400.06 WORKING DISABLED (WD) COE-025

Section 4733 of the Balance Budget Act of 1997 allowed states the option to offer Medicaid coverage to disabled working individuals who, because of relatively high earnings, cannot qualify for Medicaid. Except for their earned income, these individuals would be considered to be receiving SSI benefits (although there is no requirement for the individual to have ever received SSI). Liberalized policy allows the Division of Medicaid to determine the eligibility of WD’s using higher income and resource standards than SSI as a work incentive. The optional WD program was implemented in MS effective July 1, 1999. The following criteria must be met in order for an individual or couple to qualify for Working Disabled (WD) coverage. • The work requirement is that the disabled individual must be engaged in some type of paid activity for at least 40 hours per month. o The amount of money earned, and the type of work are not factors as long as the minimum 40 hours per month work requirement is met. o Each individual applying as a WD must be working to be considered under this COE. If a couple wants WD coverage, both must be disabled and both must be working a minimum of 40 hours per month. • The disability requirement is that all SSI disability criteria are met except for the application of substantial gainful activity or SGA. The disability determination process uses SGA in a variety of ways in making a decision as to whether a person is totally disabled. For Medicaid purposes in the WD program, SGA and the fact that the individual is working is not taken into consideration. Instead, the disabling medical condition is reviewed using SSI criteria. o Disability decisions for WD applicants who do not receive Social Security disability benefits on their own record will be determined by DDS. Refer WD disability decisions to DDS in the usual manner described in Chapter 102, Non-Financial Requirements, Section 102.09.04, Obtaining DDS Disability Decisions. However, the DOM-325 Form, Disability Determination and Transmittal, must be clearly notated that the DDS request is for a Working Disabled decision. DDS will then know to review the case according to WD criteria. o There is no requirement for the WD applicant to have had a disability determination prior to obtaining WD coverage. o Individuals aged 65 or over may be considered for WD coverage; however, disability must be determined the same as a disabled individual under age 65. DDS must establish that the aged individual is, in fact, disabled. o It is permissible for a WD to have Medicare, Part A and/or B. The WD individual would be required to apply for Medicare if Medicare Part A would be free or total countable income (earned and unearned) is at/below 100% FPL. o Total countable resources cannot exceed $24,000 for an individual or $26,000 for a couple. The higher resource limits serve as a work incentive for disabled individuals who want to work and need additional resources set aside to achieve work goals. Income Budgeting Rules The WD eligible may be an individual, a WD couple whereby both are disabled and working a minimum of 40 hours per month, or a WD eligible with an ineligible spouse, in which case allocations to ineligible children rules apply. Income is budgeted in two separate steps: 1. Earned income from all sources for the WD and spouse, if any, is combined and all appropriate earned income exclusions are applied. Countable earned income is compared to 250% FPL for an individual or couple, as applicable. Countable earnings cannot exceed 250% FPL. If countable earnings exceed 250% FPL appropriate for the budget, the WD individual is not eligible. 2. Unearned income from all sources for the WD and spouse, if any, is combined and the $50 general exclusion is applied. Countable unearned income is compared to 135% FPL for an individual or couple, as applicable. Countable unearned income cannot exceed 135% FPL. If countable unearned income exceeds 135% FPL appropriate for the budget, the WD individual is not eligible. The WD individual or couple must meet both the earned income test and the unearned income test to be eligible as WD. Effective Date of Benefits Medicaid benefits for WD coverage is effective with the first of the month in which all factors of eligibility are met, which includes up to 3 months prior to the month of application. WD coverage provides full Medicaid benefits. Payment of Premiums in the WD Program WD individuals who have earnings in excess of 150% FPL must pay a monthly premium in order to qualify for continuing WD coverage. Payment of a premium is a condition of eligibility for each WD individual who is subject to a premium. The 150% FPL is based on countable earnings only. The limit is based on either the individual or couple limit of 150% FPL: • The individual limit is used if the WD is an individual with no spouse. • The couple limit is used if both members of the couple are applying. • The couple limit is used if a WD individual has an ineligible spouse. The monthly premium payable is determined by use of the “Sliding Scale for Working Disabled Premiums,” located in Appendix Page A-5. Countable earnings of an individual or couple are used to determine if a premium is payable. If total countable earnings exceed 150% FPL, the monthly premium is calculated using 5% of countable earnings. The Specialist must explain to the individual or couple applying for eligibility in the Working Disabled category that monthly premiums may be payable based on countable earnings that exceed 150% FPL. The premium payment process, as