534          WORKING DISABLED MEDICAID BUY-IN

 

An individual with a disability who is ineligible for APA and Medicaid because of earned income that is either the individual's own income or the individual's spouse's earned income, may be eligible for Medicaid under the Working Disabled Medicaid Buy-In eligibility category.  An individual may be eligible for the Working Disabled Medicaid Buy-In category even if he or she has not received Medicaid or disability related benefits before.  See Addendum 8 for additional information about Working Disabled Medicaid Buy-In procedures.

 

534 A.      DEFINITIONS

 

For the purposes of Family Income Test and determining the need standard, count all family members as defined below:

 

 

 

534 B.     RESOURCES
 

Countable resources may not exceed:
 

 

534 C.     INCOME

 

The income eligibility determination is a two-step process:

 

1. The Family Income Test (Step 1)

 

Determine if the family's monthly net income is below 250% of the FPG for Alaska.  See the FPG chart in Addendum 1.  To determine a family's monthly net income, combine all countable income of each family member and then, using APA methodology, subtract all disregards and exemptions, including impairment related work expenses (IRWE) as described in APA Manual Section 442-2 (G).  

 

Spousal Deeming APA spousal deeming rules do not apply to the Family Income Test (Step 1) since that policy is designed to look at the income of a couple, not family income, and because the income of all family members is combined regardless.

 

Note:

An income allocation for an ineligible child (see APA Manual Section 460-5A) is not allowed in the Family Income Test because income allocations are part of the APA spousal deeming process.

 

If the family's net income is equal to or greater than 250% FPG for the appropriate household size, the individual is not eligible for this category.  If the family net income is less than 250% FPG , proceed to Step 2.  

 

2. Individual Unearned Income Test (Step 2)

 

Determine whether the disabled individual meets the financial and nonfinancial requirements to be eligible for APA related Medicaid.  Apply APA financial methodology, but exclude all earned income, including deemed earned income of the spouse.  Do count the unearned income deemed from a spouse.  Also, count the unearned income of the parents of a disabled individual under age 18.  

 

For spousal deeming calculations, use the MED 6 - Working Disabled Deeming Worksheet available on DPA e-forms.

 

534 D.      DISABILITY DETERMINATION NEEDED

 

A disability determination is required.  If the individual is already considered disabled for the purposes of Social Security, APA, or Medicaid, honor that determination.  Verification from SSA of a future disability review date should be documented.  Disability is considered to exist until disallowed by the Disability Determination Service (DDS).

 

If the applicant has no past history of SSI or SS-DS with a current disability review date, a State-only disability determination must be pursued.  

 

The Referral for Disability Determination form (GEN 141) is used when a disability determination is needed.  The caseworker must check the box Working Disabled Medicaid Buy-In to clearly indicate to the DDS to disregard substantial gainful activity (SGA).  

 

The applicant must complete a Disability and Vocational Report (APA 4) and the Authorization for Release of Medical Information forms (MED 2) for this determination.  Follow procedures described in Administrative Procedures Manual Section 115-9.

 

For an applicant age 65 or older who is over income for Adult Public Assistance because of earnings from SGA, a disability determination is required to qualify for the Working Disabled Buy-In category.

 

534 E.      PREMIUMS MAY BE REQUIRED

 

An individual who is eligible under this category may have to pay a premium to the Division of Health Care Services to continue to receive coverage.  The Division of Health Care Services Third Party Liability (TPL) Unit will determine the premium amount, send the client notice of premiums due, and collect the premiums.  Premiums are assessed on a sliding fee schedule based on the family's annual net income.  No one with family annual income below 100% FPG will pay a premium.  No one will pay a premium in excess of 10% of their annual net family income.

 

Notify the Division of Health Care Services (DHCS) for every Working Disabled Medicaid Buy-In application approved.  Send an email message to DMAtpl@Alaska.gov  so that the premium amount, if any, can be established.  The message must include the case initials, case number, and the date the application was approved.  If a premium is due, the DHCS TPL worker will send an EIS notice to the recipient.  DHCS staff may also make notes in the CANO screen.

 

Note:

Before opening a Working Disabled Medicaid Buy-In case, it is important to make sure a previous case (regardless of the case number used) was not closed for failure to pay the required premiums. A new Working Disabled Medicaid Buy-In case cannot be opened until any back owed premium is paid.

