Medicaid Buy-In Program



Medicaid Buy-In Program



With the Medicaid Buy-In program, people of any age who have a disability can have a job, earn money and still receive Medicaid if certain requirements are met. To participate in this program, most people must pay a monthly premium.

People enrolled in the Medicaid Buy-In program receive Medicaid health care services such as doctor visits, lab and X-ray services, hospital care, prescription drugs, eyeglasses, hearing aids and attendant care.

People with disabilities who want to participate in the Medicaid Buy-In program are allowed to have a higher income and more resources than allowed by other Medicaid programs. A person who earns as much as $4,320 each month may qualify. Some resources such as cash on hand and bank accounts are subject to limits. Retirement accounts and money set aside for health care and employment-related expenses are not counted when deciding if a person can participate in the Medicaid Buy-In program.

To take part in the Medicaid Buy-In program, a person must:

• Not permanently live in an institution (for example, a nursing facility or state hospital).

• Receive disability benefits through the Social Security Administration or meet Supplemental Security Income criteria without consideration of earned income.

• Work and pay federal income taxes based on earnings.

• Have earned more than $1,000 in the three months before applying for this program.

To learn more, read the Medicaid Buy-In program Frequently Asked Questions below:

|Medicaid Buy-In Program |

|Frequently Asked Questions |

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|What is the Medicaid Buy-In Program? | |

|What is the Income Pre-Test and the disability requirement? | |

|What is the resource limit? | |

|How is eligibility determined? | |

|What is the income limit? | |

|How is the monthly premium amount determined? | |

|When are the monthly premium payments due? | |

|What if a monthly premium payment is not made, how does that person get back into the Medicaid Buy-In program? | |

|What is the effective date for coverage under the Medicaid Buy-In program? | |

|What Medicaid services are available to a person enrolled in the Medicaid Buy-In program? | |

|Does a person applying for the Medicaid Buy-In program have appeal rights? | |

|How can you apply? | |

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|1. What is the Medicaid Buy-In program? | |

|It’s a program that allows people of any age who have a disability and are earning a paycheck to receive Medicaid by paying a | |

|monthly premium. A monthly premium might be required. The monthly premium is based on earned and unearned income. | |

|2. What is the Income Pre-Test and the disability requirement? | |

| | |

|Income Pre-Test:  To be eligible for the Medicaid Buy-In program, a person’s earnings and FICA contributions must be enough in a | |

|calendar quarter to count as a Social Security Administration “qualifying quarter.” This amount is $1,120 a quarter. | |

|A Social Security Administration qualifying quarter is a three-month period that ends on March 31, June 30, Sept. 30 and Dec. 31 | |

|each year. | |

|Disability:  If a person receives disability benefits from the Social Security Administration, they automatically meet the | |

|disability criteria for Medicaid Buy-In. If a person applying for Medicaid Buy-In is not receiving disability benefits from the | |

|Social Security Administration, HHSC’s Disability Determination Unit will process the application using Supplemental Security | |

|Income (SSI) criteria without consideration of earned income. | |

|3. What is the resource limit? | |

|A person’s countable resources must be equal to or less than $5,000. The most common countable resources are cash on hand, money in| |

|a bank account , stocks, bonds, life insurance with cash value, a second vehicle, and property other than a homestead.   | |

|Several types of resources are not considered when determining eligibility: | |

|Retirement-related accounts such as IRAs, 401(K)s, Tax Sheltered Annuities (TSAs), and Keoghs that comply with Internal Revenue | |

|Service regulations. | |

|Resources set aside as part of a Plan to Achieve Self-Support (PASS), as long as the plan is in effect and it has been approved by | |

|HHSC. Any money set aside for a PASS must be identifiable from other funds. | |

|PASS resources are considered “set aside” when they are one or more of the following: | |

|Owned by the individual. | |

|Used to pay for expenses. | |

|Used directly in the job. | |

|Saved for future expenses. | |

|Independence Accounts. | |

|An Independence Account is a designated, segregated account in a financial institution used to save for future health care and | |

