Purpose: This section will assist in determining eligibility for Employed Individuals with Disabilities.
Current Policy Effective Date: September 1, 2010
Date Last Reviewed: March 31, 2010
Previous Policy: October 1, 2009
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POL M1003: Determining Eligibility for EMPLOYED INDIVIDUALS with
Disabilities
1. Applicants Must Meet Basic Eligibility
Reference 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
There is no requirement to earn a certain amount of income or work a minimum number of hours each month. Verification of employment must be obtained. Reference Medicaid Table 5B.
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. Reference 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.
8. Applicants Do Not Have Resource Test
9. DD or ABI Waiver Clients May be Eligible for EID
Clients of DD or ABI 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. Reference 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 enters a public institution, excluding Uinta Hall.
· Client turns age 65.
· Client does not complete review.
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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 DFS When Premium is Not Received.
3. Income Changes Require Recalculation of Premium.
Training Link: Not available at this time.
Determining Best Estimates
1. Refer to Section M903 for information on determining best estimates.
Determining Countable Income
1. Refer to Section M901 for information on determining countable income.
Determining Disability for Applicants not Receiving Social Security Disability
1. Provide applicant or client with the EC-300 EqualityCare (Medicaid) Disability Determination Application and instructions.
2. Direct the applicant or client to forward the completed packet and previous 12 months of medical records to WDH in the enclosed self addressed postage paid envelope at the following address:
EqualityCare/Medicaid
Attn: Eligibility Unit
6101 Yellowstone Road, Suite 210
Cheyenne, WY 82002
3. If applicant or client brings the EC-300 and medical records to the DFS Office:
3A. Mail, fax or email a scanned copy of the EC-300 and medical records directly to the Eligibility Unit.
3B. Do not keep a copy of the EC-300 or medical records.
4. Send email to the Eligibility Unit with the name, and case number of the applicant.
5. Receive an approval or denial of the disability determination from WDH.
5A. WDH will provide a disability determination renewal date for all approvals.
5B. Require a new disability determination on a client who is not receiving benefits from SSA, based
on the renewal date provided by WDH.
Approving Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. For EID clients enter subtype “TW” on MERE screen in EPICS for all months including the retroactive
period.
3. For DD Waiver clients (Age 16 through the age of 20) enter subtype “T2” on MERE screen in EPICS for
all months including the retroactive period.
4. For DD Waiver clients (Age 21 and over) enter subtype “T3” on MERE screen in EPICS for all
months including the retroactive period.
5. For ABI Waiver clients (Age 21 through the age of 64) enter subtype “T4” on MERE screen in EPICS for all months including the retroactive period.
6. Authorize case on SSRM screen in EPICS, using approval code from Medicaid Table 3.
7. Send approval notice from Medicaid Table 16 to applicant.
Denying Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. Enter subtype “TW” on MERE screen in EPICS.
3. Deny case on SSRM screen in EPICS, using denial code from Medicaid Table 15.
4. Send denial notice from Medicaid Table 16 to applicant.
Determining Premium Payments
1. Enter all gross income in EPICS on one or more of the following screens:
1A. Unearned Income - Education (UNIE)
1B. Unearned Income (UNIN)
1C. Earned Income (EAIN)
1D. Self Employment Income (SEEI)
2. EPICS will calculate the premium amount using the income entered on the system. The EID premium amount will display on the SSRM authorization screen.
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 15th of the second month.
Example: Application received in June, no premium for June or July; however, August premium is due by July 15th.
3B. Require a premium for all retroactive months to be received before authorizing each benefit.
Mail premiums to the Fiscal Agent:
ACS
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. Generate approval notice, including monthly premium amount.
5. Enter any change in income on the appropriate screens in EPICS when there is an increase or decrease in income.
5A. EPICS will re-calculate the premium amount using the new income entered. The EID premium
amount will display on the SSRM authorization screen.
Acting on Non-Receipt of Premium Payments
1. Receive notification of non-payment from Fiscal Agent.
2. Review for eligibility under other Medicaid programs.
2A. Eligible for other Medicaid programs, change the subtype using the appropriate medical subtype in Medicaid Table 3.
2B. Send new approval notice according to Medicaid Table 16.
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, generate a 10-Day closure notice from Medicaid Table 16.
4A. Close EID benefits using the appropriate closure code form Medicaid Table 15.
Reinstating Benefits
1. If there is a 60-day break in Medicaid assistance, require completion of an EC-200 EqualityCare
(Medicaid) Application.
1A. Refer to program policies to determine eligibility.
1B. Eligible, reopen the case and authorize benefits for the first month of eligibility. Applicants must pay all past premium payments before reopening the EID case.
1C. Ineligible, deny case and issue notice. See Medicaid Table 16.
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.
3. Generate the 10-Day Notice for premium change.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
Closing Cases
1. Close case on SSRM screen in EPICS for the appropriate benefit month, using appropriate code from Medicaid Table 15.
2. Send 10-Day closure notice from Medicaid Table 16 when an adverse action has occurred.