####### June 9, 2003

**Medicaid and Work Incentives for People**

**with Disabilities: Background and Issues**

Joshua M. Wiener, Ph.D.

Principal Research Associate

The Urban Institute

2100 M Street, NW

Washington, DC 20037

\(202\) 261-5652

\(202\) 223-1149 (fax)

<jwiener@ui.urban.org>

# 

# This paper was prepared for the Ticket to Work and Work Incentives Advisory Committee as part of a contract with the Urban Institute. Lisa Ekman was the project officer. Anat Grosfeld of the Urban Institute provided valuable research assistance. The author is grateful for the insights and information provided by state officials and consumer advocates in Iowa, New Hampshire, Pennsylvania, South Carolina, and Connecticut. Useful comments on an earlier draft were provided by Sheila Zedlewski, Marie Strahan, Jerome Kleckley and Gina Livermore. The views presented here are those of the author and do not necessarily represent those of the Ticket to Work and Work Incentives Advisory Committee or the Urban Institute. 

Executive Summary

**Medicaid and Work Incentives for People**

**with Disabilities: Background and Issues**

Joshua M. Wiener, Ph.D.

The Urban Institute

Washington, DC

The potential loss of health benefits under Medicare and Medicaid is a
deterrent to people with disabilities entering or re-entering the labor
force. Although people with disabilities are generally not "sick," they
often have conditions that require greater than average use of medical
and long-term care services. To address this problem, Medicaid includes
several mandatory and optional provisions, including ones from the
Balanced Budget Act of 1997 and the Ticket to Work and Work Incentives
Improvement Act, that allow people with disabilities to work and retain
coverage.

This paper describes the Medicaid work incentives and how they are being
implemented at the state level. It explores the major issues involving
Medicaid and work incentives, including the state fiscal crises,
horizontal equity across states and groups, coverage of needed services,
defining disability, and the interaction between Medicaid and Social
Security Disability Insurance and Medicare. In addition, the article
also analyzes more technical design issues related to the Ticket to Work
and Work Incentives Improvement Act work incentives, including
definition of employment, age restrictions, and use of premiums.

# 

# [Introduction]{.underline}

Medicaid is a critical source of health and long-term care financing for
low-income persons with disabilities. Over the course of fiscal year
2002, Medicaid covered an estimated 7.9 million individuals with
blindness or disability.[^1] It is estimated that Medicaid provides
health coverage for approximately two-fifths of disabled persons with
incomes below the federal poverty level (FPL) and 15 percent of disabled
persons with incomes between 100 and 200 percent of the FPL.[^2]
Medicaid eligibility is consequential for blind and disabled persons
because they often have serious medical and other conditions that
require services that they cannot easily afford. Medicaid covers a wide
range of medical and long-term care services that are often critical to
enabling individuals with disabilities to work or to remain in the
community. High health insurance premiums and pre-existing condition
exclusions are significant barriers to private insurance for this group.
Even when insurance is available, it almost never covers long-term care
and other support services that people with disabilities often need.

Historically, Medicaid eligibility for persons with disabilities has
been tied to an inability to work, which means that individuals had to
choose between receiving the medical and long-term care services that
they needed and participating in the workforce. Partly as a result of
their physical and mental conditions, partly due to society's low
expectations of people with disabilities and partly because of cash
assistance and Medicaid policy, relatively few persons with disabilities
who received public benefits worked.[^3] For good reasons, people with
disabilities were unwilling to risk losing their health coverage.

In more recent years, younger people with disabilities have demanded
that they receive support to enable them to live normal lives in the
community, including participating in work. As part of the changing view
of people with disabilities, the Balanced Budget Act (BBA) of 1997 and
the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999
contained provisions that enable lower-income people with disabilities
to work and still retain Medicaid coverage. These provisions, often
referred to as "Medicaid buy-ins" because higher income beneficiaries
are required to pay premiums (thus "buying into" the program), are
coverage options available to the states, but are not required.

The purpose of this paper is to analyze the role of Medicaid for working
people with disabilities. The paper begins with an overview of Medicaid,
especially as it relates to people with disabilities. The second section
summarizes federal law regarding Medicaid work incentives for people
with disabilities and describes on a national basis how states have used
the flexibility available to them. In order to gain a more detailed
understanding of how the Medicaid buy-in programs are working at the
state level, the third section presents case studies of five states
which have chosen either the BBA or TWWIIA Medicaid work incentives
options. The fourth section analyzes some of the issues raised by the
existing structure of work incentives. The paper concludes with policy
implications for expanding work participation by people with
disabilities.

# [I. Overview of Medicaid]{.underline}

## 

## **A. Basic Features of Medicaid**

Medicaid is the principal health and long-term care financing program
for low income populations. It is a means-tested, open-ended entitlement
program, jointly financed by the federal and state governments and
administered by the states. Over fiscal year 2002, Medicaid programs
enrolled an estimated 50.9 million persons---about one in five
Americans---and spent an approximately \$216 billion in state and
federal funds for services.[^4]

While the federal government sets minimum standards, states have a
number of options in how they implement the program. Consequently,
Medicaid actually encompasses 56 separate programs (one in each state,
the District of Columbia, the four U.S. Territories, and the
Commonwealth of Puerto Rico).[^5] Federal financial assistance is
provided to states for coverage of specific categories of people and
services through federal matching payments. The rates for these federal
matching payments vary from 50 to 77 percent and are based on each
state's per capita income; states with lower per capita income have
higher federal matching rates.

Medicaid covers a very broad range of services with nominal cost
sharing, which reflects the low-income of the covered population.
Mandatory services include inpatient and outpatient hospital services;
physician, midwife, and certified nurse practitioner services;
laboratory and x-ray services; nursing home and home health care; early
and periodic screening, diagnosis, and treatment (EPSDT) for children
under age 21; family planning; and rural health clinics and qualified
health centers. In addition, states have the option to cover a very wide
range of additional services, including prescription drugs, clinic
services, prosthetic devices, hearing aids, dental care, intermediate
care facilities for the mentally retarded (ICF/MRs), and a wide range of
nonmedical home and community-based services through waivers. Unlike
Medicare, Medicaid is a major source of financing for long-term care
services.

Covering people with disabilities is important for states because this
group is relatively expensive to cover due to their high medical needs.
The Congressional Budget Office estimates that while 16 percent of
Medicaid enrollees in 2002 were blind or disabled, these individuals
accounted for 43 percent of federal Medicaid expenditures for
services.[^6] In 2002, average total (federal and state) per enrollee
Medicaid expenditures for persons with disabilities were \$11,770,
compared to \$1,999 per nondisabled adult, \$1,514 per child, and
\$13,099 per elderly person.[^7] People with disabilities have chronic
medical conditions that lead to more physician visits, higher rates of
hospitalization, greater use of prescription drugs, and increased need
for long-term care. Given the high costs of serving this population, one
way in which states limit their Medicaid financial exposure for these
services is by limiting Medicaid eligibility for blind and disabled
persons.

In 1998, the most recent year that detailed spending data are available,
57 percent of total Medicaid expenditures for people with disabilities
were for acute care services (e.g., physicians services, hospital care,
prescription drugs) and 43 percent were for long- term care services
(e.g., home care, nursing facilities and intermediate care facilities
for the mentally retarded).[^8] Medicaid's prescription drug benefit is
particularly important for disabled beneficiaries who accounted for 55
percent of total Medicaid spending on prescription drugs in 1998.
Similarly, in that same year, people with disabilities accounted for 61
percent of spending on home and community-based services.

**B. General Medicaid Eligibility Policy**

Medicaid provides coverage for only certain "categories" of low-income
people, such as children, parents, pregnant women, older people, persons
with disabilities, and individuals who are blind. In general,
nondisabled, childless adults are not eligible for Medicaid, regardless
of their income and asset levels or their medical needs. Since the
welfare reforms of 1996, Medicaid coverage is no longer automatic for
families with children who receive cash assistance.

Medicaid is a means-tested program under which people qualify based on
financial need. Financial eligibility is subject to an extensive set of
requirements that include income and financial resource (i.e., asset)
criteria. These tests consist of two parts: the standard and the
methodology. The standard is the dollar amount below which an individual
or family qualifies for coverage. For example, an income standard might
be \$ 552 per month (the SSI payment level in 2003), while the resource
or assets standards for older people and younger people with
disabilities generally are \$2,000 for individuals and \$3,000 for
couples.

The methodology is the way in which income or assets are counted for
purposes of applying the standard. For example, states must disregard
(that is, not count) some types or amounts of income, such as \$20 of
unearned income from any source and one-half of earned income, and they
have the option to disregard additional amounts. They must also exclude
some or all of the value of certain assets---for example, homes and
vehicles up to as certain value---when calculating total resources.
Under Section 1902(r)(2) of the Social Security Act, states may use
"less restrictive" income and resource methodologies than those used by
SSI.[^9] Depending on the methodology used, the effective income and
resource standards for Medicaid eligibility can be quite different from
those embodied in the standard. States have widely used this flexibility
in setting standards for eligibility options for working people with
disabilities.

### II. Medicaid Eligibility Rules Regarding Working People with Disabilities

The Medicaid program contains a number of rules that both facilitate and
hinder work by people with disabilities. The major eligibility
provisions affecting this issue involve the link to Supplemental
Security Income, Section 1619(b) of the Social Security Act, the
Balanced Budget Act of 1997 and the Ticket to Work and Work Incentives
Improvement Act of 1999. A less widely used mechanism is a Section 1115
of the Social Security Act research and demonstration waiver.
Massachusetts is the principal state using this option to provide
Medicaid to working people with disabilities as part of a much larger
demonstration project.

## **A. A Bird's Eye View of Medicaid Eligibility Policy for Aged, Blind and Disabled Persons**

States must provide Medicaid coverage for certain groups of low-income
aged, blind and disabled individuals, but they also have numerous
options to cover additional groups. Medicaid eligibility requirements
and options are briefly summarized on table 1.

Medicaid eligibility for older people and persons with disabilities is
tightly connected to eligibility for the SSI program, and many of the
Medicaid eligibility rules pertaining to these populations are derived
from rules of the SSI program. For example, federal law generally
requires Medicaid programs to cover elderly, blind and disabled
individuals receiving cash assistance from the SSI program, as well as
certain persons who lose SSI payments due to earnings from work or
increased Social Security benefits.[^10] An exception to this general
rule is that federal law gives states the option to use eligibility
criteria that are more restrictive than SSI, but only if those rules
were in effect when SSI was enacted in 1972, the so-called "209(b)"
option. In 2001, 39 states and the District of Columbia provided
Medicaid coverage to all SSI beneficiaries, while the remaining 11
states used alternative criteria for elderly and disabled beneficiaries.

