Guide to Medicaid in Illinois

Illinois is one of the many states that opted to expand Medicaid coverage under the 2013 Affordable Care Act (ACA). It now covers more than 3.9 million Illinoisans as of November 2023. The Illinois Medicaid program is an essential health insurance plan for Illinois residents and a leader in the nation for its expansive service coverage, especially its coverage for families. For example, Illinois was the first state to extend postpartum Medicaid coverage to 12 months after the baby is born—a significant change from the previous 60-day limit. To help keep Illinoisans abreast of key Medicaid changes like this, we’ve created this guide to Medicaid in Illinois with the help of experts and official government resources. You’ll find all the information you need to access Illinois Medicaid for yourself and your loved ones.

Read on to learn about the program’s eligibility requirements, covered services, and how to apply for Medicaid in Illinois. 

Eligibility for Illinois Medicaid

Under the state’s expanded Medicaid coverage, more Illinois residents are eligible for Medicaid than ever before. To qualify, you must meet certain income, age, disability, and/or citizenship status requirements. If you have health insurance through your employer, you are not eligible for Medicaid in Illinois. 

Income requirements

In states like Illinois that have opted for the ACA’s Medicaid expansion, Medicaid eligibility is based on the applicant’s modified adjusted gross income (MAGI), which has a built-in 5% income disregard. To be eligible for Illinois Medicaid based on your income, your MAGI must not exceed the percentage of the federal poverty level (FPL) established for your coverage group. The FPL limits for Illinois Medicaid’s various coverage groups are as follows:

• 142% for ages 0 to 18
• 313% for children under the separate CHIP program
• 208% for pregnant women
• 133% for parents or related caregivers of eligible children
• 133% for adults eligible under the ACA expansion

For reference, the 2023 FPL for a single individual is $15,060 per year. Therefore, an applicant who makes twice that amount ($30,120) has an income that is 200% of the FPL likely would not qualify for Medicaid based on his or her income alone. However, the same applicant may still be eligible for Medicaid or one of Illinois’ Medicaid-related programs if he or she meets certain disability or healthcare needs requirements.

Age requirements

In Illinois, residents aged 65 or older can qualify for both Medicaid and Medicare coverage through the state’s Medicare–Medicaid Alignment Initiative. To qualify for Medicaid as a senior, at the time of writing, a single person must have an income below $981 a month and countable assets below $2,000. (Note that income and asset requirements are subject to change year to year based on inflation and other factors). 

Adults aged 19 to 64 may be eligible for Medicaid in Illinois as long as they meet the state’s income or disability requirements and are not receiving Medicare coverage. 

Children aged 18 and younger may qualify for either Illinois Medicaid or the State Children’s Health Insurance Program (SCHIP), depending on their family’s income level. The SCHIP program is designed for children whose families earn too much to qualify for Medicaid but not enough to afford private health insurance. 

Disability requirements

In some states, people who qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) automatically qualify for SSA-linked Medicaid. Unfortunately, this is not the case in Illinois.

In Illinois, people on SSI must apply for Medicaid separately. Depending on their income and work status, individuals with disability designations may be eligible for one of the following Illinois Medicaid coverage programs: Aid to Aged, Blind, and Disabled (AABD), FamilyCare, ACA Adult, or Health Benefits for Workers with Disabilities (HBWD).

People with disabilities whose income exceeds the Medicaid income limits for Illinois may be eligible for the state’s Spenddown program. 

Citizenship requirements

To be eligible for Illinois Medicaid, you must reside in the state of Illinois and have been a U.S. national, citizen, or permanent resident (Green Card holder) for at least five years. Children and pregnant women of any immigration status can qualify if they meet income requirements.

Healthcare needs requirements

Illinois Medicaid provides full or partial coverage to people with certain healthcare needs who are not defined as disabled by the SSA. These programs include:

• Illinois Breast and Cervical Cancer Program (IBCCP) covers uninsured women at any income level who need treatment for breast or cervical cancer.
• State Hemophilia Program assists eligible patients in obtaining antihemophilic factors, annual comprehensive visits, and other outpatient medical expenses related to the disease.
• State Renal Dialysis Program covers the cost of renal dialysis services for eligible persons with chronic renal failure who are ineligible for coverage under Medicaid or Medicare.

Illinois Medicaid benefits

Under Illinois Medicaid, enrollees receive a full range of health benefits comparable to the coverage of a typical private health insurance provider.

Covered medical services

The medical services Illinois Medicaid covers vary depending on the coverage program. In general, Medicaid enrollees in Illinois can expect coverage for the following health services: 

• Doctor and dental care visits
• Ambulance rides
• Emergency room services
• Hospital stays
• Surgery
• Well-child care
• Immunizations for children
• Mental health and substance abuse services
• Prescription drugs
• Medical equipment/supplies

Prescription drug coverage

Some of Illinois’ Medicaid coverage programs (including All Kids and Moms & Babies) cover the full cost of prescription drugs. Other programs (like FamilyCare) require enrollees to pay a small copayment, usually ranging from $2 to $4 per prescription. Notably, All Kids, FamilyCare, and Moms & Babies must approve some medicines before a pharmacy may fill the prescription.

