Frequently Asked Questions: Spenddowns

What is a Spenddown?

A spenddown is like an insurance deductible. If your income is more than the allowed income limit, you may still qualify for medical assistance by meeting a spenddown. A spenddown is the amount you must pay towards medical bills before the state will start to pay.

There are many types of spenddowns. Your county case manager will be able to help you decide what kind of spenddown is best for you.

How is my spenddown amount decided?

The county determines your spenddown by subtracting your net income from the income limit. Your spenddown amount is based on many factors, such as your age and family size. The example below we received from the county, may help you understand how the county figures spenddowns.

Example: Your family's income is $1,500 per month. Your counted income is $1,800 per month. Your spenddown amount is $300 per month ($1,800 - $1,500 = $300). You owe $300 towards medical bills each month.

How do I find out how much my spenddown will be?

You should have received a letter from the county indicating the amount of your monthly spenddown. If you have not received a letter with this information, please contact your county financial worker or county case manager.

How does PICS fit into the spenddown process?

PCIS does not participate in the determination of a spenddown for anyone. Due to HIPPA laws, PICS is not allowed to have any information about a client's financial situation with the exception of their waiver dollars. The only time PICS learns of a client's spenddown is when we bill the state for payment and we receive a denial of payment on an invoice that is due to a spenddown. Unfortunately, we receive no additional information other than it is the client's responsibility to pay us directly.

I received a spenddown invoice from PICS but was never notified by the county of my spenddown. What should I do?

You should begin by contacting your county financial worker to determine if you should have a monthly spenddown and if so, how much it should be. If your county financial worker determines you should not have a spenddown, ask them to correct their system so you no longer receive invoices. Make sure to call PICS and let us know of the information you received so we can also correct our system.

I can't afford to pay my bill. What should I do?

Call us, we will work with you. We don't want there to be an interruption in your service. We are willing to work with all our client's to set-up payment plans or defer payment for a month if needed. Just make sure to call us, we will do anything we can to work with your situation.