November 2007
Medicaid, also known as Title 19, is a program that pays medical bills for people with low income who cannot afford medical care and who meet other program rules. It is run by the Connecticut Department of Social Services (DSS). Medicaid pays for many health care services, such as doctor visits, prescription drugs, hospital care, laboratory services, home health care, nursing home care, and more. However, Medicaid does not cover care provided by podiatrists, chiropractors, naturopaths, physical or speech therapists, or audiologists, unless these services are provided through a clinic.
Medicaid rules are complicated. Whether you can get Medicaid depends on your income, your assets (what you own, including cash), if you are in one of the categories Medicaid covers, and if you meet other program rules. Apply at DSS--do not try to figure out on your own if you qualify.
In general,
A spend-down is the amount of medical bills you must have before Medicaid will start to pay.
What are the categories or groups of people
that Medicaid typically covers?
Medicaid usually covers low income people who are:
If you have too much income but otherwise would qualify for Medicaid (see categories listed above), you will have to meet a “spend-down” before you will be covered by Medicaid. A spend-down is like a deductible in an insurance policy. It is the amount of medical bills you must have before the insurance company, or DSS in this case, will start to pay. You are responsible for paying the bills you use to meet your spend-down, but they do not have to be paid for your Medicaid eligibility to start.
Spend-downs are calculated for a 6-month period. Once you are found eligible for Medicaid with a spend-down, you will be covered by Medicaid for 6 months.
You do not have to pay the medical bills to meet your spend-down. You only have to owe that amount for medical services you receive during your spend-down period.
Important: Medicaid does not pay the bills you use to meet your spend-down. Rather, it pays for services you get after you meet your spend-down. And, Medicaid will keep paying until your 6-month spend-down period ends.
DSS will send you a notice telling you your spend-down amount and when your 6-month spend-down period begins and ends. The notice will also ask you to send DSS records of your medical bills. (DSS needs this information so they know when you have enough medical bills so Medicaid can begin paying your new medical bills). A new spend-down period begins every six months.
Tip: Keep copies of all the bills you give your DSS worker.
Your spend-down is figured out by taking the amount your monthly income is over the Medicaid income limit and multiplying it by 6, since every spend-down period lasts for 6 months. The Medicaid income limit depends on the size of your immediate family, where you live, and some other things.
Example: Bob’s income is $800 per month from Social Security Disability. The Medicaid income limit for one person in his situation is $660. His income is $140 per month above the Medicaid income limit ($800 minus $660 = $140). DSS multiplies $140 by 6 to determine his spend-down for 6 months, and the result is an $840 spend-down. This means Bob must have $840 in medical bills before he can be covered by Medicaid.
Let’s assume Bob applied for Medicaid on January 1. DSS sent him a letter saying,
“Your period of eligibility is from January 1 to June 30. You are not yet eligible for Medicaid because your income is too high. Your spend-down amount is $840. Once you have met the spend-down, you may be eligible for Medicaid coverage until the end of this eligibility period.”
Bob will probably start out his 6-month spend-down period with no Medicaid coverage. He will be responsible for his own medical bills until they total $840.
Once he has $840 in medical bills, if he brings them to his DSS worker he will get Medicaid coverage for new medical bills. His Medicaid coverage will begin the day his bills meet his spend-down amount of $840. This means even if it takes one or two weeks to get the notice telling him he is covered by Medicaid, he will be covered by Medicaid back to the day he met the spend-down.
At the end of this 6-month spend-down period (which for him is June 30), everything starts over. Bob will no longer be eligible for Medicaid until he meets his next spend-down. Every 6 months DSS will tell Bob the amount of new medical bills he will have to show DSS before Medicaid will begin to pay for his medical services.
Tip: If your income and/or living arrangements change, your spend-down amount may change. You must report any of these changes to DSS within 10 days.
Tip: Check your DSS notice for when your spend-down period begins and ends. Then, mark your spend-down period on your calendar so you can keep track.
