Health & Benefits

Medicaid is a joint state and federal program that pays for medical costs for people with low income. Medicaid covers low-income children and adults, with or without children. There are several different Medicaid programs, as well as Illinois-funded medical programs, including:

• Affordable Care Act Medicaid for Adults,
• All Kids for children up to age 19,
• YouthCare for children whose care is subsidized by the Illinois Department of Children and Family Services (DCFS) or children served by DCFS through guardianship When a person is appointed by a judge to take care of a child or an adult with a disability and adoption When an adult becomes a child's legal parent assistance programs,
• Coverage for young adults under age 26 that were on Medicaid when they left DCFS foster care at age 18 or later,
• Moms and Babies, for pregnant women (up to 12 months post-partum) and their babies,
• AABD Medicaid for people who are 65 and older, blind, or disabled,
• Family Health Plans,
• Health Benefits for Immigrant Seniors who are 65 and older (but note that no new applications have been accepted since November 6, 2023),
• Medicare Savings Programs, which help with Medicare Part B premiums, Money that must be paid every month, such as for health insurance
• Non-citizen asylum applicants, and victims of trafficking, torture, or other serious crimes,
• Breast and Cervical Cancer Program,
• Health Benefits for Workers with Disabilities, and
• Veteran's Care.

This is not a complete list of the available medical programs in Illinois. The Illinois Department of Health and Family Services (IHFS) has a complete list on their website.

In Illinois, Medicaid is available to people who are:

• Children 18 years and younger,
• Parents and caregivers responsible for a child 18 years or younger,
• Low-income adults ages 19 to 64 years,
• Over 65 years,
• Disabled,
• Blind,
• Pregnant, or
• Young adults under age 26 who were formerly in foster care.

IDHS or HFS decides if a person is eligible for Medicaid.

Each medical program has different income and asset limits. They also have different rules about what kinds of income and assets Anything a person owns that has financial value will count toward these limits.

• For adult Any person 18 years old or over US citizens, and eligible non-citizens, between 19 and 64 years of age and who do not have Medicare, the Medicaid income limit is 138% of the federal poverty level.
• For children, the income limit is 318% of the federal poverty level.
• For pregnant people, and those who have recently given birth, the income limit is 213% of the federal poverty level. They can keep this coverage for up to 12 months after giving birth.

There is no asset limit for these three Medicaid programs.

For all of these categories, Medicaid will look at a household’s size and income based on how many people file taxes, plan to file taxes together, or could file taxes together. This could include, for example, adult children who are living with their parents. It will then look at countable income from those household members.

For adults who are disabled, blind, or age 65 or older (receiving Aged Blind and Disabled (AABD) benefits) and those who have Medicare benefits, there are different rules. Their countable income must be below 100% of the federal poverty level, and they must have no more than $17,500 of non-exempt resources. Exempt resources are typically assets like a person’s home, a single car, personal belongings, other assets like life insurance policies, burial spaces, and more. If someone in this category is over the income or asset limit, they may still qualify for Medicaid with a spend-down. Read more about the income and asset rules for Aged Blind and Disabled (AABD) medical help.

Working adults who are disabled, blind and younger than 65 years of age, may be eligible for Health Benefits for Workers with Disabilities which goes up to 350% of the federal poverty limit with an asset limit of $25,000. 

Check with IDHS for the income and resource limits for your type of Medicaid. IDHS has the current standards that are in effect.

If a person transfers certain kinds of property to someone else to qualify for Medicaid, they could be penalized. For example, if a person is applying for Medicaid coverage for long-term care services, HFS will look at whether they transferred any property, such as a house or cash, in the last five years. If someone transferred property for less than fair market value during that time, they may not be eligible for Medicaid for long-term care for a certain period. Learn more about transferring property and Medicaid for long-term care.

Only US citizens and certain non-citizens, such as people with lawful permanent resident status (LPR or green card) in the US for over five years, qualify for Medicaid.

Note: The non-citizen eligibility requirements for Medicaid will change in October 2026. After the change, some non-citizens who qualified for Medicaid before will no longer be eligible. Medicaid eligibility will be limited to the following specific categories of noncitizens:

• LPRs who have met a 5-year waiting period,

• Cuban and Haitian family reunification program entrants, 

• Citizens of the Freely Associated States (Micronesia, Marshall Islands, and Palau), and

• Children under age 19 under the All Kids Program, and pregnant persons under the Moms & Babies program.

Non-citizens may qualify for Illinois-funded medical programs such as:

• Medical benefits for asylum applicants or victims of trafficking, torture or other serious crimes;
• Medical program from survivors of domestic violence; Harm by one household or family member against another household or family member. Harm may be an emotional, mental, or physical injury
• Medical program for kidney/renal disease; or
• People already enrolled in Health Benefits for Immigrant Seniors.

