What Is Medicaid With A Spenddown

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Past Paid Medical Bills

What Does Medicaid âSpend Downâ? Mean?

Past paid medical bills may be used if the medical services were provided and paid for within the three calendar months before the month you applied for Medicaid with excess income. They may be applied to meet your excess income for up to six months beginning in the month you applied, and sometimes beginning up to three months before you applied, if you want “retroactive coverage” for Medicaid to pay your recent medical bills.

Bills paid by EPIC or ADAP in the three months before the month in which you applied for Medicaid may be used to meet your excess income.

  • Example 1: You paid your 17-year old child’s dental bill in June for dental care provided in May. You have your own unpaid medical bills in the months of June and July. You apply for Medicaid in August. You may use the paid dental bill toward your excess income beginning in the month of June.
  • Example 2: Each month EPIC has been paying $100 for your prescriptions and you have been paying your $20 co-payment. In October you apply for Medicaid. You have no unpaid medical bills. You are determined eligible for Medicaid and your case is opened effective October 1 with a $50 monthly excess income. Since you do not need coverage in the three month retroactive period , the paid amount of $360 can be used to meet your excess income for six months . The $60 balance will be lost as paid bills can only be used up to a maximum of six months.

Supplemental Needs Trusts And Medicaid Spenddown

Can I use a SNT to meet my spenddown?

For some people, an SNT is a good option to avoid having a spenddown. An SNT requires monthly management and has yearly and monthly costs. An SNT works like a special kind of bank account where you deposit your spenddown amount into the SNT each month. An SNT eliminates your spenddown because the LDSS will not count any money you place in the trust when calculating your eligibility for Medicaid.

What are the requirements for SNT?

  • You must be certified disabled by the Social Security Administration or by the New York State Office of Temporary and Disability Assistance.
  • The money in the trust cannot be withdrawn as cash and must be used for your benefit only. You can direct the trust to pay for your regular expenses, such as rent to your landlord, directly from your trust account.
  • The money that is left in the trust after you die must go to the State or to the charitable organization that established the trust this is called the payback requirement.
  • The trust must be irrevocable, meaning that once you establish the trust, you cannot later dissolve it. This means you cannot take all the money out of the trust if you change your mind. However, if you no longer wish to participate in an SNT, you can still spend the money already in the SNT on expenses for yourself and stop depositing money into the trust.

Where can I set up an SNT?

Are there drawbacks to using an SNT?

What Is The Medicaid Excess Income Program

The Medicaid Excess Income program is sometimes referred to as the “Spenddown program” or the “Surplus Income program”. Here we will be referring to it as the Excess Income program.

If your monthly income is over the Medicaid level, you may still be able to get help with your medical bills. The amount your income is over the Medicaid level is called excess income. It is like a deductible. If you are eligible for Medicaid except for having excess income and you can show that you have medical bills equal to your excess income in a particular month, Medicaid will pay your additional medical bills beyond that for the rest of that month. This includes outpatient care, doctor and dental visits, lab tests, prescription drugs, and long-term care in the community such as home care and assisted living. There are special rules for hospital stays which is explained further below.

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Inpatient/hospital Care And Services

  • If you need hospital care or need help paying your hospital bills, you may be able to get Medicaid inpatient services, in addition to the outpatient care described above. You must have medical bills that are at least equal to your monthly excess income amount for six months. These bills can be paid or unpaid. They can also be for medical services other than hospital care.
  • Once your medical bills are at least equal to your excess income amount for six months, you must bring or send these bills to your local department of social services. You will then receive Medicaid for six months.

What If I Need Help Gathering And Submitting My Bills Or If It Is Difficult For Me To Travel To The Medicaid/dss Office Every Month

Medicaid Spend Down : Advice, tips and support for family caregivers ...

People with disabilities who find it difficult to go into a DSS/Medicaid office have a right to fax in bills as a reasonable accommodation for a disability. In some districts, including New York City, anyone can fax in their bills. Ask your caseworker for a fax number and fax cover sheet, or for another procedure to accommodate your disability. The fax number in New York City is 917-639-0645. If you fax bills, you must include your name, case and CIN number, the amount of your excess income, and say which month you want coverage. If you need help with producing your bills because of a disability, you can contact your local department of social services to see what reasonable accommodations can be made.

