Alyssa Lane
In Illinois, it is possible to have both private insurance and Medicaid. However, if you are eligible for Medicaid, you will no longer qualify for savings on your Marketplace plan, and you will have to pay the full price for your Marketplace plan premium and covered services. Additionally, if you don't end your Marketplace coverage when your Medicaid coverage starts, you may have to pay back some or all of the premium tax credit when you file your federal taxes.
| Characteristics | Values |
|---|---|
| Can you have Medicaid and private insurance in Illinois? | Yes, it is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. |
| How to find out what Managed Care Health Plans are available in Illinois | Visit the website for Illinois' Client Enrollment Services at www.enrollhfs.illinois.gov to compare health plans. |
| Can I keep my doctor as my Primary Care Provider (PCP) | Yes, contact your PCP to see which health plan(s) they accept. |
| What to do if you move and your current health plan is not available in your new county | Inform your Department of Human Services caseworker of your new address. You will get a new enrollment packet in the mail when your address has been updated. |
| Can I continue with my current course of treatment when I first enroll in a Health Plan? | Yes, you can continue with your provider for 90 days, whether that provider is in-network or not. |
| What to do if you want to keep your Marketplace and Medicaid or CHIP coverage | Inform your state agency. However, you may no longer qualify for CHIP and you will have to pay full price for your Marketplace plan premium and covered services. |
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What You'll Learn
Medicaid and private insurance can coexist
In Illinois, it is possible to have both Medicaid and private insurance. This is known as "third-party liability" (TPL), where a third party, such as an insurer, is legally obligated to pay for medical assistance provided under a Medicaid state plan. This means that if you have private insurance through your employer, for example, you can still enrol in Medicaid and have both forms of coverage.
It is important to note that if you have both Medicaid and a Marketplace plan, you must inform your state agency. If you do not end your Marketplace coverage when your Medicaid coverage starts, you may have to pay back some or all of the premium tax credit when you file your federal taxes. Additionally, if you keep your Marketplace plan, you may no longer qualify for CHIP (Children's Health Insurance Program).
In Illinois, if you are enrolled in a health plan and are in an ongoing course of treatment, you can continue with your provider for 90 days, even if they are out of network. You will also be able to keep your Primary Care Provider (PCP) by checking which health plans they accept and choosing one that they are in-network with.
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Medicaid covers hospital and doctor visits
In Illinois, you can have both private insurance and Medicaid. However, Medicaid benefits differ across states. In general, Medicaid provides free or low-cost health coverage for low-income individuals, families, children, pregnant women, the elderly, and people with disabilities.
Medicaid covers regular exams, immunizations, doctor and clinic visits, and relevant medical supplies. It also covers non-emergency transportation, such as pre-scheduled trips to primary care providers and the dentist, for members enrolled in fee-for-service and mainstream managed care. The Medicaid Transportation program ensures that members can get to and from their medical appointments at no cost.
In addition, Medicaid covers telehealth services, including education, assessment, diagnosis, consultation, care management, and/or self-management, and treatment. This allows individuals to connect with board-certified doctors through video chat or phone for prescriptions, help with diagnosing and treating non-emergency conditions, and more.
Medicaid also covers psychiatric admissions as an alternative to inpatient psychiatric services in some hospitals. This includes short-term intensive stays in private Institutions for Mental Disease (IMD) licensed by OMH.
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Medicaid provides free or low-cost health coverage
Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to some low-income people, families, and children, pregnant women, the elderly, and people with disabilities. In 2023, Medicaid covered nearly 4 in 10 children, over 8 in 10 children in poverty, 1 in 6 adults, and almost half of adults in poverty. Relative to White children and adults, Medicaid covers a higher proportion of Black, Hispanic, and American Indian or Alaska Native (AIAN) children and adults. Additionally, Medicaid covers more than 1 in 4 adults aged 19–64 with disabilities.
Medicaid is the primary program that provides comprehensive coverage of health and long-term care to 83 million low-income people in the United States. It accounts for one-fifth of healthcare spending, more than half of spending on long-term care, and a large share of state budgets. While Medicaid is jointly financed by states and the federal government, it is administered by states within broad federal rules. This means that each state has its own requirements for eligibility and the benefits provided.
Some Medicaid programs pay for care directly, while others use private insurance companies to provide coverage. Even if you were not enrolled in Medicaid at the time you received medical care, it may still be able to help you pay for that care, depending on your family's income. Additionally, if you qualify for Medicaid, you can change your health plan once in the first 90 days. After that, you cannot change health plans for one year, except during "open enrollment," which occurs once a year.
While Medicaid coverage varies across states, all states provide comprehensive coverage and cover prescription drugs. Some states also cover vision services, dental care, and home care. In recent years, states have expanded coverage of behavioral health services and benefits to help enrollees address social determinants of health, such as nutrition and housing.