Non-citizens 65 years or older may be eligible for the Illinois HBIS program. However, new enrollment has been paused for the HBIS program since November 6, 2023. People can continue to receive benefits if they are already enrolled.

People who have applied for or obtained a U-Visa, T-Visa, asylum, or status under the Violence Against Women’s Act (VAWA) might also be eligible for state-funded medical assistance.

If someone cannot get Medicaid because of their immigration status, they may be able to buy low-cost insurance through the Get Covered Illinois Marketplace. Financial assistance to non-citizens is limited after January 1, 2027.

Learn more about Government benefits for immigrants.

Generally, Medicaid covers “medically necessary” services and supplies for eligible adults. Something is considered “medically necessary” when a doctor or other medical professional reasonably believes a patient needs the service to prevent, diagnose, evaluate or treat an illness, injury, disease or its symptoms. For people with disabilities, services or supplies are generally medically necessary when they are required to diagnose, evaluate, treat, or manage a disability. A substantial impairment that functionally limits a person in carrying out major life activities, such as walking, lifting, seeing, or learning.

To be medically necessary, the services or supplies covered also must: 

• Follow accepted medical standards and common medical practice,
• Be appropriate for the patient’s condition, including the right type of care, amount of care, and length of treatment.
• Actually help the patient’s condition or symptoms
• Be based on what is best for the patient’s health.

Services or supplies used must not mainly be for someone else’s convenience, including the patient, doctor, caregiver, or insurance company.

Each Illinois medical program has different rules for what it covers. Each plan must be carefully reviewed to understand what will be covered. However, most people covered by Medicaid are covered for:

• Dental care,
• Doctor visits,
• Emergency services,
• Eye care,
• Family planning services and supplies,
• Hospital care,
• Hospice care,
• Long-term care services, such as skilled nursing home care,
• Medical equipment and supplies,
• Mental health care,
• Prescription drugs,
• Substance use disorder services,
• Telehealth services,
• Therapies, such as speech, occupational, or physical therapy, and
• Transportation to medical services.  

This is not a complete list. Also, some services may have special rules or limits. For example, dental care is limited for adults but more comprehensive for children.  It’s important to review Medicaid coverage plans before making any medical care decisions to ensure services are covered. 

Illinois has a separate Medicaid program for children under 19 years old. It generally covers more comprehensive preventative care, such as regular check-ups and shots. This is in addition to medically necessary services. Learn more about AllKids. 

Medicaid recipients can learn more about their specific medical program by:

• Calling the number on their medical card to ask about covered benefits,
• Calling the Medicaid Health Benefits Hotline at (800) 226-0768, or
• Reviewing their member handbook, which can generally be found online.

Medicaid covers medically necessary prescriptions and some over-the-counter products. Some drugs require prior approval from HFS. Learn more about Illinois Medicaid prescription coverage on the HFS website.

HFS must approve medications after someone fills four prescriptions in 30 days. This limit generally applies to adults Medicaid recipients. Currently, prescriptions for children under age 19 won’t be rejected because of this policy. Also, residents of Community Integrated Living Arrangements (CILAs) or Supportive Living Facilities (SLFs) won’t be rejected if HFS has the person’s living arrangement recorded in their system 

The following types of drugs do not require prior approval:

• Oncolytics, which are used to treat some cancers,
• Anti-retroviral agents, which are used to treat and prevent HIV,
• Contraceptives,
• Immunosuppressives,
• Over-the-counter drugs, and
• Non-drug items such as blood glucose test strips and monitors.

In certain situations, short-term approval will be granted. When HFS is not available to process requests, a pharmacy can give out a 72-hour emergency supply.

There are several ways to check the status of a request:

• Patients may call the Health Benefits Hotline at (800) 266-0768 or (866) 675-8440 (TTY).
• If someone used Illinois Rx Portal to enter a prior approval request, they can check the status of the request in that system.

Learn more about the Four Prescription Policy.

Possibly, depending on which Medicaid program they are in. The Illinois Client Enrollment Services will determine which managed care program an applicant is required or eligible to join. The Medicaid recipient will have an opportunity to pick their managed care plan. Within the first 90 days of initial enrollment, they can change plans once. After the first 90 days, they can only change plans once a year. The HFS website provides more information about Illinois Managed Care.

It depends. Some doctors don't participate in Medicaid. Most people in Illinois on Medicaid are in managed care organizations. This means they will probably need to choose a network of doctors and hospitals to see with their Medicaid card. Otherwise, they will choose a Primary Care Provider (PCP) who will help coordinate their care. Their PCP will refer them to specialists if they need to see one.