States can also receive federal matching funds for certain optional
populations. These optional populations include:

-   Recipients of state supplementary payments (SSP) to SSI.

-   Certain aged, blind, or disabled adults who have incomes above those
    requiring mandatory coverage, but below the FPL. This pathway is
    often referred to as "poverty-level" coverage.

-   Individuals who have incomes slightly above the SSI level or who
    have substantial medical expenses. This pathway is commonly referred
    to as "medically needy" coverage.

-   Institutionalized individuals with income and resources below
    specified limits.

-   Persons who would be eligible if institutionalized but are receiving
    care under home and community-based services waivers.

-   On a first come, first served basis, subject to the availability of
    federal funds, Medicaid also provides help paying part of the
    Medicare Part B premium for certain individuals with incomes between
    120 and 135 of the FPL.[^11]

-   Working people with disabilities with family income up to 250
    percent of the FPL (with earned income by the beneficiary being
    disregarded) or any state-designated income and resource level.

The type of coverage that people with disabilities receive from Medicaid
varies depending on their financial status and eligibility for Medicare.
Approximately 36 percent of younger people with disabilities who are
eligible for Medicare (as a result of their receipt of Social Security
Disability Insurance benefits) are also eligible for Medicaid.[^12]
Low-income aged, blind, and disabled people who are not eligible for
Medicare usually are eligible for a full range of acute and long-term
care benefits through Medicaid. Low-income persons who are eligible for
both programs receive assistance from Medicaid with Medicare's
cost-sharing requirements as well as coverage for some services that
Medicare does not provide, including prescription drugs, nursing
facility care beyond Medicare's 100-day limit, and other long-term care
services. Federal law also requires Medicaid programs to pay some or all
Medicare cost-sharing expenses---including Medicare Part A and Part B
premiums and deductibles and coinsurance---for Medicare services
provided to Medicare beneficiaries with incomes up to 120 percent of
poverty; these provisions are known as "Medicare savings programs."[^13]
Thus, Medicaid helps to fill in gaps left by Medicare and private
insurance.

**B. The Medicaid Starting Point: Supplemental Security Income (SSI)**

As noted above, state Medicaid programs generally must cover SSI
beneficiaries or a subset of them. To be eligible for SSI, a person must
be age 65 or older, blind or disabled and have limited income and
resources. Under SSI law, an individual is considered disabled if "he is
unable to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months."[^14] In 2003,
earned income exceeding \$800 per month for nonblind, disabled
individuals and \$1,330 for blind individuals is evidence of
"substantial gainful activity" or SGA.[^15]

Under section 1619(a) of the Social Security Act, however, people under
age 65 who have already qualified for SSI benefits can have earned
incomes that exceed the substantial gainful activity threshold and
receive reduced cash payments. People who are age 65 and older, blind
and younger people who meet the SSI disability requirements are eligible
to receive SSI benefits if their "countable" incomes (which can include
earned and unearned income) fall below maximum SSI benefit levels. Some
income is not "countable." In determining eligibility for SSI, the
Social Security Administration disregards \$20 of income per month from
any source and \$65 per month of earned income plus one-half of
remaining earnings, and certain other public benefits such as food
stamps and home energy or housing assistance. In 2003, once determined
to be eligible, beneficiaries can increase their income up to \$1,189
per month for individuals and \$1,743 per month for couples and still
receive SSI benefits.

From the beneficiaries' perspective, there are two advantages of these
work incentives. First, there is no cash cliff as there is with Social
Security Disability Insurance coverage where individuals are suddenly no
longer eligible; individuals lose their SSI benefits gradually. Second,
individuals may easily move back to regular SSI status if their earnings
are significantly reduced or eliminated.

The SSI program also limits the amount of countable resources that
beneficiaries may have in order to qualify. Resource limits for SSI
eligibility, which have not increased since the mid-1980s, are \$2,000
for individuals and \$3,000 for couples. These limits generally apply to
"liquid assets" such as stocks and bonds, mutual funds, and money in
bank accounts; they exclude (in entirety or up to a limit) the value of
assets such as homes, cars, burial plots or funds, personal effects, and
the cash surrender value of life insurance.[^16]

**C. Mandatory Work Incentive: Section 1619(b) of the Social Security
Act**

States must provide Medicaid coverage to "qualified severely impaired
individuals" who have already qualified for SSI and continue to have the
disabling physical or mental impairment that initially qualified them
but subsequently have more than \$800 a month in earnings (e.g.,
"substantial gainful activity") in 2003.[^17] These persons remain
entitled to Medicaid as long as their gross earnings are determined to
be less than the value of the sum of SSI, state supplemental payments,
Medicaid benefits and publicly-funded attendant care that they would be
eligible to receive in absence of their wage earnings. To measure
whether a person's earnings are high enough to replace these benefits,
the Social Security Administration calculates state-specific thresholds,
which range from a low of \$17,348 in Alabama to a high of \$41,514 in
New Hampshire in 2003 (table 2). Five states---California, Iowa,
Massachusetts, Nevada and Oregon---have higher thresholds for blind SSI
beneficiaries. If an individual earns more than the state threshold
amount, he or she can request an individualized upper limit, which
considers the persons actual use of Medicaid, publicly-funded attendant
care and work expenses. Beneficiaries can be reinstated to SSI payment
status or SSI status under section 1619(b) without a new application if
their income and resources are reduced to a level that they can once
again meet the SSI criteria.

In addition, the income limits are made more flexible by deducting from
gross earnings the cost of certain impairment-related items and services
that an employed individual with disabilities needs to work. SSI
beneficiaries also may save for items related to vocational goals and
employment outcome under "Plans for Achieving Self-Sufficiency" (PASS)
and have that money disregarded for eligibility purposes. However,
beyond this, the provisions generally do not allow states to deviate
from federal resource or assets guidelines, thus limiting efforts to
encourage savings or to reward increased earnings by beneficiaries.

These provisions guarantee extended Medicaid coverage to people who have
previously received SSI benefits, but they do not provide coverage for
those who have not received this cash assistance.[^18] Moreover, both
the Medicaid and SSI provisions have been difficult for consumers to
understand and for eligibility workers to implement. In 1999, only 1.9
percent of working age SSI beneficiaries were in the 1619(b)
category.[^19] After reviewing the evidence, Newcomb, Payne and Waid
concluded that, "While the 1619 provisions have created more opportunity
for work among SSI recipients, it does not appear that they have
significantly helped move people off the rolls."[^20]

A.  Optional Work Incentives: Medicaid Buy-In Programs

While states must provide Medicaid to most SSI beneficiaries and to
people who qualify under section 1619(b), coverage under the Balanced
Budget Act of 1997 (BBA) and the Ticket to Work and Work Incentives
Improvement Act of 1999 (TWWIIA) is optional for the states. The target
populations for the Medicaid work incentives provisions of the BBA and
the TWWIIA are primarily Social Security Disability Insurance (SSDI)
beneficiaries who cannot utilize Section 1619 protections because they
are not eligible for SSI, persons receiving SSI who have or could exceed
state-established income or resource limits under 1619(b); and
individuals with disabilities who have been working but have not or are
not currently receiving cash benefits or Medicaid coverage. The BBA and
TWWIIA provide states with more flexibility than the Section 1619
provisions. Table 3 compares the eligibility rules of the provisions of
the Balanced Budget Act and the Ticket to Work and Work Incentives
Improvement Act. Table 4 provides state-by-state information on the
implementation of the BBA and TWWIIA provisions. As of June 2002, there
were a total of 27,209 Medicaid beneficiaries in the BBA and TWWIIA work
incentives in 25 states.

## 1. Balanced Budget Act of 1997

Section 4733 of the BBA established a new optional Medicaid coverage
group, which allows states to provide Medicaid eligibility to working
people with disabilities. For people who meet the SSI definition of
disability, states may offer Medicaid coverage to individuals with net
family income below 250 percent of the federal poverty level and
resources not exceeding the SSI resource standard. In calculating
income, all earned income is disregarded, but unearned income may not
exceed the SSI income standard (which is \$552 for an individual and
\$829 for couples in 2003). There is no definition of an employed
individual and states may not establish minimum standard for number of
hours worked or minimum level of earnings. As in other parts of
Medicaid, 209(b) states may use more restrictive eligibility criteria
than are used by SSI. States may require payment of premiums and other
cost-sharing charges on a sliding scale based on income. As of June
2002, 12 states covered working people with disabilities under the BBA
provisions.[^21]

#### [Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA)]{.underline}

The Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA)
established two new Medicaid eligibility groups, the basic coverage
group and the medical improvement group, as well as a new grant program
to the states and a new Medicaid research and demonstration program.

## *Eligibility Options: Basic Coverage Group and Medical Improvement Group*

*Basic Coverage Group*. The basic coverage group is similar to the BBA
group, except that states are free to establish their own income and
resource standards or to have no income and resource standards at all
and there is an age limit (no persons under age 16 or 65 and older).
There is no definition of an employed individual and states may not
establish any minimum requirement for number of hours worked or
earnings. Currently 13 states have adopted this option.

##### Medical Improvement Group. The medical improvement group targets individuals whose disabilities are cyclical or periodic.[^22] The intent of this provision was to ensure continued medical coverage for those individuals when, due to treatment or support services, their condition improved to the point that they no longer met the disability criteria for SSI, SSDI, and Medicaid. Despite the finding of "medical improvement," these individuals must continue to have conditions that constitute a "severe medically determinable impairment." Some groups meeting this description include persons with AIDS/HIV, persons with severe and persistent mental illness who respond to psychotropic medications, persons with epilepsy, persons with certain types of multiple sclerosis, and persons with some cancers. As with the basic coverage group, eligibility is limited to persons between the ages of 16 and 64. Earned income is not automatically disregarded. There are no federally established income and resource standards.

Unlike the basic coverage and BBA groups, the medical improvement group
does have a statutory definition of an "employed individual," which is a
person who is earning at least the federal minimum wage and is working
at least 40 hours a month, or is engaged in a work effort that meets an
alternate definition as defined by the state and approved by the
Secretary of the Department of Health and Human Services. Currently,
three states have adopted this option.

Options Available to States under Basic Coverage and Medical Improvement
Groups. States have some options under the TWWIIA provisions. First, as
indicated above, states are free to establish their own income and
resource standards, or to have no income and resource standards at all.
Second, although SSI income and resource methodologies are the default,
states may use more liberal methodologies than are used by SSI as
authorized by Section 1902(r)(2) of the Social Security Act. Third, as
in other parts of Medicaid, 209(b) states may use more restrictive
eligibility criteria than are used by SSI.

