2664 Working Healthy (MS WH) - Medical coverage is available to persons with disabilities who have earned income and who meet the requirements of this section. Coverage for this group is provided under authority of the Ticket to Work and the Work Incentives Improvement Act of 1999 (TW-WIIA) and is available beginning July 1, 2002.

 

Persons eligible for Working Healthy do not have a spenddown, however a premium may be required as noted below. The full Medicaid benefit package is available to those eligible and persons are not subject to managed care. A referral to the HIPPS program per 2912 is required for all program participants.

 

Persons must also meet Social Security’s disability criteria. Because of this, all persons potentially eligible for Working Healthy also meet categorical criteria for other Medicaid programs (MS/spenddown, SI, QMB, etc.). It is most often in the client’s best interest to be found eligible under the Working Healthy program as opposed to the regular medically needy (or spenddown) group. When processing a medical application for an employed person, coverage must first be considered under Working Healthy. However, if the MS determination results in no spenddown, the client is placed in MS/spenddown, not Working Healthy. If a premium would be required, the individual must agree to pay the premium prior to enrolling in Working Healthy including premiums for prior months.

 

Coverage under the limited Medicare Savings Programs (QMB and LMB) must be considered as well, and would not be impacted by the decision to enroll in Working Healthy. Persons eligible for coverage as an SSI recipient, including deemed recipients such as those eligible under the 1619(b) provisions, are not eligible for Working Healthy as they shall remain covered under the SI program.

 

Working Healthy recipients are not eligible for HCBS per 8200, however, personal services may be available through the WORK program (see 8400). Persons entering a nursing facility for a period exceeding the temporary stay criteria of 8113 are not eligible for Working Healthy coverage. Ongoing eligibility for a current Working Healthy recipient entering one of these living arrangements must be determined using the provisions applicable. A new application is not required.

 

 

To support persons with disabilities currently working or wishing to work, regional Benefits Specialists are located throughout the state. Because increased income or assets can result in the loss or reduction of other benefits (e.g., Section 8 housing), persons must understand the impact increased earnings will have on these other benefits. Benefits Specialists are available to provide this type of service and planning. They have been trained in the various state and federal programs and are a key piece to successful employment. The Benefits Specialists will also be able to discuss any personal care services (attendant care) available to the individual and make appropriate referrals for such services. To ensure that all Working Healthy eligibles are aware of the service, a referral to the regional Benefits Specialist shall be made for every person working or expressing interest in employment. The ES-3160 shall be used for this purpose. The decision to cooperate with the Benefits Specialist shall not impact eligibility under the Working Healthy group. Benefits Specialists are supervised by the Benefit Specialist Team Leader, located in Central Office.

 

2664.1 General Eligibility Requirements - The general eligibility criteria of act in own behalf (2110), cooperation (2120), SSN (2130), citizenship and alienage (2140), and residency (2150) must be met.

 

The assistance planning rules of 4310 are also applicable. LTC and HCBS recipient spouses and parents are not included in the plan. Spouses or parents who otherwise meet the requirements of the MS program (i.e., elderly or disabled) shall have a separate plan, but are not excluded from the plan nor are Working Healthy participants excluded from the plan of the spouse. Separate case numbers are required if two MS plans exist in the same family group.

 

Persons convicted of medical assistance fraud per 11221 (5) are not eligible.

 

2664.2 Age and Blindness/Disability Requirements - Persons must be age 16 or over but under age 65. Coverage may be provided through the end of the month of the individual’s 65th birthday. Persons must also meet the disability/blindness criteria of 2662. There is no requirement that the person must have actually received Social Security disability or SSI benefits in the past. In addition, a referral directly to DDS may also be applicable per 2662.1.

 

Persons determined no longer disabled due to medical improvement may be eligible for continued coverage as per 2665.

 

2664.3 Earned Income Requirement -Persons must have verified earned income.   For Working Healthy, earned income is income received from wages or self-employment resulting from the performance of services (see 6300) and meet the following criteria:

 

  1. Social Security/OASDI or Medicare Tax Withholding: Evidence of payment or withholding of these taxes must be presented to participate in Working Healthy. These taxes are paid under the Federal Insurance and Contributions Act (FICA). The FICA tax is applicable to the majority of wage and salary payments as employers are required to withhold FICA payments from earned income. Employer letters or statements as well as paycheck stubs may be used to verify FICA withholding. In addition, wages reported on the Kansas Employment Security (KES) ‘BASI’ system also meet this requirement. Generally the absence of FICA withholding indicates the employer does not consider the individual to be an employee and such income would not be considered earned income for purposes of qualifying for Working Healthy. However, instances exist where wages are not subject to FICA withholding by federal law, such as wages received by a student from the college or university in which the student is enrolled (e.g., a graduate teaching assistant) and certain earnings of a non-resident alien. Eligibility may be approved in these instances if earnings are received and there appears to be an employer-employee relationship. Questionable situations may be referred to the Medical Assistance Manager in KHPA for review. Income received in-kind, even if received in return for labor, does not meet the definition.

