Customers in Fee-for-Service and most MCOs may be charged cost-sharing by their chosen medical provider. CountyCare Health Plan, an MCO serving customers in Cook County, has waived cost-sharing so anyone enrolled in CountyCare will not be charged cost-sharing.

All Medicaid services, except those listed in the next question, are covered for the HBIA/HBIS populations.

Not currently. New enrollment into the HBIA and HBIS programs was paused in 2023 in order to bring costs in line with the amount budgeted to pay for the programs. There is not currently an established timeframe for reopening enrollment to either program, but HFS will provide advance public notice in the event enrollment is reopened in the future.

Resources in English and Spanish can be found at enrollhfs.illinois.gov. Customers can also call the Client Enrollment Services line at 1-877-912-8880 (TTY: 1-866-565-8576) for information or to choose an MCO plan. Stay on the line to reach a customer services representative. Customers or their Approved Representative, will need either their Recipient Identification Number or Social Security Number to be able to speak to a representative. Translators are also available for other languages upon request.

The spenddown program helps some people who have too much income or too many assets (like bank accounts and other resources) to qualify for full coverage in a given month. The program works a little like an insurance deductible. Once customers pay for or incur the cost of medical care up to or over their spenddown amount, full coverage is activated. Bills can be submitted and applied for several months at a time.  The amount of a monthly spenddown depends essentially on a customer’s income and assets above the eligibility levels. 

Per administrative rule, copayments and coinsurance may only be charged on the following services:
 

1.  Non-emergency Inpatient hospitalizations: $250 copayment per stay

For this purpose, a hospital is a general acute care, psychiatric, or rehabilitation hospital. If the hospital determines the admission is an emergency, there is no copayment. 
 

2. Non-emergency Hospital Outpatient Services or Ambulatory Surgical Treatment Centers: Coinsurance will be in the amount of 10% of what HFS would pay the provider. 
 

These are for services such as hip and knee replacements, eye surgeries, outpatient therapies, including physical therapy and occupational therapy. Hospital-based procedures for the procedures listed will not be charged co-insurance (but may be charged the $250 copayment.)
 

   o The amount charged for coinsurance will differ depending on the service and the provider. Enrollees should check with the provider about whether they will have coinsurance for a service. The provider may not be able to give a total dollar amount until after the procedure but can tell a customer whether there will be coinsurance. 

   o Some of these services may be available without cost-sharing at a provider that bills as a physician and not a hospital. In some cases, customers can choose providers that do not charge coinsurance.

Long term care services, including nursing facility and home and community-based waiver services, are not covered. Transplant services are not covered except for Kidney, bone marrow and stem cell transplants, which are covered.

Managed care offers a full range of health care services while helping coordinate health care through care coordination.  When someone enrolls in a managed care organization, they become a member of that health plan.   

Yes. HFS submitted an amendment to the administrative rule to remove a previously planned $100 copay for non-emergency hospital ER services. 

Yes, for those customers enrolled in a managed care organization, medically necessary post-acute rehabilitation services are covered in a nursing facility. This is in addition to services at a rehabilitation hospital and acute care hospital.  Rehabilitation services in a facility are limited to no more than 90 days per episode and require a prior authorization from the MCO. Post acute rehabilitation services for those customers enrolled in Fee-for-Service are covered only in an acute or rehabilitation hospital setting.  

No, hospitals should not submit an application for Emergency Medical for people enrolled in HBIA/HBIS.

Care coordination through a Health Plan can help: 
 

·Find a primary care provider (PCP) if you don’t already have one
·Help manage health conditions like diabetes, high blood pressure, or asthma
·Give you information you need to stay healthy
·Help identify your health goals and create a care plan to achieve those goals

Urgent care and immediate care clinics should not charge coinsurance because they are not part of a hospital. To be sure, ask the clinic before the appointment if they will charge coinsurance. 