Fourth, states may impose premiums or other cost-sharing under both
coverage groups. Any premium or cost-sharing must be imposed on a
sliding scale based on income. For any individual whose annual family
income is less than 450 percent of the federal poverty level, the
premiums may not exceed 7.5 percent of the individual\'s income. In
addition, states must charge the full premium for any individual whose
adjusted annual gross income exceeds \$78,027 annually in 2003 (an
amount that increases annually by the consumer price index). States may
subsidize payment of premiums for individuals whose incomes exceed this
level, but any such subsidy must be made solely with state funds.
According to the Centers for Medicare & Medicaid Services, a flat
cost-sharing charge combined with a sliding scale premium would meet the
requirement that such charges be on a sliding scale based on income.

If an individual could be covered under private health insurance at no
cost to him or her, states may require the individual to enroll in the
insurance plan. Where private group health insurance is available to the
individual at some cost, states may enroll individuals in such plans
provided doing so is cost-effective and the state pays the costs of
enrolling in the plan, including premiums, deductibles and co-insurance.

*Maintenance of Effort Requirement.* The TWWIIA prohibits states from
supplanting state funds for programs to help working individuals with
disabilities with federal funds that provide Medicaid benefits under the
basic coverage group or the medical improvement group. If a state covers
either or both of these Medicaid eligibility groups, federal Medicaid
matching funds will not be available unless the state establishes, to
the satisfaction of the Secretary of the Department of Health and Human
Services, that its expenditures for those programs are not less than its
expenditures for such programs for the fiscal year ending before
December 17, 1999.

*[Infrastructure Grants and Medicaid Demonstrations]{.underline}*

Beyond establishing new coverage options, the TWWIIA also establishes a
Medicaid Infrastructure Grant Program and authorizes a new set of
Medicaid demonstrations.

*Medicaid Infrastructure Grant Program.* The Medicaid Infrastructure
Grant Program is an eleven year grant program which makes \$150 million
available to states over the first five years. The Centers for Medicare
& Medicaid Services currently is preparing to issue the fourth round of
the call for proposals. Appendix 1 summarizes state activity on the
Medicaid Infrastructure Grants. The goal of the grants is to provide
states with additional funds (and manpower) to design and implement
Medicaid activities supporting working people with disabilities. In
general, the programs are more focused than the Real Choice System
Change grants that the Centers for Medicare & Medicaid Services are
providing to states to help them expand home and community-based
services. The Medicaid Infrastructure Grants help states to:

-   Implement the Medicaid eligibility groups discussed above.

-   Design and plan a Medicaid demonstration for employed individuals
    with potentially severe physical or mental impairments.

-   Plan, design or evaluate improvements to the Medicaid State Plan for
    purposes of providing more effective employment support.

-   Create a state-to-state Medicaid Infrastructure Center to serve as a
    regional technical assistance provider for health care improvements
    supporting employment.

Funds may also be used to conduct outreach campaigns to educate
beneficiaries about the availability of Medicaid coverage for working
people with disabilities. Subject to availability of the overall annual
amount appropriated for this grant program, the minimum award to each
state is \$500,000 per fiscal year.

To be eligible for grant funds, a state must make personal assistance
services available under its State Medicaid plan to the extent necessary
to assist individuals with disabilities maintain employment. In order to
disperse the funds in a timely fashion, the Centers for Medicare &
Medicaid services have used fairly lenient criteria in determining
whether states meet the requirement for personal assistance services.

*Medicaid Demonstrations.* The companion to the grant program is a
mandated set of Medicaid demonstrations on providing Medicaid to
"workers with potentially severe disabilities." At the time of their
demonstration coverage, these individuals would not normally be
considered "disabled" under the SSI definition and would not otherwise
be Medicaid eligible. The purpose of the demonstration is to evaluate
the effect of providing early intervention in the form of health and
long-term care services on the ability of participants to retain
employment and on their physical and mental status. In other words, can
providing Medicaid coverage prevent the health and functional status of
individuals from deteriorating to such an extent that they meet the SSI
definition of disability? These demonstrations are funded at \$250
million over six years.

The demonstrations have several other requirements. Participants must be
at least 16 but less than 65 years old, and have a specific physical or
mental impairment that can reasonably be expected to lead to blindness
or disability as defined under the SSI program if Medicaid services are
not provided. Unlike the regular Medicaid program, which is an
open-ended entitlement, demonstration states will be required to cap the
number of people covered in the demonstrations. The law does not require
that states impose any income or resource test. Since they are capping
enrollment, states are permitted to operate the demonstrations on less
than a statewide basis. Three states---Mississippi, Rhode Island and
Texas\--and the District of Columbia have been granted waivers. As of
April 2003, Mississippi and the District of Columbia have begun
enrolling beneficiaries, while Rhode Island and Texas have not. The
maximum proposed enrollment in each of the four demonstration states is
quite small, 500 enrollees or less (table 5).

**[III. State Case Studies]{.underline}**

In order to obtain a better understanding of the implementation of the
BBA and TWWIIA buy-in options for working people with disabilities, case
studies were conducted of five states---Connecticut, Iowa, New
Hampshire, Pennsylvania, and South Carolina---that provided Medicaid
coverage to working people with disabilities under the BBA or the
TWWIIA. In order to gather information, state websites were searched and
telephone discussions held with state officials and consumer advocates
from January to March 2003. Topics investigated included background
history related to the state decision to provide coverage, a description
of eligibility rules and the availability of long-term care services,
experience with the coverage option, budget outlook and policy issues,
and recommendations for change. In order to encourage candor on the part
of respondents, persons interviewed were told that they would not be
quoted or otherwise identified. Appendix 2 summarizes the case study
results for each state.

**A. Background History and Budgetary Outlook**

Adoption of the Medicaid buy-in provisions had extremely broad,
bipartisan support. For example, it unanimously passed the legislature
in New Hampshire and Connecticut. Business groups, who saw these
initiatives as a way of addressing the labor shortages of the late
1990s, were often involved. In Pennsylvania, the incremental cost was
funded with tobacco settlement funds. Low cost estimates by the states
aided the adoption of the eligibility expansions, as did the ideology of
helping persons with disabilities work.

Although all of the case study states are projecting major budget
deficits, none of the states will be eliminating the buy-in program,
even though it is an optional rather than mandatory eligibility
category. However, some states are tentatively considering increasing
premiums. Some observers noted that several of the community-based
services that people with disabilities heavily depend on, such as
transportation, are at risk in the current budgetary environment. In
addition, people with disabilities obtain Medicaid through other
coverage options (e.g., medically needy programs) that are at greater
risk of being cut.

**B. Eligibility Requirements**

The Medicaid buy-in provisions are relatively liberal by Medicaid
standards, with states adopting the TWWIIA options being more generous
than those states adopting the BBA provisions. In general, states using
the BBA provisions adhere quite closely to the SSI methodologies for
determining income and resources, while states using the TWWIIA options
are more likely to disregard additional income and resources.

Most states limit income eligibility to 250 percent of the FPL, although
New Hampshire covers person with income as high as 450 percent of the
FPL (including the income of the spouse) and Connecticut covers
individuals with income as high as \$75,000 for an individual. However,
additional disregards in some states, such as unearned income and Plans
for Achieving Self-Support expenses (PASS), make the effective income
levels higher than the nominal standards. In addition, New Hampshire,
Connecticut and Iowa allow individuals who have lost their jobs and,
therefore, have no earned income to retain their Medicaid eligibility
for an extended period of time if they intend to return to work. None of
the case study states opted to totally eliminate income and asset
standards, partly because of concerns about the potential costs and
partly because they did not want it to appear that "millionaires are
getting free health insurance."

Similarly, resource standards vary substantially, but are generally much
higher than standard SSI eligibility levels, which are \$2,000 for an
individual. For example, the resource standards for an individual are
\$20,000 in New Hampshire, \$12,000 in Iowa, and \$10,000 in Connecticut
and Pennsylvania. Of the case study states, only South Carolina adhered
to SSI resource standards. In addition, states commonly excluded
retirement accounts, medical savings accounts, and accounts for
employability-related expenses, making the effective resource standards
higher. States do not count these assets because they want to encourage
savings and because accumulating some resources is part of the normal
work experience. In New Hampshire, liquid resources accumulated from
earnings while Medicaid eligible under the buy-in and kept in a separate
account will be excluded when determining future eligibility for
non-buy-in Medicaid categories.

**C. Medicaid Buy-in Premiums and Private Insurance**

All of the case study states, except for South Carolina (which also does
not impose premiums for the State Children's Health Insurance Program),
impose premiums on higher income beneficiaries. Premiums are between 5
and 10 percent of income. States typically include spousal income in
determining family income, but may count only "net" income, which
includes only about half of earned income by the person with
disabilities. Individuals with incomes above \$78,027 are charged the
"full premium." While this is true for Iowa, the maximum premium is
assessed when income is above \$35,028. All of the case study states
except Iowa credit private health insurance premiums against the
Medicaid-buy in premiums. In addition, the states will pay the private
health insurance premium of individuals if it is cost effective to do
so.

**D. Long-Term Care Services**

None of the case study states cover a broad personal care benefit
through the regular Medicaid program. New Hampshire has a
narrowly-focused benefit for people in wheelchairs. Instead, all of the
states rely on Medicaid home and community-based services waivers as a
financing mechanism for noninstitutional long-term care services for the
Medicaid buy-in population. Connecticut used to have a state-funded
program of personal care, but cases have been transferred to a home and
community-based services waiver. Although participants in the waivers
must need nursing home level of care, state officials did not report
that access to long-term care services was a problem.

**E. Outreach and Education**

States have engaged in a number of outreach and education initiatives to
increase enrollment, although the extent of these efforts vary. In New
Hampshire, for example, they made a major outreach effort using the
Medicaid infrastructure grant. These initiatives have included radio
spots, brochures and posters and the state plans to involve local
Chambers of Commerce. Benefit specialists provide counseling services on
the Medicaid buy-in and offer education and outreach other services.
Grant contracts have been made to independent living centers to provide
outreach. Training and outreach efforts have included SSA offices, area
agencies serving consumers with developmental disabilities and acquired
brain disorders, mental health agencies, one-stop centers (offering
employment related services to both employees and employers), advocacy
groups, and other local and state agencies.

