Date of Adoption: December 10, 2001.

     Purpose: New WAC 388-475-1000, 388-475-1050, 388-475-1100, 388-475-1150, 388-475-1200, and 388-475-1250 are adopted to implement the Medicaid buy-in program, to be called healthcare for workers with disabilities (HWD). The HWD program recognizes the employment potential of people with disabilities and represents Washington state's response to the landmark "Ticket to Work" legislation passed by congress in 1999.

     Statutory Authority for Adoption: RCW 74.08.090, Section 1902 (a)(10)(A)(ii) of the Social Security Act.

     Other Authority: Section 209(5), chapter 7, Laws of 2001, Part II.

      Adopted under notice filed as WSR 01-21-118 on October 23, 2001.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 6, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 6, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 6, Amended 0, Repealed 0.
     Effective Date of Rule: Thirty-one days after filing.

December 10, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (1) The HWD program provides categorically needy (CN) Medicaid services as described in WAC 388-529-0200.

     (2) The department approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 388-475-1100 for "retroactive" coverage for months before the month of application.

     (3) A person who is eligible for another Medicaid program may choose not to participate in the HWD program.

     (4) A person is not eligible for HWD coverage for a month in which the person received Medicaid benefits under the medically needy (MN) program.

     (5) The HWD program does not provide long-term care (LTC) services described in chapter 388-513 and 388-515 WAC. LTC services include institutional, waivered, and hospice services. To receive LTC services, a person must qualify and participate in the cost of care according to the rules of those programs.

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     (1) To qualify for the HWD program, a person must:

     (a) Meet the general requirements for a medical program described in WAC 388-503-0505 (3)(a) through (f);

     (b) Be age sixteen through sixty-four;

     (c) Meet the federal disability requirements described in WAC 388-475-1150;

     (d) Have net income at or below two hundred twenty percent of the federal poverty level (FPL) (see WAC 388-478-0075 for FPL amounts for medical programs); and

     (e) Be employed full or part time (including self-employment) as described in WAC 388-475-1200.

     (2) To determine net income, the department applies the following rules to total gross household income in this order:

     (a) Deduct income exclusions described in WAC 388-450-0020; and

     (b) Follow the CN income rules described in:

     (i) WAC 388-450-0005 (3) and (4), Income -- Ownership and availability;

     (ii) WAC 388-450-0085, Self-employment income -- Allowable

Expenses;

     (iii) WAC 388-450-0150 (1), (2), (3), and (5), SSI-related income allocation;

     (iv) WAC 388-450-0210 (4)(b), (e), and (h), Countable income for medical programs;

     (v) WAC 388-506-0620, SSI-related medical clients; and

     (vi) WAC 388-511-1130, SSI-related income availability.

     (3) The HWD program does not require an asset test.

     (4) Once approved for HWD coverage, a person must pay his/her monthly premium in the following manner to continue to qualify for the program:

     (a) The department calculates the premium for HWD coverage according to WAC 388-475-1250;

     (b) If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again; and

     (c) Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:

     (i) The job loss results from an involuntary dismissal or health crisis; and

     (ii) The person continues to pay the monthly premium.

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     (1) Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program. The department cannot approve HWD coverage for a month that precedes January 1, 2002.

     (2) To qualify for retroactive coverage under the HWD program, a person must first:

     (a) Meet all program requirements described in WAC 388-475-1050 for each month of the retroactive period; and

     (b) Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.

     (3) If a person does not pay premiums in full as described in subsection (2)(b) for all months requested in the retroactive period, the department denies retroactive coverage and refunds any payment received for those months.

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     (1) To qualify for the HWD program, a person must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):

     (a) (XV) for the basic coverage group (BCG); or

     (b) (XVI) for the medical improvement group (MIG).

     (2) The BCG consists of individuals who:

     (a) Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or

     (b) Are determined by the division of disability determination services (DDDS) to meet federal disability requirements for the HWD program.

     (3) The MIG consists of individuals who:

     (a) Were previously eligible and approved for the HWD program as a member of the BCG; and

     (b) Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1)(b).

     (4) When completing a disability determination for the HWD program, DDDS will not deny disability status because of employment.

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     (1) For the purpose of the HWD program, employment means a person:

     (a) Gets paid for working;

     (b) Has earnings that are subject to federal income tax; and

     (c) Has payroll taxes taken out of earnings received, unless self-employed.

     (2) To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.

     (3) To qualify for HWD coverage as a member of the MIG, a person must be:

     (a) Working at least forty hours per month; and

     (b) Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).

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     (1) When determining the HWD premium amount, the department counts only the income of the person approved for the program. It does not count the income of another household member.

     (2) When determining countable income used to calculate the HWD premium, the department applies the following rules:

     (a) Income is considered available and owned when it is:

     (i) Received; and

     (ii) Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 388-511-1130.

     (b) Loans and certain other receipts are not considered to be income as described in 20 C.F.R. Sec. 416.1103, e.g., direct payment by anyone of a person's medical insurance premium or a tax refund on income taxes already paid.

     (3) The HWD premium amount equals a total of the following (rounded down to the nearest whole dollar):

     (a) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 388-478-0070; plus

     (b) Five percent of total unearned income; plus

     (c) Two point five percent of earned income after first deducting sixty-five dollars.

     (4) When determining the premium amount, the department will use the current income amount until a change in income is reported and processed.

     (5) A change in the premium amount is effective the month after the change in income is reported and processed.    

     (6) For current and ongoing coverage, the department will bill for HWD premiums during the month following the month in which coverage is approved.

     (7) For retroactive coverage, the department will bill the HWD premiums during the month following the month in which coverage is requested and necessary information is received.     (8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following month(s).

     (9) As described in WAC 388-475-1050 (4)(b), the department will close HWD coverage after four consecutive months for which premiums are not paid in full.

     (10) If a person makes only a partial payment toward the cost of HWD coverage for any one month, the person remains one full month behind in the payment schedule.

     (11) The department first applies payment for current and ongoing coverage to any amount owed for such coverage in an earlier month. Then it applies payment to the current month and then to any unpaid amount for retroactive coverage.

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