described below, should be discussed with the applicant(s) WD Premium Billing Process When a WD individual or couple or member of a couple is approved, the system will generate an initial invoice for premiums due. The invoice is attached to the Notice of Approval and has the following premium information: • The premium due for the month of application, • Premium(s) due for any month(s) after the month of application through the month prior to the month of approval, • The premium for the month of approval, and • Premiums for the month after approval. Premiums for all of the months shown above will be due within 15 days of the date on the invoice. Invoices will be sent in advance for all subsequent months. For example: A WD application is filed in January and approved March 22. The invoice attached to the Notice of Approval will give the premiums due for January, February, March and April. All 4 months will be due within 15 days of March 22nd. The invoice billing the premium for May will be generated on April 1st, showing the premium due within 15 days. For all subsequent months, invoices will be issued on the 1st of the month for premiums due the following month. Payment of Premiums for Retroactive Month(s) of Eligibility All premiums that are due for a requested retroactive period are payable in full prior to authorizing eligibility for the retroactive period. Payment of Premiums for Retroactive Month(s) of Eligibility • Premiums due for requested retroactive month(s) are specified separately on an invoice attached to the Notice of Approval and are due and payable prior to approval of the retroactive period. Payment of the premiums due for each month of retroactive eligibility must be posted in the system in order for any retro month(s) to be authorized. If the premiums due for the retroactive period are not paid in advance of the approval of a WD case, the Notice of Approval will specify that the retroactive period is denied due to failure to pay the premiums for the retroactive period. The invoice for the retroactive period serves as written notice of the premium amounts due. • Premium payments for the retroactive period paid in advance of approval of ongoing eligibility must be posted in the system so the approval of the retroactive period will be allowed at the time of approval of ongoing eligibility. • Retro months include any eligibility that is requested in a retroactive period, which is any month(s) prior to the month of an application or reinstatement of eligibility or any months prior to the month of a review (regular or special) if an individual is transitioned to the Working Disabled COE from another COE resulting in eligibility for WD and premium(s) due for any prior month(s). • The retroactive period is subject to modification. The WD individual may choose to pay only 1 or 2 months of premiums due and not the full retroactive period, depending on the individual’s need for coverage. The retro month(s) approved are dependent on the full payment of the premium(s) due for the month(s) needed. • Payment of the premium(s) for the retroactive period is not subject to the 15- day deadline as it is for the month of application forward. The retroactive period will not be approved until full payment is received. Failure to Pay Premiums An individual or couple with premiums payable must pay their monthly premium(s) prior to the due date specified on DOM invoices. Failure to pay premiums in full will result in termination of eligibility after advance notice. Eligibility cannot be reestablished in the Working Disabled category for any future months unless or until past due premiums are paid in full for any prior month(s) of eligibility that are on file with a premium that has not been paid, unless an appeal decision authorizes undue hardship. Eligibility can be established in an alternate COE. Payment of Premiums Premiums must be paid by check or money order payable to the Division of Medicaid. Payments received by a Regional Office must be forwarded to the Office of Eligibility in the Central Office where the payments are processed. The Regional Office will be notified of any checks that do not clear due to insufficient funds. Action must be taken to terminate eligibility upon notification of insufficient funds. Social Security Administration’s (SSA) Work Incentive Programs SSA has programs that allow individuals to work and still maintain their eligibility for SSI. Individuals involved in these programs are treated as SSI eligible individuals and are entitled to Medicaid as SSI-eligible individuals, even if the SSI payment stops, provided their status in one of these programs is maintained: • 1619(a) and (b) work programs – these are programs that allow an SSI recipient to work and continue to receive Medicaid based on their need for continuing Medicaid coverage. • Ticket to Work Program – allows certain title II and title XVI (SSI) recipients to voluntarily return to work in order to eventually become self- supporting. Continued title II, SSI and Medicare eligibility is part of the program. For SSI recipients who participate in the Ticket to Work Program, Medicaid continues for as long as SSI eligibility continues. If an SSI recipient loses SSI in one of the programs cited above but continues to work, Medicaid eligibility is possible in the Working Disabled category of eligibility through the Division of Medicaid. The SSI Notice of Termination of Medicaid informs the individual of the limits and requirements of the Working Disabled Program and refers the individual to the appropriate Regional Office to file an application.