If your mom's income is too high for Medicaid, medically needy Medicaid may still let her qualify once her medical bills add up to the amount her income is over her state's medically needy limit. That limit can be far lower than the regular income limit. States choose whether to run the program and whether to include older adults: federal rules require it to cover only pregnant women, children under 18 and women just after a covered pregnancy, and aged, blind and disabled adults are an optional group.,

In This Guide

Three Questions That Decide It

Hearing "her income is too high" can feel like a door closing. It may not be. Three questions decide whether she can still qualify.

  1. Does your state run a medically needy program? Under federal Medicaid rules, medically needy coverage is a state option, set out in 42 CFR 435.301.
  2. Does it cover your parent's group? A state with a medically needy program must cover pregnant women and children under 18 who would qualify as categorically needy except for their income and resources. It must also keep covering a woman who had medically needy Medicaid while pregnant through the end of the month in which the 60-day period after her pregnancy ends. Aged, blind and disabled adults are an optional group a state may add, so whether a state's program covers ABD adults varies by state; the table below shows which states do.
  3. How low is its income standard? Her spend-down is the gap between her income and that standard, so the lower the standard, the more medical bills it takes to qualify.

Which States Have Medically Needy Medicaid?

Whether your parent's state looks like it offers medically needy Medicaid depends partly on which list you read. Two federal sources track it for ABD adults, and they don't fully match. As of September 2025, MACPAC shows 32 states plus DC with a medically needy pathway. SSA's Program Operations Manual System (POMS) list, last revised in 2016, marks 34 states plus DC. Find your parent's state below.

State MACPAC 2025 medically needy level (% of poverty) On SSA's 2016 medically needy list? MACPAC 2025 special income level (% of poverty)
Alabama None No 222%
Alaska None No 178%
Arizona None No 222%
Arkansas 8% Yes 222%
California 138% Yes None
Colorado None No 222%
Connecticut (209(b)) 64% Yes 222%
Delaware None No 185%
District of Columbia 64% Yes 222%
Florida 14% Yes 222%
Georgia 24% Yes 222%
Hawaii (209(b)) 31% Yes None
Idaho None No 222%
Illinois (209(b)) 100% Yes None
Indiana None No 222%
Iowa 37% Yes 222%
Kansas 74% Yes 222%
Kentucky 18% Yes 222%
Louisiana 8% (varies by location) Yes 222%
Maine 24% Yes 222%
Maryland 27% Yes 222%
Massachusetts 40% Yes 222%
Michigan 31% (varies by location) Yes 222%
Minnesota (209(b)) 100% (effective; see note) Yes 222%
Mississippi None No 222%
Missouri (209(b)) 85% No 130%
Montana 40% Yes None
Nebraska 30% Yes None
Nevada None No 222%
New Hampshire (209(b)) 72% Yes 222%
New Jersey 28% Yes 222%
New Mexico None No 222%
New York 138% Yes None
North Carolina 19% Yes None
North Dakota (209(b)) 90% (effective; see note) Yes None
Ohio None No 222%
Oklahoma None Yes 222%
Oregon None Yes 222%
Pennsylvania 33% Yes 222%
Rhode Island 89% Yes 222%
South Carolina None No 222%
South Dakota None No 222%
Tennessee None Yes 222%
Texas None No 222%
Utah 100% Yes 222%
Vermont 110% (varies by location) Yes 222%
Virginia (209(b)) 47% (varies by location) Yes 222%
Washington 74% Yes 222%
West Virginia 15% Yes 222%
Wisconsin 100% Yes 222%
Wyoming None No 222%

MACPAC states each level as a percentage of the federal poverty level, and for the four states whose standard varies by location it lists the highest. Minnesota and North Dakota work differently. Minnesota's medically needy income limit is $482 a month, about 37 percent of the poverty level, but the state disregards income between that limit and 100 percent of the poverty level for its ABD medically needy group. North Dakota's limit is $500 a month, about 38 percent, with income disregarded up to 90 percent. MACPAC says this effectively raises the limit to 100 percent in Minnesota and 90 percent in North Dakota, which is what the table shows. If your parent lives in either state, ask the state Medicaid agency how the disregard applies to her; our Minnesota and North Dakota income-limit guides show how to reach it.

