Medical Assistance for Workers with Disabilities (MA-WD) has two components, a Basic Coverage Group and a Medically Improved Group.  The Basic Coverage Group is for persons who have earnings but are determined to be permanently and totally disabled.  Persons can become eligible for the Medically Improved Group only after losing eligibility for the Basic Coverage Group solely due to medical improvement.

This program was authorized by Senate Bill 236 (2001) which placed into Section 208.146 of state law the Medicaid provision from Section 201 of the federal Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170).  This program was funded effective July 1, 2002.

The eligibility requirements and procedures are outlined below:

ELIGIBILITY:

To qualify for Medical Assistance as a worker with a disability, the following eligibility criteria must be met:

•  Age,
• Citizenship/alien status,
• Social Security Number,
• Residence, 
• Disability,
• Employed,
• Available Resources, 
• Income, and 
• Premium

Age:

Recipients must be age 16 through age 64.  This includes the month the person turns 16 and 65.

Disability:

The following disability criteria must be met for each eligibility group.

• Basic Coverage Group: The claimant must meet the definition of Permanent and Total Disability.  The definition is the same as for MA, except earnings are not considered in the disability determination.

Once a person is determined eligible as Permanently and Totally Disabled under MA or MA-WD - 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 recipient 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. 

MRT will make this determination whenever they find a person who is 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.

Employed:

Basic Coverage Group: An individual has earnings from employment or self-employment.

Medically Improved Group: An individual must be earning an amount that is at least equal to 40 hours per month at minimum wage.

Once an individual's earnings cease, ex-parte review procedures must be followed to determine eligibility under regular Medicaid rules.

Available Resources:

The resource limit is $999.99 whether the person is single or married.  In addition to the regular MA resource exclusions, the following additional exclusions will apply:

• Exclude up to $100,000 of available resources belonging solely to the claimant's spouse. These resources are defined as those in the name of the claimant's spouse, but not in the name of the claimant. 

• Exclude one-half of marital assets.  Marital assets are defined as those held jointly in the name of both the claimant, and claimant's spouse.

• Exclude the recipient's retirement accounts that are funded by earnings made while participating on this program, including individual accounts, 401(k) plans, 403(b) plans, Keogh plans or pension plans.  The exclusion of recipient's retirement accounts is limited to deposits of the recipient's earnings while participating on this program and earnings on such deposits.

NOTE:  Once these deposits are excluded for this program, if the person switches to another Medicaid category, continue to exclude them until the claimant reaches age 65.  Also, exclude these deposits from a Medicaid determination of the claimant's spouse or child until the claimant reaches age 65.

• Exclude medical expense accounts for the claimant set up through the claimant's employer.

• Exclude family development accounts established for the claimant under Sections 208.750 to 208.775 of State law.  Family development accounts are authorized by the Department of Economic Development with a religious or charitable community-based organization serving as the administrator.  The claimant must match the contributions of the community-based organization by contributing cash.  The program provides eligible families and individuals with an opportunity to establish special savings accounts for moneys, which may be used for education, home ownership or small business capitalization.

• Exclude the recipient's independent living development accounts.  An independent living development account is an account established and maintained to provide savings for transportation, housing, home modification, and personal care services and assistive devices associated with the claimant's disability. The exclusion of independent living development accounts is limited to deposits of the individual's earnings while participating on this program and earnings on such deposits.

Use new form IM-99A for the individual to designate an account as an independent living development account.

Income:

Compare monthly gross income to $1,846.

Include as income:

• The claimant's gross income, both earned and unearned.

• The spouse's gross income, both earned and unearned, that exceeds $8,333.33 per month. 

Persons with income above this level are not eligible for this coverage.  Persons cannot spenddown to obtain this coverage.

Premium:

Any claimant whose gross income (as computed above) exceeds $1,108 shall pay a premium to participate in this program.  Current premium amounts are listed below. 
 
 

Claimants in the premium group must select the begin date of coverage, which may be as early as the first month of the prior quarter (if otherwise eligible) but no later than the month following approval.  When approving the case, the caseworker enters the beginning date selected as the begin date of eligibility in field 13E.  Thus, the caseworker must discuss with the claimant the amount of premiums and how premium payments received will be applied and have the claimant select the month they want coverage to begin. 

Note:  If a claimant is not in the premium group, coverage should begin on the first day of the first month the claimant is eligible.

Premium collection system work is not expected to be completed until September 1, 2002.

• Prior to September, clients who become eligible for premium coverage will not be billed for the premium until September, but they will have coverage during that time.  On the premium approval letter (IM-32MA-WD) the caseworker will tell the client the amount of the premium and that they will owe the premium for the first month selected forward.    In September, the Division of Medical Services (DMS) will bill the client for the premium for months prior to and including September.  Also starting in September, DMS will bill the client in advance of the next coverage month, example in September for October.  October coverage will not begin until the premium payment is received.

• Starting in September, upon approval the Division of Medical Services (DMS) will bill the recipient for the premium amount for any past coverage selected through the month following approval.  Coverage will not begin until the premium payment is received.  If the claimant does not send in the complete amount, s/he will be credited for any full month premium amount received starting with the month after approval and going back as far as the amount of premium paid allows.  Thereafter, DMS will send an invoice to the claimant a month in advance.   If the premium is not received prior to the beginning of the new month, the person's coverage ends with the last paid month.  After four consecutive months of premium non-payment, the case will close.

