General medicaid overview
Medicaid is the need-based assistance program created by the federal Social Security Act, run for Illinois by the Illinois Department of Healthcare and Family Services (HFS), and funded jointly by the federal and state governments. To be eligible, a person must fit into a category. The categories are (1) families, children, pregnant women, and, in Illinois, sufficently low-income individuals (2) aged, blind or disabled persons. To qualify for regular coverage, the applicant must have limited income and resources. If an applicant is categorically eligible but has excess income and/or resources, then they can qualify for medical assistance under the spend-down program.
Statutes and regulations
List of eligible persons:
- All recipients of monthly cash grants under the Aid to the Aged, Blind, or Disabled (AABD) or Temporary Assistance to Needy Families (TANF) programs;
- Persons who are categorically eligible for AABD ,aged, blind, or disabled, or TANF, members of a family with dependent child, who do not receive cash assistance because of excess income or assets, but who qualify for regular or spend-down Medical Assistance – No Grant (MANG), see PM 15-01-00;
- Children under the age of 18 whose family income does not exceed 200% of the federal poverty level are eligible for other medical programs, known as KidCare Share, KidCare Rebate, and KidCare Premium. These programs provide medical coverage with various co-payments or premiums, or rebates for premiums paid by the family under private health insurance plans. DHS Policy Manual 06-08-00;
- Family members of children receiving KidCare. This is known as the Parent Assist program. As of July 1, 2003, income ceilings were set at 90% of the federal poverty level;
- A TANF family which becomes ineligible for cash benefits because of employment income, receipt of child support payments, failure to comply with certain work requirements, etc., may continue to receive Medicaid benefits for up to 12 months after TANF eligibility ends;
- Persons receiving Social Security Income (SSI) disability benefits are eligible for Medicaid benefits;
- Certain adults who have been disabled since childhood and disabled widows/widowers who were once eligible for SSI but lost their SSI eligibility because they became eligible for Social Security benefits that made them ineligible for SSI;
- Certain refugees and asylees who qualify under the Refugee Resettlement Program, see PM I-02-03-a;
- Immigrants who meet the categorical, income, and asset requirements of AABD or TANF may receive Medicaid coverage for emergency services except transplant services; and
- Certain aged, blind, and disabled individuals receiving Medicare are eligible for Medicaid coverage of Medicare cost-sharing expenses, see PM 15-01-00 and AABD.
Persons whose income meets applicable Federal Povery Levels (FPL):
- Children ages 0-18; income of 142% FPL
- Pregnant women: income of 208% FPL
- General adult population: income of 133% FPL, see Medicaid's chart.
Persons are categorically eligible for Medicaid if they are age 65 or older, blind, disabled, a child under age 18 or age 18 and a full-time student expected to complete school by age 19, pregnant, a parent in a TANF family, or individuals meeting the applicable FPL thresholds. Persons who do not fit into one of these categories are not potentially eligible for Medicaid.
Citizenship or immigrant status
Persons must be U.S. citizens to be eligible for Medicaid except in limited circumstances:
- Residing in the U.S. before August 22, 1996 and currently lawfully admitted for permanent residence;
- Refugees, political asylees, and persons for whom deportation is being withheld;
- Persons granted conditional entry before April 1, 1980; and
- Persons paroled into the U.S. at least one year before August 22, 1996. Persons entering the U.S. after August 22, 1996 must reside in the U.S. for 5 years after being lawfully admitted, to meet citizenship status for Medicaid purposes.
Medicaid coverage is available for non-citizens over the age of 65 who legally resided in the U.S. on 8/22/96 and are ineligible for SSI due to a finding of "not disabled". A child under the age of 19 who is lawfully admitted for permanent residence or is Permanently Residing in the United States Under Color of Law (PRUCOL) is eligible for all KidCare programs regardless of date of entry into the U.S. Medicaid eligibility is also available for emergency services for all undocumented immigrants who are otherwise eligible for Medicaid (who meet categorical status, income, and asset limits. Pregnant women and children under the age of one may receive medical benefits under the KidCare Mom and Babies program, without regard to citizenship status. See the Illinois Department of Healthcare and Family Services website.
