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Apple Health for Workers with Disabilities
The Apple Health for Workers with Disabilities program policy and procedures described here are effective January 1, 2020.
Purpose: This section describes the Apple Health 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 or the Ticket group of 1999 and the Balanced Budget Act (BBA) of 1997 enable 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), Community First Choice (CFC), Medicaid Alternative Care (MAC) and Home and Community Based (HCB) waiver programs administered by the Developmental Disabilities Administration (DDA) and Home and Communities Services (HCS). To be approved for services, an individual must meet functional requirements as determined by DDA and HCS.
For more information see the Apple Health for workers with disabilities (HWD) fact sheet.
- It is critical to compare the options and determine which program costs less when an individual meets the requirements for more than one program.
- 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:
- Apple Health Adults
- Apple Health for Kids (the minimum age for HWD is 16 years)
- Apple Health for Pregnant Women
- The CN disability program (S02) for a disabled adult child (DAC)
- CN programs (L22 or G03) depending upon financial and functional requirements and place of residence
- People who are eligible for both HWD and MN may prefer to receive Medicaid under the MN program. They do not have to enroll in HWD; enrollment is their choice. The HWD Award Letter provides people eligible for both with a comparison of their spenddown amount.
For most people, HWD is the preferred program because:
- CN provides more extensive coverage than MN; and
- 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) cannot 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 resources for S03 and S05 eligibility.
Note: HWD enrollees receiving Medicare get help with their Part D expenses; they receive "full subsidy" benefits. People with income above 135 percent FPL who choose MN instead of HWD receive only partial help with their Part D expenses, unless they meet their spenddown.
HWD designated staff responsibilities
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.
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) by the Division of Disability Determination Services (DDS). Obtain an ETR decision from the HWD program manager and continue HWD coverage until a redetermination of eligibility for the MIG is completed. To facilitate the MIG determination, see instructions provided in the NGMA overview.
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 an individual 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.
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 individual’s employer when necessary to verify tax withholdings.
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.
Initial premium amount
Explain to the individual they are not obligated to purchase coverage each month back to the date of application.
- 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.
- 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.
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 Health Care 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: Individuals may pay their premium directly from their bank account. To set up an account or for more information about this option go to My Secure DSHS.