medicaid06252014 - RESNA Catalyst Project

Obtaining or Retaining
Medicaid While Working
The Section 1619(b) and
Medicaid Buy-In for Working
People Programs
June 2014
Today’s Presenters
James R. Sheldon, Jr., Supervising Attorney
National Assistive Technology Advocacy Project
Neighborhood Legal Services, Buffalo, NY
[email protected] * 716-847-0650 ext. 262
Ronald M. Hager, Senior Staff Attorney
National Disability Rights Network
Washington, D.C.
[email protected] * 202-253-5252
The RESNA Catalyst Project offers CEUs for this webinar
session. The RESNA Catalyst Project is an approved
authorized provider for CEU credits by the International
Association for Continuing Education and Training (IACET).
You can receive 0.1 CEUs for a sixty to ninety minute
webinar. There is a $16 fee to receive credits for each
To learn more about CEUs or to apply for CEUs from an
archived webinar, contact Paul Galonsky,
[email protected]
Funding of AT to Support Work
Webinar Series
• July 23, 2014 - Funding Work-Related AT for the
Transition-Aged Special Education Student
• September 17, 2014 - State Vocational Rehabilitation
Agencies: Using VR Agency to Fund AT to Support a
Work Goal
• October 22, 2014 – Using SSI’s Plan for Achieving Self
Support (PASS) to Fund AT to Support a Work Goal
• November 19, 2014 - A Review of Lesser Known
Funding Sources and Funding Strategies for WorkRelated AT
• December 10, 2014-Medicaid and Medicaid Waivers As
Funding Sources
All sessions 2:00 to 3:15 Eastern Time
Services of the National
AT Advocacy Project
A Technical Assistance and Training Project
Call or email speakers for technical assistance
Any topic covered in the webinars
Any issue related to funding of AT
We can assist you in thinking through funding issues and
Additional materials available on most topics
• Contact us for copies and/or links.
Purpose of Webinar Series
Barriers to Funding AT to Support Work
• It can be expensive.
• Individuals and service providers may not be familiar
with funding sources and funding criteria.
Will discuss funding sources, funding criteria:
• Most common funders – Medicaid, special education,
vocational rehabilitation
• Less common funding sources
• Special rules within programs that support funding for
work, education, training.
Purpose of this Session
We know Medicaid is key AT funding source
• How does individual retain Medicaid when working?
Will review two Medicaid work incentives
• 1619(b) – In all states, allowing SSI beneficiaries to
retain Medicaid when working.
• Medicaid Buy-In – In most states, allowing individuals
with no SSI to retain Medicaid when working.
Format for Today’s Session
• Walk through power point (on screen, received via email)
• Participants can post questions on chat line.
• Will attempt to address questions during presentation.
• Follow up questions can be emailed to presenters.
• Contact presenters for more resources on any of the
Examples of Medicaid Funded
AT to Support Work
Usually covered as durable medical equipment (DME):
• Custom and power wheelchairs, e.g., chairs with seat
elevators, standing features
• Speech generating devices, hearing aids
Some DME allows person to maintain health, live in the
community, and/or leave the home for work:
• Specialty beds and mattresses
• Hydraulic patient lifts, ceiling track lifts
• Portable ramps to leave the home
Other Medicaid-Funded Services
Will Support Individual
This could include, for example:
Prescription drugs
Physician services, mental health counseling
Inpatient hospital services
Transportation to medical providers
Home health aid and private duty nursing service
NOTE: Some of these services are optional and not
available to adults in every state.
SSI as the Path to
Medicaid Eligibility:
Using the 1619(b) Work
Incentive to Retain Medicaid
While Working
SSI Beneficiaries Automatically
Eligible for Medicaid in Most States
Automatic in 39 states (1634 states), the District of
Columbia, and Northern Marianna Islands.
In 11 section 209(b) states, SSI eligibility does not
create automatic Medicaid eligibility.
• The 209(b) states include Connecticut, Hawaii, Illinois,
Indiana, Minnesota, Missouri, New Hampshire, North Dakota,
Ohio, Oklahoma, and Virginia.
• In these states individuals who receive SSI must apply
separately and eligibility criteria is set by each state.
