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
If you are uninsured or 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. Medicaid and CHIP eligibility is different in every state and this website will help guide you through the program applicable to you and direct you to your state’s specific site, which can help explain the unique program features in your state. You may enroll in Medicaid and CHIP at any time, not just a set time of the year like for other types of health insurance.
There are a few aspects of eligibility that are common to many states. Most states have less strict eligibility rules for children and pregnant women than for other adults. 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 women and children may still be eligible, even if most working adults are not.
Currently, Medicaid and CHIP are available to American citizens and some immigrant visa holders or permanent residents. American citizen children, regardless of the immigration status of the rest of the family, are eligible for Medicaid and CHIP if the family meets all other eligibility rules.
On October 1, 2026, restrictions on Medicaid eligibility will take effect for individuals with certain immigrant visa status. After this date, lawful permanent residents, certain Haitian and Cuban immigrants, citizens of Freely Associated States, and in some states, lawfully present pregnant women and children, will be the only immigrants eligible for Medicaid.
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.
Losing your insurance
If you receive notice that you are losing eligibility for Medicaid, you will need to determine your options. If you think that there has been a paperwork error or similar mistake, you have the right to appeal to the state about your eligibility. The letter you receive will have more information about this process, including deadlines for when you must start an appeal.
If you lose your Medicaid coverage, your choices for health insurance will be limited. If your job offers insurance, you will be able to sign up, even if it is not the usual open enrollment time. Some, but not all people will be eligible to purchase a full-priced health plan from Healthcare.gov, but many will not be eligible for tax credits that help lower the cost of these plans. If these options do not work for you, and you become uninsured, community health centers offer health care to anyone, regardless of income or insurance status. There may be other free or low-cost care available in your community. Most insulin manufacturers offer free or low-cost insulin for people without health insurance. You can find links to these programs here: Help with Costs.
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
Medicaid eligibility rules remain mostly the same for now, but will be changing in late 2026 and 2027. Be sure to pay particular attention to any mail, texts or other communications from your state’s Medicaid program during that time period if you are currently enrolled. Many states have a state specific name for their Medicaid program, so be aware of your state’s program name so you can watch for notifications from the program. Click here to find the name of the Medicaid program in your state.
Starting in late 2026, you may have to prove to your state Medicaid program that you are working or volunteering at least 80 hours per month, or in school, if you are between the ages of 19-64. Not all people who have Medicaid will be required to do this, but many will be. The state will try to use existing databases for proof, but you may be asked to produce pay stubs, proof of school enrollment or volunteer hours. If you cannot provide this proof in a timely manner, you will likely lose Medicaid coverage. There are some exceptions to this rule, such as being a caretaker to a young child or being disabled or “medically frail”. Having type 1 diabetes without complications is unlikely to be considered disabled or medically frail, but definitions will vary by state.
Future cost sharing requirements
Starting in 2028, your state Medicaid program will start charging copays for some care. Visits to your primary care provider, prescription drugs, and mental health care will be exempt, but specialist visits, hospital care and ER visits will likely have a copay of no more than $35. CGM and pump supplies as well as insulin may also be subject to this copay depending on the state. You will not be required to pay more than 5% of your family income toward these copays.