    For the self-employed, Social Security and Medicare tax is paid through the Self-Employment Contributions Act (SECA) rather than FICA. Persons claiming self-employment income must have made at least one SECA payment in the past year for the business or self-employment enterprise currently in operation to meet the earned income requirement for Working Healthy. Regular SECA payments must continue to be made and verified for continued eligibility. Verification of payments must minimally be presented annually. There is no eligibility under Working Healthy for a self-employed individual until and unless evidence of SECA tax paid is presented.

     

  2. Countable Monthly Earned Income Exceeds the Standard Earned Income Disregard: Countable earned income or self-employment income must exceed the standard earned income disregard of 7240 (2), currently $65.00 per month. For this test, countable income is determined after all applicable income-producing costs, Impairment Related Work Expenses and Blind Work Expenses have been considered. If there is no remaining income after application of these disregards, there is no eligibility for Working Healthy.

     

  3. Minimal Earnings Level of the Hourly Federal Minimum Wage (not applicable to self-employment): Earned income must be at or above the hourly federal minimum wage. Wages below this level are not considered earned income for Working Healthy purposes. For individuals with multiple jobs, the requirement is met if one position is paid at least he federal minimum wage and countable earnings exceed the standard deduction described above.

    To find the current minimum wage click this link, http://www.dol.gov/dol/topic/wages/minimumwage.htm , then scroll down and click on ‘What is the Minimum Wage?’

 

NOTE: Earned income that is specifically exempt would not be considered in determining the $65.00 per month countable earned income threshold. However, exempt earned income would be considered in determining the minimum wage requirement.

 

Example: The individual has $300.00 per month earned income that is exempt under the Older Americans Act. That $300.00 could be used to determine if the individual is earning at least minimum wage, but could not be used to determine if they meet the $65.00 per month threshold.

 

2664.4 Financial Requirements/Methodologies - Financial eligibility exists if countable resources do not exceed the limit in 5130 and countable income does not exceed the limit in 7430 (4). Countable income is established per 7240. Also see 7531. The methodologies, exemptions and disregards applicable to the MS program apply. In addition, see 5430 (17) regarding retirement funds and 6410 regarding deposits into IDA’s. These exemptions are applicable only to the Working Healthy program.

 

Coverage is established under the MS program with a program subtype of WH. One month base periods apply [see 7330 (1)].

 

Twelve (12) month review periods are applicable. A special income review every 6 months to establish the premium amount must also be completed.

 

Eligibility is denoted with a Special Medical Indicator, which is entered on the KAECSES PICK screen. The code is to be used for premium payers and non-premium payers. The Working Healthy Special Medical Indicators are:

 

WH - Working Healthy - To be used for persons eligible for Working Healthy

 

WQ - Working Healthy + QMB - To be used for persons eligible for both Working Healthy and QMB. It is necessary to use this code for QMB purposes in situations where the COLA disregard in the initial months of the calendar year prior to the implementation of the new poverty level rates per 2671.3 applies.

 

WL - Working Healthy + LMB - To be used for persons eligible for Working Healthy and regular LMB.

 

  1. Requirements for Current Medical Recipients - When a current Medicaid recipient becomes eligible for Working Healthy, coverage must be adjusted as follows:
     
    1. For persons moving from HCBS, Working Healthy begins the month following the month HCBS services end (see 8272.2). Any HCBS obligation due in the final month would still be applicable.
       
    2. For persons moving from LTC to Working Healthy, coverage is adjusted the month the change occurs.
       
    3. If an existing 6 month base period exists when Working Healthy eligibility begins.The existing base period is shortened to end the month prior to the month WH eligibility begins. One month bases apply thereafter. If a premium is applicable, the person must actually choose Working Healthy prior to taking action. WH eligibility may be backdated up to three months prior to the month of request, provided all WH criteria are met.
       
  2. Prior Medical Coverage - Prior medical eligibility per 7330 (2) is available for those meeting the criteria.
     
  3. Ongoing Eligibility - Eligibility continues until the end of the review period as long as all applicable general, financial and non-financial eligibility criteria continue to be met, including cooperation with the six month desk review. The change reporting requirements of the MS program apply and eligibility must be adjusted accordingly, given timely and adequate notice as required except for changes resulting in decreased premium amounts (see 2664.5 (1) and persons temporarily unemployed (see 2664.7).
     