Persons must have income below eligibility levels to qualify for Medicaid coverage. The income limits and budgeting methodologies for determining countable income differ for the various Medicaid programs. Persons whose incomes are above the standards may qualify for Medicaid under the spend-down program. See the Illinois Department of Healthcare and Family Services website.
Assets, or resources, are real or personal property. Many assets such as one’s house and personal belongings are not counted to determine Medicaid eligibility. The asset limits and budgeting methodologies for determining countable assets differ for the various Medicaid programs. Persons whose countable assets are above the standards may qualify for Medicaid under the spend-down program. See the Illinois Department of Healthcare and Family Services website.
Categories of eligibility
HFS divides Medicaid into several different categories. However, all categories fall into one of two groups.
- AABD-related programs for the aged, blind, and disabled
- TANF-related programs for children, pregnant women, and families
Each category and its eligibility factors, categorical status, citizenship or immigrant requirements, income limits, and asset limits, are discussed elsewhere.
Applying for medical assistance benefits
A person must formally apply in order to receive medical assistance. Applications for benefits are filed at any local DHS Office. Applications may also be filed online. DHS has a unified application policy, which means that an application is considered to be a request for any medical assistance benefits for which the applicant may be qualified. DHS Policy Manual 17-01-00 et. seq. Applicants must be allowed to file a written application. Id.
For Medicaid, an application may be backdated three months prior to the month of application if eligibility criteria are met each month. For example, if applicant applies on October 15, the application may be backdated to the beginning of July of the same year. For GA-Medical Assistance, an application may be backdated one month. See PM 17-02-05-b.
DHS must make a decision on the application within 45 days after the date of the application in all cases except those where disability is at issue. Where disability is at issue, DHS must make a decision within 60 days. DHS Policy Manual 17-01-00. If DHS does not make a decision on the application within 75 days, the applicant can request a temporary medical card which is issued monthly until a decision is made on the application. See PM 17-03-03.
HFS has a duty to assist applicants in completing the application and obtaining documents needed to verify eligibility. 305 ILCS 5/11-4. See also WAG 03-08-01. If an applicant cannot obtain needed information within the statutory time limit for making the eligibility determination, she or he can request an extension of time. Id.
HFS is required to provide assistance in obtaining items of verification to those applicants who request assistance. Id. However, HFS caseworkers rarely inform applicants that HFS will assist them in obtaining these items of verification. Additionally, if an applicant has not received treatment in the last 3 months, the local office is supposed to set up an appointment with a Medicaid provider. WAG 03-08-01. A client is unlikely to get this appointment unless they ask for one.
If the Department of Healthcare and Family Services (HFS, formerly "Public Aid") denies the application, the person has a right to appeal the denial and receive a hearing. DHS Policy Manual 01-07-00. The appeal must be filed within 60 days of the date of denial, and is filed at the local DHS office or with the Bureau of Assistance Hearings (BAH), HFS, 401 South Clinton Street, Chicago, IL 60607. A person may also appeal by telephone to the Department's toll-free number at 1-800-435-0774 or by calling (312) 793-2618. If you call to file your appeal, then request a registration confirmation number as proof of the appeal. Persons who appeal may be represented by an advocate.
Continuation of benefits
If the applicant appeals HFS' decision to terminate or reduce benefits on or before the date the change becomes effective "date of change" or within 10 days of the date of notice, whichever is later, HFS must continue benefits through the date of decision on the administrative appeal. DHS Policy Manual 01-07-04.
Department of Healthcare and Family Services (HFS) must schedule a pre-appeal conference with the appellant, the caseworker and the caseworker’s supervisor to try to resolve the appeal within 7 days of the date of appeal. DHS Policy Manual 01-07-06. As a practical matter, the conference is often scheduled well after the 7 day deadline.
At the pre-hearing conference, IDHS will probably ask client to withdraw the appeal. But client should withdraw your appeal only if:
- IDHS has said client is right and has agreed to give client full aid or to make the changes client has requested and this is written on the appeal withdrawal form and signed by the DHS supervisor;
- IDHS and client have come to a compromise that client agrees with and this is written on the appeal withdrawal form and signed by the DHS supervisor; and
- IDHS has shown client the written policy and client is sure they were right in the first place.
