1. Improving the Work Incentives in the Wisconsin’s Medical Assistance Purchase Plan (MAPP) Ellie Hartman, PhD, OFCE, DLTC, DHS Lara Rosen, OPIB, DHS Amy Thomson, OFCE, DLTC, DHS Dan Johnson, BADR, DLTC, DHS

2. Purpose of MAPP Remove financial disincentives to work; Allow participants to earn more income without the risk of losing MA-funded health care coverage; Allow participants to accumulate savings from earned income in an Independence Account to increase the rewards from working.

3. Proposed Changes to Further Program Goals Increase portability of Independence Accounts; Change premium calculations, so earnings do not trigger large premiums; Change eligibility calculations, so increased earnings are less likely to make individuals ineligible for MAPP; Increase the work requirement to ensure program functions as a work incentive; Proposal must be budget-neutral.

4. Employment Outcomes in MAPP: February 2013 22,272 participants with average monthly earnings of $121.86 – 79% of participants earned less than $121.86 average – 18% of participants earned $0 – 32% of participants earned less than $10 – 4% of participants earned more than Trial Work Period (TWP) amount of $750 – 1% of MAPP participants earned Substantial Gainful Activity (SGA) amount of $1,040

5. Wisconsin Compared to Other States Lowest average annual earnings of all 37 states with buy-in programs in 2009 – MAPP participant average of $4,652 – National Medicaid buy-in participant average of $8,677 Employment rate of 47% in 2006, the third-lowest nationwide Mathematica Policy Research, Inc. (April 2008). The Three E’s: Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2006.

6. Minnesota Medicaid Buy-In Program (MA-EPD) Average monthly earned income $537.38 (June 2011) 96% earned over $65 per month 55% earned between $201 and $720 (TWP in 2011) 24% earned over TWP 9% earned over SGA https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6250B-ENG

7. Asset Portability in MAPP Ability to use earnings to set up Independence Accounts (IA) while enrolled in MAPP – DHS−approved account that consists of savings from income earned while an individual is covered under MAPP – Can deposit up to half of an individual’s earnings Some individuals may also be accumulating retirement assets from the employer while on MAPP

8. Current Disincentives to Increase Earnings: Asset Portability Independence accounts and other retirement benefits accumulated while in MAPP considered countable assets for other MA eligibility Fear of losing accumulated retirement benefits is a disincentive to work and save Very few participants use IA – 92 (less than 1%) had an IA in February 2013

9. Solution: Increase Portability to Better Incentivize Work and Savings When determining Medicaid eligibility and cost- sharing requirements, exclude independence accounts and retirement benefits accumulated or earned while on MAPP Must first be approved by the federal government

10. Current Disincentives to Increase Earnings: Premiums The current MAPP premium was created to favor earned income over unearned income, but in practice, it is increased earnings that trigger high premiums Single Person with Work Income and SSDI Benefit Example 1Example 2 Earned Income $ 325 $ 315 Unearned (SSDI) $ 1,111 Total Income $ 1,436 $ 1,426 150% FPL Level $ 1,436 Subject to Premium? Yes No Premium Calculation – Approximate 3% of Earned Income $ 9.75 $ - Unearned Income minus $813 minus any deductions $ 298.00 $ - Total Premium $ 307.75 $ - Income Minus Premium $ 1,118.45 $ 1,386.00

11. Solution: Change Premium Structure to Better Incentivize Increased Earnings Restrictions: – Need to be cost-neutral – MAPP participants below 150% FPL cannot have a premium Solution – Premium increases should not exceed increases in earnings  Treat earned and unearned income the same – Individuals over 150% FPL paying no premium (15% of participants in February 2013)  Set minimum premium of $50

12. Solution: Change Premium Structure to Better Incentivize Increased Earnings MAPP Premium Methodology CurrentProposed Total Income for Premium Eligibility 150% FPL (for family size)150% FPL (for individual) Portion of Unearned Income Paid as Premium Any unearned income (minus deductions) above $813 3% after deductions Portion of Earned Income Paid as Premium 3%3% after deductions Round Premium Down to nearest $25 Down to nearest $25 above $50 Minimum Premium (if total income above 150% FPL) None$50

13. Solution: Change Premium Structure to Better Incentivize Increased Earnings Deductions apply to both earned and unearned income, not just unearned Premium is 3% of both earned and unearned income (after deductions) Single Person with Work Income and SSDI Benefit Example 1Example 2 Earned Income $ 325 $ 315 Unearned (SSDI) $ 1,111 Total Income $ 1,436 $ 1,426 150% FPL Level $ 1,436 Subject to Premium? Yes No Premium Calculation – Approximate 3% of Earned and Unearned Income (minus $813 and any deductions) $ 18.69 $ - Add-on to $50.00 Minimum $ 31.31 $ - Total Premium $ 50.00 $ - Income Minus Premium $ 1,386.00 $ 1,436.00

14. Current Disincentives to Increase Earnings: Income Eligibility Increased earnings may cause someone to become ineligible for MAPP. Restrictions – MAPP authorized under Section 4733 of the Balanced Budget Act of 1997 – Individual’s family income (except income excluded under federal SSI rules) must less than 250% of the FPL

15. Solution: Change Income Eligibility to Better Incentivize Increased Earnings Solution – Treat earned and unearned income the same – Deduct portion of health care costs from total income MAPP Income Eligibility Criteria CurrentProposed 1. Take earned income (applicant & spouse) 2. Subtract $65 3. Divide by 2 4. Subtract IRWE 5. Add unearned income (applicant & spouse) 6. Subtract $20 general disregard Compare total to 250% FPL for family size 1. Take total earned & unearned income (applicant & spouse) 2. Subtract $65 3. Divide by 2 4. Subtract IRWE 5. Subtract $500 in MREs and LTC costs 6. Subtract $20 general disregard Compare total to 250% FPL for family size

16. Unclear definition of gainful employment in MAPP In-kind work fulfills work requirement Low employment among MAPP participants – 18% of MAPP participants with $0 earnings – 32% of participants with less than $10 earnings Current Disincentives to Increase Earnings: Work Requirement

17. Solution: Increase the Work Requirement In exchange for more generous premiums and income eligibility, ask participants to engage in work for which they are paying taxes – In-kind compensation no longer sufficient – Documentation of tax payment or withholding required Income, FICA, Medicare or self-employment taxes People who do occasional odd jobs are eligible for MAPP as long as they pay taxes on their income.

18. Solution: Increase the Work Requirement Time to comply with new requirements – 6 month grace period – Health Counseling Employment (HEC) program will continue Up to 9 months with a 3 month grace period Can participate twice in a five year period http://www.dhs.wisconsin.gov/WIpathways/HEC.htm Similar to MN Medicaid Buy-In, but does not include minimum earned income ($65 per month in MN) http://www.positivelyminnesota.com/All_Programs_Services/Pathw ays_to_Employment/For_Service_Providers_Community_Partners/ Medical_Assistance_for_Employed_Persons_with_Disabilities.aspx http://www.positivelyminnesota.com/All_Programs_Services/Pathw ays_to_Employment/For_Service_Providers_Community_Partners/ Medical_Assistance_for_Employed_Persons_with_Disabilities.aspx

19. Conclusion Proposed changes should increase work incentives in MAPP These changes include: – Asset portability – Changes in premium and eligibility calculations, treating earned and unearned income the same – Increasing the work requirement