Funded in part by CMS Medicaid
Infrastructure Grant CFDA 93768
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An Overview of Medicaid
Financial Eligibility
• The Medicaid Categories
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Categorically Needy
Medically Needy
Waivers
Medicaid Buy-In (HWD)
• Steps used to determine financial eligibility
• A closer examination of the categories
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Individuals with disabilities that currently receive
Medicaid are from three main financial
categories:
• Those with no payment:
Categorically Needy Medicaid, The Waivers
• Those with a spend-down:
Medically Needy Medicaid
• Those who pay their own premiums:
Health Care for Workers with Disabilities
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Categorically Needy Medicaid
In order to be considered eligible for Medicaid under the
Categorically Needy Option, an individual must:
1. Be “considered to be receiving SSI”, which would include:
a. Individuals receiving SSI cash benefits;
b. Individuals eligible for 1619(b);
c. Individuals who have monthly countable income that is under the
categorically needy income level (CNIL), which is currently $623.
OR
2. In the case of someone who is eligible for a Waiver, there is an additional
option for financial eligibility… The Special Income Level…which is a gross
income standard of 300% of the SSI Federal Benefit Rate ($1,869 for
2007).
OR
3. Be on the Healthcare for Workers with Disabilities (HWD), Also known as
the Medicaid Buy-In.
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Medicaid Waivers
When an individual is already considered
Categorically Needy, they qualify financially for
the Waivers. If they are not already determined
to be Categorically Needy, the financial test for
them is to have gross income under the Special
Income Level (SIL)
This monthly income threshold is set at 300% of
the SSI FBR, which is currently $1,869.
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Medically Needy Medicaid
When countable income exceeds the Categorically
Needy income threshold of $623, an individual may
have a “spend down” (to $623) prior to having
Medicaid coverage for their medical bills IF they
are not receiving SSI, or they are not 1619(b)
eligible
Note: The Medically
Needy (MN) program
does not offer
Medicaid Personal Care.
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Medicaid Buy-In (HWD)
An individual who is working may choose to pay a
premium and purchase their own Medicaid.
Premiums cannot exceed 7.5% of total income, and
are often much less. HWD covers Medicaid
Personal Care, and other Medical Coupon costs, and
now is considered a financial eligibility group for
Waiver services.
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1.
Steps for Determining
Medicaid Category
Determine if individual qualifies for Categorically Needy
Medicaid with countable income under that threshold.
2a. If individual doesn’t qualify for Categorically Needy
Medicaid, and they are on the Waiver, calculate if they
qualify under the Waiver Special Income Level.
2b. If individual doesn’t qualify for Categorically Needy
Medicaid and they are not on the waiver, calculate for
Medically Needy Medicaid.
3. If individual has spenddown with Medically Needy
Medicaid, or they need the Medicaid Personal Care
services that come with Categorically Needy Medicaid, or
they are on the Waiver, explore Medicaid Buy-In (Health
Care for Workers with Disabilities-HWD)
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STEP 1: Does the Individual Qualify
for Categorically Needy (CN)
Medicaid?
Does the individual receive SSI Cash Benefit or
1619(b)?-- Recipients are automatically determined
Categorically Needy.
OR
Does the individual have countable income below the
Categorically Needy Income Threshold?--Go through
steps to determine countable income.
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Determining Countable Income for CN
Medicaid
a.
Exclude DAC, if DAC exclusion applies
b.
Exclude increases in SSDI, if person was concurrent
beneficiary previously. Count remaining SSDI as
unearned income
c.
Apply $20 General Exclusion on unearned or earned income
(may be used only 1 time per month on 1 source of income)
d.
Apply Earned Income Exclusion of $65
e.
Subtract any Impairment Related Work Expenses from
earned income
f.
Divide remaining earned income by 2
g.
Subtract any Blind Work Expenses from earned income
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Compare Countable Income to
Categorically Needy Income Level
(CNIL)
Compare Countable Income to Categorically Needy
Income Level (CNIL): $623
If Countable Income is less than CNIL, the individual
is Categorically Needy.
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STEP 2a: Does the Individual
Qualify for the Medicaid Waiver
Under the Special Income Level?
Can remain a Medicaid option for individuals
with disabilities that exceed the Categorically
Needy Income Level
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Determining Financial
Eligibility for the Waiver
(only available to those already on a Waiver)
1.
2.
3.
Does the individual qualify for
Categorically Needy Medicaid
because they are “considered
to be receiving SSI”?
OR
Does the individual have gross income (includes
SSDAC and SSDI, as well as other unearned
and earned income) of less than 300% of the
SSI FBR ($1,869 for 2007).
OR
Does the individual qualify for HWD…and are
they willing to enroll?
