Apple Health for Workers with Disabilities

Revised April 16, 2015

Purpose: This section describes the Healthcare for Workers with Disabilities (HWD) program. HWD recognizes the employment potential of people with disabilities. 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.

As a categorically needy (CN) Medicaid program, HWD provides access to Medicaid Personal Care services (MPC) and Home and Community Based (HCB) waiver programs administered by the Developmental Disabilities Administration (DDA) and Home and Communities Services (HCS).

For more information see the Apple Health for workers with disabilities (HWD) fact sheet.

Clarifying Information

To encourage people with disabilities to work, increase their self-sufficiency, and enhance the quality of their lives, Congress passed legislation that made an additional SSI-related Medicaid option available to states to support such employment. Under HWD, enrollees are able to earn and save more money and to purchase healthcare coverage with monthly premiums based on a sliding scale. HWD provides the only eligibility group for SSI-related coverage for those working at or above the substantial gainful activity (SGA) level who do not have Medicaid protections under Section 1619 of the Social Security Act, or no longer receive Title 2 cash benefits, such as SSDI. Also, HWD does not have a resource test.

Apple Health for Workers with Disabilities (HWD)

Some people may be eligible for HWD, who are not eligible for other SSI-related medical programs, due to:

1. Gross monthly earnings at or above the Substantial Gainful Activity (SGA) level; or
2. Countable income or resources that exceed other program standards, including the L22 coverage group used when eligibility is determined under "institutional" rules.

For more information go to the Apple Health SSI-related overview.

HWD Option for DDA and HCS Waiver Services

A person eligible for HWD, if functionally eligible for them may also receive services from the Developmental Disabilities Administration (DDA) or Home and Community Services (HCS). 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 individual who is working may be able to keep more of his/her earned income. DDD case managers review cases of their individuals 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.

Note: Waiver services received under HWD are subject to transfer of asset, annuity declaration, and excess home equity provisions that are specific to institutional programs (L22). MPC program services, however, are not subject to those provisions.

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 or calculating the HWD premium amount.

For Additional information about HWD and DDA/HCS Services, click on Working Clients and LTC.

HWD and other Insurance Coverage

Like clients approved for coverage under other Apple Health programs, HWD clients may have access to other health insurance coverage. Some may even pay for such coverage out-of-pocket or have it taken out of their earnings. These costs may not be used to reduce countable income for determining eligibility or the monthly premium amount. However, the department may be able to pay the monthly premium for the other insurance after HWD is approved. For related information, see Medical Assistance - Third Party Liability (TPL).

Worker Responsibilities

1. It is critical to compare the options and determine which program costs less when an individual meets the requirements for more than one program.
2. Since HWD requires a monthly premium payment, the program of choice for someone eligible for both HWD and another CN program is the one that costs less. Compare HWD to the following programs to determine the most advantageous to the individual:
   1. The Apple Health for Kids program
   2. The CN pregnancy program (P02)
   3. The CN disability program (S02) for a disabled adult child (DAC)
   4. CN programs (L22 or G03) depending upon financial and functional requirements and place of residence
   5. The Apple Health MAGI-based adult program (N05), which does not test for SGA and does not require a monthly premium payment.
3. 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 provides those eligible for both with a comparison of their spenddown amount.

For most people, HWD is the preferred program because:

1. CN provides more extensive coverage than MN; and
2. The HWD monthly premium is likely to be less than the monthly amount used to determine a three or six month spenddown liability.

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.

Note: Follow ACES procedures to screen for S03 and S05 when the individual is entitled to Medicare. Remember to review for resource eligibility for S03 and S05.

Note: HWD enrollees receiving Medicare get help with their Part D expenses; they receive "full subsidy" benefits. People with income above 135% FPL who choose MN instead of HWD receive only partial help with their Part D expenses, unless they meet their spenddown.

Clarifying Information

Disability Determination for Apple Health Non-Grant Medical Assistance (NGMA)

For information on procedures to obtain a determination of disability or blindness that enables adult not receiving federal cash benefits to be related to Medicaid, see the NGMA chapter and NGMA examples.

Disability Determination for the HWD Medical Improvement Group

To continue eligibility for HWD as a member of the Medical Improvement Group (MIG), an individual must have been eligible and approved for the program as a member of the Basic Coverage Group (BCG). HCA program staff determine whether an individual meets HWD MIG requirements. Having the MIG option or coverage group ensures that an individual who continues to have a significant impairment may continue to receive health care services that support their employment.

