Medi-Cal 250% Working Disabled Program: Breaking Away from the Cycle of Poverty Presented by: Karla Bell Program Manager, California Health Incentives Improvement Project San Diego State University Interwork Institute

Overview Medi-Cal 250% Working Disabled Program History Unique Features Eligibility Income and Premiums Benefits Enrollment Future: AB 1269 Resources

Medi-Cal 250% Working Disabled Program Work incentive program allowing people with disabilities the opportunity to work, earn up to $55,188/year, and pay a monthly premium to keep their Medi-Cal Medi-Cal ≠ Poverty The Medi-Cal Working Disabled program is a work incentive that allows people with disabilities the opportunity to work and earn up to $55,188/year and pay a monthly premium to keep their Medi-Cal. This Program is for ANYONE with a disability who is WORKING. It is NOT just for people on a Social Security disability benefit-but of course many people receiving Social Security Disability Insurance or Childhood Disability Benefits are also on this program. If you can show you have a medically determinable physical or mental disability and you are working you can qualify for this program. This program provides choice and opportunity to Californians with disabilities who would otherwise be ineligible for no share of cost, full scope Medi-Cal coverage due to earned income and work activity. Many people think of Medi-Cal as a poverty level program, but with the Working Disabled Program Medi-Cal does not equal poverty, You can earn a lot, build assets and keep Medi-Cal! Childhood Disability Benefits (CDB), previously called Disabled Adult Child’s benefits (DAC), are payable to a disabled adult child of an insured worker who has retired or become disabled, or has died. The child must have a disabling condition that began prior to the time the child attained age 22. The disabled child must be 18 years of age or older to access Childhood Disability Benefits. Although it was just stated that the disability had to begin prior to the age of 22, individuals cannot be found entitled to CDB until they have turned 18.

History Assembly Bill 155 (Migden 1999): California legislation that implemented the 250% Working Disabled Program in April 2000 Allowed under the Balanced Budget Act of 1997 – “Medicaid Buy-In program” States given the option to set resource and income limits and exclusions Assembly Bill 1183: 2008 Health trailer budget bill, eliminates the sunset date provision and allows the 250% Working Disabled Program to run indefinitely

History Aid Code 6G is now part of Medi-Cal Managed Care as of July 1, 2009 As of May 2010 MOE, only 5,072 individuals are enrolled statewide

Medi-Cal 250% Working Disabled Program Unique Features: Individuals can earn up to $55,188 gross per year and still qualify for full scope, no share of cost Medi-Cal A working couple can earn up to $73,884 gross per year Higher gross wages possible when there are Impairment Related Work Expenses (IRWEs) Affordable premiums: $20 - $250 (Single Person) $30 - $375 (Couples) Some unique features of this program include: Individuals can earn up to $55,188 gross per year or $73,884 for a couple and still qualify for Medi-Cal. Yes, you can earn up to $55,000 and still keep your Medi-Cal. Higher gross wages are possible when there are IRWEs-those are things you pay for out of pocket related to disability and needed for work. To receive full scope Medi-Cal you pay an affordable premium that is between $20 and $250 for an individual and $30 and 375 for a couple. For Medi-Cal Eligibility Workers on the Webinar, the Premiums are listed in SOC field of your County’s computer system.

Medi-Cal 250% Working Disabled Program Unique Features: Any IRS approved retirement products, are allowed and not counted towards the typical $2000 (or $3000) asset/resource limits for Medi-Cal Individual Retirement Accounts (IRAs), 401K, 403B, etc. Disability income not included in countable income when determining eligibility and premium amount Social Security Disability Insurance (SSDI), State Disability Insurance, Workers Comp., Childhood Disability Benefits, private disability insurance, Veterans’ benefits, etc. Another unique feature is that all IRS approved retirement products are allowed and not counted toward the $2000 or $3000 asset limit. These include IRAs, 401K, and 403B. All disability income is exempt. So it is not included as countable income when determining eligibility and premium amount. I will be showing an example of the calculation that is used to determine countable income in a little bit. Examples of disability income include SSDI, SDI, Workers Compensation, CDB, private disability insurance, Veterans benefits. Any Questions so far?