In Connecticut, the Connect to Work program encourages persons with
disabilities to return to work utilizing Medicaid to address their
medical and long-term care needs. Marketing the coverage options has
included mailings to disabled people on SSI with earned income and
disabled individuals who have lost Medicaid eligibility within the last
two years. They target people earning less than the SGA, educating them
that they can earn more and still maintain Medicaid eligibility. The
state has five benefits counselors in the field who work with
individuals with disabilities. State officials have given talks to
groups providing services to people with disabilities, such as the
Multiple Sclerosis Society.

**F. Experience to Date**

The number of beneficiaries in the Medicaid buy-in programs is not large
in absolute terms, varying from 770 participants in South Carolina to
5,048 participants in Iowa. As expected by state officials, the
substantial majority of beneficiaries in the buy-in option had
previously been Medicaid eligibles. Generally, only about 20 percent or
less of buy-in participants are new Medicaid beneficiaries. Often,
buy-in beneficiaries were previously eligible for Medicaid through the
medically needy option. The majority of beneficiaries are dually
eligible for Medicare and Medicaid, most likely meaning that they are
receiving SSDI benefits. For example, in Connecticut, 82 percent of
beneficiaries are dually eligible for Medicare and Medicaid. In
Pennsylvania, about half of buy-in participants are dually eligible.
State officials speculated that purely SSI beneficiaries were mostly
covered under Section 1619(b) provisions rather than through the BBA and
TWWIIA Medicaid buy-ins.

The BBA and TWWIIA programs in each state are designed to accommodate
individuals with fairly significant earnings by Medicaid and SSI
standards. However, although all participants in the states have
earnings or had earnings and are looking for work, the level of income
is generally modest. In states with income information, most individuals
are earning less than the SGA. For example, in Iowa, 4 percent of
beneficiaries earn \$750 per month or more; 57 percent earn \$100 per
month or less. In Iowa, approximately 42 percent of beneficiaries work
10 hours per month or less; 10 percent of beneficiaries work 80 hours a
month or more. In Connecticut, 27 percent of beneficiaries are earning
\$5,000 a year or less and 43 percent are earning between \$5,000 and
\$9,999; thus, roughly 70 percent of beneficiaries earn less than the
SGA. In Pennsylvania, although they do not track earnings, half of all
buy-in beneficiaries worked 100 hours a month or less.

Consistent with the relatively modest earnings of participants, a
substantial majority of beneficiaries do not pay premiums, except in
Pennsylvania where almost all beneficiaries are required to contribute
to the cost of their health coverage. The percentage of beneficiaries
who are paying premiums generally ranges from about 10 to 25 percent. In
New Hampshire, 18 percent of beneficiaries pay premiums and 75 percent
of those paying premiums have net incomes (i.e., disregarding half of
earned income) between 150 and 200 percent of the FPL. In Iowa, 27
percent of buy-in beneficiaries paid premiums, while in Connecticut 12
percent pay premiums. Although some officials noted that charging
premiums created some administrative complexities for the states, these
respondents did not believe that premium levels were high enough to
deter program participation.

**[IV. Key Policy Issues]{.underline}**

The current relationship between Medicaid and persons with disabilities
who want to work raises a number of policy concerns, including both
broad policy issues and more technical questions raised by TWWIIA.

**A. Broad Policy Issues**

The broad policy issues include the current fiscal difficulties of the
states and its implications for Medicaid, the variation in coverage
across states and eligibility groups, the availability of needed
Medicaid services, the use of a work rather than a functional definition
of disability to determine eligibility, and the interactions between
SSDI and Medicaid.

[1. Fiscal Crisis of the States and Medicaid]{.underline}

Battered by declining revenues and sharply rising Medicaid costs, states
are now facing one of the most severe fiscal crises of the last fifty
years.[^23] States face budget shortfalls of more than \$80 billion in
fiscal year 2004.[^24] In part because Medicaid is designed to be a
counter-cyclical program (i.e., as unemployment rises and incomes drop
in an economic downturn, more people become eligible for Medicaid), its
spending has been growing much faster than overall state spending.[^25]
Because of the fiscal pressures that they face, most states are
considering cutting Medicaid, which accounts for about a fifth of state
spending.[^26] As noted above, our case study states indicate that the
Medicaid work incentives have very broad and bipartisan support and are
not currently targets for budget cuts, although there are some
discussions of increasing premiums under the BBA and TWWIIA options. One
state, Florida, is not implementing its planned coverage of work
incentives for persons with disabilities. If state finances continue to
decline, however, more states may eliminate this optional coverage. Over
the long run, it will be difficult for states to sustain the projected
expenditures growth rate for Medicaid, over 40 percent of which is due
to persons with disabilities. The fiscal problems of the states may also
reduce the interest of states not currently participating in the BBA or
TWWIIA buy-in options from doing so.

[2. Horizontal Equity Across States and Groups]{.underline}

The Medicaid program is a mixture of federal requirements and state
options. The relative balance of those two features is a matter of
dispute. National observers tend to emphasize the great variation across
states in Medicaid coverage and other factors, while states tend to
emphasize (and chafe under) the uniform federal requirements.[^27] State
flexibility is usually justified as a way of better matching local
preferences with program design. While states must provide Medicaid
coverage to working persons with disabilities mandated under Section
1619(b) of the Social Security Act, eligibility under the BBA and TWWIIA
is optional and states have great flexibility in how they implement the
statutory provisions. As a result, while 27 states have implemented
either the BBA or TWWIIA optional categories (or a Medicaid section 1115
research and demonstration waiver), 23 states and the District of
Columbia have adopted neither. Even within states that have elected to
cover these groups, there is variation in income and resource standards
and methodologies and in premiums charged. As a result, identical
individuals will be eligible for Medicaid in some states, but not in
others, raising issues of horizontal equity (i.e., are similar
individuals treated the same?). The key question is whether Americans
believe that there is enough of a national interest in providing health
and long-term care to working people with disabilities to mandate
uniform national coverage or is the current state discretion acceptable.
In the current policy environment, federal mandates are in disfavor, but
it is unlikely that all (or even additional) states will adopt these
eligibility options without it being made a federal requirement.[^28]
Many states adopted these coverage options when state coffers were full;
the state fiscal crisis means that money is not available for
eligibility expansions. Some states are also fearful of their fiscal
liability of providing Medicaid eligibility to a potentially large
population of working people with disabilities.

A different but related issue is that of equity across eligibility
groups covered by Medicaid. There is substantial variation across groups
in the Medicaid financial eligibility standards within states as well as
across states. For example, income eligibility standards for nondisabled
parents (generally covered under Temporary Assistance for Needy Families
or related groups) are far below that for people who are aged, blind and
disabled. For example, in order to qualify for Medicaid in the median
state, a working parent can only earn 66 percent of the FPL.[^29] The
Medicaid work incentives add to that differential, both by setting
higher income and resource standards and by using much more liberal
methodologies to calculate financial status. The expanded Medicaid
eligibility for disabilities is justifiable as a way to encourage
individuals to work or to return to work, but people of all incomes and
disability status need health insurance coverage. The key policy
question is whether it is equitable only to provide the more generous
eligibility to working people with disabilities. As states consider
cutting their Medicaid programs in order to balance their budgets,
issues of equity across eligibility groups may become more prominent.

## Coverage of Needed Services, Especially Home and Community-Based Services

People with disabilities need a wide range of medical and long-term care
services, which states do not always cover as part of their Medicaid
program. This is particularly an issue for noninstitutional long-term
care services. While home health is a mandatory service, personal care
services and services available under Medicaid home and community-based
services waivers are optional to the states. In 1998-1999, 25 states and
the District of Columbia covered personal care as an optional
benefit.[^30] In addition, 44 states and the District of Columbia
offered personal care as part of a home and community-based services
waiver; all of the remaining states offered personal care as an optional
benefit as part of the regular Medicaid program. In some cases, these
services may only be provided in an individual's home and not in the
workplace or the community, reducing their utility for working people
with disabilities.[^31]

States and persons with disabilities are drawn to home and
community-based services waivers, in part, because they allow Medicaid
coverage of an exceptionally broad range of services, including many
non-medical services not normally covered by Medicaid. Services that may
be covered under the waivers include case management, homemaker/home
health aide services, personal care services, adult day health,
habilitation, respite care, non-medical transportation, home
modifications, adult day care, and other services approved by the
Secretary of the Department of Health and Human Services. In 2003, all
50 states and the District of Columbia had a Medicaid home and community
services waiver for older people and younger persons with disabilities
and for persons with developmental disabilities (principally mental
retardation). However, like other aspects of Medicaid, states vary in
the degree to which they used waivers to fund home and community
services. States may provide home and community-based services waivers
to the BBA and TWWIIA coverage groups by amending an existing waiver or
establishing a new one.

The waivers have three major constraints that limit their utility for
working people with disabilities. First, because the waivers are
intended to substitute home and community-based services for
institutional care, states must limit these waiver programs to
beneficiaries meeting the state's level of care criteria for nursing
homes, intermediate care facilities for the mentally retarded, or
hospital services.[^32] For the older population and younger adults with
physical disabilities, the comparison institution is almost always a
nursing home. Thus, persons with disabilities who do not need that level
of care, but still have significant needs, are ineligible for the
waiver.

Second, a related problem affects persons with mental illness. Federal
law and regulation require that average Medicaid expenditures for waiver
beneficiaries must be the same or less than they would have been without
the waiver. Under current regulations, this is determined by comparison
to the average Medicaid costs of the relevant institutional providers.
Since Medicaid does not cover "institutions for mental diseases" (e.g.,
psychiatric hospitals) for persons aged 22-64, it is extremely difficult
for states to meet this standard for working age persons with mental
illness since there are few expenditures. As a result, there are not
many waiver programs that focus on persons with this disability.

Third, home health and personal care services offered under the regular
Medicaid program must be offered as an open-ended entitlement---a legal
obligation on the part of government to provide services to individuals
who meet pre-established criteria regardless of the cost to the
government. This characteristic makes states potentially vulnerable to
large expenditure increases due to increased demand by the high
percentage of people with disabilities in the community who are not
receiving paid services.[^33] In contrast to the regular Medicaid
program, home and community-based services wavers are not individual
entitlements and states must limit in advance how many people they will
serve during the course of a year. Since waiver programs are not
entitlements, states may and do establish waiting lists and may
establish programs on less than a statewide basis.[^34] Thus, even in
states with home and community-based services waivers, people with
disabilities may not be able to access needed services.

