534          WORKING DISABLED MEDICAID BUY-IN

An individual with a disability who is ineligible for 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:

• Family means the applicant, the applicant's spouse, and any dependent children of either the applicant or spouse who are living in the same household a majority of the time in a month.

• Dependent Child means the natural or adopted child of either the eligible or ineligible spouse, who lives in the same household with the applicant and who is under age 18, or a student under age 22 is regularly attending a school, college, university, or vocational school in preparation for gainful employment.  See APA Manual Section 442-2(D) for the definition of regular school attendance.

534 B.     RESOURCES
 

Countable resources may not exceed:
 

• $10,000 for an individual; or
   
• $15,000 for an individual living with a spouse, whether or not the spouse is eligible for assistance.

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 FPGFederal Poverty Guidelines for Alaska.  See the FPGFederal Poverty Guidelines chart in Addendum 1.  To determine a family's monthly net income, combine all countable income of each family member and then, using APAAdult Public Assistance 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 APAAdult Public Assistance spousal deeming process.

If the family's net income is equal to or greater than 250% FPGFederal Poverty Guidelines for the appropriate household size, the individual is not eligible for this category.  If the family net income is less than 250% FPGFederal Poverty Guidelines , 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 APAAdult Public Assistance related Medicaid.  Use the Expanded Refused Cash or Special Long Term Care Income Standard, depending on what Medicaid Category they would be eligible for.  Apply APAAdult Public Assistance 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 DPADivision of Public Assistance 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, APAAdult Public Assistance, or Medicaid, honor that determination.  Verification from SSASocial Security Administration of a future disability review date should be documented.  Disability is considered to exist until disallowed by the Disability Determination Service (DDSDisability Determination Service).

If the applicant has no past history of SSISupplemental Security Income 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 DDSDisability Determination Service to disregard substantial gainful activity (SGASubstantial Gainful Activity).  

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 SGASubstantial Gainful Activity, 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% FPGFederal Poverty Guidelines 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 DHCSDivision of Health Care Services TPLThird Party Liability worker will send an EISEligibility Information System notice to the recipient.  DHCSDivision of Health Care Services staff may also make notes in the CANOCase Notes 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 EISEligibility Information System Working Disabled Medicaid Authorization (WODMWorking Disabled Medicaid Authorization) screen and notify the DHCSDivision of Health Care Services TPLThird Party Liability Unit.  When a change is reported, the DHCSDivision of Health Care Services TPLThird Party Liability 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 DHCSDivision of Health Care Services TPLThird Party Liability 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 APAAdult Public Assistance /Medicaid is set to close March 31 because of increased income.  Randy receives notice in March that his APAAdult Public Assistance /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

DHCSDivision of Health Care Services 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 DHCSDivision of Health Care Services TPLThird Party Liability 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 DPADivision of Public Assistance 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 HCBHome and Community-Based WAIVERS

An individual eligible under the Working Disabled Medicaid Buy-In category may also be eligible for Home and Community Based (HCBHome and Community-Based) Waiver services.  Use the Special Long Term Care Income Limit in the unearned income test.  This is most common with a Individuals with Intellectual and Developmental Disabilities (IDDIndividuals with Intellectual and Developmental Disabilities) waiver.  A Working Disabled/HCBHome and Community-Based waiver recipient does not have a Cost-of-Care (COCCost-of-care) obligation, but must pay the appropriate premiums.

534 K.       EXAMPLES OF AN ELIGIBILITY DETERMINATION

1.  Max Lucas is an individual with disabilities.  He is married to Anita Lucas and they have one child, Edwin. Max receives APAAdult Public Assistance, Medicaid, and Social Security.  Anita receives UIBUnemployment Insurance Benefit and Edwin receives Social Security. Max begins working and his earnings cause APAAdult Public Assistance and Medicaid closure.  Without a new application, eligibility for the Working Disabled Medicaid Buy-In category is determined for the month following the APAAdult Public Assistance 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 APAAdult Public Assistance disregards and exclusions are applied (if exempt income existed, it would be fully exempt in this step)

Family Net Income is less than 250% FPGFederal Poverty Guidelines, so applicant passes Step 1.

Step 2 - Individual Income Test

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

2. Katherine  is an individual with disabilities who is eligible for an Individuals with Intellectual and Developmental Disability (IDD) HCBHome and Community-Based Waiver.  Katherine receives Social Security Disability Income and recently started a job that causes her to go over the income limit.  Without a new application, a Working Disabled Medicaid determination is made.

Note:

The following calculations are based on current income standards.

Step 1 - Family Income Test

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

Family Net Income is less than 250% FPGFederal Poverty Guidelines, so applicant passes Step 1.

Step 2 - Individual Income Test

Katherine's total unearned income is less than the applicable Special Long Term Care Income standard.  Therefore, Katherine 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 Tiger is an individual with disabilities and has an approved Medicaid Qualifying Trust.  He is married and his wife Dawn receives UIBUnemployment Insurance Benefit.  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.

534 N.       EIS INFORMATION

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