Appealing finding of “not disabled”
If an applicant is appealing a finding that they are not disabled, then before a hearing is held, the local office must send the case back to the Client Assessment Unit (CAU) for a reconsideration of the denial. See PM 01-07-07-b. Applicants can submit additional medical evidence to be forwarded to CAU in support of their case. Id. The hearing officer may not permit the hearing to go forward if the case has not been sent back to CAU. It is generally advisable to confirm with the local office prior to the hearing, whether or not the case has been reconsidered by CAU, particularly if you have submitted additional evidence. If you confirm that CAU has not yet reconsidered the decision, you may contact BAH to request it be rescheduled without the need for an appearance.
If the matter is not resolved on pre-appeal, a hearing is held at the DHS office where the person filed his or her application. A DHS or HFS Hearing Officer hears the case. Hearing officers often appear by phone. The appellant has the right to cross-examine the Department's witnesses. The appellant may also request that the Department produce documents or persons at the hearing. The Hearing Officer must issue a written decision based exclusively on the evidence produced at the hearing. The appellant may submit additional medical evidence at the hearing, at which point the Hearing Office will likely forward the evidence to CAU for review and continue the hearing for a later date. PM 01-07-10-f. The written decision must be made and the decision implemented within 90 days after the date the appeal was filed.
What if the client can’t go?
If client cannot attend the hearing, client must contact this office to request a delay:
Bureau of Assistance Hearings
Department of Human Services
401 South Clinton, 6th floor
Chicago, IL 60607
Phone: (800) 435-0774, Fax: (312) 793-0782
Applicants are entitled to one postponement if the request is timely – at least 2 workdays before the hearing. If the request is received less than 2 business days before the hearing, good cause must be established. PM 01-07-10-c.
If client misses the hearing, client will get a notice saying that the appeal was dismissed. PM 01-07-10d. The notice will say that client’s appeal can be started again if client can show “good cause” for missing the hearing. Client must respond to the notice within 10 days. Good cause includes: death in the family; personal injury or illness that reasonably keeps you from attending, or; any sudden and unexpected emergencies.
If client misses the hearing without good cause, the appeal may be dismissed. This means that client has lost the appeal and IDHS will not change the decision. The client will then have to reapply.
How long will it take before the case is decided?
TANF, Medicaid, and AABD hearings are supposed to be held, decided, and the decision implemented within 90 days of when client filed the appeal.
Food Stamp hearings should be held and decided within 60 days of when client filed the appeal, and the decision implemented within 10 days of the decision.
If client asks for a delay, that delay will extend the time limits. IDHS will have longer to decide the appeal.
IDHS missing a deadline
IDHS often misses these deadlines. In some cases, clients can get some money from IDHS if they miss the deadlines.
If IDHS does not decide and implement an appeal within 90 days after appeal, client can get a $100 payment. Client can get another $100 for each 30-day period the decision is not implemented. This is because of a lawsuit called Jeffries. If client has an overpayment, IDHS will keep this money and apply it to the overpayment.
For Food Stamps, if IDHS does not decide and implement an appeal within 60 days and client did not get full Food Stamps pending the appeal and client ultimately wins, client may be eligible for a $100 payment and for another $100 for each additional 30-day period the decision is not implemented. This is because of a lawsuit called Dietrich.
Client should automatically receive these payments within 60 days after they qualify. If not, client can contact the Office of Legal Services, Department of Human Services, 100 South Grand Avenue, East, Springfield, Illinois 62762.
If an applicant loses her hearing at the IDHS office, she can file a case in circuit court. Appeals involving Medical Cards and TANF must be appealed under the Adminsitrative Review Act within 35 days of the final administration decision. Appeals involving Food Stamps must be appealed via a writ or certiorari which must be filed within 180 days of the final administrative decision.