#### [4. Defining Disability: Inability to Work vs. Functional Impairment]{.underline}

Eligibility for Medicaid, including the BBA and TWWIIA provisions, is
tightly linked to SSI (and SDDI) rules defining disability. Under SSI
law, an individual is considered to be disabled if he or she is unable
to work. As a result, there is an inherent contradiction in determining
that a person is disabled (i.e., meets the SSI disability standard)
while the individual is working. State disability determination agencies
and SSA must use a standard intended to prove a person cannot work while
ignoring the fact that individuals are, in fact, working. These
eligibility standards are contradictory and act as a work disincentive.
While an inability to work standard may make sense for a program that
provides a cash substitute for earned income, it is a less useful
measure of need for medical and long-term care services, where
functional and diagnostic measures are more commonly used to establish
eligibility.

[5. Interaction with Social Security Disability Insurance (SSDI) and
Medicare]{.underline}

While Medicaid policy is dominated by its link to SSI, many people
obtaining Medicaid eligibility under the BBA and TWWIIAA are SSDI
beneficiaries, most of whom are eligible for Medicare. Social Security
Disability Insurance (SSDI) is a federal, nonmeans-tested disability
insurance program for workers who have a substantial Social
Security-covered work history and have become disabled or blind before
retirement age. To ease the transition off cash benefits, SSDI
beneficiaries have a "trial work period" of nine months during which a
person may work and continue to receive SSDI cash benefits and an
"extended eligibility period" of 36 months during which a person may
work, and if necessary, return to their SSDI status if employment fails
without having to reapply.

###### SSDI beneficiaries are entitled to Medicare benefits after a two-year waiting period. SSDI beneficiaries who lose cash benefits due to increased work effort, but still have a disabling condition, are covered by Medicare for at least 93 months after they have completed the 9 month trial work period. The Medicare hospital insurance (Part A) is free, while beneficiaries have to pay the normal premium for medical insurance (Part B). 

The work incentives for SSDI are different than for SSI, which raises at
least three Medicaid and work effort issues. First, unlike SSI
beneficiaries who have a gradual reduction in benefits and extended
eligibility for Medicaid when they have significant earnings, SSDI
beneficiaries face a "cash cliff," a precipitous loss of cash assistance
when they earn more than the "substantial gainful activity" level. They
also face an eventual loss of Medicare benefits. As noted above,
preliminary data from the case study states suggest that significant
numbers of persons participating in Medicaid buy-in programs may
increase their disposable incomes but are unwilling to earn more than
the SGA, perhaps because their eligibility for SSDI will be jeopardized
by doing so. In one study, only 14 percent of Medicaid buy-in programs
had earnings over the SGA.[^35] Thus, the existing rules may limit the
work effort of SSDI beneficiaries who participate in the Medicaid buy-in
program. To address this issue, the TWWIIA mandated a demonstration that
would reduce SSDI by \$1 in benefits for every \$2 earned, making SSDI
more like SSI in its cash work incentives.

Second, a major effect of the Medicaid buy-in program is likely to be to
increase the disposable income of SSDI recipients. SSDI-only
beneficiaries will be able to obtain Medicaid without having to "spend
down" under the medically needy or 209(b) coverage options.[^36] Without
having to spend as much on medical care, the disposable income of these
individuals is likely to be higher than before.

Third, in contrast to Medicaid, where an individual receives coverage so
long as he or she meets the eligibility standards, the continuing
Medicare coverage for working people with disabilities is time limited.
Thus, in deciding whether to work and how much, SSDI beneficiaries must
consider whether they believe they will ultimately be able to obtain
private health insurance to replace their Medicare coverage and, if not,
whether they believe they will be able to qualify for Medicaid under the
buy-in or some other pathway. For state Medicaid agencies, the end of
Medicare coverage means that they will have to pay for the hospital,
physician and other services that Medicare would otherwise cover, which
can be expensive.

## **B. TWWIIA Design Issues**

##  In addition to the broad, macro policy issues, there are a number of more technical issues affecting the Medicaid buy-in options and work incentives for people with disabilities. These include the definition of employment, the age restriction under TWWIIA, and the required premium payments. 

## 1. Definition of Employment

As discussed above, states are prohibited from setting minimum number of
hours or earnings in defining whether an individual with disabilities is
employed and therefore eligible for the Medicaid buy-in options. Some
state officials have expressed a concern that persons with only nominal
work activity or earnings may be qualifying for Medicaid under these
provisions, which they believe is inconsistent with the intent of the
statute. These officials view this low level of work as problematic
because the financial eligibility criteria for working people with
disabilities are considerably more liberal than they are for other
categories of individuals and they believe it is unfair to grant
eligibility to persons who are not "really working." On the other hand,
more strictly defining eligibility would eliminate medical and long-term
care coverage for some individuals, who most likely would become
uninsured or would reduce their work effort. In addition, some people
with disabilities may need to "walk" before they can "run," and a low
initial level of work effort may be part of a process which may
eventually lead to a greater level of labor force involvement.

[2. Age Restriction Under TWWIIA]{.underline}

Under TWWIIA, eligibility for the basic coverage group and the medical
improvement group is limited to persons aged 16-64; there is no age
restriction under the BBA group. Under the TWWIIA options, working
people with disabilities who are or who become age 65 or older are
ineligible for Medicaid coverage under the TWWIIA options. Thus,
individuals with disabilities who are working with the aid of the
Medicaid services will no longer be able to be employed until or unless
they qualify for Medicaid through other eligibility categories (e.g.,
BBA, medically needy or poverty level coverage for persons aged 65 and
older). In general, individuals will have to qualify under much stricter
income and resource rules than are available under TWWIIA, and it is
likely that some individuals will have to significantly deplete their
resources before they can qualify. While this issue is likely to affect
only a small number of people for the foreseeable future, the age
restriction creates long-term disincentives for people with disabilities
to return to work because they know that they may be unable to retain
coverage beyond age 65. In addition, the provision limits their
incentives to accumulate assets since they may have to deplete those
resources to qualify for Medicaid under other coverage rules.

[3. Premiums]{.underline}

Most states impose premiums on higher income beneficiaries participating
in BBA and TWWIIA Medicaid work incentives. The rationale for doing so
is to make Medicaid more like regular health insurance, where most
workers have to pay a premium, and to impose some personal
responsibility for health care coverage on working people with
disabilities.[^37] Premiums also offset the state costs to some extent.
State staff believe that the premiums are modest and that the financial
requirements have not deterred program participation. However, in the
case study states, it is also true that the vast majority of
beneficiaries have earnings below the level for which premiums are
required. It should be noted that studies of the nondisabled population
have found that out-of-pocket premiums can deter people from enrolling
in health insurance programs.[^38] Arguably, however, health and
long-term care coverage is more important to people with disabilities
than people without disabilities and, therefore, cost less of an
impediment to participation.

**[V. Conclusions]{.underline}**

It has long been recognized that the potential loss of health benefits
under Medicare and Medicaid is a deterrent to people with disabilities
entering or re-entering the labor force. Although people with
disabilities are generally not "sick," they often have conditions that
require substantial use of medical and long-term care services. Thus,
the potential consequences of loss of medical benefits can be
significant and have prevented individuals on SSI and SSDI from working.

Even though there have been work incentives in Medicaid through Section
1619(b) of the Social Security Act for many years, the BBA and the
TWWIIA added greatly to the ability of younger persons with disabilities
to work and still retain Medicaid coverage. In general, states adopting
these options have been relatively liberal in setting income and
resource standards and methodologies (at least compared to regular
Medicaid eligibility requirements), allowing persons with income well
beyond the "significant gainful employment" level to receive Medicaid
coverage. In general, state officials and consumer advocates interviewed
for the case studies in this report were satisfied with federal rules
and options and did not have proposals for major changes.

An assessment of how well the incentives are working depends on whether
one views the current experience as the beginning or the end of the
process of integrating people with disabilities into the labor force. On
the one hand, state enrollment levels are generally modest as are the
earnings and work efforts of beneficiaries. Only a small minority of
buy-in beneficiaries appear to be engaged in full-time employment or
something close to it. Most beneficiaries appear to be working at much
below the SGA level, which may indicate a fear of loosing cash benefits,
especially SSDI payments.

On the other hand, states and people with disabilities are just
beginning to gain experience with the TWWIIA work incentives and with an
overall change in attitudes towards work by people with disabilities and
by society as a whole. State respondents emphasized that the Medicaid
eligibility expansions in many states have been in place for less than
18 months and are just beginning to mature. Moreover, there may be a
generational divide in attitudes towards work between people who have
been on SSI or SSDI for long periods of time and persons who are just
coming on the rolls.

The interaction between Medicaid and work incentives have raised a
number of broad policy issues:

-   Almost all states are experiencing severe budget shortfalls. In
    order to close these gaps, they are almost certain to cut Medicaid.
    While the Medicaid buy-in programs appear to be protected for the
    short-term, a major consideration is whether states will require
    additional federal revenues in order to retain current coverage, let
    alone to expand it.

-   While about half of the states have adopted either the BBA or TWWIIA
    provisions, half have not. Because the work incentive coverage
    provisions are not mandatory, it seems unlikely, especially in the
    current fiscal environment, that all states will cover these
    Medicaid eligibility options unless required to do so or receive
    significant additional funding. This state variation raises
    questions of horizontal equity across the states.

-   An issue similar to the coverage of eligibility groups concerns the
    coverage of services needed by persons with disabilities. States
    have broad discretion in what services they cover. Some states cover
    a lot; others cover relatively little. This again raises questions
    of horizontal equity.