Medi-Cal 250% Working Disabled Program - Eligibility To qualify for the WD program, individuals must: Be a United States resident and living in California Meet Social Security’s definition of disability (medical definition only, does not count the ability to earn income) See ACWDL 02-34 for disability determinations for 250% program The All County Welfare Directors Letter 02-34 talks about how to do disability determinations for people not already on a disability programs or SSDI. (Disability Determination unit, for special instructions on how to do disability determinations) ACWDLs are Letters written and released by the Medi-Cal Eligibility Division to the 58 counties informing the counties of policies and procedures for the implementation and administration of the Medi-Cal program. Can be found on CA Department of Health Care Services website www.dhcs.ca.gov under Forms, Laws & Publications.

Medi-Cal 250% Working Disabled Program - Eligibility To qualify, individuals must: Be employed full-time or part-time, including self employment, with countable earnings below 250% of the Federal Poverty Level An applicant may be employed by another person, business, corporation An applicant may be self employed or be an independent contractor Work is undefined No set amount of hours required No minimum earnings criteria

Medi-Cal 250% Working Disabled Program-Eligibility Work activity can be as simple as pet attending, driving, domestic support services, research, light clerical work Earnings can also be in-kind: To document have person who provides meals, room or board write up an informal agreement describing: The working arrangement and estimation for cost of meals, room or board Describe the work being performed Have both parties sign & date agreement Earnings can be as little as $20/week. Examples of work: Walk neighbor’s dog Pet sitting Domestic support services Research activities Clerical work Collect cans Considered working if receiving sick leave or vacation pay from employer

Proof of Employment Pay Stubs Written verification of employment from an employer/business If self-employed: A contract may be used W-2’s can be used or: If an applicant is an independent contractor, the 1099 IRS form can be used

Medi-Cal 250% Working Disabled Program - Eligibility 3 Eligibility Tests: Assets Unearned Income Earned Income There are three eligibility tests used: The asset test, the unearned income test and the earned income test.

Medi-Cal 250% Working Disabled Program - Eligibility Asset Test Assets must be less than: $2000 for an individual $3000 for a couple Assets, like the home you live in and one car, are not counted for this program All IRS approved retirement accounts are exempt To qualify your assets cannot exceed $2000 for an individual or $3000 for a couple. The home you live in and one car is exempt. Other exemptions include: items necessary for self employment such as inventory or bank account and things you use on the job such as tools or a second car. Assets can include checking and savings accounts, the value of stocks, bonds, & trust deeds, additional cars, recreational vehicles, promissory notes and loans that are payable to you. Remember all IRS approved retirement accounts are exempt.

Medi-Cal 250% Working Disabled Program - Eligibility Unearned Income Test Unearned Income must be less than current SSI/SSP amount Disability income is excluded (SSDI, CDB, disability pension, SDI, etc.) $20 general income exclusion is applied to any unearned income Examples of unearned income: retirement, survivor’s Social Security, net income from property, Unemployment Insurance Unearned Income must be less than the current Supplemental Security Income/State Supplement Payment amount. 2010 SSI/SSP Amounts: $845 Individual $1407 Couple Retirement income is countable unearned income. Although there is not an age limit for the Working Disabled Program, currently if a person is on SSDI and they convert to retirement at full retirement age, their retirement income will become countable unearned income. This has created a barrier for those who make that conversion and are unable to enroll in the WDP or continue because their unearned income is now too high. Later I will talk about how Assembly Bill 1269 will change this in the future. If their countable unearned income is not too high and they were disenrolled in error, I recommend contacting the County Coordinator, please see resources for link.

Medi-Cal 250% Working Disabled Program - Eligibility Earned Income Test Countable income must be below 250% of the Federal Poverty Level Countable income limits = 250% FPL For individuals: $2257/month For couples: $3036/month Gross earned income limits For individuals: approx. $4599/month For eligible couples: approx $6157/month

