| TO: | ALL COUNTY OFFICES |
| FROM: | JANEL R. LUCK, DIRECTOR |
| SUBJECT: | TICKET TO WORK HEALTH ASSURANCE (TWHA) PROGRAM MANUAL REVISION #29: 0855.000.00, 0855.005.00, 0855.005.05, 0855.005.10, 0855.005.15, 0855.005.20, 0855.005.25, 0855.005.30, 0855.005.35, 0855.005.40, 0855.005.40.05, 0855.005.40.10, 0855.005.45, 0855.005.45.05, 0855.010.00, 0855.010.05, 0855.015.00, 0855.015.05, 0855.020.00, 0855.025.00 |
DISCUSSION:
Senate Bill 577 (2007) placed into Section 208.146 RSMo the Medicaid provision from Section 201 of the federal Ticket to Work and Work Incentives Improvement Act of 1999, Public Law 106-170, creating a program for employed persons with disabilities, the Ticket to Work Health Assurance (TWHA) Program. This program is effective August 28, 2007. TWHA has two components, a Basic Coverage Group and a Medically Improved Group. Persons can become eligible for the Medically Improved Group only after losing eligibility for the Basic Coverage Group.
The gross income limit for this program is 300% of the federal poverty level (FPL). Gross income includes all income of the participant and the participant's spouse that would be considered in determining eligibility for Medical Assistance for the Permanently and Totally Disabled (PTD). There is also a net income limit based upon the limit for participants to receive non-spenddown Medicaid benefits, which is currently 85% of the federal poverty level (FPL). Participants whose gross income exceeds 100% of the federal poverty level (FPL) will pay a premium to receive TWHA benefits. The available resource limit is the same as the Medical Assistance PTD program, $999.99 for a single person and $2000.00 for a couple, but a few exceptions apply. This program is only available for disabled individuals age 16 through 64 who are employed.
The eligibility requirements and procedures are outlined below:
ELIGIBILITY:
To qualify for the TWHA Program, the following criteria must be met:
- Age,
- Citizenship/alien status,
- Social Security Number,
- Residence,
- Disability,
- Employed,
- Available Resources,
- Income, and
- Premium
NOTE: The citizenship/alien status, Social Security Number and residence requirements are the same as those for the Medical Assistance program.
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 participant must meet the definition of Permanent and Total Disability used for MA, except earnings are not considered in the disability determination.
NOTE: Submit medical records to MRT even when the individual earns more than the Substantial Gainful Activity (SGA) limit and is not claiming impairment-related work expenses.
Once a person is determined eligible as permanently and totally disabled 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 or 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 he or she meets the disability requirement for the Basic Coverage Group.
Disability determinations for both the Basic Coverage Group and the Medically Improved Group will be made by the Medical Review Team unless the person continues to receive SSI or Social Security based on disability. Submit the Social Information Summary (IM-61) and Disability Questionnaire (IM-61B) to request a disability determination as done now for the MA disability determination. Until the M-61 is revised, write in TWHA Basic Coverage Group in the Application or Redetermination box, whichever is appropriate, whenever the individual has earnings.
Employed:
Basic Coverage Group: An individual must have earnings from employment or self-employment. For income to be considered earned income it must be documented that Medicare and Social Security taxes are withheld from such income. Self-employed persons must provide proof of payment of Medicare and Social Security taxes for income to be considered earned. Self employed individuals must provide copies of their tax records to verify taxes withheld or if it is a new self employment enterprise, they must provide business records (i.e. business ledgers or gross profit statements) showing the taxes are being withheld for Social Security and Medicare. There is no minimum level of hours of employment or amount of earnings required.
Medically Improved Group: An individual has earnings from employment or self employment in an amount equal to at least 40 hours per month at minimum wage. For income to be considered earned income it must be documented that Medicare and Social Security taxes are withheld from such income. Self-employed persons shall provide proof of payment of Medicare and Social Security taxes for income to be considered earned.
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 the same as it is for Medical Assistance which is $999.99 for a single individual and $2000.00 for a couple. In addition to the regular MA resource exclusions, the following additional exclusions apply:
-
Exclude medical savings accounts for the participant. The exclusion of medical savings accounts is limited to deposits of the individual's earnings while participating in this program up to $5,000 per year and earnings on such deposits.
- Exclude independent living accounts. An independent living 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 participant's disability. The exclusion of independent living accounts is limited to deposits of the individual's earnings while participating in this program up to $5,000.00 per year and earnings on such deposits.
NOTE: These deposits must be in a separate account. Once these deposits are excluded for this program, if the person switches to another Medicaid category, continue to exclude them until the participant reaches age 65. Also, exclude these deposits from a Medicaid determination of the participant's spouse or child until the participant reaches age 65.
Use form IM-99A for the participant to designate an account as an independent living account.
Income:
The TWHA Program includes both a gross and net income limit.