Using a medicaid card
Once someone is found eligible for Medicaid, HFS will issue a "MediPlan Card" every month during which they remain eligible. DHS Workers' Action Guide 25-04-03. Generally, the recipient has "freedom of choice" to take that card to any medical provider willing to provide covered services and accept Medicaid payment.
Illinois has historically paid providers under the fee-for-service reimbursement model but, beginning with several different small managed-care programs, the state is making a shift towards an integrated care model of service delivery and reimbursement. By 2015, a significant percentage of recipients should be in a managed or “integrated” care plan. Currently, Illinois has three managed care delivery systems, the Integrated Care Program (ICP), the Primary Care Case Management (Illinois Health Connect), and the Voluntary Managed Care (VMC).
Integrated care program
The Integrated Care Program (ICP) is a program for older adults and adults with disabilities who are eligible for Medicaid but not Medicare. The ICP requires that enrollees have a medical home, a primary care provider, who coordinates their care and is responsible for referrals to specialists. The stated goals of the Integrated Care Program are both to improve member health by providing medical case-management and coordinated healthcare, and to control costs by helping prevent unnecessary healthcare expenditures. Currently, participants must choose between two health plans, Aetna Better Health and IlliniCare Health Plan, Inc. for their care. These plans are enrolling a variety of doctors and hospitals within their “networks” to provide care to plan members. With Integrated Care, members will still have some choices of doctors, specialists and hospitals but services by “out-of-network” providers will not be covered.
The ICP is a mandatory program primarily operating in suburban Cook, DuPage, Kane, Kankakee, Lake and Will Counties. Medicaid recipients in these areas will be advised of their option to choose between Aetna Better Health and IlliniCare, but if they do not choose within a set time-frame, they will be auto-enrolled in one or the other of the plans. Populations currently excluded from mandatory enrollment in the ICP include, children under 19 years of age, participants eligible for Medicare Part A, or enrolled in Medicare Part B, participants with Spenddown, all presumptive eligibility temporary benefits categories, participants in the Illinois Breast and Cervical Cancer Program, and participants with high-level private health insurance, also known as Third Party Liability or TPL.
Illinois plans to expand this program throughout the region and state by 2015.
Primary care case management
Illinois Health Connect is a statewide health plan that is available to most persons covered by an HFS Medical Program. Illinois Health Connect is based on the American Academy of Pediatricians' initiative to create medical homes to make sure that primary and preventive healthcare is provided in the best setting. People who are enrolled in Illinois Health Connect have a "medical home" through a Primary Care Provider (PCP). Illinois Health Connect functions similarly to an HMO in the private insurance market. Currently, this program serves a relatively small percentage of the eligible population.
Voluntary managed care
All kids, moms, and babies and FamilyCare clients living in certain counties may choose to enroll in a Managed Care Organization (MCO). An MCO is an HMO or HMO-like health plan that has its own network of doctors and hospitals. Clients that enroll in an MCO get all of their services from the doctors and hospitals that are in the MCO network unless they get approval from the MCO. The current MCOs include Harmony Health Plan, the Family Health Network, and Meridian Health.
The counties with a Managed Care Organization as an option include Adams, Brown, Cook, Henry, Jackson, Kane, Madison, Mercer, Perry, Pike, Randolph, Rock Island, St. Clair, Scott, Washington and Williamson. Not all MCOs are available in all of these counties.
Payment in full
Providers willing to accept Medicaid cannot charge the recipient for Medicaid services and agree to accept Medicaid reimbursement as payment in full. Some KidCare programs, however, require recipients to pay various co-payments, the amount of which depends on the program under which they are covered. A provider may not refuse treatment to a person who has not paid their co-payment.
Generally, providers such as doctors, clinicians, hospitals, outpatient clinics, etc. can choose whether or not to participate in the Medicaid program. They may not violate other statutory requirements in deciding against participation, such as impermissible discrimination under the Americans with Disabilities Act, or the Fair Credit Act.
Certain hospitals and clinics must accept Medicaid because they are federally qualified health centers or because they received capital funding under the Hill-Burton program. These facilities may choose not to participate in a given managed or integrated care program, however, without penalty at this point.
