Medicaid covers most doctor visits and hospital care, but not everything
Illinois Medicaid pays for emergency room visits, hospital stays, doctor appointments, and prescription drugs. It does not pay for dental work, vision care, hearing aids, or most cosmetic procedures. Some services require prior approval from the state before Medicaid will cover them. Other services fall outside the program entirely, and you pay out of pocket or find a separate insurance plan.
The line between covered and uncovered shifts depending on your age, income level, and which Medicaid category you fall into — there is no single list that applies to everyone. A child on Medicaid may have dental coverage that an adult does not. Someone on emergency Medicaid has fewer covered services than someone on regular Medicaid. Understanding what your specific category covers takes a phone call to the Illinois Department of Healthcare and Family Services or a look at your Medicaid card's summary of benefits.
Key Takeaways
- Illinois Medicaid does not cover dental care, vision exams, eyeglasses, or hearing aids for most adults, though children and pregnant women have some dental coverage.
- Cosmetic procedures, weight-loss surgery, and fertility treatments are not covered unless medically necessary and approved in advance.
- Services from out-of-network providers are usually not covered unless you get prior approval or the visit is an emergency.
- Long-term care in a nursing home is covered only if you meet strict income and asset limits, and you may have to spend down your savings first.
- Over-the-counter medications, vitamins, and most herbal supplements are not covered by Medicaid.
Dental, vision, and hearing services you will pay for yourself
Illinois Medicaid does not cover routine dental care for adults — no cleanings, fillings, root canals, or extractions. Children under 21 and pregnant women do get some dental coverage, including cleanings and basic repairs. If you are an adult and need a filling or have a tooth pulled, you pay the dentist directly or find a low-cost dental clinic in your area.
Vision exams and eyeglasses are also not covered for adults. Children under 21 get one eye exam per year and one pair of glasses, but adults do not. If you need new glasses or a contact lens fitting, you pay out of pocket. Some community health centers offer discounted vision services if you cannot afford full price.
Hearing aids are not covered by Illinois Medicaid for any age group. If you need a hearing test or a hearing aid, you pay for it yourself. Some audiologists offer payment plans, and some nonprofits help low-income people find affordable hearing devices.
Cosmetic and elective procedures that Medicaid will not pay for
Medicaid does not cover cosmetic surgery — no facelifts, breast augmentation, liposuction, or other procedures done purely for appearance. If a procedure is medically necessary, such as reconstructive surgery after an accident or burn, Medicaid may cover it, but you need prior approval from the state first.
Weight-loss surgery is not automatically covered. Medicaid may cover it if you have severe obesity and related health problems, but you must meet strict medical criteria and get approval before the surgery. Fertility treatments, including in vitro fertilization and egg freezing, are not covered. Medicaid does cover prenatal care and delivery once you are pregnant.
Experimental treatments and drugs not yet approved by the FDA are not covered. If your doctor recommends a new or experimental therapy, you pay for it yourself or look for a clinical trial that covers the cost.
Out-of-network providers and services without prior approval
If you see a doctor or visit a hospital that is not in the Medicaid network, Medicaid will not pay unless you got approval in advance or it was a true emergency. An emergency room visit is covered even if the hospital is out of network, but a scheduled appointment with an out-of-network specialist is not. Before you make an appointment with a specialist, ask your primary care doctor whether the provider is in network.
Some services require prior approval — meaning the doctor must ask the state for permission before you have the procedure. These include certain surgeries, imaging tests, and hospital admissions. If your doctor orders a test or procedure without getting approval first, Medicaid may refuse to pay. Ask your doctor's office whether prior approval is needed before you schedule anything.
Medications and supplements that are not covered
Prescription drugs are covered by Illinois Medicaid, but not all of them. The state maintains a list of approved medications called a formulary. If your doctor prescribes a drug that is not on the list, Medicaid will not pay for it unless your doctor requests an exception. Over-the-counter medications — aspirin, cold medicine, antacids — are not covered. Vitamins, minerals, and herbal supplements are also not covered, even if a doctor recommends them.
Some prescription drugs require prior approval before Medicaid will pay. Your pharmacy will tell you if this is the case when you try to fill the prescription. Your doctor can request the approval, which usually takes a few business days.
Long-term nursing home care and strict asset limits
Medicaid does cover nursing home care, but only if you meet strict income and asset limits. In Illinois, you can have no more than $2,000 in countable assets to may have access to for nursing home coverage. If you have more than that, you must spend it down on medical care, living expenses, or other allowed costs before Medicaid will pay for the nursing home.
Your home and one vehicle are not counted toward the asset limit, but savings, investments, and other property are. If you are married, your spouse can keep more assets, but the rules are complex. Before you enter a nursing home, talk to a Medicaid planner or your local Area Agency on Aging about how to protect your assets while still getting coverage.
Medicaid also does not cover assisted living facilities or adult day care in the same way it covers nursing homes. Some assisted living may be covered under a special waiver program, but availability and rules vary by county. Call your local Department of Healthcare and Family Services office to ask what is available in your area.
Travel, transportation, and non-medical services
Medicaid does not cover the cost of traveling to a medical appointment, even if the appointment itself is covered. Some programs offer transportation information for people with disabilities or seniors, but this is separate from Medicaid and varies by county. Ask your case manager or local aging agency whether you may have access to for free or reduced-cost medical transportation.
Medicaid does not cover meals, home cleaning, yard work, or other non-medical support services. If you need help with daily living, you may may have access to for a separate program, but Medicaid itself does not pay for it. Some counties offer home and community-based services waivers that do cover some support, so ask your local office what is available.
Frequently Asked Questions
Does Illinois Medicaid cover dental work for adults?
No. Illinois Medicaid does not cover routine dental care, fillings, root canals, or extractions for adults. Children under 21 and pregnant women have some dental coverage. Adults can look for low-cost dental clinics or dental schools that offer reduced-price care.
Will Medicaid pay for glasses or contact lenses?
Not for adults. Children under 21 get one eye exam and one pair of glasses per year. Adults must pay for vision exams and eyeglasses themselves. Some community health centers offer discounted vision services based on income.
What happens if I see a doctor outside the Medicaid network?
Medicaid will not pay unless you got prior approval or it was an emergency. Emergency room visits are covered even out of network, but scheduled appointments are not. Always ask your doctor's office whether a provider is in the Medicaid network before you make an appointment.
Does Medicaid cover weight-loss surgery?
Only in specific cases. If you have severe obesity and related health problems, Medicaid may cover it, but you must meet strict medical criteria and get approval from the state before the surgery. Your doctor can request this approval.
Can I use my Medicaid to pay for vitamins or over-the-counter medicine?
No. Vitamins, minerals, herbal supplements, and over-the-counter medications are not covered by Medicaid. Prescription drugs are covered if they are on the state's approved list, but you may need prior approval depending on the drug.