• Indiana is becoming a 1634 state during 2014.
SSI, Medicaid, and
Transition-Aged Youth
Parental income & resources count until age 18.
• This includes parents and stepparents who reside with
the child.
At age 18 the parent and/or stepparent income and
resources will no longer count.
• Young person can receive SSI based only on child’s
income and resources.
• Young person getting SSI payments will get automatic
Medicaid in 39 states.
Transition Planning – SSI, Medicaid,
and AT to Support Work
David just turned 17 and lives with his parents.
• He was on SSI and Medicaid until one year ago when
his mother started a full-time job.
• With $65,000 in combined parental income, David is not
eligible for SSI and automatic Medicaid.
David seeks funding for two items of AT.
• A power wheelchair with a seat elevator (and possibly a
standing feature).
• An i-Pad that will double as a personal computer and a
speech generating device.
The Case of David – Current
AT Funding Challenges
The power wheelchair with seat elevator
• The family private insurance plan unlikely to cover.
• If covered by private insurance, out of pocket expenses
to be very high.
i-Pad to be used as a speech generating device
• With two years of school left before college, special
education program may be able to pay for it.
• Problem – When David graduates it remains property of
school district.
The Case of David – Planning
for SSI and Medicaid Eligibility
Eligible for SSI, Medicaid next year at age 18.
Plan for Medicaid funding of two items.
• Funding could be challenge in some states.
• Plan to put together good prior approval packet.
• Eligibility for Early and Periodic Screening, Diagnosis
and Treatment (EPSDT), through age 21, will help.
State Vocational Rehabilitation agency could
fund i-Pad to support work goal.
SSI and Budgeting of Wages
The following is deducted from gross wages:
$20 general income exclusion
$65 earned income exclusion
50 percent of remaining earned income excluded
Impairment related work expenses, blind work expenses,
money put into Plan for Achieving Self Support (PASS)
Subtract countable wages from SSI base rate
• Result will be new SSI payment.
The Case of Maria
Receives SSI of $721 per month
• This is federal benefit rate (FBR).
• Some states will supplement the FBR.
• Wants to work, but fear of losing Medicaid.
Offered part-time job -- $1,085 gross per month
• How affect SSI?
• How affect Medicaid?
Maria’s SSI Budget
$ 1,000
- 500
Gross wages
Additional 50% disregarded
Countable wages
721 SSI base rate
500 Countable income
221 Monthly SSI check
(Plus automatic Medicaid in her state)
With $2,085 Gross Maria Loses
SSI – Will She Lose Medicaid?
$ 2,000
- 1,000
$ 1,000
Gross wages
Additional 50% disregarded
Countable wages
721 SSI base rate
- 1,000 Countable income
0 Monthly SSI check
SSI & Section 1619(b) Medicaid
Former SSI Recipients Can Keep Automatic Medicaid:
• Person must lose SSI due to budgeting of wages.
• Person with federal benefit rate and no state supplement
($721 in 2014), with wages only, will lose SSI if gross monthly
wages are $1,527 or higher.
• Person’s disability must continue.
• 2014 annual earned income limits vary, with a high of $68,340
in Connecticut and a low of $26,240 in Alabama. See Social
Security Program Operations Manual (POMS) SI 02302.200,
1619(b)’s Financial Criteria
Must be “otherwise eligible” for SSI
• Unearned income must be within SSI’s limits
– High SSDI payment or high spouse’s income may
eliminate 1619(b).
• Resources must be within SSI’s limits ($2,000 in
countable resources)
1619(b)’s Earned Income Threshold
• Will vary state-by-state.
• Indiana’s 2014 earned income threshold is $37,010.
• If annual wages below $37,010 and other criteria is
met, Medicaid continues.
• Some people can have an “individualized threshold” if
income over $37,010 (or rate for your state).
– The higher eligibility threshold is often due to very high
home health care costs paid by Medicaid.
1619(b) Medicaid Eligibility –
What About Maria?
Likely to be eligible in every state
• Gross annual wages of $25,020 (12 x $2,085).
• Lowest state eligibility threshold $26,240 in 2014.
Must still be “otherwise eligible” for SSI
• Unearned income must be within SSI limits.
