Medicaid Spend Down in Georgia: Calculation, Bills That Count, and Miller Trust

Medicaid spend down in Georgia is the pathway that lets people who are aged, blind, or disabled qualify for Medicaid even when their income is too high, by applying their medical bills against the excess. The program is formally called Aged, Blind, and Disabled Medically Needy, and it works like a monthly medical deductible: once your out-of-pocket health costs cover the gap between your income and Georgia’s Medically Needy Income Level, Medicaid picks up the rest for that month. It is administered by the Division of Family and Children Services (DFCS), with Medicaid oversight by the Department of Community Health.¹²

Who the Spend-Down Is For

You have to be a Georgia resident who is 65 or older, legally blind, or totally disabled. You must also be a U.S. citizen or a lawful permanent resident admitted before August 22, 1996. There is no minimum length of residency.³

Spend-down is a fallback. Before placing anyone in it, DFCS first checks whether the person qualifies for any other ABD Medicaid category (other than the Medicare Savings “Q-track” programs and SSI-based Medicaid). Only if those doors are closed does the medically needy pathway open.¹

The Income and Asset Numbers That Set the Bar

Georgia’s Medically Needy Income Level (MNIL) is $317 per month for an individual and $375 per month for a couple. Those limits were set in October 1990 and have not been adjusted since.⁴⁵ The resource limit tracks SSI: $2,000 for an individual, $3,000 for a couple, and $4,000 for an individual with an ineligible spouse.¹⁶

If your assets are over the limit, you have to bring them down before the income spend-down matters. More on that below.

How a Month’s Spend-Down Is Calculated

Your spend-down amount is simply your net countable monthly income minus the MNIL. Someone with $1,317 in net countable income has a $1,000 monthly spend-down. Georgia reviews cases over a six-month period, but each month is treated as its own separate budget, so you have to meet the spend-down again each month to get coverage that month.¹

Medical expenses are applied against the spend-down in a strict order. First come allowable bills from prior months that haven’t already been used for an earlier spend-down, taken in chronological order. If those alone eliminate the spend-down, you are eligible from the first day of the current month. If they don’t, current-month expenses are applied next, also chronologically.¹

When multiple bills share the same date, DFCS ranks them: expenses of an ineligible spouse or child come first; then non-covered items like over-the-counter drugs or visits to non-Medicaid providers; then expenses payable to a Medicaid provider. One exception overrides the chronological rule entirely: if you pay your own Medicare premium, that premium is deducted first each month, no matter when it was incurred.¹

First Day Liability and the Break-Even Date

The ranking matters because of First Day Liability. If the specific bill that finally brings your spend-down to zero is one payable to a Medicaid provider, you owe a portion of that bill yourself. Medicaid coverage then starts on the date that bill was incurred, which DFCS calls the break-even date. The liability is documented on Form 400.¹

If you don’t rack up enough qualifying expenses in a month, the case sits in suspense until you do or until the month ends with no coverage.¹

Which Medical Bills Count

Each expense you submit must be medically necessary — ordered or prescribed in writing by a recognized medical practitioner — and you must be legally responsible for paying it.¹ Allowable costs include:

Visits to physicians, dentists, chiropractors, hospitals, mental health clinics, psychiatrists, optometrists, and licensed nurses (RNs and LPNs), plus elective surgery and medically necessary ambulance transport.
Prescription drugs not covered by Medicare Part D, hearing aids, eyeglasses, contact lenses, dentures, prosthetic devices, immunizations, over-the-counter medical items, and medical tests.
Health and dental insurance premiums you pay yourself, Medicare premiums for self-payers, and Medicare Part D premiums and co-pays until Medicaid takes over.
Transportation to medical appointments, at the lesser of actual cost or the state’s maximum allowable amount.
Acquisition and maintenance costs for a guide dog or other trained service animal.
Nursing home bills, the medical portion of personal care home charges (room and board excluded), and personal sitter costs when backed by a doctor’s statement of medical necessity. These can be projected forward as billed.¹