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STEP 2b: Does the Individual
Qualify for Medically Needy (MN)
Medicaid?
For individuals with disabilities who do not qualify for
the Categorically Needy Medicaid or for the Medicaid
Waiver. Note: MN coverage does not provide
Medicaid Personal Care.
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Compare Countable Income to
Medically Needy Income Level
(MNIL)
Compare Countable Income to Medically Needy
Income Level (MNIL): $623
Subtract the MNIL from the countable income to
determine the amount of the spend down. The spend
down may be calculated for a period of 3 or 6 months.
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qualify for Healthcare for
Workers with Disabilities
(HWD)?
An individual with disabilities who works could purchase
Medicaid through the Healthcare for Workers with
Disabilities (HWD) program.
Coverage may include Medicaid Personal Care
No resource restrictions
Higher income limits than other programs
Low premiums. The premiums for HWD cannot
exceed 7.5% of the individual’s income, and may be
less than that.
Note: HWD can now cover HCBS Waiver services, and it is a Categorically
Needy Medicaid Option.
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Barb’s Story: Part 1
Barb is on the HCBS Waiver and lives in Grant County
Barb makes $1,350/mo. at her job at XYZ Bakery.
She has been on 1619(b)
Barb was just notified that she will receive $650 in
SSDAC.
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Barb’s Story: Part 1
Calculate Countable Income for
CNIL
STEP 1: Is Barb’s Countable Income Under the
Categorically Needy Income Level (CNIL)?
1. Exclude DAC.
2. Countable Income: ($1,350 - $20 -$65)/2 =
$632.50
3. Compare Countable Income to CNIL of $623.
Barb’s countable income is above the CNIL threshold.
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Barb’s Story: Part 1
Calculate Countable Income for
Waiver SIL
STEP 2a: Is Barb’s Gross Income Income Under the
Special Income Level (SIL)?
1. Add DAC to gross earned income.
2. $650 DAC + $1,350 Wages = $2,000.
3. Compare Countable Income SIL of $1,869 (300%
of SSI FBR).
Barb’s gross income is above SIL threshold.
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Barb’s Story: Part 1
Calculate countable income for
MNIL
STEP 2b: What is Barb’s Countable Income Compared
to the Medically Needy Income Level (MNIL)?
1. $650 DAC - $20 General Exclusion =$630
countable unearned income.
2. $1,350 wage - $65, with remainder divided by 2 =
$642.50 in countable earned income.
3. Total countable income is $1,272.50
4. Subtract MNIL of $623 from countable income
$1,272.50-$623 = $649.50 per month spend down
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Barb’s Story: Part 1
Determine Eligibility for HWD
What is Barb’s Countable Income and is it under 220%
of the FPL?
1. $650 DAC - $20 General Exclusion =$630
countable unearned income.
2. $1,350 wage - $65, with remainder divided by 2 =
$642.50 in countable earned income.
3. Total countable income is $1,272.50
4. Compare countable income of $1,272.50 to net
income standard of 220% of the FPL ($1,797).
Barb is eligible for HWD.
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Barb’s Story: Part 1
Calculate HWD Premium
1.
Total of Barbs Earned and Unearned income: ($650 DAC + $1,350
wages)= $2,000
2. Premium on unearned income…subtract MNIL from unearned income,
then take 50% of result [ ($650-$623=$27)x50%= $13.50]. Then
take 5% of total unearned income (5%x$650 = $32.50). Total the
two numbers: $13.50+$32.50 = $46.
3. Premium on earned income…subtract $65 from earned income, then
take 2.5% of result [($1,350-$65=$1,285)x2.5%=32.13].
4. Add Unearned and Earned premium amounts: ($46 + $32.12 =
$78.12)
5. Take 7.5% of total income: 7.5% of $2,000 = $150.
6. Premium is lesser amount from # 4 or #5 (round down to whole
dollar). So premium amount is $78.
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With the HWD Group Added
as a Waiver Financial
Eligibility Group, Barb remains
eligible for the Waiver!!
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Barb’s Story: Part 2
What would happen if Barb had an IRWE for job
coaching of $100 per month? Let’s go back and
calculate for Categorically Needy Medicaid.
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Barb’s Story: Part 2
Calculate countable income for
CNIL with IRWE
STEP 1: Is Barb’s Countable Income Under the
Categorically Needy Income Level (CNIL)?
1. Exclude DAC.
2. Countable Income: ($1,350 - $20 -$65-$100
IRWE)/2 = $582.50
3. Compare Countable Income to CNIL of $623.
Barb’s countable income is below the CNIL threshold.
She remains eligible for the Waiver!!
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Want More Information?
Susan Harrell
Susan@theinitiative.ws
360.352.9084
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