Medicare Coverage for Cystic Fibrosis: Testing, Management, and Treatments

Each part of Medicare offers different coverage that can help you get the treatments and care you need for cystic fibrosis.

It’s helpful to know which parts offer coverage for which services when you’re planning your care, especially when you’re managing a chronic condition.

Items and services covered under each part include:

• Medicare Part A. Part A is hospital insurance. It covers any inpatient care you need. This includes stays in the hospital and rehabilitation facilities, as well as limited home healthcare services.
• Medicare Part B. Part B is medical insurance. It covers outpatient care such as the treatments you receive from your doctor. Part B also covers:
  • ambulance rides
  • urgent care visits
  • diagnostic tests
  • medical equipment used at home
• Medicare Part C. Part C is also called Medicare Advantage. It covers everything that parts A and B do and often includes coverage for additional services and prescription drug coverage. Medicare Advantage plans use networks to provide coverage, so you’ll often need to stay in network to get care when you use a Medicare Advantage plan.
• Medicare Part D. Part D is prescription drug coverage. Medicare parts A and B, together known as original Medicare, don’t offer any prescription drug coverage unless you receive the medication during a hospital stay or doctor’s office visit. Stand-alone Medicare Part D plans can be added to original Medicare so that the prescriptions you take at home are covered. All Part D plans have a list, called a formulary, that tells you which prescription drugs are covered and how much they’ll cost.
• Medigap. Medigap plans, also called Medicare supplement plans, cover some of the out-of-pocket costs of original Medicare. They don’t offer additional coverage, but they can allow you to receive medical care without worrying about out-of-pocket costs like deductibles or copayments.

Now that we’ve looked at a general overview of what each part of Medicare covers, let’s look at how that applies to your healthcare needs when you have cystic fibrosis.

Healthcare services

Medicare will provide coverage for the visits, tests, treatments, and medications your doctor orders. However, different rules will apply for some covered services.

Some of the services Medicare covers are listed below:

• Testing and diagnosis. While cystic fibrosis is most often diagnosed during childhood, that’s not always the case. Some cystic fibrosis patients don’t know they have the condition until adulthood. You’ll have coverage for the testing you need under Medicare Part B or a Medicare Advantage plan.
• Doctor’s and specialist’s visits. Medicare Part B or a Medicare Advantage plan will cover your doctor’s office visits and your visits to a specialist. You don’t need a referral to see a specialist if you’re using Medicare Part B, but you will need a referral with many Medicare Advantage plans.
• Physical therapy. You can get physical therapy coverage through Part B or a Medicare Advantage plan. Medicare doesn’t limit the amount of physical therapy you can receive as long the therapy is deemed medically necessary by your doctor.
• Respiratory care. Respiratory care, including the services of a respiratory therapist, is generally covered under Part B or a Medicare Advantage plan. However, if you receive respiratory care in a hospital, skilled nursing facility, or as part of home healthcare service, it will be covered under Part A.
• Pulmonary rehabilitation. Medicare Part B and Medicare Advantage cover outpatient pulmonary rehabilitation. However, you may need preauthorization before you can use this service.
• Lung transplant. Medicare will also provide coverage if you need a lung transplant. Your doctor’s visits and preparation will be covered under Part B, while your actual transplant and hospital stay will be covered under Part A.

Medications

Your cystic fibrosis treatment plan will likely include services outside of your doctor’s visits. For example, the prescription medications you take play a huge role in your treatment.

Medicare will cover prescription drugs that have been FDA approved. Coverage will fall under a Part D plan or Medicare Advantage plan that includes prescription drug coverage.

Coverage may include:

• oral tablets
• nebulizer treatments
• nasal sprays

Commonly covered medications include:

• Medications to open your airways. Medications in this category include albuterol, ipratropium, and theophylline.
• Medications to help you cough up sputum. Medications in this group include guaifenesin, hypertonic saline, and N-acetylcysteine.
• Medications to help you absorb nutrients. Medications in this group include pancrelipase and pancreatin.
• Medications to decrease lung inflammation. Medications in this group include beclomethasone, flunisolide, fluticasone, ibuprofen, methylprednisolone, and prednisone.

Medicare will also cover medications you need temporarily — for example, antibiotics or antiviral medications you need to treat an infection.

Keep in mind that not all Medicare Part D or Medicare Advantage plans cover every prescription you might take for cystic fibrosis. Plans cover only prescriptions that are part of their formulary.

You can check for plans that include any prescriptions you currently take using the Medicare website.

Home medical equipment

Prescriptions aren’t the only at-home care you might need when you have cystic fibrosis.

Medicare will also cover the at-home medical equipment you need. This is known as durable medical equipment and is covered under Medicare Part B.

Some common covered equipment includes:

• at-home oxygen therapy, including, oxygen tanks, tubing, and other supplies
• nebulizer machines
• vests for chest physical therapy
• positive expiratory pressure devices

To ensure full coverage, you must get your equipment from a supplier that participates in Medicare and accepts assignment. You can find Medicare-approved suppliers here.

Most of the services you need will be covered by Medicare. However, there are a few exceptions, including:

• Experimental treatments. Medicare won’t cover any treatments or procedures that haven’t been approved by the FDA to treat cystic fibrosis.
• Long-term skilled nursing care. Medicare will cover only 100 days of skilled nursing care. Those 100 days are covered only if you meet set conditions, including a recent hospital stay of at least 3 days. Plus, you’ll owe daily coinsurance fees starting on day 21.
• Long-term home healthcare. Medicare covers only home healthcare that’s medically necessary for a condition expected to improve. For example, Medicare would cover home healthcare if you’re homebound and need a nurse to treat you for an infection. Medicare doesn’t cover extended home healthcare.
• Any other type of long-term care. Medicare never covers stays at assisted living, custodial care, personal care homes, or nursing homes. Medicare considers all these services to be nonmedical and doesn’t cover them.

Cystic fibrosis is a genetic condition that causes mucus to build up in your lungs, causing frequent infections. As cystic fibrosis progresses, it leads to increased trouble breathing.

Cystic fibrosis also affects other body systems, including the pancreas and liver.

Mucus buildup around the pancreas slows the release of digestive enzymes and makes it difficult for your body to absorb the nutrients it needs. Mucus buildup around the liver can trap bile and cause liver disease.

In the past, many people with cystic fibrosis didn’t survive past childhood. Today medical advancements and an increased understanding of cystic fibrosis allow many people with the condition to live into adulthood.

Recent data shows that the life expectancy for people with cystic fibrosis born between 2014 and 2018 is age 44, according to Cystic Fibrosis Foundation.

However, cases of cystic fibrosis can look very different in different people. Several factors — including the presence of other health conditions and the severity of cystic fibrosis — can have a large impact on length and quality of life.

Many people manage their cystic fibrosis at home through a combination of:

• daily medications
• breathing treatments
• airway clearance

However, because people with cystic fibrosis are at high risk for developing serious infections, it’s important to talk with your doctor right away if you have new symptoms or your symptoms change.

You should call your doctor if:

• You’re in respiratory distress.
• You have a fever.
• You have a change in your stools.
• You have any changes in your normal symptoms.

• Medicare provides coverage for the testing, treatment, and care you need for cystic fibrosis.
• You’ll need a Part D plan or Medicare Advantage plan with prescription drug coverage included to get coverage for your prescriptions.
• Medicare never pays for experimental treatments or long-term nursing care.