How Health Benefits Work

Frequently Asked Questions

How you sign up depends on the type of coverage you get:

You can qualify for Medicaid if your family’s income qualifies, even if your job offers insurance.

You cannot get subsidies for purchasing an individual health plan through Get Covered Illinois/HealthCare.gov if your job offers you affordable insurance.

In most cases, no. The actual medical coverage you get from Medicaid is the same, no matter how you qualify. Generally speaking, the big difference is that people with disabilities get extra ways to qualify and, if you have a disability and start working, you can earn more while still getting Medicaid coverage through HBWD.

For Medicaid based on having low to moderate income, the main income rules are:

  1. If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,783 per year for an individual; $43,056 for a family of four), you may qualify.
  2. If you are 18 or younger and your family’s income is at or under 318% of FPG ($99,216 per year for a family of four), you may qualify for All Kids.
  3. If you are pregnant and your family’s income is at or under 213% of FPG ($66,456 per year for a family of four), you may qualify. The unborn baby is counted as a family member.

This way of getting Medicaid, sometimes called "Medicaid expansion," is based on your Modified Adjusted Gross Income (MAGI), which includes most of your earned and unearned income. MAGI doesn't include some types of income, like Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.

If you have a disability, you may be able to get Medicaid coverage if your income is a lot higher than this, thanks to Health Benefits for Workers with Disabilities (HBWD). Learn more about HBWD.

Health Coverage Income Limits for Your Family

It depends on your situation:

Note: Illinois has temporarily paused new enrollment in the Health Benefits for Immigrant Adults and Health Benefits for Immigrant Seniors programs.

There are different health coverage options as your income goes up:

  • Depending on how much your income goes up, your Medicaid may continue, unchanged.
  • If you got Supplemental Security Income (SSI) before you started earning more, you can usually keep Medicaid thanks to SSI’s 1619(b) rule.
  • If you have a disability and work, you can also consider Health Benefits for Workers with Disabilities (HBWD), which offers Medicaid coverage (you may have to pay a monthly premium). With it, you could earn as much as $4,468 per month ($53,610 per year) and still qualify.
  • If your employer offers it, you may be able to get employer-sponsored coverage.
  • If your employer does not offer coverage, you should consider private individual coverage. You may get government help to pay for an individual plan on Get Covered Illinois/HealthCare.gov. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

The bottom line: There is a coverage option for almost everybody. Do not worry that getting a job will leave you without health coverage.

To qualify for Health Benefits for Workers with Disabilities (HBWD), you must:

With HBWD coverage, you pay a premium of up to $500 each month (the higher your income, the higher your premium).

Learn more about HBWD.

Medicare has three main parts:

  • Medicare Part A helps pay for medical care you get while you’re in a hospital.
  • Medicare Part B helps pay for medical care you get outside of a hospital.
  • Medicare Part D helps pay for prescription drugs.

Medicare Advantage (also called Medicare Part C) is a way to get a single combined plan including Parts A, B, and D through a private company. With Medicare Advantage plans, you may have less flexibility, but your costs could be lower.

If you or your spouse worked enough time while paying Medicare taxes, you qualify for Medicare Parts A and B:

  • When you turn 65
  • When you’ve been getting Social Security Disability Insurance (SSDI) benefits for two years, or
  • If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

Note: If your disability began before you turned 22 years old and you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you start getting Medicare.

No. Medicare only helps pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you have to pay for it yourself, unless you have other coverage, such as Medicaid, employer-sponsored coverage, or a Medicare supplement (Medigap) policy.

For certain services, you pay a deductible, copayment, or co-insurance before Medicare begins to help pay for that service. For Medicare Part B or Part D, or for Medicare Advantage, you may have to pay a monthly premium.

You may qualify to get help paying for your Medicare premiums, copayments, and deductibles if you have low income. Medicare Savings Programs help pay for Part B coverage and the Low Income Subsidy (LIS) helps pay for Part D coverage. Note: If you don't qualify for an MSP, but do qualify for AABD Medicaid, you may not have to pay a Part B premium.

Learn more about getting help paying for Medicare.

Yes. Other types of coverage that you can have with Medicare include:

Learn more about how Medicare interacts with other types of coverage.

You may pay nothing, a percentage of the cost, or whatever amount your employer doesn't pay.

Employers are supposed to offer plans that cost the employee, for the employee’s policy alone, less than 9.12% of the employee’s household income for the monthly premium. Also, that coverage must meet bronze-level standards for copayment, co-insurance, and deductible expenses.

If your employer offers a plan that does not meet these standards, you may qualify for government help through tax subsidies to reduce the premium on an individual plan.

Note: The coverage your employer offers must meet affordability standards for the employee, but not for the family. It may be very expensive for family members to join an employer-sponsored health plan. Before 2023, the spouse or children of an employee would not qualify for subsidies on Get Covered Illinois/HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on Get Covered Illinois/HealthCare.gov.

Yes, if you are under 26 and cannot get health coverage through your own employer. Employers who offer coverage to their employees must also offer it to their children under the age of 26.

Employers do not have to offer coverage to the spouses of employees, but many do.

Note: While employers must offer this coverage to children, the employee may be required to pay for all of it.

Yes. Plans cannot deny people coverage. When you apply for insurance, they cannot reject your application and they cannot say that they won’t cover medical needs related to your disability. They also cannot charge you more because you have a disability.

Additionally, all Affordable Care Act (ACA) compliant plans must cover the Essential Health Benefits (EHBs), which means that they offer comprehensive coverage, including chronic disease management, rehabilitative and habilitative services and devices, and mental health and substance abuse coverage, just to name a few.

Depending on your situation, you may qualify to have the government help pay for your individual health plan through tax credits. Here's how it works:

  1. When you sign up at Get Covered Illinois/HealthCare.gov, you give details about your family's situation. Get Covered Illinois/HealthCare.gov reviews that information instantly. If your family qualifies for government help to pay for individual coverage, Get Covered Illinois/HealthCare.gov tells you and lists insurance options for you.
  2. Your insurance options list the full cost of the monthly premium, how much of that premium the government pays each month, and how much you pay each month. The government helps pay for the premium by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
  3. In January or February, the government sends you a form listing your total health coverage tax credits for the previous year. You need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this is sorted out when you file your taxes.

No, but depending on your income, you may get more help from the government if you get a silver-level plan:

  • The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is.
  • If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, the government also pays to reduce your copayments, co-insurance, deductible, and out-of-pocket maximum. That means you pay less each time you need medical services. If you get this help, your silver plan might actually be as good or better than many platinum or gold plans. If you do not get a silver plan, the government does not help you with these expenses.

When Get Covered Illinois/HealthCare.gov looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

Health Coverage Income Limits for Your Family

Usually, when you sign up for a plan through Get Covered Illinois/HealthCare.gov, you need to stay on the plan for the entire calendar year. So, if you are signed up for 2024, then you can’t leave that plan until 2025.

However, in certain situations you may be able to change plans mid-year:

  • If your income changes and you gain or lose eligibility for government help paying for your coverage
  • If your health provider is not meeting its obligations
  • If you move, or
  • In other life-changing circumstances, such as having a child or getting married.

The first one is the key. If your income goes down and you can’t afford your plan anymore, report your change in income to Get Covered Illinois/HealthCare.gov. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance (meaning that you have to pay less).

Note: American Indians do not have these restrictions and can change up to once a month.

Learn more