-   For work incentives programs, there is a fundamental inconsistency
    in measuring disability by an inability to work. Inability to work
    has a logical relationship to cash benefits, but it does not
    distinguish who most needs medical and long-term care benefits. A
    more functional definition of disability might do a better job of
    identifying people who most need these services, without pushing
    individuals to stop working.

```{=html}
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-   While Medicaid has the most experience interacting with SSI,
    Medicaid involvement with SSDI and Medicare is also consequential
    for work incentives. It would appear that the abrupt ending of SSDI
    cash benefits when earnings reach a specific level has a deterrent
    effect on the amount of work in which beneficiaries are willing to
    engage under the Medicaid options. Advocates of change would like
    SSDI to be closer to the SSI model of gradual loss of cash benefits,
    while opponents contend that doing so could be costly.

As policymakers review the experience with BBA and TWWIIA Medicaid
options, there are also a number of specific issues that should be
considered.

-   While states are not actively seeking to trim persons from the
    rolls, many observers noted that the minimum level of employment for
    the basic coverage group was so low that it ended up including a
    significant proportion of people who did not have "real jobs."
    Advocates of tightening the definition of employment contend that
    coverage of persons with minor levels of employment is inconsistent
    with the goals of the program and unfair to other groups who do not
    enjoy such generous Medicaid eligibility criteria. On the other
    hand, opponents of tightening the definition of employment argue
    that many persons may need to start employment slowly before they
    are able to work more extensively.

-   Under the TWWIIA eligibility options, Medicaid coverage cannot be
    offered to persons age 65 or older. Advocates of eliminating the
    restriction contend that society needs to encourage older people to
    work. Opponents note that people generally do not work after age 65
    and that Medicaid has numerous other eligibility options for older
    people, albeit not as generous as those offered under TWWIIA.

-   Most states impose premiums on higher-income Medicaid beneficiaries
    who are eligible under BBA and TWWIIA. To some observers, it is only
    fair that higher income beneficiaries help contribute to the cost of
    their care. However, some policy analysts worry that the premiums
    are a barrier to participation.

People with disabilities are increasingly entering the workforce as
people with disabilities demand new opportunities and society changes
its conceptions about what persons with disabilities can and should do.
A key component of helping working people with disabilities is providing
the health and long-term care services that they need. Federal Medicaid
law sets a framework to help people work, but that structure has not yet
resulted in a large movement from SSI and SSDI to work.

Endnotes

![](media/image1.wmf){width="5.9944444444444445in"
height="7.922916666666667in"}

**Table 2: 1619(b) Thresholds by State, 2003**

 

**Persons with Disabilities**

 

Alabama: \$17,348.00

Alaska: \$36,310.00

Arizona: \$21,586.00

Arkansas: \$20,682.00

California: \$26,837.00

Colorado: \$30,728.00

Connecticut: \$39,727.00

Delaware: \$24,654.00

District of Columbia: \$31,765.00

Florida: \$20,234.00

Georgia: \$19,555.00

Hawaii: \$20,886.00

Idaho: \$25,162.00

Illinois: \$26,001.00

Indiana: \$28,346.00

Iowa: \$21,146.00

Kansas: \$25,546.00

Kentucky: \$21,307.00

Louisiana: \$20,762.00

Maine: \$22,454.00

Maryland: \$25,205.00

Massachusetts: \$28,766.00

Michigan: \$22,265.00

Minnesota: \$31,389.00

Mississippi: \$19,575.00

Missouri: \$25,559.00

Montana: \$20,537.00

Nebraska: \$25,303.00

Nevada: \$29,067.00

New Hampshire: \$41,514.00

New Jersey: \$27,144.00

New Mexico: \$22,785.00

New York: \$34,136.00

North Carolina: \$25,795.00

North Dakota: \$28,410.00

Ohio: \$26,424.00

Oklahoma: \$21,200.00

Oregon: \$25,508.00

Pennsylvania: \$21,796.00

Rhode Island: \$31,632.00

South Carolina: \$21,591.00

South Dakota: \$24,977.00

Tennessee: \$17,787.00

Texas: \$22,452.00

Utah: \$19,612.00

Vermont: \$23,756.00

Virginia: \$21,778.00

Washington: \$20,345.00

West Virginia: \$20,862.00

Wisconsin: \$23,151.00

Wyoming: \$18,990.00

North Mariana Island: \$14,268.00

 

**Blind**

 

California: \$28,325.00

Iowa: \$21,674.00

Massachusetts: \$29,615.00

Nevada: \$31,690.00

Oregon: \$26,108.00

Source: Social Security Administration.

**Table 3: Basic Rules of Medicaid Work Incentives Under Balanced Budget
Act and Ticket to Work and Work Incentives Improvement Act of 1999**

+--------------+---------------+-------------------+-------------------+
|              | **BBA**       | **TWWIIA**        | **TWWIIA Medical  |
|              |               |                   | Improvement       |
|              |               | **Basic Coverage  | Group**           |
|              |               | Group**           |                   |
+==============+===============+===================+===================+
| Who Can Be   | Disabled      | Disabled          | Employed          |
| Covered?     | individuals   | individuals age   | individuals with  |
|              |               | 16 through 64     | a medically       |
|              |               |                   | determinable      |
|              |               |                   | severe impairment |
|              |               |                   | who lose          |
|              |               |                   | eligibility under |
|              |               |                   | the XV group      |
|              |               |                   | because they are  |
|              |               |                   | no longer         |
|              |               |                   | disabled.         |
+--------------+---------------+-------------------+-------------------+
| Income       | **1.** 250    | State establishes | State establishes |
| standard     | percent of    | its own standard. | its own standard. |
|              | the Federal   |                   |                   |
|              | poverty level | All earned income | All earned income |
|              | for family.   | disregarded.      | disregarded.      |
|              |               |                   |                   |
|              | **2.** If (1) | State can choose  | State can choose  |
|              | is met, the   | not to have an    | not to have an    |
|              | applicant\'s  | income standard.  | income standard.  |
|              | unearned      |                   |                   |
|              | income is     |                   |                   |
|              | less than SSI |                   |                   |
|              | FBR           |                   |                   |
|              | (currently    |                   |                   |
|              | \$512 a month |                   |                   |
|              | for an        |                   |                   |
|              | individual,   |                   |                   |
|              | \$769 for a   |                   |                   |
|              | couple). All  |                   |                   |
|              | earned income |                   |                   |
|              | is            |                   |                   |
|              | disregarded.  |                   |                   |
+--------------+---------------+-------------------+-------------------+
| Resource     | SSI resource  | State establishes | State establishes |
| standard     | standard      | its own standard. | its own standard. |
|              | (\$2,000 for  |                   |                   |
|              | individual,   | State can choose  | State can choose  |
|              | \$3,000 for   | not to have a     | not to have a     |
|              | couple).      | resource          | resource          |
|              |               | standard.         | standard.         |
+--------------+---------------+-------------------+-------------------+
| Rules for    | SSI rules and | If State          | If State          |
| determining  | methodologies | establishes       | establishes       |
| eligibility  |               | income and/or     | income and/or     |
|              |               | resource          | resource          |
|              |               | standards, SSI    | standards, SSI    |
|              |               | rules and         | rules and         |
|              |               | methodologies     | methodologies     |
|              |               | apply.            | apply.            |
|              |               |                   |                   |
|              |               | If State chooses  | If State chooses  |
|              |               | not to establish  | not to establish  |
|              |               | income and        | income and        |
|              |               | resource          | resource          |
|              |               | standards, no     | standards, no     |
|              |               | rules or          | rules or          |
|              |               | methodologies     | methodologies     |
|              |               | apply.            | apply.            |
+--------------+---------------+-------------------+-------------------+
| Use of more  | Yes           | Yes               | Yes               |
| restrictive  |               |                   |                   |
| eligibility  |               |                   |                   |
| rules than   |               |                   |                   |
| SSI (209(b)  |               |                   |                   |
| States)      |               |                   |                   |
+--------------+---------------+-------------------+-------------------+
| Use of more  | Yes. States   | Yes. States that  | Yes. States that  |
| liberal      | can disregard | establish an      | establish an      |
| income and   | additional    | income and/or     | income and/or     |
| resource     | income        | resource standard | resource standard |
| m            | (earned or    | can disregard     | can disregard     |
| ethodologies | unearned)     | additional income | additional income |
| than SSI     | and/or        | and/or resources  | and/or resources  |
| (section     | resources in  | if they choose to | if they choose to |
| 1902(r)(2)). | either/both   | do so.            | do so.            |
|              | the 250       |                   |                   |
|              | percent       | FFP limits do not | FFP limits do not |
|              | family income | apply to income   | apply to income   |
|              | test and the  | disregards.       | disregards.       |
|              | individual    |                   |                   |
|              | eligibility   |                   |                   |
|              | d             |                   |                   |
|              | etermination. |                   |                   |
|              |               |                   |                   |
|              | States can    |                   |                   |
|              | disregard all |                   |                   |
|              | income and    |                   |                   |
|              | resources if  |                   |                   |
|              | they choose   |                   |                   |
|              | to do so.     |                   |                   |
|              |               |                   |                   |
|              | FFP limits do |                   |                   |
|              | not apply to  |                   |                   |
|              | income        |                   |                   |
|              | disregards.   |                   |                   |
+--------------+---------------+-------------------+-------------------+
| Premiums and | States        | **1.** States     | **1.** States     |
| cost-sharing | [may          | [may]{.underline} | [may]{.underline} |
| charges      | ]{.underline} | (but are not      | (but are not      |
|              | require       | required to)      | required to)      |
|              | payment of    | require payment   | require payment   |
|              | premiums and  | of premiums and   | of premiums and   |
|              | other         | other             | other             |
|              | cost-sharing  | cost-sharing      | cost-sharing      |
|              | charges on a  | charges on a      | charges on a      |
|              | sliding scale | sliding scale     | sliding scale     |
|              | based on      | based on income.  | based on income.  |
|              | income.       |                   |                   |
|              |               | **2.** For        | **2.** For        |
|              | States are    | individuals with  | individuals with  |
|              | not required  | income over       | income over       |
|              | to collect    | 250percent of the | 250percent of the |
|              | premiums or   | poverty level,    | poverty level,    |
|              | cost-sharing  | States            | States            |
|              | charges.      | [may]{.underline} | [may]{.underline} |
|              |               | (but are not      | (but are not      |
|              |               | required to)      | required to)      |
|              |               | charge 100        | charge 100        |
|              |               | percent of        | percent of        |
|              |               | premiums.         | premiums.         |
|              |               |                   |                   |
|              |               | If the State      | If the State      |
|              |               | chooses to        | chooses to        |
|              |               | charge100 percent | charge100 percent |
|              |               | of premiums for   | of premiums for   |
|              |               | these             | these             |
|              |               | individuals,      | individuals,      |
|              |               | there is a limit  | there is a limit  |
|              |               | on the total      | on the total      |
|              |               | amount of         | amount of         |
|              |               | premiums of 7.5   | premiums of 7.5   |
|              |               | percent of their  | percent of their  |
|              |               | income if their   | income if their   |
|              |               | income is less    | income is less    |
|              |               | than 450 percent  | than 450 percent  |
|              |               | of the poverty    | of the poverty    |
|              |               | level.            | level.            |
|              |               |                   |                   |
|              |               | **3.** States     | **3.** States     |
|              |               | [                 | [                 |
|              |               | must]{.underline} | must]{.underline} |
|              |               | charge 100        | charge 100        |
|              |               | percent of        | percent of        |
|              |               | premiums for any  | premiums for any  |
|              |               | individual whose  | individual whose  |
|              |               | adjusted gross    | adjusted gross    |
|              |               | annual income (as | annual income (as |
|              |               | defined under IRS | defined under IRS |
|              |               | rules) exceeds    | rules) exceeds    |
|              |               | \$75,000.         | \$75,000.         |
|              |               |                   |                   |
|              |               | This requirement  | This requirement  |
|              |               | applies           | applies           |
|              |               | regardless of     | regardless of     |
|              |               | whether a State   | whether a State   |
|              |               | charges premiums  | charges premiums  |
|              |               | and cost-sharing  | and cost-sharing  |
|              |               | under (1) or (2)  | under (1) or (2)  |
|              |               | above.            | above.            |
+--------------+---------------+-------------------+-------------------+
| Maintenance  | No            | Required          | Required          |
| of effort -  | requirement   |                   |                   |
| States must  |               |                   |                   |
| demonstrate  |               |                   |                   |
| that they    |               |                   |                   |
| are          |               |                   |                   |
| maintaining  |               |                   |                   |
| funding for  |               |                   |                   |
| programs     |               |                   |                   |
| (other than  |               |                   |                   |
| Medicaid) to |               |                   |                   |
| assist       |               |                   |                   |
| disabled     |               |                   |                   |
| individuals  |               |                   |                   |
| who want to  |               |                   |                   |
| work.        |               |                   |                   |
+--------------+---------------+-------------------+-------------------+

