8400 Work Opportunities Reward Kansans (WORK)

This section sets forth guidelines for persons who receive services under the WORK program. WORK provides personal care and other related services to employed persons with disabilities, including assistive services and independent living counseling. WORK services are only provided in a community based setting and are not appropriate for institutional residents.

Although the services a beneficiary receives under WORK are similar to the services provided under an HCBS waiver, WORK is not an HCBS waiver. Therefore, program guidelines are not the same. Persons can either be served under an HCBS waiver or WORK - a beneficiary cannot have both services in the same time period.

WORK is considered a 'cash and counseling' model of delivering long term care services. Under the cash and counseling model, personal care services provided to WORK participants will be made in the form of an allocation paid to the applicant/recipient or designee.

Information regarding functional eligibility criteria and available services can be found in the KDHE-DHCF WORK Program Manual.

8400.1 Working Healthy Recipient Status - To enroll in WORK, persons must be eligible for and receiving Medicaid coverage through Working Healthy (see 2664). An individual enrolled in another eligibility group is not eligible for WORK. All Working Healthy criteria must be met, including age and employment status.

Except for individuals eligible as mandatory categorically needy (2611 (1) (a)), persons receiving Medicaid under another program who meet Working Healthy eligibility criteria, but are not enrolled in Working Healthy, may elect to change coverage in order to participate in WORK. Persons eligible under a mandatory categorically needy program (including SI, MP and the protected groups) cannot choose to enroll in Working Healthy.

Although the Medicare Savings Plans are considered mandatory categorically needy plans, because eligibility is restricted to Medicare cost sharing, enrollment in these groups does not prohibit enrollment in Working Healthy.

Example 1: Bill has 1619(B) status with Social Security and is considered an SSI recipient per KEESM 2634. Therefore, Bill is categorically needy and cannot elect to receive Working Healthy coverage. Bill cannot enroll in WORK as he cannot enroll in Working Healthy.

Example 2: Will has an open medically needy case and requests WORK. Will may elect to switch from medically needy to Working Healthy in order to get WORK services. If he decided to change, Will may have to pay a Working Healthy premium.

Persons eligible for Working Healthy under a Temporary Unemployment period as per 2664.7 may also receive WORK services.

8400.2 Integrated Employment - In addition to meeting the Working Healthy eligibility criteria, all WORK participants must be employed in a competitive, integrated work setting. A determination regarding the type of employment must be made prior to enrolling in WORK. The eligibility worker will work with Benefits Specialist to make this determination.

Competitive employment is defined as work performed in the competitive labor market on a full or part time basis for which individuals are compensated at or above minimum wage, but not less than the customary wage and level of benefits paid a non-disabled individual for the same or similar work. 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?’

Integrated employment is defined as a setting typically found in the community in which individuals with the most severe disabilities interact with non-disabled individuals according to the duties and responsibilities of the position. If the individual's only interaction with a non-disabled person is with a caretaker, the requirement is not meet.

The individual's employment arrangement must meet both of these criteria. Self employment enterprises will be evaluated on a case-by-case basis.

8400.3 Level of Care - An individual must be determined to need WORK services in order to live and work in the community. All individuals seeking WORK services are referred to the WORK Program Manager in KDHE-DHCF Central Office. The program manager will then refer the individual to the contracted entity to perform the assessment.

Following the assessment, if the individual chooses WORK and meets the necessary level of care, the information is then sent to the Program Manager for final approval. If approved by the Program Manager, an ES-3160 form is sent to the eligibility worker and assigned Benefit Specialist with information regarding the enrollment in WORK and the effective date. The individual is also referred to the community organization responsible for providing Independent Living Counseling services.

8400.4 Premium Requirement - Because all WORK participants must enroll in Working Healthy, all the program requirements must be met, including the premium requirements of 2664.5. Because the WORK participant must participate in any premium payment, there is no Client Obligation or patient liability to receive WORK services.

