Expenses that can be applied towards Medicaid spend down vary by state, but many allow for medical care costs not covered by Medicaid as well as personal care costs. As you pay for qualified expenses, like medical treatment, prescriptions, nursing home care, and personal assistance services, you reduce your countable assets. Once your assets reach the state’s Medicaid limit, you become eligible for full coverage. Medicaid spend down does not apply to expenses made before the lookback period, which is typically 60 months prior to the application date.
What Expenses Qualify for Medicaid Spend Down?
Medicaid spend-down is a process by which certain medical expenses can be used to reduce the amount of money a person needs to pay out-of-pocket for Medicaid coverage. This is possible because Medicaid is a need-based program, and the amount of assistance a person is eligible for is based on their financial situation. When a person’s medical expenses exceed their income and assets, they may be eligible for Medicaid spend-down.
Determining Spend-Down Amount
To determine the amount of spend-down, the state Medicaid agency will first calculate the person’s monthly income and assets. This includes all income from sources such as wages, Social Security, and pensions, as well as any assets such as cash, stocks, and bonds. The state will then subtract certain allowable expenses from the person’s income and assets. These expenses may include:
- Medical expenses
- Premiums for health insurance, Medicare, or long-term care insurance
- Child care expenses
- Dependent careexpenses
- Housing expenses (rent, mortgage, and property taxes)
- Utilities (electricity, gas, water, and sewer)
- Food
- Clothing
The amount of the spend-down is the difference between the person’s income and assets and the amount of their allowable expenses. This amount is then used to reduce the person’s Medicaid costs.
Table of Allowable Expenses
| Expense Category | Allowable Expenses |
|---|---|
| Medical expenses |
|
| Health insurance premiums |
|
| Child care expenses |
|
| Dependent care expenses |
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| Housing expenses |
|
| Food |
|
| Clothing |
|
Medical Expenses That Count Toward Spend-Down
When applying for Medicaid, individuals and families may need to meet a spend-down requirement. This means that they must spend a certain amount of their own money on eligible medical expenses before Medicaid will begin to cover their costs. The amount of the spend-down varies from state to state and is based on the applicant’s income and assets.
There are a number of medical expenses that can count towards the spend-down requirement. These include:
- Doctor visits
- Hospital stays
- Prescription drugs
- Dental care
- Vision care
- Hearing aids
- Medical equipment
- Nursing home care
- Home health care
- Personal care services
In order to be eligible, medical expenses must be:
- Unreimbursed by insurance or any other source
- Incurred during the spend-down period
- For medically necessary services
The rules for what expenses qualify for the spend-down requirement can be complex. It is important to consult with a Medicaid representative to determine which expenses will count towards the spend-down in a particular state.
| Expense | Qualifies for Spend-Down? |
|---|---|
| Doctor visits | Yes |
| Hospital stays | Yes |
| Prescription drugs | Yes |
| Dental care | Yes |
| Vision care | Yes |
| Hearing aids | Yes |
| Medical equipment | Yes |
| Nursing home care | Yes |
| Home health care | Yes |
| Personal care services | Yes |
| Cosmetic surgery | No |
| Experimental treatments | No |
| Over-the-counter medications | No |
Qualified Expenses for Medicaid Spend Down
When applying for Medicaid, individuals may have certain expenses and assets that can be counted towards meeting the program’s financial eligibility criteria. The process of reducing countable assets and income to meet Medicaid’s eligibility limits is known as “spend down.” In most states, a “spend down” period is allowed for the applicant to reduce their countable assets and meet the Medicaid eligibility criteria.
Exemptions and Limitations on Expenses
- Medical Expenses: Medical bills and healthcare costs incurred in the month of application and medical services provided in previous months.
- Nursing Home Care: Costs associated with skilled nursing facility care and intermediate care facilities.
- Prescription Drugs: Out-of-pocket costs for prescription medications.
- Health Insurance Premiums: Premiums paid for Medicare Part B, Medicare Part D, Medicare Advantage Plans, and other qualified health insurance.
- Medical Supplies: Expenses for medically necessary supplies such as wheelchairs, oxygen tanks, and blood glucose monitors.
- Dental Expenses: Dental services and procedures considered medically necessary.
- Vision Care: Necessary eye exams and corrective lenses.
- Other Allowable Expenses: In some states, certain living expenses, such as rent, utilities, and food, may be included in the spend-down calculation.
Limitations:
- Date of Incurrence: Expenses must be incurred during the spend-down period, typically the month of application and the preceding months.
- Documentation: Individuals must provide proof of expenses through receipts, bills, and other documentation.
- Asset Limits: Assets and income above certain limits can affect Medicaid eligibility.
- State Variations: Spend-down rules and allowable expenses may vary from state to state.
Additional Information:
| Expense | Qualifying Criteria | Examples |
|---|---|---|
| Medical Bills | Must be for medically necessary services | Doctor’s visits, hospital stays, emergency room care |
| Nursing Home Care | Must be skilled nursing or intermediate care | Nursing home stays, assisted living facilities |
| Prescription Drugs | Must be prescribed by a doctor | Co-payments, deductibles, and drug costs |
| Health Insurance Premiums | Must be for qualified health insurance plans | Medicare Part B, Medicare Part D, Medicare Advantage |
| Medical Supplies | Must be medically necessary | Wheelchairs, oxygen tanks, blood glucose monitors |
Conclusion:
Medicaid spend-down allows individuals to meet Medicaid’s financial eligibility criteria by using certain qualified expenses. Medical expenses, nursing home care, prescription drugs, health insurance premiums, and other allowable expenses can be counted towards the spend-down. Understanding the spend-down process and allowable expenses can help individuals qualify for Medicaid and access necessary healthcare services.
Spend-Down Period
The spend-down period is a specific time, usually a month, during which you must pay for medical expenses out-of-pocket until you reach your spend-down amount. Once you reach this amount, Medicaid will begin to cover your eligible medical expenses.
The spend-down period starts on the first day of the month you apply for Medicaid and ends on the last day of the month.
If you have more than one medical expense during the spend-down period, you can combine them to reach your spend-down amount faster.
Reporting Requirements
You are required to report all of your medical expenses to the Medicaid office during the spend-down period. This includes expenses that are not covered by Medicaid, such as over-the-counter medications, dental care, and vision care.
You can report your medical expenses by:
- Submitting a monthly report to the Medicaid office.
- Keeping a record of your medical expenses and providing them to the Medicaid office when requested.
- Authorizing the Medicaid office to access your medical records.
Qualifying Medical Expenses
The following expenses may qualify for Medicaid spend-down:
| Expense | Qualifying |
|---|---|
| Doctor visits | Yes |
| Hospital stays | Yes |
| Prescription drugs | Yes |
| Medical equipment | Yes |
| Nursing home care | Yes |
| Home health care | Yes |
| Dental care | No |
| Vision care | No |
| Over-the-counter medications | No |
Thanks for giving my article a read, folks! I hope you found it helpful in understanding what expenses qualify for Medicaid spend down. If you have any other questions, feel free to drop me a line. In the meantime, keep an eye out for more informative content coming your way. Until next time, keep your finances in check and take care!