SUBJECT:
ELIMINATION OF MEDICAL ASSISTANCE FOR WORKERS WITH DISABILITIES
DISCUSSION:
Senate Bill 539 (2005) eliminated the Medical Assistance for Workers with Disabilities (MA-WD) program effective August 28, 2005. The last day of Medicaid coverage under MA-WD will be August 31, 2005. All MA-WD cases must be reviewed to determine if the recipient continues to be eligible for any other Medicaid category. It is anticipated that most MA-WD recipients will be eligible for Medical Assistance (MA) Spenddown. Caseworkers must complete these reviews and notify the recipients of the result no later than August 10, 2005. All MA-WD cases need to be converted to another category or closed by August 26, 2005. Cases cannot be closed or converted to MA spenddown without the caseworker sending an Adverse Action Notice giving the recipient an opportunity to request a hearing.
SYSTEM GENERATED REVIEW FORM
To assist with this determination and give the recipients the opportunity to provide up-to-date information, a special Medical Assistance Eligibility Review form (sample attached) with a cover letter was mailed to each recipient July 8, 2005. All cases active in the Income Maintenance (IM) computer system as of July 1, 2005 were sent the form. The cover letter informs the recipient that MA-WD is eliminated effective September 1, 2005. It also states they need to complete and return the review form by July 29, 2005, to assist us in determining if they are eligible for another Medicaid category. It states failure to return the form MAY result in their Medicaid coverage ending August 31, 2005.
CASE REVIEWS
All MA-WD cases, including those that do not return the Review form, must be reviewed to determine if the recipient qualifies for another Medicaid category. If the form is not returned, the review is to be based on the information in the case record as of August 1, 2005.
If adequate information is in the record, the caseworker does not need to wait for the returned form to begin the review. Adequate information should be in the record if the case has been reinvestigated or approved in the past twelve months and the recipient is not married. It would be possible for adequate information to be in the record if the recipient is married and both spouses are on MA-WD or another program as long as the spouse's information is in the record.
The caseworker must evaluate the recipient's potential eligibility for all Medicaid categories, but especially for coverage based on Section 1619 of the Social Security Act (Section 0850.000.00 of the MA manual) and receipt of Home and Community Based Waiver (HCB) services ( Section 0820.000.00). It will be necessary to contact the local Social Security Administration (SSA) office to confirm Section 1619 status unless the recipient has provided documentation from SSA. If reviewing for potential HCB eligibility it will be necessary to contact Department of Health and Senior Services to verify the recipient is receiving HCB waiver services.
Cases determined eligible under Section 1619, HCB, MA non-spenddown (using 85% of FPL as the income limit), Medicaid for Pregnant Women or any other non-spenddown categories are to be switched to that category as soon as the determination is made. The caseworker will send an IM-33 informing the recipient of the change. The reason for the change on the form is to include:
Senate Bill 539 (2005) eliminated the Medical Assistance for Workers with Disabilities program. A review of your case determined you remain eligible for Medicaid under [name of program].
Cases that will be eligible for Medical Assistance (PTD) on a spenddown basis must be sent the MA-WD to Spenddown Adverse Action Notice (sample attached). The IMU5 action to transfer these cases must NOT be entered until August 1, 2005. If the recipient requests a hearing due to transfer to spenddown, the caseworker will follow regular hearing procedures.
The case review could result in the recipient being determined ineligible for any Medicaid category in the following circumstances:
- Assets excluded for MA-WD that are not excluded for MA (examples include the spouse's assets and money are in an independent living development account) that cause ineligibility for MA.
- The review form is not returned and it has been over 12 months since the last approval or reinvestigation.
In either of these situations, the recipient must be sent an Adverse Action Notice (IM-80) informing them of the reason their Medicaid case will close. The reason for ineligibility on the IM-80 is to include the following:
- Senate Bill 539 (2005) eliminated the Medical Assistance for Workers with Disabilities program.
AND
- The reason for MA ineligibility; either available resources exceed the limit or you failed to provide the information necessary to determine your eligibility for other Medicaid categories.
DISABILITY DETERMINATIONS
If the MA-WD recipient is not receiving Social Security Disability benefits, Supplemental Security Income (SSI), or in Section 1619(b) status a new Medical Review Team (MRT) determination of disability MAY be required. A new MRT decision is only required if the recipient is engaged in Substantial Gainful Activity (earning more than $830.00 per month). When sending medical information to MRT, include the amount of earnings.
Recipients who require a new MRT decision are to be transferred to the appropriate Medicaid category, as stated above, pending the outcome of the MRT decision. If MRT determines the recipient does not meet the disability requirement for MA, send an IM-80 stating the following reason:
- Senate Bill 539 (2005) eliminated the Medical Assistance for Workers with Disabilities program.
AND
- You do not meet the disability requirement to receive Medical Assistance based on permanent and total disability.
HEARING PROCEDURES
As stated above, normal hearing procedures are to be followed when a recipient requests a hearing based on eligibility being terminated or changed to spenddown as a result of the case review. These cases must remain open and not changed to spenddown until a hearing decision is made. Instructions on how to keep these cases open if a hearing decision has not been made by August 26, 2005, will be sent in a separate memorandum.
PREMIUM PAYMENTS
MA-WD premium invoices will not be sent in August for September. Effective July 15, 2005 will be the final date auto withdrawals are made from MA-WD recipients' bank accounts for premiums. If it is determined that the recipient should become a spenddown, an initial spenddown invoice for September, 2005 will be sent when the change is entered in the IM system. The recipient will need to sign another auto withdrawal request if they want their spenddown to be withdrawn from their account, even if their MA-WD was setup for auto withdrawal.
NEW MA-WD APPLICATIONS
Persons with disabilities who are working and apply for Medicaid through November 30, 2005 can continue to be approved for MA-WD for months prior to September 2005. A determination of eligibility for MA for the months after August must be made prior to the approval for MA-WD. The approval letter for MA-WD is to address the result of the MA determination. MA-WD invoices will continue to be sent for new approvals for the months the client is determined to be a MA-WD premium case.
For determinations made prior up to August 26, 2005, first approve the case as MA-WD. The next day or August 1st, whichever is later, change the case to the category for which the client is eligible in September. Further instructions on entering MA-WD approvals in the IM system after August 26 will be issued in a separate memorandum.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
- Begin reviewing and taking appropriate action on MA-WD cases.
Attachments:
