Work Incentives Working Group

State Public Benefits Manual

Returning to Work:
Questions and Answers for People Recieving SSI and/or SSDI

 

State Public Benefits Manual

CHAPTER FOUR
HOW THE MEDICAL ASSISTANCE PROGRAMS WORK

In Chapter Three, the eligibility criteria for the various medical programs were discussed. This chapter addresses what services are covered under Medicaid and GA Medical Assistance; and the spenddown program.

A. COVERED SERVICES

B. SPENDDOWN

What Is Spenddown?

Spenddown works like an insurance deductible for persons potentially eligible for Medicaid who cannot qualify because their income and/or assets are too high. The spenddown amount, or deductible, is the difference between countable income and/or assets and the applicable Medicaid income and asset limits.

A person or family who qualifies is enrolled in the spenddown program and informed of their spenddown amount. Any month in which that person or family shows medical expenses, either billed or paid, that equal or exceed the spenddown amount, they are eligible for Medicaid to cover additional health care costs.

What Are The Income and Asset Limits for Spenddown?

Individuals and family members may be able to qualify for Medicaid coverage even if their countable income and/or resources are above the income limits. Persons must meet all other eligibility factors to qualify under the spenddown program. Thus, persons must be categorically eligible (age 65 or older, disabled, blind, a child under the age of 19, pregnant, or a parent in family) and be a U.S. citizen or eligible immigrant. See discussion in Chapter Three.

The income limits used are the AABD MANG and Parent Assist levels. These levels are also used for children whose family incomes are over the KidCare 185% federal poverty line and pregnant women whose incomes are over the Moms and Babies 200% federal poverty line. The applicable income standards are set forth below for a spenddown:


* These income limits are used to calculate monthly spenddown (deductible) amounts for parents whose incomes are above the Parent Assist levels and children whose family’s incomes are above the Kidcare levels. Those income levels are set out on page 63.

**The spenddown income cutoff amounts increase on July 1, 2022 to 85% of the Federal Poverty Level (FPL). On July 1, 2002, the cutoff amount will increase to 100% of the FPL.

The asset limits are as follows. They do not apply to children, parents, and pregnant women if these individuals have countable monthly income over the income limits for KidCare, Parent Assist, and Moms and Babies coverage, respectively.

Spenddown cases are approved when a person or family has countable income or assets that are over the correct MANG standard and asset limits. The extra countable income and assets are the spenddown amount. This spenddown amount works like an insurance deductible -- that is, IDPA will pay for any additional medical care once the person can show that he/she owes or has paid medical bills in the amount of the spenddown amount.

Spenddown cases get a MediPlan Card for part or all of the month when they show that allowable medical bills and paid receipts equal the month's spend down amount.

EXAMPLE:
John Smith is 43 years old and has been diagnosed with schizophrenia. He has assets of less than $2,000. He lives alone and he has income of $800 per month in SSDI benefits. His spend-down amount is calculated by subtracting the monthly MANG income level (This income standard will increase again on July 1, 2001. See the table on page 72.) from the countable income amount. He is allowed a $25 standard deduction from his income.


What Medical Expenses Can Be Used To Meet The Spenddown?

  • The following medical expenses may be used to meet a person's or family's spenddown amount:
  • Medicare and other medical insurance premiums if paid by Medicare enrollee (does not cover QMB or SLIB payments);
  • Medicare or private insurance deductibles, coinsurance charges, or client co-payments, whether paid or unpaid;
  • Illinois Department of Revenue Pharmaceutical Assistance Program enrollment fees and monthly deductibles;
  • Medical expenses for items or services recognized under state law even if not covered by Medicaid program;
  • Estimated cost of OMH and ODD Community Based Services (for elderly and disabled);
  • Estimated cost of ORS HSP;
  • Cost-sharing amounts incurred by persons receiving in-home services from the Department of Aging;
  • Expenses paid by the Division of Specialized Care for Children;
  • Amounts incurred for in-home services purchased from a private party;
  • Medical transportation expenses at $0.24 per mile if person provides own transportation and at actual cost if another form of transportation such as taxicab, service car, Medicar;
  • Costs of a service animal such as seeing eye dog, hearing guide dog, or housekeeping animal (AABD only);
  • Over-the-counter drugs or items if ordered by physician;
  • Medical bills of anyone in the spenddown unit may be used to assist another individual in unit in meeting spenddown; and
  • Medical bills paid by someone else other than a responsible relative if the bill is used within 6 months of the date of payment and the person paying the bill wants to be repaid.

There are time limits for use of bills and receipts. Bills must be dated within the past six months to be applied to the monthly spend-down amount. If the bill is dated more than six months ago, the person need only have it reissued by the health care provider to use it for spend-down purposes. A charge may only be used once. The excess can be carried over indefinitely. Paid bills (including bills paid by someone else who expects to be paid back) and receipts are good for six months beyond the month in which bill is paid. The excess can be carried for six months.

So How Does the Spenddown Work?

When someone who is enrolled in the spenddown program has bills or receipts sufficient to meet the spenddown amount, she or he takes the bills and/or receipts to the local IDHS office. The IDHS worker is required to review the bills and receipts to determine whether the spenddown amount is met. The IDHS worker is required to finish the review within two business days and issue a written decision as to whether the spenddown has been met.

In assessing bills and receipts, the IDHS worker is to review them in the following order:

  • ORS Home Services Program charges and OMH and ODD Community Based Services charges;
  • Receipts, including carryover amounts for receipts used in prior months, subject to the 6 month rule on use of receipts;
  • Medical bills, including carryover amounts from bills used in prior months. Bills are to be considered by date of service, using the oldest bills first.

If the spenddown amount is met, the person or family is to be allowed to choose the month of Medicaid coverage. For example, if a person takes medical bills that meet the spend-down to the IDHS office on the 20th of the month, the person could decide to receive Medicaid for the remainder of that month or receive Medicaid for the entire following month.

In addition, if the person decides to use Medicaid eligibility for the month in which he has submitted a bill, that bill covers service provided in that month, and the service is one that is covered by Medicaid, the portion of the bill that exceeds the spenddown amount may be paid by IDPA. This is called splitting the bill.

 

 

BACK TO TOP

CHAPTER ONE
SOCIAL SECURITY DISABILITY PROGRAMS

CHAPTER TWO
HOW TO WORK AND MAINTAIN SOME SSDI OR SSI BENEFITS

CHAPTER THREE
STATE ADMINISTERED BENEFITS

CHAPTER FOUR
HOW THE MEDICAL ASSISTANCE PROGRAMS WORK

CHAPTER FIVE
MEDICARE

CHAPTER SIX
OTHER STATE AND LOCAL PROGRAMS THAT PROVIDE CASH OR MEDICAL ASSISTANCE

CHAPTER SEVEN
FOOD STAMPS

CHAPTER EIGHT
OFFICE OF REHABILITATIVE SERVICES (ORS)

CHAPTER NINE

OTHER BENEFITS AND/OR PROTECTIONS