Medi-Cal 250% Working Disabled Program - Income How Countable Income is determined: Net countable income = SSI Methodology (unearned income* - $20) + (earned income - $65 ÷ 2) *All disability income exempt Impairment Related Work Expenses (IRWE) can also be used as deductions Out of pocket expenses related to one’s disability and needed to work Examples: medications, medical equipment, attendant care services Countable income is calculated using the same calculation steps used to determine SSI payments. This calculation is used to determine your countable income for eligibility and premium amount for the WDP. If you don’t have any Unearned Income the $20 income exclusion will be applied to your earned income. IRWEs can also be used as deductions. These are out of pocket expenses that are related to one’s disability and needed to work. If a person has any IRWEs they will need to show proof that they paid for it such as a receipt. Some examples include: all costs related to a service dog (e.g.: food, training, grooming, vet bills, licenses), medical supplies, cost of medications, dialysis equipment, modifications to your home or vehicle (e.g. handbrake or electric lift), attendant care services, assistive technology (e.g.: special keyboards, typing aids, software, vision and sensory aids) that is needed to do your job and the cost of any training to use such equipment

Countable Income Example Mary $1,500/month in gross earned income $900/month in SSDI (exempt) $100/month in Impairment-Related Work Expenses (IRWEs) Mary’s Countable Income: $1,500 (earned income) - 20 (general income exclusion) - 65 (earned income exclusion) -100 (IRWE) $1,315 ÷ 2 = $657.50 (countable income)

250% Medi-Cal Working Disabled Program – Premium Chart Countable Earned Income From: Countable Earned Income To: Premium for Eligible Individual Premium for Eligible Couple $1 $600 $20 $30 $601 $700 $25 $40 $701 $900 $50 $75 $901 $1100 $100 $1101 $1300 $150 $1301 $1500 $125 $200 $1501 $1700 $225 $1701 $1900 $175 $275 $1901 $2100 $300 $2101 $2257 $250 $375 $2258 $3036 N/A

Medically Needy Share of Cost vs. 250% Working Disabled Program Mary’s Total Income = $2400 Mary’s Working Disabled Program Premium = $25/month If in Medically Needy Share of Cost Program, share of cost = $950

250% Working Disabled Program Benefits The ability to work and maintain affordable health coverage through Medi-Cal No large shares of cost (Medi-Cal or IHSS) Liberal definition of employment Disability-related income/Worker’s Compensation is exempt in determining eligibility and premium However, earning income may impact cash benefits

250% Working Disabled Program Benefits Can build retirement accounts Maintain In-Home Supportive Services at home and in the workplace Medi-Cal’s Health Insurance Premium Payment program (Medi-Cal/HIPP) IHSS Advance Pay: You can maintain this status while on the WDP. Advance pay is when the county provides IHSS recipients a check at the beginning of the month that they can use to pay their attendants (this provides flexibility for those who have more than 1 provider) Health Insurance Premium Payment Program HIPP: If you have Medi-Cal through WDP, 1619b or AD& FPL, SOC less than $200 the State may pay for the premium of other health coverage under certain conditions such as: if you are about to lose or have lost private coverage or you have it available and aren’t using it. This could be private insurance, Employer Sponsored health insurance or COBRA. The are other criteria to qualify such as you have a high cost medical condition (cancer, HIV/AIDS/organ transplant, diabetes, asthma, paralysis) and you have lost or are about to lose private coverage. IHSS NO SOC, Buy Out eliminated due to budget, IHSS SOC used to less than Medi-Cal SOC, now they are the same

250% Working Disabled Program Benefits If also on Medicare – are fully “dually-eligible”: Medi-Cal pays Medicare Part B premium Medi-Cal’s co-pay and premium payment programs for Qualified Medicare Beneficiaries (QMB) Access IHSS services (not covered by Medicare) Automatically qualify for Medicare Part D Low Income Subsidy (LIS) QMB: Medicare Savings Program Helps to pay for Medicare costs such as Part A and B premium, deductibles, coinsurance For more information about Medicare/QMB go to DB 101 and the HICAP website: Cahealthadvocates.org 1-800-434-0222

250% Working Disabled Program Benefits The Part D Low-Income Subsidy (LIS) program covers the premium and deductible of benchmark plans You are responsible for copayments of $1.10-$6.30 for each covered prescription Medi-Cal does not pay for Part D co-pays for prescriptions Medi-Cal does cover the co-pay for prescriptions for private insurance For more information about the Part D LIS and Medicare in general I recommend: Health Insurance Counseling and Advocacy Program (HICAP) Free Medicare Counseling 1-800-434-0222 http://www.cahealthadvocates.org/HICAP/ They can help you pick a Part D plan and with your Medicare questions.