A service or device must be covered under the Medicaid program as long as it is medically necessary. This includes, but is not limited to:
- Hospital, physician, and out-patient services;
- Long term care and supportive living services;
- Physical rehabilitation services;
- Nurse midwife services;
- Home health care services, including nursing services, physical therapy, occupational therapy, and speech therapy;
- In-Home Care services, also known as the "Medicaid Waiver," intended to keep elderly and disabled persons in their homes and not institutionalized. This includes case management services, homemaker services, chore and housekeeping services, adult day care, nursing services, physical & occupational therapy, and habilitation services;
- Eye care, including physician/optometrist exams, lenses and frames, artificial eyes and low-vision devices;
- Dental services;
- Podiatry services;
- Chiropractic services;
- Mental health services, including physician and inpatient and outpatient treatment;
- Laboratory and X-ray services;
- Medical supplies and equipment;
- Renal dialysis;
- Transportation in order to obtain care covered under Medicaid, or in certain other circumstances;
- Hospice care;
- Alcohol and drug abuse treatment;
- Organ transplants; and
- For all Medicaid eligible children under age 21, Medicaid pays for all necessary medical services, and for screening with the goal of early detection, diagnosis and treatment of physical, mental or other developmental problems. Healthy Kids statute, 305 ILCS 5/5-19, and the federal Early and Periodic Screening, Diagnosis and Treatment "EPSDT" statute, 42 USC §1396d.
Note: HFS has been granted a waiver by the federal government for fragile and technologically dependent children under the age of 21. This program is administered by the University of Illinois and provides a variety of services to prevent institutionalization, including private duty nursing services, case management services, respite care services, home health care aides, special equipment and supplies, medically supervised day care, in addition to the more traditional Medicaid services. Under this waiver, the income and assets of the child's parents are not considered in determining eligibility. See DHS Policy Manual 06-11-01.
Beginning January 1, 2018 long term care facilities will have to submit a patient's admission documents through any of the following systems:
- Medical Electronic Data Interchange (MEDI)
- Recipient Eligibility Verification System (REV)
- Any successor system.
Long term care facilities can no longer submit patient admission documents directly to the Department of Human Services. The facility must date stamp the required prescreening information before submitting it within 15 days after receiving it.
If the long term care facility does not submit a claim within 15 days through MEDI or REV, the claim will not be eligible for payment under the medical assistance program. The State of Illinois will not have to pay the claim unless the Illinois Department of Healthcare and Family Services (IDHS) waives one or more of the timeframes listed in the policy. IDHS may waive the timeframe if it determines the following:
- The services provided were medically necessary and were provided in good faith;
- Failure to meet the timeframe was an employee mistake; and
- Withholding the reimbursement would create a financial hardship that could prevent the facility from paying employees, providing for the basic needs of residents, and ensuring the highest quality of care.
Prior approval required for certain medical services
Department of Healthcare and Family Services requires that recipients receive prior approval from HFS before it will pay for certain types of medical services or equipment. This involves primarily medical equipment, such as wheelchairs, hospital beds, hearing aids, and the like. It also includes services such as dental and podiatry services. DHS Policy Manual 20-03-01 and Workers' Action Guide 20-03-01. There are specific deadlines that HFS must meet in reviewing requests for prior approval. If HFS takes longer, it is required to automatically approve the services for payment.
HFS does not give prior approval when a less expensive service or item can meet the client's need or the client already has equipment that meets their needs.
Generally, HFS will not pay for bills submitted by providers later than 12 months after the service has been provided, unless the reason for the delay is due to HFS' error, an administrative decision or a court order. DHS Policy Manual 20-04-01-c.
Providers who have agreed to accept Medicaid payment for service may not seek payment from the recipient if Medicaid payment is not made due to the provider’s failure to follow the procedures required in order for the provider to obtain Medicaid reimbursement. A provider has accepted Medicaid payment if:
- The provider makes an affirmative representation to the recipient that payment for services will be sought from Medicaid;
- The recipient presents the provider with his or her Medicaid card and the provider does not indicate that other payment arrangements will be necessary; and
- The provider submits a bill for the covered services to HFS.
