What Does Meridian Health Plan Cover in Illinois?

Meridian Health Plan covers a full slate of Illinois Medicaid benefits at no cost to members: doctor visits, hospital care, prescriptions, dental, vision, behavioral health, maternity care, therapy, durable medical equipment, long-term services and supports, and non-emergency transportation.¹ There are no copays, deductibles, or premiums for covered services under the HealthChoice Illinois plan.

Medical and Preventive Care

Every member picks a primary care provider at enrollment. That PCP handles routine care, manages ongoing conditions, and makes referrals to specialists in the network.² Hospital services, home health care, and therapy are standard HealthChoice Illinois benefits.

Emergency room care is covered for life-threatening situations such as chest pain, difficulty breathing, severe burns, and uncontrollable bleeding. For things like ear infections, high fevers, sprains, and minor cuts when a PCP’s office is closed, in-network urgent care is covered.³ Meridian’s access standards require urgent or sick primary care visits to be available within 24 hours of a request.

Preventive care costs nothing out of pocket. Children under 21 are automatically enrolled in the state’s EPSDT program (branded as “Healthy Kids”), which covers well-child visits, growth and developmental screenings, hearing tests, immunizations, lab work, nutritional assessments, and specialist referrals.⁴ Dental screenings and vision tests for kids don’t need a referral.

Members can also use telehealth with in-network providers for non-emergency concerns like sinus problems, allergies, respiratory infections, colds, and skin issues.⁵ A 24/7 Nurse Advice Line is available at 866-606-3700.

Prescription Drugs

Prescriptions are free when filled at an in-network pharmacy. Coverage follows the Illinois Department of Healthcare and Family Services Preferred Drug List, which includes both prescription and over-the-counter medications, and the pharmacy network is managed by Express Scripts.⁶

Some drugs need prior authorization, some have quantity limits based on FDA guidelines, and some require step therapy, meaning the member tries a preferred medication first before the plan covers an alternative.⁷ A prescriber can request an exception through a prior authorization form if a Preferred Drug List medication isn’t effective, though exceptions cannot override state-level exclusions.

Mail-order service covers 90-day supplies of maintenance medications. Members on six or more prescriptions can enroll in the pill pack program, which delivers pre-sorted doses to their home.⁸ Reimbursement is available if a member pays out of pocket for a covered medication. Pharmacy Services can be reached at 855-580-1688.

Dental, Vision, and Hearing

Dental coverage includes two free oral exams and cleanings per year, with free transportation to and from the appointment.⁹ Children under 21 can get dental screenings without a referral.

Routine eye exams are covered annually. Adults 21 and older get one pair of eyeglasses (lenses and frames) every 24 months with no prior authorization needed.¹⁰ Replacements inside that window require prior authorization and must meet medical necessity criteria, such as a significant prescription change, post-cataract surgery needs, or damage that cannot be repaired. Children through age 20 can replace their glasses as needed without approval. The plan also covers treatment for eye diseases and injuries, custom artificial eyes, low vision devices, age-related macular degeneration treatment, and glaucoma screening for high-risk individuals (one per year).

For standard Medicaid members under 21, hearing screening and treatment, including hearing aids, are covered through EPSDT.¹¹ Adults with Medicaid only should check specific hearing benefits through Member Services; the richer hearing package (annual exam, yearly hearing aid fitting, one pair of hearing aids every three years) applies to dual-eligible members under Wellcare Meridian Dual Align.¹²

Behavioral Health and Substance Use

Mental health coverage includes inpatient psychiatric stays, partial hospitalization, intensive outpatient programs, and outpatient therapy, counseling, and medication management.¹³ Substance use services cover detoxification, residential treatment, and medication-assisted treatment.

Children under 21 diagnosed with autism spectrum disorder can access Adaptive Behavior Support services. The Pathways to Success program adds family peer support, intensive home-based therapy, respite care, therapeutic mentoring, and personal support for children with complex behavioral needs.¹⁴

Virtual therapy, psychiatry, and medication management are offered through providers like Brave Health, Chestnut Health Systems, Rosecrance, and Thresholds. Crisis services include mobile crisis response and the CARES line. Meridian does not cover hypnotherapy, biofeedback, experimental non-drug therapies, or transcranial magnetic stimulation for Medicaid members.¹⁵

Pregnancy and New-Baby Support

Pregnant members are assigned a MomCare Advocate who helps with scheduling, health planning, birth plans, and connecting with doulas or midwives.¹⁶ Members with higher-risk pregnancies (diabetes, high blood pressure, history of miscarriage, or premature births) get a care manager through the Start Smart for Your Baby program.

