The following disability criteria must be met for each TWHA eligibility group:
- Basic Coverage Group: The participant must meet the definition of Permanent and Total Disability. The definition is the same as for Medical Assistance (MA), except earnings of the participant are not considered in the disability determination. Disability for the Basic Coverage Group will be determined either by receipt of SSI or Social Security based on disability, or the Medical Review Team (MRT). Once a person is determined eligible as Permanently and Totally Disabled (PTD) under MA or TWHA Basic Coverage Group, persons who gain and lose employment may switch between these Medicaid categories without a new medical determination. Resubmit medical information at the scheduled medical redetermination period.
- Medically Improved Group: The participant must continue to have a severe medical impairment, but have lost eligibility in the Basic Coverage Group due solely to an improvement in his/her medical condition. Eligibility for the Medically Improved Group must be determined by MRT. MRT will make this determination whenever they find that a person being redetermined for the Basic Coverage Group has medically improved. A person receiving SSI or Social Security based on disability would not be in the Medically Improved Group, as they meet the disability requirement for the Basic Coverage Group.
Request a determination of disability from MRT by submitting the Social Information Summary (IM-61), the Disability Questionnaire (IM-61B), and gathered medical evidence (refer to Section 1060.005.05 Obtaining Medical Evidence for Medical Review Team) whenever a participant has earnings, write in or check Basic Coverage Group in the Application or Redetermination box of the IM-61.
NOTE: An individual may lose eligibility for Social Security based on disability due to having earned income above the Substantial Gainful Activity (SGA) limit. The SGA requirement does not apply to TWHA. If an individual loses disability status due to SGA, redetermine disability status through the MRT process as noted above. Do not close TWHA until MRT’s assessment is complete.
For individuals who are over the income limits for TWHA, only consider income earned from a work activity completed in that month when evaluating income for the SGA limit. Income received from sick and/or vacation pay should not be counted toward the SGA limit, but should still be included in financial budget.
All income should be reported on the IM 61 in the Work History/Income section and staff should specify what is earned income and what is sick and/or vacation income. Refer to Appendix D – Substantial Gainful Activity in the December 1973 manual and IM-19 February 23, 2017 for more information on SGA.