Disputed bill inquiry process
When HFS refuses to pay a medical bill, providers usually pursue the recipients for payment. When recipients receive a demand letter or are sued by a provider, recipients can make an inquiry to HFS as to the reason for the denial. The inquiry must be in writing and must include the recipient's name and case number, the name and address of the medical provider, the date of the service, the charge for the service, a description of the service, and evidence of the pending collection activity or lawsuit. Recipients may obtain an inquiry form by calling DHS' toll free number (800) 843-6154. HFS must investigate after receiving an inquiry, and give notice of the outcome of the investigation to the recipient within 30 days of the inquiry if litigation is pending, and 40 days otherwise.
If a claim for payment was rejected, the notice must state why. Recipients have the right to appeal such decisions within 30 days, unless the recipient was already informed of the denial of payment (e.g., where prior approval was requested and denied) and afforded appeal rights.
If the claim should have been paid in full or in part, HFS must take corrective action to pay it. If the claim was already, in fact, paid, HFS must so notify the recipient and the provider, and state in the notice that Medicaid payment constitutes payment in full for service that was provided.
The above procedure is not contained in the DHS policy manual but is based on the Collins Consent Decree, which is legally binding on HFS.
Lien and estate claim provisions
The Department of Healthcare and Family Services (HFS) may make a claim against an estate or place a lien on real estate owned by a recipient and a claim against their estate under certain circumstances.
Real property liens
HFS may place a lien against real property for medical assistance paid out at any time for a recipient who has been institutionalized for at least 120 days, and for all AABD cash benefits. The 120-day period starts with the first day the client goes into a medical institution. When a client is admitted to a long term care facility from a hospital, the 120-day count begins with the date of admission to the hospital. A move from the hospital to a long term care facility, or from a long term care facility to a hospital, does not interrupt the 120-day count. If the client is released from the medical institution to the community, the 120-day count starts over.
HFS will not place a lien on real property when one of the following people lives in the property: the client's spouse; or the client's minor, disabled, or blind child; or the client's brother or sister, if they have lived in the house for at least one year before the client went into the medical institution, and they have an equity interest in the house.
The lien can be enforced when: there is a transfer of the real property that has the lien, an example is when the property is sold or mortgaged; or there is fraud; or the client dies. HFS can collect on a lien in any one of three ways: through a claim against the estate of a deceased client, through foreclosure of HFS's lien, by getting paid the same amount that HFS would get through the estate or foreclosure i.e., some individual pays the amount of the lien to HFS on client’s behalf. Foreclosure against a client's home can be done only when the client has died. Foreclosure is delayed when there is still one of the following relatives living in the home: the client's spouse, the client's child who is under age 21, the client's child who is age 21 or over and is disabled, the Medical client's brother or sister who has lived in the house for at least one year immediately before the client went into a medical institution, or the Medical client's child who has lived in the house for at least 2 years immediately before the client went into a medical institution.
The lien is released when any of the following happens:
- Everything owed is paid, up to the value of the property or the client's portion of the property;
- A bond is filed guaranteeing that what is owed will be paid. There must be legal guarantees before agreeing to the bond;
- An AABD client is discharged from a medical institution and returns to the home which has a lien filed against it;
- An AABD Cash case is closed for reasons besides the death of the client and there is a spouse and minor children. For example, when taking the lien off the property will help the family become self-supporting and reduce the chance they will have to receive cash benefits again; and
- The lien was filed by mistake.
HFS’ claim against the estate of a deceased recipient includes:
- AABD cash benefits received by the recipient;
- All medical assistance paid out at any time for a recipient institutionalized for at least 120 days and whose real property is under an HFS lien;
- Prior to October 1, 1993, all AABD medical assistance paid out for a recipient while 65 years of age or older;
- After October 1, 1993, all AABD medical assistance paid out for a recipient while 55 years of age or older; and
- The spouse of any of the above clients.
Again, HFS will not enforce the claim from real property if a spouse, a child under 21, or a disabled child over 21 continue to reside in the property. In addition, recovery will not be made from an estate if such recovery would cause an heir or beneficiary undue hardship.