The Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA)
Medicaid and Medicare Provisions

States, advocacy groups, and consumers should be aware of the following with regard to the national Medicaid and Medicare programs:

The TWWIIA provides:

Improved access to employment training and placement services for people with disabilities who want to work (administered by the Social Security Administration).
Increased opportunities for States to limit barriers to employment for people with disabilities by improving access to health care coverage available under Medicare and Medicaid (administered by the Department of Health and Human Services, Health Care Financing Administration (HCFA)).

TWWIIA Expands the Availability of Health Care Services for Workers with Disabilities:

Title II of TWWIIA governs the provision of health care services to disabled workers.
Effective October 1, 2000, Title II provides new optional eligibility groups by creating two new Medicaid buy-in categories, extends the period of premium free Medicaid Part A eligibility and requires consumer protection for individuals with Medigap coverage.

Two New Medicaid Eligibility Groups

States have the option to offer a Medicaid buy-in for individuals at least 16 but less than 65 years of age who, except for their income and resource levels, are eligible to receive SSI benefits can be eligible.

States have the option to offer a Medicaid buy-in for employed individuals with a medically improved disability who lose Medicaid eligibility under the group described above because they no longer meet the SSI definition of disability.
States offering the second buy-in must also cover the first buy-in group.
States may impose premiums or other cost-sharing charges on sliding scale based on income for individuals eligible for either of the new eligibility groups.

Extended Period of Medicare Eligibility

TWWIIA extends to 8 _ years premium free Medicare Part A benefits to SSDI beneficiaries who lose cash assistance because they return to work.

TWWIIA requires, at a policyholder’s request, suspension of Medigap coverage and premiums for those entitled to Medicare Part A, if the disabled individuals are covered under certain group health plans. TWWIIA also requires automatic reinstatement of a Medigap policy if group coverage is lost.

TWWIIA Establishes Two New Fully Funded Grant Programs

Beginning October 1, 2000, qualifying States are eligible to receive monies under two grant programs designed to support working individuals with disabilities. Solicitations for both programs will be released in May with details on how States can apply.

Medicaid Infrastructure Grant Program

$150 million available over the first five years for States to design establish and operate health care delivery systems that support the employment of individuals with disabilities.

States cannot use infrastructure grant funds to provide direct services to individuals with disabilities. To be eligible, States must provide personal assistance services under their Medicaid programs sufficient to support the employment of disabled individuals.

Medicaid Demonstration Projects

Funded at $250 million over six years. Under the demonstration, States can provide Medicaid services to workers with potentially severe impairments that are likely to lead to blindness or disability. This demonstration gives States the opportunity to evaluate whether providing these workers with early access to Medicaid services delays the progression to actual disability.

States define the number of individuals with potentially severe disabilities that they decide to cover, and which potentially severe impairments they will target.

Technical Assistance

Additional guidance materials are being developed by HCFA.


Key Questions and Considerations for States & Advocates on the Medicaid Buy-in Program

Three key questions for States concerning the Medicaid Buy-In Program:

  1. How to design it?
  2. How to pay for it?
  3. How to administer it?

Design: What income level do you want to cover? What level of assets do you want to disregard? How much do you want to allow people to keep to promote self-sufficiency? How do you want to charge premiums?

Design Variables for Consideration

Income and Eligibility

  1. How high on the federal poverty level do you want to set eligibility for your program?
  2. Do you want to get at the basic level at 250% of the federal poverty level? (Balanced Budget Act of 1997)
  3. Do you want to go above the 250% of the federal poverty level? (TWWIIA)
  4. Do you want to continue Medicaid Buy-In eligibility for those participating in the programs that lose their eligibility for federal disability programs due to medical improvement? (TWWIIA)


There are three main considerations for assets:

  1. Amount: How much do you want to disregard;
  2. Type: Are there particular assets you’d like to treat differently; and
  3. Source: Do you want to differentiate how the assets are regarded—for example, once individuals are enrolled in a program can they save monies from earnings and put them in an account that will be disregarded? Will the state allow assets up to a certain level to enter the program?


  1. The premium rate is required by law to be structured according to income. This means the premiums can be approached from two perspectives:
  2. Sliding scale based on income; or
  3. According to percentage of the federal poverty level.

There are a lot of considerations around setting a premium structure. First of all, how will you treat earned and unearned income? Will they be counted the same or differently when you establish your program’s premium rate? You can set different rates for these, which can give you a different incentive structure. For example, a program that heavily counts unearned income and has more liberal disregards for earned income creates more of an incentive for participants to work more hours and make higher wages.

A second consideration is how will the program operate when an individual participant loses their job because of disability. For example, when someone is forced to go into the hospital and is not receiving wages will the state still charge premiums? How long will an individual remain in the Medicaid Buy-in program when they are not working due to disability? And if they are not working, will the state oblige them to pay premiums?

Finance: How will you pay for it?

Again, there are three main elements of designing a cost model for projecting the cost of your Medicaid Buy-in program:

  1. How many people will enroll?
  2. How many people will transfer into this program from other programs? (Who already has Medicaid coverage and probably does not need to be budgeted in as an additional cost to the development of the Medicaid Buy-in)
  3. What kind of cost savings will accrue to the state as a result of the Medicaid Buy-in?

The complexity of your cost model is up to you. Some states have simply looked at how many people with disabilities had been applying for their Medicaid program and calculated how many had been denied due to excess income. Other states have reviewed census data and have constructed complicated models that review income survey data. Both approaches work equally well.

Identifying savings to other programs can be tricky. It will vary from state to state. For example, some states cover drugs for people with mental illness who are not Medicaid eligible and pay for this benefit with state dollars. If these individuals participate in the new Medicaid Buy-in program then the state is eligible for full federal match for each state dollar expended. This creates a cost saving for that specific program and more state dollars can be expended in the state fund program. Remember, there is a requirement for maintenance of effort or a non-supplanting clause in both the Balanced Budget Act and the TWWIIA.

Administration: How will the state administer the program?
How will the state administer this new program? There are a number of considerations the state must make in determining how to establish and maintain a program administratively.

Basic planning and design (upfront administration and coordination). Which agency will administer? Who needs to be trained? Who will do the disability determinations? Eligibility determinations? Again, which agency will administer it? Who needs to be trained? How will this be operationalized? Will you automate eligibility? Will you need to do a manual over-ride of your existing system?



General Program:
Joe Razes, HCFA –

Eligibility Issues:
Roy Trudel, HCFA –

Infrastructure Grants:
Carey O’Connor, HCFA -

This fact sheet was prepared by the Health Care Financing Administration and the SSI Coalition for a Responsible Safety Net.


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