Questions and Answers About
Medicaid Spend-Down
Elderly and disabled persons, some families, and most children are
eligible for Medicaid depending on their incomes and assets.
Many people are unsure what their medical benefits are under the
Medicaid Spend-Down Program. The information provided here applies to
general situations and is not meant to be legal advice or to replace
advice from a lawyer.
What is a spend-down?
Does having a spend-down mean that I am ineligible for
Medicaid?
Why do some people have a Medicaid spend-down while some do
not?
How is my spend-down calculated?
How can they expect me to live on $$$ per month?
How do I meet my spend-down?
Can I use an old medical bill to meet my spend-down?
Should I give my medical bills to my Public Aid caseworker as
soon as I get them?
Does the spend-down have to be applied to the current month
or can it be used for future months or past months?
What if my bill is more than the amount of my spend-down?
What types of expenses can I use to meet my spend-down?
Public Aid recently terminated my Medicaid case. Why?
What should I do if I have further questions about my
spend-down?
Your Local Legal Services Office
What is a spend-down?
Back
A spend-down is similar to a deductible under a conventional insurance
policy.
Does having a spend-down mean that I am ineligible for
Medicaid?
Having a spend-down does not mean that you are ineligible for medical
assistance, but means that you will get a medical card only after you show
the Department of Public Aid that you have met the spend-down amount.
Why do some people have a Medicaid spend-down while some
do not?
If your income is low enough, you will not have a spend-down and you will
automatically qualify for a medical card every month. However, if your
income is above the required amount, you will qualify for a medical card
only for the months when you meet the spend-down requirement.
How is my spend-down calculated?
Back
Your spend-down is based on your monthly income. From that income, your
caseworker will subtract the "allowable income standard" and a
"monthly income disregard" of $25. The monthly income standard
is the amount that the Medicaid program allows for the household to use
for expenses other than medical. The amount that remains is considered to
be available for you to use for medical expenses. That is your spend-down
amount. For example, if your monthly income is $500 from Social Security
Retirement benefits and you live alone, your spend-down will be $192. It
is calculated in the following way:
| Income |
|
$500 |
| Less income standard for a household of one |
|
$283 |
| Less monthly income disregard |
|
$ 25 |
| Spend-down amount |
|
$192 |
How can they expect me to live on $308 [$283 + $25] per
month?
Unfortunately, the income standard has not been revised in some time and
has not kept up with rising costs. Until the current law is changed, this
amount (formula) is not negotiable. This is one of the most problematic
aspects of the spend-down program.
How do I meet my spend-down?
Back
You meet the spend-down amount by incurring (not necessarily paying)
medical bills in the amount of your spend-down. This means that as soon as
you have medical bills totaling $192, you can meet your spend-down, even
though you may not be able to pay all of those bills as yet. It is very
important, therefore, that you keep copies of all medical bills,
prescription receipts, and records of other medical expenses. When you
accumulate enough bills to meet your spend-down, submit copies of the
bills to your caseworker in the local Public Aid office. These will then
be processed so that you can receive a medical card.
Can I use an old medical bill to meet my spend-down?
Yes, if the bill is for services or medications purchased within the past
six months. In some cases, you can use a bill which is older than six
months if the bill is re-issued and you are still obligated to pay it
(provided that you were eligible for Medicaid at the time the bill was
incurred). However, you may not use the bill more than once to meet your
spend-down. That is, if you use an old hospital charge this month to meet
your spend-down, you cannot again use the unpaid portion next month.
Should I give my medical bills to my Public Aid
caseworker as soon as I get them?
Back
The answer depends on several things. Using the above example, you may
wish to submit the medical bills once you reach the $192 amount. Having
submitted those, you have met the spend-down for one month. Then you face
a new decision - which month? You can tell your caseworker to apply the
spend-down in several different ways. You should choose the option that is
most advantageous to you. It is very important that you communicate with
your caseworker in order to assure that Public Aid applies the spend-down
in the way you choose.
