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

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Pennsylvania program

Spend-down Medical Assistance for a period of huge bills

Medical Assistance for a period of large unpaid medical bills. A spend-down uses qualifying bills against income before coverage begins.

What it is

Medical Assistance for a period of large unpaid medical bills. A spend-down uses qualifying bills against income before coverage begins.

Medically Needy Only MA compares income with a very low six-month standard. Bills that remain your responsibility can help meet the gap. This is a different calculation from ordinary child MA, and PH95 may offer a simpler route for a child under 18.

Eligibility rules
  • Pennsylvania's medically needy child group includes children under 21. The county compares net income after allowable medical expenses with the six-month standard.
  • For household sizes 2–6, the posted monthly standards are $442, $467, $567, $675 and $758.
  • The six-month standard is $2,800 for three people, $3,400 for four and $4,050 for five. Bills you owe must use up everything you earn above that figure before coverage starts.
  • The child resource exemption applies under 21. Adult resource rules are a separate question.
What you get
  • MA coverage after qualifying bills meet the spend-down.
  • A six-month period for the income-and-bills calculation.
  • No savings test for a child under 21.
What the help includes
  • An unpaid bill must remain the applicant's legal obligation, with no third party responsible for paying it.
  • A bill cannot have been used in an earlier eligibility calculation or be payable by MNO after authorization.
  • Paid bills count only from the application month or retroactive period. Older unpaid bills can qualify if the other requirements are met.
If you decide to apply
  1. Ask the financial counselor to discuss a Medically Needy Only review with the County Assistance Office.
  2. Bring dated itemized bills, insurance statements and income records for the period being reviewed.
  3. Ask for the calculation in writing so you can see which bills count and when coverage would begin.

1-866-550-4355 · Official page ↗

After you ask
  • The social worker can ask the County Assistance Office for a Medically Needy Only review through the MA application process and check whether extra forms are needed. Ask for a written six-month calculation showing which bills meet the spend-down and the first date MA would pay. Amounts used to meet spend-down are not automatically paid by MA; hospital financial assistance can be a separate question.
  • The county's written calculation should identify the budget period, allowed bills and coverage date.
Good to know

Insurance-paid bills do not count toward the spend-down. The bills used to meet it are not then paid by MNO-MA.

Other details
  • For a family of four, everything earned above $3,400 over six months has to be matched by medical bills you still owe before coverage begins, so this only fits a period of very large bills.
  • PH95 has no spend-down for an eligible child under 18. Age, disability and the child's own income decide whether that route fits.

Federal background: Medically needy Medicaid.

Official sources
Ask your social worker

“If we have bills insurance does not cover, would a spend-down help or would PH95 be better? Could you show us which bills qualify and what we would still owe before we decide?”

Why I’m asking: I need to know whether using our bills to qualify actually leaves us with less to pay.

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

Gather the dated bills and pay stubs for the six-month period and ask for the spend-down calculation.

Your social worker

The social worker pulls the itemized bills and insurance statements, checks which ones count, and asks the county for the calculation.

The care team

Records and letters when the application asks for them.

Who decides
The County Assistance Office (the county benefits office)
Ask your social worker
“Can you get us the six-month spend-down calculation for the admission period, and tell us which of these bills count?”

How to apply

First step: Ask the County Assistance Office (through COMPASS or 1-866-550-4355) for a Medically Needy Only spend-down review. Bring itemized bills for the months you need covered.

  1. Ask the county for the six-month spend-down calculation for the period with the admission.
  2. Hand over itemized bills and insurance statements for those months.

Official application / program page ↗

Where it starts: Apply for MA on COMPASS or at the County Assistance Office and ask for a Medically Needy Only spend-down review with the itemized bills (routing inference; no separate MNO form was found).

What to gather

  • Itemized hospital and clinic bills with dates of service
  • Insurance explanations of benefits showing what is left to you
  • Pay stubs for the same months

How long: The county calculates a six-month period. We found no published processing time for spend-down; the general COMPASS standard is 30 days.

What a yes looks like

A written calculation naming the spend-down amount and the date it was met. MA pays from that date to the end of the period. Give every provider the dates so they rebill.

What a no looks like, and the next move

Ask whether it failed on bills already paid, bills payable by insurance, or the wrong period. Ask for the written calculation. Appeal by the notice date.

Watch out

  • The standard is not the MA income limit. For four people it is $567 a month, so the spend-down is almost the whole six months' income.
  • Bills paid by insurance do not count. Bills you still owe do, even old ones, as long as no one else has to pay them.
  • A child under 18 within 24 months of diagnosis has a better option: PH95 is free and needs no spend-down.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 9, 2026.

What it is worth

MA once bills pass the spend-down. Monthly standards $442 (two people) to $758 (six); six-month standards $2,650 to $4,550. No savings test for a child under 21.

  • $442/month — Monthly standard, 2 people
  • $467/month — Monthly standard, 3 people
  • $567/month — Monthly standard, 4 people
  • $675/month — Monthly standard, 5 people
  • $758/month — Monthly standard, 6 people
  • $2,800 — Six-month standard, 3 people
  • $3,400 — Six-month standard, 4 people
  • $4,050 — Six-month standard, 5 people

Covers: Medical Assistance services for the covered part of the period

What it costs the family: You must first owe bills equal to the spend-down (your income above the standard).

The eligibility facts, as published

Age
under 21 (state plan medically needy group)
Income
countable net income less allowable medical expenses compared with the six-month standard (55 Pa. Code §181.14(c))
Budget period
six months
Resources
exempt for children under 21 (MA Handbook 340 Appendix A)
Deductible bills
unpaid bills not payable by a third party, still the applicant's legal obligation, not payable by MNO after authorization and not used in a prior determination; paid bills only from the application month or the retroactive period
Standards effective
1990-02-03, still posted

The trap: For four people the standard is $567 a month ($3,400 over six months). Bills must use up income above that, which is nearly the whole period's income. Do not multiply the monthly figure by six; the county uses the six-month cell.

Where I read this

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