The two lists disagree on four states. SSA's 2016 list marks Oklahoma, Oregon and Tennessee, where MACPAC's 2025 table shows no medically needy pathway, and MACPAC gives Missouri a medically needy level of 85 percent of the federal poverty level, which SSA's list doesn't mark. If your parent lives in one of these four, ask the state Medicaid agency two things: whether it has a medically needy (spend-down) program for people who are aged, blind or disabled, and, if so, what its current medically needy income level is. Our Oklahoma, Oregon, Tennessee and Missouri income-limit guides show how to reach each agency.

Both lists cover ABD adults only, so a state's absence says nothing about children or pregnant women. Our guides for Pennsylvania, Georgia, Arkansas and Massachusetts go deeper.

How Low Is the Medically Needy Income Limit?

For a parent on a modest fixed income, this number decides almost everything. Federal rules don't set one national figure. Each state sets its own medically needy income standard within a federal floor and ceiling.

The result can land far below what families expect. In 21 of the 33 jurisdictions (32 states and DC) with a medically needy level on MACPAC's table, that level is under 74 percent of the federal poverty level, the figure the table lists for Supplemental Security Income (SSI) recipients in most states.

Georgia shows how low it can go. Its July 2026 ABD limits chart sets the ABD Medically Needy income level at $317 a month for one person and $375 for a couple, as net income (gross minus $20), and MACPAC's table puts Georgia's level at 24 percent of the federal poverty level. Every dollar of her net countable income above $317 is spend-down, so a mother living on a Social Security check can have to match most of it with medical bills every month before Medicaid will pay.,

How a Spend-Down Period Works

Under medically needy Medicaid, income above the state's medically needy income standard is the spend-down. Once the medical bills your parent has incurred exceed that amount, she can become eligible for Medicaid.

Federal rules require budget periods of no more than 6 months, and a state may use more than one, so how long each period runs is settled state by state. In Georgia's ABD Medically Needy program, each month is a separate budget period.

A Georgia example, with round numbers for illustration: say her only income is $1,000 a month from Social Security. Georgia's chart states the $317 level as net income, gross minus $20, so $980 is measured against it and her spend-down is $663 for the month, before any other deduction Georgia allows. Once her allowable medical bills for the month reach $663, she can be approved from the day the spend-down is met through the end of that month, and she is responsible for paying a first day liability (FDL) computed for that day. If bills incurred before the month already cover it, she is eligible from the first day of the month.,

Which bills count:

  • Expenses for necessary medical and remedial services recognized under state law, even when your state's Medicaid plan doesn't cover the service.
  • Services the plan does cover, including care beyond the plan's limits on amount, duration or scope. A state may set reasonable limits on how much it deducts for some of these, including services outside its plan.
  • Bills incurred by your parent, her family or financially responsible relatives.

Federal rules also list Medicare and other health insurance premiums, deductibles and coinsurance among the expenses a state must count. In Arkansas, for example, her Part B premium counts unless a Medicare Savings Program is paying it.

Keep every medical bill and receipt, paid or unpaid, because older bills can need proof. Arkansas, for one, counts bills from the retroactive period just before the spend-down period whether she has paid them or not. A bill from before that retroactive period counts only if it is unpaid and she proves she still owed it when the spend-down period began; a paid one can't be deducted.

Two rules can feel unfair:

  • Medicaid doesn't pay or reimburse the bills used to meet the spend-down.
  • A bill a third party is liable to pay can't be counted. Georgia's manual, for one, says VA Aid and Attendance is not a third-party liability.,

What Your State May Call It

Searching under the wrong name is an easy way to miss the program. A few of the names states use:

Medically Needy vs. Categorically Needy Medicaid

If your parent was turned down because her income is over the limit for Medicaid's regular eligibility groups, that isn't necessarily the last word. Medically needy Medicaid is the optional route for people with significant health needs whose income is too high to qualify under Medicaid's other eligibility groups. The link to categorically needy coverage is written into the rule: the pregnant women and children under 18 every medically needy program must cover are people who would be eligible as categorically needy except for their income and resources. The modified adjusted gross income (MAGI) rules of 42 CFR 435.603 aren't applied to someone evaluated as medically needy.

Benefits can differ too. Federal law sets a separate minimum service list for medically needy programs, and it never requires nursing facility care outright. A state whose medically needy program covers care in an institution for mental diseases or an intermediate care facility for people with intellectual disabilities must offer one of two broader packages. One, the services in 42 CFR 440.10 through 440.50, includes nursing facility care; the other, any seven of the services in 440.10 through 440.165, can leave it out.

