Eligibility Online Manual

M1003 Employed Individuals With Disabilities (EID)

Purpose: This section will assist in determining eligibility for Employed Individuals with Disabilities (EID).


Current Policy Effective Date: May 1, 2014

Date Last Reviewed: March 27, 2014

Previous Policy: October 1, 2013

POL M1003: DETERMINING ELIGIBILITY FOR EMPLOYED INDIVIDUALS WITH DISABILITIES (EID)

1. Applicants Must Meet Basic Eligibility

Refer to Section M600 for a description of all basic eligibility factors.

2. Applicants Must Be Age 16 Through 64

3. Applicants Must Be Disabled

Individuals are considered disabled if they are receiving disability benefits from SSA or are determined disabled by WDH.

4. Applicants Must Be Employed

Applicants must have documented proof of employment. This verification should include a current statement indicating hours worked, amount earned, and contain an employer signature or a signed employer statement specifying applicant is on medical leave. Refer to Medicaid Table 5B.

Employment must be verified every year, or more often when changes occur.

5. Applicants Must Meet Income Requirements

Require the countable income to be within the maximum income standard. Refer to Medicaid Table 1A for the income standards. Refer to Section M901 to determine if income is countable.

Earned income is exempt when determining eligibility for this program. Earned income is used when calculating the premium.

6. Benefits Begin First Day Of The Application Month If Determined Eligible

7. Clients May Receive Retroactive Medicaid

Applicants may receive retroactive Medicaid benefits if they incurred medical bills during any of the three months prior to application.

Both approved and denied applicants must be reviewed. Reviewer must verify and determine eligibility separately for each retroactive month to determine whether the case would have been eligible if an application had been made.

Premiums for retroactive months must be paid prior to approving retroactive benefits.

8. Applicants Do Not Have Resource Test

9. Waiver Clients May Be Eligible For EID

Clients of Comprehensive and Support or ABI Waiver programs, losing eligibility due to increased earned income or excess resources, may be eligible under EID. These clients will retain their waiver benefits.

10. Clients Pay Premium Based On Gross Monthly Income

Clients will pay a monthly premium based on 7.5% of gross monthly income. Allow a $50 deduction from monthly unearned income.

11. Applicants Under Age 19 May Have Eligibility For 12 Continuous Months

The eligibility continues for 12 months from the effective date of eligibility or for 12 months from the last periodic review.

12. Clients Must Be Reviewed

Clients must be reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.

Clients must be reviewed for other Medicaid program eligibility before closing cases.

13. Clients May Lose Benefits

The case will close on the first day of the next month when any of the following occur:

    • Client does not pay premium, except clients under age 19.

    • Client is no longer employed.

    • Client dies.

    • Client determined no longer eligible.

    • Client fails to pay premium.

    • Client enters a public institution, excluding the Geriatric Hall at the State Hospital in Evanston.

    • Client turns age 65.

    • Client does not complete review.

Reference:

Defining Group: 42 CFR 435 Subpart F

Social Security Act § 1902(a)(10)(A)(ii)(xv)

Income: 42 CFR 435 Subpart K

Clarifying Information:

1. Employed Individual with Disabilities (EID) is defined as the Medicaid program that allows a low-income, working disabled individual age 16 through 64 to continue to work and purchase medical coverage under the Medicaid work incentives improvement option.

2. Fiscal Agent Must Notify The Worker When Premium Is Not Received.

3. Income Changes Require Recalculation Of Premium.

4. COLA increases to Social Security benefits may affect EID eligibility as well as the premium payment amount.

5. All income, including exempt income, is countable when calculating the premium.

6. In-Kind income can be counted as income for the EID program as long as there is a value put to it and there is verification by statement.

Worker Responsibilities:

Determining Best Estimates

1. Refer to Section M903 for information on determining best estimates.

Determining Premium Payments

1. Enter all gross earned and unearned income in WES.

2. WES will calculate the premium amount using the income entered on the system. The EID premium amount will display on the Medical Eligibility Determination Results screen on the Income Test tab.

3. Monthly premiums are due as follows:

3A. Require no premium for first and second months; however, require premium to be prepaid for the third month and received by the 10th of the second month.

Example: Application received in June, no premium for June or July; however, August premium is due by July 10th.

3B. Require a premium for all retroactive months to be received before authorizing each benefit.

Mail premiums to the Fiscal Agent:

Conduent

ATTN: EID Program

P.O. Box 667

Cheyenne, WY 82003

3C. Fiscal Agent provides payment coupons to remind clients of the monthly premium amounts and the due date of premium payment.

4. Finalize eligibility and authorize benefits. WES will automatically generate an approval notice, including monthly premium amount.

5. Enter any change in income on the appropriate screens in WES when there is an increase or decrease in income.

5A. WES will re-calculate the premium amount using the new income entered.

Acting On Non-Receipt Of Premium Payments

1. Receive notification of non-payment from Fiscal Agent.

2. Review for eligibility under other Medicaid programs.

3. Ineligible for other programs and under age 19, eligibility continues for 12 months from the effective date of eligibility or for 12 months from the last periodic review.

4. Ineligible for other programs and over age 19, finalize eligibility and close for non-payment of premium.

Reinstating Benefits

1. If there is a 60-day break in Medicaid assistance, require completion of a new Medicaid application.

1A. Refer to program policies to determine eligibility.

1B. Eligible, finalize and authorize benefits for the first month of eligibility. Applicants must pay all delinquent premium payments before reopening the EID case.

1Bi. Case file should include a copy of the email from the Fiscal Agent stating delinquent premiums have been paid in full.

1C. Ineligible, finalize eligibility and deny benefits in WES.

2. If there is less than a 60-day break in Medicaid assistance, accept the premium.

2A. Reinstate benefits for the month of closure.

2B. Recalculate premium amount when change in income is reported and verified. WES will recalculate the premium using the new income entered.

3. Finalize eligibility and authorize benefits.

4. WES will automatically generate an approval notice, including monthly premium amount.

Reviewing Cases

1. Refer to Section M1403 for information on reviewing cases.

Approving Cases For Remainder Of The 12 Continuous Months Period

1. Change coverage group in WES to the 12 Month Continuous Waiver group, beginning the month the child under the age of 19 is found ineligible.

2. Finalize eligibility and authorize benefits.

3. WES will automatically generate a closure notice for the waiver services and an approval for the 12 Month Continuous Waiver group.

Closing Cases

1. Finalize eligibility and close benefits in WES when the applicant is no longer eligible.

2. Allow 15-day closure notice when an adverse action has occurred.