When Medicaid in Illinois Will Pay for a Nursing Home, Assisted Living, or Home Health Care

Long-term care services in Illinois are expensive, including nursing homes, assisted living facilities, and home health care. Private health insurance policies generally do not cover long-term care (LTC), and Medicare coverage for LTC services is quite limited. LTC insurance policies can help pick up some of the tab, but few people purchase it. This leaves Medicaid, which has become a very common source of funding for long-term care.

There are, however, strict rules for Medicaid eligibility for long-term care in Illinois. Besides qualifying financially, you also need to qualify medically for Medicaid to pay for any LTC service like a nursing home, assisted living facility, or home health care.

Medicaid for Illinoisans in Nursing Homes

In Illinois, people who are sixty-five (65) or older, disabled, or blind, can qualify for Medical Assistance (Illinois' name for Medicaid) through the Aid to the Aged, Blind and Disabled (AABD Medical) program, if they also meet income and asset limits. Medical Assistance and the AABD program, administered through the Illinois Department of Healthcare and Family Services (HFS), also provides cash benefits.

If you already receive Medical Assistance in Illinois, then your Medicaid coverage includes nursing home care if you need it. Nursing homes are residential facilities that offer around-the-clock skilled nursing care in addition to other supportive services. You can find a list of licensed nursing homes in Illinois here.

Income Limits for Medicaid in Illinois

The income limits for AABD Medical are different depending on whether you live in the community or in a nursing home or assisted living facility.

Income Limits for People Living in the Community

AABD Medical covers elderly, blind, and disabled residents living in the community (at home or with friends or relatives) with income up to 100% of the federal poverty level (FPL). In 2019, that is $1,041/month for a household of one or $1,409/month for a household of two.

If your income is more than the FPL, you can still qualify for AABD Medical by "spending down" your excess income every month on certain expenses. The state determines your spend-down amount based on your income. You qualify for Medicaid every month you can show the state that you have incurred the expenses. You do not have to actually pay the bills, just show the state that you have incurred them.

For example, Mrs. Brown has excess income above the AABD Medical income standard. Illinois tells Mrs. Brown her spend-down amount is $120/month. She has a doctor's appointment that will cost her $250 out of pocket. She has met her spend-down and qualifies for AABD Medical that month.

AABD Medical recipients who are living in the community can also qualify for "Pay-In Spend-Down." That means that they do not need to bring in proof of their medical expenses each month. They can just pay the spend-down amount to the state and qualify for AABD Medical that month. So Mrs. Brown could just pay the state $120 each month and be sure that she would get her medical benefits. Pay-In Spend-Down is not available for residents of nursing or supportive living facilities.

Income Limits for People Living in a Facility

If you are living in a nursing facility, you can have more income than 100% of the FPL, but you will be required to pay almost all of your monthly income toward your care. Illinois allows single AABD recipients in nursing homes to keep only $60/month for themselves. The state does have rules that allow a "community spouse" (the spouse not entering a nursing home) to keep more income.

If your monthly income exceeds the cost of the nursing or supportive living facility, then you may still qualify for AABD Medical benefits if you spend-down your excess income every month on other eligible expenses.

Resource Limit for Medicaid in Illinois

To qualify for AABD Medical, you must have less than $2,000 in resources. Resources are assets like money and property. If you have a dependent or spouse in your household, you can have $3,000 in resources together.

Some property doesn't count toward the resource limit. Your home is not counted as an asset for Medicaid in Illinois. Your personal belongings and household goods of reasonable value are exempt. One car is also exempt if someone in your family uses it to get to work or to get attend medical appointments, if it is modified to transport a disabled person, or if it is needed for essential daily activities.

If you have resources that exceed the limit but need AABD Medical in order to move into a nursing home, you can spend-down your assets and qualify. If you have a spouse who is remaining at home, then you will be allowed to keep assets to help support that person.

When a Nursing Home Is Medically Necessary

Medicaid will pay for a nursing home only when it is medically necessary. Medicaid will not pay for nursing home care that is just "custodial," meaning non-medical care such as help with transferring to and from a wheelchair, bathing, or eating.

