Program

Eligibility

Details

Illinois Covered Choices:

Allows small businesses and individuals to buy into private health plans regardless of health status or income level.

Employer Eligibility:

• Employer must employ no more than 25 eligible employees.
• Employer must contribute at least 80% of an individual employee’s healthcare insurance premium and at least 65% of an employee’s family healthcare insurance premium.
• Illinois is the principle location of business.

Individual Eligibility:

• Employer does not provide group health insurance and has not provided group health insurance for 18 months prior to the individual’s application.
• Income of less than 400% FPL for the first year of implementation with no income eligibility standards each year thereafter.
• Ineligible for Medicare.
• Illinois resident who works at least 25 hours a week.

Eligibility Requirements Waived For:

• Veterans exempted from income eligibility guidelines.
• Individuals who had health insurance terminated due to a death of a family member under which the individual was covered; change of residence (employer-based health insurance is no longer available); or legal separation, divorce or annulment.

Benefits:

• Managed care entities are required to propose benefit designs to the Department (HFS) for approval.
• Benefits must include major medical care and coverage for serious mental illness (coverage for long-term care and infertility treatments is not required).
• Contracts issued will include only in-plan benefits (the option of dental and vision coverage will be offered at a higher expense to eligible individuals.
• All health insurance plans will be subject to pre-existing conditions limitations (the Department can take pre-existing conditions, as well as chronic care and participation in wellness activities into account when determining deductibles, co-pays, and benefit levels).

Hospital Reimbursement Rates:

• HFS will set the rates by administrative rule, but these rates must be, in aggregate, no lower than base Medicare rates.
• Hospital reimbursement rates set at 105% of base Medicare rates for critical access hospitals; 112% for all others, including research hospitals.
• If a Medicare rate is not available, rate shall be at least 90% of lowest insurer rate.
• Providers that participate in any managed care plan are required to provide services under the Illinois Covered Choices program.

Premium Rates:

• Authorizes the Department of Insurance to adjust premium rates, if modifications are deemed necessary.
• Only the following rating factors may be used to determine premiums: geographic area, age, smoking status, and participation in wellness or disease management activities.
• Allows for premium discount of 10% for wellness programs.
• Limits how much premiums may differ from one group or employer to another.

Program provisions also provide Stop Loss Protection, authorize program publicity, and require data reporting.

Illinois Covered Rebate:

Provides financial assistance to individuals and families to help cover their healthcare premiums.

Individual Eligibility:

• Must be at least 19 years of age but no older than 64 years of age.
• Must be an Illinois resident who meets immigration requirements.
• Income level must be below 300% FPL.

Rebate Schedule:

• For individuals with employer-sponsored healthcare, rebates capped at 20% of the annual premium paid by the policy holder, or $1,000 annually.
• For individuals with an income below 250% FPL enrolled in IL Covered Choices, rebates are capped at $2,500.
• For individuals with an income at or above 250% FPL enrolled in IL Covered Choices, rebates are capped at $1,500.
• For individuals with coverage through a small employer enrolled in IL Covered Choices, rebates are capped at $350 annually.

Rebate limits are doubled for family coverage.

Individuals must apply for premium assistance for employer-sponsored healthcare coverage between January and April for premiums paid in the previous year.

Illinois Covered Assist:

Provides healthcare services through a medical home to uninsured adults who do not otherwise qualify for other State healthcare programs.

Individual eligibility:

• Must be at least 19 years of age but no older than 64 years of age.
• Must be an Illinois resident who meets immigration requirements and has no dependents.
• Income level must be at or below 100% FPL

Benefits:

• Benefits include primary health care services, disease management, non-elective inpatient care, and a pharmacy benefit that must not exceed the drug benefit currently provided under IL Cares Rx.
• Benefits are not entitled and are subject to appropriation.

Administration and Reimbursement:

• Program is administered by community health providers and hospitals.
• Funding for program is set at $100 million for community health providers and $100 million for inpatient hospital care (once funding is exhausted, these providers are expected to continue providing services as part of their charity care programs).
• Funding is to be allocated outside of traditional Medicaid appropriations.
• Reimbursement for services must be submitted through existing HFS procedures (and paid along rates established under the Medicaid program).
• Payments to hospitals will be based on a formula that takes previous charity care into consideration (no single hospital may receive more than 10% of the $100 million allocated to hospitals under the program).