What it is:
A spenddown is the amount of medical expenses for which you are responsible, similar to an insurance deductible. This program is an option when your income exceeds the income limits set in WAC 182-519-0050.
You won’t have Apple Health coverage (Medicaid) until you’ve provided medical bills to DSHS to show you meet your spenddown liability. DSHS will not pay these bills. They’ll be used to reduce your spenddown liability.
We calculate your Spenddown Liability period into either 3 or 6 consecutive calendar months. This period is called your base period. Once your spenddown liability is met, you may receive health care coverage for all or part of the base period. Depending on your medical needs, you can choose your base period that will give you the longest coverage or least liability for your needs
Call 877-501-2233 to choose a base period that best fits your needs. If you don’t contact us, your default base period will be 6 months.
Spenddown example:
A single person receives $1,200 per month in Social Security Disability benefits and has $1,000 in savings. Their resources are below the resource limit, but their income is above the income limit.
They would then be eligible for Apple Health coverage once they’ve met their spenddown liability by providing bills.
| SSA Benefit Amount | $1,200 |
|---|---|
| Minus the General Income Disregard | $1,200 - $20 = $1,180 |
| Countable Income | $1,180 |
| Medically Needy Income Limit | $967 |
| Subtract the income limit from the countable income | $1,180 - $967= $213 |
| Total amount over the monthly income limit | $213 |
The calculation below is a comparison of a 3-month and 6-month base period.
| 6 Month Base Period = Amount over income limit multiplied by 6 months | $213 x 6 = $1,278 |
|---|---|
| 6 Month Spenddown Liability Amount | $1,278 |
| 3 Month Base Period = Amount over income limit multiplied by 3 months | $213 x 3 = $639 |
| 3 Month Spenddown Liability Amount | $639 |
Example:
A person has a 6-month spenddown liability of $1,278 starting on Jan 1, 2025
The following bills were submitted to DSHS.
| Medical Expense | Amount Applied To Spenddown | Date Applied to Spenddown | Remaining Spenddown Liability |
|---|---|---|---|
| Emergency Room Visit- $200 | $200 | 1/15/2025 | $1,078 |
| Copays- $400 | $400 | 1/20/2025 | $678 |
| Prescriptions- $500 | $500 | 2/1/2025 | $178 |
Hearing Aid/Supplies-$500
| $178
| 3/1/2025
| $0 *This is the date medical coverage will begin. |
Note: Each expense applied toward the spenddown is the customers responsibility. DSHS won’t pay bills used to meet your spenddown.
Qualified medical expenses are subtracted from your spenddown liability. Once your liability is at $0, that is the date your medical coverage begins. In this example, coverage begins March 1 and will end on June 30.
What kind of bills can I provide to meet my spenddown?
The table below gives common examples of allowable vs. expenses not allowed. See the resource section below for a full list.
| Allowable Expenses | Expenses Not Allowed |
|---|---|
| Medical supplies and drugs, including OTC drugs prescribed by an M.D., D.O. or A.R.N.P. | OTC drugs and medications not prescribed, including medical cannabis, even if it is prescribed |
| Hospital services, emergency room, clinic (including mental health clinics) and nursing facility expenses | Massage Therapy, unless prescribed (must be provided by licensed practitioner) |
| Medical transportation by personal vehicle at the current state reimbursement rate | Food, health food and nutritional supplements, unless prescribed |
Bills used to meet your spenddown must:
- Show statement date within the current base period
- Show original date of service and provider name
- This does not include the statement from your insurance provider showing potential expenses
- Be unpaid expenses at the beginning of your base period
- Be for services incurred during the base period
- Be for medical services incurred and paid during the three month retroactive base period if eligibility for Apple Health Medicaid was not established in that base period.
Prescription receipts must show:
- The name and prescription number of the prescription purchased
- The out-of-pocket amount for the prescription
- The pharmacy you purchased the prescription from
- The date the prescription was purchased
Reminder: Bills do not have to be paid to be applied to your spenddown, just show the expense that are owed.
Additional Resources
| Topic | Link |
|---|---|
| Income and Resource Information | Program standard for income and resources |
| Spenddown Overview Manual | Apple Health spenddown overview |
| WA Apple Health Eligibility Overview | Eligibility Overview |
| Allowable Spenddown Expenses | Allowable Expenses Chart |
| Allowable Spenddown Providers | Allowable Practitioners |
| Questions | Contact Information |