Several incentives are tied to prenatal and postpartum care:

$100 prepaid card for completing a Notification of Pregnancy form in the first trimester, or $50 in the second trimester.¹⁷
$50 prepaid card for a first-trimester prenatal visit, plus a choice of baby gear such as a car seat, stroller, or highchair.
$100 prepaid card for a postpartum provider visit within 12 weeks after delivery.
Up to $370 in incentives during the baby’s first year for checkups and immunizations.¹⁸

Maternity benefits also include prenatal and postpartum dental and vision care, blood pressure cuffs, glucose monitors, breast pumps, doula services for high-risk pregnancies, and behavioral health support.¹⁹ After delivery, the Ready to Grow program offers lactation support, physical and mental health check-ins, and help finding a pediatrician. Members can request a free at-home pregnancy test by mail.

Therapy, Equipment, and Transportation

Physical, occupational, and speech therapy are covered. Adults 21 and older can get up to 24 outpatient physical therapy visits per therapy type without prior authorization; anything beyond that is reviewed.²⁰ Services must be medically necessary, ordered by a qualified provider, and follow a written treatment plan. Maintenance programs, educational or vocational services, and work conditioning are generally not covered. Children under 21 are entitled to medically necessary habilitative therapy beyond standard limits under EPSDT.

Durable medical equipment, prosthetics, and orthotics are covered subject to medical necessity review and prior authorization, and must come from in-network suppliers.²¹

Non-emergency medical transportation is free for trips to provider offices, pharmacies, dental appointments, behavioral health visits, WIC offices, and DME vendors.²² Options include car or van service, bus tickets, mileage reimbursement for members who drive themselves, and non-emergency ambulance or stretcher transport. Rides should be scheduled at least three business days ahead, with short-notice exceptions for hospital discharges, dialysis, and chemotherapy. Book through the MTM Link app, mtm.mtmlink.net, or by calling 866-796-1165. Members 16 and older may ride alone.²³

Long-Term Services and Supports

Meridian administers Managed Long Term Services and Supports (MLTSS) for members who qualify through the Illinois Department on Aging or the Division of Rehabilitation Services. Coverage runs through five home and community-based waivers:²⁴

Elderly Waiver (Community Care Program) for people 60 and older who meet nursing facility level of care, covering adult day health, emergency home response, homemaker services, and transportation.
Persons with Disabilities Waiver for people under 60 with a physical disability, covering adult day care, home modifications, home health aide, homemaker, personal assistant, skilled nursing, therapy, respite, and specialized equipment.
Persons with Brain Injury Waiver, covering behavioral services, day habilitation, prevocational services, supported employment, and other community-based supports.
HIV/AIDS Waiver, covering home health aide, homemaker, nursing, personal care, therapy, and environmental adaptations.
Supportive Living Program for people with a disability aged 22 and older, or those 45 and older who would otherwise need a nursing facility, covering apartment-style housing with personal care, medication assistance, nursing, and social programming.²⁵

All MLTSS waiver services require prior authorization. MLTSS members also get a $10 monthly over-the-counter allowance, non-emergency transportation, behavioral health services, and the Nurse Advice Line.²⁶ Members choose whether to receive care in a nursing facility, a supportive living facility, or at home.

Rewards and Extra Programs

The Healthy Rewards program pays prepaid gift cards for completing preventive services like well-child visits and prenatal appointments.²⁷ Nutrition services include counseling, diabetic education classes, weight management programs (including a free Weight Watchers membership), and smoking cessation support. A disease management program adds support for chronic conditions like diabetes. Members in the Affinity Patient Coordination program receive pharmacist-driven care coordination.

Dual-Eligible Members

Members who qualify for both Medicare and Medicaid were previously served by the Meridian Medicare-Medicaid Plan. That plan ended December 31, 2025, and members were automatically enrolled in Wellcare Meridian Dual Align (HMO D-SNP) effective January 1, 2026.²⁸ It’s a Fully Integrated Dual Eligible Special Needs Plan with zero-dollar cost sharing: no premiums, deductibles, or copays. Benefits include comprehensive dental with a $4,000 annual maximum, routine vision exams and eyeglasses, hearing exams and hearing aids, and prescription coverage across a formulary of over 3,300 medications.²⁹

How to Enroll and Stay Enrolled

Meridian is a HealthChoice Illinois plan, so eligibility starts with Medicaid itself. Apply through the state’s Application for Benefits Eligibility portal at abe.illinois.gov.³⁰ Once approved, pick a primary care provider in Meridian’s network. Enrollment can be completed through the Illinois enrollment portal or by calling Illinois Client Enrollment Services at 1-877-912-8880. Members already in another HealthChoice Illinois plan can switch to Meridian during their annual open enrollment period.

Keeping coverage requires an annual renewal (redetermination). Each member has a unique renewal date, visible by logging into Manage My Case at abe.illinois.gov. When the notice arrives, there’s generally about one month to submit the renewal online, by mail, or by phone.³¹ Coverage stays active while the decision is pending. Not responding ends benefits automatically. Members found ineligible typically have 30 to 60 days to enroll in an alternative plan.

For general questions, Meridian Member Services is at 866-606-3700 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. CST.