Does the spend-down have to be applied to the current
month or can it be used for future months or past months?
The answer is, it can be used for present, future, or past months. You
need to look closely at your situation to determine which option is best
for you.
Using a spend-down of $192 as an example, let's assume that on
January 15, 1999, you accumulate medical bills from the last three months
that total $192. These are your options:
- Current Month: You can submit them to your caseworker at that
time and obtain a medical card for January. However, because a medical
card is only valid for one month and it is now the middle of the
month, you will obtain the benefits of that medical card for only 16
days. This may be your best option if you have an expensive medical
procedure scheduled for later in the month. Because you have met your
spend-down, Medicaid will cover the full cost of most medical expenses
for the remainder of that month. Or, you may need refills on your
medication and have no other money available for that purpose.
- Future Month: You can submit the bills to your caseworker and
ask the worker to apply them to the month of February. This way, on
February 1, you will receive a medical card in the mail which will be
valid for the full month. If you have been waiting to schedule surgery
or another medical procedure, you can schedule it for February when
Medicaid will cover the full cost.
- Past Month: In the event you have another large medical bill
for a past month, for example an in-patient hospitalization in
December of 1998, which is over and above the bills used to meet the
spend-down, you can ask for a medical card for December and have
Medicaid pay for that bill in full.
What if my bill is more than the amount of my
spend-down?
Back
Again, you have several options to choose from. The one you choose depends
on your individual situation:
- You can use the first $192 (or whatever your spend-down amount is)
to meet your spend-down for the current month. Because you now become
Medicaid eligible, Medicaid will pay the remainder of the bill (up to
their maximum payment level) and most other medical expenses for the
current month. This may be your best option if the bill is a large
one, such as for an in-patient hospitalization.
- If your goal is to meet your spend-down for the current month and a
later month, you can split the bill. That is, you can use the first
$192 (or whatever your spend-down amount is) to meet your spend-down
for the current month. The remainder of the bill will not be paid by
Medicaid, but will be used to meet your spend-down for future months.
Let's again take the example of the person above with the $500 per month
income. Let's assume that on January 3, 1999, she goes to the emergency
room of her local hospital and incurs a bill of $425.
If the person follows option number 1 above, she will be responsible to
the hospital for $192 of the $425 bill. Medicaid will pay the rest. After
she submits the bill to the Deparment of Public Aid, she will receive a
medical card for the remainder of the month of January.
If she follows option number 2 above, she will be responsible to the
hospital for the full $425. However, she can obtain a medical card for
January and February because she has met the $192 spend-down for two
months. In addition, she can apply $41 toward her spend-down for March or
a later month (within six months, or through June of 1997).
| Hospital bill |
|
$425 |
| Less January spend-down |
|
$192 |
| Less February spend-down |
|
$192 |
| Applied to March |
|
$ 31 |
What types of expenses can I use to meet my spend-down?
Back
In addition to physician and hospital services and medications, some other
expenses that can be used to meet your spend-down are: cost of travel to
obtain medical care (when Medicaid is not directly paying for travel),
Medicare and other medical insurance premiums, deductibles or other
insurance co-payments, some dental expenses, many in-home care services,
and over-the-counter medicines when prescribed by a physician.
Public Aid recently terminated my Medicaid case. Why?
Due to a recent procedural change, the Department of Public Aid has
decided to terminate all spend-down cases where the spend-down was not met
for three consecutive months. However, that should not discourage clients
from re-applying at the time they have sufficient bills to meet the
spend-down. Because of Medicaid's backdating provisions which allow
coverage for up to three full months preceding the month of application,
you can also re-apply after you incur a medical expense that is sufficient
to meet your spend-down.
What should I do if I have further questions about my
spend-down?
Back
You can call your local Prairie State Legal Services office or contact
your caseworker at the Illinois Department of Public Aid.