Source: Centers for Medicare & Medicaid Services,
<http://cms.hhs.gov/twwiaa/comchart.asp>, accessed January 6, 2003.

  ------------- ------------- ------------- -------------- -------------- ----------------- ---------------
  **Table 4:                                                                                
  Medicaid                                                                                  
  Buy-In                                                                                    
  Policies and                                                                              
  Enrollments                                                                               
  as of June                                                                                
  30, 2002**                                                                                

  **State**     **Type**      **Effective   **Date of      **June 30,2002 **Income          **Resource
                              Date**        1^st^          Enrollment**   Disregards and    Disregards and
                                            Enrollment**                  Policies**        Policies**

                                                                                            

  Alaska        BBA 1997      04/01/99      07/01/99       143            Payments received Up to \$2,000
                                                                          from the Alaska   per individual
                                                                          Longevity Bonus   per year in
                                                                          Program are       distributions
                                                                          disregarded to    from Alaska
                                                                          the extent the    Native Claims
                                                                          payment does not  Settlement Act
                                                                          cause total gross corporations is
                                                                          income to exceed  excluded.
                                                                          300 percent of    Dividends and
                                                                          the SSI FBR. All  benefit
                                                                          earned income of  payments from
                                                                          a spouse or other the Alaska
                                                                          family member of  Permanent Fund
                                                                          the disabled      Dividend
                                                                          individual is     Program are
                                                                          excluded.         excluded.

  Arkansas      TWWIIA Basic  02/01/01      N/A            70             An applicant's    \$10,000 in
                Coverage                                                  income cannot     savings for
                                                                          exceed 250% of    special
                                                                          the federal       purposes are
                                                                          poverty level for disregarded
                                                                          a family.         that is
                                                                                            approved by
                                                                                            Human Services.
                                                                                            Countable
                                                                                            assets may be
                                                                                            increase up to
                                                                                            \$6000 for an
                                                                                            individual and
                                                                                            up to \$6400
                                                                                            for a family of
                                                                                            four.

  California    BBA 1997      04/01/01      N/A            500            All disability    There are no
                                                                          income of the     resource
                                                                          disabled          disregards.
                                                                          individual is     
                                                                          disregarded       
                                                                          (e.g., federal    
                                                                          and state         
                                                                          disability income 
                                                                          and private       
                                                                          disability income 
                                                                          such as indemnity 
                                                                          payment from an   
                                                                          insurance company 
                                                                          based on the      
                                                                          individual's      
                                                                          disability.)      

  Connecticut   TWWIIA Basic  10/01/00      10/01/00       2,306          An applicant's    An individual's
                Coverage                                                  yearly income     retirement
                /Medical                                                  must be less than accounts,
                Improvement                                               \$75,000 per      Medical savings
                                                                          year. Assets of   accounts and
                                                                          \$10,000 for and  employability
                                                                          individual and    accounts are
                                                                          \$15,000 for a    all
                                                                          couple are        disregarded.
                                                                          disregarded.      

  Florida       TWWIIA Basic  04/01/02      N/A            \*             No Info on CMS    
                Coverage                                                  website.          

  Illinois      TWWIIA Basic  12/01/01      N/A            82             No Info on CMS    
                Coverage                                                  website.          

  Indiana       TWWIIA Basic  07/01/02      N/A            \*             No Info on CMS    
                Coverage/                                                 website.          
                Medical                                                                     
                Improvement                                                                 

  Iowa          BBA 1997      03/01/00      03/01/00       4,092          In order to be    A resource
                                                                          eligible, an      disregard of
                                                                          applicant's       \$12,000
                                                                          income cannot     applies to
                                                                          exceed 250% of    individuals and
                                                                          the federal       a disregard of
                                                                          poverty limit.    \$13,000
                                                                          Unearned income   applies to
                                                                          is disregarded    couples.
                                                                                            Medical savings
                                                                                            accounts are
                                                                                            allowable if
                                                                                            they are IRS
                                                                                            exempt.
                                                                                            Retirement and
                                                                                            Assistive
                                                                                            technology
                                                                                            savings
                                                                                            accounts are
                                                                                            disregarded.
  ------------- ------------- ------------- -------------- -------------- ----------------- ---------------

  --------------- -------------- ------------- -------------- -------------- ----------------- --------------
  **State**       **Type**       **Effective   **Date of      **June 30,2002 **Income          **Resource
                                 Date**        1^st^          Enrollment**   Disregards and    Disregards and
                                               Enrollment**                  Policies**        Policies**

  Kansas          TWWIIA Basic   07/01/02      N/A            **\***         Coverage group:   Assets of up
                  Coverage                                                   Working           to \$15,000
                                                                             individuals with  
                                                                             disabilities,     
                                                                             ages 16-64.       
                                                                             Family incomes up 
                                                                             to 300 percent of 
                                                                             the federal       
                                                                             poverty level.    

  Maine           BBA 1997       08/01/99      08/01/99       755            Disregard         Disregard all
                                                                             unearned income   assets less
                                                                             exceeding the     than \$8,000
                                                                             SSI/SSP income    for an
                                                                             standard that is  individual or
                                                                             up to and         \$12,000 for a
                                                                             including 100     couple.
                                                                             percent of the    
                                                                             FPL.              

  Massachusetts   1115 Waiver    07/01/97      N/A            6,227          No Info on CMS    
                                                                             website.          

  Minnesota       TWWIIA Basic   07/01/99      07/01/99       5,840          The state will    Allowable
                  Coverage\*\*                                               offer Medicaid to resources up
                                                                             anyone working    to \$20,000
                                                                             with a disability for an
                                                                             age 18 through 64 individual.
                                                                             with family       
                                                                             income up to 250  
                                                                             percent of the    
                                                                             federal poverty   
                                                                             level (FPL).      

  Mississippi     BBA 1997       07/01/99      N/A            345            In order to be    A resource
                                                                             eligible, an      disregard of
                                                                             applicant's       \$4,000
                                                                             income cannot     applies to
                                                                             exceed 250\$ of   individuals
                                                                             the federal       and a
                                                                             poverty limit     disregard of
                                                                                               \$6,000
                                                                                               applies to
                                                                                               couples.
                                                                                               Retirement
                                                                                               accounts are
                                                                                               disregarded if
                                                                                               they are
                                                                                               through an
                                                                                               employer

  Missouri        TWWIIA Basic   07/01/02      N/A            \*             No Info on CMS    
                  Coverage/                                                  website.          
                  Medical                                                                      
                  Improvement                                                                  

  Nebraska        BBA 1997       06/06/00      07/01/99       88             In determining    Disregard an
                                                                             eligibility under additional
                                                                             the individual    \$2,000 in
                                                                             income test,      resources for
                                                                             disregard all     an individual
                                                                             earnings, plus    and an
                                                                             unearned income   additional
                                                                             contingent upon a \$3,000 in
                                                                             trial work period resources for
                                                                             (such as a Social a couple.
                                                                             Security Trial    
                                                                             Work Period).     

  New Hampshire   TWWIIA Basic   02/01/02      02/01/02       640            The state will    Allowable
                  Coverage                                                   offer Medicaid to resources up
                                                                             anyone working    to \$20,000
                                                                             with a disability for an
                                                                             age 18 through 64 individual and
                                                                             with a family     \$30,000 for a
                                                                             income up to 450  couple.
                                                                             percent of the    
                                                                             federal poverty   
                                                                             level (FPL).      

  New Jersey      TWWIIA Basic   10/01/00      N/A            405                              
                  Coverage                                                                     

  New Mexico      BBA 1997       01/01/01      01/01/01       621            An applicant's    An