Who should consider enrolling: Anyone with a disability who is working Individuals enrolled in Medi-Cal and IHSS with a Share of Cost Individuals receiving Social Security Disability Insurance (SSDI) or Childhood Disability Benefits (CDB) If your earned income from work exceeded the Supplementary Security Income (SSI) 1619(b) threshold amount

How to Enroll If you are already receiving Medi-Cal: Contact your Medi-Cal Eligibility Worker and ask them to enroll you. If you have a Share of Cost ask to be determined eligible. If you do not know who your Eligibility Worker is, contact your local Medi-Cal County office If you’re not currently receiving Medi-Cal: Apply for Medi-Cal at your local Medi-Cal county office. If you report earnings, you should be automatically enrolled. http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx Ideally, the application process without the disability determination is 45 days.  If there is a disability determination it should be no longer than 90 days.  Retroactive months: individual may be eligible for three months of retroactive Medi-Cal Benefits if otherwise eligible and if applicable premium is paid for each month for which retroactive coverage is requested.

How to Enroll Mention that the program is “Aid Code 6G” County Coordinator may be contacted if Eligibility Worker or Supervisor are unfamiliar with the program http://www.chiip.org/wdp_county_coordinators.html Medi-Cal Application is available online, or from your County office http://www.dhcs.ca.gov/services/medi-cal/pages/medicalapplications.aspx Write on top of your application form: Applying for the 250% Working Disabled Program-Aid Code 6G If their eligibility worker is not aware of the program, or states that it doesn’t exist, they should ask to speak to a supervisor or direct them to the Medi-Cal Working Disabled Program County Coordinator (listed on the CHIIP website) If you have continue to have difficultly contact the county coordinator county coordinators act as policy liaisons and address complaints from individuals or their representatives that are having difficulties such as a lack of knowledge of the Working Disabled Program at the local office level or an incorrect eligibility determination-so problems trying to get on the Working Disabled Program OR Contact your local advocacy agency: Disability Rights CA, Legal Aid for assistance-See links at end of ppt I also recommend that you write the following on the top of the application form: Applying for the 250% Working Disabled Program -- Aid Code 6G Include CHIIP WDP Brochure or use it to talk to eligibility worker about program Our brochures are free and later in the ppt I have information on how to request!

How to Enroll Completed application should be submitted with: Latest SSA award letter confirming medical disability determination is still active Copies of two most recent payroll checks or stubs (or letter from employer) Copies of two most recent bank statements

Premium Payment for Enrollees: Mail premium payments to: Program Analysis Unit MS4720-Dept 155 Department of Health Care Services P.O. Box 997423 Sacramento, CA 95899-9918 Make check or money orders payable to DHCS If using personal check recommend writing note such as “JUL 2010 Prem Pymt-250% WDP” in check field entitled “for” or “memo”

Premium Payment for Enrollees: To check and see if premium payment was received contact: Third-Party Liability-Marilyn Eaves 916-650-0533 Need WDP envelopes for premium payments contact: Jami Chan (916) 319-8525 Jami.Chan@dhcs.ca.gov The envelopes instruct individuals to make the checks/money orders payable to DHCS. The backside portion of the envelope also has a space to enter the name, amount and CIN#. 250% Working Disabled Program (WDP) Envelopes: The warehouse is closed. Jami Chan from Third Party Liability (TPL) will be taking requests from counties and beneficiaries. Discontinued from program if the person does not pay premiums for two consecutive months. Eligibility retained for 2 transition months. 6 month penalty period-to reenroll must pay current premiums and past owed or reapply after 6 month period has passed. NOA will be sent with appeal rights, will also state that county will automatically evaluate eligibility for any other Medi-Cal programs.