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Medicaid beneficiaries have better access to care
In Illinois, Medicaid is jointly financed by the state and federal governments but administered by the state within broad federal rules. The program is available to people who fall under specific categories, such as young adults under 26 who were formerly in foster care, children, pregnant women, women who have recently given birth, adults with disabilities, blind people, and adults over 65. Each group has different income and asset rules, with adults earning up to 138% of the federal poverty level being eligible for Medicaid.
Medicaid beneficiaries in Illinois have better access to care for several reasons. Firstly, Medicaid covers a wide range of services, including births, children with special healthcare needs, nursing home residents, adults with mental illnesses, and adults with HIV. It also provides wraparound coverage for services not fully covered by Medicare, such as long-term care expenses. This comprehensive coverage ensures that beneficiaries can access the care they need without incurring high out-of-pocket costs.
Secondly, Illinois has established Medicaid eligibility requirements that are close to the national averages, making the program accessible to a significant portion of the state's population. Additionally, Illinois has expanded its Medicaid program to cover all people below certain income levels, further increasing access for low-income individuals and families. The state also allows individuals covered by Medicaid to choose either a fee-for-service plan or a managed care plan, providing flexibility in choosing a suitable healthcare option.
Moreover, Medicaid beneficiaries in Illinois have better access to care due to the program's ability to help with costs retroactively. In some cases, Medicaid may cover medical expenses incurred up to three months before enrollment, even if the individual was not yet enrolled in the program at the time of receiving care. This provision ensures that beneficiaries can seek necessary medical attention without worrying about immediate payment capabilities.
Finally, the COVID-19 pandemic led to a significant increase in Medicaid enrollment in Illinois, including Medicaid expansion enrollment. This expansion ensured that more individuals had access to healthcare services, particularly during a public health crisis. While enrollment numbers are expected to decrease post-pandemic, the temporary surge in enrollment highlights the program's ability to provide better access to care for those who need it.
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Switching from Marketplace to Medicaid
Understanding Medicaid and Marketplace Plans:
Medicaid is a government-funded program that provides free or low-cost health coverage to eligible individuals and families with low incomes, including children, pregnant women, the elderly, and people with disabilities. On the other hand, Marketplace plans refer to private health insurance plans purchased through the Health Insurance Marketplace, which is an online platform where individuals can compare and buy health insurance.
Eligibility and Cost:
Eligibility for Medicaid is typically based on income, family size, and specific criteria set by your state. In Illinois, you can check your eligibility for Medicaid by updating your address information with the state's Medicaid program. You can do this online at medicaid.illinois.gov or by calling 877-805-5312. Additionally, you can explore the Illinois Client Enrollment Services website at www.enrollhfs.illinois.gov to compare health plans and determine your eligibility for different programs.
If your income is slightly above the level to qualify for Medicaid, you may still be able to obtain affordable coverage through the Marketplace, as you may be eligible for savings or low-cost plans. However, it's important to note that if you qualify for Medicaid, you won't be eligible for savings on a Marketplace plan, and you'll have to pay the full price.
Switching Coverage:
If you're already enrolled in a Marketplace plan and want to switch to Medicaid, there are a few important things to keep in mind:
- End your Marketplace Coverage: When you become eligible for Medicaid, you should end your Marketplace coverage to avoid paying full price for your Marketplace plan. Contact your state agency to inform them of your switch to Medicaid. Ending your Marketplace coverage before receiving a final decision may result in a gap in coverage, so it's essential to wait for your Medicaid coverage to start.
- Timing and Transition: In Illinois, if you have an ongoing course of treatment, you can continue with your current provider for 90 days, even if they are out of your new health plan's network. This allows for a smoother transition between coverage plans.
- Choosing a Health Plan and PCP: Once enrolled in Medicaid, you will receive an enrollment packet with information to help you choose a health plan and a Primary Care Provider (PCP). You can also contact your PCP directly to see which health plans they accept. Remember that, as a new enrollee, you can change your health plan within the first 90 days. After that, you typically need to wait for the "`open enrollment`" period, which occurs once a year.
- Avoid Gaps in Coverage: If you lose your Medicaid coverage, Illinois offers a "special enrollment period" of 60 days to enroll in a new plan. This ensures that you can quickly secure alternative health insurance without experiencing a gap in coverage.
By following these steps and staying in close communication with your state agency and health plan providers, you can effectively switch from Marketplace to Medicaid in Illinois, ensuring that you receive the necessary healthcare coverage for yourself and your family.
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Frequently asked questions
Yes, it is possible to have both Medicaid and private insurance in Illinois. Third-Party Liability (TPL) refers to the legal obligation of third parties (e.g. insurers) to pay part or all of the expenditures for medical assistance under a Medicaid state plan.
To qualify for Medicaid, you must meet specific income requirements. Each state has different rules, so it is best to check with your state agency.
If you don't end your Marketplace coverage when your Medicaid coverage begins, you may have to pay back some or all of the premium tax credit when you file your federal taxes.
Yes, you can keep your doctor as your Primary Care Provider (PCP) when you switch to Medicaid. Contact your PCP to see which health plan(s) they accept.
