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:
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)).
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.
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
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 policyholders 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.
Establishes Two New Fully Funded Grant Programs
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
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
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.
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.
materials are being developed by HCFA.
Questions and Considerations for States & Advocates on the Medicaid
Three key questions
for States concerning the Medicaid Buy-In Program:
- How to design it?
- How to pay for
- How to administer
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?
Variables for Consideration
Income and Eligibility
- How high on the
federal poverty level do you want to set eligibility for your program?
- Do you want to
get at the basic level at 250% of the federal poverty level? (Balanced
Budget Act of 1997)
- Do you want to
go above the 250% of the federal poverty level? (TWWIIA)
- 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:
- Amount: How much
do you want to disregard;
- Type: Are there
particular assets youd like to treat differently; and
- Source: Do you
want to differentiate how the assets are regardedfor 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?
- The premium rate
is required by law to be structured according to income. This means
the premiums can be approached from two perspectives:
- Sliding scale based
on income; or
- 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 programs 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?
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:
- How many people
- 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)
- 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.
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.
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.
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
Will you automate eligibility? Will you need to do a manual over-ride
of your existing system?
Joe Razes, HCFA
Roy Trudel, HCFA
Carey OConnor, HCFA - firstname.lastname@example.org
This fact sheet
was prepared by the Health Care Financing Administration and the SSI Coalition
for a Responsible Safety Net.