Community Ask: I have severe glaucoma. I had Illinois Medicaid and recently qualified for Medicare, as well. Why was it so difficult to find treatment from an ophthalmologist?
Mark Terran of Streamwood contacted the BGA for help navigating the state Medicaid system to find glaucoma treatment.
Terran said his Medicaid provider was Aetna Better Health of Illinois, and finding health treatment was challenging. In September, he was told his Medicaid plan did not cover the treatment he received earlier. Terran said it took many phone calls to change his Medicaid plan in January to access his needed treatment. He then turned 65 earlier this month — the starting age to qualify for Medicare — and said he is now enrolled in a joint Medicare-Medicaid plan that covers his treatments.
Although Terran is now covered, his journey to navigate the publicly funded Medicaid and Medicare systems wasn’t easy. Here’s the breakdown of the systems if you’re looking for the right health insurance.
What’s the difference between Medicaid and Medicare?
Medicaid is funded by the state and federal governments to help pay for the medical treatment of low-income residents. Eligibility depends on age, current medical state (whether you are pregnant or whether you are disabled) and resident status, according to Benefits.gov, the government benefits website.
Medicare is a federal health care program for people age 65 or older or anyone with end-stage renal disease (people younger than 65 with certain disabilities can also qualify), according to the Illinois Department of Central Management Services. The government pays for some of the costs for eligible members, depending on how long they paid Medicare taxes while they worked, according to Medicare.gov, the federal Medicare website.
It’s also possible to qualify for both programs. For example, Illinois offers a Medicare-Medicaid Alignment Program in certain counties for low-income seniors and people with disabilities who meet certain eligibility requirements, according to the Illinois Department of Healthcare and Family Services.
Finding a Medicaid plan
Visit the Benefits.gov Illinois Medicaid page to determine your eligibility and learn more about Medicaid.
The website helps you check eligibility requirements and offers a Health Benefits Hotline at 800-843-6154 to speak with an agent. Scroll to the middle of the page, and click “Apply for Medicaid,” which links to the Illinois Application for Benefits Eligibility website.
Illinois also offers additional support in navigating medical benefits to some low-income individuals and families through its HealthChoice Illinois program, found here.
Finding a Medicare plan
Medicare coverage is separated into several parts.
Original Medicare combines two parts: Medicare parts A and B. Medicare Part A is hospital insurance. It’s typically premium-free for those 65 or older collecting retirement benefits from Social Security or the Railroad Retirement Board, according to the Illinois Department of Central Management Services. Those who don’t qualify for premium-free Part A can buy it. However, all members are responsible for a deductible and coinsurance, according to the federal Medicare website.
Medicare Part B covers outpatient care and medical insurance, including medically necessary or preventive care services. Anyone enrolled in Part A who is retired or has lost their current employment status must also enroll in Part B. This insurance plan requires a monthly premium, deductible and coinsurance for all members.
Medicare Part D covers prescription drugs, and enrollment is optional. Members must pay a monthly premium, except for people who qualify for additional assistance.
Medicare Advantage, also known as Medicare Part C, is a plan offered by a private insurance company. It includes the same coverage as Part A, Part B and usually Part D. These plans may offer lower out-of-pocket costs or extra benefits, such as vision, hearing and dental.
Visit Medicare.gov to determine your eligibility for Medicare and learn more.
Enrolling in Medicare-Medicaid
To enroll in Illinois’ Medicare-Medicaid Alignment Initiative, call an enrollment counselor at 877-912-8880.
Have you worked with an Illinois Medicaid or Medicare program or tried using Benefits.gov or Medicare.gov?
Use the form below to share your experiences with us, and let us know how these services are working for you.