U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract #HHS-100-00-0018 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and George Washington University. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Andreas Frank, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: Andreas.Frank@hhs.gov.
This policy paper was funded through a contract with the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation supporting a project entitled "Case Studies and Technical Assistance for Medicaid Buy-Ins for People with Disabilities." This paper was also funded by a grant from the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education supporting the Rehabilitation Research and Training Center on Workforce Investment and Employment Policy for Persons with Disabilities. In addition, the paper was supported by a grant from the Robert Wood Johnson Foundation.
The opinions contained in this paper are those of the authors and do not necessarily reflect those of the U.S. Department of Health and Human Services, the U.S. Department of Education, or the Robert Wood Johnson Foundation.
As we begin the new millennium, individuals with significant disabilities have greater opportunities for employment than ever before in the history of our Nation. These opportunities are aided by advancements in public understanding of disability and innovations in assistive technology, medical treatment, and rehabilitation. These opportunities also are aided by important public policy initiatives such as the work incentive provisions in Section 1619 of the Social Security Act, the Ticket to Work and Work Incentives Improvement Act (TWWIIA), the Workforce Investment Act, the Individuals with Disabilities Education Act, the Rehabilitation Act, and the Americans with Disabilities Act.
In addition, coverage under Medicaid in many states of personal assistance services, prescription drugs, durable medical equipment, as well as basic health care remove many of the barriers between significant disability and work and are powerful and proven tools facilitating the ability of individuals with significant disabilities to obtain and retain employment.
Despite such historic opportunities and the desire of millions of disability recipients to work and support themselves, few of the more than 8.4 million Americans with significant disabilities who receive income from the Social Security Disability Insurance (SSDI) program or the Supplemental Security Income (SSI) program return to work. In fact, according to the Social Security Administration (SSA), less than one-half of 1% of SSDI and SSI recipients leave the disability rolls and return to work.
The reality facing many persons with significant disabilities is that too often they are unable to obtain health insurance in the private sector that provides coverage of the services and supports that enable them to live independently and enter, remain in, or rejoin the workforce. Thus, there is a need to supplement private insurance or rely on Medicaid for necessary services and supports.
For individuals with disabilities currently receiving health care under Medicaid, the fear of losing health care and related services is one of the greatest barriers keeping such individuals from maximizing their employment, earnings potential, and independence. For many individual SSDI and SSI recipients, the risk of losing Medicare and Medicaid coverage that is linked to their cash benefits is a risk that is an equal or greater work disincentive than the loss of cash benefits associated with working.
In addition to the fear of loss of health care coverage, SSDI and SSI recipients and other individuals with significant disabilities cite as barriers to employment the cumulative effect of the following: financial disincentives to work and earn income, lack of adequate employment training and placement services, continuing discrimination, complexity of existing work incentives, and the lack of benefits counseling providing accurate and easy-to-understand information about their options. In addition, individuals cite the lack of a comprehensive integrated system of short and long-term services and supports that addresses the individual's overall needs, including education, training, health care, housing, food, and transportation.
Eliminating barriers to health care and other needed services and supports and creating financial incentives to work can greatly improve their short and long-term financial independence and financial well being. So concluded Congress when it included a Medicaid Buy-In option in Section 4733 of the Balanced Budget Act (BBA) and when it enacted TWWIIA.
In a nutshell, by authorizing states to offer Medicaid Buy-In programs, these landmark pieces of legislation have opened a window of opportunity for states to develop comprehensive work incentive initiatives that encourage people with disabilities to work or increase their level of work.
To date, 19 states1 have chosen to design and implement Medicaid Buy-In programs for working persons with disabilities; several additional states2 have enacted legislation to create such programs, and one state (Massachusetts) created a similar program under Section 1115 Demonstration Project authority. A limited number of additional states are seriously exploring the possibility of implementing Medicaid Buy-In programs. A significant number of states are still taking a wait and see approach before pursuing the authority provided by these laws.
As a general proposition, states do not make major changes to entitlement programs like Medicaid without the existence of accurate, relevant, comprehensive, easy-to-understand information. State policy makers demand such information before they will support new policy initiatives. They need answers and information regarding such issues as:
The best source of information is often the experience of other states that are similarly situated (e.g., have similar eligibility criteria (income and resources) and benefits packages under the regular Medicaid program). Policy makers do not like to reinvent the wheel. They want to know what has worked, what has not worked, and why.
To date, vehicles for disseminating information about state-specific experiences include a website developed by the Department of Health and Human Services (HHS) (www.hcfa.gov/Medicaid/twwiia/twwiiahp.htm), a website developed by the Center for Health Services Research and Policy at the George Washington University Medical Center entitled “Comprehensive, Person-centered State Work Incentive Initiatives: A Resource Center for Developing and Implementing Medicaid Buy-In Programs and Related Employment Initiatives for Persons with Disabilities” (www.uiowa.edu/~lhpdc/work/index.html) and a guide for state legislators developed by the National Conference of State Legislatures entitled "Ticket to Work: Medicaid Buy-in Options for Working People with Disabilities" (July 2000).
In addition, two technical assistance centers focusing on assisting state efforts relating to Medicaid Buy-In programs and infrastructure development have been approved by the Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration (HCFA)):
These resources provide some, but not all, of the information critical for assisting states design and improve Medicaid Buy-In programs. The Project Team was asked by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), in coordination with CMS to fill a critical gap in knowledge regarding the employment of persons with significant disabilities and the design and implementation of Medicaid Buy-In programs for workers with disabilities.
The overall project has several purposes:
To examine and describe (using quantitative and qualitative information) the early implementation experiences of states that have opted for the Medicaid Buy-In for working disabled persons.
To use the descriptive information to primarily inform and provide technical assistance to state policy makers about the lessons that can be learned (i.e., the range of options and tradeoffs that can be made in developing and improving Medicaid Buy-In programs as part of a comprehensive effort to improve systems that support the employment of persons with disabilities).
To inform federal policy makers so that they can better understand the experiences of states implementing Medicaid Buy-In programs.
To use the descriptive information to secondarily inform other stakeholders in the state, including persons with disabilities, service providers, and employers about the range of policy options and tradeoffs that can be made in developing and improving Medicaid Buy-In programs as part of an overall effort to improve systems that support the employment of persons with disabilities.
In order to accomplish the four purposes of the project, the Project Team is preparing the following products:
A nine state Case Study.
A summary of the lessons learned and policy implications from the nine state Case Study.
A policy guide for developing health care and income assistance components of a state's comprehensive work incentive initiative for disabled workers.
A summary of conclusions and recommendations for use by federal agencies to enhance employment and earnings for persons with significant disabilities.
This paper describes the findings from the nine state Case Study. The Project Team identified three purposes for conducting the case studies:
To examine early implementation experience among the states in order to gain an understanding of the programmatic, fiscal, and political context in which design decisions were made.
To gather quantitative and qualitative descriptive information for use in providing technical assistance to other states regarding the range and scope of state approaches to enable state policy makers to make informed decisions.
To inform federal policy makers and other stakeholders about issues associated with Medicaid Buy-In programs.
The Project developed a comprehensive data analysis plan for conducting the case studies.
First, the Project Team developed a discussion guide for categorizing state information based on key issues and themes, including design features.
Second, the Project Team secured feedback from ASPE, HCFA (renamed CMS), and selected stakeholders in the states (particularly states that have not as of yet enacted Medicaid Buy-In programs) and other stakeholders regarding the issues and themes.
Third, the Project Team requested state participation. Generally, the Team’s initial contact for the case studies was the person within the state who is assuming lead responsibility for the implementation of the Medicaid Buy-In program.
Fourth, at the initial stages of the case studies, the Project Team field-tested the discussion guide with two states with mature Medicaid Buy-In programs that had agreed to participate in the study. Based on input from the states as well as ASPE and HCFA (renamed CMS), the discussion guide was modified to ensure that information requested from the remaining states in the Case Study produced information that was relevant and useable for other states.
Fifth, the Project Team gathered primary source materials from the states describing policies and procedures relevant to operation of the states' Medicaid programs; SSI state supplementation programs, Medicaid Buy-In programs, and related employment initiatives. The materials reviewed included laws, regulations, policy manuals, and handbooks generally available to the public as well as internal documents not generally available to the public.
Sixth, the Project Team identified key stakeholders in the state for purposes of gathering relevant information about the state’s program. The purpose of making these contacts was to secure a better understanding and complete picture of the state’s policies and procedures, not to evaluate the efficacy of program implementation. Key stakeholders contacted included, as appropriate, the person in the state with lead responsibility for the Medicaid Buy-In, the Medicaid director (if different), state officials and service providers with relevant insight about the state’s program. The Project Team also asked independent groups such as cross-disability coalitions and state independent living centers for recommendations for additional contacts.
Seventh, the Project Team completed the review of written materials prior to phone interviews. Phone interviews with key stakeholders in the state (within and outside state government) were used to verify the accuracy and completeness of information gathered by mail.
Eighth, the Project Team drafted state-by-state descriptions of policies and procedures using issues and organizing themes. The Project Team then shared these descriptions of state programs with key stakeholders in each state to ensure accuracy. Drafts were also reviewed by ASPE and HCFA (renamed CMS). This paper reflects the comments received from the states and HHS.
The Project Team selected nine states with Medicaid Buy-In programs in the early stages of implementation for case studies. Early implementation states are those states that have actual operational experience, including experience in enrolling persons with disabilities in the program.
States with Medicaid Buy-In programs included in the case studies are:
The Project Team used the following selection criteria:
Geographic diversity
Role of stakeholders (state legislature, executive agencies, consumers, employers, service providers).
Does the experience of the particular state provide information that reflects priorities of other states for technical assistance?
The Case Study for each state begins with an overview of the key findings. This overview will help readers get the "big picture" and understand the unique aspects of the state's initiatives. The Case Study then describes the impetus and foundation for the state's policy activities to help explain how the state initiative evolved, including how and why certain policy tradeoffs were made.
Next, the Case Study includes three interrelated sections that discuss the design features of each state's Medicaid Buy-In program within the context of a state's overall Medicaid program and other state initiatives. The three sections are:
Description of the SSI state supplementation policies and the regular Medicaid eligibility categories.
Description of the Medicaid Buy-In program and comprehensive work incentive initiatives (if any).
Description of the relationship between the SSI state supplementation program, regular Medicaid eligibility categories and the Medicaid Buy-In program.
The findings in these three sections build on the fact that every state with a Medicaid Buy-In program and every state contemplating such a program start from a different baseline against which to measure impact and change. This baseline is a significant factor that may explain different design decisions and enrollment numbers among the states.
To understand a state's baseline and how and why a state structured its Medicaid Buy-In program as it did, it is necessary to describe relationships between the state's Medicaid Buy-In program and the state's regular Medicaid eligibility categories and other related state programs such as the SSI state supplementation program. For example, a person in STATE A who becomes newly eligible for Medicaid under the state's Medicaid Buy-In program already could have been eligible for Medicaid -- without the Medicaid Buy-In -- in STATE B.
The Medicaid Buy-In program is but one strategy to achieve the goal of enhancing employment opportunities for persons with significant disabilities (particularly SSI and SSDI recipients) and concomitantly to reduce or eliminate dependence on income maintenance programs. This section discusses other complementary strategies underway such as initiatives that include benefits counseling and requests for demonstration authority from SSA to test alternatives to the current policies under the SSI and SSDI programs.
Next, the case studies describe the various legislative and executive branch policy approaches, administrative systems used to manage the program and stakeholder involvement. In addition, the case studies describe the processes used to gather data to make cost estimates and assumptions that underpinned the budget modeling and cost projections. This information is critical because policy makers in the various states may have different fiscal constraints and wish to target different categories of disabled persons. Finally, the case studies describe a state's program experience and outcomes, focusing on program performance data now available from states.
Many health care policy experts have limited knowledge of the SSDI and SSI programs and the workforce investment system, including the vocational rehabilitation program. Similarly, many experts in SSDI and SSI or the workforce investment system have limited knowledge of the Medicaid and Medicare programs. To provide additional background for the reader, the report includes as an appendix an "A Summary Description of the Federal Income Maintenance and Health Care Programs for Disabled Persons Who Are Working or Want to Work." The overview highlights (using bold face) the key words and phrases relating to SSDI, SSI, SSI state supplementation, Medicaid, and Medicare used in the case studies.
Alaska was the first state to pass legislation authorizing a Medicaid Buy-In program (1998) and the second state to implement its program (1999). The Medicaid Buy-In program is part of a comprehensive work incentive initiative called Alaska Works, that also includes benefits counseling and efforts to establish a unified, seamless workforce investment system with public vocational rehabilitation programs as an integral component.
The Medicaid Buy-In program uses two monthly income thresholds to determine eligibility: a family income test and an individual unearned income test. To meet the first test, an applicant must have a family monthly net income that is below 250% of the Federal Poverty Level (FPL). Net income excludes half of the family's earned income and certain impairment-related work expenses (IRWE). If family net income is below the 250% of the FPL family income test, the applicant's individual unearned income is compared to the Adult Public Assistance (APA) standard of need. If unearned income is lower than the APA need standard and the individual meets SSI asset standards, the individual qualifies for the Medicaid Buy-In.
An eligible participant pays no monthly premium if his family net income is less than or equal to 100% of the FPL. If family income is more than 100% of the FPL, the individual is assessed an income-based premium of up to 10% of net income beginning in the third month of eligibility.
Under Alaska's Medicaid State Plan, personal assistance services are available to persons with disabilities statewide seven days a week, 24 hours a day, both within and outside the home. The personal care assistance (PCA) program includes both an agency and an independent contractor option.
The state's budget model assumed that persons who would use the Medicaid Buy-In program would be SSI or APA recipients who chose to work and would otherwise lose Medicaid because of their increased earnings. The budget model assumed that enrollment in the Medicaid Buy-In category would be temporary with people subsequently moving off the Medicaid rolls. The fiscal note assumed savings from APA reductions to offset continued Medicaid costs, with cumulative APA savings resulting in net savings to the state by the third year of the Medicaid Buy-In program.
As of May 2001, 99 persons were enrolled in the Medicaid Buy-In program. Nearly 60% of the participants were paying a premium for their Medicaid coverage, averaging $34 a month across those who were paying premiums or $19 a month if averaged across all beneficiaries. Half of the individuals paying premiums paid $25 or less per month. Two-thirds of the enrollees received Medicare in addition to Medicaid. Twelve percent of enrollees had private insurance coverage.
Early in 1997, Alaska's Governor convened a Disability Summit at which the high unemployment rate of persons with severe disabilities was identified as a problem. With input from advocates, consumers, and providers, the Governor's Council on Disabilities and Special Education identified barriers to employment of persons with disabilities. The fear of losing health benefits was among those barriers, as were financial disincentives, lack of knowledge of existing work incentive systems, lack of comprehensive vocational services, and limited work opportunities.
In July 1997, the Alaska Mental Health Trust Authority provided funds to the Work Incentives Project to design a comprehensive, person-centered employment program for Alaskans with severe disabilities. Project funds were used to identify barriers, survey people with severe disabilities and employers, convene planning meetings of key partners, and conduct field research on comprehensive vocational rehabilitation services.
A study of Alaska-specific work incentives identified administrative, policy and legal barriers to the employment of Alaskans with severe disabilities. The findings suggested that greater attention be given to making SSI work incentives known to beneficiaries. It also recommended Medicaid waivers, partnering with the private sector to subsidize private insurance coverage, and rethinking the delivery of long-term support services.
A survey of 1,000 Medicaid beneficiaries with severe disabilities found significant differences in perceptions of employment barriers between persons who had some earnings and the majority of respondents who had not worked. Persons who had not worked were more likely to report significant barriers to work, including lack of transportation, lack of control over the pace and scheduling of work, and inability to work because of their disability. The study described the results as a "powerful and instructive finding about the support and benefits counseling needed to facilitate return-to-work efforts as well as the positive impact that success on the job can have on dispelling fears about loss of benefits."3
As part of the state's field research, Juneau Works, a community rehabilitation provider, received funds to provide comprehensive vocational rehabilitation services, including benefits analysis and counseling and an array of vocational services such as situational assessments, job-seeking skills, job development, placement, training and ongoing support. The program targeted individuals with severe mental illness, developmental disabilities and/or severe physical disabilities who had never worked or had not worked successfully since becoming disabled. The field research reinforced the importance of intensive and sustained benefits counseling and family and employer education as well as a safety net for those who are not successful in sustaining gainful employment.
Alaska's SSI state supplementation standards, its Medicaid eligibility standards, and its approach to implementing SSI work incentives provide a base for understanding the state's Medicaid Buy-In program. These eligibility pathways and the maximum monthly incomes associated with them are shown on Chart 1. The state has elected a "standard of need" option (similar to a poverty level option) but does not have a medically needy program.
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The Alaska APA is the state's optional cash supplement to the federal SSI program. In 2001, Alaska paid a maximum monthly SSI supplement of $362 to an individual for a total maximum payment (SSI plus state supplement) of $893 per month. The supplement is administered by the state.
Alaska is one of seven states in the country that uses SSI rules as a basis for Medicaid eligibility but requires applicants to file a separate application for Medicaid.4 Individuals who receive APA cash payments (the state's state SSI supplement) without qualifying for SSI also receive Medicaid.
Individuals with disabilities who are ineligible for federal SSI payments or APA cash payments can qualify for Medicaid by meeting the APA standard of need. APA need standards are set at a higher level than APA payment standards. For calendar year 2001, the monthly individual APA need standard was $984. This eligibility category is similar to the "poverty level" option available to states.
Individuals whose medical conditions qualify them for Medicaid-financed long-term institutional care and who receive community-based services under a Home and Community-Based Services (HCBS) waiver can qualify for Medicaid coverage with incomes of up to $1,590 monthly (300% of poverty). The state sets a maximum caseload figure for participation in the waiver.
While Alaska's Medicaid eligibility levels are generous, the rules create a disincentive for earning money beyond the APA standard of need. If an individual's countable income exceeds the need standard by any amount, he loses Medicaid. Because the state does not have a medically needy program, individuals cannot use a "spend down" route to qualify for coverage.
Work incentives in Section 1619 of the federal SSI law provide continued Medicaid eligibility for SSI beneficiaries whose income from earnings could otherwise make them ineligible for coverage. These incentives enable such individual to maintain a connection to both the SSI income assistance program and the Medicaid program when they work. Under Section 1619(a), an individual whose earnings exceed the Substantial Gainful Activity (SGA) earnings test receives SSI cash benefits on a gradually reduced basis and continues to receive Medicaid. In June 2001, 41 persons in Alaska, with average monthly earnings of $949, received SSI and Medicaid on the basis of Section 1619(a).
Under Section 1619(b) and Section 1905(q) of Medicaid law, a person who no longer receives SSI payments because of his earnings level is entitled to Medicaid as long as his disability continues and his earnings are below a federally determined equivalence standard ($2,934 monthly in Alaska). Whether a state provides automatic Medicaid eligibility for SSI beneficiaries and whether it chooses federal or state administration of its SSI state supplement affect the capacity of eligible persons to access Section 1619(b) protections.
In Alaska, a state requiring a separate Medicaid application for SSI beneficiaries, guaranteeing continued Medicaid for persons entitled through Section 1619(b) is administratively complex. When an individual leaves SSI, the state Medicaid agency must review SSA data to track his 1619(b) eligibility status and determine him eligible for continued Medicaid coverage. (By contrast, where Medicaid eligibility is automatic for SSI beneficiaries, the Federal Government sends the state a list of Medicaid-eligible persons, including persons eligible through Section 1619(b).) In June 2001, SSA identified 168 Alaskans, with average monthly earnings of $1,066, as potentially eligible for Medicaid under Section 1619(b). Information on the actual enrollment status of these individuals is not available.
Under its state-administered SSI state supplement program, Alaska does not apply 1619(b) work incentive protections to recipients of SSI state supplementation who do not also receive a federal SSI check. (In states with federally administered SSI state supplements, such persons retain their Medicaid coverage under rules similar to those in effect for SSI recipients.)
Alaska's Medicaid State Plan benefit package includes personal assistance services. Alaska's PCA program meets the definition of a "fully qualified" program as defined by the CMS Infrastructure Grant guidelines. Services are available statewide, seven days a week, 24 hours a day, both within and outside the home and are deemed capable of supporting full-time competitive employment. The PCA program includes both an agency model and an independent contractor model where the consumer hires the worker directly.
Under state regulations, the Medical Assistance Agency or an approved personal care agency may authorize personal care services for up to a 12-month period. Reauthorization for subsequent periods is based on physician orders, a nurse's evaluation, and treatment plan approval by the Medical Assistance Agency or an approved personal care agency.
Alaska has two HCBS waivers that serve working-age adults, one for persons with developmental disabilities and one for persons with physical disabilities. Waiver services include care coordination, adult day services, habilitation services, residential supported living, respite care, meal services, chore services, environmental modifications, private duty nursing, and specialized equipment and supplies.
General Criteria
Alaska's Medicaid Buy-In program provides
continued Medicaid eligibility when earnings from work result in a level of
income exceeding the APA need standard. Individual unearned income must be less
than the APA standard of need.
Income Criteria
Alaska's Medicaid Buy-In program uses two
monthly income thresholds to determine eligibility -- a family income
test and an individual unearned income test. To meet the first test, an
applicant must have a family monthly net income, using SSI
standards and methodologies, of less than 250% of the FPL. (For 2001 in Alaska,
this amount is $2,235 for a family of one or $3,023 for a family of two). If an
applicant meets the family income test, his individual unearned
income is compared to the APA standard of need. If his unearned income is lower
than the need standard, he qualifies for the Medicaid Buy-In Program.
Resource Limitations
The state uses SSI standards and
methodologies in determining countable resources under the Medicaid Buy-In
program. An individual's assets cannot exceed $2,000; a couple's cannot exceed
$3,000.
Eligibility Period
Enrollees are certified for a one-year
period.
An individual's premium liability is based on his family net income. No premiums are due if family net income is less than or equal to 100% of the FPL. If the net family income is more than 100% of the FPL, the individual is assessed an income-based premium beginning in the third month of eligibility. A single individual with a net family income of 250% of the FPL pays the maximum percentage premium of 10% of that income. Persons with lower incomes pay a smaller percentage.5
The Third Party Liability Unit within the Division of Medical Assistance determines the premium amount, sends premium due notices, and collects premiums. If an individual is at least 60 days behind in paying premiums, Medicaid eligibility through the Medicaid Buy-In is terminated.
There is no formal link between enrollees and employer health plans.
There are no special provisions related to continued eligibility for persons who are not able to continue to work.
Alaska's Medicaid Buy-In program was conceived as part of a broader work incentive initiative. Alaska first received federal funding in the mid-1980s to develop a supported employment system for people who require long-term, ongoing supports to maintain their employment. For the past four years, the Governor's Council on Disabilities and Special Education has spearheaded a cross-agency, comprehensive initiative called Alaska Works to address the major barriers that keep people with disabilities from working. Alaska Works is designing and implementing reforms focusing on the role of one-stop centers, intake and referral procedures, and benefits counseling.
Chart 2 shows the major Medicaid eligibility categories available to working adults with disabilities, including SSI work incentives and the Medicaid Buy-In. It sets forth the maximum monthly income levels for each category, including, as appropriate, earned and unearned income limits.
As noted earlier, prior to enactment of the Medicaid Buy-In, persons who lost their state SSI supplements due to earnings but had not been on SSI did not retain Medicaid eligibility. Under the Medicaid Buy-In program, such persons have access to Medicaid work incentive protections comparable to those available to SSI recipients.
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The Medicaid Buy-In program has the effect of raising the maximum monthly unearned income limit for continued eligibility for Medicaid, if working, from the SSI standard ($552) to an amount equal to the state's Medicaid standard of need ($984).
Because the program has a limit on unearned income ($984 per month), the number of persons who can qualify for the program is reduced.
Alaska was the first state to enact a Medicaid Buy-In law and the second state to implement its program. H.B.459, the bill authorizing the Medicaid Buy-In program, was enacted in 1998 with strong bipartisan support from the legislature and the Governor. The law added employed persons with disabilities as an optional coverage group, amended the definition of personal care services in a person's home to allow more flexibility in service delivery, and removed a provision requiring physician authorization of personal care services.
The state has worked extensively with Workforce Investment Boards and One-Stop employment centers to enhance their knowledge of the Medicaid Buy-In program. Vocational rehabilitation services are located at the One-Stop centers. Resource specialists are working with one-stop employment center staff to improve their ability to assist persons with disabilities.
Passage of legislation and implementation of the Medicaid Buy-In program were among the outcomes of the Work Incentives Project created in 1997. People with disabilities representing a cross-section of the disability population were part of the planning team. Groups involved include the state Independent Living Council, the Governor's Committee on Employment and Rehabilitation of People with Disabilities, the Alaska Human Resources Investment Council and the Alaska Mental Health Trust Authority.
The state's budget estimate, prepared in 1998, assumed an enrollment of 17 people in FY 1999 (a partial year), 28 people in FY 2000, 23 people in FY 2001, and 22, 23, and 21 persons in FY 2002, FY 2003, and FY 2004 respectively. The fiscal note assumed that persons who would use the new eligibility category were existing SSI or APA recipients who otherwise would lose Medicaid because of their increased earnings. It assumed temporary enrollment with people moving from APA to the Medicaid Buy-In program and then off the Medicaid rolls.
The fiscal note says: "We do not anticipate individuals using this new eligibility category to access Medicaid for the first time. Consequently, this option will not result in an increase in new Medicaid cases, but will only have the effect of extending the Medicaid eligibility of existing recipients for about one year."6 The fiscal note assumed savings from reduced APA cash outlays to offset continued Medicaid costs, with cumulative APA savings resulting in net savings to the state by the third year of the project. In other words, the estimates assumed persons enrolling in the Medicaid Buy-In would leave the APA rolls, thereby saving state funds, and eventually would leave the Medicaid rolls.
As of May 2001, 99 persons were enrolled in the Medicaid Buy-In program, up from 50 persons enrolled in May 2000. Enrollment levels exceed the original projections.
An analysis of Medicaid Buy-In recipients conducted in October 2000 showed that 58% of the participants were paying a premium for coverage, averaging $34 a month for those who paid premiums or $19 a month if averaged across all beneficiaries. Half of the individuals with premiums paid $25 or less per month. Two-thirds of the enrollees were receiving Medicare in addition to Medicaid. Twelve percent of enrollees had private insurance coverage.
Early data indicate that persons enrolled in the Medicaid Buy-In program cost Medicaid less than they had when enrolled in a different eligibility category. The Medicaid agency compared program costs for those Medicaid Buy-In participants enrolled during the 12-month period beginning July 1, 1999 who had also been on Medicaid in another eligibility category during calendar year 1998. During 1998, Medicaid payments on behalf of these individuals averaged $1,015 per month. During the 1999-2000 period, costs averaged $850 per month. It is too early to determine whether enrollees in the Medicaid Buy-In program will continue to incur lower costs nor is it possible to determine the reasons for the lower costs.
As part of an effort to expand the number of personal assistance service providers available to consumers and increase the number of consumers served, Alaska is planning to convert the independent contractor model into a consumer-directed model. In the new model, consumers will arrange for, hire, train, manage, and fire their assistants, while a fiscal intermediary will handle reimbursement and related fiscal functions.
Alaska Works has identified a need for a broader array of personal assistance services and other individualized supportive services within the Medicaid program to support persons with disabilities at the worksite. Through the state's Medicaid Infrastructure Grant, Alaska Works is surveying working people with disabilities and their employers to determine how effective their current services are in helping them maintain employment. The Infrastructure Grant is also supporting development of a transportation plan to improve options for working people with disabilities.
Advocates are seeking program changes related to resource levels and income disregards to encourage additional enrollment in the Medicaid Buy-In program. Advocates are seeking to increase resource levels and income disregards to provide an incentive for savings and to promote job retention. Another proposal would disregard all employment-related disability payments, such as private disability coverage, veteran's disability payments, railroad disability payments, and SSDI, when determining income eligibility.
Alaska Department of Medical Assistance. Adult Public Assistance Need and Maximum Payment Standards. Fall 2000.
Alaska Works Performance Report: Clarification and Additional Information. July 9, 1999.
CMS web site at www.cms.gov/medicaid/twwiia/twwiiahp.htm.
Explanation of the Working Disabled Medicaid Buy-In. Accessed at www.hss.state.ak.us/dma/news.htm#anchor146212.
"Expanding Health Care Coverage for Alaskans with Disabilities." Press Release from the Governor's Council on Disabilities and Special Education. Summer 2000.
H.B.459 in the Twentieth Legislature. Accessed at old-www.legis.state.ak.us.
"Medicaid for the Disabled. Fiscal Note Summary." Obtained from Kevin Henderson. February 2001.
P Hanes and Associates. Review of Alaska-specific Work Disincentives for Individuals with Significant Disabilities. September 1998.
Welcome to Medicaid. Presentation to the Alaska State Legislature. February 6, 2001. Accessed at www.hss.state.ak.us/dma/table.htm.
Connecticut's Medicaid Buy-In program legislation was signed into law in June 2000 and began operating on October 1, 2000. The Medicaid Buy-In program is part of a comprehensive work incentive approach that also includes benefits counseling and changes in personal assistance services. Connecticut is the only Case Study state that includes both the Basic Insurance Group and the Medically Improved Group in its Medicaid Buy-In program.
The Medicaid Buy-In program in Connecticut provides categorical Medicaid eligibility for persons who have too much SSDI or other unearned income to become eligible for work incentives available to recipients of SSI or state-administered SSI supplementation. The Medicaid Buy-In program is also an alternative to the medically needy program for working persons with disabilities.
In order to be eligible for the Medicaid Buy-In, an applicant must be paid for his work and must make FICA contributions either through payroll taxes or through payment of self-employment taxes. In addition, an individual must have a monthly gross income of $6,250 or less ($75,000 annually) or net countable monthly income of $3,082 or less. To protect persons with temporary job interruptions, an individual can continue to meet the employment test for up to one year from the date of employment loss.
To meet the program's family asset test, a single applicant must have countable assets of $10,000 or less; a married couple $15,000 or less. Funds in retirement accounts or medical savings accounts set up under federal law and in designated accounts established for purchasing goods or services to increase the individual's employability are not counted. Any assets in such accounts remain excluded during the person's lifetime if he seeks Medicaid eligibility under other eligibility categories.
A participant in the Medicaid Buy-In pays a premium of 10% of his family income in excess of 200% of the Federal Poverty Limit (FPL). Fees paid for private insurance are deducted from the individual's Medicaid Buy-In premium liability. Individuals enrolled in the Medicaid Buy-In are categorically eligible for the state's PCA waiver program.
Connecticut's Medicaid State Plan benefit package does not include personal care services. Instead, the state provides personal assistance services under Medicaid through a HCBS waiver.
To develop its budget estimate for the Medicaid Buy-In program, the state analyzed eligibility records of currently or recently disenrolled disabled Medicaid clients with earnings. They estimated 1,208 persons (a number equal to 1.3% of the total adult disabled population in the state) would enroll in the Medicaid Buy-In, including 301 persons who had qualified under existing categories and 907 persons who were ineligible under existing rules.
As of October 1, 2001, 1,600 persons were enrolled in the Medicaid Buy-In program. Currently, 85% of enrollees are not liable for premiums; 15% do pay premiums. Nearly three-quarters of those paying premiums pay less than $50 monthly. Another 15% pay between $50 and $100 monthly. Slightly over one-fifth of enrollees have monthly earnings exceeding the SGA test of $740; the remainder have earnings below that level. Most enrollees receive unearned income, with more than two-thirds of enrollees receiving unearned monthly income of $600 or more. Almost 5% of enrollees receive no unearned income.
Over ten years ago, the Work Incentives Committee of the Northwest Connecticut Mental Health Planning Board, in cooperation with staff from the state Medicaid agency and state Vocational Rehabilitation agency, began working to increase the use of existing work incentives and advocate for improvements in them. One policy change occurred in 1994, when the state Medicaid agency extended SSI work incentives to persons who were receiving a state-administered SSI supplement, but were not receiving federal SSI benefits. As a result of this policy, persons who lose their state SSI supplement because of earnings can remain eligible for Medicaid up to income thresholds specified in SSI law.
In 1999, a cross-disability coalition of consumers and advocates with leadership from legal assistance groups began urging the adoption of the Medicaid Buy-In program. Building on their initiative, the Human Services Committee in the Connecticut House of Representatives established a Work Incentives Working Group in the Fall of 1999. That group, whose members included legislators, legislative and executive branch staff, representatives from disability and legal assistance groups, and persons with disabilities, designed legislation to allow SSDI eligible people to work and retain their health care under Medicaid. The Governor endorsed the effort in January 2000, the legislature passed a bill in April 2000, and the Governor signed the bill in June 2000.
The Northwest Regional Mental Health Board and the Work Incentives Working Group set forth scenarios under which individuals lost Medicaid eligibility when they went to work. They discussed disincentives faced by SSDI beneficiaries in comparison to SSI recipients. In particular, they provided information about the out-of-pocket expenditures required for "spending down" to become eligible for Medicaid coverage. The Work Incentives Working Group launched an education and awareness campaign involving personal contact with legislators, newspaper and radio coverage, and meetings with legislators and the Governor.
The two groups also identified state-funded programs serving a significant number of SSDI beneficiaries, including ConnPace (the state-funded pharmacy assistance program) and the Working Persons Personal Assistance Program. They highlighted the financial benefits to the state of gaining federal matching funds to support these programs for persons who could qualify for the Medicaid Buy-In.
The state's state SSI supplementation program standards, its Medicaid eligibility standards, and its approach to implementing SSI work incentives provide a base for understanding the state's Medicaid Buy-In program. These eligibility pathways and the maximum monthly incomes associated with them are shown on Chart 1. As shown on the chart, Connecticut has a medically needy program but has not elected a poverty level option.
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Connecticut provides an income supplement to the federal SSI program. In 2001, the state's supplement was a maximum of $216 monthly for a total maximum monthly payment of $748 for an individual. The state supplement an individual receives is based on an individual budgeting process that considers shelter costs. Connecticut has chosen to administer its supplement at the state level rather than have it administered by the Federal Government.
Connecticut does not provide automatic eligibility for Medicaid for SSI recipients. It is among the states exercising an eligibility option under Section 209(b) of the Social Security Disability Act Amendments of 1973. Under 209(b), states may use Medicaid eligibility criteria that differ from SSI standards as long as the criteria are not more restrictive than the state’s approved standards when the SSI law was enacted in 1972. In the absence of automatic eligibility for SSI recipients, adults with disabilities living in the community file a separate application for Medicaid.
Individuals with disabilities who are not eligible for SSI or state SSI supplementation can qualify as "medically needy". To do so, they must either have a very low-income level ($477 monthly for an individual) or incur medical expenses through a "spend down” that reduce their remaining monthly income to the state's Protected Income Level of $477.
Individuals whose medical conditions qualify them for Medicaid-financed long-term institutional care and who receive community-based services under a HCBS waiver can qualify for Medicaid coverage in the community with incomes of up to $1,590 monthly (300% of poverty). The number of individuals who qualify for coverage through waiver eligibility is limited by a maximum caseload figure set by the state.
Work incentives in Section 1619 of the federal SSI law provide continued Medicaid eligibility for SSI beneficiaries whose income from earnings could otherwise make them ineligible for coverage. These incentives enable such individual to maintain a connection to both the SSI income assistance program and the Medicaid program when they work. Under Section 1619(a), an individual whose earnings exceed the SGA earnings test receives SSI cash benefits on a gradually reduced basis and continues to receive Medicaid. In June 2001, 232 persons in Connecticut, with average monthly earnings of $924, received SSI and Medicaid on the basis of Section 1619(a).
Under Section 1619(b) and Section 1905(q) of Medicaid law, a person who no longer receives SSI payments because of his earnings level is entitled to Medicaid as long as his disability continues and his earnings are below a federally determined equivalence standard ($3,050 monthly in Connecticut). Whether a state provides automatic Medicaid eligibility for SSI beneficiaries and whether it chooses federal or state administration of its state SSI supplementation program affect the capacity of eligible persons to access Section 1619(b) protections.
In Connecticut, a state requiring a separate Medicaid application for SSI beneficiaries, guaranteeing continued Medicaid for persons entitled through Section 1619(b) is administratively complex. When an individual leaves SSI, the state Medicaid agency must review SSA data to track his 1619(b) eligibility status and determine him eligible for continued Medicaid coverage. (By contrast, where Medicaid eligibility is automatic for SSI beneficiaries, the Federal Government sends the state a list of Medicaid-eligible persons, including persons eligible through Section 1619(b).) In June 2001, SSA identified 1,101 persons in Connecticut, with average monthly earnings of $896, as potentially eligible for Medicaid under Section 1619(b). Information on the actual enrollment status of these individuals is not available.
Under its state-administered state SSI supplementation program, Connecticut extends work incentive protections similar to Section 1619(b) to state SSI supplementation program recipients. This policy decision provides continued access to Medicaid for non-SSI, state supplement recipients who enter the workforce. (In states with federally administered state SSI supplements, such persons automatically retain their Medicaid coverage under rules similar to those in effect for SSI recipients.)
Connecticut's Medicaid State Plan benefit package does not include personal care services. Instead, the state provides personal assistance services under Medicaid through an HCBS waiver. Connecticut's personal assistance services meet the requirements for "conditional eligibility" under CMS Infrastructure Grant guidelines.
For persons ineligible for the waiver, the state-funded PCA Working Person's Program provides up to $15,000 per person annually for the purchase of personal care services for adults with severe physical disabilities that are working or likely to work.
General Criteria
Connecticut extends Medicaid coverage to
both the Basic Insurance Group and the Medically Improved Group. To be
eligible, an individual must meet a disability test and an employment test.
Persons in the Basic Insurance Group must meet the disability criteria of the
SSDI/SSI program (except those related to inability to work), must be paid for
his work, and must make FICA contributions through payroll deductions or
payment of self-employment taxes.
To qualify under the Medically Improved Group, an individual must have been previously eligible under the Basic Insurance Group. He must be determined during a regularly scheduled medical review to have a severe medically determinable impairment but to no longer meet the Basic Insurance program's disability criteria due to medical improvement. Participants in this group must work at least 40 hours per month at a wage no less than the federal minimum wage or earn a monthly wage equal to the minimum wage times 40.
Income Criteria
To qualify in either the Basic Insurance Group
or the Medically Improved Group, an applicant's individual gross monthly
income must be $6,250 or less ($75,000 per year) or his individual net
countable monthly income (after SSI disregards) must be $3,082 or less.
Resource Limitations
A single applicant's assets cannot exceed
$10,000 and a married applicant's joint assets cannot exceed $15,000.
Retirement accounts or medical savings accounts set up pursuant to federal law
are excluded from consideration as are designated accounts established for
purchasing goods or services that will increase the employability of the
applicant. Any assets held in retirement, medical savings or designated
accounts are exempt from consideration as assets during the person's lifetime,
even if he loses Medicaid Buy-In eligibility and seeks enrollment through a
different eligibility category.
Eligibility Period
Enrollees are certified for a one-year
period.
An applicant's cost sharing obligation is based on his net family income, including the income of his spouse but not of dependent children. To derive net income, standard SSI deductions, IRWE and self-employment expenses are subtracted from gross income. Individuals with net family incomes above 200% of the FPL must contribute 10% of their income in excess of 200% of the FPL as a premium. For individuals with net family incomes in excess of 250% of the FPL but not greater than 450% of the FPL, the amount of the monthly premium cannot exceed 7.5% of net family income. Payments are due by the end of the month covered by the premium.
Like all other Medicaid recipients, Medicaid Buy-In program enrollees must accept employer-sponsored health insurance benefits for which they qualify if such coverage meets cost-effectiveness tests. If an individual buys private health insurance for anyone in his family, his Medicaid Buy-In premium is reduced by the amount of his private insurance payment. If an individual's private insurance costs exceed his Medicaid Buy-In premium liability, the state may contribute to the cost of the private health insurance.
To protect persons who have temporary health problems or are involuntarily terminated, an individual can continue to meet the employment test for a period of up to one year from the date of employment loss. To do so, the individual must profess an intention to return to employment. As noted earlier, an individual's assets in retirement, medical savings, and designated accounts are excluded from consideration during his lifetime if he reapplies for Medicaid under a different category.
Under provisions in Connecticut's Medicaid Buy-In legislation, enrolled individuals are categorically eligible for the state's HCBS waiver (the waiver that offers personal assistance services). Previously, eligibility for the waiver had been limited to persons with incomes at or below 300% of the SSI level, potentially disqualifying some Medicaid Buy-In enrollees. All Medicaid Buy-In enrollees previously participating in the state-funded PCA Working Persons Program will convert to the waiver unless they do not meet other non-financial waiver criteria.
Counselors at the Vocational Rehabilitation agency provide advice about the Medicaid Buy-In as part of their benefits planning process for persons with disabilities who are seeking employment. The counselors help individuals assess how the Medicaid Buy-In will affect their other benefits and determine whether the Medicaid Buy-In is appropriate for them. The Department of Social Services has launched an outreach effort to inform persons about the Medicaid Buy-In program.
The Medicaid Buy-In legislation authorizes the executive agencies to seek demonstration authority from the SSA to afford greater protections and flexibility for SSI and SSDI recipients participating in Medicaid Buy-In programs.
Chart 2 shows the major Medicaid eligibility categories available to working adults with disabilities, including SSI work incentives and the Medicaid Buy-In. It sets forth the maximum monthly income levels for each category, including, as appropriate, earned and unearned income limits.
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Connecticut's Medicaid Buy-In program builds on state-designed Medicaid work incentive provisions for persons qualifying for SSI or for a state-administered state SSI supplement. The Medicaid Buy-In program extends these incentives to individuals whose SSDI or other unearned income payments exceed SSI or state supplementation program standards.
As discussed earlier, prior to adopting the Medicaid Buy-In, Connecticut's SSI work incentive protections covered individuals who did not qualify for SSI but qualified for a state-administered SSI state supplement. Under the previous rules, individuals with higher levels of unearned income -- that is, individuals who did not qualify for state SSI supplementation -- could not access the state's SSI-related Medicaid work incentives. With the Medicaid Buy-In, these individuals now receive Medicaid protections.
Medically Needy
The Medicaid Buy-In program serves as an
alternative to the medically needy program for persons with earnings. By
converting to the Medicaid Buy-In category, an enrollee can exchange a monthly
spend down for a smaller, more manageable premium and retain more of his income
for other purposes.
The Connecticut Department of Social Services has instructed eligibility workers to be proactive in moving individuals into the Medicaid Buy-In category. To facilitate transfers, the Department provided workers with the names of medically needy persons with disabilities with earnings. These persons are being transferred automatically to the Medicaid Buy-In eligibility category.
Home and Community-Based Services Waivers
Connecticut extended
eligibility for the state's Personal Care (HCBS) waiver to persons qualifying
for the Medicaid Buy-In. Because their incomes exceeded the waiver's previous
income limit of 300% of SSI, many of these individuals had been enrolled in a
state-funded personal care program. With the conversion of their service
coverage to Medicaid, the state is newly eligible for federal funds for their
personal care and other health services.
The state received new federal matching funds to offset the costs of personal assistance and prescription drugs previously paid entirely with state funds.
State legislation enacting the Medicaid Buy-In program provided the framework for comprehensive work incentives efforts. In addition to describing basic eligibility guidelines, the legislation mandated revisions to the PCA waiver and directed the Department of Social Services commissioner to seek waivers from SSA for demonstration projects to enhance work incentives.
In October 2000, the Department of Social Services published a brochure entitled "Medicaid for the Employed Disabled: A Tool for Self-Sufficiency," describing the program and listing application sites. In November 2000, the Department issued a press release noting the commitment of the Governor and legislature to the right of individuals to retain their health coverage while pursuing a career.
The Medicaid Buy-In program is managed through the Medicaid eligibility, management, and service delivery structure. A manual prepared for eligibility workers provides a detailed explanation of the Medicaid Buy-In and SSI-related work incentives and their application in Connecticut. Eligibility workers use this guide to advise persons with disabilities about their options for continued Medicaid enrollment. The Vocational Rehabilitation Agency, located within the Department of Social Services, provides benefits counseling. Ongoing outreach efforts of the Department are being expanded under the state's Medicaid Infrastructure Grant.
Several committees focusing on work incentive issues are advising state officials on the Medicaid Buy-In program and other work incentives. These include the State Rehabilitation Council, the state Committee for Persons with Disabilities within the Department of Social Services, and a group associated with Connecticut's efforts under the Real Choices Systems Change grant.
The Department of Social Services used data gathered about current and former Medicaid clients with disabilities when it developed its budget estimate. It determined the number of potentially eligible clients, estimated average per person costs, calculated potential client premium contributions, and identified possible offsets for some of the costs.
The Department began its analysis by identifying medically needy Medicaid clients with disabilities who had earnings. They considered both current enrollees and persons leaving the rolls during the previous two years. From a caseload of 12,112 medically needy persons, the Department identified a total of 1,208 persons with earnings. After subtracting 301 persons who had already qualified for Medicaid, the Department identified 907 previously ineligible persons who would likely qualify for the Medicaid Buy-In program. They further assumed that all 1,208 qualifying individuals would enroll. This represents 1.3% of the total disabled population in the state, an estimate the state found consistent with rates in other states.
The Department estimated monthly Medicaid expenditures of $453,000 for the 907 new enrollees (assuming a $500 monthly per case cost) or $5.4 million annually. After offsets from client co-pays and prescription drug savings, the Department projected $4.1 million in additional annual state expenditures. The Fiscal Note prepared for the General Assembly made similar projections, estimating 1,000 new persons would be served, with an annualized cost of $5.2 million.
The budget model assumed very few new clients other than the 907 identified from the current or past medically needy rolls. As noted by the analysts: "Medical assistance is a prerequisite for survival for many disabled individuals and people generally tailor their finances to stay within program boundaries. A broadening of the boundaries would therefore allow people to improve their standard of living, but it would not bring significant numbers of new individuals into the Medicaid program."7 In other words, the analysts assumed that Medicaid is so essential that almost every person with disabilities had been willing to forego earnings if that was necessary to meet Medicaid requirements.
A state-funded program, ConnPACE, provides prescription drug coverage for Medicare-eligible persons with incomes of $15,100 or less (approximately 180% of the poverty level) and includes on its rolls working individuals whose incomes exceed Medicaid standards and who have not spent down to the Medicaid level. In determining program offsets, the analysts found that almost half of the potential Medicaid Buy-In participants were eligible for ConnPACE and were costing the state approximately $219 per month per client. With those individuals enrolled in the Medicaid Buy-In program, the costs of prescription drug coverage are split with the Federal Government.
The analysis assumed Medicaid Buy-In fees paid by clients of approximately 4-5% of total costs. It suggested other savings might accrue to the state from increased use of private insurance or reduced expenditures in other programs, but did not quantify them for the budget estimate.
As of October 1, 2001, 1,600 persons were enrolled in the Medicaid Buy-In program. Connecticut has exceeded its original estimate of 1,208 persons at full enrollment.
Twenty-one percent of the enrollees in the Medicaid Buy-In program have monthly earnings exceeding the $740 SGA earnings test for disability. The remaining participants have lower monthly earnings. Over two-thirds of enrollees receive unearned income of over $600 a month. Most of the remaining enrollees receive some unearned income, although almost 5% receive no unearned income.
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As shown in the pie chart, 85% of enrollees were not liable for premiums in October 2001. Fifteen percent did pay premiums. Nearly three-quarters of those paying premiums paid less than $50 per month. Another 15% paid between $50 and $100. The proportion of persons paying premiums is consistent with estimates when the Medicaid Buy-In was initiated and has increased over time. In March 200l, only 8% of enrollees paid premiums.
Connecticut is gathering data on the enrollees in the Medicaid Buy-In program through its Medicaid management information system. The state expects to publish additional utilization and cost data after automated eligibility is instituted for this eligibility group during the next several months.
Cohen, Robin. State Medicaid Buy-In Programs for Working People with Disabilities. Prepared for Connecticut Department of Social Services. November 22, 1999.
Connecticut Department of Social Services. Adult Services Division. Eligibility Desk Guide: Medicaid for the Employed Disabled and Adult Work Incentives. Hartford, December 2000.
Connecticut Department of Social Services. “Cost Estimate for the Work Incentives Budget Proposal.” Office of the Commissioner. Hartford, December 20, 1999.
Connecticut Department of Social Services. Uniform Policy Manual. Updated October 1, 2000.
Connecticut Department of Social Services. “State Initiative Ending ?Catch-22’ in Job Market: More People with Disabilities Can Work Without Losing Medical Coverage.” Public and Government Relations Office. November 27, 2000. Press Release.
Connecticut Department of Social Services. Medicaid for the Employed Disabled: A Tool for Self-Sufficiency. Publication 00-6. October 2000. Brochure.
Connecticut GA 5249, An Act to Provide Work Incentives and Health Care for Persons with Disabilities.
Infrastructure Grant Proposal. Submitted to the Centers for Medicare and Medicaid Services.
“Medicaid for the Employed Disabled.” Connecticut Department of Social Services. November 8, 2000.
Office of Legislative Research. Bill Analysis, HB 5778 (File 562). Prepared for Connecticut House of Representatives. April 12, 2000.
Office of Legislative Research. Amended Bill Analysis, HB 5778 (File 562, as amended by House “A”). Prepared for Connecticut House of Representatives.
Iowa's Medicaid Buy-In program was signed into law on April 30, 1999 after passing both houses of the legislature by unanimous votes. Implementation of the Medicaid Buy-In began in March 2000. The program was marketed as an economic development tool and the business community led efforts to pass the legislation. The organized disability community did not play a direct role in securing passage and does not have a formal role in implementation. Iowa's Medicaid Buy-In program is not part of a comprehensive state work incentive initiative, although benefits planning is available from several providers in the state.
For an individual to qualify for Iowa's Medicaid Buy-In program, he or she must be disabled, less than 65 years of age, and have earned income from employment or self-employment. The individual's monthly net family income (earned and unearned) must be less than 250% of the FPL, allowing all standard SSI disregards and exemptions. The asset limit is $12,000 for an individual and $13,000 for a couple. Excluded from the resource limit are retirement and pension funds, medical savings accounts exempt by the IRS, and funds in pre-approved assistive technology accounts.
Premiums are assessed if an individual's gross income is at or above 150% of the FPL. At 150% of the FPL, the monthly premium is $20. The premium increases with income brackets to $201 a month. Enrolled persons have continuous eligibility with annual reviews. Premium adjustments occur every six months. Participants may remain eligible for the Medicaid Buy-In program through a period of work stoppage not greater than six months.
Currently, Iowa's Medicaid State Plan does not include personal assistance services. In 1996, the Iowa Department of Human Services (DHS) implemented a pilot personal assistance services program, through a state appropriation, which currently operates in three counties. Iowa also operates six HCBS waivers, all of which offer personal assistance services. Medicaid Buy-In enrollees are eligible for waiver services.
The state assumed in budget projections that half of Medicaid Buy-In participants would come from existing SSI rolls and would pay average monthly premiums of $40. Persons with disabilities who formerly qualified as medically needy would constitute 20% of enrollees and pay average monthly premiums of $100. Enrollees new to Medicaid would account for 30% of the caseload and pay average monthly premiums of $100. The projections assumed that by FY 2002, the mix of enrollees would shift slightly, with new enrollees then accounting for a 45% share. The state estimated that 400 persons would be enrolled in the Medicaid Buy-In program by June 2001, with a gradual increase to 700 persons by June of 2002.
Enrollment has greatly exceeded the state's estimates. As of April 2001, 2,105 people were enrolled in the Medicaid Buy-In program. The state credits extensive outreach for the increased enrollment. About 30% of participants pay a premium. A majority of beneficiaries (57%) have monthly earnings of less than $250. Approximately 5% have monthly earnings exceeding $750. Over 60% of the Medicaid Buy-In enrollees in Iowa received unearned income exceeding $600 per month with another quarter receiving unearned income of between $500 and $600.
The Iowa Business Council, consisting of the 25 largest businesses in the state, recognized that persons with disabilities were an untapped pool of potential employees. Creative Employment Options (CEO), the employment policy arm of Iowa’s University-Affiliated Program, convened a group of six major employers in 1997 to address concerns raised by the Business Council. The group was aware of the congressional deliberations surrounding the BBA of 1997 provision authorizing states to establish a Medicaid Buy-In program. The group concluded that people with disabilities were not applying for jobs in part because they feared losing Medicaid eligibility due to the resource and asset tests used under the regular eligibility criteria.
When the state was awarded a State Program Initiative grant from SSA, it used part of its grant to educate more employers about the barriers inhibiting disabled workers who were unemployed and underemployed. A member of the Iowa legislature convened a group consisting of representatives from the DHS, including the Medicaid Director, and CEO. The organized disability community did not play an overt role in securing passage. The legislation, passed by both houses on unanimous votes, was marketed by its sponsors as a tool for economic and workforce development.
The Medicaid Buy-In program was developed without the benefit of a formal needs assessment of the population of persons with disabilities. Legislative committees relied on information provided through informal discussions and meetings with DHS staff and others. Specific legislators and the Legislative Service Bureau requested technical information about options available under BBA.
Iowa's state SSI supplementation program policies, its Medicaid eligibility standards, and its approach to implementing SSI work incentives provide a base for understanding the state's Medicaid Buy-In Program. These eligibility pathways and the maximum monthly incomes associated with them are shown on Chart 1. As shown on the chart, Iowa has a medically needy program, but has not elected a poverty level option.
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Iowa is one of the few states without an state SSI supplementation program for individuals receiving SSI. (Iowa provides an state SSI supplement for blind individuals, persons with dependents, individuals in certain residential settings, or individuals with special needs.)
People with disabilities in Iowa are categorically eligible for Medicaid if they receive SSI benefits. A person with a disability who is not eligible for SSI can qualify for Medicaid through the medically needy category if his monthly income is at or below $483. An individual may spend down to the medically needy category by incurring medical bills sufficient to reduce his monthly income to the protected income level of $483.
Work incentives in Section 1619 of the federal SSI law provide continued Medicaid eligibility for SSI beneficiaries whose income from earnings could otherwise make them ineligible for coverage. These incentives enable such individuals to maintain a connection to both the SSI income assistance program and the Medicaid program when they work.
Under Section 1619(a), an individual whose earnings exceed the SGA earnings test receives SSI cash benefits on a gradually reduced basis and continues to receive Medicaid. In June 2001, 283 persons in Iowa, with average monthly earnings of $942, received SSI and Medicaid on the basis of Section 1619(a).
Under Section 1619(b) and Section 1905(q) of Medicaid law, a person who no longer receives SSI payments because of his earnings level is entitled to Medicaid as long as his disability continues and his earnings are below a federally determined equivalence standard ($1,731 monthly in Iowa). Whether a state provides automatic Medicaid eligibility for SSI beneficiaries affects the capacity of eligible persons to access Section 1619(b) protections. Where Medicaid eligibility is automatic for SSI beneficiaries, the Federal Government sends the state a list of Medicaid-eligible persons, including persons eligible through Section 1619(b). When Medicaid eligibility is not automatic, the state must carry out additional administrative tasks to provide access to continued coverage.
In June 2001, SSA identified 1,660 persons in Iowa, with average monthly earnings of $763, as potentially eligible for Medicaid on the basis of Section 1619(b). Because Iowa provides automatic Medicaid eligibility for SSI recipients, persons who lose their entitlement to SSI payments due to earnings automatically remain on the Medicaid rolls. Thus, access to SSI work incentives is relatively easy for SSI recipients in Iowa.