|work-related expenses for the purpose of increasing a person’s independence and employment potential.  A person may deposit up to | |

|50 percent of their gross earned income during a Social Security Administration qualifying quarter into the account. The funds in | |

|this account may only be used to pay for health care or work-related expenses.  | |

|If the person puts more than 50 percent of their gross earnings into an Independence Account or if the money is used for anything | |

|other than to pay for health care or work-related expenses, the money in that account will be considered a countable resource. This| |

|resource will be counted in the 12 month period beginning with the first month after the Social Security Administration qualifying | |

|quarter in which a person deposits more than 50 percent of their gross earnings or uses the funds to pay for anything other than | |

|health care or work-related expenses. | |

|4. How is eligibility determined? | |

|Each person is considered a household of one when applying for the Medicaid Buy-In program. | |

|If the person applying is married to someone who is eligible for Medicaid, that person and his or her spouse are each considered a | |

|household of one. | |

| | |

|Being a household of one means a spouse is not penalized for assets owned by the other spouse.  For example, if a husband applies | |

|for the Medicaid Buy-In program, only his assets are considered when determining his eligibility for the program. If both spouses | |

|own the asset, only half of the asset is considered owned by the husband and the other half is considered owned by the wife. | |

|If the person applying for the Medicaid Buy-In program is a minor and lives with his or her parents, the assets of the parents are | |

|not considered the minor’s assets. | |

|5. What is the income limit? | |

|To be eligible for the Medicaid Buy-In program, a person’s countable earned income must be less than $2,257 a month, which is 250 | |

|percent of the federal poverty level. All earned income is countable except for the following exclusions, which are applied in the | |

|order listed: | |

|Earned income tax credit payments and child tax credit payments. | |

|Up to $30 of earned income in a month, if it is infrequent or irregular. | |

|Earned income of blind or disabled student children, subject to a monthly and yearly limit. The monthly limit is $1,640 and the | |

|yearly limit is $6,600. | |

|$20 monthly general income exclusion. | |

|$65 monthly earned income exclusion. | |

|Earned income used to pay Impairment-Related Work Expenses (IRWE). | |

|The amount of Impairment-Related Work Expenses that can be deducted are subject to reasonable limits. Deductions for needed items | |

|and services will be made only if the person pays the cost. | |

|The cost of certain items and services that a person with disabilities under age 65 uses to help them work can be deducted from | |

|earnings as Impairment-Related Work Expenses, even though such items and services also are needed for normal daily activities. | |

|The cost of certain attendant care services, medical devices, equipment, prosthesis, and similar items and services may be deducted| |

|as Impairment-Related Work Expenses. | |

|The costs of routine drugs and routine medical services are deductible as Impairment-Related Work Expenses if the drugs or services| |

|are necessary to control the disabling condition, allowing the person to work. | |

| | |

|Expenses that are not directly related to the impairment(s) cannot be deducted as Impairment-Related Work Expenses. Examples of | |

|non-deductible items include: | |

|Routine annual physical examinations. | |

|Routine optician services (unrelated to a disabling visual impairment). | |

|Routine dental examinations. | |

|Health and life insurance premiums. | |

|Continuing with the list of earned income that may not be considered in the eligibility calculation on a Medicaid Buy-In | |

|application: | |

|One-half of remaining earned income. | |

|Earned income of people who are blind used to meet work expenses, known as Blind Work-related Expense (BWE). | |

|Any income that is set aside and used to fulfill an HHSC-approved Plan to Achieve Self-Support. This income is excluded from | |

|countable income as long as the plan is in effect. | |

|Income is considered “set aside” when it is used to pay for expenses already incurred or when it is saved for future expenses.  Any| |

|income set aside must be identifiable from other funds, especially when funds are being saved for a future use. | |

|A person may not set aside more income than the Plan to Achieve Self-Support allows. There is no limit to the number of Plans to | |

