1. Obtaining or Retaining Medicaid While Working The Section 1619(b) and Medicaid Buy-In for Working People Programs June 2014

2. 2 Today’s Presenters James R. Sheldon, Jr., Supervising Attorney National Assistive Technology Advocacy Project Neighborhood Legal Services, Buffalo, NY jsheldon@nls.orgjsheldon@nls.org * 716-847-0650 ext. 262 Ronald M. Hager, Senior Staff Attorney National Disability Rights Network Washington, D.C. Ron.Hager@ndrn.orgRon.Hager@ndrn.org * 202-253-5252

3. CUEs 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 webinar. To learn more about CEUs or to apply for CEUs from an archived webinar, contact Paul Galonsky, pgalonsky@resna.org. pgalonsky@resna.org 3

4. 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 Work- Related AT December 10, 2014-Medicaid and Medicaid Waivers As Funding Sources All sessions 2:00 to 3:15 Eastern Time 4

5. 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 appeals Additional materials available on most topics Contact us for copies and/or links. 5

6. 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. 6

7. 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. 7

8. 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 content. 8

9. 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 9

10. 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. 10

11. SSI as the Path to Medicaid Eligibility: Using the 1619(b) Work Incentive to Retain Medicaid While Working 11

12. 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. 12

13. 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. 13

14. 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. 14

15. 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. 15

16. 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. 16

17. 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. 17

18. 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? 18

19. Maria’s SSI Budget $ 1,085Gross wages - 85Disregarded $ 1,000 -500Additional 50% disregarded $500Countable wages $721SSI base rate -500 Countable income $221Monthly SSI check (Plus automatic Medicaid in her state) 19

20. With $2,085 Gross Maria Loses SSI – Will She Lose Medicaid? $ 2,085Gross wages - 85Disregarded $ 2,000 - 1,000Additional 50% disregarded $ 1,000Countable wages $721SSI base rate - 1,000 Countable income $ 0Monthly SSI check 20

21. 21 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, https://secure.ssa.gov/apps10/poms.nsf/lnx/0502302200. https://secure.ssa.gov/apps10/poms.nsf/lnx/0502302200

22. 22 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)

23. 23 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.

24. 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. 24

25. 25 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 = $300) Medicaid should continue through 1619(b): –SSI lost due to wages –Should meet other criteria.

26. 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. 26

27. 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. 27

28. Cynthia’s Individualized Thresho ld Cynthia now earns $55,000 per year Lives in Maryland with $41,746 general eligibility threshold. 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). 28

29. 29 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.

30. The Medically Needy/Spend Down Program & The Medicaid Buy-In for Working Individuals Program 30

31. 31 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

32. 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. 32

33. 33 “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

34. 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 34

35. 35 Problem with Spend Down As Wages Increase: Spend down increases by $1 or each $2 of extra wages 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

36. 36 Medicaid Buy-In for Working People Known by Different Names in Different States

37. 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 Disabilities 37

38. 38 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

39. 39 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)

40. 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). 40

41. 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 41

42. 42 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

43. 43 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 levels.

44. 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). 44

45. John’s Monthly MBI Budget (Part-Time Job) Step 1:Unearned income $ 1,029.00 General income exclusion - 20.00 Counted unearned income $1009.00 Step 2:Earned income $ 365.00 Earned income exclusion - 65.00 300.00 Additional 50 % exclusion - 150.00 Counted earned income $ 150.00 Step 3:Total counted income ($1,009 + 150) $ 1,159.00 Eligible for MBI since countable income is less than $2,432. 45

46. John’s Monthly MBI Budget (Full-Time Job) Step 1:Unearned income $ 1,029.00 General income exclusion - 20.00 Counted unearned income $1009.00 Step 2:Earned income $ 2,500.00 Earned income exclusion - 65.00 2,435.00 Additional 50 % exclusion - 1,217.50 Counted earned income $1,217.50 Step 3:Total counted ($1,009 + 1,217.50) $2,226.50 Eligible for MBI since countable income is less than $2,432. 46

47. 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 http://choosework.net/resource/jsp/searchByState.jsp. Scroll down to search for WIPA program by zip code.http://choosework.net/resource/jsp/searchByState.jsp 47

48. 48 Conclusion 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 Project: –The “Working” newsletter or policy-to-practice brief on Medicaid –both available at the Research/Publications section of website, http://ilr-edi-r1.ilr.cornell.edu/nymakesworkpay/http://ilr-edi-r1.ilr.cornell.edu/nymakesworkpay/

49. Thank you! Please use your chat box to ask questions James R. Sheldon, Jr., Supervising Attorney jsheldon@nls.orgjsheldon@nls.org * 716-847-0650 ext. 262 Ronald M. Hager, Senior Staff Attorney National Disability Rights Network Ron.Hager@ndrn.orgRon.Hager@ndrn.org * 202-253-5252 49