Health & Benefits

Medicaid is a jointly-run state and federal program. The agencies involved are:

• US Department of Health and Human Services (HHS),
• Centers for Medicare and Medicaid Services (CMS),
• Illinois Department of Human Services (IDHS), and
• Illinois Department of Healthcare and Family Services (HFS).

Medicaid is a means-tested program. It is generally only available to people within certain income and resource limits. There are some exceptions.

Medicare is a health insurance program with multiple parts (A, B, C, and D) that is run by the federal government:

• Part A covers in-patient hospital services and some other limited services,

• Part B covers medical services,

• Part C is also called Medicare Advantage, an alternative to Medicare Parts A and B and is offered by private companies, and

• Part D is for prescription coverage.

There are different types of Medicare Advantage Plans. All Medicare Advantage Plans cover Parts A and B. Some even cover Part D. For more information, go to Getting Medicare benefits.

CMS and HHS run the Medicaid program. It is available to many people over age 65. People under 65 who get Social Security Disability A federal program that gives money to people who cannot work because of a disability Insurance (SSDI) may also qualify. Unlike Medicaid, there are no income or resource limitations for Medicare. 

Medicare participants must also pay: 

• Premiums, Money that must be paid every month, such as for health insurance
• Deductibles, and
• Co-payments. Money paid for health care in addition to what the insurer pays

Both Medicaid and Medicare have important enrollment periods. Also, applying may involve some research on the available plans. It is important to review the coverage options before you need medical assistance.

Yes. Some people may qualify to receive both Medicaid and Medicare. This is called dual-eligibility. “Dual-eligibles” are people receiving both Medicare and Medicaid. These people may receive Medicare Part A, Part B, or both. They may receive full Medicaid benefits. They may also receive assistance through a Medicaid Savings Program like:

• Qualified Medicare Beneficiary A person that gets property or money from someone when they die (QMB) – Helps pay for Part A and/or Part B. This includes plan premiums, Money that must be paid every month, such as for health insurance deductibles, coinsurance, and co-payments, Money paid for health care in addition to what the insurer pays
• Specified Low-Income Medicare Beneficiary (SLMB) – Helps pay for Part B premiums,
• Qualifying Individual – Helps pay for Part B premiums, and
• Qualified Disabled Working Individual – Pays the Part A premiums. Only certain people who have disabilities and are working qualify.

Dual-eligibles need to complete applications for each program they are eligible for individually. They would need to apply for Medicaid via the Illinois state application process, apply for Medicare through the Social Security Administration's process. 

Dual-eligibles also need to apply to enroll in a Prescription Drug Plan (PDP), also known as Medicare Part D. If a person doesn’t apply for their preferred PDP, they will be randomly assigned a plan. The plan should have a monthly premium at the average premium or less for available Illinois plans.

Dual-eligibles and those with Extra Help, can make changes to their prescription drug plans once per month.

If a dual-eligible Medicaid recipient was randomly assigned to a Medicare prescription plan, they can still switch plans. They can only do so during the annual Open Enrollment Period. The Open Enrollment Period is from October 15 - December 7. Changes made during this time will take effect January 1 of the following year.

Yes. Dual-eligibles will not pay any cost sharing in their Medicare PDP, even if they live in a Long-Term Care (LTC) Facility. This means they will not have to pay any co-payments, Money paid for health care in addition to what the insurer pays a premium, or a deductible. Medicare pays for it all.

For purposes of Medicare drug coverage, LTC facilities include:

• Skilled or unskilled nursing facilities,
• Inpatient psychiatric hospitals, and
• Intermediate care facilities for developmentally disabled adults (ICF/MR).

Learn more about dual-eligibility on the Center for Medicare and Medicaid Services website.