250% Working Disabled Program Future Changes Assembly Bill 1269 was signed into law by our Governor on 10/11/09 The new rules will not be implemented until ARRA funds run out This bill would make its provisions operative 30 days after the date that the increase in the state's federal medical assistance percentage (FMAP) pursuant to the federal American Recovery and Reinvestment Act of 2009 (ARRA) is no longer available. Department of Health Care Services (DHCS) anticipates that AB 1269 will be implemented when maintenance of effort (MOE) requirements to receive enhanced funding under ARRA no longer apply. Enhanced federal funding may end anywhere from December 31, 2010 or June 30, 2011

250% Working Disabled Program Future Changes AB 1269 policy changes improves the 250% WDP: Eliminate Age 65 restriction Eliminating the asset limit when money is placed in a separate account Change premium structure Grace period of 26 weeks if employment ends For individuals previously on SSDI and reach full retirement age, their Social Security retirement income will be exempt for ELIGIBILITY, but not premiums Eliminating the asset limit when money is placed in a separate account Each individual will pay a monthly premium that is equal to 5% of his or her individual or spousal countable income (premium will keep the same minimum and maximum range of $20-$250 for individuals and $30-$375 for couples) Disability Income will be exempt for ELIGIBILITY, but not premiums Same three eligibility tests will apply If a person on the program becomes unemployed, they can elect to remain on Medi-Cal for a period up to 26 weeks as long as premiums are still paid and extend resource exemptions to apply under any other Medi-Cal program under which the person later becomes eligible

Resources For more information: Disability Benefits 101 http://www.disabilitybenefits101.org See Medi-Cal Eligibility Procedures Manual, section 5R http://www.dhcs.ca.gov All County Welfare Directors Letters (ACWDLs) Go to Forms, Letters & Publications The Medi-Cal Eligibility and Procedures manual can be found on Department of Health Care Services website: www.dhcs.ca.gov Forms, Laws & Publications Publications Under categories go to “Manuals” You can find under Medi-Cal Manuals: Medi-Cal Eligibility Procedures Manual ACWDLs are Letters written and released by the Medi-Cal Eligibility Division to the 58 counties informing the counties of policies and procedures for the implementation and administration of the Medi-Cal program. Can be found on CA Department of Health Care Services website www.dhcs.ca.gov under Forms, Laws & Publications.

Resources List of 250% WDP County Coordinators http://www.chiip.org/wdp_county_coordinators.html Find your local County Office http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx Medi-Cal Application http://www.dhcs.ca.gov/services/medi-cal/pages/medicalapplications.aspx

Resources Talent Knows No Limits http://www.talentknowsnolimits.info/ Work Incentives Planning and Assistance Projects Benefits counselors for SSI/SSDI beneficiaries https://secure.ssa.gov/apps10/oesp/providers.nsf/bystate Area Work Incentives Coordinators (AWIC) http://www.ssa.gov/sf/awic.htm

Resources Local Independent Living Centers One-on-one benefits counselors http://www.cfilc.org Health Insurance Counseling and Advocacy Program (HICAP) Free Medicare Counseling 1-800-434-0222 http://www.cahealthadvocates.org/HICAP/

Resources Health Consumer Alliance Local health consumer centers for help getting health care http://healthconsumer.org/ Disability Rights California Advocacy and legal work http://www.disabilityrightsca.org/ 800-776-5746 (Toll free) 800-719-5798 (TTY)

Resources: 250% Working Disabled Program - ACWDLs 00-16 – Introductory letter and procedures 00-51 – Frequently asked questions 01-26 – 250% WDP forms and notices 01-46 – 250% WDP update 01-65 – 250% WDP and IHSS 02-34 – Disability Determination for the WDP 05-07 – 250% WDP envelope request information 06-27 – 2006 CHIIP outreach and training activities 08-47 – 2008 Elimination of sunset date 09-29 – 250% WDP and Managed Care 09-33 – Eligibility and beneficiary discussions on 250% WDP All County Welfare Directors Letters (ACWDLs) ACWDLs are Letters written and released by the Medi-Cal Eligibility Division to the 58 counties informing the counties of policies and procedures for the implementation and administration of the Medi-Cal program. Can be found on CA Department of Health Care Services website www.dhcs.ca.gov under Forms, Laws & Publications.

Resources For more information on outreach and training activities or questions, contact Karla Bell at 619- 594-5381, kbell@interwork.sdsu.edu To order brochures or promotional materials, contact Nicholas Moore at 916-654-8194, Nicholas.Moore@edd.ca.gov Medi-Cal Working Disabled Program Brochure I Can Work Brochure