How to Become Eligible for Medicaid Long Term Care Through the Medically Needy Pathway
Summary
The Medically Needy Pathway is a way for people to qualify for Medicaid Long Term Care even if they are over their Medicaid income limit. To use the Medically Needy Pathway, you or your loved must spend your monthly excess income on medical bills. The Medically Needy Pathway is not available in every state, and those states that do offer it have different rules that govern it.
Medically Needy Pathway Overview
The Medically Needy Pathway is for Medicaid applicants who have monthly income above their specific Medicaid income limit. It is an option in 32 states and Washington, D.C. (for full list, see below), and the rules surrounding the program can be very different depending on the state. Using the Medically Needy Pathway may also be referred to as “spending down,” because you spend your excess income on medical expenses until it goes down enough to make you eligible.
The Medically Needy Pathway has different names in different states. In New York, for example, it’s called the Medicaid Excess Income Program. In Illinois, it’s called the Medical Spenddown Program.
How Does the Medically Needy Pathway Work?
In states where the Medically Needy Pathway is available for applicants above the Medicaid income limit, you must “spend down” your excess income on medical bills in order to qualify for Medicaid as an applicant and to maintain your eligibility as a Medicaid Long Term Care recipient. The amount of income you need to spend down (also known as a spend down amount) is determined using your income and your state’s Medically Needy Income Limit (MNIL). In short, your spend down amount is your income minus the MNIL.
Each state also has a spend down period which can be anywhere from 1-6 months. You must meet your spend down amount each spend down period to be eligible for Medicaid. So, it works like an insurance deductible. After you meet the spend down amount during the spend down period, Medicaid will kick in and start covering expenses.
Example
Here is an example of when the Medically Needy Pathway might work for a Medicaid applicant who is over the income limit:
In California, the MNIL is $600/month for an individual, and the spend down period is one month. Jane has $2,100/month in income. So, her spend down amount would be $1,500 ($1,100 income – $600 MNIL). Once Jane spends $1,500 on Medicaid-allowed healthcare expenses, Medicaid will cover her expenses for the rest of the 1-month spend down period. When that month ends, the process starts again and Jane will have to meet her $1,500 spend down amount again.
For a full list of states’ Medically Needy Income Limits, see below.
For Which Types of Long Term Care Does Medically Needy Medicaid Apply?
There are three types of Medicaid Long Term Care relevant to seniors – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers and Aged, Blind and Disabled (ABD) Medicaid.
In states that offer the Medically Needy Pathway (complete list below), it can always be used with ABD Medicaid. But not all of those states offer it in conjunction with Nursing Home Medicaid or HCBS Waivers. To find out the rules in your state, you can contact your local Medicaid agency, or use our 50-state guide to go to your state’s page. The information will be in the “Qualifying with Medicaid Planning” section.
As of 2025, the following states offer a Medically Needy Pathway: Arkansas, California, Connecticut, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, West Virginia and Wisconsin, as well as the District of Columbia.
The income limits in these states can vary, and those limits can also vary depending on the type of Medicaid Long Term Care. In general, however, the 2025 income limit for Nursing Home Medicaid and HCBS Waivers is $2,901/month for an individual and $5,802/month combined for a couple with both spouses applying. When only one spouse is applying to either of those programs, the income limit of the non-applicant spouse is not counted and the income limit (in most states in 2025) for the applicant is $2,901/month.
For ABD Medicaid, the 2025 income limit in most states ranges from $967/month to $1,795/month, and for a couple (whether one or both spouses is applying) it’s $1,450/month to $2,658/month, depending on the state.
Remember, if you are above these income limits and live in a state that offers it, you can use the Medically Needy Pathway to reduce your income and help you become Medicaid eligible. But you don’t spend down to these limits with the Medically Needy Pathway, you have to spend down to your specific Medically Needy Income Limit.
What Are Allowable Medical Expenses for Medically Needy Spend-Down?
In every state that offers a Medically Needy Pathway, money spent on Medicare or other health insurance premiums counts as “spending down,” meaning it may be deducted from an applicant’s income when determining eligibility.
Other spend-down expenses allowed will depend on the state. Medicaid may consider any of these to be medical expenses:
- Doctor bills
- Hospital services
- Prescriptions (drugs and/or equipment)
- Nursing home services
- Eyeglasses
- In-home help with Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
- Portion of assisted living costs allocated for assistance with the Activities of Daily Living (may be state-dependent)
- Therapies
- Transportation to medical appointments
Medically Needy Asset Limits
In addition to an income limit, Medicaid also requires applicants to meet an asset limit. In most states in 2025, the individual asset limit is $2,000, but this can vary by state, Medicaid Long Term Care program and the applicant’s marital status. Some states adjust their asset limits for seniors who use the Medically Needy Pathway, while others do not.
