health care survival guide > Hospital care

If you have no insurance and need to be hospitalized, the hospital should admit you first and then take an application from you for state medical assistance for you to cover your stay. Once you are admitted to the hospital, the bills you accumulate will be deducted from your income, which should bring you under Medical Assistance eligibility standards. You should work out this plan with the hospital business office.

This is called SPEND DOWN or PATIENT PAY. All costs after you reach the Medical Assistance level will be covered by the Commonwealth by Pennsylvania. You should then work out a reasonable payment plan for whatever is not covered by Medical Assistance.

Unfortunately, many health providers are unaware of this program and its benefits. It allows doctors and hospitals to treat uninsured patients and get paid for their services. If you are uninsured and in need of inpatient hospital care you should ask that you be admitted using the Spend-Down to cover your bill. Hospitals can take a Spend down application for MA for someone who has already been admitted.

You may be eligible for the Spend-Down program during any 1 month or 6 month period in which you incur high medical bills. The length of time you need medical treatment and the costs for that treatment each month will determine which category of spend-down you will be eligible for. Each category has different spend-down limits. People who are disabled, such as those on SSDI or Workers' Compensation, have to spend down to the SSI income limit (see SSI section page 53). People with minor children who are not disabled can spend down to the TANF income level for their family size (see page 45). Single, non-disabled adults without minor children can spend down to the Medically Needy Only (MNO) limit (see previous page) based on their income or expected income over a six month period, or to the lower GA income limit each month as long as they fit into one of the categorical eligibility requirements.

How to figure out the Spend-Down

Take the difference between your income and any allowable medical expenses or deductions for MA eligibility level

For example:

If your monthly income is $1,000 per month and the limited MA income requirements for a single person is $205 per month, then you would be responsible for $795 of your hospital or medical bills and Medical Assistance would pay the rest.

For one month of full MA benefits:

All bills over $795 will be covered for that month, meaning that the vast majority of any hospital stay would be covered.

For six months of limited benefits:

All bills over $3,600 would be covered for the next 6 months allowing you hospital care and follow up coverage.

In either case, as soon as you get medical bills equal to the amount of your spend-down, you become eligible for MA.

If you have been told that you have a spend-down, make sure that all of your allowable bills have already been subtracted from your income. Allowable bills include any unpaid medical bills or medical bills you have paid in the three months prior to applying for the Spend down.

Although the limited MA benefits eligibility levels are higher per month than full benefits levels, by the time excess income is multiplied by 6 months, the spend-down to full benefits can become sizable. The only way to get a one-month spend-down to the MNO program is to apply for retroactive authorization.

• For example:
  Mr. Jones lives alone and is disabled. He gets a monthly Social Security Disability (SSD) check of $795 a month. His income is too high for Healthy Horizons. Therefore, to be eligible for Medical Assistance he must incur a spend-down. Since he is disabled, he can spend-down to the SSI income limit of $558 a month. If you take his monthly income ($795) and subtract the SSI income limit ($558) you get $125. Therefore, Mr. Jones must incur $237 in medical bills each month before he becomes eligible for MA. Once he has incurred $237 in bills, MA will pay the rest of his medical. If he has regular prescription expenses of $237 for example, he could qualify for ongoing MA.
  

Call the UIC Hotline (215)-557-0848 or the Pennsylvania Health Law Project HealthLine at (800) 274-3258 for further information and assistance with the Spend Down program.

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