Iowa’s Medicaid State Plan does not include a specific personal care services option. Iowa qualifies for “conditional eligibility” under the CMS Medicaid Infrastructure Grant classifications. (This is a change from the first Infrastructure Grant funding cycle, which awarded Iowa “transitional eligibility.”) In 1996, DHS implemented a pilot personal assistance services program in three counties. In this ongoing program, each person is assessed and eligible individuals receive $200, $400, $700, or $1,000 per month, depending on the amount of assistance required. This money goes directly to the disabled individual to hire and pay an attendant.
Under the state plan, home health agency intermittent services, including skilled nursing care and home health aide services, are available in the consumer’s home for up to three visits a week for two to three hours at a time. Private duty nursing and personal care is also available to persons with disabilities age 20 and under as part of Early and Periodic Screening Diagnosis and Treatment (EPSDT) benefits.
Iowa operates six Section 1915(c) HCBS waiver programs, serving more than 6,000 individuals. HCBS waivers exist for the following populations: AIDS/HIV, Brain Injury, Elderly, Ill and Handicapped, Physical Disability, and Mental Retardation. All six HCBS waivers offer Consumer-Directed Attendant Care (CDAC). The consumer may select an agency or an individual to provide skilled or non-skilled attendant care services to assist an individual with disabilities to get ready for or return from work, as well as at the job site. Supported employment is available under Mental Retardation and Brain Injury waivers. Supported employment services include instruction and supervision on gaining and maintaining employment, employment-related transportation services, and personal care services at the worksite. Several of the waivers include home health aide and nursing services that can be utilized after maximizing the similar services available under the state plan. Several of the six HCBS waivers include assistance in the purchase of specialized medical equipment, home and vehicle modification, and homemaker services. Iowa amended its waivers for persons with physical disabilities and persons with mental retardation to allow individuals qualifying for Medicaid through the Medicaid Buy-In program to use waiver services.
Iowa offers a State Supplementary Assistance program to provide health care in the home, prevent out-of-home placement, and preserve independent self-care. This program -- funded with 100% state funds -- provides health care to a person, of any age, in the person’s own home. The person must require health care because of a mental or physical challenge. The services are approved by a physician and supervised by a registered nurse. The program is available to persons statewide who qualify for the program. The in-home health-related care program includes both skilled and personal care services. The person or the person’s family has the primary responsibility for locating a provider. This program can provide personal care services to assist an individual to get ready for their workday.
General Criteria
In order to qualify for the Medicaid Buy-In
program, a person must be disabled, under 65 years of age, and have earned
income from employment or self-employment.
Income Criteria
In order to be eligible for Iowa’s
Medicaid Buy-In program, an individual’s monthly net family income
(earned and unearned) must be less than 250% of the FPL, allowing all standard
SSI disregards and exemptions.
Resource Limitations
The asset limits to qualify for the
Medicaid Buy-In program are higher than for other Medicaid coverage groups:
$12,000 for the individual and $13,000 for a couple. Excluded from the resource
limit are retirement or pension funds, medical savings accounts exempt by IRS,
and funds in assistive technology accounts. A physician or other vocational or
medical professional must certify a need for assistive technology devices or
services and establish that the technology is expected to enhance an
individual’s employability.
Eligibility Period
Persons enrolled in the Medicaid Buy-In
program have continuous eligibility with annual reviews. Premium adjustments
are made every six months. Participants may remain in the Medicaid Buy-In
category through a period of work stoppage not greater than six months if their
intent is to return to work.
Premiums are assessed if an individual’s gross income is at or above 150% of the FPL. There are eleven different premium brackets depending on income level. At 150% of the FPL ($1,074/month), the monthly premium is $20. Individuals with incomes at or above 390% of the FPL pay the maximum premium of $201 per month.
Premiums are determined for a six-month period based on the individual's income during the approval month. If an individual's income increases during the six-month period, his premium does not increase. The premium may decrease during the six-month period if a recipient reports an income reduction. (If eligibility is established retroactively, premiums are determined for each retroactive month based on actual income received.) An individual's first bill is for the two months following the month of approval (“beginning months”). Billing is monthly thereafter. Separate bills are sent for the month of approval, any months between application and approval, and up to three retroactive months. These payments are due within 60 days.
Failure to pay the bill for the two beginning months by the due date -- the 14th of the month after the approval month -- results in cancellation of coverage. If premiums are not paid for the prior months (those due within 60 days), Medicaid coverage continues but the beneficiary loses eligibility for the unpaid months. Premiums may be paid in advance on a quarterly or semi-annual basis within the six-month premium period. The Quality Assurance Unit of the Medicaid agency collects premiums.
Through the Health Insurance Premium Plan, the Medicaid agency will pay a participant’s premium in an employer health plan if it is less costly than providing all services through Medicaid. The Medicaid program then provides wrap-around coverage for the beneficiary.
If employment ends for medical or other reasons, the Medicaid Buy-In program participant may remain eligible under this group for up to six months after the month of job loss if he intends to return to work within those six months. The applicant must write a statement to DHS indicating his intent to return to work within six months and continue to pay monthly premiums. As in other scenarios when income falls, the premium may be reduced during this time.
Under the State Partnership Systems Change Initiative (SPI) grant, Iowa has submitted a request to SSA for demonstration authority under SSDI to make income exclusions for IRWE and blind work expenses identical. Iowa’s experience was that 90% or more of people with blindness used the blind work expense exclusion while fewer than 10% of people with other disabilities used their exclusion of IRWE.
The Medicaid Buy-In program is not part of a broader work incentive initiative, although some benefits counseling occurs through Vocational Rehabilitation contracts or through Independent Living Centers.
Chart 2 identifies the Medicaid eligibility categories for adults with disabilities, including the Medicaid Buy-In category. It sets forth the maximum monthly income levels for each category, including, as appropriate, earned and unearned income limits. As noted earlier, the state does not have a general state SSI supplement for persons with disabilities in the community.
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Medically Needy
The Medicaid Buy-In program serves as an
alternative to the medically needy program for persons with earnings. By
converting to the Medicaid Buy-In category, an enrollee can exchange a monthly
spend down for a smaller, more manageable premium and retain more of his income
for other purposes.
The Medicaid Buy-In program has a resources limit of $12,000 ($13,000 for a couple) whereas the medically needy program has a resources limit of $10,000. While the difference between the two limits is much less in Iowa than in states using SSI asset levels ($2,000 for an individual) in their regular Medicaid categories, individuals in Iowa can also deduct retirement accounts and medical savings accounts if they enroll in the Medicaid Buy-In category. In addition, the income of an applicant's spouse is not counted in the calculation of premium payments in the Medicaid Buy-In program; spousal income is counted in the medically needy program.
There are no explicit targeting or cost-control provisions in the Iowa Medicaid Buy-In program.
Legislation enacting the Medicaid for Employed Persons with Disabilities (MEPD) plan was signed on April 30, 1999 (Senate File 211). Framed as a workforce issue, rather than as a human services initiative, the legislation passed unanimously. Implementation began in March 2000. The legislation provides general authority for the Medicaid Buy-In program and gives DHS broad parameters for its structure.
The state Medicaid agency within DHS is the lead agency responsible for the implementation of the Medicaid Buy-In program. The agency issued regulations, printed pamphlets and posted the policy manual on the Internet.
DHS established a “charter group” to help draft administrative rules for the program. This group consisted of consultants from the Disability Determination Service, income maintenance workers and program managers from the state Medicaid agency, staff from the Division of Mental Health and Developmental Disabilities, and CEO.
Iowa budgeted nearly $400,000 for the development of an automated eligibility and billing system and additional improvements are expected as part of the Medicaid Infrastructure Grant. The state has also tried to streamline operations by having all premiums sent to the Central Office, rather than collected at the county level. DHS is conducting a second generation of training for state income maintenance workers to clarify how to interpret program rules.
After enactment of its Medicaid Buy-In program, DHS and CEO offered about ten outreach and public information events throughout the state directed at consumers, businesses, and other agencies (e.g., vocational rehabilitation, case managers, county administrators). As an additional outreach strategy, pamphlets were developed for businesses and potential enrollees. Under the authority of the SPI grant, CEO has convened workforce issues forums for businesses to market the Medicaid Buy-In program.
While consumers are not formally involved in policy making in the Medicaid Buy-In program, people with disabilities have played a critical role in enhancing personal care services. The Personal Assistance and Comprehensive Family Support Services Council was established in 1995. It is made up of eleven people (six with disabilities who use personal care and five who are parents of children with disabilities). The Council was important in adding attendant care to all HCBS waivers. Nine members of the Council were included in the Advisory Committee that began in August 2000. The Advisory Committee consists of 24 members and at least half are people with disabilities, family members, and advocates. The Advisory Committee is currently drafting a personal care option for inclusion in the state plan.
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The state assumed in budget projections that the majority of Medicaid Buy-In program participants would already be receiving Medicaid. The fiscal note assumed that SSI recipients would make up about half of Medicaid Buy-In program enrollees in the first year of the program and would pay premiums of $40 per month. Persons with disabilities who formerly qualified for Medicaid under the medically needy category would make up about 20% of enrollees and pay premiums of $100 per month on average. New enrollees on Medicaid would be about 30% of Medicaid Buy-In program enrollees, paying about $100 per month in premiums. By SFY 2002, those numbers would shift slightly, with new enrollees on Medicaid making up 45% of the Medicaid Buy-In population.8
Based on an examination of the adult population with disabilities in Iowa, the state estimated that 700 people would come on to the program by the end of SFY 2002, but expected enrollment to be gradual. In March 2000, officials estimated that 100 people would be enrolled by June 2000, with program costs of approximately $39,000, and data system and administrative costs of $440,000. The state expected to garner offsets totaling $21,000 in premium payments during the first year. By June 2001, enrollment was expected to reach 400 with a total net cost of $327,000 after premium payments totaling $221,000 were used as offsets. For June 2002, anticipated enrollment was 700, premium payments were estimated to be $554,000, and net costs were expected to be $902,000.