How to Apply for the Medically Needy Pathway to Eligibility
Someone who wants to use the Medically Needy Pathway to gain and maintain Medicaid eligibility will need to indicate that in their Medicaid Long Term Care application. For more details on the application and how to indicate you need to use the Medically Needy Pathway, contact your local Medicaid office. Or you can consult with a professional.
In order to apply for the Medically Needy Pathway, you will need the following documentation to prove medical expenses:
- Medical bills
- Medical receipts
- Cancelled checks that paid bills
Medically Needy Income Limits by State
Medically Needy Income Limits for Medicaid Long Term Care Eligibility as of Jan. 2025 | ||
State | Individual | Couple |
Arkansas | $108.33 | $216.66 |
California | $600 | $934 |
Connecticut | $803 | $1,090 |
District of Columbia | $809.08 | $851.67 |
Florida | $180 | $241 |
Georgia | $317 | $375 |
Hawaii | $469 | $632 |
Illinois | $1,255 | $1,703 |
Iowa | $483 | $483 |
Kansas | $475 | $475 |
Kentucky | $235 | $291 |
Louisiana (may vary depending on region) | $100 | $192 |
Maine | $315 | $341 |
Maryland | $350 | $392 |
Massachusetts | $522 | $650 |
Michigan | $1,255 | $1,703 |
Minnesota | $1,255 | $1,704 |
Missouri | $1,067 | $1,448 |
Montana | $525 | $525 |
Nebraska | $392 | $392 |
New Hampshire | $888 | $1,033 |
New Jersey | $367 | $434 |
New York | $1,732 | $2,351 |
North Carolina | $242 | $317 |
North Dakota | $1,130 | $1,533 |
Pennsylvania | $425 | $442 |
Rhode Island | $1,133 | $1,175 |
Utah | $1,255 | $1,704 |
Vermont (may vary depending on region) | $1,333 | $1,333 |
Virginia (may vary depending on region) | $401.69 | $511.35 |
Washington | $967 | $967 |
West Virginia | $200 | $275 |
Wisconsin | $1,255 | $1,703.33 |
Medically Needy Spend Down Periods by State
Medically Needy Spend Down Periods as of Jan. 2025 | |
State | Spend Down Period |
Arkansas | 3 months |
California | 1 month |
Connecticut | 6 months |
District of Columbia | 6 months |
Florida | 1 month |
Georgia | 6 months |
Hawaii | 1 month |
Illinois | 1 month |
Iowa | 2 months |
Kansas | 6 months |
Kentucky | 3 months |
Louisiana | 3 months |
Maine | 6 months |
Maryland | 6 months |
Massachusetts | 6 months |
Michigan | 1 month |
Minnesota | 6 months |
Missouri | 1 month |
Montana | 1 month |
Nebraska | 1 month |
New Hampshire | 1 or 6 months |
New Jersey | 6 months |
New York | 1 month |
North Carolina | 6 months |
North Dakota | 1 month |
Pennsylvania | 6 months |
Rhode Island | 6 months |
Utah | 1 month |
Vermont | 1-6 months |
Virginia | 1-6 months |
Washington | 3 or 6 months |
West Virginia | 6 months |
Wisconsin | 6 months |
Medically Needy Asset Limits by State
Medically Needy Asset Limits (first figures is for an individual, second figure for a couple) as of Jan. 2025 | |
State | Medically Needy Asset Limits |
Arkansas | $2,000/$3,000 |
California | N/A |
Connecticut | $1,600/$2,400 |
District of Columbia | $4,000/$6,000 |
Florida | $5,000/$6,000 |
Georgia | $2,000/$4,000 |
Hawaii | $2,000/$3,000 |
Illinois | $17,500/$17,500 |
Iowa | $10,000/household |
Kansas | $2,000/$3,000 |
Kentucky | $2,000/$4,000 |
Louisiana | $2,000/$3,000 |
Maine | $2,000/$3,000 |
Maryland | $2,500/$3,000 |
Massachusetts | $2,000/$3,000 |
Michigan | $2,000/$3,000 |
Minnesota | $3,000/$6,000 |
Missouri | $5,909.25/$11,818.45 |
Montana | $2,000/$3,000 |
Nebraska | $4,000/$6,000 |
New Hampshire | $2,500/$4,000 |
New Jersey | $4,000/$6,000 |
New York | $31,175/$42,312 |
North Carolina | $2,000/$3,000 |
North Dakota | $3,000/$6,000 |
Pennsylvania | $2,400/$3,200 |
Rhode Island | $4,000/$6,000 |
Utah | $2,000/$3,000 |
Vermont | $2,000/$3,000 |
Virginia | $2,000/$3,000 |
Washington | $2,000/$3,000 |
West Virginia | $2,000/$3,000 |
Wisconsin | $2,000/$3,000 |