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Are You Eligible For Medicaid (Title 19)?

This article was produced by LARCC in cooperation with CLS, GHLA, NHLAA, and SLS.

Are You Eligible For Medicaid (Title 19)?

What is Medicaid and what kinds of health care does it pay for?

Medicaid is health insurance that helps low-income people pay some or all of their medical bills.

Medicaid pays for many health care services, including:

  • Doctor visits,
  • Prescription drugs,
  • Hospital care,
  • Lab services,
  • Home health care,
  • Nursing home care, and
  • Other health care services.

If the patient is an adult, Medicaid also covers the following services, but only if they are provided at a clinic:

  • Podiatry,
  • Chiropractic care,
  • Naturopathy,
  • Physical / speech therapy, and
  • Audiology.

Children (under 21) are covered no matter where they get these services.

Who can get Medicaid?

Many low-income people who cannot afford medical care can get Medicaid. Medicaid generally decides if you qualify based on your income, assets, and other program rules.

Some people automatically qualify, including people who are in one of these programs now:

  • Welfare (TFA)
  • Aid to the Aged, Blind and Disabled, also called AABD or State Supplement,
  • SSI (Supplemental Security Income) but only if your assets also are below a certain limit.

If you are not on one of these programs now but have very low income, you may still qualify for Medicaid.

Important! Eligibility rules can be very complicated. Apply at DSS (Department of Social Services). They will help you with the application and answer your questions.

What if my income is too high to qualify for Medicaid?

If you don't qualify for Medicaid now, you may qualify for one of these programs:

  • MED-Connect (Medicaid for Working Individuals with Disabilities)
  • Breast and Cervical Cancer Program
  • Home Care Program for Elders
  • Personal Care Assistance Program
  • Acquired Brain Injury Program

If your income is higher than Medicaid's income limit, you may still qualify for Medicaid using a "spend-down."

What is a spend-down?

If you have too much income but meet all other Medicaid requirements, your "spend-down" is the amount of medical bills you must have before Medicaid will cover you. It is like a deductible in an insurance policy. Medicaid will give you 6 months to meet your "spend-down."

DSS will send you a notice to tell you:

  • The amount of your spend-down, and
  • When your 6-month spend-down period starts and ends.

The notice will also ask you to send copies of your medical bills to DSS. DSS needs your bills to decide when Medicaid can begin paying your new medical bills.

Important! Keep copies of the bills you give DSS. Also note what date and how you delivered them.

You must meet your spend-down amount during a 6-month period. As soon as your spend-down is met, you can get Medicaid for the rest of that 6-month period. You can start a new spend-down period every 6 months, and repeat the same steps so you can get Medicaid.

You do not have to pay the medical bills to meet your spenddown. You can use unpaid bills and recently paid bills to meet your spend-down.

How does DSS decide my spend-down amount?

Your spend-down amount depends on your income and your monthly Medicaid income limit.*

Example:

Bob gets $900 a month from Social Security Disability.
His monthly Medicaid income limit is $784.
His income is $116 above Medicaid’s monthly income limit.*

$900   Your monthly income
- $784   minus Medicaid’s monthly income limit
$116 
     X6   (for 6 months)
$696   Your spend-down amount

*Medicaid's monthly income limit depends on the size of your immediate family, where you live, and other factors.

This means Bob must have $696 in medical bills before Medicaid can cover him during a 6-month spend-down period.

If Bob applied for Medicaid on January 1, he would get a letter from DSS saying this:

  • Your eligibility period is January 1 — June 30.
  • You are not eligible for Medicaid yet because your income is too high.
  • Your spend-down amount is $696. If you meet the spend-down amount, you can get Medicaid until June 30 (the end of your eligibility period).

Bob can start his 6-month spend-down period with no Medicaid coverage. He is responsible for his medical bills until they total $696. At that point, he can take his medical bills to DSS. Medicaid will cover any new medical bills. His Medicaid coverage starts the day he reaches the spend-down amount. This means he is covered by Medicaid as of that date, even if he does not get a notice from Medicaid until later.

On June 30, when the 6-month spend-down period ends, everything starts over:

Bob will not be eligible for Medicaid until he meets his next spend-down.
DSS will tell Bob the amount of new medical bills he will have to give DSS before Medicaid will cover him.

TIPS:

  • If your income or living situation changes, your spenddown amount may change, too. Tell DSS about any change within 10 days.
  • Use a calendar to keep track of the dates of your spend-down period.
  • Save all your medical bills. Keep track of the date and amount of each bill, and the date you pay any medical bill. Important! Make copies of your bills before you give them to DSS, and write down the date you give them to DSS and how you delivered them.
  • Keep all notices and envelopes that DSS sends you.
  • If Medicaid says they will not pay for something your doctor ordered, ask for the reason — in writing. DSS will send you a written explanation and information about your right to appeal. If this happens, call Statewide Legal Services for legal advice (even if you don't get a written notice): 800-453-3320.

