Purpose: This section describes the Healthcare for Workers with Disabilities (HWD) program. HWD recognizes the employment potential of people with disabilities, and is Washington State’s response to the landmark “Ticket to Work” legislation passed by Congress in 1999. The enactment of the federal Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999 enables many people with disabilities to work and keep their health care.
Under HWD, enrollees are able to earn and save more money and to purchase healthcare coverage with monthly premiums based on a sliding income scale. HWD does not have an asset (or resource) test. Since it is a categorically needy (CN) Medicaid program, it provides Medicaid Personal Care services (MPC) for those approved to receive them. HWD is also an additional eligibility group for most Home and Community Based Services (HCBS) waiver programs administered by the Aging and Adult Services Administration Divisions of Developmental Disabilities (DDD) and Home and Community Services (HCS).
Healthcare for workers with disabilities (HWD) - Premium payments.
NOTE:
Because enrollees meet federal disability requirements, equal access policies and procedures are followed at all times. See NSA (Necessary Supplemental Accommodation) which contains chapter 388-472-WAC.
WAC 388-475-1000
WAC 388-475-1000
Effective January 1, 2007
WAC 388-475-1000 Healthcare for workers with disabilities (HWD) - Program description.
This section describes the healthcare for workers with disabilities (HWD) program.
The HWD program provides categorically needy (CN) scope of care as described in WAC 388-501-0060.
The department approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 388-475-1100 for "retroactive" coverage for months before the month of application.
A person who is eligible for another Medicaid program may choose not to participate in the HWD program.
A person is not eligible for HWD coverage for a month in which the person received Medicaid benefits under the medically needy (MN) program.
The HWD program does not provide long-term care (LTC) services described in chapters 388-513 and 388-515 WAC. LTC services include institutional, waivered, and hospice services. To receive LTC services, a person must qualify and participate in the cost of care according to the rules of those programs.
WAC 388-475-1050 Healthcare for workers with disabilities (HWD) - Program requirements.
This section describes requirements a person must meet to be eligible for the healthcare for workers with disabilities (HWD) program.
To qualify for the HWD program, a person must:
Meet the general requirements for a medical program described in WAC 388-503-0505(3)(a) through (f);
Be age sixteen through sixty-four;
Meet the federal disability requirements described in WAC 388-475-1150;
Have net income at or below two hundred twenty percent of the federal poverty level (FPL) (see WAC 388-478-0075 for FPL amounts for medical programs); and
Be employed full or part time (including self-employment) as described in WAC 388-475-1200.
To determine net income, the department applies the following rules to total gross household income in this order:
Once approved for HWD coverage, a person must pay his/her monthly premium in the following manner to continue to qualify for the program:
The department calculates the premium for HWD coverage according to WAC 388-475-1250;
If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again; and
Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:
The job loss results from an involuntary dismissal or health crisis; and
WAC 388-475-1100 Healthcare for workers with disabilities (HWD) - Retroactive coverage.
This section describes requirements for retroactive coverage provided under the healthcare for workers with disabilities (HWD) program.
Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program. The department cannot approve HWD coverage for a month that precedes January 1, 2002.
To qualify for retroactive coverage under the HWD program, a person must first:
Meet all program requirements described in WAC 388-475-1050 for each month of the retroactive period; and
Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.
If a person does not pay premiums in full as described in subsection (2)(b) for all months requested in the retroactive period, the department denies retroactive coverage and refunds any payment received for those months.
Some people may be eligible for HWD, who are not eligible for other SSI-related medical programs, due to:
Gross monthly earnings at or above the substantial gainful activity (SGA) level; or
Countable income or resources that exceed other program standards, including the C01 coverage group used when eligibility is determined under "institutional" rules.
As described in WAC 388-475-0050 and the SSI Related Medical - General chapter, to be eligible for "regular" SSI-related Medicaid, a person must be unable to work at or above SGA, i.e. must not have gross earnings at or above SGA.
However, a person with higher earnings and/or resources may enroll in HWD, when all other program requirements are met. HWD is a Medicaid Buy-in program that has less restrictive requirements than the SSI program. HWD has no eligibility test for SGA or assets/resources.
NOTE:
HWD provides an additional financial eligibility group for most DDD and HCS programs.
Substantial Gainful Activity (SGA) - How HWD is Different
To get a disability determination for those without one, people are referred to the Division of Disability Determination Services (DDDS). HWD Medicaid Only, a Non-Grant Medical Assistance (NGMA) program, removes "Step 1" of the sequential evaluation process - the test for work at SGA. In contrast, DDDS staff automatically deny an individual with earnings at or above SGA for federal cash benefits, e.g. SSI or SSDI. For the SGA amount, see the SSA "Red Book - A Guide to Work Incentives - What's New."
NOTE:
For the determination of disability for non-grant medical assistance (NGMA), DDDS waives the SGA test for all applicants. CSO and HCS staff must apply the SGA test to determine which SSI-related Medicaid programs to consider when completing the application. Examples below illustrate which office - the local CSO or the HWD Unit - completes the DDDS referral and maintains the case record, and which program is appropriate when DDDS approves NGMA - S02 or S08 - based on gross earnings.
NOTE:
For Medicaid purposes, an IRWE approved by SSA or the financial worker may be used to reduce gross earnings that are compared to SGA. See WAC 388-475-0840 and SSA Red Book - Employment Supports for information about IRWEs. The determination of a Subsidy and/or Special Conditions, which are sometimes used to reduce gross earnings compared to SGA, may be approved only by SSA.
EXAMPLE
#1 - APPLICANT HAS GROSS EARNINGS BELOW SGA AND COUNTABLE INCOME BELOW CNIL/MNIL
Boston, 35, is applying for SSI-related medical and earns $665 a month at his job. He also receives a VA benefit of $300. Boston has no countable resources. He is single and has no children. Since he claims to have a disability and is not approved for federal disability benefits, staff must complete a referral for him to DDDS.
