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Copyright 2006 Reprint or modify with express permission only (206) 343-0881 WWW.THEINITIATIVE.WS Funded in part by CMS Medicaid Infrastructure Grant CFDA.

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Presentation on theme: "Copyright 2006 Reprint or modify with express permission only (206) 343-0881 WWW.THEINITIATIVE.WS Funded in part by CMS Medicaid Infrastructure Grant CFDA."— Presentation transcript:

1 Copyright 2006 Reprint or modify with express permission only (206) Funded in part by CMS Medicaid Infrastructure Grant CFDA 93768

2 Copyright 2006 Reprint or modify with express permission only (206) An Overview of Medicaid Financial Eligibility The Medicaid Categories Categorically Needy Medically Needy Waivers Medicaid Buy-In (HWD) Steps used to determine financial eligibility A closer examination of the categories

3 Copyright 2006 Reprint or modify with express permission only (206) 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

4 Copyright 2006 Reprint or modify with express permission only (206) 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.

5 Copyright 2006 Reprint or modify with express permission only (206) 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.

6 Copyright 2006 Reprint or modify with express permission only (206) 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.

7 Copyright 2006 Reprint or modify with express permission only (206) 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.

8 Copyright 2006 Reprint or modify with express permission only (206) Steps for Determining Medicaid Category 1.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)

9 Copyright 2006 Reprint or modify with express permission only (206) 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.

10 Copyright 2006 Reprint or modify with express permission only (206) 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 Determining Countable Income for CN Medicaid

11 Copyright 2006 Reprint or modify with express permission only (206) 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.

12 Copyright 2006 Reprint or modify with express permission only (206) 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

13 Copyright 2006 Reprint or modify with express permission only (206) Does the individual qualify for Categorically Needy Medicaid because they are “considered to be receiving SSI”? OR 2. 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 3. Does the individual qualify for HWD…and are they willing to enroll? Determining Financial Eligibility for the Waiver (only available to those already on a Waiver)

14 Copyright 2006 Reprint or modify with express permission only (206) 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.

15 Copyright 2006 Reprint or modify with express permission only (206) 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.

16 Copyright 2006 Reprint or modify with express permission only (206) 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. STEP 3. Does the individual qualify for Healthcare for Workers with Disabilities (HWD)?

17 Copyright 2006 Reprint or modify with express permission only (206) 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.

18 Copyright 2006 Reprint or modify with express permission only (206) 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 = $ Compare Countable Income to CNIL of $623. Barb’s countable income is above the CNIL threshold.

19 Copyright 2006 Reprint or modify with express permission only (206) 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, Compare Countable Income SIL of $1,869 (300% of SSI FBR). Barb’s gross income is above SIL threshold.

20 Copyright 2006 Reprint or modify with express permission only (206) 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 = $ in countable earned income. 3.Total countable income is $1, Subtract MNIL of $623 from countable income $1, $623 = $ per month spend down

21 Copyright 2006 Reprint or modify with express permission only (206) 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 = $ in countable earned income. 3.Total countable income is $1, Compare countable income of $1, to net income standard of 220% of the FPL ($1,797). Barb is eligible for HWD.

22 Copyright 2006 Reprint or modify with express permission only (206) 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 = $ Premium is lesser amount from # 4 or #5 (round down to whole dollar). So premium amount is $78.

23 Copyright 2006 Reprint or modify with express permission only (206) With the HWD Group Added as a Waiver Financial Eligibility Group, Barb remains eligible for the Waiver!!

24 Copyright 2006 Reprint or modify with express permission only (206) 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.

25 Copyright 2006 Reprint or modify with express permission only (206) 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 = $ Compare Countable Income to CNIL of $623. Barb’s countable income is below the CNIL threshold. She remains eligible for the Waiver!!

26 Copyright 2006 Reprint or modify with express permission only (206) Want More Information? Susan Harrell


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