1. MAWD And other Disability-Related Medicaid Categories
Kyle Fisher
November 2015

2. Topics Disability-Related Medicaid Categories
Healthy Horizons
Breast and Cervical Cancer Prevention and Treatment
Medical Assistance for Workers with Disabilities
Categorical Eligibility
Financial Eligibility
How to Apply
Two big buckets – MAGI categories / disability-related

3. Categories that existed before expansion, continue to exist, worth keeping in mind

4. Who’s still uninsured?
Nearly half remaining uninsured in Pa elig for Medicaid; about 1/3 inelig for ACA coverage
*Kaiser Family Foundation, New Estimates of Eligibility for ACA Coverage among the Uninsured (Oct. 2015)

5. Eligibility Basics
Residency
Category
Income Limits
Immigration Status

6. Medicaid Basics 3-step analysis for each person
What category does the person fit in?
What is the person’s household size?
Is the person under the income limit for that category and household size?

7. Category MAGI Adults (Expansion) Children Pregnant Women Non-MAGI
Categorical Eligibility
MAGI
Adults (Expansion)
Children
Pregnant Women
*no resource test
Non-MAGI
Persons with Disabilities
Older Adults
Workers with Disabilities
Diagnosis of Breast or Cervical Cancer
From enrollment perspective – it’s hard to get Medicaid in disability-rel category. It’s more work. Extra forms. Extra info to verify.

8. For Older adults & adults with disability (“Healthy Horizons”)
Medicaid Eligibility
For Older adults
& adults with disability
(“Healthy Horizons”)

9. Healthy Horizons Healthy Horizons–Two ways to qualify:
Age <or>
Disability
Social Security Disability Insurance (SSDI), or
Box 1 or 2 on Employability Assessment Form
First option for low-income Medicare beneficiaries
Required to apply for Social Security (if under age 65)

10. Income Limits Healthy Horizons (100% FPL) Plus disregards!
Resource Limit: $2000 (HH of 1)
$3000 (HH of 2+) See MAEH Ch. 319
Household Size
Monthly
Annual
HH of 1
$981
$11,770
HH of 2
$1,328
$15,930
HH of 3
$1,675
$20,090
HH of 4
$2,021
$24,250
Note lower than 138, expansion category – and harder to get in

11. Healthy Horizons
To prove disability, must be on SSDI or use the Employability Assessment Form:  
Can work, incentivizes work

12. Proving Disability Employability Assessment Form (PA 1663), used for:
Healthy Horizons
MAWD
GA-related MA (for immigrants)
Must include start and end dates
Good faith estimate required, not clairvoyance
Start date can be in the past
MA will be stopped at end date, absent a new form

13. Example
Kanye (age 32) and Kim (age 34) live off Kim’s Social Security Disability of $1300 per month. They have $2200 in savings. Kim has Medicare.
Does either qualify for Medicaid?
Medicaid
Why?
Kanye 
Adult category: Under age 65
and under 138% FPL (HH of 2)
Kim
Healthy Horizons: on SSDI & under 100% FPL & $3000 resource limit.
Under $1328, HH of 2 for healthy horizons.

14. COMPASS tip
Comment: “I am only applying for Medicaid expansion coverage. I am not required to submit proof of assets or disability. Please process my application without it.”
Worded in overly broad manner. If yes – then need to process switches to review for Hhorizons – verify disability and resources. Fine – for applicants who want to apply for Social Security. If not – consider checking no. Wording overinclusive. Under claiming disability not helping them get benefits – same benefit package, same MCO.

15. SSI vs SSDI SSI SSDI Social Security
Social Security Disability Insurance
Requires work history
Benefit typically = $ /month
Confers Medicare after 2 years!
SSI
Supplemental Security Income
No work history required
$755 /month
Confers Medicaid automatically

16. Breast & Cervical Cancer Prevention and Treatment
BCCPT
Requires:
Diagnosis of breast or cervical cancer
Or precancerous condition
Uninsured
Under age 65
Separate application (PA 600B) See MAEH Ch. 317
Household Size
Income Limit
Resource Limit
HH of 1
None!
HIPAA’s creditable coverage standard (Medicare Part A sufficient)

17. For workers with disabilities
Medicaid Eligibility
For workers with disabilities

19. MAWD Underused category Age 16-64 Requires 5% premium
Medical Assistance for Workers with Disabilities
Underused category
High income & resource limits
Minimal work requirement
Many who do not consider themselves “disabled” meet the MAWD disability standard
Age 16-64
Requires 5% premium
Based on recipient’s income only, after disregards

20. MAWD “Workers” work is defined loosely:
no specific hours or wage required
1 hour per week enough
can be informal
requires some amount of paid work monthly
“With Disabilities”
murkier
theory: SSDI or Medical Review Team (MRT) finding: “perm. & totally disabled” w/o regard to actual work
Disability ≠ unable to work
Practice tip: if serious long-term condition, apply!
Struggle with depression or anxiety; chronic back-pain  apply!