Gross Income:
The individual must have a gross income of 300% or less of the federal poverty level (FPL). Effective April 1, 2007, 300% FPL for a single individual is $2,553.00 and $3,423.00 for a couple.
Include as income:
- The participant's gross income, both earned and unearned.
- The spouse's gross income, both earned and unearned.
To arrive at gross income, allow overhead expenses and income exclusions allowed for the Medical Assistance program as outlined in the IM Online Manual Section 0805.015.10 Income Exclusions, Section 0805.015.15 Overhead Expense of Producing Income, and Section 0805.015.20 Determination of Gross Earned Income.
NOTE: Exclude any income earned by individuals eligible for certified extended employment at a sheltered workshop. The exclusion applies to income earned at both a sheltered workshop and a different employer when the individual is certified for extended employment at a sheltered workshop.
Persons with income above the gross income limit are not eligible for TWHA. Persons cannot spenddown to obtain this coverage.
Net Income:
The participant's net income cannot exceed the limit for permanently and totally disabled individuals to receive non-spenddown Medical Assistance benefits. Effective April 1, 2007, the income limit to qualify for Medical Assistance non-spenddown coverage is $724.00 for a single individual and $970.00 for a couple. To determine net income the following shall be disregarded:
- All earned income of the disabled worker.
- The first $65 and one-half of the remaining earned income of a non-disabled spouse's earned income.
- A twenty dollar standard exemption.
- Health insurance premiums.
- A seventy-five dollar a month standard deduction for the disabled worker's dental and optical insurance when the total dental and optical insurance premiums are less than seventy-five dollars. If the total dental and optical insurance premiums exceed $75, allow the actual premium.
- All Supplemental Security Income (SSI) payments received.
- The first fifty dollars ($50) of the disabled worker's SSDI payment.
- A standard deduction for impairment-related employment expenses equal to one-half of the disabled employee's earned income. The disabled worker is entitled to this deduction even if the earned income is excluded from the gross income test as sheltered workshop income.
Individuals with net income that exceeds the net income limit for their assistance group are not eligible for TWHA coverage.
A budget worksheet designed to assist the eligibility specialist in determining the participant's eligibility for TWHA coverage based upon meeting gross and net income guidelines is included with this memorandum. Systems work is being done to create an automated budget determination process through the IM Budget Calculation Area (IBCA) system. Staff will be notified in a separate memorandum when the TWHA IBCA system work is completed.
Premium:
Any individual whose gross income (as computed above) exceeds 100% FPL must pay a premium to participate in this program. 100% FPL is currently $851.00 for a single individual and $1141.00 for a couple. Eligibility for TWHA coverage will not begin until the premium is paid. A couple will be billed only one premium amount. Premiums shall be paid through check, money order or electronic funds transfer. Participants who are required to pay a premium will be able to sign up for electronic funds transfer through the state in order to have their premium amount deducted automatically from their bank account on the 15th of each month. The first payment, however, must be paid with a check or a money order.
A participant whose gross income exceeds 100% FPL but is less than 150% FPL must pay a premium equal to 4% of income at 100% FPL. A participant whose gross income equals or exceeds 150% FPL but is less than 200% FPL must pay a premium in an amount equal to 4% of income at 150% FPL. A participant whose gross income equals or exceeds 200% FPL but is less than 250% FPL must pay a premium in an amount equal to 5% of income at 200% FPL. A participant whose income equals or exceeds 250% FPL but is not more than 300% FPL must pay a premium equal to 6% of income at 250% FPL. Current premium amounts can be found in the attached TWHA Program Premium Charts 
.
Participants 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. Eligibility cannot begin prior to August 28, 2007. When approving the case, the eligibility specialist must enter the beginning date selected as the begin date of eligibility in Field 13E. Thus, the eligibility specialist must discuss with the participant the amount of premiums and how premium payments received will be applied and have the participant select the month they want coverage to begin.
NOTE: If a participant is not in the premium group, coverage should begin on the first day of the first month the participant is eligible.
Premium collection systems work is expected to be completed by September 2007.
Participants who are eligible for premium coverage in August and September 2007 will not be billed for the premium until September. On the premium approval letter (IM-32 TWHA) the eligibility specialist must inform the participant the amount of the premium and that he or she will owe for September and forward. In September, the Division of Medical Services (DMS) will bill the participant for the September and October premiums. If the participant pays the September 2007 premium, he or she will also have coverage for August 28 - August 31, 2007, without paying an additional premium as long as the eligibility specialist enters August 28, 2007, as the beginning date of eligibility in Field 13E of IMU5. Coverage will not begin until the September 2007 premium is received.
Also starting in September, DMS will bill the participant 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 participant does not send in the complete amount, he or she 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 participant a month in advance. If the premium is not received prior to the beginning of the new month, the participant's coverage ends with the last paid month.