 

534 F.      REPORTING CHANGES

 

A Working Disabled Buy-In recipient is under the same obligation as all other recipients to report changes in income and resources.  Because changes in income and household size may also affect the amount of the recipients premium, the caseworker must update the prospective budget on the EIS Working Disabled Medicaid Authorization (WODM) screen and notify the DHCS TPL Unit.  When a change is reported, the DHCS TPL Unit will recalculate the prospective annual income to determine if a premium adjustment is needed or if the premiums should end or begin.

 

534 G.      WHEN PREMIUMS ARE DUE

 

Once eligibility is established for this category, the DHCS TPL Unit calculates the amount of the premium and needs time to give adequate notice of the premium obligation to the recipient.  Therefore, the first premium is not due until the second month of eligibility following the month the recipient is notified of their eligibility for this category.

 

Example 1:

Randy's APA /Medicaid is set to close March 31 because of increased income.  Randy receives notice in March that his APA /Medicaid case is closing and that eligibility for the working disabled category begins April 1.  May is the first premium month since it is the second month of eligibility following the month he was notified (March).

 

Example 2:

Amy applies in January and requests retroactive coverage.  The caseworker works the case and approves the application in February.  Eligibility is determined for the month of application (January) and retroactive eligibility is determined for December, November, and October.  April is the first premium month since it is the second month of eligibility following the month that Amy was notified (February).

 

534 H.      FAILURE TO PAY PREMIUMS

 

DHCS will monitor payments made.  If an individual is at least 60 days delinquent in payment of premiums, Medicaid eligibility under the Working Disabled Buy-In category will be terminated.  The DHCS TPL Unit will notify the caseworker that the person is ineligible.  The caseworker should review the individual's current information to determine if there is eligibility for any other Medicaid category.  If not, send timely notice (M413 - Medicaid Closed - Other Reasons), citing that the individuals benefits will stop due to failure to pay their Medicaid premium.  

 

Note:  

A DPA hearing representative will handle a fair hearing request after loss of benefits for failure to pay Medicaid premiums like any other eligibility issue.

 

534 I.      LOSING ELIGIBILITY IN ANOTHER CATEGORY

 

If an individual is losing Medicaid eligibility in another category, a new application for this category is not required.  The caseworker should automatically make an eligibility determination if the individual is losing eligibility in another category due to earnings.

 

534 J.        WORKING DISABLED AND HCB WAIVERS

 

An individual eligible under the Working Disabled Medicaid Buy-In category may also be eligible for Home and Community Based (HCB) Waiver services.  This is most common with a Individuals with Intellectual and Developmental Disabilities (IDD) waiver.  A Working Disabled/HCB waiver recipient does not have a Cost-of-Care (COC) obligation, but must pay the appropriate premiums.

 

534 K.       EXAMPLE OF AN ELIGIBILITY DETERMINATION

 

Joe Smith is an individual with disabilities.  He is married to Mary Smith and they have one child, Jane. Joe receives APA, Medicaid, and Social Security.  Mary receives UIB and Jane receives Social Security. Joe begins working and his earnings cause APA and Medicaid closure.  Without a new application, eligibility for the Working Disabled Medicaid Buy-In category is determined for the month following the APA closure.  

 

Note:  

The following calculations are based on current income standards.

 

Step 1 - Family Income Test

The income of all family members is considered and APA disregards and exclusions are applied (if exempt income existed, it would be fully exempt in this step)

 

Joe's SSDI

$785.00

Mary's UIB

$400.00

Jane's SSA

$200.00

Total Unearned Income

$1,385.00

$20 General Income Exclusion

 - $20.00

Countable Unearned Income

$1,365.00

 

 

Joe's earnings

$1,500.00

$65 Earned Income Exclusion

 - $65.00

1/2 Earned Income Exclusion

- $717.50

Total Countable Earned Income

$717.50

 

 

Family Net  

 $2,082.50

250% FPG (as of 4/1/2017)

$5,317.00

 

Family Net Income is less than 250% FPG, so applicant passes Step 1.

 

Step 2 - Individual Income Test

 

Joe's SSDI (may end due to SGA soon)

  $785.00

Spouses deemed unearned income

    $239.00

(From deeming worksheet MED 6)

 

$20 General Income Exclusion

- $20.00

Total Unearned Income

  $1004.00

APA Need standard - A2S (as of 1/1/2017)

$1,640.00

 

Joe's total unearned income is less than the applicable APA need standard.  Therefore, Joe is eligible for the Working Disabled Medicaid Buy-In Category.