Recipients will receive an enrollment packet after starting Medicaid that explains the process of managed care. The enrollment packet will explain the choices of plans and doctors in their area. People should carefully review the plans and pick the one that is best for them. Once a plan is chosen, they might not be able to change plans again until the annual open enrollment period. Learn more about managed care.

Some medical care requires prior approval when the patient has a Medicaid plan. Depending on the plan they are on, they may or may not need prior approval. If their plan requires prior approval, their doctor must explain why the treatment is medically necessary. Otherwise, their doctor will not receive payment.

Prior approval is commonly required for non-routine care or if medical equipment or assistive devices are needed.

People may also need prior approval for certain prescription drugs. The specific Medicaid plan will state whether prior approval is needed for medical care or prescriptions.

People can apply online for Medicaid on the Illinois Application for Benefits Eligibility (ABE) website. They can also apply via mail, in person at an IDHS office, or over the phone. Paper applications can be found on the IDHS website.

If someone is approved for Medicaid, they receive a letter in the mail with information about their medical benefits. Illinois Medicaid does not issue physical Medicaid cards like they used to. However, the approval letter can be used to provide doctor offices and hospitals with the information they need to bill Medicaid. It is also used to show coverage for prescription drugs and other medical care. Most medical providers will check a person's current eligibility by looking them up in the Medicaid system.

If someone needs to get a new copy of their approval letter, they can get one through their online Manage My Case account. Or they can visit their local DHS office to ask for another copy.

Managed care programs will often provide a medical card that can be shown to medical providers.

Learn more about applying for Medicaid.

People have a right to appeal A request to change a court's decision any denial When a court rejects or refuses to allow a request; for example, when a judge decides not to grant an attorney's objection. or termination When something ends of Medicaid cover or prior approval for a treatment, prescription, or other medically necessary services. When an application for Medicaid is denied, an appeal must be filed within 60 days after the date of the denial letter.

If a person’s benefits are being terminated, the appeal deadline is also 60 days from the date of the notice. However, if the recipient wants to continue benefits while their appeal is pending, they must file the appeal before the "Date of Change”, or within 10 calendar days, whichever is later. 

For calculating the appeal deadline, the date on the letter counts as day one. So, if someone’s denial letter is dated March 1, they must file their appeal by April 29. To be considered filed in time, the appeal must have a postmark by the deadline, or be received by the IDHS office before 5pm on the day of the deadline. If the deadline falls on a weekend or a holiday, the appeal must be submitted by the next business day. 

The denial or termination letter will have specific instructions on how to appeal. It’s important to review the letter carefully and make sure that an appeal that asks for continuing benefits is filed before the correct date. If the appeal instructions were not included with the termination, contact the IDHS office that sent the letter as soon as possible to get a copy of the instructions. The exception to receiving continuing medical benefits while an appeal is pending is if the Medicaid recipient received temporary Medicaid because IDHS did not timely process their application.

Learn about appealing Medicaid decisions.

The State of Illinois and Cook County Health & Hospitals System (CCHHS) operate a Medicaid managed care program for uninsured adults in Cook County called CountyCare. This is a Medicaid program through the Affordable Care Act (ACA). Recipients of CountyCare get medical care from providers in the CCHHS and others.

To qualify for CountyCare, a person must:

• Live in Cook County,
• Meet income requirements, and
• Be a US citizen or meet certain immigration requirements.

Learn more about CountyCare.

Websites

The Illinois Department of Healthcare and Family Services (HFS) website has information about the various Illinois medical programs. HFS encourages people to apply for and manage their benefits online. There is no penalty for applying even if someone is found ineligible for benefits. People can use this online tool to:

• Check if they might be eligible for benefits,
• Apply for benefits,
• Check their application status,
• View benefit details,
• Report a change,
• Renew their benefits,
• Upload documents, and
• Access the website to appeal A request to change a court's decision their benefits decision.

Information about other ways to apply for Medicaid benefits can be found on the IDHS website.

The ABE Customer Support Page offers resources, including an ABE User Guide, ABE Appeals Guide, instructions on setting up "Manage My Case," answers to frequently asked questions, and more. 

Phone numbers

HFS also offers a benefits hotline where people can get information about:

• Whether they qualify for Medicaid, or
• Whether a healthcare provider participates in Medicaid.

The hotline for most benefits programs is at:

• (866) ALL-KIDS (866-255-5437) toll free, or
• (877) 204-1012 (TTY).

The DHS can help people locate their nearest DHS office or give them other information about health benefits. They can be reached at:

• (800) 843-6154,
• (866) 324-5553 (TTY), or
• Online using the local office locator.

Additional government websites

Social Security Administration

Medicare

Medicaid

Illinois Department of Healthcare and Family Services

Illinois Department of Human Services