Medicaid Medically Needy Program

Individuals applying for the Medicaid health care program must meet strict requirements in order to be considered eligible for receiving these benefits.

Additionally, that is the case for various government programs. Furthermore, states offering Medicaid can opt to provide medically needy programs for individuals whose income exceeds the financial eligibility stipulated for Medicaid. In general, these medically needy programs are subsidiaries of Medicaid. Moreover, they are offered whenever the medical expenses of a resident reduce his or her taxable income below a specific threshold that is determined by the state. Therefore, to qualify for these programs, you will need fall within a “spending down” amount.

If you make a living wage above the poverty line that makes you ineligible for Medicaid, utilizing a medically needy program can help you attain the health care you need. To learn about eligibility requirements for the medically needy programs and what is considered a “spending down” amount by different states, read the sections below.

How to Determine Your Eligibility for a Medically Needy Program

If you have applied for Medicaid and were denied coverage due to the fact that you exceeded the program’s maximum income, which was established by the federal government, you may be eligible to receive care through a medically needy program. However, you must have significant health care needs to qualify for these programs, as your total health care cost will need to reduce your income below a certain threshold, allowing you to fall in between a “spending down” amount. Also known as “spenddown,” a “spending down” amount is categorized as the difference between your income and the expenses you have incurred while paying for health care services.

As a general rule, to qualify for medically needy programs, your health-related expenses can be incurred through remedial care or medical care. However, the expenses must occur while you are receiving services without being covered by health insurance. Moreover, your state will stipulate the medically needy income level you must meet before you are deemed eligible for one of these programs. Once the incurred expenses exceed the medically needy income level established by your state, you will become eligible to receive Medicaid coverage.

What states offer medically needy programs?

Medicaid is a federal government-sponsored program. However, the state you reside in may offer different benefits in comparison to other regions of the country. In general, states that fall into the 209(b) category utilize more restrictive requirements for medically needy programs than other states. On the other hand, states falling under the 209(b) classification are required to provide “spenddown” programs for individuals who have disabilities, are blind or are older than 65 years of age, even if they do not meet the more restrictive requirements. Thus, in order to evaluate whether you are eligible for a medically needy program, make sure to identify whether your state falls under the 209(b) category.

Currently, medically needy programs are available in 36 states throughout the country, as well as in the District of Columbia. In these states, you will either be able to gain access to a “spenddown” program or a medically needy program, regardless of whether a state is considered a 209(b) state. However, you may have to contact Medicaid directly to determine which specific programs are offered in your state prior to enrollment. Some of the states offering medically needy programs are:

  • Connecticut
  • Georgia
  • Illinois
  • Kentucky
  • Maine
  • Montana
  • Nebraska
  • New Hampshire
  • North Dakota
  • Washington
  • West Virginia

Missouri, Ohio, and Oklahoma are considered 209(b) states and do not offer medically needy programs. However, residents in Missouri or Ohio who have a disability or are older than 65 years of age may be able to qualify for Medicaid benefits rather than enrolling in a medically needy program. On the other hand, Oklahoma does not offer a “spenddown” program of any kind. Thus, residents in that state must meet the federal government requirements for Medicaid to receive coverage.

What benefits are included in a Medicaid medically needy program?

Medically needy programs with a “spenddown” amount will stipulate a particular period in advance, in which you must meet the requirements for the program. During this timeframe, your income and medical expenses will be assessed to determine if you have qualified for coverage. Moreover, you will need to re-apply for the Medicaid medically needy programs during each “spenddown” period, as your enrollment will not carry over long-term. Once you have met this threshold, you will be able to actively receive Medicaid benefits for the remainder of the year, even after the “spenddown” period has concluded.

After you have entered a medically needy program and have been afforded Medicaid coverage for the remainder of the year, you will be entitled to every benefit provided by the program. Benefits included in Medicaid medically needy programs include basic levels of health care, such as inpatient and outpatient hospital services. In general, there are federally mandated benefits that you must receive through Medicaid coverage in every state, and then there are additional benefits provided on an optional basis depending on each state. To determine what optional benefits are available through your state, you must contact a Medicaid representative and learn more about the services offered there. Furthermore, in most states, you can gather this information by contacting a local Social Security office. However, it is a good idea to make an appointment to speak with a representative before visiting a Social Security office, as these establishments experience long wait times in certain locations.

Additional benefits you can gain through a Medicaid medically needy program include home health services, family planning services and physician services. If you are required to frequently visit your primary care physician to receive treatment for an ongoing treatment, this will be covered under the Medicaid program. For individuals who are unable to travel to an office to receive treatment, they may be eligible to receive home health services that meet the needs of their ongoing health condition. In addition, the treatments that you have throughout a given year that drive up your accrued expenses for medical treatment will be covered by Medicaid once you have gained entry to the medically needy program. Furthermore, this will help to make the cost of treatment more manageable for the duration of the year.

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