1
Meridian Health Plan of Illinois is a Medicaid managed care plan that covers medical, dental, vision, behavioral health, pharmacy, and transportation services at no cost to members.
2
Members select a primary care provider when they enroll, and that PCP serves as the main point of contact for routine care, referrals, and ongoing health management.
3
For non-life-threatening issues when a PCP’s office is closed, members can visit in-network urgent care centers for conditions like ear infections, high fevers, sprains, and minor cuts.
4
For children under 21, the federal Early and Periodic Screening, Diagnostic, and Treatment program (called “Healthy Kids” in Illinois) provides comprehensive well-child visits that include growth and developmental screenings, hearing tests, immunizations, lab work, nutritional assessments, and specialist referrals.
5
Meridian also covers telehealth visits, allowing members to connect with in-network providers by audio and video or audio-only for non-emergency concerns like sinus problems, allergies, respiratory infections, colds, and skin issues.
6
Coverage is based on the Illinois Department of Healthcare and Family Services Preferred Drug List, which includes both prescription and over-the-counter medications. The pharmacy network is managed by Express Scripts and includes retail, mail-order, and specialty pharmacies.
7
Some medications require prior authorization before they can be dispensed, and certain drugs have quantity limits based on FDA guidelines. Members may also encounter step therapy requirements, meaning they need to try a preferred medication before the plan will cover an alternative for the same condition.
8
Mail-order pharmacy service is available for 90-day supplies of maintenance medications. Members taking six or more prescriptions may qualify for the “pill pack program,” which delivers pre-sorted medications directly to their home.
9
Members receive two free oral exams and teeth cleanings per year. Free transportation to and from dental appointments is also provided.
10
Adults aged 21 and older are eligible for one pair of eyeglasses (lenses and frames) every 24 months without prior authorization.
11
For standard Medicaid members under 21, hearing screening and treatment, including hearing aids, are covered through the EPSDT benefit.
12
Under the Meridian Medicare-Medicaid Plan (now transitioned to Wellcare Meridian Dual Align for dual-eligible members), hearing exams to diagnose and treat hearing and balance issues are covered at no cost, including one routine hearing exam per year. Hearing aid fitting and evaluation are covered once per year, and one pair of hearing aids is covered every three years.
13
Covered behavioral health services include inpatient psychiatric hospital stays, partial hospitalization, intensive outpatient programs, and outpatient therapy, counseling, and medication management.
14
The Pathways to Success program covers additional services for children with complex behavioral needs, including family peer support, intensive home-based therapy, respite care, therapeutic mentoring, and personal support.
15
Meridian does not cover hypnotherapy, biofeedback, experimental non-drug therapies, or transcranial magnetic stimulation for its Medicaid members.
16
The MomCare Connect program assigns each expecting member a dedicated MomCare Advocate who helps with appointment scheduling, health planning, birth plans, and connecting with doulas or midwives.
17
Members can earn a $100 prepaid card for completing a Notification of Pregnancy form in the first trimester ($50 in the second trimester)
18
A $100 prepaid card is available for completing a postpartum provider visit within 12 weeks of giving birth, and up to $370 in incentives is available during the baby’s first year for completing checkups and immunizations.
19
Covered maternity services also include prenatal and postpartum dental care, vision services, medical equipment like blood pressure cuffs, glucose monitors, and breast pumps, doula services for high-risk pregnancies, and behavioral health support including therapy and crisis intervention.
20
For outpatient physical therapy, members aged 21 and older can receive up to 24 visits per therapy type without prior authorization. Requests beyond that threshold require additional review.
21
Meridian covers durable medical equipment, prosthetics, and orthotics as part of its Medicaid benefits. These items are subject to medical necessity review and prior authorization. Members must use in-network DME suppliers
22
Non-emergency medical transportation is covered at no cost for trips to provider offices, pharmacies, dental appointments, behavioral health visits, WIC offices, and durable medical equipment vendors.
23
Members 16 and older may ride alone. Gas reimbursement is available for members who drive themselves, with requests accepted up to 30 days in advance.
24
The plan coordinates benefits under five Medicaid home and community-based waivers
25
Supportive Living Program: For individuals with a disability aged 22 and older, or those 45 and older who would otherwise require a nursing facility. Covers apartment-style housing with personal care, medication assistance, nursing services, and social programming.
26
Additional benefits for MLTSS members include a $10 monthly over-the-counter product allowance, non-emergency transportation, behavioral health services, and access to the 24/7 Nurse Advice Line.
27
The Healthy Rewards program provides prepaid gift cards for completing preventive services like well-child visits, prenatal appointments, and other health milestones.
28
That plan ended on December 31, 2025, and members were automatically enrolled in the Wellcare Meridian Dual Align (HMO D-SNP) effective January 1, 2026.
29
Benefits include comprehensive dental coverage with a $4,000 annual maximum, routine vision exams and eyeglasses, hearing exams and hearing aids, and prescription drug coverage across a formulary of over 3,300 medications.
30
To enroll, individuals must first apply for Medicaid benefits through the state’s Application for Benefits Eligibility portal at abe.illinois.gov.
31
When notified, members generally have about one month to submit the renewal form online, by mail, or by phone.