* Flashback to May 27, 2020…

Illinois will become the first state to provide Medicaid for undocumented seniors not only because of what state Rep. Delia Ramirez has heard from her constituents, but because of her own family’s experience.

Tucked in near the end of the 465-page budget implementation bill that passed the Illinois General Assembly late Saturday night was a provision giving Medicaid access to noncitizens over 65 years old and whose income is $12,670 or less, which is at or under the federal poverty level.

Gov. JB Pritzker said he will approve next year’s budget and its implementations. Medicaid services for qualified undocumented seniors will kick in July 1 when the 2021 budget year begins.

The expansion was a big win for the Legislative Latino Caucus, which Ramirez took lead on the effort through the health and human services working group leading up to the special session. She said the coverage will save the state money in the long run, costing about $2 million, which in her opinion, “is nothing to a $2 billion Medicaid bill.”

Emphasis added because cost and enrollment have always been extremely tough to predict, partly because not enough is known about the folks who are eligible and whether they’d even apply. That $2 million prediction was widely believed at the time, but the Fiscal Year 2021 cost for the senior program turned out to be $67 million and it doubled a year later and more than tripled by FY23.

* People ages 42-64 were added during the Fiscal Year 2022 budget. First-year costs were about $52.5 million. The following year, in FY23, costs rose 725 percent to $433 million. Total costs for all age groups was $644 million by that time, up from $187 million the year before.

And that’s when this happened…

On June 16th, 2023, Illinois Department of Healthcare and Family Services abruptly announced that enrollment for the Health Benefits for Immigrant Adults (HBIA) program, which provides vital health coverage for Illinois immigrants ages 42-64, will be paused effective July 1. The notice also permits co-pays and reduced reimbursements to hospitals. One of the largest parts about HBIA and HBIS was that this Medicaid-like health insurance provided access to healthcare coverage with $0 premiums and $0 co-payments. With the changes that have been made, no new applicants of HBIA or HBIS will be accepted and those who are currently covered by these programs will have $250 co-pays for inpatient hospitalization, $100 co-pays for emergency room visits and will be charged 10% of the department rate for hospital or ambulatory surgical treatment center outpatient services.

Those changes were authorized by SB1298.

The actions stopped the rapid cost increases, and enrollment fell…

In FY21, 6,884 individuals were enrolled in HBIS (65+). HBIS (65+) enrollment increased to 11,362 in FY22, 15,831 in FY23, and decreased to 11,464 in FY24. The HBIA (55-64) enrollment increased from 6,675 in FY22, to 17,024 in FY23, before decreasing to 13,596 in FY24. The HBIA (42-54) enrollment increased from 5,823 in FY22, to 36,912 in FY23, before decreasing to 27,941 in FY24.

And by this past December, total projected costs for Fiscal Year 2025 were down to $558 million, with total enrollment plunging from about 70,000 at its height in FY23 to 41,505.

* Even so, the costs were still far too high. During his budget address, the governor proposed eliminating the program for everyone but the seniors…

Gov. JB Pritzker’s recently unveiled 2026 budget proposal includes a controversial cut.

It proposes to get rid of two programs that allow immigrants without legal status to receive healthcare coverage, specifically impacting undocumented adults aged 42 to 64. However, coverage for those 65 and older will remain intact.

The move has sparked backlash from the General Assembly’s Latino Caucus, as well as pro-immigrant advocacy groups.

If the HFS projected costs for this fiscal year holds up, getting rid of coverage for the 42-64 age cohort would save the state $419 million, leaving a $139 million cost for seniors, although that will likely fall too because entry is still cut off.

* The governor’s office undoubtedly knew the recent audit findings were published before he made those proposals. The Auditor General must submit his reports to agencies and allow them to respond. HFS responded on January 21st, so it had the report on-hand long before the governor’s budget address on February 19th.

The report focused on two things: Actual enrollment and costs far exceeded initial projections; And…

During a review of the enrollment data, auditors identified 6,098 enrollees designated as “undocumented” who also had a Social Security Number. Auditors provided the 6,098 enrollees to HFS asking whether enrollees classified as undocumented enrollees should also have a Social Security Number. HFS officials reviewed and provided responses for a sample of 94 enrollees. Auditors determined that 19 of the 94 should have been recorded in the system as lawfully present or as being a legal permanent resident, not undocumented. This is an important distinction as after five years in the country, legal permanent residents become eligible for Medicaid and thus the State would receive federal matching dollars.

Auditors identified 688 enrollees who were enrolled in the HBIS (65+) program who were not 65 years of age or above. These 688 exceptions were provided to HFS for comment. After HFS’s review of 151, it was determined that 79 were signed up in error. Many of the errors occurred from incorrect birthdates provided by the enrollee, which were later corrected when documentation was provided.

During a review of the enrollment data, auditors identified 394 enrollees who appeared to have been enrolled in HBIS or HBIA after they had been in the country legally for over five years. These individuals are eligible for Medicaid, thus the State would receive federal matching dollars. These exceptions were provided to HFS for review and comment. HFS reviewed a sample of 17 and determined that 13 were approved incorrectly. Allowing ineligible enrollees in State-only funded programs should be avoided when possible.

HFS pledged to strengthen its internal controls. We’ll see.