Your Local Legal Services Office
Land of Lincoln Legal Assistance Foundation Legal Services For The
Elderly Project:
Champaign Office - Serving
Champaign, Ford, and Vermillion Counties
1817 South Neil
P.O. Box 1278
Champaign, IL 61824
(217) 356-1351 / (217) 442-4141 / (800) 747-5523
Decatur Office - Serving
DeWitt, Macon, Moultrie, Piatt, and Shelby Counties
601 Millikin Court P.O. Box 1722
Decatur, IL 62525
(217) 423-0516 / (800) 747-2099
Prairie State Legal Services:
Back Bloomington - Serving
Livingston and McLean Counties
102 North Center Street, #405
Bloomington, IL 61701
309/827-5021 / 800/874-2536
Carol Stream - Serving
DuPage County
350 South Schmale Road, #150
Carol Stream, IL 60188
630/690-2130 / 800/690-2130
Kankakee - Serving
Iroquois, Kankakee, and Kendall Counties
191 South Chicago Avenue
Kankakee, IL 60901
815/935-2750 / 800/346-2864
Ottawa - Serving
Bureau, Grundy, LaSalle, Lee, and Putnam Counties
613 LaSalle Street
Ottawa, IL 61350
815/434-5903 / 800/892-7888
Peoria - Serving
Back
Marshall, Peoria, Tazewell, and Woodford Counties
331 Fulton, #600
Peoria, IL 61602
309/674-9831 / 800/322-2280
Rockford - Serving
Boone, Carroll, Jo Daviess, Ogle, Stephenson, and Winnebago Counties
975 North Main Street
Rockford, IL 61103
815/965-2902 / 800/892-2985
Rock Island - Serving
Henry, Mercer, Rock Island, and Whiteside Counties
208 - 18th Street, #202
Rock Island, IL 61201
309/794-1328 / 800/322-9804
St. Charles - Serving
Back
Kane and DeKalb Counties
10 East State Avenue, #102
St. Charles, IL 60174
630/232-9415 / 800/942-4612
Waukegan - Serving
Lake and McHenry Counties
415 West Washington Street, #002
Waukegan, IL 60085
847/662-6925 / 800/942-3940
Prairie State Legal Services, Inc. is a private
not-for-profit organization offering legal assistance at no charge to
persons age 60 and older and low income persons regardless of age. Legal
advice is available by telephone in a wide range of matters. Legal
representation is focused on issues involving medical assistance, elder
abuse, governmental income programs, housing problems, some family
matters, and other problems that affect people's ability to meet their
basic needs or make important decisions in their lives.
This booklet was prepared through special funding under Title III-F of
the Older American's Act by East Central Illinois Area Agency on Aging and
special funding from Central Illinois Agency on Aging. Funding for the
printing of this publication was provided by East Central Illinois Area
Agency on Aging, Central Illinois Agency on Aging, the Illinois Bar
Foundation, and the Laurie J. Cohen Memorial Fund of Prairie State Legal
Services, Inc.
Prairie State Legal Services, Inc. is funded by Central Illinois Agency
on Aging, East Central Illinois Area Agency on Aging, Northeastern
Illinois Area Agency on Aging, Northwestern Illinois Area Agency on Aging,
and Western Illinois Area Agency on Aging to serve persons age 60 and
older. Prairie State is a United Way agency.
Prairie State Legal Services, Inc. does not discriminate
in admission to programs or treatment of employment in programs or
activities in compliance with the Illinois Human Rights Act, the U.S.
Civil Rights Act, Section 504 of the Rehabilitation Act, the Age
Discrimination Act, the Age Discrimination in Employment Act, and the U.S.
and Illinois Constitutions. If you feel you have been discriminated
against, you have a right to file a complaint. For information, contact
the Managing Attorney of your local Prairie State Legal Services office.
The information in this booklet is current as of September 1, 1998.
A United Way Agency
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