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Monroe County Legal Assistance Corporation
What is a Medicaid
Spend Down and how does it work?
Some people have too much
income to qualify for Medicaid. This amount is called excess
income. Some of these people may qualify for Medicaid if they
spend the excess income on medical bills. This is called a spend
down.
For example, a person
over 65 is denied Medicaid because her monthly income is $50 more than
the limit for Medicaid eligibility. If she incurs medical bills of
$50 per month, the rest of her medical bills will be covered by
Medicaid. The spend down in this case is the $50 of medical bills
she incurs
.
Who can get a spend
down?
Not everyone. You
must be in one of the groups listed below:
-
Child under 21 years
of age
-
Adult over 65 years
of age
-
Disabled or blind
-
Families with one or
both parents absent, dead, disabled or out of work.
How does a spend
down work?
It works almost like a
deductible for car insurance. When you have accumulated medical
bills (paid or unpaid) greater than you excess income, you will get
Medicaid for that month. You are responsible for the bills up to
the excess amount; Medicaid will only pay those bills over the excess
amount.
If you have been
hospitalized recently, you may qualify for Medicaid for up to 6 months.
If you have been hospitalized within the past 6 months, be sure to tell
your worker.
What medical bills
can be counted toward a spend down?
$
Your own medical bills
$
Your spouse's medical bills
$
Parent's bills for their children's spend down
$
Bills of a child living with you
$
Bills of a child who does not live with you, but whose medical bills
you help pay for
$
Past unpaid medical bills (sometimes up to 6 years old) for yourself
or any of the people named above.
$
The part of any medical bill not coverend by Medicare or private
insurance.
$
Medical expenses (including insurance premiums) paid for you by
certain public programs, for example, the Elderly Pharmaceutical
Insurance Program (EPIC) and the Child Health Insurance Program
(CHIP).
What types of
medical expenses count toward spend down?
Many
types, including:
$
Paid and unpaid medical bills from previous months.
$
Transportation expenses to get medical services (sometimes).
$
Medical expenses or payments to therapists, day treatment, drug and
alcohol programs, nurses, personal care attendants, and home health
aides (as required by a physician).
$
Prescription drug bills.
$ Payments made
toward surgical supplies, medical equipment, prosthetic devices,
hearing aids, and eye glasses (as ordered by a physician).
Are there others
that count?
Yes, the following
medical expenses also count toward a spend down, although Medicaid will
not pay for them:
$
Medical services not covered by Medicaid.
$
Medical services from providers who do not participate in the Medicaid
program
$
Some over-the-counter drugs and medical supplies, such as bandages and
dressings, if they have been ordered by a doctor or are medically
necessary.
$
Bills for cosmetics and other non-medical items DO NOT count
How do you know if
you qualify for a spend down?
If you have been denied
full coverage under the Medicaid Program, the notice MCDSS must send you
will tell you if you qualify for a spend down and, if so, how much the
spend down for medical expenses needs to be. |