Tip: Save all of your medical bills to give to DSS and always save all notices and envelopes that DSS sends you.
The bills must be for medical services or items for you (and your spouse if your spouse’s income is counted) which no other insurance or program is going to pay. There are limits on using the bills you received before you applied for Medicaid. Ask your DSS worker about using those bills. Medical bills you can use include:
Tip: If you are told Medicaid will not pay for something, ask for the reason. There are some legitimate reasons why Medicaid will not pay. However, if your doctor has recommended an item or treatment and Medicaid refuses to pay, you should call Statewide Legal Services at 1-800-453-3320 for legal advice.
Once a bill is used to meet a spend-down, it cannot be used (counted) again. However, if you do not meet your spend-down in one period, you can use those same bills in the next period if the bills have not been paid or you owe a loan that was taken out to pay for those medical bills.
Example: Luz’s spend-down amount is $500 and her spend-down period is March 1 to August 31. Luz saves all her medical bills, but she has only $350 by August 31, which means she did not meet her spend-down for this period. BUT, she can add this $350 in bills to try to meet the spend-down in the next period (September 1 to February 28). Once Luz has another $150 in medical bills after September 1, she will meet her spend-down for this new period because DSS must add the old bills ($350) to her new bills ($150) which equals her $500 spend-down. Luz will be covered by Medicaid as of the day she meets her spend-down.
Tip: Keep a list of all the dates and amounts of your medical expenses, the date you give each bill to your DSS worker, and the date you pay any medical bill.
PLANNING AHEAD:
Sometimes it takes almost the whole 6 months for your bills to
meet your spend-down. If so, you will be covered by Medicaid for only a few weeks before
your next spend-down begins. You can get longer coverage if you plan ahead. Example, with
one month left in the spend-down period, Luz has enough bills to meet her spend-down. It
might be a good idea for Luz to hold onto those bills, not give them to DSS, and stay off
Medicaid for that entire period (March 1 - August 31). Then, on the first day of the next
spend-down period (Sept. 1), Luz can give DSS all of the bills from March 1 - August 31.
She will be covered by Medicaid for the following 6 months (September 1 - February 28).
This planning method is legal and should be better for her financially as she would be on
Medicaid for 6 full months each year rather than for a short time every 6 months.
There are three categories of bills. DSS uses all of the bills from the first category before moving to the second category, then all the bills from the second category before moving to the third. (Within each category, the oldest bills are used first.) The categories are:
Ask your DSS worker for a printout or written statement about which bills were used to meet your spend-down. This information should be in the DSS computer. If your worker cannot send you the information, send your worker a letter confirming what she/he said to you about which bills were used to meet the spend-down. Keep a copy of your letter with your other records.
Medical bills for services provided in your current spend-down will be used whether they are paid or unpaid. However, medical bills from a previous spend-down period will be used only if the medical bills are still unpaid, or you owe a loan which written records show was to pay the medical bills (such as an unpaid credit card bill showing you charged the medical bill).
Tip: If you expect you will not have enough medical bills to meet your next spend-down amount, you might choose to wait to pay an earlier, uncounted medical bill. Then you can use it to meet the next spend-down. Bills can be used only once to meet a spend-down. (See next two questions).
As with any other bill, you are responsible for paying the medical bills you owe. There is no special exception allowing you to wait to pay medical bills because you want to use them to meet a later spend-down. There are risks to paying a bill late including late fees, interest, reports to credit agencies, collection actions including additional costs, and possibly loss of service by the medical provider. If you have an ongoing relationship with a doctor or pharmacist, ask them if you can make payments over the 6-month spend-down period or some other acceptable time frame, rather than paying the full bill right away.
Tip: Statewide Legal Services (1-800-453-3320) can give you information on your rights and steps you can take if someone harasses you to pay a bill or starts a collection lawsuit against you.
