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Understanding Medicaid Spend Downs: What It Is and How It Works

For many individuals, especially older adults and those with disabilities, affording healthcare and long-term care can be a significant financial challenge. Medicaid offers crucial support, but not everyone qualifies based on income or asset limits. That’s where understanding Medicaid Spend Downs is important. It is a pathway to eligibility for those who exceed Medicaid’s financial thresholds but still have high medical costs.

What Is Medicaid Spend Down

Medicaid Spend Down is a process that allows individuals with income or assets above Medicaid eligibility limits to “spend down” their excess resources on medical expenses to qualify for Medicaid coverage. It’s similar to an insurance deductible; once you’ve paid out a specific amount in medical bills, you become eligible for Medicaid assistance for the rest of the period.

There are two common types of spend down:

• Income Spend Down: For people whose monthly income is too high but who have recurring medical expenses.
• Asset Spend Down: For those whose savings or property exceed Medicaid’s asset limits.

Who Needs a Spend Down

Spend down is often needed by:

• Seniors over age 65
• Individuals with disabilities
• People in need of long-term care
• Those receiving home and community-based services

For example, someone with a small pension or Social Security income that slightly exceeds their state’s Medicaid income limit might still qualify if they have regular out-of-pocket medical costs like prescription drugs, doctor visits, or even insurance premiums.

How Does It Work

Each state administers Medicaid differently, so spend down rules and procedures vary. However, the basic process looks like this:

1. Determine Excess Income/Assets: Compare income or resources to the state’s Medicaid limits.
2. Calculate the Spend Down Amount: This is the amount you must use for medical expenses to qualify.
3. Submit Proof: Provide receipts or bills to your state Medicaid office as evidence of your medical expenses.
4. Become Eligible: Once you meet your spend down requirement, Medicaid covers your additional medical costs for a certain period; often between one and six months.

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What Counts Toward a Spend Down

Expenses that may count include:

• Unpaid medical bills
• Prescription drugs
• Health insurance premiums
• Doctor and hospital visits
• In-home care services
• Medical equipment

Important Considerations

• Timing Matters: Medicaid coverage through spend down is usually limited to specific timeframes (e.g., a one- or six-month period). Beneficiaries will need to re-qualify at the end of each spend down period. The length of each spend down varies by state.
• Asset Rules Are Strict: Some assets are exempt (like your home or one vehicle), but others may need to be spent down or placed in a trust.
• Documentation Is Key: Keep all receipts and records of medical expenses as proof.

Medicaid Spend Down can be a lifeline for those who need healthcare but don’t meet traditional financial eligibility criteria. It requires careful planning and documentation, but it opens the door to critical services like long-term care and in-home support.

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If you or a client may benefit from Medicaid but don’t meet the income or asset limits, a CMP (Certified Medicaid Planner) or elder law attorney can provide spend down options and help beneficiaries make informed decisions.

Because so many people confuse the terms Medicare and Medicaid, we will discuss Medicare vs Medicaid and explain the difference between the two terms. Although the terms are often mentioned in the same sentence, these programs serve different populations, have different eligibility rules, and provide different types of coverage.

Medicare

Medicare is a federal health insurance program. In general, beneficiaries of Medicare are:

• Individuals who are 65 and older
• Those under 65 with specific qualifying disabilites
• People who have beendiagnosed with either ESRD (End-Stage Renal Disease) or ALS

The Parts of Medicare

1. Part A – Hospital insurance (covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care)
2. Part B – Medical insurance (covers outpatient care, doctors’ visits, preventive services, and durable medical equipment)
3. Part C – Medicare Advantage Plans (offered by private insurers as an alternative to Original Medicare, often including vision, dental, and drug coverage)
4. Part D – Prescription drug coverage

Medicare Cost

Medicare is not entirely free. Most people get Part A premium-free, but they pay a monthly premium for Part B. They also may pay a premium for Part C and/or Part D. There are also optional Medicare Supplement plans available which also have a monthly premium. Medicare costs include things like deductibles, co-pays and coinsurance. The out-of-pocket amounts differ depending on the plan or plans chosen.

Medicaid

Medicaid is a program that is put in place by both federal and state governments. Individuals who receive this coverage are:

• People with low income who meet the income threshold amount (this varies by state)
• Certain pregnant women and children who meet the income level required
• People with disabilities with income that falls into the state requirement
• Some seniors, including those who also qualify for Medicare

Because Medicaid is administered by each state, the programs vary by state, including eligibility requirements and the services that the program provides.

Medicaid generally covers

• Hospital and doctor visits
• Long-term care (nursing home care)
• Home and community-based services
• Preventive care, mental health services, and more

In many cases, Medicaid covers services that Medicare does not; such as long-term custodial care.

Medicaid Cost

In most cases, Medicaid is either free or very low cost for eligible individuals. States may charge small copays for some medical services.

Medicare vs Medicaid – Key Differences

Can Individuals Have Both

The short answer is, yes! Some individuals qualify for both programs. These are called “dual eligibles.” For these people:

• Medicare typically pays first
• Medicaid may help cover Medicare premiums, deductibles, and services that Medicare does not cover (like long-term care)

Seniors with limited income or disabled individuals who qualify as dual-eligible receive comprehensive coverage at little to no cost.

Additionally; Medicare and Medicaid both play crucial roles in our healthcare system. They each serve a different purpose and population. Understanding who qualifies and what each program covers helps agents, individuals and families make informed healthcare decisions.

For assistance with eligibility or enrollment, consider contacting:

• Medicare.gov or 1-800-MEDICARE
• Click here for each state’s Medicaid office
• A local State Health Insurance Assistance Program (SHIP) for free counseling