 

534 L.      WORKING DISABLED WITH A MEDICAID QUALIFYING TRUST

 

A Medicaid Qualifying Trust can be used to reduce income in either Step 1 or Step 2 of the financial eligibility determination.

 

Countable income for the Step 1 test must include any payment to the applicant that comes out of the trust, plus any other income that the client receives that is not going into the trust.  

 

In the Step-2 Unearned Income Test, a payment to the applicant from the trust is considered unearned income.

 

The Medicaid Qualifying Trust may pay the premium on behalf of the client.  As long as the payment is sent directly to the Division of Health Care Services as a vendor payment, it will not count as income to the client.

 

534 M.       EXAMPLE OF AN ELIGIBILITY DETERMINATION WITH A MEDICAID QUALIFYING TRUST

 

Jim Moneyman is an individual with disabilities and has an approved Medicaid Qualifying Trust.  He is married and his wife Dawn receives UIB.  Jim begins working and his earnings cause Medicaid closure. An eligibility determination is made for the Working Disabled Buy-In category for the month following the regular Medicaid closure.  

 

Note:  

The following calculations are based on current income standards.

 

EXAMPLE 1:  FAMILY NET MORE THAN 250% FPG (STEP 1)

 

Step 1 Family Income Test

Jim's SSDI

$1150.00

Dawn's UIB

$499.00

Total Unearned Income

$1,649.00

$20 General Income Exclusion

- $20.00

Countable Unearned Income

$1,629.00

 

 

Jim's earnings

$5,601.00

$65 Earned Income Exclusion

- $65.00

1/2 Earned Income Exclusion

 - $2,768.00

Total Countable Earned Income

$2,768.00

 

 

Family Net

$4,397.00

250% FPG (as of 4/1/2017)

$4,228.00

 

- $169.00

 

 

The Family Net Income is more than 250% FPG, so Jim must increase the amount going into the trust by more than $169.00 to pass Test 1.

 

 

Step 2 Individual Income Test

Jim's SSDI (may end due to SGA soon)

$1150.00

Spouses deemed unearned income

$499.00

$20 General Income Exclusion

- $20.00

Total Unearned Income

$1,629.00

 

 

APA Need Standard -A2S (as of 1/1/2017)

$1,640.00

 

 

Jim's total unearned income is less than the applicable APA need standard.  Therefore, Jim is eligible for the Working Disabled Medicaid Buy-In Category by use of his Medicaid Qualifying Trust in Step 1.

 

 

EXAMPLE 2:  UNEARNED INCOME OVER APA NEED STANDARD (STEP 2)

 

Step 1 Family Income Test

Jim's SSDI

$1,200.00

Dawn's UIB

$800.00

Total Unearned Income

$2,000.00

$20 General Income Exclusion

- $20.00

Countable Unearned Income

$1,980.00

 

 

Jim's earnings

$3,600.00

$65 Earned Income Exclusion

-  $65.00

1/2 Earned Income Exclusion

 - $1,767.50

Total Countable Earned Income

$1,767.50

 

 

Family Net

$3,747.50

250% FPG (as of 4/1/2017)

$4,228.00

 

The Family Net Income is less than 250% FPG, so Jim passes Test 1.

 

Step 2 Individual Income Test

Jim's SSDI (may end due to SGA soon)

$1,200.00

Spouse's deemed unearned income

$800.00

$20 General Income Exclusion

- $20.00

Total Unearned Income

$1,980.00

 

 

APA Need Standard -A2S (as of 1/1/2017)

$1,640.00

- $340.00

 

Jim's total unearned income is more than the applicable APA need standard.  Therefore, Jim must increase the amount of the trust by at least $340.00 to qualify for the Working Disabled Medicaid Buy-In Category.

 

 

534 N.       EIS INFORMATION

 

EIS allows you to enter all data for both the Step 1 and Step 2 eligibility process and then calculates both steps simultaneously.

 

EIS INFORMATION

Eligibility Code:

11

Pregnant Woman

20

No other eligibility codes apply

31

Waiver Medicaid Adults with Physical and Developmental Disabilities

41

Waiver Medicaid Older and Disabled Adults

71

Waiver Medicaid Individuals with Intellectual and Developmental Disabilities

81

Waiver Medicaid Medically Complex Child

Medicaid Subtype:

DW

Working Disabled

Waiver Code:

DA

Adults with Physical and Developmental Disabilities

AG

Older and Disabled Adults

MD

Individuals with Intellectual and Developmental Disabilities

MC

Children with Complex Medical Conditions

 

 

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MC #43 (04/17)