Dental coverage

Similar to the state’s prescription drug coverage, some Medicaid programs in Illinois include comprehensive service coverage for dental, which fully covers the cost of dental visits. There may be a small copay for dental visits under other coverage programs (for example, FamilyCare).

For children, dental coverage includes the cost of diagnostic services (e.g., oral exams, X-rays), preventive services (e.g., cleanings, topical fluoride, sealants), restorative services (e.g., fillings, crowns), endodontic services (e.g., root canals), periodontal services, prosthodontic services (e.g., dentures, bridges), oral and maxillofacial services (e.g., surgical extractions), orthodontic services, general anesthesia, and sedation. 

Adult Medicaid enrollees receive coverage for most of the same dental services but with certain exceptions. For example, adults are limited to one oral exam and cleaning every 12 months, whereas children may receive these services every six months. 

Vision coverage

All Kids, FamilyCare, and Moms & Babies provide coverage for optometrist services and the cost of prescription eyeglasses. Similar to dental coverage, the extent of vision coverage varies by program, with children receiving the most coverage. 

Long-term care services

Illinois Medicaid is crucial in providing long-term care services for seniors and individuals with physical disabilities. The state offers various programs, each tailored to meet the specific needs of its residents requiring Nursing Facility Level of Care. 

Nursing Home and Institutional Medicaid

Illinois Nursing Home Medicaid is designed to cover the cost of long-term care in nursing homes for financially limited seniors. This includes coverage for the following:

• room and board 
• personal care assistance
• skilled nursing care
• physician’s visits 
• prescription medication 
• medication management 
• mental health counseling 
• social activities

However, it’s important to note that certain items and services are not covered, such as private rooms, specialized food, and comfort items beyond routine necessities. 

Illinois Nursing Home Medicaid operates as an entitlement, ensuring that all qualified applicants are entitled by law to receive benefits without a wait. Despite this entitlement, not all nursing homes accept Medicaid, and availability from your chosen facilities is not guaranteed.

Home and Community Based Services (HCBS) Waivers

Home and Community Based Services (HCBS) Waivers offer an alternative to nursing home care, supporting financially limited seniors in remaining in their communities. These waivers act like vouchers, covering long-term care goods and services for individuals who meet the Nursing Facility Level of Care criteria.

Supportive Living Program (SLP)

The Supportive Living Program (SLP) targets disabled or seniors who require a Nursing Facility Level of Care but choose to live in state-approved residential settings such as board and care homes, assisted living facilities, or memory care units. SLP benefits encompass nursing care, Personal Emergency Response Systems, housekeeping assistance, medication management, and personal care assistance.

Unlike Nursing Home Medicaid, SLP operates with a limited number of enrollment spots and places additional applicants on a waitlist once full.

Waiver for the Elderly

The Waiver for the Elderly, also known as the Persons who are Elderly Waiver, supports seniors who require a Nursing Facility Level of Care but opt to live at home or with a loved one. Benefits include adult day care, Personal Emergency Response Systems, housekeeping and shopping assistance, and personal care assistance.

Similar to SLP, the Waiver for the Elderly has a large but limited number of enrollment spots, and eligible applicants beyond the capacity are placed on a waitlist.

Understanding the unique differences of Illinois Medicaid’s long-term care programs is essential for individuals and their families as they navigate the options that fit their unique needs. From nursing home coverage to community-based waivers, Illinois Medicaid strives to provide comprehensive support for those needing long-term care services.

Illinois Medicaid programs

Jointly funded by the federal government, Medicaid operates with benefits and administration exclusively managed at the state level within federal guidelines. Each state has the authority to shape coverage programs and set eligibility requirements.

While there are minimum eligibility thresholds and a federal mandate for covered services, states can surpass these requirements, providing greater generosity in their Medicaid offerings. This flexibility allows states to tailor their programs to meet the unique needs of their residents better, ensuring a comprehensive approach to healthcare without compromising federal guidelines.

Overview of Illinois Medicaid programs

In Illinois, there are several Medicaid coverage programs for low-income families, children, pregnant women, seniors, and individuals with disabilities. In addition to income, eligibility for these programs is based on the applicant’s age, health needs, parental/caregiver role, disability, and employment status. The most notable Illinois Medicaid coverage programs include:

• FamilyCare
• All Kids
• Moms & Babies
• Aid to Aged Blind and Disabled (AABD)
• Health Benefits for Workers with Disabilities (HBWD)

FamilyCare: Health coverage for low-income parents

FamilyCare is an Illinois Medicaid program that offers healthcare coverage to low-income parents living with children aged 18 years old or younger. It also covers relatives who have taken on guardianship of children in place of their parents.