Some individuals will be assigned a care coordinator based on their health needs, but anyone can request a care coordinator.  Care Coordinators will help members reach your goals.  A care coordinator can:

·Answer questions about your care
·Help you find a doctor or specialist
·Help you transition out of a hospital or facility
·Help connect you with community resources

In managed care, there is a network (group) of providers who work together to give you the healthcare you need.  Once someone becomes a member of a health plan, they must visit doctors and other providers that are in the health plan’s network, unless there is a special agreement with an-out-of network provider.  

Many services will continue to be free, including services or visits to:
 

- Primary care provider offices or Federally Qualified/Rural Health Centers (FQHCs and RHCs) Federally Qualified Health Center (FQHC) - Illinois | Page 9 (npidb.org).
-Public health departments
-Community mental health providers
-Non-surgical vision, dental, and audiology providers
-Prescriptions at pharmacies
-Durable medical equipment (DME)
-Vaccines, including those received at a pharmacy
-Transportation

Other services may be free, if received and billed by a provider that is not a hospital.   Customers should check with the provider to see if there will be coinsurance. Customers can ask their MCO or HFS to help find providers that will not charge a coinsurance.

Five (5) MCOs participate, they are listed below.  Check out their websites for more information include provider and pharmacy lists, the member handbook and prescription drug list:
 

·Aetna Better Health of Illinois
www.aetnabetterhealth.com/illinois-medicaid / 1-866-329-4701
 

·Blue Cross Community Health Plan
www.bcbsil.com/bcchp/ | 1-877-860-2837
 

·CountyCare Health Plan (Cook County only)
www.countycare.com | 1-855-444-1661
 

·Meridian Health Plan (Former Youth in Care Only)
corp.mhplan.com/en/member/illinois | 1-866-606-3700
 

·Molina Healthcare
www.molinahealthcare.com | 1-855-687-7861

The most important thing to consider is the network of providers, including pharmacies.   Check with existing providers to see what MCO(s) they accept.  Also consider whether the MCO is waiving cost-sharing requirements and what extra benefits they offer.  

Yes, assuming the cost savings expected from the proposed programmatic actions and revenues are generated in line with current estimates. 

On the Marketplace, premiums are dependent on household income. On Marketplace coverage individuals may be eligible for financial help based on their income. There is cost sharing for covered services.

Individuals can apply 60 days prior to their current coverage ending. They do not need to wait until coverage has ended

The HBIA and HBIS programs both launched during the federal public health emergency, during which Medicaid redeterminations were paused. The Department was required to resume redeterminations for the Medicaid program in 2023. The intention has always been to conduct annual renewals for the HBIA/HBIS programs, following what is standard practice for the Medicaid program. Given that redeterminations have not previously occurred in the fairly new HBIA/HBIS programs, the Department started with resuming redeterminations for the regular Medicaid program and moved HBIA/HBIS renewals to the end of the unwinding. 

The May 2024 cohort is the final cohort of the PHE unwinding. It will include the remaining Medicaid customer cases and all HBIA/S customer cases

If HealthCare.gov can’t electronically verify your immigration status, you will need to provide documentation

You can access ACA Marketplace coverage by going to our shop and enroll page which is located on the Get Covered Illinois website. We encourage anyone in need of assistance with enrollment to connect with a trained Navigator choosing “Get Free Help” on our home page menu. You can type in your zip code to find help in your local area and choose your language preference. 

Yes, the bar is up to 150%, so any income under that income level would qualify.

Have your documents ready. The application will ask if you have eligible immigration status. If you are a Legal Permanent Resident (LPR) who has been in the United States for less than five years, answer yes. The marketplace must verify that applicants are ineligible for Medicaid based on their immigration status before determining their eligibility for financial help. 

We acknowledge that these are difficult changes, and we know they will create turbulence for impacted individuals. We are fully committed to doing all that we can to ensure that enrollees who will lose HBIA/HBIS coverage and be referred to the ACA Marketplace to find alternative coverage, are provided with useful information that will allow them to seamlessly find and enroll in that coverage. We are working with our partners at the Department of Insurance to make sure Get Covered Illinois resources are available for this transition, and Navigators will be available to provide enrollment assistance by phone. 