Worker Responsibilities

HWD Designated Staff Responsibilities

1. For an individual receiving HWD benefits who appears to no longer meet the disability requirements for the BCG, follow local procedures to obtain an ETR decision from the HWD program manager before terminating coverage.
   Example: #1 - An HWD individual 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 an individual receives this letter from SSA, it might appear he/she does not continue to meet disability requirements for coverage under the HWD Basic Coverage Group (BCG). This is not true, since the client is only beginning the EPE. The client remains eligible for coverage under the BCG during the EPE. Staff need to recalculate the monthly premium amount and send proper notification.

   For more information about this SSDI work incentives, see the SSA Red Book Extended Period of Eligibility.

   Example: #2 - An individual completes the EPE and remains enrolled in HWD. If medical improvement has occurred, the client's coverage continues until the completion of a disability determination for the Medically Improved Group (MIG). Obtain an ETR decision from the HWD program manager and continue HWD coverage until a redetermination of eligibility for the MIG is completed.

2. 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.
3. For an individual receiving HWD benefits that no longer meets the eligibility requirements for BCG or MIG, continue HWD coverage until you re-determine eligibility for other medical programs.

Clarifying Information

Employment - Basic Coverage Group (BCG)

Individuals do not have to work a certain number of hours or earn a minimum amount of income to be eligible for HWD coverage under the BCG. Individuals who want to participate in the HWD program must provide proof they have earned income.

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. Individuals can meet this requirement by providing evidence that FICA and payroll taxes are taken out of their earnings.

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

Individuals who are self-employed can meet this requirement by providing business records and a copy of 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 provide evidence of self-employment.

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: #3 - 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: #4 - 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 babysitting 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: #5 - 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: #6 - 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)

When reviewing for continued HWD coverage under the MIG group, the 40 hours (per month) work requirement does not apply. They must continue to meet the employment requirements of the Basic Coverage Group (BCG).

Worker Responsibilities

1. 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.
2. Contact the individual’s employer when necessary to verify tax withholdings.
3. For individuals who are self-employed, but have not been in business long enough to file a tax return, accept business documents as evidence of self-employment. Advise them to maintain business records and provide a copy of their federal tax return.

Clarifying Information

Countable Income - Premium Amount

States have 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.

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.

ACES 3G 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 sent to the Office of Financial Recovery (OFR) for billing purposes.

Premium Example: A person earns $965 per month and receives $898 SSDI.

Initial Premium

If a person applies in one month for HWD coverage, but not approved until the next month, the first monthly premium include costs for both months. Purchasing the initial month is optional.

Example: #7 - An individual applies for HWD on July 10 and provides information on August 6. HWD is approved on August 7 for coverage beginning July 1. The individual receives a bill for the initial premium, which includes charges for July and August.

Changes in Premium

Changes in the HWD premium takes effect the first of the following month in which the change is reported and processed as a change in circumstances. Individuals who experience a job loss may choose to continue HWD coverage as described in WAC 182-511-1050 (4)(c).

ACES - OFR Interface

The interface between ACES and OFR is used to communicate information regarding premium payments. Nonpayment of premiums triggers the AU to close for Reason Code 342 - Termination/Denial Due to NonPayment of Premium and imposes a four month sanction.

Worker Responsibilities

Initial Premium Amount

Explain to the individual they are not obligated to purchase coverage each month back to the date of application.

Retroactive Coverage

1. Encourage the individual who has paid for services received in the retroactive period that providers are not obligated to accept Medicaid reimbursement for those months.
2. Explain to the individual that premiums for retroactive coverage must be paid in advance. Premiums must be paid within 120 days or the retroactive coverage will be denied.

Note: If the premium billing invoice is sent to a Protective Payee, a copy will not be sent to the client. Add free form text in a letter to the individual to let them know this.

Note: Members of an American Indian/Alaska Native (AI/AN) population are exempt from HWD premiums. By entering the appropriate valid value for race, ACES automatically bills for a payment of $0.

Premium payment questions are managed by the CSO. Do not refer individuals to OFR or to HCA MACSC.

CSO staff only: If you have questions about HWD premium payments, the OFR contact is:

Note: If the individual states they did not get the premium bill, check for returned mail.

Undelivered premium billings are returned to the HCA Imaging and Mail Services, not to OFR.

If the individual has lost the premium notice and asks where to send the payment, tell the individual 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:

  Office of Financial Recovery
  PO Box 9501
  Olympia, WA 98507-9501

Note: An individual may pay their premium directly from their bank account, if they choose to set up an account they may go to MY Secure DSHS. Go to My Secure DSHS for more information on this option.

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