Who is eligible
Children ages 0-18 with family income levels up to 142% of FPL. Pregnant women with family income up to 208% of FPL. Adults with family income up to 133% of FPL.
- healthinsurance.org contributor
- October 3, 2016
Medicaid is an important part of the Illinois healthcare system, covering more than 3 million of the state’s 12.9 million residents.
Compared to other states, Illinois Medicaid eligibility guidelines are more restrictive for children and about average for pregnant women and parents. Illinois did opt to expand Medicaid through the Affordable Care Act to other non-elderly adults, which contributed to a net increase of more than 461,000 people in the Medicaid program in the first two years after expansion was implemented.
Far more Illinois residents have enrolled in expanded Medicaid than the state expected. Although that means the state will receive more federal Medicaid funding than projected, it also means Illinois will have to pay more than projected, as the state will eventually be responsible for 10 percent of the cost of providing coverage for the newly eligible population.
Medicaid funding for enhanced mental health care?
In September 2016, Illinois officials requested permission from the federal government to use existing Medicaid funds (with no changes to eligibility or funding) to test different approaches to treating Medicaid enrollees who need mental health and/or substance abuse treatment. If approved by CMS, the changes would take effect in July 2017.
The idea is to focus more on preventive care, supportive housing services, and community-based care, rather than institutional care. The state notes that while 25 percent of Illinois Medicaid enrollees have mental health and/or substance abuse diagnoses, their treatment accounts for 56 percent of the Medicaid program’s total cost.
Hepatitis C drugs for some, but not all
In the past few years, drugs that can cure Hepatitis C have burst onto the medical scene, heralded as miracles. But they can also be a strain on budgets, as the pills can cost more than $1,000 per day, and the treatment course lasts 12 weeks. Medicaid programs across the country have been grappling with how to handle the situation, and Illinois announced in September 2016 that they would loosen their guidelines in terms of when Hepatitis C drugs would be covered.
Rather than restricting coverage only to the sickest patients, Illinois Medicaid will now cover Hepatitis C drugs for people with stage 3 and 4 liver scarring, rather than just 4. Advocates cheered the new rules, but cautioned that there is still no coverage for treatment in people with chronic Hepatitis C that hasn’t progressed as far as stage 3 liver scarring, and urged the state to continue to consider the issue.
Eligibility guidelines for Illinois Medicaid
Federal law specifies mandatory and optional coverage groups for Medicaid. States must cover the mandatory groups to receive federal Medicaid funding, and they qualify for additional funding if they cover optional groups.
The federal government specifies minimum thresholds for eligibility for the various groups, for example, 133 percent of the federal poverty level. States can set their requirements at or above the minimum threshold. Illinois has established requirements that are near national averages.
Illinois’ eligibility standards for Medicaid are:
- Children ages 0-18 qualify with family income levels up to 142 of the federal poverty level (FPL); the Children’s Health Insurance Program covers children with family income up to 313 percent of FPL
- Pregnant women qualify with family income up to 208 percent of FPL
- Parents and other adults qualify with family income up to 133 percent of FPL (138 percent with the built-in 5 percent income disregard).
How to apply for Medicaid
You have several options for applying for Illinois Medicaid:
- Apply online using the Illinois wesbite or Healthcare.gov.
- Apply in person and get help from the Department of Human Services (DHS). Find the nearest Family Community Resource Center.
- Apply by mail or fax, or apply online or call at 1-800-843-6154 (TTY 1-800-447-6404) and ask DHS to mail you an application. Complete the application and mail or fax it back to the nearest Family Community Resource Center.
Medicaid expansion in Illinois was authorized in July 2013 and went into effect Jan. 1, 2014. Making Medicaid available to low-income, non-elderly adults is a key part of the Affordable Care Act’s strategy to reduce the nation’s uninsured rate. However, a Supreme Court ruling made Medicaid expansion optional, and as of late 2016, there were still 19 states that had not expanded Medicaid.
The federal government will pay 100 percent of the cost for the Medicaid expansion population through 2016. After that, the federal government’s portion will gradually decrease, reaching 90 percent by 2020, with Illinois covering the other 10 percent (it will remain at that level after 2020).
At the time Medicaid expansion was approved, Illinois officials estimated that 342,000 Illinois residents would qualify. But according to the Chicago Tribune, about 350,000 new enrollees were approved in just the first several months, by June 2014. And a year later, by June 2015, total enrollments under Medicaid expansion in Illinois had reached 623,000.
By July 2016, total enrollment in Medicaid and CHIP in Illinois stood at nearly 3.1 million, and was 18 percent higher than it had been at the end of 2013.
More information about the Illinois Medicaid program
Medicaid was implemented in the state of Illinois in January 1966.
Individuals covered by Illinois Medicaid can choose either a fee-for-service plan or a managed care plan. The Illinois DHS site explains these options.
Illinois has been slower than many other states in moving beneficiaries to managed care plans. However, the state did pass a law in 2011 that required expanding managed care to at least half the state’s Medicaid beneficiaries by Jan. 1, 2015.
In June 2014, Gov. Pat Quinn signed a Medicaid reform bill. The law restores adult dental care and podiatry services, aligns Illinois law with federal law to provide Medicaid coverage to children who have been without private insurance for three months, streamlines hospital and nursing-home reimbursement, and more.