Because Medicaid is a health insurance program for the poor, one must have income and assets below a certain limit to be eligible. For a single elderly or disabled person in New York State in 2009, these limits are $767/mo. of income and $13,800 in total assets. (The income limits for people Disabled, Age 65+, or Blind ("DAB"), people age 18-21 and their parents, grandparents or other "caretaker relatives" living with them are in BOX 3 on the HRA Medicaid Chart ). Because of the high cost of living, especially medical expenses, many people find that although they are barely scraping by, they are "too rich" to get Medicaid. Fortunately, there is sometimes a way of getting Medicaid even if your income and/or assets are over the limit: spend-down.
The spend-down program (also called excess or surplus income) is a way for certain categories of applicants to get Medicaid even though their income or assets are over the limit, by offsetting their excess with medical expenses. For example, imagine two potential Medicaid applicants (who we will assume both are in the DAB category and both have assets below the limit). One has income of $700/mo., and is therefore fully eligible for Medicaid ($700 is less than $767). The other has income of $900/mo., but also spends $140/mo. on medical supplies and doctor's visits. The second person would ordinarily not be eligible for Medicaid, because his income is over the limit by $133/mo. However, he can "spend-down" his income to the Medicaid level by using the $140/mo. of medical expenses. Once he shows Medicaid that he has $140/mo. of medical expenses in a given month, then his Medicaid coverage will be activated for the rest of that month. It is almost like a monthly deductible.
Note that the spend-down program is not available to all New York Medicaid applicants. Those who are aged 21-64 who are neither disabled nor have children under age 21 in the household (aka Single/Childless Couples or S/CC) are not eligible to use spend-down. If their income is over the Medicaid limit, they should consider Family Health Plus, which has higher income limits, but keep in mind that Family Health Plus does not allow spend-down, and also is never retroactive. It is only effective in the month after the application is accepted. So.. if you need medical bills to be paid or reimbursed, if they were incurred in the 3 months before you applied, or while the application is pending, Medicaid is the only option.
Selfhelp has published some training materials on the spend-down program, which you can download below:
The above training materials explain some little-known rules:
HOT NEWS -- Submit medical bills by fax in NYC -- See the May 2009 announcement that the NYC Medicaid program now accepts submission of medical bills by fax, and download the official NYC Spend-down Fax cover sheet.
ADVOCACY: Read the May 2009 Report by the New York Health Foundation on "Streamlining New York's Excess Income Program," prepared by Manatt Health Solutions and the Consumer Workgroup Response.
This article was authored by the Evelyn Frank Legal Resources Program of Selfhelp Community Services, Inc.
