Health & Benefits

A person can qualify for a Medicaid spend-down if they:

• Are over 65 years old,
• Have Medicare,
• Have a severe disability, A substantial impairment that functionally limits a person in carrying out major life activities, such as walking, lifting, seeing, or learning. or
• Are blind.

A spend-down is a dollar amount that someone’s income or assets Anything a person owns that has financial value are over the Medicaid limit. If a person has a spend-down, they must “meet” the spend-down to qualify for Medicaid. After they meet the spend-down, they can receive Medicaid coverage for the rest of their expenses for the month. There are two ways to meet the spend-down. A person can either:

• Submit proof of medical expenses that add up to the spend-down amount, or
• Pay the Illinois Department of Healthcare and Family Services (HFS) the spend-down amount. This is known as a “pay-in spend-down”.

Only certain Medicaid recipients can qualify for pay-in spend-down. If a person is eligible for pay-in spend-down, they can choose when to pay-in or when to use medical expenses to meet their spend-down. 

For example, if someone is $100 over the income limits for their Medicaid program, their spend-down amount is $100. This means that they can either:

• Show their Illinois Department of Human Services (IDHS) caseworker they have medical expenses of at least $100, before Medicaid will cover the rest for that month, or
• Pay HFS $100, then Medicaid will cover the rest of their expenses for that month, if they qualify for pay-in.

Only certain medical expenses count toward spend-down.

A person can use any of the following to meet their spend-down:

• Physician and hospital services,
• Medications,
• Cost of travel to get medical care (when Medicaid is not directly paying for travel),
• Medicare and other medical insurance premiums, Money that must be paid every month, such as for health insurance deductibles or other insurance co-payments, Money paid for health care in addition to what the insurer pays
• Some dental expenses, many in-home care services, and over-the-counter medicines when prescribed by a physician,
• Nursing home services,
• Clinic services,
• Medical supplies and equipment prescribed by a doctor,
• Eyeglasses,
• Insurance premiums, including Medicare premiums,
• Speech, occupational, and physical therapy, or
• Co-payments or deductibles for medical care.

A person can also count medical expenses of anyone that lives with them that they are responsible for. This includes their spouse and any children under 18 years old.

Once a bill is used to meet a spend-down, the same bill cannot be used to meet a spend-down again.

If someone spends more than their spend-down amount in one month, that bill could be used to meet spend-down for more than one month. For example, if someone’s spend-down is $100 and they receive a $200 bill, they can use that bill twice. It can count for $100 in one month, and $100 in a second month. In the first month, if HFS pays off the remaining $100 of the $200 bill, then it can’t be applied to meet the spend-down in the second month.

Yes. The medical bills must be from less than six months before the month a person wants to use them to meet the spend-down. In other words, a person can use bills that are up to six months old. For example, if someone has a medical bill with a January date, they can use it to meet their spend-down in January, February, March, April, May, or June. They cannot use it to meet their July spend-down.

The bills can be unpaid when they’re used to meet the spend-down, but the Medicaid recipient must still pay them on their own.

It is very important to keep copies of all medical bills, receipts, and records of other medical expenses. The documents must show:

• The type of medical care, drugs or supplies provided,
• Who gave the care,
• Who got the care,
• The date the care was given,
• The cost, and
• The date of the bill or receipt.

When someone gathers enough proof of their expenses to meet their spend-down, they must send copies of them to their IDHS caseworker at their local IDHS office. The program will then process the bills so that they can receive a medical card.

If a person’s medical bills are not enough to meet their spend-down for the month, they can save the medical bill to use in a future month. Hopefully, when they combine it with other future medical bills, they can meet their spend-down for that month.

For example, if someone’s spend-down is $75, and they have medical bills in January for only $50, they cannot meet their spend-down for January. This means they cannot get a medical card for January. They can save their $50 January medical bills to use in February, March, April, May, and June. In February, they have another $100 in medical bills. So they have $150 in medical bills from January and February. The person can meet their February spend-down by applying their $50 January bills and $25 of their February bills. There is $75 remaining from the February bill. This can be used to meet their March spend-down.

If someone has not met their spend-down for six consecutive months, HFS will send them a letter stating that their Medicaid case has been canceled. This means they can no longer receive a Medicaid card.

However, people can reapply for Medicaid once they have enough bills to meet their spend-down.

They can apply for Medicaid with a spend-down the same way they apply for regular Medicaid. IDHS will send them a notice stating they are only eligible for Medicaid with a spend-down. The notice will list their monthly spend-down amount. Their Medicaid will not be active until IDHS has determined they met the spend-down.

Another option is a pay-in spend-down, which gives you the option of paying your spend-down amount to HFS. This is like paying a health insurance premium each month.

Only people who are age 65 or over, blind, or disabled, are eligible for pay-in spenddown. They must also be living in the community. This means they do not live in a nursing home or intermediate care home.

Once a person’s spend-down amount is determined, they will receive a statement each month from HFS with how much they must pay. Payments can be made with a money order, cashier’s check, Visa or Mastercard. Personal checks can’t be used for paying a spend-down to HFS. A person will receive their Medicaid after their payment is processed.

You can call your local IDHS Family Community Resource Center, or visit the HFS website.