• Countable resources must be below $2,000.
1619(b) and Low Wage Earner
Cynthia receives $620 SSDI, $121 SSI
• Works, earns $665 per month in gross wages.
• Will lose SSI (with $900 countable income)
– More than $721 SSI rate (living with others)
– $600 countable SSDI ($620 – 20)
– $300 countable wages ($665 – 65 = 600/2 =
• Medicaid should continue through 1619(b):
– SSI lost due to wages
– Should meet other criteria.
1619(b) – What if Cynthia had
Much Higher Wages?
Cynthia now earns $26,000 per year ($2,167 per month)
• Countable wages now more than $1,000 per month.
She loses SSI.
• So long as she meets other 1619(b) criteria (and she
should), Medicaid eligibility should continue.
• NOTE: In some states she could be getting close to
eligibility threshold. Five states have eligibility thresholds
of under $30,000.
1619(b)’s Individualized Threshold
If annual wages higher than state threshold
• Start with base amount from threshold chart
• Then add
– Medicaid amount from chart, or annual Medicaid costs for
person if higher
– Impairment related work expenses
– Blind work expenses
– Income set aside in approved PASS
– Publicly funded attendant care lost based on higher wages
• If total is higher than annual wages, person is eligible for
1619(b) Medicaid.
Cynthia’s Individualized Threshold
Cynthia now earns $55,000 per year
• Lives in Maryland with $41,746 general eligibility
• Medicaid pays out $48,000 annual for her care, most of it
for home health aid services.
Individualized threshold is $63,824, based on:
• Base amount of $18,324 from POMS chart
• $46,500 per year Medicaid pays for his care
• Since this is more than her annual wage, Cynthia will be
eligible for Medicaid under 1619(b).
Problem with 1619(b)
• Only available to former SSI recipients
• Not available if unearned income or
resources go over SSI limits
• Solution, in many states, will be Medicaid
Buy-In for Working Individuals.
The Medically Needy/Spend
Down Program
The Medicaid Buy-In for Working
Individuals Program
Medically Needy or
“Spend Down” Program
An optional program
• Exists in about two thirds of states
In spend down state
• If disabled, but not eligible for SSI
• Must apply separately for Medicaid
• Unless eligible through special Medicaid category
Spend Down – the
New York Example
Monthly income limit in 2014
• $809 for one person household
• Resource limit = $14,550
• If countable income over $809, must pay or incur “spend
down” amount
Income and resource limits will vary by state
• Keep in mind this is an optional program.
“Spend Down” and Working
Spend Down uses SSI Budgeting Rules:
• First $20 of income disregarded
• Next $65 of earned income disregarded
• 50% of what remains disregarded
• Impairment related work expenses, blind work
expenses, and Plan for Achieving Self-Support
(PASS) contributions disregarded
• If remainder more than state eligibility level, must pay
spend down
Spend Down and Work Example
June receives $969 monthly SSDI, lives in New York
• Countable income of $949 ($969 – 20)
• Medicaid spend down of $140 ($140 above New York’s $809
Medicaid income threshold)
If June works:
Under regular rules, first $65 ignored.
Then spend down increases by $1 for every $2 earned.
If $465 gross wages, $200 counted ($465 – 65 – 200)
Spend down increases by $200 to $340
Problem with Spend Down
As Wages Increase:
• Spend down increases by $1 or each $2 of extra
• Under spend down, no longer eligible when wages
exceed Substantial Gainful Activity (SGA) limit
• SGA limit in 2014 is countable income of $1,070/mo
for non-blind and $1,800/mo for the blind
Solution: Medicaid Buy-In for Working People
Medicaid Buy-In for
Working People
Known by Different Names in
Different States
Different Names for Medicaid
Buy-In (MBI) Program
Many states simply call it the Medicaid Buy-In.
