Written by a parent, not a doctor. Nothing here is medical advice.

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Maryland program

Spend-down Medical Assistance for a stretch of big bills

A route to Medical Assistance when income is too high and medical bills are large. It is called spend-down.

What it is

A route to Medical Assistance when income is too high and medical bills are large. It is called spend-down.

Spend-down compares medical bills with income above a state standard. It may help when ordinary child coverage does not fit. The worker needs the actual bills and must explain the calculation for your child.

Eligibility rules
  • This route covers eligible children under 21 living in Maryland.
  • The usual consideration period is six months beginning with the application month, subject to regulatory exceptions.
  • The worker sets an income standard for your child’s household and works out how much in medical bills must be reached over six months before coverage starts. Ask for that calculation in writing.
What you get
  • Medical Assistance for the certified period once the spend-down is met.
  • Some older unpaid bills can count toward the amount.
What the help covers
  • Full Medical Assistance benefits apply for the approved certification period. There is no premium.
If you decide to apply
  1. Ask the local health department or the hospital financial counselor for a spend-down review for your child.
  2. Have itemized bills ready, including older unpaid bills, and records of payments or write-offs.
  3. Ask the worker to show the income standard, period and bills used in the calculation.

Maryland Department of Human Services; the hospital financial counselor can help with the spend-down request. · Official page ↗

After you apply
  • The Department of Human Services handles F99 processing. The hospital financial counselor can help obtain the itemized bills the eligibility worker needs.
  • Your social worker can ask the Department of Human Services which unit and form handle children's F99 spend-down. Accepted medical expenses must meet the calculated amount before coverage begins for the remaining period. Medicaid does not reimburse the bills used to meet spend-down. The agency confirms the exact start date and whether a cash pay-in option exists; a lump-sum payment is not assumed.
Good to know

The total billed is not necessarily the amount that counts. A bill paid by someone else or already used for another period cannot count again.

Other details
  • Older bills must still be owed and cannot have been forgiven, paid by another party or used for an earlier certification.

Federal background: Medically needy Medicaid.

Official sources
Ask your social worker

“Could the bills we still owe help our child qualify through spend-down? What would it cover and leave us owing, and could you help us request the calculation before we decide?”

Why I’m asking: I want to understand whether large medical bills can open coverage when our income is over the usual line.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask for spend-down by name and hand over every itemised bill, including older unpaid ones.

Your social worker

The hospital financial counselor gives you the itemised bills in the form the eligibility worker needs.

The care team

Records and letters when the application asks for them.

Who decides
The Maryland Department of Health decides; the Department of Human Services handles the paperwork for this group.
Ask your social worker
“Can we ask for a spend-down determination for my child, hand in the itemised bills including the ones from before we applied, and see which income schedule the worker used?”

How to apply

First step: Ask the local health department or Department of Social Services for spend-down, and use the words coverage group F99.

  1. Ask the local health department or Department of Social Services for spend-down and name coverage group F99.
  2. Collect every itemised bill, including any from before the month you apply.
  3. Ask the caseworker to show you which schedule your child is budgeted against.

Official application / program page ↗

Where it starts: Apply for Medical Assistance and ask in writing for spend-down, naming coverage group F99.

What to gather

  • Every itemised hospital and pharmacy bill
  • This month's income for the household
  • Proof that older bills are still owed

How long: The consideration period is six months from the month you apply.

What a yes looks like

A certification covering the six-month period, with the date coverage starts once the bills met the difference.

What a no looks like, and the next move

Ask which schedule was used and what figure your income was compared against, then appeal by the date on the notice.

Watch out

  • Keep every itemised bill. A bill already used for another certification, paid by someone else or written off cannot be counted again.
  • Maryland's own documents point at two different income schedules for a child. Ask the worker to show you the calculation rather than accepting a bare no.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 11, 2026.

What it is worth

Coverage for a six-month period once bills cover the difference between your income and the standard. The published non-MAGI monthly standards are $434 for three, $475 for four and $521 for five, with six-month figures of $2,600, $2,850 and $3,126.

  • $434/month — Non-MAGI medically needy monthly income standard, assistance unit of 3
  • $475/month — Non-MAGI medically needy monthly income standard, assistance unit of 4
  • $521/month — Non-MAGI medically needy monthly income standard, assistance unit of 5
  • $2,600 — Published six-month medically needy standard, assistance unit of 3
  • $2,850 — Published six-month medically needy standard, assistance unit of 4
  • $3,126 — Published six-month medically needy standard, assistance unit of 5
  • $3,200 — Non-MAGI medically needy resource standard, assistance unit of 4

Covers: Full Medical Assistance benefits for the certified period

Legal protection: Bills from before the application month can count where they were not used before, were not paid by someone else and are still owed

What it costs the family: No premium is stated. Expenses used to meet spend-down are not reimbursed by Medicaid. DHS confirms the exact coverage start date and whether any cash pay-in option exists.

The eligibility facts, as published

Age
under 21
Age max exclusive
21
Income
Non-MAGI Schedules MA-1 and MA-2 for the unit size (COMAR 10.09.24.09). The Coverage Group Guide separately gives coverage group F99 a MAGI income floor of 123% FPL and centralises its processing at the Department of Human Services. The two were not reconciled in the research.
Period
Six-month consideration period beginning with the month of application, subject to the regulation's exceptions
Residency
Maryland

The trap: Older unpaid bills can count, but only if they were not used for an earlier certification, were not paid by anyone else, are still owed and were not forgiven. Keep every itemised bill. Which schedule the state actually budgets a child against was not established: the regulation points to the non-MAGI Schedules MA-1 and MA-2, while the coverage guide gives this group a separate income floor of 123 percent of the poverty level and sends the paperwork to a different agency.

Where I read this

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