 

2664.5 Premium Requirement - A monthly premium will be charged for coverage under the Working Healthy group for plans with income in excess of 100% of the federal poverty level for the appropriate size household. The premium amount is based on a sliding scale keyed from the poverty level percentage of the assistance plan. The rate is based on net countable income (gross income less disregards). See Appendix item #F-8 for current premium levels and rates. Premium levels and/or amounts are adjusted annually based on changes in the federal poverty level guidelines.

 

NOTE: The 1 person plan shall be used to determine the premium level for a single individual. The 2-3 person plan shall be used to determine the premium level for a married couple (including when only one of them is a recipient). The 2-3 person plan shall also be used for a child under the age of 18 who is living with one or both parents.

American Indian/Alaska Native (AI/AN) recipients are exempt from the premium requirement. These individuals may participate in the Working Healthy program without a premium. The classification of an individual as AI/AN is based on client statement and requires no further verification.

 

Premium amounts are not reduced or offset by other medical expenses. Persons or organizations outside of the family group may pay the premium. Premiums are due monthly, but eligibility is not impacted until the individual is a full 2 months behind in paying the premium amount [see (2) below].

 

Premiums for prior medical periods are determined based on actual, countable income for the month. Varying premiums may result if income or household size fluctuates between base periods in the prior period. Prior to approving coverage for any prior month with a premium obligation, the individual must agree to pay the premium for the month. A referral to the Benefits Specialist is required prior to case authorization to ensure the consumer understands and agrees to pay the premium obligation. A written statement obtained from the consumer noting the choice to pay premiums is also acceptable, and may be required in some instances. The ES-3165 may be used for this purpose.

 

The EES Specialist is responsible for determining the premium obligation. Any required premium will be entered on KAECSES and will be communicated to the premium payment vendor, Electronic Data Systems (EDS), through an automated report. EDS is responsible for premium billing, collection, and monitoring. EES is required to communicate with EDS regarding status requests on specific cases.

 

Monthly premium notices will be sent by EDS to all plans subject to a premium. The initial premium statement will be mailed on either the 1st or 15th of the month, depending on when coverage is authorized. Subsequent monthly premium statements will then be mailed on the 1st day of the month. For new premium cases, the premium amount for the current period and any prior period will be reflected on the premium statement. The initial billing statement will reflect the current month and any prior months. The premium bill will also reflect past premium amount(s) due. All premium payments are due on the last day of the month. Premium payments are to be sent to the following address:EDS Kansas Premiums, P.O. Box 842195, Dallas, TX 75284-2195. Information regarding premium status (current overdue) is available to EES staff by accessing the premium billing system.

 

  1. Premium Changes - As indicated in 2664.4 (3), all applicable changes must be reported. However, changes increasing the amount of countable income (e.g., amount of income, IRWE or family size) and therefore, increasing or establishing a premium obligation, shall not be acted upon until the next scheduled 6 month desk review or full review. Changes decreasing the amount of countable income which decrease or eliminate the premium obligation are acted upon effective the month following the month the change is reported. In all other situations, the amount of the premium is not adjusted until the next scheduled review or 6 month desk review, if the premium was correctly determined. Incorrect premiums must be corrected per 2664.5 (5).
     
  2. Impact on Eligibility - Although premiums are due monthly, non-payment of premiums shall not impact eligibility until the individual is a full 2 months behind in making payment. Once the individual is a full 2 months behind in payments, coverage under the Working Healthy program is terminated effective the last day of the next month, allowing for timely notice.

    Persons may be reinstated without additional action if payment is made which lowers the overdue amount to less than 2 full premiums by the last day of the month of closure. The client must report payment of the premium to EES in these situations. Persons in the plan remain ineligible for Working Healthy coverage until the delinquency is cured. However, eligibility under other categories shall be provided without regard to the delinquent Working Healthy debt if all other eligibility factors are met.

    When a former Working Healthy recipient requests Working Healthy coverage be reopened, a check of the premium billing system is necessary to determine if there are overdue premiums before coverage is approved. All overdue premium amounts must be paid in full before an otherwise eligible individual may be reapproved for coverage.
     
  1. Six Month Desk Review - In order to redetermine any applicable premium obligation, a desk review shall be conducted between regularly scheduled reviews.

    Because the purpose of the review is to rebudget income, earned income must be verified at the 6 month review. Other questionable eligibility factors may also be verified at this point (e.g. resources within $300 of the limit) but it is not necessary to routinely verify other eligibility factors with this review. The six month review is applicable to all Working Healthy households, including those eligible without a premium. Coverage terminates on the last day of the six month period for persons who fail to respond to the request for the six month desk review or who fail to cooperate with the process. As with a regular eligibility review, coverage may continue if the individual is behind no more than  full two months of premium payments.