A new screen will be developed to show dates of coverage based on premium payment.  You will be sent information about this screen prior to September.  Until the new screen is developed, IXIX and IPAR will show dates that a person is eligible.

When a Medicaid case changes from non-premium to premium, the claimant will receive notice prior to the premium adjustment.  Notification of premium changes will be provided on the premium invoice.  See eligibility procedures below for required case entries. 

SPOUSE OF MA-WD

When a spouse of a MA-WD claimant applies for MA, the spouse's eligibility determination will differ depending on whether the spouse is also employed.

If the spouse is determined disabled and is employed, each person will be determined as a MA-WD claimant.  In determining each person's eligibility, deem the income and resources (after allowing the MA-WD exclusions) from the other spouse.  If a spouse does not meet MA-WD eligibility (ex: their income exceeds the gross income limit for MA-WD), then that spouse's eligibility would be determined as for regular MA as discussed below for non-employed spouses.  Note:  If both spouses meet MA-WD and both are in a premium group, then both will pay a premium.

If the spouse is not employed, then the non-employed spouse's eligibility is determined as it is now.  The regular MA disability, need and resource determination is made using the couple need and resource standards.  Count the income, allowing the earnings disregards for the MA-WD spouse's earnings.  Count the resources of the MA-WD claimant without allowing the additional MA-WD resource exclusions, other than the accounts funded with the MA-WD claimant's earnings as specified above under retirement accounts and independent living development accounts.

APPLICATION AND ELIGIBILITY PROCEDURES:

Effective July 1, 2002, when an employed person with a disability makes an application for Medical Assistance, register the application as a non-spenddown Medical Assistance application through the IAPP process.  The beginning date for coverage for MA-WD cannot be prior to July 1, 2002.  MA-WD provides full Medicaid benefits.  The application form for MA-WD is the IM-1MA, or IM-2 if combined with a Food Stamps or Temporary Assistance application.

If eligible for this new program, approve the claimant by entering the first day of eligibility in IMU5 Field 13e, the Medicaid Begin Date, and by entering a "T" level of care in Field 13g and a level of care/reason code (field 13g2) as follows:

"1" - Basic Coverage Group, premium 
"2" - Basic Coverage Group, non-premium 
"3" - Medically Improved Group, premium 
"4" - Medically Improved Group, non-premium 

Enter one of the following codes in Field 23, MA-NC Eligibility Criteria:

"T" - Basic Coverage Group
"I" - Medically Improved Group

Edits have been added to ensure that the correct entries are made in fields 23 - MA-NC eligibility criteria; 33 - expense; 34 - net income; 35 - deficit/surplus; and 41- gross income, for the above Medical Assistance groups. 

Approvals for MA-WD cannot be entered in IMU5 until July 8, 2002, as that is the date the new codes will be available.  Starting July 8th IMU5 will accept the new codes with a Medicaid begin date of 7/1/02.

The approval notice for the MA-WD program is the IM-32.  An IM-32MA-WD is attached to this memorandum for persons to use for approvals for the premium group prior to September.  The IM-32 is being revised to include the MA-WD program with premium information as it will work after September.  That IM-32 will be sent under separate cover at a later date.  A pamphlet (IM-4 MA-WD) has been developed to explain the basic program requirements.  Use the pamphlet to explain the program to interested persons.  Also include it with an approval letter for this program.  A copy of this pamphlet is attached.

If a claimant is determined ineligible on any factor (either at the annual review or an interim contact) follow normal closing procedures.  These include ex-parte procedures in memorandum IM-193 (2001) for the aged, blind and disabled Medicaid programs.  Premium group closings will close at the end of the month.  Non-premium group closings are date-specific.

When changing from a non-premium to a premium group, send an IM-80.  Follow regular adverse action and hearing procedures.  Once the adverse action and any Administrative Hearing procedures are completed, update IMU5 fields 33, 34, 35, 41, 13g, 13g2 and 13e.  The date entered in field 13e should be the first day of the second month, following the date the change is entered.  For example, if the change is entered on July 15, the Medicaid Begin Date (13e) would be September 1.

Note:  Use the following legal citation for this program on notices sent to the claimant:  208.146 RSMo.

When a change occurs resulting in moving a recipient from a premium group to a non-premium group, the date entered in field 13e should be the first day of the month the claimant became non-premium.

CONVERTING EXISTING CASES TO MA-WD

Persons currently receiving MA based on disability may already be employed, and therefore qualify for MA-WD.

For non-spenddown persons, review this program with the recipient at the next redetermination or at the recipient's request or if the recipient reports employment. 

For spenddown recipients, review this program with the recipient at the next spenddown period.  If the spenddown recipient would be non-premium, switch the recipient to this coverage.  If the spenddown recipient would be in the premium group, the recipient must choose which coverage they want.

HIPP:

If a recipient's employer offers employer-sponsored health insurance, refer the recipient to the existing Health Insurance Premium Payment program, using form HIPP-1.  HIPP staff will determine whether it is cost effective for HIPP to pay the individual's insurance premium.  If so, Medicaid will pay the recipient's portion of the insurance premiums, co-payments and other costs for Medicaid covered services associated with participation in the employer-sponsored health insurance.

• Review this memorandum with appropriate staff.

• Follow the procedures outlined in this memorandum to determine eligibility for the MA-WD program beginning July 1, 2002.

• File the IM-99A form and instructions in the Forms Manual.

• #1 - Independent Living Development Account Designation Form
• #2 - Instructions
• #3 - Pamphlet
• #4 - Notice of Case Action Form