Medicaid allows you to have assets only up to $1,600 for one person and $2,400 for two people. If you are close to your asset limit, be careful to make sure your assets do not go above your asset limit. DSS will stop your Medicaid coverage as of the day you went over the asset limit. Medicaid rules about assets are complicated. Call Statewide Legal Services if you have any questions.
Tip: If you are close to your asset limit, it may be better to make payments on large medical bills rather than risk losing Medicaid coverage. Be careful to keep your assets below the limit.
If you do not have enough medical bills to meet your spend-down, Medicaid will not pay for any medical bills in that spend-down period. However, each spend-down amount is in effect for only one spend-down period (6 months). So, if you do not meet your spend-down in one period, you may be able to get Medicaid coverage by using those bills in the next spend-down period. There may be times when you have a lower spend-down amount because of changes in your income or living arrangements.
Tip: In the last month of your spend-down period,
A special program allows people with disabilities to work if they are able without losing Medicaid. And in many cases, they would not have a spend-down. The program is called “Medicaid for Working Individuals with Disabilities.” The income limit is $6,250 per month. You are eligible if:
The income and asset limits are much higher for this program than for regular Medicaid. Ask your DSS worker how to apply.
Connecticut has several Medicaid programs that have higher income limits than regular Medicaid and do not have a spend-down. These programs are for women with breast or cervical cancer who are diagnosed by state-run clinics (see below), elderly or people with disabilities who need home care, and people with brain injuries.
This program has no income or asset limits. You are eligible if:
As long as you need cancer treatment, you receive Medicaid without a spend-down for all of your medical needs, not just cancer treatment.
Call the Department of Public Health for the locations of the Early Detection sites. (Telephone: 860-509-7804.) The screeners at the sites will help you complete an application and make sure it goes through quickly.
If you are 65 years of age or older and need assistance with some of your activities of daily living (ADLs), you may qualify for the Connecticut Home Care Program for Elders (CHCPE). Activities of daily living include bathing, dressing, toileting, preparing food, shopping, taking medications, or housecleaning. This program pays for home health aides, homemakers, companions, skilled nursing, emergency response alert, meals on wheels, adult day care and case management.
The income limit for this program is much higher than the income limit for regular Medicaid, although the asset limit is the same ($1600 for one person). If you qualify for CHCPE, you receive Medicaid without a spend-down.
You can apply for this program by calling the Alternate Care Unit at DSS, telephone: 1-800-445-5394.
If you are disabled and need assistance with activities of daily living (ADLs) such as bathing, dressing, toileting, preparing food, eating, taking medications, or housecleaning, you may qualify for the Personal Care Assistance Program. This program allows you to hire personal care assistants to perform necessary activities of daily living.
The income limit for this program is higher than the income limit for regular Medicaid, although the asset limit is the same ($1600 for one person). If you qualify for the Personal Care Assistance Program, you receive Medicaid without a spend-down.
You can apply for this program by calling your local DSS office. Call Infoline at 2-1-1 to find the DSS office that serves your town.
If you are disabled due to a brain injury and would otherwise require services in an institutional setting such as a nursing home, you may qualify for Medicaid under the Acquired Brain Injury Program. This program offers 21 home and community-based services to meet your individual needs to help you live at home.
The income limit for this program is higher than the income limit for regular Medicaid, although the asset limit is the same ($1600 for one person). If you qualify for the Acquired Brain Injury Program, you receive Medicaid without a spend-down.
You can apply for this program by calling your local DSS office. Call Infoline at 2-1-1 to find the DSS office that serves your town.
This document was produced by the Legal Assistance Resource Center of CT in cooperation with CT Legal Services, Greater Hartford Legal Aid, New Haven Legal Assistance Association, and Statewide Legal Services.
The information in this document is based on the laws in CT as of November 2007. We hope that the information is helpful. It is not intended as legal advice for an individual situation. If you need further help and have not done so already, please call Statewide Legal Services (see above) or contact an attorney. Copyright: November 2007.