    The six month review shall generally occur 6 months following initial Working Healthy approval and 6 months following each subsequent review. The 6 month period begins with the first month of Working Healthy eligibility and ends on the last day of the sixth month. The prior medical period is not considered when establishing the 6 month period. However, if the regular review period ends prior to the sixth month, the 6 month desk review is waived. For example, the review period of an ongoing HCBS case expires 12-31-02. The person converts to Working Healthy 09-01-02. A 6 month review would not be needed because the regular review will occur before the sixth month (05-03). Coverage may continue if the individual is behind no more than two full months of premium payments.

  2. Premium Refunds and Prior Adjustments -
     
    1. Overstated Premiums - When the agency determines a premium has been overstated for a prior period, immediate action to correct future premiums shall be taken. In addition, a premium is adjusted for a prior period in the following situations:
       
      1. An agency error resulted in the incorrect premium; or
         
      2. A timely reported change could not be acted upon timely and resulted in the incorrect premium.

        Failure on the part of the client to report a change timely shall not result in an adjusted premium for a prior period.
         
    2. Understated Premiums - When the agency determines a premium has been understated for a current or prior period, immediate action to correct future premiums shall be taken given timely and adequate notice requirements. An overpayment may be established for prior periods. Overstated premiums can be adjusted retroactively if the client was given notice of the correct premium amount and the correction regards a billing issue only.
       

 

Current or future premiums shall never be adjusted to account for under or over stated past premiums. All requests for adjustments shall be sent to the Benefits Specialist Team Leader, who will determine if refunds or billing modifications are appropriate to account for the adjustment. All other refund requests shall also be sent to the Benefits Specialist Team Leader.

 

2664.6 Ongoing Eligibility - When Working Healthy coverage ends, medical eligibility must be considered under other Medicaid coverage groups. Persons with accumulated resources may not be eligible for continuing coverage. The following action shall apply:

 

  1. Working Healthy to Independent Living - For spenddown cases, the 6 month period begins the month following the month Working Healthy ends.
     
  2. Working Healthy to HCBS - HCBS budgeting begins the month HCBS begins. Any applicable HCBS obligation is also determined. Working Healthy premiums paid or owed in the month HCBS begins are allowed against the obligation. If the entire premium obligation cannot be accounted for in the initial month, the bill may be allowed over multiple months until the entire obligation is accounted for.
     
  3. Working Healthy to LTC - LTC budgeting begins the month following the month of entrance, unless Spousal Impoverishment provisions apply. Any premium amount must be paid in full the month the arrangements begins.
     

2664.7 Extension of Coverage for Temporary Unemployment - Working Healthy recipients who become temporarily unemployed and intend to return to work may remain eligible for a period up to 9 months following the month in which employment ended. Unemployment may be for any reason, but the recipient must provide a clear reason for the unemployment. Continued eligibility during the temporary unemployment period is only provided if the individual is otherwise eligible for Working Healthy. A temporary unemployment period may be granted for an individual who is employed, but fails to meet the earned income requirements of 2664.3 (FICA/SECA, minimum wage and earnings tests). This extension is not available to persons whose only employment occurred in a prior medical period per 7330 (2)

.

 

  1. Temporary Unemployment Plan
    The individual must have an active Temporary Unemployment Plan (TUP) in place in order to receive continued coverage under this provision. Persons who report becoming unemployed shall be referred to the Benefits Specialist for establishment of the TUP and the individual must cooperate with the Benefits Specialist in this process. The purpose of the TUP is to establish a plan to return to work. The Benefits Specialist has much leeway in the establishment of the plan, as the plan shall consider factors such as disability and job skills. Failure to cooperate with establishment of the plan will result in termination of Working Healthy coverage.

  2. Temporary Unemployment Period
    The 9 month period shall begin the month following the month unemployment began. If the individual is cooperating with the Benefits Specialist and all other eligibility factors are met, coverage may be provided through the last day of the 9 month period. Any required review, either an annual review or a six month desk review, must be completed at scheduled intervals during the period. Regular reporting requirements also continue to apply.

    Persons who have not returned to work at the end of the 9 month period are no longer eligible under Working Healthy, but coverage may be considered under other programs (e.g., LMB, QMB, Medically Needy, etc)


  3. Impact on Premium Obligation -Any changes to the premium obligation as a result of a change in income are made the month following the month of report. Any new or additional income the individual has began receiving as a result of unemployment (e.g., disability payments from the employer, Social Security payments, etc.) must be considered in the recalculated premium. However, action to change the premium shall not be delayed in anticipation of a change in income source. The premium will be considered and rebudgeted at the next review, annual or 6 month desk review. The individual must remain current on any premiums during this period.