Before Medicaid will pay for nursing home care, you must have a "needs screening." If you are in a hospital, the hospital will arrange the needs screening for you. If you are in your home, you should contact the state to arrange for a screening. Individuals who are 60 and over can call the Department of Aging at 800-252-8966 to arrange for a needs screening. Individuals with a physical disability can call the Department of Human Services (DHS) at 877-761-9780 to arrange for a screening. Individuals who are developmentally delayed or have a mental illness can call DHS at 800-843-6154.

Medicaid uses the information in your needs screening to decide whether you need a nursing home and, if so, what kind of nursing home is appropriate for you. In general, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of skilled nursing care that is only available in an institution.

Medicaid for Illinoisans in Supportive Living Facilities

Supportive living facilities (SLFs, also known as assisted living facilities) provide apartment-style room and board, therapy and nursing services, and supervision. SLFs are generally less expensive and less medically intensive than nursing homes. In Illinois, SLFs are specially licensed and monitored.

Illinois operates a Medicaid waiver program called the Supportive Living Program (SLP) to pay for some of the costs of supportive living facilities.

To qualify for SLP, you must be 65 or over or an adult with a physical disability. If you have a primary or secondary diagnosis of developmental disability or serious and persistent mental illness, then you will not qualify for SLP. You must require the nursing home level of care.

If you qualify, then SLP will pay for many of the services that you can receive in an SLF, like personal care services, housekeeping, meals, exercise programs, medication supervision, and temporary nursing care. You must pay the room and board fee for the living facility. You must have monthly income that is equal to or greater than the SSI amount to qualify for this program. In 2019, that is $771 per month.

If you are eligible for SLP, you will need to pay almost all of your monthly income to the facility. SLF residents are allowed to keep $90/month as a personal needs allowance.

To apply for SLP, contact a participating facility directly, and the facility will help you get the appropriate assessments and paperwork done.

Assistance for Illinoisans Needing Home Health Care

Home health care can include skilled nursing or therapy services, home health aide services like medication management or bathing assistance, and personal care aide services like meal preparation or cleaning. Illinois has several programs that offer payment for home health care services.

First, if you receive AABD Medical, the program will pay for some limited home care services. The services must be prescribed by your doctor as part of a plan of care for a particular problem, and the services must be directed at curing or rehabilitating you. AABD Medical will not pay for services that you might need on a long-term basis like housekeeping, but it will pay for services provided by a home health care agency, a physical therapist, speech therapist, or an occupational therapist.

If you are a disabled individual under 60, then you may qualify for Illinois' Persons With Disabilities program. The program pays for home health services like a personal assistant, therapy or nursing in your home, delivered meals, and housekeeping. To qualify, you must have a needs assessment that shows that you are at risk of being placed in a nursing home without these services. Illinois operates a similar program for adults suffering from brain injuries. You can obtain more information and apply for the programs online here.

Illinois also operates a program called the Community Care Program (CCP). If you qualify for CCP, you can receive homemaker services, adult day care services, and emergency home response services. To qualify, you must be 65 or over, or 60-64 and physically disabled. You must have an assessment that shows you are at risk of being placed in a nursing facility. CCP is not a Medicaid program, and so you can have income and assets above the AABD Medical limits discussed above. However, you must have less than $17,500 in assets. If you have enough monthly income, you may be required to contribute to the cost of the services. To apply, contact the Department on Aging Senior Help Line at 800-252-8966.

De-Institutionalization in Illinois

Illinois has been sued several times by groups of disabled institutionalized adults who alleged that the state was effectively forcing them into institutions by failing to offer necessary community-based services. The state entered into agreements to settle the lawsuits and has moved to expand its community-based services.

If you are in a nursing home but would like to move out into a less restrictive setting, you should consult your care coordinator about options for leaving.

The state has established a program called Pathways to Community Living to help people move out of institutions and get the supportive services they need to live in the community. You can use an online referral form to get an evaluation and find out if you qualify for assistance.