8400.5 Enrollment Guidelines - WORK enrollment is prospective, meaning the IL Counselor and Program Manager will plan for a transition to WORK services to begin in the future. WORK begins the first day of the month and ends the last day of the month. WORK participation   terminates upon entry into a nursing facility or other institution.

Action to approve WORK coverage must be taken by medical card deadline in order to be effective the first day of the next month. If action is taken after the medical card deadline, WORK coverage is not effective until the first day of the second month after the month of action. This applies to both new applications and reinstatement after case closure.

WORK participants are approved for payment on the KAECSES LOTC screen:

Living Arrangement - WK (Work)
Level of Care - NA
Patient Liability - $00.00

The WK/NA LOTC combination will also exempt the individual from Medicaid copayments and managed care requirements.

8400.6 Allocation Payments (see KEESM 6410) - Personal services will not be paid in the traditional fee-for-service model in the WORK program. Instead, a monthly allocation payment will be paid to each WORK participant for necessary personal care services. The allocation is directly based on the number of hours of assistance the individual requires each day. The WORK participant is responsible for securing attendants and other services to meet his or her needs. The WORK participant is also responsible for ensuring service providers are reimbursed for services. All allocation payments will be made at the beginning of the month for which services are rendered in the month of payment.

1. Allocation Expenditures - Payments made from the WORK allocation must be used to purchase services or goods to support the recipient's ability to live as independently as possible and will develop an individualized budget to reflect the use of WORK allocation funds in ways that are related to the service and give the recipient some latitude in expending the WORK allocation payment. The allocation may be used for direct attendant pay, including applicable payroll deductions. Alternative payments may also be made, if approved by the Program Manager. The recipient may purchase equipment or devices which could reduce the dependence on individual attendants (for example, a washing machine or microwave oven). The individual is allowed to save for these major purchases over time. Certain payments have been determined inappropriate for payment with an allocation. These include: gifts to family, friends or workers; loans; rent or mortgage payments: utilities; entertainment; televisions, DVD players and similar equipment.
   
   
2. Individual Budget - With the assistance of the Independent Living Counselor, the WORK participant will be required to develop an individual budget detailing the plan for expending the allocation. A monthly allocation report detailing the actual expenditures must be submitted to the Program Manager. A WORK participant who fails to comply with terms of the individualized budget or fails to complete the monthly allocation report is subject to termination of WORK services, as determined by the Program Manager.
   
   
3. WORK Account - Each program participant is ultimately responsible for the management of their allocation payments.     All WORK program participants are required to use the Fiscal Management contractor to manage their WORK account. The Fiscal Manager is responsible for receiving the WORK allocation, maintaining the account, and payment of all expenses.
   

8400.7 WORK Disenrollment - Persons shall be terminated from WORK when program requirements are no longer met. Persons who become ineligible for Working Healthy coverage for any reason are immediately terminated. Persons who return to Working Healthy may be allowed back on WORK as determined by the Program Manager.

Persons who fail to comply with the rules regarding payment, distribution and savings of the allocation payment are subject to immediate termination from the program, as determined by the Program Manager. Any suspected abuses or misuse of the allocation are to be immediately reported to the Benefits Specialist for investigation. Funds remaining in the WORK account must be returned to KDHE-DHCF upon termination in the WORK program. Inappropriate expenditures are subject to recovery action.

8400.8 Communication - The ES-3160 and ES-3161 shall be used to communicate between the WORK Program Manager, EES eligibility staff, and the Benefit Specialist assigned to the case. The WORK Program Manager is responsible for notifying the EES eligibility staff and the Benefit Specialist of assignment to the WORK program with the effective date. EES eligibility staff and the Benefit Specialist are responsible for reporting case changes (including case closure) to each other via the ES-3161. In event of case closure, EES eligibility staff shall also notify the WORK Program Manager (in addition to the Benefit Specialist) of the closure via the ES-3161.