21. MAWD–Types of Client SSDI recipient Needs to work Use a simple letter
Include name, work done, amount paid, date, and contact info
see template
Minimal work will not affect SSDI
Worker w/ Ailments
Needs to show ‘disability’
Use either EAF, HSM, or basic doctor’s letter stating:
Diagnosis
Duration
Ask for “presumptive” eligibility
See MAEH 316.2

22. Income Limits MAWD (250% FPL) Plus income disregards!
Resource Limit: $10,000 (any HH size)
Household Size
Monthly
Annual
HH of 1
$2,453
$29,425
HH of 2
$3,319
$39,825

23. Depression = presumptive elig. for MAWD;
Example 1
Paula (age 42) works cleaning offices and earns $2000/mnth. She takes medication for depression. Both she and her 8 year old daughter, Miley, are uninsured. Paula has $3000 in retirement savings from her last job. What are their coverage options?
Medicaid
PTC
CHIP
Why?
Paula 
Depression = presumptive elig. for MAWD;
under 250% FPL;
~$50 MAWD premium
Miley
Age 8, over 138% FPL
Likely doesn’t think of herself as disabled. She’s working, managing her depression. Chronic MH condition – in our experience, enough.

24. MAWD if any work; under 250% FPL;
Example 2
Josie (age 52) has bipolar disorder, anxiety, and insomnia. She has SSDI of 1400/month and Medicare, but cannot afford the cost-sharing from her BC/BS supplemental plan. She no longer has any savings. What are her coverage options?
Medicaid
PTC
Why?
Josie 
MAWD if any work; under 250% FPL;
$70 MAWD premium
Category, HH size, income – resources too

25. MAWD if any work; under 250% FPL;
Example 3
Josie (age 52) has bipolar disorder, anxiety, and insomnia. She has SSDI of 1400/month and is in the 2 year waiting period for Medicare. She no longer has any savings. What are her coverage options?
Medicaid
PTC
Why?
Josie 
PTC <or>
MAWD if any work; under 250% FPL;
$70 MAWD premium
Category, HH size, income – resources too

26. MAWD MAWD MAWD vs. Premium Tax Credits 5% premium Premiums 3% - 9.5%
After disregards
Cost-sharing
No deduct, very small copays ($1/$3 Rx; no PCP copay)
More benefits
Dental, vision, transport.
APTC
Premiums 3% - 9.5%
Sliding scale:
of household income
Cost-sharing
Actuarial value: 73%-94%
Compare actual $ amounts
More doctors available?
*for some clients, not supposed to have choice, screen as MAWD elig, no PTC

27. Single 45–Year-Old in Allegheny County Earning $28,000/year
MAWD
Marketplace – Silver Plan
Monthly Premium
$57 - $116
(depending on income type)
$178
Annual Deductible
None
$1,750
PCP Co-Pay
$3.80 max
$20
Specialist Co-Pay
$80
Generic Drug Co-Pay $1 $8
Brand Name Drug Co-Pay $3
$45
Benefit Limits
Limited Dental benefits
Limits on PT, OT, Speech.
NO Dental coverage
Hypo at 237% FPL – getting APTC and some CSR

28. Disability-related Categories
Income-Counting & Household Size rules

29. What Income Counts For Healthy Horizons & MAWD Earned Income
All types of income count
Key question – is the income earned or unearned?
Disregards apply spousal income too
Earned Income
Disregard: $65 +half of remaining income
Huge! Compare to 5% MAGI disregard
Unearned Income
Disregard: $20
Earned income – common usage: wages, salaries, profit from self-empl,
nonMAGI categories – work income is special, hugely incentivized

30. Not categorically eligible
Example 4
Frank (age 54) receives SSDI of $1220/month and works 1 hr/week for his cousin. His wife Claire (age 51) works and earns $4065/month. (Annual total=$63,400.) No savings.
Is either eligible for Medicaid?
Medicaid
Why?
Frank 
MAWD; under 250% FPL
with disregards:
Unearned: =1200
Earned: *1/2=2000
Countable income=3200
Claire
Not categorically eligible
Premium of 60- would count his EI too, left out for simplicity

31. Whose Income Counts Household Size: For MAWD:
Count only a spouse – maximum HH size of 2
For Healthy Horizons:
Household size is based on family size
Count spouse & children, and their income, if living together
Child under 21 = optional household member
Unlike MAGI, not based on tax filing unit

32. What Resources Count General rule – all resources count
Including retirement assets and spouse’s resources
Exceptions (plus others, see MAEH 340.8):
House used as residence
Household goods, clothing, et cet.
One motor vehicle
Exception to the resource test altogether:
If child under age 21 in household, no resource test for the parent for Healthy Horizons

33. How to Apply Online: COMPASS or Healthcare.gov By phone: 866-550-4355
(“Please review for MAWD”)
By phone:
By mail: paper application (PA 600WD)
In County Assistance Office
*Recommend COMPASS for consumers eligible for Medicaid, especially in disability-related categories.
Decision w/in 30 days; or 5 days if medical emergency

34. How to Apply How quickly will an application be processed?
30 days – normal processing timeframe
5 days – for applicants who have a medical emergency
Does the consumer have recent medical bills?
Medicaid can be retroactive (up to 3 calendar months)

35. Resources
Medical Assistance Eligibility Handbook
“Estimates of Eligibility for ACA Coverage among the Uninsured,” Kaiser Family Foundation (Oct 2015).
PHLP MAWD Guide
PHLP Medical Assistance Eligibility Manual
PHLP Helpline: