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What
is a Medicaid spend-down?
Medicaid, also known as Title 19, is a medical assistance program
for low-income people who are elderly (65 years and older), disabled, blind, or who meet
some other category of eligibility. Some people have so little income that they
automatically qualify for Medicaid. But seniors and people with disabilities, whose
incomes exceed the income limit, may qualify for Medicaid if they have medical bills that
equal or are greater than their "excess" income. The process of
subtracting those medical bills from the individual’s income over a six month period
is called a Medicaid "spend-down."
Seniors placed on spend-downs by the Connecticut Department of
Social Services (DSS) have incomes that are in excess of the Medicaid limit set by
DSS. They qualify for Medicaid if within a six-month period they incur medical
expenses in an amount that equals or exceeds the amount their income exceeds the Medicaid
limit. When that occurs they will receive full Medicaid coverage -- and only until
the end of the six-month spend down period.
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Who is eligible for a Medicaid spend-down?
A person must be disabled, blind or at least 65 years of age, have
assets of no more than $1600 if single, or $2400 if married, and have income which exceeds
the Medicaid limit in order to qualify for a Medicaid spend down.
Eligible people living in their own home, apartment, senior
housing, congregate housing, etc. are eligible to be placed on a spend-down if they have
income over the Medicaid limit. People who live in institutions such as nursing
homes and hospitals, as well as those who live in residential care homes do not have to go
through the spend down process. They must contribute most of their income, however, to the
cost of their care.
Recipients of State Supplement benefits and the Connecticut Home
Care Program for Elders (Category 3) also do not have to spend down excess income because
Medicaid is provided automatically with these programs.
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How much is my spend-down amount?
The amount of your spend-down is the extra income that is
over the limit to receive Medicaid automatically. DSS figures out this amount for
each person, taking into account the person’s income and living arrangements.
There are three regions in Connecticut with different income limits.
Region A is generally the western part of Fairfield
County. The following towns are in Region A: Bethel, Bridgewater, Brookfield, Danbury,
Darien, Greenwich, New Canaan, New Fairfield, New Milford, Newtown, Redding, Ridgefield,
Roxbury, Sherman, Stamford, Washington, Weston, Westport and Wilton. The monthly
Medicaid income limit for Region A is $574.86 for a household of one and $733.59
for a household of two.
Regions B and C contain the towns in the rest of the
state. The monthly Medicaid income limit for Regions B and C is $476.19
for a household of one and $633.49 for a household of two.
Seniors and people with disabilities with unearned income
such as Social Security do not have to count $207 which is the standard deduction.
Example 1: John, a Hartford resident, receives
Social Security income of $683 per month. His Medicaid income limit is $476.19.
He would be eligible for Medicaid because his countable income is $476 after
subtracting the standard deduction of $207 ($683 - $183 = $476).
Example 2: Joe, a Stamford resident, receives $781
per month from Social Security. His Medicaid income limit is $574.86. He would
be eligible for Medicaid because his countable income is $574 after subtracting the
standard deduction of $207 ($781 - $207 = $574).
Example 3: Judy, who lives in New Haven, gets $1000
per month from Social Security. She would be placed on a Medicaid spend down.
Subtracting the standard deduction of $207 from her Social Security income of $1000
results in a countable income of $793. The income limit for Judy is $476.19 because
she lives in Region B. Judy would have excess income of $316.81 per month ($793 -
$476.19 = $316.81). DSS would multiply this number by 6 (for the six month period)
to determine that the spend down amount would be $1,900.86. Therefore, the day that
Judy incurrs that amount of medical bills during the 6 month spend-down period, DSS would
begin to pay her future medical bills until the end of the six month period.
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How often do I have to meet the spend-down?
You will have to meet the spend-down every six months
unless your income and living arrangements have changed so much that you qualify for Title
19 without a spend-down. To get Medicaid in any six month period, you will have to
meet the spend-down first. Once you meet the spend-down, Title 19 will pay your
medical bills for the rest of the six-month period. Then Title 19 will stop until
you run up enough medical bills to meet the spend-down again.
For example, if your monthly income is $50 over the
income limit for Title 19, your spend-down amount for the six-month period would be $300
($50 x 6 = $300). You would have to have $300 in medical bills before the State would
start paying for your medical expenses. It is very important that you save all your
medical and pharmaceutical bills to give to your worker.
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What medical bills can I use to meet the spend-down?
The bills must be ones which you owe for medical services
or items for you (and your spouse if your spouse’s income if counted ) which no other
insurance or program is going to pay. (There is an exception for prescriptions paid by
ConnPACE. See below.) There are limits on using bills you received before you
applied for Title 19.
Your medical bills include not only the usual doctor,
hospital and prescription bills, but also medical supplies, such as bandages, gauze,
etc.); over the counter drugs and vitamins prescribed by your doctor; and health insurance
premiums, co-payments and deductibles.
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