State Public Benefits Manual
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
What Is 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.
Are The Income and Asset Limits for Spenddown?
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
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:
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.
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.
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.
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:
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.
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.