Medicaid and type 1 diabetes
Medicaid is the health insurance program for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.
It is run by each individual state, with the federal government setting some rules for the program. Because each state runs its own program, coverage and eligibility vary greatly.
Children’s Health Insurance Program (CHIP) is similar to Medicaid, but only for children in families with low- to moderate- income.
Eligibility
The easiest way to determine if you or your family is eligible for Medicaid or CHIP is by visiting HealthCare.gov. This website will help guide you through the program applicable for you direct you to your state’s specific site, which can help explain the unique program features in your state.
Medicaid and CHIP eligibility is different in every state. Most states have less strict eligibility rules for children and pregnant people than for other adults. No matter which state you live in, if you are having trouble paying for your or your child’s diabetes care, go to HealthCare.gov to determine if you may be eligible for Medicaid, CHIP or other insurance help. You may enroll in Medicaid and CHIP at any time, not just a set time of the year. Some states have expanded Medicaid to make it available to nearly anyone with a low-income. If your income is less than 138% of FPL and you live in one of the following states, then you and your spouse and/or children may be eligible for Medicaid.
| Alaska | Indiana | Nebraska | Pennsylvania |
| Arizona | Iowa | Nevada | Rhode Island |
| Arkansas | Kentucky | New Hampshire | South Dakota |
| California | Louisiana | New Jersey | Utah |
| Colorado | Maine | New Mexico | Vermont |
| Connecticut | Maryland | New York | Virginia |
| Delaware | Massachusetts | North Carolina | Washington |
| District of Columbia | Michigan | North Dakota | West Virginia |
| Hawaii | Minnesota | Ohio | |
| Idaho | Missouri | Oklahoma | |
| Illinois | Montana | Oregon |
If you don’t live in one of those states, Medicaid is still available, but only to a limited number of people with severe disabilities or very low income. However, pregnant people and children may still be eligible, even if most working adults are not.
No matter which state you live in, if you are uninsured, go to HealthCare.gov to see if there are any health insurance programs available to you.
Medicaid/CHIP is available to some immigrants, but eligibility varies based on visa type and length of time in the US. American citizen children, no matter the immigration status of the rest of the family, are eligible for Medicaid and CHIP if the family meets all other eligibility rules.
Using your insurance
If you or your child are eligible for Medicaid or CHIP, you may be asked to pick a health plan that will help you access your care. All of these plans will cover prescription drugs, doctor visits, and hospital care. Plans may have some differences in the doctors, drugs or other services that they cover. If you find that a plan isn’t covering something, it may be covered by another plan. In most states, you have 90 days after enrollment to change plans, then you must wait a year until you can change plans. Note, in many states, decisions such as who can get a CGM are made by the state, not the plan, so changing plans may not help if a state has decided to not cover certain devices or treatments.
Both Medicaid and CHIP provide similar benefits and have similar applications. In some states, CHIP families may have to pay a monthly premium and higher copays for health care. In all states, Medicaid does not charge a monthly premium and usually does not charge more than a few dollars for any care that you receive.
Coverage for diabetes drugs and devices
For most people on Medicaid, prescription drugs, including insulin, are free or are a few dollars at the pharmacy. However, coverage for insulin pumps and CGMs varies by state. In some states, anyone with T1D can access a CGM and an insulin pump, while in others, only children have access to these devices. Some other states don’t cover either type of device for anyone with diabetes.
Some Medicaid plans cover additional services that can help you stay healthy. Nearly all kids with Medicaid or CHIP will have coverage for eyeglasses and dental care. Some states cover these services for adults too. Many people with Medicaid coverage are eligible for rides to their medical appointments. If you have any questions about your plan or what is covered, call the phone number on your Medicaid card.
Medicaid coverage of organ transplants
For people with T1D, complications may lead to the need for a kidney transplant. For many people who need a kidney transplant, their medical team may recommend a pancreas transplant as well, since this will reduce or eliminate the need for insulin therapy. Breakthrough T1D supports coverage of all medically necessary treatments for people with T1D including pancreas-kidney transplantation when appropriate.
In most cases, states will cover a kidney transplant. However, some states will not cover a simultaneous pancreas-kidney transplant. In cases where state Medicaid policies do not provide coverage of pancreas and/or kidney transplants when it is considered medically necessary care, it is important to work closely with your physician and care team to seek authorization or other possible care alternatives. You can appeal the state’s decision, but there is no guarantee of coverage.
Keeping your insurance
Once you are enrolled in Medicaid, it is important to respond to any mail that the state Medicaid agency or health plans sends you. Unlike employer-sponsored insurance, Medicaid eligibility may not last a full year after you sign up. The state Medicaid agency may ask for proof of income every few months. You may also be required to report a new job or change in who lives in your household. Be sure to update your phone number and/or address if they change while you have Medicaid coverage.