Since Boston's gross earnings of $685 are below SGA, local CSO staff facilitate the referral to DDDS for the determination of disability for non-grant medical assistance (NGMA), complete the application, and maintain the case record.
If NGMA is approved, determine eligibility for CN (S02) Medicaid. Test for resources and determine countable income. Using Boston's unearned income, deduct the $20 general disregard from his VA benefit ($300 - $20) = $280. Using his earned income, deduct $65 and 1/2 the remainder ($665 - $365) = $300. Add countable income ($300 + $300) = $600 and compare it to the one person CNIL.
Since Boston's gross earnings are below SGA and his countable income is below the CNIL (FBR), he is eligible for CN Medicaid under the S02 coverage group.
EXAMPLE
#2 - APPLICANT HAS GROSS EARNINGS ABOVE SGA AND COUNTABLE INCOME BELOW CNIL/MNIL
Dallas, 35, is applying for SSI-related medical and earns $1,285 a month. She has no other income and no countable resources. She is single and has no children. Also, she does not pay out of pocket for any impairment-related work expenses (IRWEs). Since she claims to have a disability and is not approved for federal disability benefits, staff must complete a referral for her to DDDS.
Since Dallas's gross earnings of $1,285 are above SGA, staff must forward an application received at the local CSO to the Centralized Medical Unit (CMU) via DMS CSO 132@HWD. CMU facilitates the referral to DDDS for the determination of disability for non-grant medical assistance (NGMA). In this case, the NGMA request is for HWD.
If NGMA is approved, the CMU HWD Unit completes the application for CN (S08) Medicaid. Using Dallas's earned income, deduct the $20 general disregard ($1,285 - $20) = $1,265. Then deduct $65 and 1/2 the remainder ($1,265 - $665) = $600. Since Dallas has gross earnings above SGA:
She is not eligible for S02, even with countable income below the CNIL/FBR; and
If she had additional income, which resulted in countable income above the CNIL/MNIL, she would not eligible for S95 or S99.
She must meet program requirements and enroll in HWD, in order to be eligible for and receive SSI-
related Medicaid.
HWD Unit - Determination of Eligibility and Monthly Premium
Using the HWD Website, determine eligibility and the monthly premium amount. Since her countable income is less than the HWD standard of 220% FPL, she is eligible for CN Medicaid under the S08 coverage group. Her monthly premium amount is $30.
NOTE:
For SSDI or SSI cash applications, an individual working at SGA may request SSA to complete an individual determination of SGA and be approved for an impairment-related work expense (IRWE) and/or a Subsidy or Special Consideration that reduces gross monthly income below SGA. Otherwise, the application for cash benefits is automatically denied. See SSA "Red Book - SSDI and SSI Employment Supports" for additional information.
SGA - How it is Different for SSDI and SSI Beneficiaries
Once an individual is approved for SSDI or SSI cash benefits, he/she may have gross monthly earnings at or above SGA and continue to receive them (as allowed under work incentives added to the Social Security Act over time). Some work incentives apply only to the SSDI program or only to the SSI program, while some apply to both.
Many individuals are eligible for benefits under both the SSDI and SSI programs at the same time. SSA uses the term "concurrent" when individuals are eligible for benefits under both programs. For a description of how an individual's concurrent benefits are affected by his/her return to work, see SSA "Example of Concurrent Benefits and Employment Supports."
SGA - How it is Different for Medicaid Clients, including Waiver Clients
The definition of disability used to determine eligibility for federal cash benefits remains in its original form as defined by federal statute, and is described in WAC 388-475-0050 SSI-related medical - General Information. For general application of this rule, see subsections (c)(i)(A) and (B).
"'Disabled' means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
Can be expected to result in death; or
Has lasted or can be expected to last for a continuous period of not less than twelve months."
Since the beginning of SSA and Medicaid programs, however, SSA has crafted rules that encourage people with disabilities to work, increase their self-sufficiency, and enhance the quality of their lives. In the past decade, an additional Medicaid option became available to states to support such employment by implementing the Medicaid Buy-in program.
An individual in Washington State with gross monthly earnings at or above SGA may work and keep Medicaid benefits based on disability, according to the following program requirements.
He/she may be approved for and continue to receive Medicaid coverage, if he/she:
a) Receives a partial SSI cash grant;
b) Is granted "1619 (a) or (b)" status by SSA;
c) Is considered "eligible for SSI" for Medicaid purposes, after use of special income
disregards described in WAC 388-475-0880; or
d) Meets requirements of the HWD program.
He/she may be denied or becomes ineligible for Medicaid under any SSI-related program except by enrolling in HWD, even when financial requirements (other than the SGA test) might appear to met, such as:
a) Net countable income under the CNIL for S02;
b) Net countale income under the standard based on the facility rate for G03;
c) Gross non-excluded income under the Special Income Level (SIL) for C01; or
d) Net countable income above the CNIL/MNIL for S95 or S99.
Maximize the Incentive to Work
The person with disabilities who wants to work has a number of options that allow him/her to pursue employment goals without fear of losing comprehensive health care. In some cases, a person meets requirements for more than one program that will meet individual needs. In such cases, it is critical to compare the options and determine which program costs less - to maximize the incentive to work.
For a broader description of coverage group options that may apply to individual circumstances, follow this link to "A Desk Tool for Benefits Planners." Benefits Planners (sometimes called Community Work Incentive Coordinators) provide critical information about the impact of employment on benefits, including but not limited to SSDI/SSI and Medicaid. For a complete list of SSA work incentives, see the SSA Red Book - "Guide to Employment Supports." An additional source of information is available in the Long Term Care section of the EAZ Manual; see "Working clients on long-term care programs."
