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Frequently Asked Questions
Q: If I’m pregnant and I need healthcare right away, what do I do?
You might be eligible for a program called Medicaid Presumptive Eligibility (MPE). MPE is a program for pregnant women only. It offers immediate, temporary coverage for health services when you are not hospitalized. If you are pregnant and meet the income requirements for Medicaid Presumptive Presumptive Eligibility (MPE), you can get medical coverage through MPE. You do not have to be a citizen or a legal immigrant to get MPE.
To get Medicaid Presumptive Eligibility (MPE) you must apply through an MPE provider. You must tell the MPE provider your family's gross monthly income. If you are pregnant and you meet the income requirements for MPE, you can get MPE medical services right away. It is still important to apply for regular Medicaid so you have health coverage in time for you to deliver your baby and after.
If your doctor or clinic is not an MPE provider, or if you do not have a doctor or clinic, call the HFS Health Benefits Hotline at 1-800-226-0768. A hotline representative will help you find a Medicaid Presumptive Eligibility (MPE) provider where you live.
Q: If I qualify for Medicaid, will I be penalized if I do not enroll?
The Affordable Care Act (ACA) requires most people in the United States to have health coverage that meets certain requirements. Medicaid meets those requirements. However, some people are excluded from the requirement to have health coverage. If you do not have to pay taxes because of the amount of your income, you will not be penalized for not having health coverage.
If you are eligible for Medicaid, and don’t have other health coverage, we hope you will consider enrolling so you can get the health care you need at little or no cost to yourself. This will protect you from getting medical bills if you do have to see the doctor or have an accident or emergency.
Q: I have very little income and I need health insurance, but I am not a U.S. citizen. Can I still qualify for Medicaid?
You may qualify for Medicaid. To be eligible for Medicaid you must meet the household income requirements and either be a legal resident who has lived in the United States for 5 years or more or be a refugee. Information you provide in a Medicaid application will not be used by U.S. Customs and Immigration Enforcement division for any purpose, and applying for health coverage will not affect your ability to become a citizen.
The following types of people may be eligible for Medicaid, even if they have not lived in the United States as a legal resident 5 years:
Children and pregnant women are eligible for Medicaid if they qualify base on income, regardless of their immigration status.
People admitted to the United States with a special Medicaid qualifying status including: refugees, asylees, victims of domestic violence and their parents and children, Cuban/Haitian entrants, U.S. military veterans, active duty military and their dependents, and others.
Q: If I am approved for Medicaid, will it cover my doctor/pharmacy bills from the date I applied?
If you are approved for Medicaid, Medicaid may cover unpaid bills from a Medicaid provider for Medicaid covered services from the date of your application. Medicaid may also cover unpaid bills for Medicaid covered services for three months before your date of application if you need that. You will not be reimbursed for anything you already paid.
If you need to see a provider before your Medicaid application has been approved, tell your provider that you have applied for Medicaid, and ask if they will accept Medicaid payment, or if your service will be covered if you are approved. Asking this question in advance will help ensure that if you are approved for Medicaid, you will not billed for services not covered by Medicaid.
Q: What is the Medical Spenddown Program?
If you are a pregnant women, a child under 19, an adult aged 65 or older, or are blind, or have a disability, but have too much income or too many assets to qualify for Medicaid, you may be able to get Medicaid in the spenddown program for some of your medical care. The spenddown program works almost like an insurance deductible. If you are eligible for spenddown, the State sets an amount you have to spend on medical care each month before Medicaid pays for other medical expenses that month. This is called your spenddown amount and is based on a person’s income and assets. Once you show bills or receipts for medical care, drugs or supplies that equal your monthly spenddown amount, you can get a medical card to pay for other medical care they need for the month.
For more information on the Illinois Health and Family Services (HFS) Medical Spenddown Program, visit our Infocenter:
Q: I want to withdraw my Medicaid application because I got other coverage or was able to buy coverage on the Marketplace. What do I do?
You can call the DHS Helpline at 1-800-843-6154 to withdraw your application
Q: What do I do if my provider says they’re in a health plan but Client Enrollment Services says they’re not?
Please ask the provider to contact the health plan you are enrolled with so they can be sure they are in your plan. If it turns out that the provider is not in your plan, you must choose another provider. You have the option to choose another plan if you are within 90 days of enrolling in your plan.
Q: Does auto-enrollment into a health plan take into account an ongoing relationship with medical providers?
If you do not choose a health plan yourself, the state will auto-enroll you into a health plan. The state will look at the history of your health care claims to find you a health plan with a Primary Care Provider (PCP) that you may have seen regularly in the past. If you have not seen any providers regularly, the state may choose a health plan with a provider who your family members may be enrolled with. As a last resort, the state will assign you to a health plan that offers Primary Care Providers close to where you live.
Q: If someone is auto-enrolled in a plan, will that plan automatically assign them a Primary Care Provider?
Even if you are auto-enrolled in a plan you will have the option to choose your own Primary Care Provider. If you do not choose a PCP, the plan will assign you to one.
