Ohio Medicaid Spend-Down: What To Do Instead

If someone has told you to "spend down" to get onto Ohio Medicaid, that advice is out of date. Ohio ended the aged, blind, and disabled (ABD) income spend-down on August 1, 2016, when it became a Section 1634 state, and nothing replaced it.1 What stands in its place depends on the care you need: a Qualified Income Trust for nursing facility or waiver Medicaid, the Medicaid Buy-In if you work, and several protections for people who lose Supplemental Security Income (SSI) that can settle the income question outright.

See who qualifies at Ohio Medicaid

In This Guide

• Why you are still being told to spend down for Ohio Medicaid
• What Ohio ended, and when
• Nursing facility or waiver care: the Miller Trust
• If you are working: the Medicaid Buy-In
• Protections that may make income irrelevant
• The Ohio Medicaid asset spend-down that still exists
• Medicare Savings Programs
• Appeals
• Key phone numbers and contacts
• Frequently Asked Questions

Why you are still being told to spend down for Ohio Medicaid

Ohio ran an ABD spend-down for decades, so a great deal of advice still assumes it exists. It survives in older guides, in county handouts that were never revised, and from relatives who went through the process themselves before 2016. Some search results still describe the three monthly options and the county pay-in in detail.

None of it has applied for nearly a decade. Ohio does not operate an ABD Medicaid spend-down, and an aged, blind, or disabled applicant in the community whose countable income is over the limit cannot use a monthly pay-in or accumulated medical bills to become eligible.1 If you are told to pay your county a monthly amount to buy Medicaid coverage, that is a program Ohio closed. It is worth asking when the person last checked.

What Ohio ended, and when

Before August 1, 2016, Ohio operated under Section 209(b), which allowed it to use Medicaid eligibility rules stricter than SSI's. Paired with that was a spend-down, so someone over the income limit could still qualify by incurring or paying medical expenses.

On August 1, 2016, Ohio converted to a Section 1634 state, meaning SSI eligibility determines Medicaid eligibility directly. The Ohio Department of Medicaid's Medicaid Eligibility Procedure Letter No. 115 records the consequence plainly: under the prior 209(b) policy individuals could spend down, and when Ohio became a 1634 state on that date, individuals would no longer be able to spend down to become eligible for Medicaid.1

No successor pay-in program was created, and the administrative rule series that governed the old pathway is no longer in the Ohio Administrative Code (OAC).1

Nursing facility or waiver care: the Miller Trust

This is the situation most families arrive with, and it has a real answer.

Ohio is an income-cap state for institutional and Home and Community-Based Services waiver Medicaid. If countable income exceeds the special income level (300% of the SSI federal benefit rate, or $2,982 per month for a single applicant in 2026, effective January 1, 2026), the applicant does not spend down. They establish a Qualified Income Trust, also called a Miller Trust, under 42 U.S.C. § 1396p(d)(4)(B).2

The trust is not a way to keep the money. Income above Ohio's special income level is deposited into the Qualified Income Trust each month and applied to the cost of care, with Ohio named as remainder beneficiary. What the trust does is stop the income cap from disqualifying the applicant outright.2

Two practical points. The trust has to be established and funded before eligibility begins, so it is an early step rather than a response to a denial. And it is a genuine legal instrument, which is the point at which an elder-law attorney earns their fee. See Ohio Miller Trust (QIT) for how one is set up and administered.

If you are working: the Medicaid Buy-In

Ohio runs a Medicaid Buy-In for Workers with Disabilities, created at Ohio Revised Code (ORC) sections 5163.09 through 5163.098 as Ohio's coverage of the federal optional eligibility groups for working people with disabilities.4

Under ORC 5163.091, an applicant qualifies by showing all of the following:4

• Age: at least 16 and under 65
• Disability and work: either considered disabled for SSI purposes (whether or not an SSI check actually arrives) with earnings from employment, or an employed individual with a medically improved disability
• Resources: resources, after disregards, no higher than the amount ORC 5163.092 sets
• Income: income, after the disregards Ohio law allows, at or below 250% of the federal poverty line4

One detail is worth checking against whatever else you have read, because it changed recently. ORC 5163.094 is still titled "Amount of annual individual premium," and it once set one. Ohio's House Bill 96 (136th General Assembly) replaced the text of ORC 5163.094, and since September 30, 2025 that Ohio statute reads, in full, that an individual "shall not be required to pay a premium as a condition of qualifying for the medicaid buy-in for workers with disabilities program." Guides that describe the Buy-In as premium-based are quoting the old statute.4

Note the age ceiling: this is a route for a working adult with a disability rather than for someone already past 65.