Program Choice - HWD or Other Medical Programs
The HWD program isn't the best program for everyone who meets program requirements. Since HWD always requires a monthly premium payment, the program of best choice for someone eligible for both HWD and another CN program is the one that costs less. For example:
Look at the Apple Health for Kids program first for any older child (young adult).
Look at the CN pregnancy program (P02) first for a pregnant woman.
Look at the CN disability program (S02) first for a disabled adult child (DAC).
Look at CN programs (C01 or G03) to determine which program costs less, depending upon all financial and functional requirements and place of residence.
Program Choice - HWD or MN
Some people who are eligible for both HWD and MN may prefer to receive Medicaid under the MN program. They do not have to participate in HWD, unless they choose to do so. The HWD Award Letter will provide those eligible for both and approved for HWD with a comparison of what their spenddown amount would be under the MN program.
For most people, HWD is the preferred program because:
CN provides more extensive coverage than MN; and
The HWD premium is most likely less than the monthly spenddown amount.
A person who is approved for MN (in active status) can't be opened for HWD CN coverage until the first of the month after MN coverage is closed. In certain situations, it also may be to the client's advantage to continue the current MN certification period.
EXAMPLE
#3 - With medical expenses incurred in December and January, a client meets the spenddown requirement of $948 on January 10 for the base period of December, January, and February. The department approves MN coverage effective January 10. The client contacts staff with the thought of switching to the HWD program, although his medical needs for February do not require the additional services provided under the CN scope of care. Since the client is now open on MN and the department cannot approve HWD coverage until February, it would not be to the client’s advantage to switch to the HWD program until March.
EXAMPLE
#4 - A person that meets all HWD requirements has a health insurance premium he/she pays out of pocket that reduces countable income to the MN standard. This person, who would have no spenddown, may choose the MN program that provides less comprehensive coverage and does not require a premium payment, if gross earnings are below SGA.
NOTE:
Health insurance premiums are not a deductible expense for the HWD program when determining eligibility or the amount of monthly premiums.
NOTE:
Because of the SGA test, a person who loses eligibility because of countable income above the HWD standard, when gross earnings are at or above SGA, isn't eligible for CN or MN Medicaid.
SSI Clients - CN
People with disabilities who work and remain "eligible for SSI" remain eligible for CN Medicaid because of the status provided them under 1619(a) and 1619(b) provisions of the Social Security Act. They areeligible for CN Medicaid as a member of the S01 coverage group and do not participate in the HWD program.
People with disabilities who work and remain "eligible for SSI" after use of special income disregards described in WAC 388-475-0880 also remain eligible for CN Medicaid, if countable income that remains is at or below the CNIL. They, like those with "1619(a) or (b)" status, are not subject to the SGA test. They areeligible for CN Medicaid as a member of the S02 coverage group and do not participate in the HWD program.
The HWD program provides an incentive for those "eligible for SSI" to begin earning money in excess of the 1619(b) threshold amount and/or saving resources above the SSI standard, if they are able and choose to do so. Although earnings above the threshold may change their being considered "eligibile for SSI" for Medicaid purposes, they can continue their Medicaid coverage by enrolling in the HWD program, if they meet other program requirements.
For clients who want HWD, staff must screen for S08 instead of S02 when entering client information into ACES. Otherwise, ACES will look at CN (S02) first, then S95 and S99, if appropriate. S02 will not trickle to S08. If an SSI-related client has income below the CNIL and resources above the CN / MN standard, the client can be considered for the HWD program if they meet other program requirements. If an SSI-related client has income that exceeds the CNIL and has resources at or below the CN/MN standard, the client can be considered for either HWD or MN program, if gross earnings are below SGA.
NOTE:
ACES does not currently apply the SGA test. Staff must apply the SGA test and not screen for S02 to determine eligibility when the client has gross earnings above the current SGA amount. When using the HWD Website below, staff must remember it does not apply the SGA test, since it is waived for HWD.
NOTE:
Although a client with gross monthly earnings at or above SGA may have countable income at or below the CNIL after SSI-related deductions are applied, he/she must enroll in HWD in order to be eligible for Medicaid, unless he/she is considered "eligible for SSI" as described above.
Premiums and Spenddown
HWD premiums and incurred medical expenses used to reduce a person’s spenddown should not be confused with one another when determining eligibility for Medicaid.
Medical expenses used to reduce spenddown are not used to reduce an HWD premium.
Premiums owed by a person whose HWD coverage has ended because of non-payment cannot be used to reduce spenddown for the MN program. Only incurred medical expenses or health insurance premiums actually paid can be used to reduce a person’s spenddown amount.
HWD Option for DDD and HCS Waiver Services
A person eligible for HWD may receive DDD or HCS Waiver services, if functionally eligible for them. In some cases, accessing these services as a member of the HWD eligibility group may be to the client's advantage. An HWD enrollee pays only a monthly premium for medical benefits and doesn't participate in the cost of services under "institutional" rules; the enrollee does continue to pay room and board, if living in an alternate living facility. As a result, the client who is working may be able to keep more of his/her earned income. DDD case managers review cases of their clients on an individual basis to determine which option is better for them and communicate this information to designated HWD staff, using the DSHS 15-345 CSO/DDD Communication.
The HWD Website was developed by the Finance Division and the Health and Recovery Services Administration (HRSA) to determine eligibility and premium amounts. It can also be used as a trial eligibility calculator and to provide a spenddown comparison amount. Staff can use the spenddown amount to discuss a client’s program options.
When discussing the option of choosing HWD with a client living in an ALF, staff should estimate the comparison amount of non-institutional Medicaid in an ALF to be non-excluded income above the MNIL. The client keeps the personal needs allowance described in WAC 388-478-0045 and pays what remains of the MNIL to the facility for room and board. See Non-Institutionalized in Long Term Care.
