Working clients on long-term care programs (Waiver, residing in a medical institution or MPC)

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Working clients on long-term care programs (Waiver, residing in a medical institution or MPC)

Revised July 22, 2009

Healthcare for Workers with Disability, Substantial Gainful Employment (SGA) and SSI clients with 1619B status

Purpose: This section explains how to choose the correct program when a client is working and needing HCB services. This section also describes how to code ACES. This section gives additional information on the healthcare for workers with disability program (HWD). Eligibility for HWD is used for both the DDD and HCS CN Waiver programs as well as medicaid personal care (MPC).

Working clients on COPES (or any HCB service) or MPC

SSI clients that no longer receive a SSI check due to earnings but Social Security still considers an active SSI client.   (1619B status).

Healthcare for Workers with Disabilities (HWD). HWD may be more beneficial to a working clients who have earnings.
HWD provides categorically needy (CN) scope of care, including Medicaid Personal Care (MPC) servics. Effective 4/1/2009 eligibility for HWD has been included in the HCB CN Waivers authorized by Home and Community Services (HCS). Starting 4/1/2009 either MPC or HCB CN Waivers can be considered for HWD eligible clients. Use MPC as a priority if needs can be met under MPC.

HWD has been an eligibility coverage group for DDD Waivers since June 2006. MPC or DDD Waiver can be considered for HWD eligible clients who are determined eligible for services by Division of Developmental Disabilities (DDD).

When is HWD (S08 in ACES) better than using HCS CN (COPES) rules (C01 in ACES).

No asset test for HWD.

May have gross income over the SIL with HWD.

No participation toward personal care. There is a monthly HWD premium.

Earned income can be over the social security substantial gainful activity (SGA). SGA is not a factor for HWD because it is waived for the HWD program.  It is a factor for most SSI related medicaid including HCS Waivers

When can HCB Waiver (COPES) be better than HWD

Client's income is low enough where there is no participation toward personal care and there is already -0- out of pocket cost under the COPES program.

Spousal impoverishment rules do not apply to HWD. Spousal income follows SSI related rule for the HWD program. Many individuals with a community spouse may be better off using the rules under the C01/Waiver program because of the benefit of the spousal impoverishment rules.

Adding HWD to the HCS CN waiver effective 4/1/09.

Effective 4/1/2009, HWD eligibility has been included in the HCS CN Waivers. WAC 388-515-1507 has been filed under an emergency adoption.

Prior to 4/1/2009 HWD did not cover eligibility for the HCB Waiver (COPES/New Freedom) program.

HWD is a “medicaid buy in” medicaid program for working disabled individuals under age 65. HWD clients must pay a monthly premium to the state for medicaid coverage.

HWD premiums are paid to financial service administration (FSA). The amount of the premium is based on income and determined by financial workers that specialize in HWD.

HWD clients still meet disability criteria even if their income equals or exceeds the substantial gainful employment test (SGA) used by social security.

How is HWD similar to other SSI-related medical (CN)?

Same application form SSI rules when determining eligibility.

NGMA is needed if no current disability determination.

Medical identification card - (S08) Fee for service medical coverage Provides Medicaid Personal Care

How is HWD different from other SSI-related medical (CN)?

No asset test

Higher income standard - clients pay monthly premiums instead of meeting spenddown liability or pay participation liability HWD Website determines eligibility and premium amount

Only designated HWD staff determine eligibility

The substantial gainful activity (SGA) is not a factor for HWD. For all other SSI related Medicaid programs, the SGA IS a factor and earnings cannot equal or exceed the SGA amount (1/09 SGA is $980). For HWD disability, this test does not apply. For a client earning $980 or more per month, HWD is the only SSI related program that should be considered. More information on SGA is indicated below. HWD is limited to individuals under age 65.

NOTE:
HWD is not an eligibility group for the Medically Needy (MN) Waivers. (MNIW, MNRW) authorized by HCS. An individual eligible for HWD needs to be considered for CN Waiver (COPES) or MPC.

What is substantial gainful activity (SGA) and why is it important?

To be eligible for disability benefits, a person must be unable to engage in substantial gainful activity (SGA).

A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA.

The amount of monthly earnings considered as SGA depends on the nature of a person's disability.

The Social Security Act specifies a higher SGA amount for statutorily blind individuals; Federal regulations specify a lower SGA amount for non-blind individuals. Both SGA amounts increase with increases in the national average wage index. See WAC 388-475-0050.

The monthly SGA amount for statutorily blind individuals is $1,640

For non-blind individuals, the monthly SGA amount for is $980 SGA for the blind does not apply to Supplemental Security Income (SSI) benefits, while SGA for the non-blind disabled applies to Social Security and SSI benefits.

See: >http://www.ssa.gov/OACT/COLA/sga.html

Why is SGA important for SSI related medicaid programs?

SGA criteria is waived for the HWD program. SGA criteria is not waived other SSI related medicaid programs. If a client has income at or above the SGA amount and is not in 1619B status for continued SSI eligibility, HWD is the only SSI related program that can be considered. The client no longer fits the SSI related disability criteria for eligibility except the HWD program.

