What is Spend Down?
You may be ineligible for Medicaid because your countable income exceeds the applicable Medicaid income limit. However, you may still be eligible for Medicaid through “Spend Down”. “Spend Down” Medicaid is for individuals who have income over the Medicaid limit but also have high medical bills which they are responsible for paying. Most Medicaid eligibility groups may be eligible for Medicaid through the Spend Down process with some exceptions like Adults without Dependent Children (Childless Adults) and QMB beneficiaries. You can use medical bills to obtain Medicaid coverage during your spend down eligibility period.
If you have medical expenses, which you are responsible for paying outstanding for the three months before you applied, you may also be eligible through Spend Down for some of those bills to be paid.
If you become eligible through Spend Down, you will be responsible for paying some of your bills, and Medicaid will cover the rest during your spend down eligibility period you are eligible as long as the bills are for Medicaid-covered services.
Contact the Spend-Down Unit at (202) 698-4202 with questions.
How do I meet my Spend Down amount?
A Spend down amount is met by adding up medical costs. Payments for medical care, supplies and prescriptions may apply to your spend down amount. You will be eligible for Medicaid on the first of the month that you meet your spend down amount. Regular “community” Medicaid eligibility under Spend Down is a one-month budget period, and you will be eligible for the entire month; while “long term care” Medicaid eligibility under Spend Down is a six-month period, and you will be eligible starting the first day of the month in which you meet your spend down amount through the rest of the six-month period.
Only the portion of the bill that you must pay can be applied to meet your spend down amount. You cannot use bills that someone else pays for you or that insurance pays to qualify for spend down coverage. If insurance pays part of the bill and you pay the rest, only the part that you have to pay is counted.
Medicaid will not pay for medical expenses used to meet your spend down amount.
If you have a large medical expense or if you are close to meeting your spend down amount, take your bills to ESA as soon as you get them.
You can use current and old medical bills to meet the Spend Down deductible based on these rules:
- You can only use medical expenses that you are responsible for paying. You cannot use expenses that are covered by other insurance or Medicare, or that the medical provider is not charging you for.
- You can use old medical bills as long as you still owed the money on the bills three months prior to the date of Medicaid application
- You can use current medical expenses, whether you have paid them or still owe them.
Medical Bills
These are types of medical expenses that you can use to meet your spend down amount:
- Physician services,
- Inpatient and outpatient medical services,
- Nursing Home services
- Medical or personal care in your home
- Clinic Services
- Prescription and medically necessary Over The Counter drugs,
- Medical equipment and devices prescribed by a physician,
- Ambulance services,
- Other medical expenses usually covered by Medicaid,
- Other medical expenses not usually covered by Medicaid but medically necessary,
- Transportation to and from medical visits,
- Health insurance premiums, including Medicare premiums
- Co-payments and deductibles on medical expenses
- Eyeglasses;
- Speech, occupational and physical therapy.
- Dental services, and
- Chiropractic services.
How to Submit Medical Expenses for Spend Down
You can submit medical expenses to the Spend Down Unit in the Department of Human Services to receive a determination of whether the person may qualify for Spend Down by:
- Mailing them or bringing them to:
Department of Human Services – Spend Down Unit
645 H Street NE
5th Floor
Washington, DC 20002
- Scanning them and emailing them to [email protected].
- Sending them by fax to (202) 724-8963
Be sure to write your account number on your medical expenses. You will receive a notice in the mail regarding the status of your spend down.
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