Local Office Responsibilities
If a client who is applying for or receiving other benefits expresses interest in the HWD program:
Determine whether the client appears to meet program requirements, which include:
Being age 16 through 64;
Have at least a self-reported disability; and
Have earned income; and
Forward client information to designated staff, if the client appears to meet program requirements and wants to apply for HWD.
Local staff who want to use the HWD Website for determining income eligibility and the premium may do so, if this will facilitate discussing program options with a client.
NOTE:
Depending upon individual circumstances, the client’s program options may include HWD, MN at home CN/MN (non-institutional Medicaid in an alternate living facility (ALF), or one of the DDD or HCS waiver programs.
NOTE:
Clients living in an ALF who enroll in HWD continue to pay room and board which is not a service covered by Medicaid programs. The room and board amount is not deducted when determining eligibility for calculating the HWD premium amount.
The HWD Website can be used as a trial eligibility calculator by clicking on the Entry Form tab to begin the process. Only designated staff “Log In” and save entries. See HWD Website and Central Processing - Designated Staff Responsibilities below for information on using the Website.
NOTE:
If you use the HWD Website to discuss a client’s program options before sending information to designated staff, document your discussion with the client in the ACES narrative.
Explain to the client that only designated staff make the final determination of eligibility and the HWD premium amount.
For a client applying for HWD who is applying for or receiving other benefits, route or fax a copy of the application (or the DSHS 14-078 Eligibility Review Form) to designated staff.
NOTE:
Designated CSD staff have ACES Super User status and do not determine or maintain eligibility for other program benefits. They coordinate eligibility for other programs with the CSO worker of record.
Designated HCS Staff coordinate eligibility for other programs with the HCS worker of record in their region.
For a client applying for HWD who is not applying for or receiving other benefits, route the case record to designated staff.
When routing HWD applications or case records, the following contact information applies:
CSD - Forward to the Centralized Medical Unit via DMS CSO 132@HWD.
Centralized Medical Unit (CMU) contact information:
Address: DSHS - CMU PO Box 34350 Seattle, WA 98124-9511
Phone: (206) 272-2169, or Toll Free 1 (800) 337-1835
HCS - Send to the designated staff in your region. The regional information phone numbers are:
Region 11
1-800-459-0421
Region 14
1-800-346-9257
Region 12
1-800-822-2097
Region 15
1-800-442-5129
Region 13
1-866-608-0836
Region 16
1-800-462-4957
For HCS Staff Only
For a client who is employed, not eligible for LTC or non-institutional Medicaid in an ALF as described in WAC 388-513-1305, and wants to apply for HWD:
Deny the application for LTC or non-institutional Medicaid; and
Transfer the case to designated HCS staff to determine HWD eligibility.
Use the HWD Website to determine eligibility and premium amounts.
When determining income to enter into the HWD Website, do notcount income described in the rules below. The HWD calculator doesn't recognize exempt income types. Counting them results in an incorrect amount of income being used to determine eligibility and premium requirements.
For spouses living together or separately after one moves into an alternate living facility (ALF) described in WAC 388-513-1305 (1), see WAC 388-506-0620 (5).
NOTE:
The HWD Website does not apply rules regarding excluded income or the separation of income in the month after the month of separation for spouses living in an ALF.
To determine HWD eligibility, the HWD Website applies SSI-related income disregards and deeming rules for the CN program. To compare the spenddown amount, it applies SSI-related income disregards and deeming rules for the MN program.
To determine HWD premiums, the HWD Website uses income entered to determine eligibility and applies rules described in WAC 388-475-1250 (1) and (3) and Clarifying Information that follows the WAC.
Enter the HWD client as the AU head of household (HOH). The HOH will cross over to OFR as the client to be billed for HWD coverage. If both spouses within a household are approved for HWD, use separate AUs and enter each client as the HOH in their own AU.
NOTE:
When both spouses are enrolled in HWD, clients may pay premiums for both accounts with one check or money order, if they include both billing coupons that detach from their monthly statements or a written statement that includes both CLIDs in their payment envelope.
For entering information into ACES for retroactive coverage under HWD, see WORKER RESPONSIBILITIES - 5. Retroactive Coverage under WAC 388-475-1250.
Enter the correct AREP type in ACES to send the medical assistance ID card and/or notices to the AREP.
Enter AREP type [SB] in ACES to send the premium billing invoice to a Protective Payee who is responsible for managing a client's benefits.
NOTE:
If the premium billing invoice is sent to a Protective Payee, a copy will not be sent to the client. Include text in a letter to the client to let them know this. Send a copy of all letters to the client's authorized representative or protective payee when using Word documents to notify the client of program eligibility, etc., including those that show the premium amount.
NOTE:
Payments received will show on the following month's billing statement. The department does not issue another kind of receipt for payment of HWD premiums received, unless the person makes them in person at OFR. Payment by mail is the preferred method of making HWD premium payments.
Document results obtained from the HWD Website in ACES for those who choose HWD.
For eligible clients, follow ACES procedures to screen for the S08 program. On the SPEC screen enter a “Y” in the eligibility field and the premium amount. See WORKER RESPONSIBILITIES - Initial premium amount under WAC 388-475-1250 for entering the initial premium amount. ACES will open HWD coverage for twelve months.
For ineligible clients, follow ACES procedures to screen for the S08 program. On the STAT screen enter a 599 reason code in the AU Status field.
NOTE:
Members of an American Indian / Alaska Native (AI / AN) population are exempt from HWD premiums. Until WAC 388-475-1250 is amended to reflect the AI / AN exemption, follow normal procedures to obtain an ETR approval before opening benefits and entering the exemption in ACES.
When determining eligibility for members of an AI / AN population, do not finalize the premium calculation on the HWD Website. On the SPEC screen inter a "Y" in the eligibility field and a "0" for the premium amount.
