Individuals Covered (Workers with Disabilities) 510-05-57-10

(Revised 7/1/14 ML #3406)

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(N.D.A.C. Section 75-02-02.1-24.2)

An individual may be enrolled under the Workers with Disabilities coverage if he or she:

Is gainfully employed;

Is at least sixteen, but less than sixty-five, years of age;

Is disabled;

Is not in receipt of any other Medicaid benefits under Service Chapter 510-03 or 510-05, other than coverage as a QMB or SLMB; and

Pays a one-time, per lifetime, enrollment fee of $100. Indians who are enrolled members of a Federally-recognized Indian tribe are exempt from this requirement.

An individual may be eligible under this coverage for the entire month in which the individual turns age sixteen. An individual may not be eligible under this coverage during the month the individual turns age sixty-five.

An SSI recipient, or an individual who is eligible as a 1619a or 1619b, is not eligible under this coverage if categorically eligible for Medicaid.

An individual who loses their SSI or Title II benefits because of employment and receives a Ticket-to-Work from Social Security is considered disabled for Medicaid.

The Social Security Administration may refuse to determine disability for a new applicant who is gainfully employed. In these situations, the State Review Team will make a medical determination of disability without regard to gainful employment. This disability determination is valid for all Medicaid coverages, however, these individuals will likely remain eligible for Medicaid under the Workers with Disabilities coverage. In the event that an individual stops working, or reduces their hours, and becomes eligible as medically needy, the individual must be referred back to Social Security to apply for Title II benefits. Because of the decrease in employment, the individual may now be considered disabled by Social Security and may be entitled to a benefit. Per 05-35-90 , applicants and recipients must apply for other benefits to which they are entitled.

Applicants or recipients who are eligible under this coverage, but who may also be eligible as medically needy, may choose which coverage they want, and will likely be based on which is more cost-effective for them. Once a recipient has been authorized as eligible for a current or past benefit month under one coverage, and the eligibility cannot be unauthorized, the recipient cannot switch coverages for that benefit month. A recipient can switch between coverages prospectively.

The $100 enrollment fee must be collected prior to authorizing coverage under this provision. If coverage is denied, the applicant is not responsible for the fee, and any fee collected for the application must be returned to the applicant. If coverage is initially approved for a future month, but coverage doesn't begin because the Medicaid case closes or coverage is changed to a different Medicaid coverage, the applicant is not responsible for the fee, and any fee collected must be returned to the applicant. Enrollment fees for eligible recipients must be submitted to the Department's Fiscal Administration unit using the Medicaid credit form, SFN 828 .

If an enrollment fee is paid by check, and the check is returned due to non-sufficient funds, the enrollment fee is considered unpaid, and eligibility for Workers with Disabilities coverage must end until the fee is paid.