(SGA note: there is a special consideration such as IRWE, work modification, productivity percentage of like work that is deducted before reaching the countable SGA by Social Security, consult the Social Security office if there are questions regarding the SGA criteria and disability).

In other words, the client would still be considered disabled for the purposes of HWD when income is over the SGA amount, but not considered disabled for any other SSI related medicaid program.

It is important to consider SGA when closing the HWD program and considering another SSI related Medicaid program including rules under the C01 (Waiver) program.

NOTE:
HWD covers short stays in nursing homes. HWD does not cover medical institutionalization projected 30 days more more. Institutional programs under the L track (L02, L95) or C track for Hospice must be considered for individuals living or projected to live in an institution 30 days or more.

Working clients in a Medical Institution
Working clients in a medical institution do not receive the 65 and 1/2 earned income disregard in initial or post eligibility.

WAC 388-513-1380 (4) allows a post eligibility deduction for:

mandatory taxes out of wages.

department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction employment expenses are not deducted.

The client PNA, mandatory taxes, department approved wage deduction and guardianship fee deduction cannot exceed the MNIL.

HWD does not cover nursing facility payment when an individual is institutionalized 30 days or more in a medical facility. See short stays for using HWD for nursing facility admissions under 30 days.

HWD specialists in the CSO and HCS
CSO specialty unit 132, HWD and HCS cases.

CSO 132, Region 4 medical call center uses a specialty unit for the HWD program for the state. All HWD cases not on HCS services are maintained by CSO 132 as a specialty program.

The financial record is requested from CSO 132 when HCS services are opened unless there is a TANF or children/family medical case attached to the household

HCS maintains their own HWD financial cases for clients receiving services with HCS (and no TANF or children/family related medical attached).

An application for HWD and HCS services goes to the HCS Regional specialist.

An application for HWD and no HCS services goes to the CSO 132 specialty unit. This includes HWD clients on DDD MPC or Waiver services.

The CSO HWD specialist contact is:

Joshua Smay

132 call center number- 1 (800) 337-1835

HWD Message line (206) 272-2169

How to request an active HWD case from CSO 132:

Set a “Same Day” barcode Tickle under @HWD for CSO 132 requesting the transfer.   In addition to the tickle, a direct e-mail to Joshua Smay fast tracks the case transfer .

For questions regarding HWD and assistance in choosing the most beneficial program for HCS clients contact:

HCS Headquarters :

Lori Rolley, Financial Policy Analyst

Peggy Rezac, Financial Policy Analyst

HCS HWD Specialists:

Region 1:

Robert O’Dowd, Gary Olson, Theresa Zavala

Region 2:

Diane Storms, Harvey Cardwell

Region 3:

Rob Murphy, Jyl Phipps

Region 4:

Mathew Sipes, Shelly Bradford-Johnson, Michelle Joseph, Graham Zuch

Region 5:

Roberta Blocker

Region 6:

Frankie Sokso, Crystal Boling, Colleen Bouldin, John Hanrahan

Worker Responsibilities.

The HWD computation is not supported by ACES,see complete HWD program information.

The calculation is done by a calculator located on the Financial Services Administration (FSA) website at: http://fsa.dshs.wa.gov/hwd/. (Click on the Entry Form Tab)

Only designated financia staff receives a User name for the HWD calculator.

Changes in ACES on a S08 case must be done by an HWD specialist. (Changes made by a non HWD specialist can result in incorrect eligibility including notification issues).

HCS service eligibility is indicated on the INST screen of the S08. The HWD premium amount is indicated in ACES on the SPEC screen by the HWD specialist. This is sent over to FSA so the correct premium notice is sent to the client.

HWD letters are hand done using letter templates. The information is cut and pasted info into an ACES general correspondence letters.

HWD receiving Waiver services are subject to transfer of asset, annuity declaration and excess home equity provisions that are specific to institutional programs (C01). (MPC services are not subject to these provisions).

HWD specialists must inform the social worker or case manager that the room and board standard is the only cost for an HWD client in an ALF. ACES does not support the room and board calculation for HWD on HCS CN Waiver. The award letter for HCS CN Waiver must be hand-done using the HWD templates.

MPC is the preferable program if needs can be met under the MPC program. This determination is made by the social worker/case manager.

The medical coverage group S08 must be used for HWD clients in order for the premium bill to go out to the client from FSA. (Waiver or MPC service information is indicated on the INST screen under the HCB service field).

The C01 program is not used in ACES for HWD, but a client can still get services under the HCB Waiver.

It is important for the client, financial worker and the client case manager/social worker to know that it is very important for the client and/or their representative to pay the HWD premium to FSA timely. There are penalties described in the HWD chapter when premium payments are overdue. This penalty could result in no HWD coverage for 4 months which could affect the client's eligibility for continued services.

When a NGMA is needed for HWD, make sure the following language is added to the NGMA cover sheet to DDDS:

Disability determination is needed for Healthcare for Workers with Disabilities (HWD). SGA is waived for this program.

Follow NSA/Equal Access for individuals needing assistance.

HWD and ACES coding

SPEC screen in ACES

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