|Achieve Self-Support a person can have, but a person can have only one Plan to Achieve Self-Support at a time. | |

|A person may have Blind Work-related Expenses, Impairment-Related Work Expenses and a Plan to Achieve Self-Support at the same | |

|time, but each must be for different expenses. | |

|6. How is the monthly premium amount determined? | |

|The monthly premium amount is based on both unearned and earned income as follows: | |

|Unearned Income: | |

|The unearned income premium amount is all unearned income over the SSI federal benefit rate, which is $674 a month. | |

|Example: Fred’s total unearned income is $700 a month | |

|Fred’s unearned income | |

|$700 | |

| | |

|SSI federal benefit rate | |

|-$674 | |

| | |

|Unearned Income Premium Amount | |

|$26 | |

| | |

| | |

|Earned Income: | |

|All program participants whose net pay (gross income, minus mandatory payroll deductions) exceeds 150 percent of the federal | |

|poverty limit (FPL) are required to pay an amount based on their earned income. Earned income premium amounts are as follows: | |

|Amount of earned income | |

|Premium amount | |

| | |

|Less than or equal to $1,354 | |

|$0 | |

| | |

|Earnings above 150% FPL up to and including 185% FPL | |

|(greater than $1,354 up to including $1,670) | |

|$20 | |

| | |

|Earnings above 185% FPL up to and including 200% FPL | |

|(greater than $1,670 up to including $1,805) | |

|$25 | |

| | |

|Earnings above 200% up to and including 250% FPL | |

|(greater than $1,805 up to including $2,257) | |

|$30 | |

| | |

|Earnings Above 250% FPL | |

|(greater than $2,257) | |

|$40 | |

| | |

|Example: | |

|Fred’s unearned income premium amount | |

|$26 | |

| | |

|Fred’s earned income premium amount | |

|+$20 | |

| | |

|Total Monthly Premium | |

|$46 | |

| | |

|Total Monthly Premiums: | |

|Total monthly premiums range from $0 to $500. Those who are approved for coverage do not pay monthly premiums if their: | |

|Unearned income is at or below the SSI federal benefit rate, and | |

|Earned income is at or below 150% FPL. | |

|7. When are the monthly premium payments due? | |

|A person who applies for the Medicaid Buy-In program is not enrolled until the first premium is paid.  The person applying will | |

|receive a notice containing the amount of the premium and the premium due date. | |

|First Premium Payment:  In most cases the applicant has at least two weeks to make the first premium payment. | |

|Ongoing Premium Payments:  Monthly premiums are due the end of each month.  If we do not receive payment by the end of the month, | |

|that person’s Medicaid Buy-In coverage will be terminated the end of the following month. | |

|If we do not receive payment by the end of the month due date, but we receive a one-month payment before the end of the following | |

|month, that payment will be treated as payment for the overdue month. The person will then be notified of the remaining amount due | |

|and the deadline for payment. | |

|If we receive the remaining amount due by the deadline for payment, then that person’s coverage will not be interrupted. | |

|If the remaining amount due is received after the deadline for payment, the person’s coverage will be terminated and the payment | |

|will be refunded to that person. | |

|8. What if the client misses a monthly premium payment? How does that person get back into the Medicaid Buy-In program?  | |

|A person who is removed from the program for failing to make payments must pay all past due and current monthly payments to get | |

|back into the program. | |

|9. What is the effective date for coverage under the Medicaid Buy-In program? | |

|Once a person is found to be eligible for the Medicaid Buy-In program, that person is given optional start dates – the dates they | |

|can start their Medicaid coverage – and premium amounts for each of the optional start dates. | |

|The person applying can choose a start date up to three months before the application file date by paying the premium amounts for | |

|the earliest date that person wants to start coverage. This option is only available at the time of the first payment. | |

|If the person applying for coverage pays the premium only for the current month, that person will not receive medical coverage for | |

|any of the prior months of potential eligibility. | |

|If the person applying pays more than one month’s premium, but not enough for all prior months of potential eligibility, then the | |