Follow ACES procedures to screen for S03 and S05 when the client is entitled to Medicare.
NOTE:
The department pays the Part B premium for all Medicaid clients not eligible for S03 or S05.
NOTE:
Enrollment in the HWD program is optional. In some instances it may be to a client’s advantage to choose the MN program instead, e.g., a person who is eligible for MN that has unpaid medical expenses to meet spenddown and does not need additional services provided under the CN program.
A person approved for MN (in Active status) cannot be opened for HWD CN coverage until the first of the month after MN coverage is closed.
When denying MPC or LTC Services under regular CN rules, look at HWD as an option, if the client is employed.
For a client approved for HWD who wants to switch to MN (CN or MN in an ALF), do the following:
If the change can be made before the ACES deadline, close HWD at the end of that month and open the other program for the first of the following month.
EXAMPLE
#5 - HWD client calls on June 15 to request her medical coverage be changed to MN. She must enter the hospital for surgery next month and will not be able to work for several months. The hospital bill will meet her spenddown liability. HWD coverage is closed effective June 30 and a pending MN case is screened for the base period beginning July1.
If the change cannot be made before the ACES deadline, close HWD at the end of the next month and open MN for the first of the following month.
EXAMPLE
#6 - HWD client calls on June 25 to request her medical coverage be changed to MN. She must enter the hospital for surgery later next month and will not be able to work for several months. Because of the admission date and the nature of the procedure, she may remain in the hospital for a few days in the following month of August. HWD coverage is closed effective July 31 and a pending MN case is screened for the base period beginning August 1. The HWD premium for July for which she will be billed in August will remain her responsibility and is used to reduce any spenddown amount for the base period beginning in August.
For a client identified by a DDD case manager (per DSHS 15-345 CSO/DDD Communication ) as receiving Waiver services as a member of the HWD eligibility group, use the ACES Coverage Group S08. Do not use Coverage Group C01 Waiver program. Code the INST screen with the HCB/MPC. Indicate Type "P" for the DDD Waiver, the service start date of the Waiver service, and "DD" for the Plan Approval Section. If DDD indicates approved service is MPC, indicate type "M" for the service and the start date under the HCB/MPC field on INST.
Send letters to the client, using Word documents made available to designated staff and adding free form text when appropriate. Be sure to send a copy of all letters to the client's authorized representative. For clients accessing DDD Waiver services, enter the local DDD mailing address on the AREP screen to receive notices.
Document approval or denial as well as any letters sent on the ACES narrative page.
When denying an application or review, follow ACES procedures to determine eligibility for other medical programs. HWD is subject to redetermination rules described in Chapter 388-434 WAC.
WAC 388-475-1150
WAC 388-475-1150
Effective January 14, 2002
WAC 388-475-1150 Healthcare for workers with disabilities (HWD) - Disability requirements.
This section describes the disability requirements for the two groups of individuals that may qualify for the healthcare for workers with disabilities (HWD) program.
To qualify for the HWD program, a person must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):
(XV) for the basic coverage group (BCG); or
(XVI) for the medical improvement group (MIG).
The BCG consists of individuals who:
Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or
Are determined by the division of disability determination services (DDDS) to meet federal disability requirements for the HWD program.
The MIG consists of individuals who:
Were previously eligible and approved for the HWD program as a member of the BCG; and
Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1) (b).
When completing a disability determination for the HWD program, DDDS will not deny disability status because of employment.
Disability Determination - Medicaid Eligibility under HWD
In Washington State, the Social Security Administration contracts with the Division of Disability Determination Services (DDDS) to determine whether a person currently meets federal disability requirements for program services.
HWD introduces a different level of disability for Medicaid eligibility because of the Medical Improvement Group (MIG) established under Section 1902 (a) (10) (A) (ii) (XVI) of the Social Security Act. Under this Act, a person with a medically improved disability must have a severe medically determinable impairment and meet all other program requirements, including that of employment described in WAC 388-475-1200, to continue HWD eligibility.
NOTE:
To continue eligibility for HWD as a member of the Medical Improvement Group, a person must have been eligible and approved for the program as a member of the Basic Coverage Group (BCG).
At this time, HRSA Headquarters staff determine whether a person has a severe medically determinable condition that meets HWD requirements. See WORKER RESPONSIBILITIES below.
HWD Referral to DDDS
HWD introduces a change in the disability determination process. When determining disability for Medicaid under the HWD program, DDDS will not look at the person's earnings. This differs from the process DDDS uses when determining disability for SSDI or SSI cash benefits.
WORKER RESPONSIBILITIES
DDDS Referral for NGMA - Local CSO or HWD Unit
Local CSO Staff:
The local CSO must complete the disability determination referral to DDDS for a person with gross monthly earnings less than the SGA amount. The only exception is a person who also has countable resources that exceed the SSI standard.
Follow local procedures to initiate and complete a disability determination from DDDS.
If approved, see SSI-Related Medical-General and review eligibility for appropriate coverage group, according to program requirements of S02, C01, or G03.
If S08 (HWD) appears to be the only coverage group for which a person may be eligible, or HWD would require a lower cost share amount, transfer the case to the Centralized Medical Unit via DMS (CSO 132@HWD).
Central Processing - Designated Staff Responsibilities
For a client not currently approved for disability benefits, follow local procedures to initiate a disability determination from DDDS. Contact the client to client to gather medical and social information currently available and obtain signed release of information forms for the referral packet.
If a client has a pending application for SSDI or SSI, which is a different application than one for HWD coverage, contact DDDS by telephone or email and follow up with staff there by completing a request for an HWD/NGMA disability determination. DDDS does not look at the amount of a person's earned income when determining disability status for HWD Medicaid Only.
