • Individuals with end-stage renal (kidney) disease (ESRD)

Typically, people with CF qualify for Medicare through SSDI prior to turning 65. People younger than 65 who receive SSDI are automatically enrolled in Medicare Part A (hospital) and Part B (medical) and coverage begins after receiving their SSDI benefit payments for 24 months. People with CF who have ESRD may be eligible for Medicare benefits sooner if they need dialysis or a kidney transplant.

Enrolling in Original Medicare (Parts A and B) and Part D

Enrollment periods for Original Medicare may depend on how you will receive benefits: through SSDI or by aging in at age 65 or older. You should enroll in Medicare Parts A, B, and D during your initial enrollment period to avoid financial penalties.

There are certain conditions under which eligible people may choose to delay enrollment in Parts B and D — for example, if they are covered by an employer insurance plan based on active employment. However, Medicare must be notified of any choice to delay enrollment to avoid late enrollment penalties. Special enrollment periods allow individuals to sign up for Part B and D outside of initial enrollment due to life changes like loss of active employment insurance.

If you delayed your Part B enrollment during your initial enrollment period, you can enroll in Part B during Medicare general enrollment period from Jan. 1 and Mar. 31 and your Part B will start on the first day of the following month.

Enrolling in Medicare Advantage Plans

When first eligible for Medicare Parts A and B, a person with CF may choose to enroll in a Medicare Advantage plan instead. Any changes to coverage -- for example, switching to a different Medicare Advantage plan or to Original Medicare -- may be made only during open enrollment periods. From October 15 to December 7th each year, you can join, switch, or drop a Medicare drug or Advantage plan. Plans selected during this time start the first of the next year. 

There is a special open enrollment period for those already enrolled in a Medicare Advantage plan that begins annually on Jan. 1 and continues through March 31. During this time, a person can switch to a different Medicare Advantage plan or go back to Original Medicare. They can only make a change once during this period. Coverage will begin the first day of the month after a person enrolls or makes changes to the plan. 

If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare.

For more information about Medicare, download the Medicare & You official handbook.

Dual Eligibility

People who qualify for both Medicare and full Medicaid are known as dual eligible. For Medicare-eligible individuals with limited incomes, dual eligibility allows for more comprehensive coverage and typically applies to those with significant medical needs. You can still pick how you want to get your Medicare coverage: Original Medicare or Medicare Advantage (Part C).

If you choose to join a Medicare Advantage Plan, there are special plans for dual eligibles that make it easier for you to get the services you need, include Medicare coverage (Part D), and may also cost less, like:

  • Special Needs Plans
  • Medicare-Medicaid Plans (only available in certain states)
  • Program of All-Inclusive Care for the Elderly (PACE) plans can help certain people get care outside of a nursing home 

What Services Are Covered?

Dual eligible individuals receive all benefits included in Medicare Part A, Part B, Part D, and Part C. In addition, Medicaid may also cover some medications and other benefits that Medicare does not cover, such as long-term services and support, 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.

Medicare Savings Programs

You can get help from your state to paying your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums through a Medicare Savings Program. If you qualify, Medicare Savings Programs might also pay your Part A and Part B deductibles, coinsurance, and copayments. There are four programs, and your state determines which program you qualify for based on your income and resources. Contact your state for eligibility.

  • Qualified Medicare Beneficiary (QMB) Program: Helps pay for Medicare Part A and/or Part B premiums, deductibles, coinsurance, and copayments.
  • Specified Low Income Medicare Beneficiary (SLMB) Program: Helps pay for Medicare Part B premiums.
  • Qualified Individual (QI) Program: Helps pay for Medicare Part B premiums 
  • Qualified Disabled Working Individual (QDWI) Program: Pays for Part A premiums for certain people who have disabilities and are working. 
Get Help

If you need help understanding Medicare:

  • Learn more about Medicare and CF with Navigating CF
  • Contact CF Foundation Compass at 844-COMPASS (844-726-7277) to talk with a case manager about your Medicare questions and concerns
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