Medicare provides coverage for many cystic fibrosis treatments and medications. You may need to use different parts of Medicare together to get complete coverage or enroll in an Advantage (Part C) plan.

If you have cystic fibrosis and Medicare, you’re covered for a wide range of services. Medicare covers the testing, treatments, and care you need to manage cystic fibrosis.

Keep reading to learn more about what’s covered.

Each part of Medicare offers different coverage to help you get the treatments and care you need if you have cystic fibrosis.

Knowing which parts offer coverage for which services can be helpful when planning care, especially when managing a chronic condition.

Items and services covered under each part include:

Medicare Part A

Part A is hospital insurance. It covers inpatient care, including:

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:

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. You can only get a Medigap plan with Original Medicare, not a Medicare Advantage plan.

Medicare Advantage plans (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.

Let’s examine what the different parts of Medicare cover when you have cystic fibrosis.

Healthcare services

Medicare generally covers the visits, tests, treatments, and medications your doctor orders. However, different rules apply to some covered services.

Some of the covered services include:

  • 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. Medicare Part B or a Medicare Advantage plan covers testing for cystic fibrosis.
  • Doctor’s and specialist’s visits: Medicare Part B or a Medicare Advantage plan covers doctor’s office and specialist visits. 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 your doctor deems the therapy medically necessary.
  • Respiratory care: Respiratory care, including the services of a respiratory therapist, is generally covered under Part B or a Medicare Advantage plan. But if you receive respiratory care in a hospital, skilled nursing facility, or as part of a 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 also provides coverage if you need a lung transplant. The doctor’s appointments 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, including prescription medications you take at home.

Medicare generally covers FDA-approved prescription drugs. Coverage will fall under a Part D or Medicare Advantage plan that includes prescription drug coverage.

These plans typically cover certain drugs in each drug class. You can determine which specific drugs a plan covers by checking the formulary. This may include generic or brand-name versions.

Coverage may include:

  • oral tablets
  • nebulizer treatments
  • nasal sprays

Commonly covered medications include:

  • Medications to open your airways: Medications in this category include albuterol (ProAir HFA), ipratropium (Atrovent), and theophylline (Theo-24).
  • Medications to help you cough up sputum: These include guaifenesin (Mucinex), hypertonic saline, and N-acetylcysteine.
  • Medications to help you absorb nutrients: This may include pancrelipase and pancreatin.
  • Medications to decrease lung inflammation: These can include beclomethasone (Qvar), flunisolide (Aerospan), fluticasone (Flovent HFA), ibuprofen (Advil), methylprednisolone (Medrol), and prednisone (Rayos).

Medicare also covers medications you need temporarily, such as antibiotics or antiviral medications to treat an infection.

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

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

Home medical equipment

Medicare also generally covers at-home medical equipment you need under Part B. This is known as durable medical equipment.

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 get full coverage, you must get your equipment from a supplier that participates in Medicare and accepts assignment, or the Medicare-approved cost for the device. 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 does not cover treatments or procedures that the FDA has not approved to treat cystic fibrosis.
  • Long-term skilled nursing care: Medicare covers 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. You’ll also 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 does not cover 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.

Medicare provides coverage for the testing, treatment, and medical care for cystic fibrosis.

You’ll need a Part D 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. However, they may cover some costs associated with participating in a clinical trial, such as hospital fees.