Request retroactive approval if the client had a medical need in any of the three months before the month of application.
Pend the application until you receive the DDDS decision. Inform the client that a determination may take up to up to 60 days. Document in ACES the reason for delays beyond 60 days from the date of application, e.g., no response yet from DDDS.
For a person receiving HWD benefits who appears to no longer meet the disability requirements for the BCG, contact the HWD program manager at HWDProgramManager@dshs.wa.gov.
EXAMPLE
#7 - An HWD client receives a letter from SSA that states he/she no longer meets the disability requirement to receive SSDI cash after completing his/her Trial Work Period (TWP) and has earnings at or above the substantial gainful activity (SGA) level for one subsequent month.
He/she will be eligible for and receive the SSDI benefit for that one month and the following two months. However, during any month in which earnings fall below the SGA level, the individual remains eligible for his/her SSDI cash benefit during the Extended Period of Eligibility (EPE). The EPE begins the month after SSDI ends because of earnings and continues for 36 months. To receive SSDI for a month in which earnings fall below SGA, the client must call SSA and document for them the amount of earnings; no application is necessary.
When a client receives this kind of letter from SSA, it might appear he/she does not continue to meet disability requirements for coverage under the HWD Basic Coverage Group (BCG). That is not true, however, since the client is only beginning the EPE. The client remains eligible for coverage under the BCG during the EPE, and no action is taken in response to the letter regarding the end of eligibility for the cash benefit. Staff need only to recalculate the monthly premium amount and send a letter to the client to notify him/her of the new premium amount.
For more information about SSDI work incentives, see the SSA Red Book.
EXAMPLE
#8 - A client completes the EPE and remains enrolled in HWD. It is not clear whether the client remains eligible for coverage under the BCG and it appears that he/she may need a disability determination for the Medically Improved Group. Staff must contact the HWD program manager and continue current HWD coverage until a redetermination of eligibility is completed.
Continue HWD coverage until you receive a decision from the HWD program manager as to whether the client meets the disability requirement for the MIG.
To approve HWD coverage for a member of the MIG, use the new “Disability Source” (CD) code to indicate the client has a medically improved disability as determined by the HWD program manager.
For a client receiving HWD benefits that no longer meets the eligibility requirements for BCG or MIG, continue HWD coverage until you redetermine eligibility for other medical programs. HWD is subject to redetermination rules described in Chapter 388-434 WAC.
Send letters to the client, using Word documents made available to designated staff and adding free form text when appropriate. Be sure to send a copy of all letters to a client's authorized representative.
Document approval or denial as well as any letters sent on the ACES narrative page.
WAC 388-475-1200
WAC 388-475-1200
Effective January 14, 2002
WAC 388-475-1200 Healthcare for workers with disabilities (HWD) - Employment requirements.
This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the healthcare for workers with disabilities (HWD) program.
For the purpose of the HWD program, employment means a person:
Gets paid for working;
Has earnings that are subject to federal income tax; and
Has payroll taxes taken out of earnings received, unless self-employed.
To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.
To qualify for HWD coverage as a member of the MIG, a person must be:
Working at least forty hours per month; and
Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).
A person doesn't have to work a set number of hours or earn a minimum amount of income to be eligible for HWD coverage under the BCG. However, people who want to enroll in the HWD program must provide proof they have earned income, i.e., they are working as described in the program requirements.
To satisfy the program requirement of being employed or self-employed, a person must provide proof that the work activity they perform is generating income subject to federal income tax rules. Those working within an employee/employer relationship can meet this requirement by providing evidence that FICA and payroll taxes are taken out of their earnings. Those working as a self-employed person - conducting a trade or business - can meet this requirement by providing legitimate business records and a copy of any Internal Revenue Services (IRS) forms completed and filed, e.g. IRS Schedule SE or IRS Form 1040, Schedule C or Schedule F, showing entries for net earnings or losses. If the person hasn't been in business long enough to file a tax return, detailed records, such as a combination of ledger sheets, receipt books, self-employment worksheets for tracking potential tax liability must be provided. A business license does not in and of itself enough provide evidence of self-employment.
NOTE:
If a person works for an employer that by law is not required to withhold FICA or payroll taxes or is prohibited from doing so, such as tribal governments or certain sheltered workshops, HWD coverage may still be approved.
Self- Employment Tax
Self-employment tax (SE tax) is a social security and Medicare tax primarily for individuals who work for themselves. Payments of SE tax contribute to an individual's coverage under the social security system. Social security coverage provides retirement, disability, survivor, and hospital insurance (Medicare) benefits. All deductions allowed by the IRS, including depreciation, may be used.
An individual must pay SE tax and file Schedule SE (Form 1040), if the individual has:
Net earnings from self-employment of $400 or more or
Church employee income of $108.28 or more
Self- Employment Definition - Examples
The following examples are taken from the Social Security Administration (SSA) Program Operations Manual System to help determine whether a person meets the program requirement of employment.
EXAMPLE
#9 - Mrs. Bell reports she started babysitting for her grandchild while her daughter works. Sometimes the child comes to her home, but usually, she goes to her daughter's home because the child's toys and other items are there. She does not baby sit for anyone else. She receives about $20 a week from her daughter.
Although a caregiver is a recognized occupation, Mrs. Bell is not holding herself out as a provider of daycare services, nor does she have intent to produce income. Therefore, Mrs. Bell is not considered self-employed when determining whether she meets the program requirement of employment.
EXAMPLE
#10 - Mrs. Simon files for SSA benefits. When asked about any income she receives, she says she does baby sit for various neighbors and friends, but does not consider herself as self-employed. She files no tax forms for this income. She began baby sitting when her own children were young to make some extra money. She gets new business by word of mouth. Although Mrs. Simon does not consider herself to be in the daycare business, she meets all of the factors indicating the existence of a trade or business. Therefore, Mrs. Simon is considered to be self-employed when determining whether she meets the program requirement of employment.
