Medicaid for Young Adults (Age 18 and Older)

Young adults in Illinois may qualify for Medicaid. Medicaid, which is run by the Illinois Departments of Human Services and Public Aid, provides payment for certain medical services and equipment.

Young adults in Illinois are potentially eligible for Medicaid if they are in one of the following groups:

Children under the age of 19 may qualify for Medicaid or KidCare;

Pregnant women–Medicaid covers the pregnancy and 60 days post-partum;

Persons with minor children;

Persons who meet the Social Security definition of disability; and

Persons who meet the Social Security definition for blindness.

In addition, young adults must be United States citizens or in an eligible group of immigrants.

Medicaid eligibility determinations are handled by the Illinois Department of Human Services (IDHS). Medical service and item coverage issues are handled by the Illinois Department of Public Aid (IDPA).

Unlike most states, persons who are receiving SSI disability benefits must apply separately at an IDHS office and meet stricter eligibility criteria to receive Medicaid. In other words, getting SSI does not guarantee Medicaid eligibility in Illinois.

Income and Assets Limits

IDHS looks at a young adult’s income to determine Medicaid eligibility. IDHS, however, will not consider the income and assets of parents in determining Medicaid eligibility once the young adult turns age 18.

The income rules for persons with disabilities are as follows: $25 deduction from all income and an earned income deduction, counting only net income (what is left after the payroll deductions for taxes, etc.), of $30 of the first $60 in earned income. Any impairment related work expenses may also be deducted. SSI income, however, is not counted. Social Security income is counted except for adult disabled children (see discussion below).

Countable income is compared to the income limits listed below:

1 in Household equals $738

2 in Household equals $995

3 in Household equals $1,252

4 in Household equals $1,506

 

Young adults whose countable income falls below these levels will qualify for a Medicaid card automatically each month, so long as all other eligibility criteria are met.

Young adults whose countable monthly incomes are above these levels may still qualify for Medicaid under two separate provisions: the § 1619 program and the spenddown program (each discussed below).

Young adults must also meet an asset test. Their countable assets (resources) cannot exceed $2,000. Assets that are not counted include: a house, a motor vehicle up to $4500 equity value, personal belongings and household furnishings.

What does Medicaid cover for young adults?

Covered services for young adults include hospital services, prescription drugs, physician services, optical and eyeglasses, dental, laboratory and x-rays, home health care, long term care, durable and non-durable medical equipment, respiratory equipment and supplies, hospice care, some substance abuse treatment, and community mental health treatment.

Some services and items require prior approval. IDPA has responsibility for coverage and payment issues under Medicaid.

Spenddown

Young adults whose income and/or assets are higher than the limits described above may still qualify for Medicaid coverage under the spenddown program. When a Medicaid applicant is over the income and/or asset limits, IDHS is required to calculate the amount by which income and/or assets are over the limits. This amount is called the spenddown amount.

The spenddown amount works like an insurance deductible–that is, Medicaid will pay for the cost of additional medical care in a month once the spenddown amount has been met. To meet the spenddown amount, a young adult, once enrolled in Medicaid, must present IDHS with bills or receipts for medical care, drugs, or supplies in an amount that equals or exceeds the spenddown amount.

If the spenddown amount is met, the young adult will receive medical coverage for the remainder of the month in which the bills or receipts are presented or for a later calendar month if the young adult so chooses. The amounts of bills used to meet the spenddown amount each month are the responsibility of the young adult.

How To Apply for Medicaid

Medicaid applications are filed at an Illinois Department of Human Services office. Once filed, IDHS has 45 days to determine Medicaid eligibility (60 days if the person seeks Medicaid because of disability).

The Appeal Process

Persons who apply for Medicaid and are denied eligibility or coverage for medical care may appeal. The appeal must be filed within 60 days of the date of the decision. Generally speaking, once the appeal is filed, the person appealing will have a hearing (either in person or by telephone) with an IDHS hearing officer. If the person loses the hearing, s/he can file a lawsuit in the state circuit court for relief.

Special Coverage Issues for Medicaid

Adult Disabled Children – Young adults who are receiving Social Security benefits on the earnings record of a parent may qualify to receive Medicaid without a spenddown even if their monthly Social Security payments are higher than the limits set forth above if they meet the following criteria: (1) they are receiving Social Security benefits on a parent’s earning record for a disability that began before age 22; (2) they received SSI benefits previously due to their disability; and (3) SSI benefits were lost due to qualifying for Social Security benefits.

§ 1619 Benefits – Young adults who are receiving Medicaid, and start working, are allowed to continue receiving Medicaid. When monthly wages are greater than $800 (in 2003), or if they are no longer eligible for a SSI check because of their monthly earnings, to the point where they are earning approximately $2,166.75 a month or $26,001 (in 2003) annually, they are 1619 eligible through SSA and administered by DHS. Young adults would also be eligible to receive SSI benefits until their monthly income reaches $1,189 (in 2003).

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