Protections that may make income irrelevant

Check these before assuming the income limit is the obstacle. Each preserves Medicaid for a specific group, and any one of them may mean the question never arises.

Pickle Amendment. Under Section 503 of Public Law 94-566 and 42 CFR 435.135, someone who lost SSI only because Social Security cost-of-living increases raised their income keeps Medicaid if they would still qualify for SSI with those increases disregarded. Many older Ohioans with Social Security at or just above the SSI federal benefit rate keep Medicaid this way.5

Disabled Adult Child protections under Section 1634(c) of the Social Security Act, 42 USC 1383c(c). An adult whose blindness or disability began before age 22, and who loses SSI because they become entitled to Social Security child's insurance benefits on a parent's record (or to an increase in them), is still treated as an SSI recipient for Medicaid, for as long as they would qualify for SSI with those benefits set aside.6

Disabled Widow(er) protections. The federal groups for disabled widows and widowers are 42 CFR 435.137 and 42 CFR 435.138, which cover, among others, disabled widows and widowers "who would be eligible for SSI except for the increase in disability benefits resulting from elimination of the reduction factor under Pub. L. 98-21." Ask the county to check this group by name; a caseworker who is thinking about ordinary ABD limits may not.6

Section 1619(b) work continuation under 42 USC 1382h(b). An SSI recipient whose earnings stop the cash payment keeps Medicaid if they still have the disabling impairment, still meet every non-earnings SSI rule, need Medicaid in order to keep working, and have gross earnings at or below their state's threshold amount. Earning above that charted amount does not end it automatically: the Social Security field office then works out an individualized threshold.7

The Ohio Medicaid asset spend-down that still exists

This is the distinction that matters most, because the two are constantly confused.

What Ohio eliminated was an income spend-down. Spending down excess assets, meaning reducing countable resources to the $2,000 limit for a single applicant before qualifying, was never affected and remains ordinary Medicaid practice.3

So when a caseworker or attorney says to spend down before applying, ask which they mean. If they mean assets, they are right. If they mean paying the county monthly to buy coverage, they are describing the closed program.

Ohio Medicaid Asset Spend-Down covers the valid version, including which assets are exempt and how the transfer penalty interacts with it.

Medicare Savings Programs

For anyone with Medicare, these run separately from everything above and are worth checking on their own.

Ohio administers the Medicare Savings Programs as its Medicare Premium Assistance Programs, publishing 2026 monthly income guidelines as gross Federal Poverty Level standards for a single person.8

The FPL percentages and Ohio monthly figures come from Ohio's own 2026 guidelines; what each program pays is the federal rule that applies in every state.8

A note on the $20 disregard: Ohio publishes gross FPL figures and then deducts the standard $20 income disregard from countable income, while the federal framing adds the $20 to the limit and states QMB $1,350, SLMB $1,616, QI-1 $1,816. The eligibility result is identical; the figures differ only in which side of the equation the $20 sits.8

Appeals

If a county Department of Job and Family Services denies, reduces, or terminates Medicaid, you may request a state hearing from the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings. The rules are OAC 5101:6-3-02 for hearing requests and OAC 5101:6-4-01 for keeping benefits while the appeal is pending.9

• Filing deadline: ODJFS must receive the request within 90 days of the mailing date of the notice of action
• How to file: call or write your county agency, or complete the state hearing request form mailed with the adverse notice and send it to ODJFS Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825, or fax it to (614) 728-9574
• Keeping benefits during the appeal: if an existing benefit is being reduced, stopped, or restricted, request the hearing within 15 days of receiving that notice; call the Bureau of State Hearings at 1-866-635-3748 to ask whether your benefits should be continuing, and to ask to take part in the hearing by telephone9
• The trade-off: if benefits continue and you lose the hearing, you may have to repay what you were not eligible to receive9

If you are in an Ohio managed care plan, the plan's own internal appeal generally comes first, and the state hearing follows once that is exhausted.10

If a denial rests on a caseworker applying spend-down rules, say so in the appeal and point to the 1634 conversion.

Key phone numbers and contacts

Learn More

Find personalized help navigating Ohio Medicaid 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.