EXAMPLE
#11 - Mr. Lyons, an SSDI recipient, reports that since he needed extra money to meet his rent and food expenses, he started collecting aluminum cans from the street. He redeems them at the recycle center for cash. Sometimes his neighbors or local organizations call him to pick up their cans. He does not file any tax returns, but he thinks he makes about $200 a month.
Since this is an ongoing, regular activity that includes some third party collection pickups and was established with the intent of producing income, it is determined that Mr. Lyons is self-employed. To establish and document this eligibility criteria, Mr. Lyons must provide completed IRS forms or legitimate business records as described above.
EXAMPLE
#12 - Mr. Kent reports that he earned some money cutting the lawn for one of his neighbors. His car needed some repairs and he did not have the money. His neighbor told Mr. Kent that he could cut his lawn for the month of July for $80. Since he needed the cash to pay for the repair, he decided to cut the lawn. Mr. Kent is not holding himself out as a lawn service. Further, this is not an ongoing regular activity nor does Mr. Kent plan to do this activity to make a profit. He only did it to earn enough to pay for the car repair. Therefore, Mr. Kent is not considered to be self-employed when determining whether he meets the program requirement of employment.
Employment - Medical Improvement Group (MIG)
HWD coverage does not require that a person be working a set number of hours or be making a certain amount of money, unless he/she becomes ineligible under the Basic Coverage Group (BCG). A person loses disability status for the BCG, only if after a regularly scheduled continuing disability review completed by DDDS, the person's medical condition has improved to the point that he/she is no longer disabled as SSA defines the term for federal cash benefits.
In addition to providing evidence of their employment, people who have a medically improved disability and want to continue their HWD coverage must be working at least 40 hours per month and be earning at least minimum wage.
People with a medically improved disability who are self-employed must provide the same evidence required for members of the BCG.
WORKER RESPONSIBILITIES
Use documents obtained from the client for determining income to verify employment status, if the documents indicate tax withholdings, e.g., Social Security and Medicare.
Do not use a personal check or pay stub that does not indicate tax withholdings as evidence of earnings gained through employment for HWD eligibility requirements.
Contact the client’s employer when necessary to verify tax withholdings.
For clients who are self-employed, but have not been in business long enough to file a tax return, accept legitimate business documents as evidence of self-employment. Advise them to maintain business records and require them to provide a copy of their federal tax return when it becomes available.
WAC 388-475-1250
WAC 388-475-1250
Effective January 14, 2002
WAC 388-475-1250 Healthcare for workers with disabilities (HWD) - Premium payments.
This section describes how the department calculates the premium amount a person must pay for healthcare for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.
When determining the HWD premium amount, the department counts only the income of the person approved for the program. It does not count the income of another household member.
When determining countable income used to calculate the HWD premium, the department applies the following rules:
Income is considered available and owned when it is:
Received; and
Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 388-475-0600(5), 388-475-0650, and 388-475-0700(1).
Loans and certain other receipts are not considered to be income as described in 20 C.F.R. Sec. 416.1103, e.g., direct payment by anyone of a person's medical insurance premium or a tax refund on income taxes already paid.
The HWD premium amount equals a total of the following (rounded down to the nearest whole dollar):
Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 388-478-0070; plus
Five percent of total unearned income; plus
Two point five percent of earned income after first deducting sixty-five dollars.
When determining the premium amount, the department will use the current income amount until a change in income is reported and processed.
A change in the premium amount is effective the month after the change in income is reported and processed.
For current and ongoing coverage, the department will bill for HWD premiums during the month following the month in which coverage is approved.
For retroactive coverage, the department will bill the HWD premiums during the month following the month in which coverage is requested and necessary information is received.
If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following month(s).
As described in WAC 388-475-1050(4)(b), the department will close HWD coverage after four consecutive months for which premiums are not paid in full.
If a person makes only a partial payment toward the cost of HWD coverage for any one month, the person remains one full month behind in the payment schedule.
The department first applies payment for current and ongoing coverage to any amount owed for such coverage in an earlier month. Then it applies payment to the current month and then to any unpaid amount for retroactive coverage.
The “Ticket to Work” legislation gives states flexibility when determining the type and amount of cost sharing they require for enrollment in the HWD program with the following exception. States cannot require a premium amount that exceeds 7.5% of the enrollee's total income.
The standard income methodology used for SSI-related programs does not apply when determining countable income used to calculate HWD premiums. For the determination of HWD premiums, the HWD Website uses income entered to determine eligibility and applies rules described in WAC 388-475-1250 (1) and (3).
Income used to calculate HWD premiums includes only that of the person enrolling in the program. If both spouses apply, their premiums are calculated separately using only the income of each spouse.
NOTE:
Members of an American Indian / Alaska Native (AI / AN) population are exempt from HWD premiums.
Follow normal procedures to obtain an ETR approval before opening benefits and entering the exemption into ACES. See WORKER RESPONSIBILITIES #5 under WAC 388-475-1100 for entering the exemption.
The HWD Website calculates the HWD premium using the program formula and then compares that amount to 7.5% of the enrollee's total income. The lesser of the two is indicated as the correct premium amount and transmitted to the Office of Financial Recovery (OFR). OFR uses the information it receives from the HWD Web for data comparison, but uses the premium amount entered in the ACES SPEC screen for billing purposes.
Premium Example: A person earns $665 per month and receives $874 SSDI.