Q: What do I do if I’m billed for a medical service that Medicaid doesn’t cover?
A Medicaid enrolled provider is required to tell you if a medical service is not going to be covered by Medicaid before they provide you with that medical service. They are only allowed to bill you for that medical service if you know that it will not be covered by Medicaid and you agree to pay for it anyway. If you still need to appeal the bill for the uncovered medical service, you can appeal by calling HFS toll free at 1-855-418-4421. (TTY:1-877-734-7429). You can also send a written request via mail, fax, or email to:
Illinois Department of Healthcare and Family Services
Attn: Fair Hearings Section
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax #: 1-312-793-2005
Q: What if I think a service should be covered but it isn’t?
You should first try to work it out through your medical plan’s appeals process. If this does not work, then send an appeal to HFS (See contact information above).
Q: What happens if I forget to take my HFS Medical Card to my medical appointment?
If you forget your HFS Medical Card, you can still receive healthcare services. Give your Medical Card number or any two of the following pieces of information to your provider.
Name
Social Security Number
Date of Birth
Q: How do I transfer my Medicaid case to a different DHS office in Illinois?
If you would like to transfer your case to another office in Illinois, contact the office currently serving your case to request the transfer.
Q: How do I add a person to my Medicaid case?
In most cases, you will need to contact the DHS office currently servicing your case to add someone to the case. If it is a newborn, ask the hospital to fill out the paperwork to add your baby to your case. Get a copy of the hospital paperwork for your files
Q: What happens if I lose my redetermination form?
If you just have Medicaid and lose your redetermination form or didn’t get one after you have been on Medicaid for about one year, call 1-866-255-5437. If you have Medicaid and other benefits such as cash assistance or SNAP, go to the DHS office servicing your case and fill out a redetermination form while you are in the office.
Q: What happens to my Medicaid benefits when my child turns 18?
Parents or caregivers whose youngest child turns 18 will no longer be eligible for Medicaid through the Family Health Plan, even though the child will continue on All Kids until age 19. However, parents or caregivers may be eligible for health coverage through Medicaid in the new ACA adult Medicaid program. The Illinois Medicaid Redetermination Project (IMPR) will send the clients a redetermination notice to fill out and return to get redetermined eligible under a new group. The notice will be sent in the mail about 60 days before the parents/caretaker relatives are scheduled to lose health coverage. Complete and return this form to the address listed on the form as soon as possible.
Q: What happens to my child’s Medicaid benefits when they turn 19?
If your child is turning 19 and is in a medical only case, the Illinois Medicaid Redetermination Project (IMPR) will send you a redetermination notice for your child to fill out and return to get redetermined eligible as an adult. If your child turning age 19 is on a cash or SNAP case and needs medical coverage after age 19, they can also apply directly for Medicaid by calling the DHS helpline at 1- 800-843-6154 or applying through www.abe.illinois.gov
Q: When my baby is born, will they automatically be enrolled in Medicaid?
In order for your newborn to be added to your case, the hospital must notify Medicaid within 60 days of the birth. Ask the hospital for a copy of the paperwork for your files. If the hospital does not submit the right form to the state, you will have to do it yourself through the DHS office that is serving your case.
The baby will also be automatically enrolled in the same managed care plan as the mom. However, the family does have 90 days to choose a different health plan for the baby.
Q: What do I do if my provider says that I am no longer eligible for Medicaid benefits?
When scheduling your appointment, ask the provider’s office to verify your eligibility over the phone. If the provider tells you that you are no longer eligible for Medicaid, call the DHS Helpline at 1-800-843-6154 to find out more.
Q: How do I appeal a Medicaid decision related to medical services or my Medicaid eligibility?
An appeal is filed either with the Illinois Department of Healthcare and Family Services (HFS) or the Illinois Department of Human Services (DHS), depending on the agency that made the decision and sent you the letter informing you of its denial or action.
You may appeal within sixty (60) calendar days of the date on the letter from the Department informing you of its denial or action. If you want your services to stay the same while you appeal, you must file your appeal no later than ten (10) calendar days from the date on the Department’s letter informing you of its denial or action.
HFS can be reached via the telephone, toll free at 1-855-418-4421 (TTY:1-877-734-7429). You can also send a written request via mail, fax, or email to:
Illinois Department of Healthcare and Family Services
Attn: Fair Hearings Section
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax #: 1-312-793-2005
Email: HFS.FairHearings@illinois.gov
DHS can be reached via the telephone, toll free, at: 1-800-435-0774. You can also send a written request via mail, fax, or email to:
Illinois Department of Human Services
Attn: Bureau of Hearings
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax #: 1-312-793-3387
Q: If I file an appeal, what information do I need to include?
When you file your appeal to either the Illinois Department of Healthcare and Family Services (HFS) or the Illinois Department of Human Services (DHS), describe specifically what action or decision you disagree with and want the department to review. Be sure to include your name, address, phone number, email, and your HFS Medical Card Identification Number (the “ID#” next to your name on the Medical Card).