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Illinois Life Span Program

Becoming A Dual Medicare-Medicaid Eligible Recipient

Last Updated September 2023

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Table of Contents

Are you an Adults with DD Waiver participant with Medicaid as your only insurance?

When you become a Dual Eligible and participate in the DD waiver, you will become exempt from Medicaid Managed Care and need to notify your Medicaid Managed Care Organization (MCO) to process your disenrollment. 

As a Dual you will be in Fee for Service (FFS) Medicaid and Traditional Medicare (not a Medicare Advantage plan). You need to: 

  1.  Apply to the Illinois Medicare Savings Program: https://hfs.illinois.gov/info/brochures-and-forms/brochures/hfs3757.html
  1.  Select a Medicare Part D plan for prescription coverage. Seniors and adults with disabilities can call the Senior Health Insurance Program (SHIP) for help with questions about Medicare at 1-800-252-8966 or Age Options (708-383-0258/1-800-699-9043). 
  1. Apply for “Extra Help,” which is a federal program that helps with costs of Part D Prescriptions: www.ssa.gov/benefits/medicare/prescriptionhelp.html  
  1. When scheduling medical appointments, ask beforehand if the provider accepts both Medicare and Medicaid. 
    • If healthcare provider accepts both forms of insurance, they are not allowed to bill for any balance left on an individual’s account (called balance billing) 
    • If healthcare provider accepts Medicare only, but not Medicaid, then you must decide: 
      • Will you see the provider/pay the balance due yourself?
      • Will you look for another provider who accepts Medicare and Medicaid? 

Are you an adult dual eligible with IDD who is not participating in the Adults with DD waiver, or on the PUNS list waiting to be selected to apply for the Adults with DD waiver? 

When you become a Dual Eligible – not in the Adults with DD waiver – and you receive long term services and supports (LTSS) either in a nursing home or through one of these five Home and Community Based Waiver programs (Persons who are Elderly, Supportive Living Facilities, or one of the three Department of Rehabilitation Services (DRS) Home Service program waivers:Persons with Disabilities, Persons with Brain Injury, or Persons with HIV or Aids), it is mandatory to be enrolled in a Medicaid managed care program for LTSS services either through MMAI (Medicare-Medicaid Alignment Initiative) or MLTSS (Managed Long-Term Services and Supports). https://hfs.illinois.gov/medicalproviders/cc/mmai.html 

  • Individuals who receive LTSS cannot be enrolled in both an MMAI and MLTSS plan 
  • If a dual receiving LTSS opts out of MMAI and returns to traditional Medicare and Medicaid, they must enroll in a MLTSS plan. Services include LTSS, transportation and some behavioral health. 
  • MLTSS is mandatory; cannot opt-out

Are you are a Dependent Adult Child (DAC) covered by parental insurance from parental employment? 

For people covered under an employer or retiree health plan, including adults with disabilities on a parental employer or retiree health insurance plan: 

  • Generally, private insurance will be primary, Medicare will be secondary. Medicaid is always the payor of last resort. 
  • If you choose to see a provider who accepts only your private insurance and Medicare, you are liable for any balance due. 
  • If you get a prescription from a provider who is not enrolled in Illinois Medicaid, you will only be able to have your private coverage and possibly Medicare Part D cover it. 
  • You can ask your healthcare provider to enroll in Medicaid 

Illinois laws require that for a insured plan, the insurance company must cover the children of the policyholder up until the age of 26.  If the child is disabled, the insurer in Illinois (fully insured, not self-insured) must carry the child past the age of 26. Most health plans of large companies are self-insured, meaning they can cover their own health costs, even if they use a major healthcare insurer to process their bills. The continuation of coverage for an adult dependent older than age 26 does not apply to self-insured employers.  If the employer is fully insured and purchases a policy from an Illinois health insurance company, then continuation of coverage law applies. You can check with your HR Department to learn if your employer is self-insured. 

When becoming a Dual (Medicare and Medicaid Eligible) think about: 

  • What is current coverage? 
  • What will change? 
  • What can you afford? 
  • What else may not be covered? 
  • What else needs to be done? 
  • What have medical providers shared about possible future needs? 
  • Are new providers (primary care and/or specialists) needed? 
  • Is person tax dependent? 
  • Is person under age 26? 
  • Does 1968 IL insurance continuation law apply? (info provided above) 
  • What state and federal requirements do you need to be aware of? 
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