By JERRY NOWICKI
Capitol News Illinois
jnowicki@capitolnewsillinois.com

Gov. JB Pritzker’s administration will pause enrollment in a state-funded health care program for certain immigrants aged 65 and older beginning Nov. 6 – the fulfillment of a previously announced plan to cap spending on the program. 

It’s an expected move that the administration announced in June to control the rising costs of a program that has proven more expensive than its initial estimates since it became law in 2020. While no new enrollees will be accepted for the time being, those already in the program will not see any changes to their current benefits.

The Health Benefits for Immigrant Seniors program provides state-funded Medicaid-like benefits to individuals who would qualify for the federal program based on their income levels if not for their immigration status. That includes individuals in the U.S. without legal permission and those who have obtained a green card but not yet completed a five-year waiting period making them eligible for federal benefits. An associated state program – Health Benefits for Immigrant Adults – provides similar benefits to noncitizens aged 42-64. 

But unlike traditional Medicaid, which is jointly funded with state and federal money, the immigrant health care programs are funded almost entirely with state dollars due to federal reimbursement limitations for noncitizens. 

Together, lawmakers allocated $550 million to fund those programs in fiscal year 2024, which began July 1. Lawmakers also gave the Pritzker administration authority to take action through the state’s administrative rulemaking process to keep spending at those levels. 

Wielding that authority shortly after signing the bill, Pritzker capped HBIA enrollees as of July 1 and announced a 16,500 cap on HBIS enrollees – a threshold the Department of Healthcare and Family Services expects to hit early next month. 

Read more: Pritzker quickly wields expanded authority to freeze noncitizen health care enrollment 

But the latest cost estimates from HFS show that those caps – combined with administrative delays in launching copay and co-insurance requirements for enrollees – have failed to control program spending. 

An analysis dated September 2023 from the HFS website shows the program is expected to cost $831 million in FY 2024, more than $280 million beyond the allocated amount. That estimate was based on total program enrollment of nearly 69,000 individuals with a per-patient-per-month cost estimate provided by the actuarial firm Milliman, which contracts with the department. 

While the latest estimate exceeds the budgeted amount, it’s nearly $300 million below a May estimate from the Pritzker administration that projected program cost could grow to $1.1 billion without cost-saving measures. 

Read more: Expected cost for Illinois’ noncitizen health care program grows to $1.1 billion 

The advocates behind the push for the noncitizen health care programs – most notably the Illinois Legislative Latino Caucus – have long argued that providing health care, especially preventative care, to immigrant populations would be cheaper than making them dependent on emergency room visits. 

The Healthy Illinois Campaign – an advocacy coalition that’s another main backer of the programs – has also long referred to health care as a human right. They took to social media Thursday to encourage eligible enrollees to apply for the program prior to the cap taking effect. 

“While expected, today’s announcement is still a disappointing step backwards from the collective progress our state has made around health care access,” Healthy Illinois Campaign Director Tovia Siegel said in a statement. “The HBIS program provides vital, lifesaving health care services to thousands of vulnerable older adults across Illinois.”

She said the move will “significantly diminish the state’s ability to care for its elderly residents” and urged the administration to “continue to work with advocates and community organizations to find fiscally responsible solutions” while protecting health care access for those enrolled in the program.

But the administration has noted that the costs are greater for new enrollees in the programs because they have often gone long periods without preventative care. While it is expected that individual patients’ costs will level out as they receive routine care, growing enrollment means the expensive first-time costs continue to grow as well. 

“Compared with the traditional Medicaid population, month-over-month enrollment has grown at a higher rate, and per-enrollee costs have tracked higher among the HBIA and HBIS-enrolled populations due to more prevalent, untreated chronic conditions and higher hospital costs, pushing the limit of the funds made available for these programs for the current fiscal year,” HFS said in a statement. 

Before a legislative rulemaking oversight committee earlier this week, HFS attorney Omar Shaker said the department remains in discussions with the federal government to implement copay and cost-sharing measures. 

Initially scheduled to go live on July 1, the copays would have cost $250 for inpatient hospitalizations and $100 for an emergency room visit. Enrollees receiving certain outpatient services at hospitals or surgical centers would be subject to 10 percent coinsurance, which the department said at the time “could range from $3.70 to $202.95, depending on the service received.”

Read more: Copay requirements paused for noncitizens on state health plan 

But early last month, the administration paused those requirements to ensure they don’t jeopardize federal matching dollars for services that are subject to reimbursement, such as emergency room care. Providers who had collected copays were instructed to return them. 

Shaker told the Joint Committee on Administrative Rules this week that the department would like to reinstate the copay and coinsurance measures, possibly as early as Jan. 1. But he acknowledged that the new rules authorizing them might not be ready by that date. 

As of Jan. 1, however, he said he did expect the department to begin a “coordinated effort” to involve managed care organizations in the provision of the health care program. That’s a state system that involves private insurers in the Medicaid program, ensuring patients receive regular checkups and follow-up care. 

Shaker said the department expects that move to further lower program costs. 

Capitol News Illinois is a nonprofit, nonpartisan news service covering state government. It is distributed to hundreds of newspapers, radio and TV stations statewide. It is funded primarily by the Illinois Press Foundation and the Robert R. McCormick Foundation, along with major contributions from the Illinois Broadcasters Foundation and Southern Illinois Editorial Association.