These programs both launched during the pandemic, and many of the changes we are making in spring 2024 would already have been in place if not for the federal public health emergency that we’ve been unwinding from for the past year. The program changes that are being implemented in spring 2024 will bring the HBIA and HBIS programs more operationally in line with the Medicaid program. In addition, these changes are being made to bring the projected programs cost in line with budget, both for the current fiscal year and for the next fiscal year. 

HFS understands these programs have provided critical health care access for thousands of previously uninsured Illinois residents, and the Department will continue to balance its commitment to ensuring that HBIA and HBIS remain sources of high-quality health coverage for those who are eligible, with the fiscal sustainability of the program.

HBIA/S actual and projected costs can fluctuate over time based on a variety of factors, including, but not limited to, retroactive claims adjustments for prior months, provider rate changes and program enrollment. PMPM estimates have been adjusted to reflect additional claims experience and program changes, including the shift to managed care, enrollment suspensions, and the introduction of cost sharing. 

Effective in January, HFS has updated the PMPMs used to estimate costs going forward. This is because the majority of HBIA/S enrollees are transitioning into managed care plans between January and April 2024, one of the revenue-generating changes HFS put into place for the HBIA and HBIS programs in calendar year 2023. 

As part of the managed care transition, HFS worked with its actuarial firm to determine the estimated PMPMs HFS would pay to the Managed Care Organizations (MCOs) using a capitated rate methodology. The actuaries developed separate PMPMs for HBIA and HBIS enrollees. 

Applying for ACA Marketplace coverage will not affect an individual’s chances of becoming a U.S. citizen. The information that an individual uses to apply for ACA Marketplace plan may be used only for the operations of that program. Information will not be shared for immigration enforcement purposes. Government workers, Navigators, application assisters and individuals that help with applications are required by law to keep the information they receive private and secure.

HFS is committed to providing robust assistance during this process that meets the needs of the affected customers during the transition to the Marketplace. HFS has been working closely with the Department of Insurance to prepare and to make this transition as seamless as possible for the individuals who are affected. Get Covered Illinois resources will be deployed to support individuals seeking to enroll in coverage through the Marketplace. Navigators will be available to assist individuals in person, by phone, or by video call. They can convey important information in languages other than English, which we know is critical for this enrollee population. Anyone who is referred to the ACA Marketplace and needs assistance with enrolling in coverage is encouraged to connect with a Navigator by:

· Visiting Getcoveredillinois.gov and choosing ‘Get Free Help’ on the menu. 

      o  It will take you to a Find Local Help tool, which can be used to search for assistance by zip code, distance, and language.

· Calling the ACA Marketplace call center at 1-800-318-2596.

There is no current timeline or plan to reopen enrollment.

The Department made the decision in February 2024 about what cost-saving options to implement this spring. 

The current HBIA/HBIS enrollees whose coverage will end because they qualify for ACA Marketplace coverage are those with an LPR (green card holder) status, who have been present in the country for under five years. Approximately 6,300 individuals are expected to be affected by this change.

There is a question on the application that asks if you have been denied Medicaid. If you have lost HBIA, you will answer yes.

Legal permanent residents in the country for under 5 years, who are be eligible for coverage through the Marketplace, will have a Social Security number and should have the documentation that will be required of them to be able to enroll into the marketplace

No, moving customers to the Marketplace will not affect public charge, and this is being communicated to them in the client notice they are receiving that details how the change will affect them and how they can enroll in Marketplace coverage.

Applying for or getting a Marketplace health coverage, including financial help, does not make you a "public charge.” It won’t affect your chances of becoming a U.S. citizen. If you have questions about public charge, please visit the PIF-IL website or email pifillinois@povertylaw.org.

The information a person provides while applying for an ACA Marketplace plan may be used only for the operations of that program—not for immigration enforcement purposes. Government workers, enrollment assisters, and people who help with insurance applications are required by law to keep information private and secure.

Healthcare.gov has a Special Enrollment Period (SEP) for consumers at or below 150% FPL. This SEP remains open through December 31, 2025. It is not tied to a life event and does not require an individual taking action within a certain period of time. We understand the importance of continuous coverage and will be working closely with Navigators and other Assisters and community partners to prevent or minimize any gaps in coverage.

