by James Sheldon and Ed
Lopez
Finally, New York is
implementing the Medicaid Buy-In program adopted by the state legislature and
signed by the Governor on January 16, 2002. The legislation, §§62-69 of Part A
of Chapter 1 of the NYS Health Workforce Recruitment and Retention Act of 2002,
extended Medicaid coverage to working disabled applicants/recipients who have
net incomes at or below 250% of the federal poverty level (FPL) and non-exempt
resources at or below $10,000.
Originally, the
legislation was to be implemented by April 1, 2003. Unfortunately, the April
Fool's joke was on potential recipients as that date came and went without
implementation. Fortunately, the community of working individuals with
disabilities put pressure on the governor to make implementation a priority.
The governor then announced that the legislation would become effective on July
1, 2003, even if no regulations had been promulgated.
On June 9, 2003, the
Department of Health issued Administrative Directive (ADM) 03-04,
providing local Departments of Social
Services interim implementation instructions for the Medicaid Buy-In program.
The Medicaid Buy-In
program is designed to help those disabled persons who are not eligible for
traditional Medicaid because their earnings or resources surpass the limits
under SSI's §1619(b) program. Recall that § 1619(a) of the Social Security Act
allows an individual to continue to receive SSI even when earned income exceeds
the substantial gainful activity (SGA) level. In New York, the 2003 income
limit for §1619(b) is $34,136 in wages per year. The income limit can be higher
if medical expenses are high enough. Other rules governing unearned income and
resources also apply.
The reality facing many of
these disabled persons is that too often they are unable to obtain health
insurance in the private sector that provides coverage for the services and supports
that enable them to live independently and enter, remain in, or rejoin the work
force. Thus, there is a need to supplement private insurance or rely on
Medicaid for necessary services and supports. 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.
Congress included a
Medicaid Buy-In option in §4733 of the Balanced Budget Act of 1997 and when it
enacted the Ticket to Work and Work Incentives Improvement Act (TWWIIA). By
authorizing states to offer Medicaid Buy-In programs, these landmark pieces of
legislation 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, thereby reducing or eliminating their dependency
on cash assistance programs.
New York's Medicaid Buy-In
Program
New York is the 27th state
to implement the Medicaid Buy-In program. New York's program is quite unique as
it will establish two eligibility groups: the Basic Coverage Group and the
Medical Improvement Group.
To be eligible for
the Basic Coverage Group, an individual must have a disability that meets the
medical criteria established by the Social Security Administration (SSA) but
have too much income to qualify for SSI. In addition to the usual Medicaid
rules, the specific requirements are:
_ Disability
- Certified disabled by SSA (SGA step eliminated)
_ Age
- Be at least 16 but not yet 65 years of age
_ Work
- Be engaged in paid work (includes part-time and full-time work)
_ Income
- Have a gross income that may be as high as $46,170 for an individual and
$61,870 for a couple (as of January 1, 2003)
_ Resources
- Have non-exempt resources that do not exceed $10,000.
To
be eligible for the Medical Improvement Group, an individual must meet all the
criteria met by individuals in the Basic Coverage Group. Additionally, the
individual must receive coverage through the basic group and be no longer
determined disabled by SSA but continuing to have a severe medically determined
impairment. Keep in mind that loss of eligibility under the Basic Coverage
Group must be the direct and specific result of loss of disability status
because of medical improvement. Finally, an individual in the Medical
Improvement Group must be employed at least 40 hours per month and earn at
least the federally required minimum wage.
For both groups,
individuals with net income below 150% of the FPL will not need to pay a
premium. Individuals with a net income above 150% of the FPL but below 250% of
the FPL will have a premium calculated as 3% of net earned income plus 7.5% of
net unearned income.
Luckily, for an individual
who qualifies for the Medicaid Buy-In program now, a moratorium on premium
payments has been instituted until such time as systems support for an
automated premium collection and tracking is available. The Department of
Health estimates that the implementation date for collection of the premiums
will be[ in delete DN] [[‘the’ delete AP]]Spring 2004. Individuals who are then
found eligible for the Medicaid Buy-In program but with a premium will be
assessed a premium prospectively.
Individuals must apply for
the Medicaid Buy-In program at their local Department of Social Services (DSS)
by completing the general public assistance application form. In addition, the
local DSS must conduct a face-to-face interview to ensure that the applicant
meets the basic program requirements: age, disability, work, income, and
resources. [NOTE: A separate ADM will be issued to provide case
processing instructions for New York City.]
In those cases in which
the individual has not been previously certified disabled, the local DSS must
assist the applicant in establishing proof of disability by having the
individual sign the appropriate consent forms for release of medical
information and by sending requests for medical information to all relevant
medical providers. In all cases, the local DSS must provide the applicant with
information about the Plan for Achieving Self Support (PASS) and Impairment
Related Work Expenses (IRWE), two SSI work incentives that also allow for
deductions from income in the Medicaid spend down and Buy-In programs
Applicants with an income
that is below 150% of the FPL are eligible to participate in a managed care
plan through the Medicaid Buy-In program. All other applicants are excluded
from the managed care option. Finally, individuals cannot be required to enroll
in managed care even in counties with mandatory participation in managed care.
Local DSS agencies must
send application packages -- consisting of copies of the application, all
required documentation for eligibility and consent for release of medical
information forms and requests for medical records -- to the Medicaid Buy-In
Coordinator at the Albany Central Office for processing, within 10 days of the
application, even if it does not contain all the required documentation.
If the application for the Medicaid Buy-In program is granted, the
recipient will be entitled to up to three months of retroactive eligibility.
Recipients found eligible for the program prior to October 1, 2003 will be
eligible for retroactive eligibility to July 1, 2003 only.
A
major question asked by individuals awaiting news implementing the Medicaid
Buy-In program is what happens to a participant if he or she stops
working [[delete/redundant: from the
Medicaid Buy-In program will be processed while participating in the happens to
a participant if he or she stops working
AP]]while participating in the program. According to the ADM, recipients
may be granted a grace period, meaning that a recipient is not working but
remains eligible for the program, of up to six months in a 12-month period.
Multiple grace periods may be granted as long as the sum of the grace periods
does not exceed six months in a 12-month period. Two types of grace periods may
be granted:
Change[d delete ‘d’ AP]]in
Medical Condition: A grace period of up to six months will be allowed if, for
medical reasons, the Medicaid Buy-In recipient is unable to continue working.
Medical verification will be required.
Job Loss (through no fault
of participant): A grace period of up to six months will be allowed if, through
no fault of the recipient, job loss occurs (layoff, etc.). The local DSS must verify
that the recipient is reasonably expected to return to work as it is a
temporary layoff, or that the recipient is actively seeking new employment. The
local DSS agencies will be responsible for grace period determinations.
For mixed households, only
the applicant for the Medicaid Buy-In program will be eligible for
participation in the program. For mixed households, only the application of the
individual seeking assistance from the Medicaid Buy-In program will be
processed by the Albany Central Office. Normal Medicaid eligibility for the
rest of the household will be determined by the local DSS. For an existing
mixed household, the local DSS will coordinate with the Albany Central Office
to set up a separate case.
According to the ADM, an
additional administrative directive will be issued at a later date from the
Albany Central Office to explain the automated premium payment system as well
as the transition of the Medicaid Buy-In program to the local DSS. In addition,
New York City will have separate case processing instructions for the Medicaid
Buy-In program.
If you have questions
about the Medicaid Buy-In, call the State Work Incentives Support Center's toll
free hotline at 1-888-224-3272.