Medicare and Medicaid sound similar but work very differently. Confusing them costs Illinois families thousands of dollars and weeks of unnecessary delay. Here's a clean breakdown — and where home health fits into each.

The fundamental difference

Medicare is a federal health insurance program based on age (65+) or disability (regardless of income). If you've worked and paid Medicare taxes for 10+ years (or your spouse has), you're eligible at 65.

Medicaid is a joint federal-state program based on financial need. In Illinois, it's administered by HFS through managed care organizations.

Many Illinois seniors qualify for both — that's called dual eligibility, and it's one of the most powerful coverage combinations available.

Medicare home health

Medicare pays 100% of approved home health when the four conditions are met (doctor's order, homebound, intermittent skilled need, certified agency). No copay. No deductible. No maximum visit cap.

What Medicare home health does NOT cover:

  • 24/7 care
  • Custodial-only care (bathing, dressing, meal prep) without a skilled need
  • Homemaker services
  • Meal delivery (though some MA plans add this)

Illinois Medicaid home health

Illinois Medicaid covers home health for income-eligible adults (typically under 138% of the federal poverty level for adults under 65) and for seniors with limited assets. It also covers care for children with disabilities under EPSDT and for adults under various waiver programs (Community Care Program, Persons with Disabilities Waiver, etc.).

Medicaid is often more flexible than Medicare for:

  • Personal care hours
  • Long-term home support
  • In-home services for chronic conditions

Dual eligibility — when both apply

If your loved one qualifies for both, Medicare pays first as primary insurance and Medicaid pays second as secondary. The result: virtually no out-of-pocket cost for covered services, plus expanded aide hours and personal care that Medicare alone doesn't cover.

Spend-down rules

If your income is slightly above Medicaid eligibility, Illinois has a "spend-down" process that lets you qualify after deducting medical expenses. Optimum's medical social worker can help families navigate this.

How to apply

  • Medicare: Apply at SSA.gov or call 1-800-772-1213. Effective the first of the month you turn 65.
  • Medicaid: Apply at ABE.illinois.gov (Application for Benefits Eligibility) or call 1-800-843-6154.

What home health agencies need from you

When you call Optimum, have ready: insurance cards (front and back), the ordering doctor's name and number, the hospital discharge summary if recent, and a list of current medications. We handle the rest of the verification.

Call (773) 878-8738 — coverage verification in 24 hours, no commitment.