MAWDAnd other Disability-Related Medicaid

Categories

Kyle FisherKFisher@phlp.org

November 2015

Topics

Disability-Related Medicaid Categories Healthy Horizons Breast and Cervical Cancer Prevention and

Treatment

Medical Assistance for Workers with Disabilities Categorical Eligibility Financial Eligibility

How to Apply

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Who’s still uninsured?4

*Kaiser Family Foundation, New Estimates of Eligibility for ACA Coverage among the Uninsured (Oct. 2015)

Eligibility Basics

ResidencyCategoryIncome LimitsImmigration Status

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Medicaid Basics

3-step analysis for each person

1) What category does the person fit in?

2) What is the person’s household size?

3) Is the person under the income limit for that category and household size?

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Categorical Eligibility

MAGI

Adults (Expansion)ChildrenPregnant Women

*no resource test

Non-MAGI

Persons with DisabilitiesOlder AdultsWorkers with

DisabilitiesDiagnosis of Breast or

Cervical Cancer

Category7

FOR OLDER ADULTS & ADULTS WITH DISABILITY

(“HEALTHY HORIZONS”)

Medicaid Eligibility8

Healthy Horizons

Healthy Horizons–Two ways to qualify:

1. Age 65+ <or>2. Disability

Social Security Disability Insurance (SSDI), or Box 1 or 2 on Employability Assessment Form

First option for low-income Medicare beneficiariesRequired to apply for Social Security (if under age

65)

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Income Limits

Healthy Horizons (100% FPL)

Plus disregards!Resource Limit: $2000 (HH of 1)

$3000 (HH of 2+) See MAEH Ch. 319

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Household Size

Monthly Annual

HH of 1 $981 $11,770

HH of 2 $1,328 $15,930

HH of 3 $1,675 $20,090

HH of 4 $2,021 $24,250

Healthy Horizons11

To prove disability, must be on SSDI or use the Employability Assessment Form:

Proving Disability

Employability Assessment Form (PA 1663), used for: Healthy Horizons MAWD GA-related MA (for immigrants)

Must include start and end datesGood faith estimate required, not

clairvoyanceStart date can be in the pastMA will be stopped at end date, absent a new

form

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Example

Kanye (age 32) and Kim (age 34) live off Kim’s Social Security Disability of $1300 per month. They have $2200 in savings. Kim has Medicare. Does either qualify for Medicaid?

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Medicaid Why?

Kanye Adult category: Under age 65 and under 138% FPL (HH of 2)

Kim Healthy Horizons: on SSDI &

under 100% FPL & $3000 resource limit.

COMPASS tip

Comment: “I am only applying for Medicaid expansion coverage. I am not required to submit proof of assets or disability. Please process my application without it.”

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SSISupplemental Security

Income

No work history required

$755 /monthConfers Medicaid

automatically

SSDISocial Security

Disability Insurance

Requires work historyBenefit typically =

$1100-1500/month

Confers Medicare after 2 years!

SSI vs SSDI15

Social Security

Breast & Cervical Cancer Prevention and Treatment

BCCPT

Requires:Diagnosis of breast or cervical cancer

Or precancerous condition UninsuredUnder age 65Separate application (PA 600B) See

MAEH Ch. 317

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Household Size Income Limit Resource Limit

HH of 1 None! None!

FOR WORKERS WITH DISABILITIES

Medicaid Eligibility17

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MAWD

Medical Assistance for Workers with Disabilities

Underused category High income & resource limits Minimal work requirement Many who do not consider themselves “disabled”

meet the MAWD disability standard

Age 16-64Requires 5% premium

Based on recipient’s income only, after disregards

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MAWD

“Workers”work is defined

loosely:

no specific hours or wage required 1 hour per week

enoughcan be informalrequires some

amount of paid work monthly

“With Disabilities”murkier theory: SSDI or Medical

Review Team (MRT) finding: “perm. & totally disabled” w/o regard to actual work

Disability ≠ unable to work

Practice tip: if serious long-term condition, apply!

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MAWD–Types of Client

SSDI recipient

Needs to workUse a simple letter

Include name, work done, amount paid, date, and contact info

see template Minimal work will not

affect SSDI

Worker w/ Ailments

Needs to show ‘disability’

Use either EAF, HSM, or basic doctor’s letter stating: Diagnosis Duration

Ask for “presumptive” eligibility

See MAEH 316.2

Income Limits

MAWD (250% FPL)

Plus income disregards!Resource Limit: $10,000 (any HH size)

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Household Size

Monthly Annual

HH of 1 $2,453 $29,425

HH of 2 $3,319 $39,825

Example 1

Paula (age 42) works cleaning offices and earns $2000/mnth. She takes medication for depression. Both she and her 8 year old daughter, Miley, are uninsured. Paula has $3000 in retirement savings from her last job. What are their coverage options?