The Medicaid agency collects information on the number of clients enrolled in the Medicaid Buy-In program, the number of hours worked in a month, the amount of earned and unearned income, and the number of participants who pay a premium.
Enrollment has greatly exceeded the state's estimates of 100 people by June 2000 and 400 people by June 2001. As of April 2001, 2,105 people were enrolled in the Medicaid Buy-In program. The state credits its outreach program for the increased enrollment. About 30% of participants pay a premium.
Based on August 2000 data collected on 1,427 Medicaid Buy-In program enrollees, the average amount of money earned by enrollees is relatively low. Approximately 5% of enrollees had monthly earned incomes exceeding $750. As shown in the following table, a majority of beneficiaries (57%) have monthly earnings of less than $250.
Data from August 2000, displayed in the following table, shows that unearned income is an important source of income for many enrollees. Over 60% of Iowa's Medicaid Buy-In program participants received unearned income exceeding $600 a month with another quarter having monthly unearned income of between $501 and $600.
DHS is considering provisions affecting eligibility for the Medicaid Buy-In program, such as limiting eligibility to those workers who are paying FICA taxes. Changes to the saving account provision are also under consideration. Currently, a worker with disabilities may save money in a pre-approved assistive technology savings account. In response to requests from the disability community, DHS is considering allowing participants to save without pre-authorization.
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Iowa is in the process of developing options to add personal care to the state plan. A PAS Consumer/Advocate Workgroup assisted with the development of legislation and a 24-member Advisory Committee (with many of the same members) has been convened to develop accurate cost estimates and identify sources of funds. Another significant change under development is the addition of CDAC services at the worksite. All six HCBS waivers offer these services in the home.
There are issues surrounding the potential implementation of a Medically Improved Medicaid Buy-In category, particularly for persons with mental illness. There is also a continued concern that SSDI recipients are maintaining their earnings at levels less than the SGA level of $740 per month due to their fear of losing SSDI benefits. The state has also found it difficult to adequately define work in a way that encourages meaningful workforce participation.
CMS Medicaid Infrastructure Grant Awardees, accessed October 3, 2001 at http://www.hcfa.gov/medicaid/twwiia/infrastr.htm.
Iowa Infrastructure Grant submission.
Laws of Iowa. 441 IAC 75.1(39) “c.”
Medicaid for Employed People with Disabilities brochure, Iowa Department of Human Services Communication 180 (Rev November 2000).
Medical Assistance Fiscal Note RFI 9340, HF 586, Iowa Department of Health Services, March 24, 1999.
Medical Assistance Fiscal Note Worksheet RFI 9340, HF 586, Iowa Department of Health Services, March 24, 1999.
Policy Manual 8-F, Medicaid Coverage Groups, Iowa Department of Human Services, Office of Policy Analysis, p.118-126, accessed on October 3, 2001 at http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Master/8-f.pdf.
Policy Manual 8-G, Medicaid Case Maintenance, Iowa Department of Human Services, Office of Policy Analysis, p. 43, accessed on October 3, 2001 at http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Master/8-f.pdf.
Selected Statistics, Medicaid for Employed Persons with Disabilities Program, March-August 2000, prepared by James D. Overland, Iowa Division of Mental Health and Developmental Disabilities, October 12, 2000.
Maine's Medicaid Buy-In program was established through a Medicaid State Plan amendment and revisions to Medicaid regulations. Maine's legislature provided funding for the Medicaid Buy-In program in 1999 and the program began operating in August 1999. The Medicaid Buy-In program is not associated with a formal comprehensive work incentive initiative. Nonetheless, state agencies are working closely with several key provider organizations to coordinate work incentive efforts funded under TWWIIA, including benefits counseling.
There is a two-step income test to become eligible for the Medicaid Buy-In program. First, countable unearned income must be equal to or less than 100% of the FPL plus $75. Second, total countable earned and unearned income must be less than 250% of the FPL. Assets must be less than $8,000 for an individual and $12,000 for a couple.
The premium amount is based on countable monthly income projected for a six-month eligibility period. If monthly countable income is between 150% and 200% of the FPL, the monthly premium is $10. Persons with monthly countable income over 200% of the FPL have a $20 monthly premium. There is no premium for individuals with monthly countable income under 150% of the FPL or paying a Medicare Part B premium.
Maine's Medicaid State Plan offers consumer-directed attendant services of up to 35 hours per week and a night attendant seven nights a week for individuals meeting eligibility criteria. Private duty nursing and personal care services are also available for up to 24 hours a day, seven days a week. The state also includes personal assistance services in several waiver programs.
When planning its program, Maine anticipated that many people who received Medicaid through the "SSI-related" Poverty Level category would enroll in the Medicaid Buy-In programs, including SSDI recipients who could pass the unearned income eligibility test. The state estimated its first year cost based on 200 participants at an average statewide per capita non-institutional monthly cost of $600 and an average participant monthly premium payment of $30.
As of December 2001, 633 persons were enrolled in the Medicaid Buy-In program. A total of 1,214 people had been enrolled in the Medicaid Buy-In program for at least one month since its inception. Based on data collected in 2000, 8% of the individuals enrolled were paying premiums. The majority of enrollees had been on Medicaid in the month prior to enrollment; only 15 persons had no prior Medicaid history.
Several advocacy groups pushed for a Medicaid Buy-In program in the 1990s. A "Legislative Resolve" passed in 1996 directed the state Medicaid agency to submit a waiver request to HCFA for a Medicaid Buy-In program and created a state oversight group. That group prepared a recommendation to the legislature in 1998, taking advantage of the newly created federal Medicaid Buy-In option under the BBA of 1997. Maine's legislature did not take action; rather the Department of Human Services (DHS) through regulation and an amendment to its Medicaid State Plan created the Medicaid Buy-In program. Maine’s legislature agreed to appropriate $295,236 out of the $417,600 estimated costs of the program. The Medicaid agency issued rules for the program in May 1999, and the program then began in August 1999.
Two surveys in 1997 revealed the needs and concerns of individuals with disabilities in Maine. The first, conducted by Disability Income Systems, Inc., found that the majority of persons with disabilities were unemployed or underemployed and that onset of disability forced many to leave the workforce permanently. Another survey in late 1997 was aimed specifically at providing information to the Legislature and assisting in the design of the Medicaid Buy-In program. This survey found that only 26% of disabled adults surveyed were working. Of those surveyed, 34% indicated they would go to work or work additional hours if they knew they could retain their medical benefits.
Maine's state SSI supplementation program standards, its Medicaid eligibility standards, and its approach to implementing SSI work incentives provide a base for understanding the state's Medicaid Buy-In Program. These eligibility pathways and the maximum monthly incomes associated with them are shown on Chart 1. The state has elected a poverty level eligibility option and a medically needy eligibility option in its Medicaid program.
The state-administered Maine SSI supplement is $10 per month for a total cash benefit, when added to the SSI benefit, of $541. Maine provides for a $55 income disregard (in addition to the federal disregard of $20) to make additional persons eligible as state SSI supplementation recipients. Thus, individuals with incomes of less than $616 ($531 + $55 state disregard + $20 federal disregard + $10 state supplement amount) are eligible for the state SSI supplementation program.
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SSI and state SSI supplementation program recipients in Maine are automatically eligible for Medicaid in Maine. As noted, Maine's higher state disregard provides state SSI supplementation program eligibility -- and thus Medicaid coverage -- for some persons who would not receive eligibility using federal disregards alone.
Persons with higher incomes may qualify for Medicaid through a poverty level group (called SSI-related in Maine) or a medically needy group. The upper income limit for the poverty level group is $791 in monthly income. (This figure is the poverty level of $716 plus $75 in state and federal disregards.) Individuals with higher levels of countable income must spend down to the medically needy protected income level of $315 per month to qualify for Medicaid.
Work incentives in Section 1619 of the federal SSI law provide continued Medicaid eligibility for SSI beneficiaries whose income from earnings could otherwise make them ineligible for coverage. These incentives enable such individuals to maintain a connection to both the SSI income assistance program and the Medicaid program when they work. Under Section 1619(a), an individual whose earnings exceed the SGA earnings test receives SSI cash benefits on a gradually reduced basis and continues to receive Medicaid. In June 2001, 152 persons in Maine, with average monthly earnings of $948, received SSI and Medicaid on the basis of Section 1619(a).
Under Section 1619(b) and Section 1905(q) of Medicaid law, a person who no longer receives SSI payments because of his earnings level is entitled to Medicaid as long as his disability continues and his earnings are below a federally determined equivalence standard ($1,948 monthly in Maine). Whether a state provides automatic Medicaid eligibility for SSI beneficiaries and whether it chooses federal or state administration of its SSI state supplement affect the capacity of eligible persons to access Section 1619(b) protections.
Because Maine provides automatic Medicaid eligibility for SSI recipients, persons who lose their entitlement to SSI payments due to earnings remain on the Medicaid rolls with no additional administrative work required of the state Medicaid agency. SSA sends the state a list of Medicaid-eligible persons, including persons eligible t