Medicaid Buy-In Elizabeth Gregowicz Department of Assistive and Rehabilitative Services Medicaid Infrastructure Grant Administrator

Page 2 Medicaid Buy-In Authorized by Senate Bill 566, 79th Legislature, Regular Session, Allows people of any age who have a disability and who are working to receive Medicaid by paying a monthly premium. Individuals may use the H1010 Integrated Application or any of the H1200 Application for Assistance - Aged and Disabled series to apply. Monthly premium is based on earned and unearned income.. Available statewide in September 2006.

Page 3 Disability Requirement If a person already receives disability benefits from the Social Security Administration (SSA), they automatically meet the disability criteria. If an applicant is not already receiving disability benefits from SSA, HHSC’s Disability Determination Unit will process the request using Supplemental Security Income (SSI) criteria without consideration of earned income.

Page 4 Work Requirement A person’s earnings and FICA contributions must be enough in a calendar quarter for the SSA to count the quarter as a Qualifying Quarter. For 2006, this amount is $970 per quarter. For 2007, this amount is $1000 per quarter. For 2008, this amount is $1050 per quarter. An SSA Qualifying Quarter is a three-month period that ends on March 31, June 30, Sept. 30 and Dec. 31 each year.

Page 5 Resources Not Counted for Eligibility Retirement related accounts including:  IRAs,  401(k)s,  Tax Sheltered Annuities (TSAs),  KEOGHs that comply with IRS regulations. Resources set aside as part of an HHSC-approved Plan to Achieve Self-Support (PASS). An Independence Account: a designated, segregated account in a financial institution used to save for future health care and work-related expenses for the purpose of increasing a person’s independence and employment potential. $3000 MBI Resource Exclusion

Page 6 Eligibility Determination Each applicant is considered a household of one. If an applicant lives with a spouse who is eligible for Medicaid, the applicant and spouse are each considered a household of one. If the person is a minor and lives with his or her parents, the assets of the parents are not considered the minor’s assets.

Page 7 Income Limit A person’s countable earned income must be less than $2,042 a month for 2006 (250% of FPL). Effective March 1, 2008 this amount will be $2,128. Exclusions:  Earned income tax credit payments and child tax credit payments.  Up to $30 of earned income in a month, if infrequent or irregular.  Earned income of blind or disabled student children, subject to a monthly and yearly limit.  $20 monthly general income exclusion.  $65 + one half of the remainder monthly earned income exclusion.  Earned Income used to pay Impairment Related Work Expenses (IRWE) and Blind Work Expenses (BWE) – subject to reasonable limits.  Income set aside and used to fulfill an HHSC-approved PASS.

Page 8 Monthly Premium Determined by examining both unearned and earned income. Unearned income premium amount is all unearned income over the SSI federal benefit rate, currently $637 a month. All participants whose net pay (gross income, minus mandatory payroll deductions) exceeds 150% of FPL are required to pay an amount ($20-$40) based on their earned income.

Page 9 Premium Payments Eligibility is not established until first premium is paid. Applicant will receive a notice containing the amount of the premium and the premium due date. Medicaid Buy-In coverage can start as early as the first day of the third calendar month before the application file date.  Earliest date is September 1, 2006, which is the program implementation date. Monthly premiums are due the end of each month. If payment is not received by the end of the month, the coverage will be terminated the end of the following month.

Page 10 Program Benefits Same Medicaid services available to adult Medicaid recipients, which include office visits, hospital stays, X-rays, vision services, hearing services, and prescriptions. Eligible for attendant services and day activity health services, if they meet the functional requirements for these programs. A person cannot participate in the Medicaid Buy-In program and receive long-term care waiver services at the same time.

Page 11 Service Delivery Models As of September 2006, Medicaid Buy-In participants will receive services either through traditional Medicaid (fee-for-service) or through the Primary Care Case Management (PCCM) program, depending on where they live. In the future, people in the Medicaid Buy-In program in certain urban areas will transition into managed care programs.

Page 12 Appeal Rights Any applicant dissatisfied with the Health and Human Services Commission’s decision concerning their eligibility for medical assistance has the right to appeal through the appeal process established by the Health and Human Services Commission. The appeal process is outlined in the HHSC Fair Hearings and Fraud Handbook at

Page 13 More Information Medicaid Buy-In Program Frequently Asked Questions: Elizabeth Gregowicz (512)