What medical bills can I use to meet the spend-down?

You can use medical bills for medical services or goods that are not covered by any other plan, including:

  • Doctor and hospital services,
  • Ambulance services,
  • Medical supplies, such as bandages, gauze, etc.,

Prescription drugs,

  • Over-the-counter drugs and vitamins prescribed by your doctor, and
  • Health insurance premiums, co-payments, and deductibles.

The bills must be for services or goods received by:

  • You, or
  • Your parent and/or spouse (if their income is counted)

Note: There are limits on bills you received before you applied for Medicaid. Your DSS worker can explain how to use those bills.

How often can I use a bill to meet my spend-down?


You can only use a bill once.

Exceptions:

  • If part of that bill was not counted to meet your spenddown, you can use the uncounted amount in your next spend-down period.
  • If you do not meet your spend-down in one period, you can use the same bills again for the next period.

Example:

Luz's spend-down amount is $500. Her spend-down period is March 1 — August 31. By August 31, Luz only has $350 in medical bills, which means she did not meet her spenddown for this period. If no one pays these bills, she can add this $350 to any new bills to try to meet the spend-down in the next period.

If Luz has $150 more in medical bills after September 1, she will meet her spend-down for the new period. ($350 in old bills + $150 in new bills = her $500 spend-down.) Medicaid will cover Luz as of the day she meets her spend-down.

Plan Ahead

Sometimes it takes almost the whole 6 months to meet your spend-down. If so, you will be covered by Medicaid for only a few weeks before your next spend-down begins. If you plan ahead, you can get longer coverage.

Example:

If Luz meets her spend-down amount one month before her spend-down period ends, she could hold onto those bills, not give them to DSS, and stay off Medicaid for that entire 6-month period.

Then, on the first day of the next spend-down period, Luz can give DSS all her bills from the previous period. That way, Medicaid will cover her for the following 6 months. This method is legal and would give Luz longer periods of Medicaid coverage.

In what order does DSS use my bills to meet my spend-down?

DSS classifies your bills in 3 categories:

1. Medicare premiums, co-payments and deductibles.

2. Medical expenses not covered by Medicaid. (For example, services provided to an adult by a podiatrist, chiropractor, naturopath, or therapists not working out of a clinic.)

3. Medical expenses that are covered by Medicaid.

Medicaid counts all bills in Category 1 first, then all bills in Category 2, and last, it counts all bills in Category 3. Within each category, Medicaid counts the oldest bills first.

How do I know which bills DSS used to meet my spend-down?

Ask DSS for a written statement about which bills were used to meet your spend-down. The DSS computers have this information. If your worker cannot give you this information, send your worker a letter confirming what s/he said about which bills were used to meet the spend-down. Keep a copy of your letter with your other records.

If I pay my medical bills, will DSS still  count them to meet my spend-down?

Medical bills for services provided in your current spend-down period are used whether they are paid or unpaid. But medical bills from a previous spend-down period are used only if they are unpaid or you owe a loan to pay the bills. You must have written records about that loan, such as an unpaid credit card balance showing you charged the medical bill.

If you expect you will not have enough medical bills to meet your next spend-down amount, see Plan Ahead above.

What will happen if I do not pay a medical bill?

As with any other bill, you are responsible for paying the medical bills you owe. There is no special exception that allows you to wait to pay your bills because you want to use them to meet a later spend-down.

Caution! If you do not pay a bill on time, you may also have to pay late fees and interest penalties and costs for credit agency reports and collection actions. Sometimes the medical provider will no longer care for you. If you have an ongoing relationship with a doctor or pharmacist, ask them if you can pay over time, instead of paying the full bill right away.

If bill collectors are harassing you or taking legal action against you, contact Statewide Legal Services to learn about your rights: 800-453-3320.

Can I save money to pay a medical bill?

Most people on Medicaid have an asset limit. But for some people covered by Medicaid, especially children pregnant women and parents of children under 18, there is no asset limit. Ask DSS if you have an asset limit to stay on  Medicaid, and what it is.

For most people on Medicaid with asset limits, the  limits are:

$1,600 for 1 person
$2,400 for a married couple

Exception: The asset limits for MED-Connect are $10,000 for 1 person and $15,000 for a married couple.

If you are close to your asset limit, be careful not to go above it. Even a few cents over the limit from interest on a bank account can cause DSS to stop your Medicaid coverage. If this happens to you, the coverage would stop on the day you went over the asset limit.

Tip: If you are close to your asset limit, you could pay for some large medical bills to keep your assets below that limit.

Medicaid rules about assets are complicated. Call Statewide Legal Services if you have any questions.

What if I do not meet my spend-down?

If you do not have enough medical bills to meet your spenddown, Medicaid will not pay for any medical bills in that period. But each spend-down amount is only for one spend-down period (6 months). If you do not meet your spend-down in one period, you may be able to get Medicaid coverage by using those unpaid bills in the next spend-down period. There also may be times when you have a lower spend-down amount because of changes in your income or living arrangements.

Tip: If you do not meet the spend-down amount, tell DSS that you want to stay in the Medicaid program, and ask them to recalculate your spend-down amount for the next period. Tell DSS about any changes in your income, family size or living situation. Also give your DSS worker copies of current statements showing which bills you already gave DSS but were not used to meet your last spend-down period. These unpaid bills can be used in the new spend-down period.

Will my spend-down go up if I go back to work and have more income?

A special program, called MED-Connect, allows people with disabilities to work without losing Medicaid. And in many cases, they will not have a spend-down. MED-Connect is short for "Medicaid for Working Individuals with Disabilities."

You are eligible if:

  • You meet the Social Security Administration's definition of disability, even if you do NOT receive Social Security benefits.
  • You have some earned income that connects you to the federal tax system. For example, you can be self-employed or work a few hours per week.

The income and asset limits for this program are higher than regular Medicaid limits.

In 2013, the limits are:

Monthly income limit: $6,250

Asset limit:
$10,000 for 1 person;
$15,000 for a married couple

Ask your DSS worker how to apply.

Can I get Medicaid without a spend-down?

If you do not qualify for Medicaid without a spend-down, you still might qualify for one of the following programs, which have higher income limits.

Breast and Cervical Cancer Program

This program has no income or asset limits. You are eligible if:

  • You are under 65.
  • You are a U.S. citizen or a qualified alien.
  • You do not have medical insurance.
  • You are not eligible for Medicaid under any other category.
  • You have been screened at one of the 18 Early Detection and Screening Program sites. You must get screened, even if your doctor says you have breast or cervical cancer. To find an Early Detection site near you, call: 860-509-7804.

If you qualify for this program, Medicaid will cover all of your medical needs (not just cancer treatment) during the time you need cancer treatment. And you do not have to have a spenddown.

All of the Early Detection sites will help you complete an application and make sure it goes through quickly.

Connecticut Home Care Program for Elders (CHCPE)

You may qualify for the Connecticut Home Care Program for Elders (CHCPE) if:

  • You are 65 or older, and
  • You need help with some of your daily living activities, such as bathing, dressing, toileting, preparing food, shopping, taking medications, or housecleaning.

The income and asset limits for this program are higher than regular Medicaid limits.

In 2013, the income and asset limits are:

  • Monthly income limit: $2,130
  • Asset limit: $1,600 for 1 person; for married couples the limit depends on amount of your marital assets at the time you needed these services.

This program pays for home health aides, homemakers, skilled nursing, emergency response alert, meals on wheels, adult day care and case management, and all other services covered under regular Medicaid.

If you qualify for CHCPE, you can get Medicaid without a spend-down.

To apply for this program, call DSS's Alternate Care Unit: 800-445-5394.

Personal Care Assistance Program

You may qualify for the Personal Care Assistance Program if:

  • You have a disability, and
  • You need help with some of your daily living activities, such as bathing, dressing, toileting, preparing food, eating, taking medications, or housecleaning.

This program lets you hire personal care assistants who will help you with your daily living activities and all other services covered under regular Medicaid.

The income and asset limits for this program are higher than regular Medicaid limits.

In 2013, the limits are:

  • Monthly income limit: $2,130
  • Asset limit: $1,600 for 1 person; call DSS for married couple asset limits

If you qualify for CHCPE, you can get Medicaid without a spend-down.

To apply for this program, contact the DSS. To find the closest DSS office:

Acquired Brain Injury Program

You may qualify for the Acquired Brain Injury Program if:

  • You have a disability related to a brain injury, and
  • You meet all other Medicaid requirements, except income.

The income and asset limits for this program are higher than regular Medicaid limits.

In 2013, the limits are:

  • Monthly income limit: $2,130
  • Asset limit: $1,600 for 1 person; call DSS for married couple asset limits

This program offers 21 home and community-based services that can help you meet your needs so you can live at home, instead of in a nursing home.

If you qualify for this program, you can get Medicaid without a spend-down.

To apply for this program, contact DSS. To find the closest DSS office:

This booklet was produced by the Legal Assistance Resource Center of Connecticut in cooperation with Connecticut Legal Services, Greater Hartford Legal Aid, New Haven Legal Assistance Association, and Statewide Legal Services.

The information in this booklet is based on laws in Connecticut as of 03/2013. We hope that the information is helpful. It is not intended as legal advice. For advice on your situation, call Statewide Legal Services or contact a lawyer. © 03/2013

For more information, contact:

Statewide Legal Services: 860-344-0380 (Central CT & Middletown) or 1-800-453-3320 (all other regions).

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