| Meeting the Medicaid Surplus
Income Spenddown
What is Medicaid surplus?
When you have private health insurance with a deductible, you are
required to to meet that deductible once a year by paying out of
pocket medical expenses before your insurance will start honoring
your claims.
The easiest way to understand Medicaid with a surplus spenddown
is to think of it as a deductible which has to be met every month
instead of every year.
Example: As of January 2007, individuals are
allowed to have $700 (there is a $20 disregard on income) in monthly
income
to be eligible for regular Medicaid coverage without a surplus.
If you applied for Medicaid and your income was $920 per month,
you would receive a letter from Medicaid stating that you have
been accepted into the Medicaid program with a surplus of $200.
This
means that if you want to use your medicaid card in a given month,
you would be responsible for the first $200 of medical expenses
incurred in that month. Once you submit the paid bills (they will
also accept unpaid bills) along with a copy of the Medicaid acceptance
letter; Medicaid will activate your coverage for that full month
allowing you to use your Medicaid card for any service covered
by
Medicaid.
How can I meet the Surplus Income Spenddown?
As a person with HIV illness, you no doubt have limited income
and high medical expenses. The AIDS Drug Assistance Program (ADAP),
administered by The New York State Department of Health, offers
a solution which could enable you to meet your Medicaid surplus
without incurring out of pocket expenses as described above. If
you take medication for HIV illness, the medication you take may
be paid for by ADAP (you can determine that by calling ADAP at 1-800-542-2437).
If the monthly cost of the medication is at least equal to the amount
of your Medicaid surplus, you can apply for ADAP to meet the Medicaid
surplus without incurring out of pocket expenses. If the cost of
the medication you take is less than the amount of your Medicaid
surplus, you should still apply for ADAP but you will have to incur
some out of pocket expenses to meet the full amount of your Medicaid
surplus.
Example: Let's say it is January and you have
just received the letter from Medicaid accepting you with a $200
surplus. You don't need Medicaid for anything in January, but you
have an appointment on February 15 at a clinic, and you need Medicaid
to pay for the visit. In the beginning of February, you would fill
your prescriptions at your pharmacy using your ADAP card to pay
for them. The pharmacist will be able to give you a paid receipt
for the cost of the medication (let's say $230) which you can send
or take to your local Medicaid office. You should include a copy
of your Medicaid surplus letter. Several days later, you should
receive a letter from Medicaid stating that your coverage has been
activated for the month of February and that you have a credit of
$30 towards your surplus for March. If you need to use your Medicaid
card in March, you can repeat the same process to activate coverage.
(ADAP Plus receipts can be used in the same way.)
Can ADAP help with my deductible for my health insurance?
Health insurance deductibles generally have to be met once a year,
usually starting in January. If you inform ADAP that you need to
use ADAP for the deductible, bills will be sent to your insurance
company as you use your ADAP card. (ADAP will require a copy of
your insurance booklet to confirm the amount of the deductible.)
For details, please call ADAP at 1-800-542-2437.
The Client Advocacy Unit at GMHC is available to assist
you. For more information, please call our Helpline: 212/367-1125,
Wednesdays 2 pm to 5:30 pm. Walk-in services are availableTuesdays and Thursdays, 10 am to 1 pm.
Revised 3/07
© 2007 Gay Men's Health Crisis
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