|excess premium amounts are applied in reverse chronological order to each of the prior months until there is only a partial month | |

|premium remaining. The partial amount will be refunded to that person. | |

|Example: | |

|John files an application on Jan. 10, 2009. | |

|HHSC determines John is eligible for the Medicaid Buy-In program on Feb. 20, 2009 (this is within the 45 days from the time John | |

|submits the application that HHSC has to determine eligibility). | |

|A letter notifying John that he is eligible is dated Feb. 20 and indicates the premium amount is $46.00 per month. | |

|John’s coverage can start as early as Oct. 1, 2008 – three months before the application was filed. To start coverage on Oct. 1, | |

|2008, John must pay $276 by March 31. | |

|If John makes a payment of $184 by Feb. 28, the effective date for coverage is Dec. 1, 2008. This is because the $184 is applied as| |

|follows: | |

|$46 March 2009 (month after notification letter received) | |

|$46 February 2009 (month notification letter received) | |

|$46 January 2009(month application was filed) | |

|$46 December 2008 (one month before application filed) | |

|If John paid $200, the effective date for coverage would still be Dec. 1, 2008 because the $184 would be applied the same as above | |

|and $16 would be refunded back to John. | |

|  | |

|$46 | |

|$46 | |

|$46 | |

|$46 | |

|  | |

|March 2009 (month after notification letter received) | |

|February 2009 (month notification letter received) | |

|January 2009(month application was filed) | |

|December 2008 (one month before application filed) | |

| | |

|  | |

| | |

|  | |

| | |

|10. What Medicaid services are available to a person enrolled in the Medicaid Buy-In program? | |

|Medicaid services | |

|People in the Medicaid Buy-In program will have access to the same Medicaid services available to adult Medicaid recipients, which | |

|include office visits, hospital stays, X-rays, vision services, hearing services and prescriptions. People in the Medicaid Buy-In | |

|program will be eligible for attendant services and day activity health services, if they meet the functional requirements for | |

|these programs. | |

|If a person in the Medicaid Buy-In program wants to be in one of Texas’ long-term care waiver programs (e.g., Community-based | |

|Alternatives), they may get on the waiver interest list. However, a person cannot participate in the Medicaid Buy-In program and | |

|receive long-term care waiver services at the same time. If a person in the Medicaid Buy-In program makes it to the top of a waiver| |

|interest list, qualifies for the waiver and wants to receive long-term care waiver services, that person must switch from the | |

|Medicaid Buy-In program into another Medicaid program in order to enter the waiver program. | |

|Service delivery models | |

|As of September 2006, Medicaid Buy-In program participants will receive services either through traditional Medicaid | |

|(fee-for-service) or through the Primary Care Case Management (PCCM) program, depending on where they live. | |

|Bexar, Dallas, El Paso, Harris, Lubbock, Nueces, Tarrant, and Travis Service Areas (these counties and surrounding counties) | |

|Traditional Medicaid (fee-for-service) | |

| | |

|All Counties Outside of the Above Service Areas (including rural Texas) | |

|Primary Care Case Management (PCCM). Each member has a primary care provider | |

| | |

|Participants in traditional Medicaid and Primary Care Case Management may receive up to three prescriptions per month. | |

| | |

|In the future, people in the Medicaid Buy-In program will get their Medicaid services through managed care programs, just as those | |

|who receive Supplemental Security Income (SSI) and live in certain urban areas do. | |

|11. Does a person applying for the Medicaid Buy-In program have appeal rights? | |

|An applicant not satisfied with HHSC’s decision concerning eligibility for medical assistance has the right to appeal through the | |

|process outlined in the HHSC Fair Hearings and Fraud Handbook. | |

|12. How can you apply? | |

|You can apply for the Medicaid Buy-In program the same way you apply for other Medicaid benefits. Call 2-1-1, go | |

|to , or visit your local HHSC benefits office. | |

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