What If Your Parent Lives in a 209(b) State?

Living in a 209(b) state can work in your parent's favor on one point: even if the state has no medically needy program for older adults, she may still be able to spend down.

209(b) states use stricter Medicaid rules than SSI for ABD adults. MACPAC's table and SSA's list name the same eight: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota and Virginia.

A 209(b) state must let ABD applicants subtract incurred medical expenses from income to qualify, even if it has no medically needy program for them, under 42 CFR 435.121. In a 209(b) state, someone who qualifies through that spend-down may count as categorically needy rather than medically needy.

If Your State Isn't on Either List

Fifteen states show no ABD medically needy pathway on either list; they are the rows marked None and No in the table above. That doesn't mean there's no way in. MACPAC notes its table doesn't include every eligibility pathway, and all 15 show a special income level on it.

The special income level is a state option for people who need at least 30 days of nursing facility or other institutional care and have income up to 300 percent of the SSI benefit rate, for institutional services, waiver services, or both.,

Two examples. In Texas, someone whose countable income is over the special income limit for institutional or home and community-based waiver Medicaid can use a Qualified Income Trust, also called a Miller trust, to get past the special income limit; other rules such as resources still apply (our Texas guide). Ohio ended its ABD spend-down when it became a 1634 state on August 1, 2016, and a qualified income trust is its route for long-term care applicants with income above the special income level (our Ohio guide).

For a nursing home, whether a state's medically needy program covers nursing facility care is the state's choice, and it matters. Federal law allows a Miller trust, one holding only her pension, Social Security and other income, in a state that covers the special income level group but doesn't offer nursing facility care through its medically needy program. States may also count projected nursing home costs, at the Medicaid rate, toward the spend-down. See Income Too High for Nursing Home Medicaid?,,

In any state, if your parent has Medicare, ask about the Medicare Savings Programs (by state). Then see how to apply.

Frequently Asked Questions

Is medically needy Medicaid considered health insurance?

Yes. It's Medicaid: once her spend-down is met, she's covered by her state's Medicaid program for that budget period (in Georgia, through the end of the month). But federal law sets only a minimum set of services every medically needy program must provide, such as prenatal and delivery care for pregnant women and ambulatory services for children under 18 and people entitled to institutional services. Nursing facility care is never required outright, so ask what your state's program covers.,,

Does spending down income fix having too much in savings?

Not in Georgia. Even when her spend-down is met, her resources must be at or under the AMN limit, which Georgia sets at the SSI individual resource limit: $2,000 in countable resources for one person. Check your state's rules and what counts as an asset for Medicaid.,

Can older unpaid bills count toward the spend-down?

Yes, within limits. Federal rules list required deductions based on the age of bills, plus optional ones a state may choose. In Georgia, a bill counts toward a month's spend-down only if it meets all of the conditions in Georgia's manual: it's unpaid as of the first day of the month or incurred or paid during that budget period, she (or another person whose income Georgia counts with hers) is legally obligated to pay it, no third party is liable for paying it, and it's medically necessary. Bills incurred before the month can meet it. Ask about retroactive eligibility too.,

Learn More

MedicaidWhat Is Medicaid? A Guide for Seniors and FamiliesWhat is Medicaid? A federal-state program each state runs, so whether Mom qualifies is a state answer. Who it's for, what it pays for, and how to apply. MedicaidMedicaid by State: Eligibility, Coverage, and How to ApplyMedicaid works differently in every state, from who qualifies to what's covered and how to apply. See what varies and jump to your state's full guide. MedicaidWhat Is Medicaid Spend-Down?Medicaid spend-down lets people whose income is over the limit qualify by applying medical bills to the excess. Here is how the medically needy path works. MedicaidMedicaid Income Limits: Which Number Applies to YouMedicaid income limits for 2026 depend on your pathway: expansion adults, aged and disabled, or nursing-home care. See the figures and your state's limits. MedicaidIncome Too High for a Medicaid Waiver? Home Care and Assisted Living Options by StateIncome too high for a Medicaid waiver? At home or in assisted living, the nursing-home fix may not apply. See the four ways states handle it and what Mom keeps. MedicaidWhat Happens to Your Medicaid When You Turn 65Turning 65 doesn't end Medicaid on its own, but it can close the group you qualified under and add a savings test. What changes, and what to do first.

Chat with Brevy's care navigator about whether your state's medically needy program covers your parent at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.