Other names for the program:
Ohio – Medicaid Buy-In for Workers with Disabilities
Alaska – Working Disabled Medicaid Buy-In
Kansas – Working Healthy Medicaid Buy-In
Nebraska – Medicaid Insurance for Workers with Disabilities
Illinois – Health Benefits for Workers with Disabilities
New York – Medicaid Buy-In for Working People with
Medicaid Buy-In - Optional Program
Exists in More than 40 States
Two MBI Eligibility Groups
• Basic Eligibility Group
• Medical Improvement Group (an option for states)
New Applicants in Basic Eligibility Group
Basic Coverage Group Criteria
The following will be required in all states:
• Disability – certified disabled under SSI rules
• No SGA test – can earn over $1,070/$1,800 if blind
• Age – between 16 and 64
• Work – some paid work required (some states impose
minimum earnings requirements)
MBI Eligibility – Income and
Resource Rules Vary by State.
Must use SSI rules for counting income and resources.
• E.g., $65 plus 50 percent of remaining wages excluded.
• Can apply rules that are more liberal than SSI rules.
Most states: income up to 250% of federal poverty level
• One-person countable income limit of $2,432 in 2014
• $59,380 per year, if only income is earned
• Some states combine earned and unearned income. Some
have separate limit for unearned income.
• States may set higher income limits (e.g., 350 % of FPL in
Illinois, 450 % of FPL in North Carolina and New Hampshire).
MBI Eligibility – Income and
Resource Rules Vary by State.
Resource limits, exempt resources will vary.
The New York MBI program
• Non-exempt resource limit – $20,000
• All retirement accounts fully exempt
– Includes, for example, IRA, 401k, and 403b accounts
Optional Medical Improvement
Group – New York Example
Must meet Basic Group criteria, and:
• Was in Basic Coverage Group, no longer disabled
but continuing to have severe medical impairment
• Must continue to work
• Must be employed at least 40 hours a month (New
York has no minimum work hours for basic group)
• Must make at least the federal minimum wage
Premiums Are Optional
States may charge premiums but premiums
are not required.
• Where premiums are charged they can be as low as
$25 per month.
• Some states charge premiums based on a “sliding
scale,” with premiums higher at higher income
Medicaid Buy-In Example
John is 33, has a mental illness, lives in New York, and
will soon graduate from college.
• He is single, was approved last year for $1,029 in SSDI benefits,
and must pay a $200 spend down to qualify for Medicaid.
• John is not eligible for the Buy-In because he is not working.
John will earn $365 gross for working about 30 hours
per month during his last semester.
Following graduation, John will start a job earning
$30,000 per year ($2,500 per month).
John’s Monthly MBI Budget
(Part-Time Job)
Step 1: Unearned income
General income exclusion
Counted unearned income
Step 2: Earned income
Earned income exclusion
Additional 50 % exclusion
Counted earned income
Step 3: Total counted income ($1,009 + 150)
$ 1,029.00
- 20.00
$ 365.00
- 65.00
- 150.00
$ 150.00
$ 1,159.00
Eligible for MBI since countable income is less than $2,432.
John’s Monthly MBI Budget
(Full-Time Job)
Step 1: Unearned income
General income exclusion
Counted unearned income
Step 2: Earned income
Earned income exclusion
$ 1,029.00
- 20.00
Additional 50 % exclusion
Counted earned income
$ 2,500.00
- 65.00
- 1,217.50
Step 3: Total counted ($1,009 + 1,217.50)
Eligible for MBI since countable income is less than $2,432.
John’s Need for Work
Incentives Counseling
When he starts the $30,000 per year job
• He will need advice concerning his right to a trial work period,
a period of extended Medicare eligibility, and the potential
operation of several other work incentives (in addition to the
Medicaid Buy-In).
Free work incentives counseling available
• Can refer John to Work Incentives Planning and Assistance
(WIPA) project in your state
• Go to
Scroll down to search for WIPA program by zip code.
• 1619(b) and the Medicaid Buy-In can address medical
health needs of many individuals who work despite
severe disabilities.
• For more information on these programs check out the
following publications of the NY Makes Work Pay
– The “Working” newsletter or policy-to-practice brief on
– both available at the Research/Publications section of
Thank you!
Please use your chat box to ask questions
James R. Sheldon, Jr., Supervising Attorney
[email protected] * 716-847-0650 ext. 262
Ronald M. Hager, Senior Staff Attorney
National Disability Rights Network
[email protected] * 202-253-5252