Income
Monthly earned income
$665.00
Monthly unearned income (Social Security)
$874.00
Total monthly income
$1,539.00
Premium Calculations - first
Subtract the MNIL ($674) from unearned income
($874 - $674)
$200.00
Take 50% of the result
(.5 x $200 = $100)
$100.00
Include the result as part of your premium
$100.00
Calculate 5% of unearned income
(.05 x $874 = $43.70)
$43.70
Include the result as part of your premium
$43.70
Subtract $65 from gross earned income
($665 - $65 = $600)
$600.00
Take 2.5% of the result
(.025 x $600 = $15)
$15.00
Include the result as part of your premium
$15.00
PREMIUM AMOUNT (rounded down) - using formula
$158.00
Premium Calculations - second
Calculate 7.5% of total income (.075 X $1,539)
$115.42
PREMIUM AMOUNT (rounded down) - using formula
$115.00
ACTUAL PREMIUM (Lesser of first and second calculation)
115.00
When calculating premiums, round down to the nearest whole dollar. In this example, the client pays $115 per month.
Initial Premium
If a person applies in one month for HWD coverage that is not approved until the next month, the first monthly premium will include costs for both the first and second month, unless he/she chooses not to purchase coverage for both months.
EXAMPLE
#13 - A client applies for HWD on July 10 and provides information needed to complete the application on August 6. HWD is approved on August 7 for coverage beginning July 1 and OFR receives the premium calculation from ACES via the interface on the last business day of August. The client receives a bill for the initial premium, which includes charges for both July and August for HWD coverage that begins July 1.
NOTE:
In this example, if the client does not pay this bill in full by the end of September, the client will be one month behind in making premium payments.
Changes in Premium
Changes in the HWD premium will take effect the first of the following month in which the change is reported and processed as a change in circumstances. For a person who experiences a job loss, and chooses to continue HWD coverage as described in WAC 388-475-1050 (4)(c), the premium will be based on unearned income only when earnings are no longer received.
WORKER RESPONSIBILITIES
Initial Premium Amount
When approving an application that includes months prior to the current month and/or back to the month of application), enter a total amount of premiums owed for each of these months and the current month as the first month's premium amount. Add free form text to itemize the amount for each month on the award letter, using Word documents made available to designated staff, and explain that the total amount is the first month's premium.
NOTE:
The client is not required to pay a premium for each of the months back to the month of application in which no medical need occurred. Once it has been made clear for which months the client wants to purchase HWD coverage, the premium amount entered on the SPEC screen should reflect the number of months for which the initial medical assistance card will be issued.
Take immediate action to process any change in the client's premium amount after allowing the 10-day advance notice requirement.
NOTE:
Since the HWD premium amount is billed in the month following the month of coverage, the premium amount should reflect the income received during the month of coverage whenever possible. If not possible, due to time of reporting, advance notice or processing requirements, make the change effective the first of the next following month unless a different income amount can and should be applied for the next month of coverage.
Explain to client the importance of correctly identifying months in the retroactive period for which HWD coverage will be purchased. For each month identified, the client must pay the monthly premium in advance.
Explain to the client the importance of talking to providers from whom they have received services for which they have already paid during retroactive months. Providers are not required to reimburse clients for such payment when they later present a medical assistance card.
For retroactive coverage, enter information in the HWD Website and screen for S08 coverage in ACES for retroactive months under a different AUID. Pend the application for retroactive coverage until notified by OFR (by email) whether the client has paid premiums for the months requested. Note: Follow local procedures, such as setting a tickler for checking to see if premiums are paid, before taking action on the request for retroactive coverage, if such action is preferred to pending the additional AUID.
For a client that pays premiums for retroactive coverage, open the months of coverage historically in ACES and send a letter of approval, using Word documents made available to designated staff.
For a client who does not pay for one or more months chosen in the retroactive period, enter a 599 reason code in ACES and send a letter of denial, using Word documents made available to designated staff. Allow up to 90 days before denying retroactive coverage for which payment hasn't been made.
ACES - OFR interface
The interface between ACES and OFR is used to communicate information regarding the payment of ongoing premiums. Take immediate action on the alertgenerated by OFR via the interface when the client has not paid premiums for four consecutive months.
When OFR notifies you via the interface that the client has not paid premiums for four consecutive months:
Send notice to close HWD coverage.
Enter the four-month sanction period on the SANC screen, using a 200 code.
NOTE:
Data entered on the SANC screen provides information staff should check when determining eligibility for HWD coverage that was previously closed because of non-payment of premiums. For HWD, completion of the SANC screen does not prevent future benefits from being authorized and issued; ACES does not currently provide that functionality for S08. As stated below, contact with OFR is a second step that needs to occur before approving HWD previously closed for non-payment of premiums.
Send letters to the client, using Word documents made available to designated staff and adding free form text when appropriate. Be sure to send a copy of all letters to a client's authorized representative or protective payee.
Document approval or denial as well as any letters sent on the ACES narrative page.
DO NOT REFER CLIENTS TO OFR OR TO THE MAA 1-800 PHONE LINES. All premium-related issues are a condition of eligibility and cannot be resolved outside of the CSO.
Contact OFR when a client applying for HWD had previous coverage closed for not paying premiums. OFR does not communicate to ACES via the interface whether premiums owed in the past have been paid.
If you, as CSO staff, have questions about HWD premiums, your OFR contacts are:
If the client states they did not get the premium bill, check for returned mail.
Undelivered premium billings are returned to the CMU, not to OFR.
If the client has lost the premium notice and asks where to send the payment, tell the client to:
Make the check or money order out to DSHS;
Include the billing coupon that detaches from the monthly statement, or a written statement if the coupon has been lost, which states the payment is for Healthcare for Workers with Disabilities or HWD premium; and
Include their account number (the CLID of the head of household); and
Mail the payment to:
DSHS
Office of Finance Division
PO Box 9501
Olympia, WA 98507-9726
At this time, OFR does not accept electronic payments such as a credit or debit card. Payments must be made directly to OFR as indicated above. And payments can't be accepted at a CSO.
Modification Date: October 1, 2009
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