EXAMPLE: Mr. Smith applies in October and the eligibility specialist is ready to approve him for TWHA in November. He is eligible for prior quarter as TWHA. Mr. Smith's premium is $34 per month. If he selects September as his beginning month of coverage, he will owe $136 (34 x 4) for September, October, November and December with his first premium payment. If he selects November, he will owe $68 (34 x 2) for the months of November and December with his first premium payment. Mr. Smith could also select December if he did not want the approval month or any previous months' coverage, in which case he will owe $34. The date Mr. Smith selects must be entered in Field 13E of IMU5. If Mr. Smith selects November but only sends in $34, he will be given coverage starting with December. In December, DMS will send an invoice for the premium for January's coverage.
The MSPI screen will show dates of coverage based on premium payment.
TWHA Couple Cases
A TWHA participant's need is determined as a single individual or a married couple as it is for Medical Assistance PTD non-spenddown and spenddown programs. In determining eligibility for a married individual, consider the income and resources of both individuals.
To prevent TWHA couples from both paying a full TWHA premium, the IMU5 system requires married couples to be combined in one TWHA case. Couples will be responsible to pay one premium amount whether one or both members of the couple are eligible for TWHA. Both spouses can receive TWHA coverage if both meet all eligibility factors for TWHA. If both spouses are eligible for TWHA enter both as a level of care “T” in field 13G in IMU5. If one spouse is eligible for TWHA and the other is not, the system requires the non-eligible spouse to be entered as an included person (level of care “Z” in Field 13G) in IMU5. The spouse not meeting TWHA criteria could be determined eligible for another Medicaid category following the rules of that category.
If the spouse is disabled but is not employed or does not meet other TWHA eligibility criteria, 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 TWHA spouse's earnings. Count the resources of the TWHA participant other than the medical savings accounts and independent living accounts funded with the TWHA participant's earnings.
APPLICATION AND ELIGIBILITY PROCEDURES:
Effective August 28, 2007, 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 TWHA cannot be prior to August 28, 2007. TWHA provides full Medicaid benefits. The application form for TWHA is the IM-1MA, or IM-2 Addendum if combined with a Food Stamps, Temporary Assistance, or Family Medical Assistance application.
If eligible for this new program, approve the individual 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 Field 23, MA-NC eligibility criteria; Field 33, expense; Field 34, net income; Field 35, deficit/surplus; and Field 41, gross income, for the above Medical Assistance groups.
When an employed person with a disability makes application for Medical Assistance, explore the individual's eligibility under the various Medical Assistance programs (Medical Assistance Non-Spenddown/Spenddown, Section 1619 Status, HCB, and TWHA). If eligible for multiple categories, approve the individual for the category that provides the lowest cost sharing. In some cases the individual may be eligible for both a MA non-spenddown category and TWHA non-premium. MA non-spenddown categories including Section 1619, HCB, and MOCDD should always be approved before TWHA. Approve in the following order:
- MA-PTD non-spenddown, HCB, MOCDD, Section 1619
- TWHA non-premium
- MA-PTD spenddown or TWHA premium, whichever is lower
NOTE: If a non-spenddown individual deposits earnings into either a medical savings account or independent living account and the balance exceeds the allowable resource limit for MA, do not reject. Send the specific case data along with a copy of the account to Program and Policy for a determination of eligibility for the TWHA program.
Approval Notices and Changes in Eligibility:
The approval notice for the TWHA program is the IM-32 TWHA 
which includes the TWHA program and premium information. An IM-4 TWHA Information Pamphlet has been created and should be sent with the approval notice.
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 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 September 15, the Medicaid Begin Date (13E) would be November 1.
When a change occurs resulting in moving a participant from a premium group to a non-premium group, the date entered in Field 13E should be the first day of the month immediately following the month in which the change was reported.
CONVERTING EXISTING CASES TO TWHA
Participants currently receiving MA based on disability may already be employed, and therefore qualify for TWHA.
Non-spenddown participants should continue to receive coverage under the Medical Assistance non-spenddown program. Do not convert these cases to TWHA.
Explore TWHA eligibility with MA spenddown participants at the next redetermination or at the participant's request or when the participant reports employment. If the spenddown participant would be non-premium under TWHA, switch the recipient to TWHA coverage. If the spenddown participant would be in the premium group, the participant must choose which coverage they want.
HIPP:
If an eligible participant's employer offers employer-sponsored health insurance and the Department of Social Services determines that it is more cost effective, such person must participate in the employer-sponsored insurance. The Department will pay the participant's portion of the premiums, co-payments, and any other costs associated with participation in the employer-sponsored health insurance.
If a participant's employer offers employer-sponsored health insurance, refer the participant 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.
NECESSARY ACTION:
- Review this memorandum with appropriate staff.
ER
ATTACHMENTS:
TWHA BUDGET WORKSHEET 
IM-4 TWHA INFORMATION PAMPHLET
IM-99A INSTRUCTIONS
IM-99A INDEPENDENT LIVING ACCOUNT DESIGNATION
IM-32 TWHA
TWHA PROGRAM PREMIUM CHARTS