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How Does The Medicaid Spenddown Program Work

Each month, in order to get Medicaid coverage, you have to meet your spenddown. You may do this in two ways:

Paying the amount of your spenddown directly to your LDSS through the Pay-In Program. You may pay for one to six months of coverage at a time. If you pay between one and five months of coverage, you will have Medicaid coverage for all outpatient services for that number of months. If you pay for six months of coverage, you will have Medicaid coverage for all outpatient and inpatient services for the next 6 months.*

Submitting medical bills to your LDSS that are equal to or greater than your spenddown amount. How the bills are treated by the Spenddown Program depends on the type of bill you submit:

You will want to submit paid or unpaid bills by the first week of the month during which you are requesting coverage. By meeting your surplus early in the month, you can receive Medicaid coverage for the remainder of the month with no out-of-pocket expense.

*If you do go into the hospital when you have not paid for six months of coverage, inpatient coverage can still be activated at that point.

S Before Spending Down Assets

Prior to developing a Medicaid Spend Down plan, families should take the following steps.

Mind the Look-Back PeriodAn applicant over the limit has the option to spend down their assets in order to become Medicaid-eligible, though the process can be complicated and the applicant must always consider the look-back period, which is a timeframe that will be reviewed by Medicaid officials to make sure applicants have not spent assets in a way that violates Medicaid rules, such as large-sum cash gifts or selling items at less than market value.

Determine Your Asset LimitThe first step of spending down assets is to determine the applicants asset limit and then figure out how much must be spent down. Asset limits for Medicaid programs, even those programs that primarily serve elderly individuals, are complicated. Most state Medicaid programs have a blanket figure for a single person and a married couple , but many other factors must be weighed.

Its crucial to understand ones asset limit before applying for Medicaid Long Term Care programs, because a mistake will lead to denial of benefits, and appealing a denial is time-consuming and difficult.

The CSRA is usually an option for married couples with one spouse applying for Nursing Home Medicaid or a Home and Community Based Services waiver. When one spouse applies for Aged, Blind, and Disabled Medicaid, however, the CSRA is not applicable, and the couples combined assets must be valued below $3,000 .

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How Do You Get Medicaid Through The Excess Income Program

First, you need to contact or visit your local department of social services to tell them that you want to be in the Excess Income Program.

If your Medicaid case is opened with excess income, you will get a notice telling you the amount of your excess income.

You can spenddown to the Medicaid level in one of two ways:

Is There Anything I Should Know About My Spenddown During The Covid

What is the Medicaid Spend Down?

Some local districts have put in place policies that allow for an extension of Medicaid coverage when Medicaid recipients meet their spend-down at least once during the public health emergency, or when they demonstrate they tried to submit documents to show they met their spenddown during the public health emergency. Please check with your LDSS for more details.

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What Is Considered Low Income In Georgia

Subtitle: Households that earn less than metro Atlantas overall area median income of $86,200 are considered low income by HUD and may be eligible for housing assistance, once family size is taken into account. A single person making $48,300 is low income, as is a family of five earning $74,500.

Strategies To Spend Down Assets To Gain Medicaid Approval

When one is over the Medicaid asset limit, it becomes imperative to spend down excess, non-exempt assets in order to qualify for Medicaid. In general, any spending is fine, so long as ones assets are not given away or sold for significantly less than they are worth. Gifting ones assets can put one in violation of Medicaids 5-Year Look-Back Period, resulting in a period of Medicaid ineligibility. It should also be mentioned that one should not spend down non-exempt assets by purchasing other non-exempt assets. Because those newly purchased assets would still be counted.

Below is a list of common ways that individuals and / or couples can spend-down in order to gain Medicaid eligibility without violating the look-back period. It is suggested one contact a Medicaid expert before undertaking any of the following purchases. Subtleties exist that can result in ineligibility for the program.

Home Improvements Since ones home is considered a non-countable asset, it makes sense to put extra assets into it, which may even be seen as an investment. Home improvements include:

  • Putting on a new roof
  • Adding a wheelchair ramp or a stairlift
  • Building a handicap-accessible bathroom
  • Building a shed in the backyard

Uncovered Medical Devices Examples include hearing aids, dentures, and eyeglasses.

Pay Off DebtOne can pay off credit card debt, their mortgage loan, their automobile loan, etc.

  • Funeral director services

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What Types Of Bills Am I Allowed To Submit

  • Bills you submit must include your name, the date, description and cost of service, and if paid, the date paid.
  • You may submit bills from both Medicaid and non-Medicaid providers.
  • You can submit bills for services that Medicaid does not cover, such as services from a chiropractor or receipts for pharmacy items such as vitamins and ointments. While a bill for a non-Medicaid-covered service will help you meet your monthly spenddown, Medicaid will not cover the bill.
  • You can submit bills from a Certified Home Health Agency . CHHA providers may also submit bills directly to your LDSS for you.
  • Medical expenses that are paid on your behalf by public programs can be used to cover your spenddown. These costs can be submitted to your LDSS directly by the public program.

What Is Not Covered By Medicaid

What is Medicaid Spend

Although it seems that Medicaid covers practically everything someone needs, it doesnt necessarily provide full coverage. Medicaid does not cover private nursing, for example, nor does it cover services provided by a household member. Also, things like bandages, adult diapers, and other disposables arent covered.

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Calculating The Spend Down Amount

While one may know its necessary to spend-down some of their countable assets to qualify for Medicaid, the exact amount that needs to be spent down may be unclear. This is because the asset limit varies by state, as well as if one is single or married, and if married, if one or both spouses are applying for Medicaid. While the preceding factors are relatively simple to calculate, states also vary in the way they calculate the amount of countable assets a healthy spouse can keep. This adds to the complexity of the calculation.

IndividualsThe asset limit for a single elderly individual for long-term care is $2,000 in most states. However, there are some exceptions. For example, as of 2022, the asset limit for a single individual in Connecticut is $1,600, in Nebraska it is $4,000, and in Minnesota it is $3,000.

When a couple is married, all assets are considered joint assets. Learn more about joint assets here. In most states, the asset limit for a couple where both spouses are applying for Medicaid is $3,000. Again, there are exceptions to this rule. For instance, in 2022, the asset limit in this situation for long-term care is $4,000 in Arizona, $6,000 in North Dakota, and $24,600 in New York.

2022 Medicaid Community Spouse Resource Allowance

Couples Combined Assets

How Much Is Too Much For Medicaid

States that signed up extended Medicaid eligibility to all adults earning up to 138 percent of the federal poverty level, or about $16,105 for an individual. But if you live in one of the 23 states that didnt expand coverage, the limits can be really strict, according to a new report from the Kaiser Family Foundation.

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What If I Don’t Have Bills That Are Equal To Or Exceed My Excess Income

If you do not have medical bills but you need medical care, there is another option called the Pay-In Program. You can pay your monthly excess income amount for any month to your local department of social services. You should only do this if you need services in that month. Ask your local department of social services about this option.

If you do not choose the Pay-In option and you do not have any medical bills that are equal to or exceed your excess income, you will not have Medicaid coverage for that month.

Cash Value Vs Face Value

Medicaid Spend Down- How does it work?

Permanent insurance policies have both face values and cash values. Since Medicaid eligibility rules touch on both, its critical to know the difference before you design an asset spend down strategy.

Face value is the same as the death benefit of your policy. If your whole life policy pays out $50,000 to your beneficiaries when you pass, the face value is $50,000. Cash value, on the other hand, is the value assigned to the investment portion of your policy. Medicaid considers this a countable asset because its fairly liquid depending on the type of policy, you can borrow against or withdraw cash balances.

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Medigap And Medicare Advantage

You may also consider a MSP in combination with a Medigap or Medicare Advantage plan.

Medigap policies cover some of the costs Original Medicare does not cover like copayments, coinsurance, and deductibles. You have to pay a separate premium for Medigap in addition to any Medicare Part A, B, and D premiums you pay. Medigap policies generally do not cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. A Medigap plan may be a good option for you instead of Medicaid with a spenddown if 1) you have no home care or do not have many dental or vision needs, 2) you do not qualify for QMB, 3) you have high out-of-pocket costs for cost-sharing or Medicare-covered services, and 4) the costs associated with the Medigap plan are less than your spenddown amount.

Can A Family Member’s Bills Be Used Toward Your Excess Income Amount

Yes. Bills may be for medical care given to you, your spouse, or your children who are under 21 years old. If you provide medical support for a child not living with you, you may be able to use the child’s bills. Medical bills for your parent may also be used toward meeting your monthly excess if you are under 21 and live with your parent.

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How Is The Amount Of My Excess Income Determined

Your Medicaid caseworker will determine the monthly excess income amount. The amount is the difference between the monthly Medicaid income limit and your countable income. When we count your income, we take your gross monthly income and then subtract certain deductions. There are different deductions depending on whether you are certified disabled or blind or age 65 or older, or whether you are under age 21, pregnant, or a parent of a child under age 21.

Past Unpaid Medical Bills

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Past unpaid medical bills may be used to meet your excess income amount even if they are old, as long as they are still viable, meaning that the medical provider is still able to bring a legal action to collect them. These bills may be applied to meet your excess income indefinitely into the future.

  • Example: You have a hospital bill from four years ago and received a collection notice from the hospital this year. The bill is for $2,000. Your excess income is $200. You may submit this bill to meet your excess income for six consecutive months. After the six months is over, if the provider is still trying to collect on the bill, you can continue to use the balance of the bill for four more consecutive months.

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