Some things don’t count. If a third party (insurance, Medicare) already paid part of a bill, only the balance you still owe can be applied. Debts the provider wrote off are out. Prescriptions covered under Medicare Part D are out, though the Part D co-pays do count. VA Aid and Attendance benefits are not treated as third-party payments, so a veteran’s expenses are not reduced by that benefit.¹

Acceptable proof includes bills, receipts, statements, and Explanation of Benefits forms, and the bills can be either unpaid or paid during the relevant month.¹

How to Apply

You can apply online through the Georgia Gateway portal at gateway.ga.gov, print and mail a paper application from medicaid.georgia.gov, or call 1-877-423-4746 to request a paper form.² A telephone interview is required for every ABD Medically Needy application.¹

Have these ready: proof of age (birth certificate or driver’s license), Social Security card, pay stubs and other income documentation, and statements for bank and investment accounts.² For the spend-down itself, submit copies of the medical bills you want applied. If you are already enrolled in a Medicare Savings Program (QMB, SLMB, or QI-1), you don’t need a separate application; you can request the medically needy program verbally or in writing.¹

If Your Assets Are Over the Limit

Georgia counts cash, bank accounts, stocks, bonds, investments, cryptocurrency, and non-primary real estate. Personal belongings, household furnishings, one automobile, and a primary home (within equity limits) are generally exempt.⁵

You can’t just give extra assets away. Medicaid uses a 60-month look-back period, and uncompensated transfers trigger a penalty period calculated by dividing the value of what was transferred by the average Georgia private-pay nursing home rate.⁷⁵⁸

Some transfers are exempt from the look-back penalty entirely: transfers to a community spouse, to a blind or disabled child of any age, or to a trust established solely for a disabled individual under 65. Homestead transfers have their own exceptions, including transfers to a child under 21, to a caretaker child who lived in the home for at least two years before the applicant’s institutionalization, or to a sibling with an equity interest who lived in the home for at least one year.⁷

If You Need Nursing Home Care: The Miller Trust Alternative

The spend-down is one route. For nursing home applicants whose income exceeds Georgia’s institutional income cap, Qualified Income Trusts (Miller Trusts) are a separate option that shelters excess income from the eligibility calculation. The trust must be irrevocable, contain only income, name the Department of Community Health as remainder beneficiary up to the total Medicaid paid, be set up for a single individual (not a couple), and use a state-approved template. The applicant cannot serve as their own trustee, and the trust cannot be backdated. Failing to fund it each month costs eligibility.⁹ Help is available through the Georgia Senior Legal Hotline (1-888-257-9519) and local Area Agencies on Aging (1-866-552-4464).¹⁰

Two Things Worth Knowing Before You Enroll

If one spouse enters a nursing home and the other stays in the community, federal spousal impoverishment rules let the community spouse keep a share of the couple’s assets and a minimum monthly income, so you are not required to drain the household to qualify the ill spouse.¹¹

Georgia also runs a Medicaid estate recovery program. After death, the state can seek reimbursement from the estates of recipients who were in a nursing facility (any age) or who were 55 or older and received nursing home, personal care, home and community-based, hospital, or prescription drug services. Estates with a gross value of $25,000 or less are exempt for deaths on or after July 1, 2018, and recovery is blocked while a surviving spouse, a child under 21, or a blind or permanently disabled child lives in the home.¹²¹³

1
Georgia DFCS PAMMS. ABD Medically Needy Spenddown
2
BenefitsCheckUp. Georgia Medicaid
3
Georgia DFCS. ABD Medicaid Fact Sheet
4
Georgia DFCS PAMMS. Appendix A1 – ABD Limits
5
Medicaid Planning Assistance. Medicaid Eligibility Georgia
6
DB101 Georgia. SSI Resource and Income Limits
7
Georgia DFCS PAMMS. Transfer of Assets
8
Paying for Senior Care. Medicaid Spend Down
9
Georgia DFCS PAMMS. Qualified Income Trusts
10
Georgia DHS. Medicaid Information for Long-Term Care
11
Centers for Medicare and Medicaid Services. Spousal Impoverishment Standards
12
Georgia Department of Community Health. Medicaid Estate Recovery
13
Georgia Secretary of State. Medical Assistance Estate Recovery