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Medicaid PTC CHIP Why?

Paula

Depression = presumptive elig. for

MAWD; under 250% FPL;

~$50 MAWD premium

Miley Age 8, over 138% FPL

Example 2

Josie (age 52) has bipolar disorder, anxiety, and insomnia. She has SSDI of 1400/month and Medicare, but cannot afford the cost-sharing from her BC/BS supplemental plan. She no longer has any savings. What are her coverage options?

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Medicaid PTC Why?

Josie MAWD if any work; under 250% FPL; $70 MAWD premium

Example 3

Josie (age 52) has bipolar disorder, anxiety, and insomnia. She has SSDI of 1400/month and is in the 2 year waiting period for Medicare. She no longer has any savings. What are her coverage options?

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Medicaid PTC Why?

Josie

PTC <or>MAWD if any work; under 250% FPL; $70 MAWD premium

MAWD vs. Premium Tax Credits

MAWD

5% premium After disregards

Cost-sharing No deduct, very small

copays ($1/$3 Rx; no PCP copay)

More benefits Dental, vision, transport.

APTC

Premiums 3% - 9.5% Sliding scale: 8%

@250%FPL of household income

Cost-sharing Actuarial value: 73%-94% Compare actual $ amounts

More doctors available?

MAWD26

Single 45–Year-Old in Allegheny County Earning $28,000/year

  MAWD Marketplace – Silver Plan

Monthly Premium$57 - $116

(depending on income type)

$178

Annual Deductible None $1,750

PCP Co-Pay $3.80 max $20

Specialist Co-Pay $3.80 max $80

Generic Drug Co-Pay $1 $8

Brand Name Drug Co-Pay $3 $45

Benefit Limits Limited Dental benefitsLimits on PT, OT, Speech.

NO Dental coverage

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INCOME-COUNTING & HOUSEHOLD SIZE RULES

Disability-related Categories

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What Income Counts

For Healthy Horizons & MAWD All types of income count Key question – is the income earned or unearned? Disregards apply spousal income too

1. Earned Income1. Disregard: $65 +half of remaining income 2. Huge! Compare to 5% MAGI disregard

2. Unearned Income Disregard: $20

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Example 4

Frank (age 54) receives SSDI of $1220/month and works 1 hr/week for his cousin. His wife Claire (age 51) works and earns $4065/month. (Annual total=$63,400.) No savings.Is either eligible for Medicaid?

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Medicaid Why?

Frank

MAWD; under 250% FPL with disregards:

Unearned: 1220-20=1200Earned: 4065-65*1/2=2000

Countable income=3200

Claire Not categorically eligible

Whose Income Counts

Household Size:

For MAWD:Count only a spouse – maximum HH size of 2

For Healthy Horizons:Household size is based on family size

Count spouse & children, and their income, if living together

Child under 21 = optional household member

Unlike MAGI, not based on tax filing unit

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What Resources Count

General rule – all resources count Including retirement assets and spouse’s resources

Exceptions (plus others, see MAEH 340.8):

House used as residence Household goods, clothing, et cet. One motor vehicle

Exception to the resource test altogether: If child under age 21 in household, no resource test

for the parent for Healthy Horizons

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How to Apply

Online: COMPASS or Healthcare.gov(“Please review for MAWD”)

By phone: 866-550-4355

By mail: paper application (PA 600WD)

In person:@ County Assistance Office

*Recommend COMPASS for consumers eligible for Medicaid, especially in disability-related categories.

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How to Apply

How quickly will an application be processed? 30 days – normal processing timeframe 5 days – for applicants who have a medical emergency

Does the consumer have recent medical bills? Medicaid can be retroactive (up to 3 calendar months)

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Resources

Medical Assistance Eligibility Handbook http://services.dpw.state.pa.us/oimpolicymanuals/ma/index.htm

“Estimates of Eligibility for ACA Coverage among the Uninsured,” Kaiser Family Foundation (Oct 2015). http://kff.org/report-section/new-estimates-of-eligibility-for-aca-coverage-

among-the-uninsured-data-note/

PHLP MAWD Guide http://www.phlp.org/wp-content/uploads/2011/10/MAWD-Guide-9.2011.pdf

PHLP Medical Assistance Eligibility Manual http://www.phlp.org/wp-content/uploads/2015/02/Eligibility-Manual-2015.pdf

PHLP Helpline: 1-800-274-3258 Kfisher@phlp.org

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