Benefits & Coverage

Our Members get the same benefits as Medicaid recipients. If you have questions about your benefits, call 1-844-807-9734 from 8 a.m. to 5 p.m. or Illinois Relay 711 if you’re hearing impaired.

This same list is in your Member Handbook.

A list of the Main Types of Care, Benefit Limits, and Copays for Adults and Persons with Disabilities under Medicaid (This list does not include all benefits).

Type of Care Description Benefit Limit Copay
Medical Services
Emergency Room Visit If visit is because of a health emergency. Includes post-stabilization services. These services include care you need to maintain a stable condition after an emergency. None. Prior authorization is not required. $0
Hospital Outpatient This is if you receive care at the hospital, but do not need to be admitted. Your doctor will tell you if you need this service. $0
Medication and Prescription Services
Brand Prescriptions This type of medication uses a brand name. Your doctor will know which medication is right for you. None. $0
Generic Prescriptions A type of medication similar to the brand. None. $0
Over the Counter Prescriptions You can receive certain over the counter prescriptions at a lower cost, if you get a prescription from your doctor. Contact your Care Coordinator for more information. None. $0
Mental Health Services
Behavioral Health Includes counseling for mental health conditions. None. $0
Mental Health Inpatient Services If you are admitted to the hospital because of a mental health condition. This can include substance abuse treatment. A doctor will let you know if you need to be admitted to the hospital. $0
Mental Health Outpatient Services If you receive mental health services at the hospital. Your doctor will tell you if you need this service. $0
Substance Abuse Treatment (drugs and alcohol) Treatment for a substance problem, such as alcohol abuse or drug abuse. None. $0
Preventative Care
Cervical cancer screening Women over the age of 21 should be screened for cervical cancer. Women over age 30 should be screened for both cervical cancer and HPV. None. $0
Mammogram Image of the breast to screen for possible cancer. Mammogram covered for women 40 years or older. $0
Prostate cancer screening Exam to screen for prostate cancer in men. The prostate is a gland that is part of a man’s reproductive system. Covered for men 40 years or older who are at risk, and covered for all men 50 or older. $0
Flu Shot  A shot during flu season to help you stay healthy. None. $0
Family Planning Services
Family Planning Family planning includes services relating to:

  • Contraception to prevent pregnancy
  • HPV vaccination
  • Pap test and any follow-ups for abnormal Pap tests
  • HIV testing
  • Other procedures to permanently prevent pregnancy (this includes a vasectomy and “tying tubes”)
Your doctor will help you decide if these services are needed. $0
Maternity Care Includes care for women during pregnancy. Women need checkups before and after the baby is born. Be sure to tell your Care Coordinator if you are pregnant. $0
Care for Your Teeth, Eyes, and Ears
Dental Care for your teeth. It is important for your overall health to be sure your teeth are healthy. Includes services to diagnose problems, prevent problems, restore teeth, and more.
  • Oral exams for adults limited to first visit per dentist.
  • Your dentist will decide if you need specialized dental services.
  • For some services, prior authorization is required.
  • No copays for preventive or diagnostic visits.
  • Copays may be charged for certain specialized services.
$0
Eye Glasses & Exams Get an eye exam to see if you need glasses. Receive an eye exam and one pair of glasses once a year. $50 allowance for glasses from a licensed provider. Prior authorization required. $0
Hearing Care Exam to test your hearing. Can also cover hearing aids, if needed. One hearing aid every three years. $0
Transportation
Ambulance or emergency transportation Transportation by a medical ambulance or other type of emergency vehicle. None. $0
Non-emergency Transportation If you aren’t able to arrange a ride to your doctor, your Care Coordinator can assist you. Approval required. Work with your Care Coordinator to get approval for transportation services. $0
Other Medical Services
Dialysis Treatment for kidney disease. Dialysis performs some of the functions of a healthy kidney. Covered for those that have kidney disease. $0
Home Health Care Help in your home by a nurse, someone who provides you with therapy, or some other qualified professional. Your doctor will tell you if you need this service. $0
Hospice Care Care that is needed if you have a serious illness or need end of life care. Your doctor will tell you if you need this service. $0
Hysterectomy A surgical procedure to remove a woman’s uterus. Only covered if your doctor believes it is necessary. $0
Radiology Images, like x-rays, taken of your body to see what type of injury or internal problem you may have. Your doctor will tell you if you need this service. $0
Laboratory Services This covers a range of tests your doctor may request, such as blood or urine tests. Your doctor will tell you if you need this service. $0
Medical Equipment and Supplies Items you may need for your health, such as a wheelchair or oxygen. Your doctor will need to get approval. He/she will fill out the needed forms. $0
Occupational Therapy Helps you with daily activities. Your doctor will tell you if you need this service. Limit of 20 visits per year. Prior authorization is required. $0
Observation If your health condition needs to be monitored in the hospital, but you do not need to be admitted. Your doctor will tell you if you need this service. $0
Physical Therapy Help with movement. For example, this could be help after an injury. Your doctor will tell you if you need this service. Limit of 20 visits per year. Prior authorization is required. $0
Podiatry Foot care. Limited to people with diabetes. $0
Speech Therapy Help with speaking and language skills. Your doctor will tell you if you need this service. Limit of 20 visits per year. Prior authorization is required. $0
Sterilization Procedures Procedure that prevents pregnancy. This can be for both men and women. This type of procedure is permanent. Your doctor will have you complete forms. These forms make sure you understand the procedure and give your consent. $0
Ultrasound Type of image used by doctors to see what’s happening in the body. Typically used for women during pregnancy. Only covered if your doctor believes it is necessary. $0

Services Not Covered

Medicaid do not cover these services:

  • Experimental procedures: treatments that aren’t normally asked for.
  • Research procedures: treatments that aren’t normally asked for.
  • Medical exams for entrance into adult educational or vocational programs.
  • Autopsy: explains a person’s death.
  • Artificial insemination: helps women become pregnant.
  • Medical or surgical procedures for cosmetic purposes, like plastic surgery.
  • Medical or surgical transsexual treatment services to change someone’s gender.
  • Acupuncture: placing needles in certain parts of the body.
  • Chiropractic services: for the back or spine.
  • Elective surgery: surgery that is not necessary for your health.

This is not a complete list. If you do not know if a service is covered, please call us first at 1-844-807-9734. If you’re hearing impaired, call Illinois Relay at 711.