Medicaid Spend Down for the Young and Able
June 29, 2012 11:46 AM   Subscribe

Can anyone explain Medicaid spend down benefits for the non-elderly, non-disabled?

My brother has employer based health insurance, but needs a surgery that is only partially covered by his private insurance. His children have Medicaid as secondary insurance, so he and his wife have Medicaid "spend down" as a secondary. Trying to untangle this has a been a mess. Is anyone familiar with how this works? The provider maintains that they don't dictate what my brother may end up owing out of pocket, that Medicaid does. Medicaid says the provider will bill him. I don't see how both those statements can be accurate, but I don't understand this system well at all.
posted by Athene to Health & Fitness (6 answers total)
 
The term to describe your brother, in Medicaid terms, which might help for searching, is that he's eligible because he's "Medically Needed" -- but how it works will depend on the state.
posted by MCMikeNamara at 12:15 PM on June 29, 2012


Oops I meant to say "Medically Needy"
posted by MCMikeNamara at 12:15 PM on June 29, 2012


Response by poster: This is the part that's confusing to me. Under the Medically Needy rubric for our state, a couple's income limit is $500. My brother makes far, far more than this, which, apparently, is why it's referred to as a spend down.
posted by Athene at 12:33 PM on June 29, 2012


The basic idea (I just learned here) is that "Individuals with higher incomes who meet a 'spend-down' obligation can also qualify for coverage. Spenddown is met when, after deducting medical expenses from income, a person’s remaining income is below the state’s MNIL." In other words, it seems that you qualify if you seem poor (by some measure) after you subtract (some measure of) your medical expenses from (some measure of) your income.

Rules vary by state. If you are not getting anywhere through the state Medicaid office, you could try getting a referral to someone who could explain it to you through a state or local office on aging. (Yes, I know he's not aged, but they should be familiar with Medicaid rules or know someone who is.)
posted by Mr.Know-it-some at 12:57 PM on June 29, 2012


Best answer: As mentioned above, rules vary by state. Also, ask for a supervisor in the Medicaid office if you are not understanding from the front line worker how the program works.

The following applies in my state:

"Non-elderly, non-disabled" means 'no Medicaid'. Just because the kids are covered, the parents may not be.

Spend down is the amount of liability the participant has in a particular month. It is a lot like a deductible, with coverage beginning the date on which the spend down is met by allowable expenses.

Allowable expenses are qualifying expenses (not everything counts) that are not subject to payment by private insurance (or Medicare or other third party).

The Medicaid office determines the amount of spend down based on income.

The provider should be able to tell you roughly how much private insurance will pay and the amounts (if any) of deductibles and/or copays.

Once the surgery is done, the provider bills the participant (and the insurance company).

The insurance company pays what it is responsible for.

The participant submits the bill to the Medicaid office. The Medicaid office will determine the spend down coverage date and the amount of spend down liability still owed by the participant.

The participant may also owe insurance company deductibles and/or copays.
posted by badger_flammable at 3:02 PM on June 29, 2012


When I dealt with Medicaid (admittedly several years ago), Medicaid spenddown operated like what badger_flammable described. While I can't speak to Medicaid being a "secondary" insurance, generally spenddown means that once you spend a certain amount towards your eligible medical bills, Medicaid kicks in as coverage.

This also varies by state. What needs to happen is that your brother needs to see if he can get an estimate of what the surgery would cost, how much his insurance covers, and proof of his income. He will need at least that much information to determine how spenddown will work for this particular situation.
posted by MultiFaceted at 3:28 PM on June 29, 2012


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