All Kids: Health coverage for children

All Kids provides comprehensive health benefits to eligible children aged 18 years old and younger. To qualify, children must live in families with countable family income at or below 147% of the federal poverty level (FPL) for their household size. 

Health Benefits for Workers with Disabilities

The Health Benefits for Workers with Disabilities (HBWD) program is for individuals with disabilities who work and earn up to 350% of the FPL. Unlike FamilyCare and All Kids, HBWD requires enrollees to buy into Medicaid by paying a small monthly premium. 

Medical assistance programs for seniors

The Aid to Aged, Blind, and Disabled (AABD) Medicaid program covers seniors, the blind, and persons with disabilities who earn up to 100% of the FPL and have less than $2,000 of non-exempt resources.

Services for children and pregnant women

The Illinois Medicaid coverage program for pregnant women is called Moms & Babies. It provides a full slate of health benefits to eligible pregnant women and babies up to one year of age. You must have countable family income at or below 213% of the FPL for your household size to qualify.

How to apply for Illinois Medicaid

You can apply for Illinois Medicaid online, with a paper application, over the phone, or in person at a local Department of Human Services (DHS) office. The application is the same for every coverage program; just be sure to check the correct box to indicate the specific program(s) you want to apply for. 

In addition to medical assistance, the Medicaid Illinois application allows applicants to apply for cash assistance and the supplemental nutrition assistance program (SNAP). However, if you’re not interested in applying for those benefits, you can simply leave their respective sections of the application blank.  

Required documents for the application

There are no required documents to submit the initial Medicaid application, but once DHS has received and processed your application, you’ll need to provide additional supporting documents, such as tax returns, pay stubs, or another document accepted as proof of income. 

On the initial application, you will also need to provide the Social Security number (SSN) of each person for whom you request benefits, but you won’t need to present a physical SSN card. 

Online application process

For most individuals, the easiest way to apply for Illinois Medicaid is to submit an online application. Before accessing the application, you’ll need to set up an account using the Application for Benefits Eligibility (ABE) online form. 

In-person application process

You can apply for Medicaid in person at certain Illinois Department of Human Services locations called Family Community Resource Centers (FCRCs). To find your nearest FCRC, use the online DHS Office Locator. Additionally, some hospitals, health centers, and other community-based organizations may be able to assist you in applying for Medicaid as well as for other benefits.

To schedule an appointment for in-person help, call Get Covered Illinois at 1-866-311-1119. 

Paper application process

Follow this link to download the paper application for Illinois Medicaid (also called medical assistance). 

After completing the application, drop off, mail, or fax it to your local Family Community Resource Center (FCRC). You can find the address or fax number of your nearest FCRC using the online DHS office locator.

Cost of Illinois Medicaid

The cost of Illinois Medicaid varies with the coverage program. There is no monthly premium for FamilyCare, All Kids, or Mom & Babies. However, other coverage programs (e.g., HBWD) may require enrollees to pay a small monthly premium based on their income range. 

Additional Illinois Medicaid resources

• https://abe.illinois.gov/
  • Use this site to apply for and manage your Medicaid benefits
• https://getcovered.illinois.gov/
  • If you don’t qualify for Medicaid, shop the ACA Marketplace and enroll in a health insurance plan. 
• https://www.illinois.gov/hfs/MedicalProviders/cc/mmai/Pages/default.aspx
  • Learn about the Medicaid renewal process and other services the Illinois Department of Healthcare and Family Services (HFS) offers.

Illinois Medicaid FAQ

How to find a doctor who accepts Medicaid

To find a healthcare provider in Illinois who accepts Medicaid, visit the online DHS Medicaid Provider Directory.

How to renew Medicaid coverage

You can complete your renewal for Medicaid when it is due at abe.illinois.gov. 

When it’s time for renewal, the Department of Healthcare and Family Services will mail you a letter with instructions. It is imperative you don’t delay your renewal. If you fail to respond in time, your coverage may automatically end, and you could lose all the benefits you receive through Medicaid.

How to appeal a denied claim

The simplest way to appeal a denied claim is through your online Manage My Case account. The ‘appeals’ button is at the top of every screen: click it, select the reason for your appeal from the list, and follow the on-screen directions to file your appeal.

You can also file an appeal by phone, fax, mail, email, or in person. You can find links to the forms you need to file your appeal on the DHS website.

How to report Medicaid fraud

To report Medicaid fraud by a recipient, fill out an online OIG Recipient Fraud Complaint or call 1-844-ILFRAUD.

To report Medicaid fraud by a provider, fill out an online OIG Provider Fraud Complaint or call 1-844-ILFRAUD.