Copays, coinsurance may be charged for some non-emergency services
SPRINGFIELD – New copays and coinsurance for existing enrollees in the Health Benefits for Immigrant Seniors (HBIS) and Health Benefits for Immigrant Adults (HBIA) programs will go into effect on Feb. 1, as the Department of Healthcare and Family Services (HFS) previously announced.
Most services covered by the HBIA and HBIS programs, which provide health care coverage for individuals who would be eligible for Medicaid coverage if not for their immigration status, will continue to be free for customers, including primary care visits, prescription medications and vaccinations at a pharmacy or doctor’s office. The new copays and co-insurance will apply to the use of non-emergency hospital or surgical center services, like nonemergent elective surgeries, physical therapy and lab work.
Copays are fixed amounts paid for health care services covered by a health plan, while coinsurance is a type of cost-sharing where a customer pays a percentage of the total price for a covered health care service, and their insurer pays the remainder. Both copays and coinsurance are common cost-sharing practices used in both commercial insurance and in Medicare. Enrollees should always check with their provider on whether they will be charged out-of-pocket costs for a service.
The impact of copays and cost-sharing will vary for participants based on their enrollment in Medicaid Managed Care, which many HBIA and HBIS participants will be transitioning to over the next several months. The copays and coinsurance and the transition to managed care for HBIA and HBIS enrollees are among the cost-saving measures HFS has implemented in order to bring program costs within the budgeted amount for State Fiscal Year 2024.
For those already enrolled or in the process of enrolling in a Managed Care Organization (MCO), out-of-pocket costs will depend on the MCO. Some MCOs are waiving all or some of the allowable charges, which means hospitals or surgical centers will not charge members of that MCO an out-of-pocket cost for some or all non-emergency procedures and services. Those not enrolled in an MCO can be charged copayments or coinsurance.
No copay or cost-sharing may be charged for an emergency service needed to evaluate or stabilize an emergency medical condition, which is a condition with symptoms severe and painful enough that a reasonable person would think they are life-threatening and need immediate medical care. Individuals who have severe symptoms that could be life threatening should not hesitate to seek immediate treatment, and in those instances will not have cost sharing requirements.
Copays and cost-sharing may only be charged on the following services:
• Non-emergency Inpatient hospitalizations: $250 copayment per stay.
• Non-emergency Hospital Outpatient Services or Ambulatory Surgical Treatment Center: 10% of what HFS would pay the provider. The amount an enrollee can be charged will vary depending on the service and the provider, and enrollees should check with the provider on whether they will need to pay an out-of-pocket cost for a service.
HFS has removed a previously planned $100 copay for non-emergency hospital ER services, after consulting with the Centers for Medicare & Medicaid Services and confirming that the state can seek reimbursement for all emergency room care. In addition, some of the MCOs are waiving copays for certain service types: CountyCare, which only serves customers in Cook County and will serve the majority of HBIA and HBIS enrollees, is waiving all copays and coinsurance for HBIA and HBIS customers.
Beginning January 1, 2024, many HBIA and HBIS customers have begun receiving services through HealthChoice Illinois, the State of Illinois’ Medicaid Managed Care Program. Previously, services were delivered to HBIA and HBIS customers solely via a fee-for-service model. The shift to managed care provides a level of care coordination for customers that isn’t available with fee-for-service. Care coordinators help customers connect with the medical care and social services they need.
MCO enrollment for HBIA and HBIS customers is taking place in waves, with the last cohort of HBIA and HBIS customers enrolling with an MCO April 1. HBIA and HBIS customers are receiving enrollment packets in the mail that explain the transition to managed care and what they need to do. A sample MCO enrollment letter is available here.
HBIA and HBIS enrollees who have comprehensive private insurance or spenddown will remain in fee-for-service and will not enroll with a managed care plan or receive an MCO enrollment mailing.