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

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Virginia program

Medicaid after medical bills are counted (spend-down)

This route subtracts eligible medical expenses from income to see whether your child can get Medicaid.

What it is

This route subtracts eligible medical expenses from income to see whether your child can get Medicaid.

The agency looks at a six-month period. The income standards are low, so bills may need to be large. Savings and parental income also matter.

Eligibility rules
  • Parental income is counted or deemed for a child living at home.
  • The income standard is very low: about $712 to $939 a month for four people depending on where you live, and the office works it over six months.
  • There is a savings test: $2,000 for one person, $3,000 for two, plus $100 for each additional person.
What you get
  • For an eligible child, Medicaid can begin on the date the spend-down is met, followed by 12 months of continuous coverage, subject to the children’s coverage exceptions.
What the rules cover
  • A bill used in an earlier spend-down cannot be used again.
If you decide to apply
  1. Ask the local Department of Social Services for a medically needy evaluation.
  2. Bring paid and unpaid medical bills, income records and savings information. Ask hospital billing for an itemized statement.

The local Department of Social Services · Official page ↗

If you decide to apply
  • A child under 18 refused FAMIS must be offered a medically needy evaluation.
Good to know

Your child must be under 18 when the spend-down is first met. The bills used to meet it stay yours to pay.

Other details
  • Over six months, everything a family of four earns above roughly $4,273 to $5,633 (depending on locality) has to be matched by medical bills before coverage starts. You do not need to wait six months to bring in bills you already owe; those bills stay yours to pay.

Federal background: Medically needy coverage

Official sources
Ask your social worker

“Could our medical bills open spend-down Medicaid? Which bills would count, what would remain ours to pay, and could you help us request the evaluation?”

Why I’m asking: Large bills may change our options even when income is above the ordinary Medicaid limit.

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

Collect every medical bill, paid and unpaid, and ask for the evaluation.

Your social worker

The hospital billing office can print an itemised statement of everything charged so far.

The care team

Records and letters when the application asks for them.

Who decides
The local Department of Social Services works out the six-month arithmetic.
Ask your social worker
“Our income is over the Medicaid line but the bills are enormous. Can we ask the benefits office for a medically needy spend-down evaluation, and what documents do they want?”

How to apply

First step: Gather every bill from the admission onward and ask the local benefits office for a medically needy evaluation.

  1. Keep every bill and every statement from the admission onward.
  2. Ask the local benefits office in writing for a medically needy evaluation.

Official application / program page ↗

Where it starts: Ask the local benefits office for a medically needy evaluation and take the bills with you. A child under 18 turned down for the state child plan must be offered this evaluation.

What to gather

  • Itemised hospital statements
  • Pharmacy and clinic bills, paid and unpaid
  • This month's income

How long: The agency works in six-month periods; no measured turnaround was published.

What a yes looks like

A notice states when the spend-down is met and the child’s continuous-coverage dates.

What a no looks like, and the next move

A notice explains which income, resources or bills prevent eligibility. The office can review newly incurred bills during the budget period.

Watch out

  • Entry to this children’s group requires age under 18. An approved continuous-coverage period does not automatically end at 18.
  • Do not multiply the monthly standard by six; the agency uses its own published six-month figure.
  • A bill already used in an earlier spend-down cannot be used again.

The numbers and the rules

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

What it is worth

Medicaid can start when an eligible child meets the spend-down, followed by 12 months of continuous coverage subject to child coverage exceptions.

  • $712.2/month — Monthly spend-down standard, unit of 4, lowest locality group
  • $776.95/month — Monthly spend-down standard, unit of 4, middle locality group
  • $938.81/month — Monthly spend-down standard, unit of 4, highest locality group
  • $2,000 — Savings limit, one person
  • $3,000 — Savings limit, two people

Covers: Full Medicaid from the spend-down date, followed by 12 months of child continuous coverage subject to exceptions

What it costs the family: Bills used to meet the spend-down can remain the family’s responsibility.

The eligibility facts, as published

Age
under 18 for the ordinary children's group
Age max exclusive
18
Income
countable income over six months, less incurred medical expenses, compared with the published locality standard
Resources
$2,000 for one person, $3,000 for two, plus $100 each; a December 2003 section still in the current manual
Parental income
counted or deemed for a child living at home
Budget period
six months

The trap: The standards are locality standards, not poverty percentages, and they are very low. For four people the monthly standard is $712.20, $776.95 or $938.81 depending on the locality. So this works only when the bills are big enough to close a wide gap.

Where I read this

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