That will be done through the attestation process. Individuals will attest to making less than 150% of the federal poverty level but will not need to upload proof or documentation at that time. The marketplace will try to verify information through data matching and may ask for information once the person files.   

HealthChoice Illinois is the statewide managed care program that the HBIA/HBIS customers will enroll in, if required

Individuals who have an undocumented status are not eligible for ACA Marketplace health plans. If someone who has an undocumented status is removed from HBIA/HBIS coverage because they are determined to be ineligible based on their income or some other eligibility factor, they would not qualify for Marketplace coverage. 

Coverage will start the first of the month after the month that you apply. For example, if you apply on April 26, your coverage will start on May 1.

HFS has a weekly operations meeting with MCOs and the HBIA/S program is a standing agenda item at that meeting

In total, roughly 17,950 current enrollees are expected to be affected by one of the changes HFS will be making in the coming months, but many of those individuals have alternative coverage options. 

·Approximately 450 individuals are legal permanent residents in the country for over 5 years and will be automatically moved to Medicaid coverage if they otherwise meet eligibility requirements.  

·Approximately 5,500 individuals who are legal permanent residents in the country for under five years will be referred to the ACA Marketplace for alternative coverage, for which they are eligible. Noncitizens who are “lawfully present” are eligible for Marketplace subsidies. HFS is working with Department of Insurance (DOI) to ensure Navigators are available to assist individuals in person, by phone, and video calls.

·An estimated approximately 5,200 individuals will be closed because they are deemed no longer eligible for HBIA/HBIS coverage, effective May 1.

·An estimated approximately 6,000 individuals will lose coverage through the redetermination process. 

Customers below 150% FPL have access to $0 premium Marketplace plans with cost-sharing reductions that lower the deductible, cost-sharing, and out-of-pocket maximum. Each customer’s costs will vary depending on which Marketplace plan they select. The annual out-of-pocket maximum for customers below 150% FPL is $3,150 for an individual and $6,300 for a family.

HFS needs to make several changes related to HBIA/HBIS program eligibility to bring the program cost in line with the funds available to operate the programs in FY25. HFS decided to make eligibility changes for legal permanent residents because they qualify for alternative health care coverage that is subsidized on the Health Insurance Marketplace. Individuals can prospectively enroll through a Special Enrollment Period prior to losing HBIA/S coverage to prevent a gap in coverage.

HFS remains committed to implementing the program to provide health coverage for individuals who meet eligibility requirements and have no other options for health insurance. Our goal is to maintain a robust set of services for those who are eligible for and enrolled in the program.  

HFS will continue to ensure fiscal responsibility in the implementation of the program and garner federal match whenever possible.

The Health Benefits Hotline provides support for anyone receiving medical benefits who are not enrolled in an MCO.  Customers can call 1-800-226-0768 for help locating a provider. Choose option 2 for Spanish. 

You have the right to talk with a caseworker by calling 877-805-5312.

The Department is changing the program eligibility requirements for legal permanent residents, as one of several changes we are making in the coming months to bring the HBIA/HBIS program budget within the allocation in the proposed FY25 budget. Legal permanent residents in the country for over five years will automatically transition to Medicaid, and legal permanent residents in the country for under five years will be referred to the Affordable Care Act Marketplace for alternative coverage. To be clear, LPRs qualify for alternative coverage. This is the only change that requires amending the emergency rules, but HFS will also be implementing redeterminations for HBIA/HBIS, as is the standard practice in the Medicaid program.

HFS is committed to ensuring that LPRs in the “five-year waiting period” receive the information and assistance needed to ensure they can successfully connect to and enroll in quality alternative coverage. HFS is working closely with the Department of Insurance and Get Covered Illinois to make sure Navigators are available to assist current HBIA/HBIS enrollees with individualized assistance in person, over the phone, or over a video call where they can share their screen to talk through health plan options. Navigators have resources available to them that allow them to convey important information in languages other than English, which is a critical need for many individuals in this population.