                                                                             yearly income     individual's
                                                                             must be less than retirement
                                                                             250% of the       accounts are
                                                                             federal poverty   disregarded
                                                                             limit.            
  --------------- -------------- ------------- -------------- -------------- ----------------- --------------

+-------+------+-----+-------+---------+----------------+-----------+
| **St  | **Ty | **  | *     | **June  | **Income       | *         |
| ate** | pe** | Eff | *Date | 30,2002 | Disregards and | *Resource |
|       |      | ect | of    | Enrol   | Policies**     | D         |
|       |      | ive | 1^st^ | lment** |                | isregards |
|       |      | Dat | En    |         |                | and       |
|       |      | e** | rollm |         |                | P         |
|       |      |     | ent** |         |                | olicies** |
+-------+------+-----+-------+---------+----------------+-----------+
| Ve    | BBA  | 10  | 01/   | 365     | An applicant's | Disregard |
| rmont | 1997 | /01 | 01/00 |         | yearly income  | and       |
|       |      | /00 |       |         | must be less   | a         |
|       |      |     |       |         | than 250% of   | dditional |
|       |      |     |       |         | the federal    | \$12,000  |
|       |      |     |       |         | poverty limit. | in        |
|       |      |     |       |         |                | r         |
|       |      |     |       |         |                | esources. |
|       |      |     |       |         |                | An        |
|       |      |     |       |         |                | 'earnings |
|       |      |     |       |         |                | for       |
|       |      |     |       |         |                | working'  |
|       |      |     |       |         |                | savings   |
|       |      |     |       |         |                | account   |
|       |      |     |       |         |                | can be    |
|       |      |     |       |         |                | est       |
|       |      |     |       |         |                | ablished. |
|       |      |     |       |         |                | This      |
|       |      |     |       |         |                | money and |
|       |      |     |       |         |                | interest  |
|       |      |     |       |         |                | are       |
|       |      |     |       |         |                | dis       |
|       |      |     |       |         |                | regarded. |
+-------+------+-----+-------+---------+----------------+-----------+
| Washi | TW   | 01  | N/A   | \*      | The state will |           |
| ngton | WIIA | /01 |       |         | offer Medicaid |           |
|       | B    | /02 |       |         | to anyone      |           |
|       | asic |     |       |         | working with a |           |
|       | Cove |     |       |         | disability age |           |
|       | rage |     |       |         | 18 through 64  |           |
|       |      |     |       |         | with countable |           |
|       |      |     |       |         | income up to   |           |
|       |      |     |       |         | 220 percent of |           |
|       |      |     |       |         | the federal    |           |
|       |      |     |       |         | poverty level. |           |
+-------+------+-----+-------+---------+----------------+-----------+
| Wisc  | BBA  | 03  | N/A   | 2,660   | All of the     | \$13,000  |
| onsin | 1997 | /15 |       |         | applicant's    | in        |
|       |      | /00 |       |         | unearned       | resources |
|       |      |     |       |         | income, and    | is        |
|       |      |     |       |         | any unearned   | excluded. |
|       |      |     |       |         | income deemed  | Resources |
|       |      |     |       |         | available from | of an     |
|       |      |     |       |         | an ineligible  | i         |
|       |      |     |       |         | spouse, is     | neligible |
|       |      |     |       |         | disregarded in | spouse    |
|       |      |     |       |         | determining    | are       |
|       |      |     |       |         | whether the    | excluded. |
|       |      |     |       |         | 250 percent of | Funds     |
|       |      |     |       |         | the federal    | held in   |
|       |      |     |       |         | poverty income | an        |
|       |      |     |       |         | test is met.   | In        |
|       |      |     |       |         |                | dependent |
|       |      |     |       |         |                | Account   |
|       |      |     |       |         |                | are       |
|       |      |     |       |         |                | exc       |
|       |      |     |       |         |                | luded. 1) |
|       |      |     |       |         |                | Only      |
|       |      |     |       |         |                | deposits  |
|       |      |     |       |         |                | made      |
|       |      |     |       |         |                | after the |
|       |      |     |       |         |                | i         |
|       |      |     |       |         |                | ndividual |
|       |      |     |       |         |                | is        |
|       |      |     |       |         |                | eligible  |
|       |      |     |       |         |                | for       |
|       |      |     |       |         |                | Medicaid  |
|       |      |     |       |         |                | under the |
|       |      |     |       |         |                | BBA group |
|       |      |     |       |         |                | are       |
|       |      |     |       |         |                | excluded. |
|       |      |     |       |         |                | 2)        |
|       |      |     |       |         |                | Deposits  |
|       |      |     |       |         |                | cannot    |
|       |      |     |       |         |                | exceed 50 |
|       |      |     |       |         |                | percent   |
|       |      |     |       |         |                | of earned |
|       |      |     |       |         |                | income in |
|       |      |     |       |         |                | any       |
|       |      |     |       |         |                | calendar  |
|       |      |     |       |         |                | year. 3)  |
|       |      |     |       |         |                | Accounts  |
|       |      |     |       |         |                | must be   |
|       |      |     |       |         |                | separate  |
|       |      |     |       |         |                | from      |
|       |      |     |       |         |                | n         |
|       |      |     |       |         |                | on-exempt |
|       |      |     |       |         |                | resources |
|       |      |     |       |         |                | and are   |
|       |      |     |       |         |                | subject   |
|       |      |     |       |         |                | to prior  |
|       |      |     |       |         |                | approval  |
|       |      |     |       |         |                | by the    |
|       |      |     |       |         |                | State. 4) |
|       |      |     |       |         |                | Amounts   |
|       |      |     |       |         |                | deposited |
|       |      |     |       |         |                | and all   |
|       |      |     |       |         |                | gains,    |
|       |      |     |       |         |                | dividends |
|       |      |     |       |         |                | and       |
|       |      |     |       |         |                | interest  |
|       |      |     |       |         |                | earned in |
|       |      |     |       |         |                | an        |
|       |      |     |       |         |                | e         |
|       |      |     |       |         |                | mployer's |
|       |      |     |       |         |                | r         |
|       |      |     |       |         |                | etirement |
|       |      |     |       |         |                | fund and  |
|       |      |     |       |         |                | an        |
|       |      |     |       |         |                | ind       |
|       |      |     |       |         |                | ividual's |
|       |      |     |       |         |                | IRA       |
|       |      |     |       |         |                | account   |
|       |      |     |       |         |                | after     |
|       |      |     |       |         |                | becoming  |
|       |      |     |       |         |                | eligible  |
|       |      |     |       |         |                | for       |
|       |      |     |       |         |                | Medicaid  |
|       |      |     |       |         |                | qualify   |
|       |      |     |       |         |                | as part   |
|       |      |     |       |         |                | of an     |
|       |      |     |       |         |                | Ind       |
|       |      |     |       |         |                | ependence |
|       |      |     |       |         |                | Account   |
|       |      |     |       |         |                | if        |
|       |      |     |       |         |                | properly  |
|       |      |     |       |         |                | r         |
|       |      |     |       |         |                | egistered |
|       |      |     |       |         |                | with the  |
|       |      |     |       |         |                | State.    |
+-------+------+-----+-------+---------+----------------+-----------+
| Wy    | TW   | N/A | N/A   | \*      | Working        |           |
| oming | WIIA |     |       |         | Individuals    |           |
|       | B    |     |       |         | with a         |           |
|       | asic |     |       |         | disability     |           |
|       | Cove |     |       |         | ages 16-64     |           |
|       | rage |     |       |         | with incomes   |           |
|       |      |     |       |         | up to 100% of  |           |
|       |      |     |       |         | the Federal    |           |
|       |      |     |       |         | Poverty Level  |           |
|       |      |     |       |         | (FPL)          |           |
+-------+------+-----+-------+---------+----------------+-----------+
|       |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+
| ##    |      |     |       | 27,209  |                |           |
| Total |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+
|       |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+
| \*    |      |     |       |         |                |           |
| State |      |     |       |         |                |           |
| was   |      |     |       |         |                |           |
| not   |      |     |       |         |                |           |
| act   |      |     |       |         |                |           |
| ively |      |     |       |         |                |           |
| enro  |      |     |       |         |                |           |
| lling |      |     |       |         |                |           |
| on    |      |     |       |         |                |           |
| 6/    |      |     |       |         |                |           |
| 30/02 |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+
| \*\*  |      |     |       |         |                |           |
| Init  |      |     |       |         |                |           |
| ially |      |     |       |         |                |           |
| app   |      |     |       |         |                |           |
| roved |      |     |       |         |                |           |
| under |      |     |       |         |                |           |
| BBA   |      |     |       |         |                |           |
| 1997  |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+
| So    |      |     |       |         |                |           |
| urce: |      |     |       |         |                |           |
| Ce    |      |     |       |         |                |           |
| nters |      |     |       |         |                |           |
| for   |      |     |       |         |                |           |
| Med   |      |     |       |         |                |           |
| icare |      |     |       |         |                |           |
| and   |      |     |       |         |                |           |
| Med   |      |     |       |         |                |           |
| icaid |      |     |       |         |                |           |
| Serv  |      |     |       |         |                |           |
| ices. |      |     |       |         |                |           |
+-------+------+-----+-------+---------+----------------+-----------+

![](media/image2.wmf){width="5.227083333333334in"
height="1.2152777777777777in"}

+------+------+----------------------+---+--------------------------------+
| **   |      |                      |   |                                |
| Appe |      |                      |   |                                |
| ndix |      |                      |   |                                |
| 1:   |      |                      |   |                                |
| D    |      |                      |   |                                |
| emon |      |                      |   |                                |
| stra |      |                      |   |                                |
| tion |      |                      |   |                                |
| and  |      |                      |   |                                |
| In   |      |                      |   |                                |
| fras |      |                      |   |                                |
| truc |      |                      |   |                                |
| ture |      |                      |   |                                |
| G    |      |                      |   |                                |
| rant |      |                      |   |                                |
| Ac   |      |                      |   |                                |
| tivi |      |                      |   |                                |
| ties |      |                      |   |                                |
| Rel  |      |                      |   |                                |
| ated |      |                      |   |                                |
| to   |      |                      |   |                                |
| TWWI |      |                      |   |                                |
| IA** |      |                      |   |                                |
|      |      |                      |   |                                |
| **S  |      |                      |   |                                |
| tate |      |                      |   |                                |
| Pro  |      |                      |   |                                |
| gram |      |                      |   |                                |
| De   |      |                      |   |                                |
| scri |      |                      |   |                                |
| ptio |      |                      |   |                                |
| ns** |      |                      |   |                                |
+------+------+----------------------+---+--------------------------------+
| ## * | **   | **Medicaid Buy-in    |   | #                              |
| *Sta | Agen | Activities**         |   | Medicaid Services Improvements |
| te** | cy** |                      |   |                                |
+------+------+----------------------+---+--------------------------------+
| ###  | Gov  | · Assess why people  |   | · Training and technical       |
| #### | erno | do not join the      |   | assistance for staff members   |
| # Al | r\'s | Medicaid buy-in.     |   | on the buy-in, personal        |
| aska | Cou  |                      |   | assistance services and        |
|      | ncil | · Assess the impact  |   | TWWIIA.                        |
|      | on   | and                  |   |                                |
|      | Disa | cost-effectiveness   |   | · Link job center staff and    |
|      | bili | of covering the      |   | the Adult Public Assistance    |
|      | ties | medically improved.  |   | staff through co-location,     |
|      | and  |                      |   | outreach and electronic        |
|      | Spe  | · Conduct outreach   |   | resources.                     |
|      | cial | to people with       |   |                                |
|      | E    | disabilities,        |   | · Work with trade              |
|      | duca | service providers,   |   | associations, training         |
|      | tion | employers and state  |   | programs, and planning and     |
|      |      | and federal agencies |   | advocacy groups to disseminate |
|      |      | about the Medicaid   |   | information about              |
|      |      | buy-in and personal  |   | infrastructure improvements.   |
|      |      | assistance services. |   |                                |
|      |      |                      |   | · Build the capacity of        |
|      |      |                      |   | personal assistance service    |
|      |      |                      |   | providers.                     |
|      |      |                      |   |                                |
|      |      |                      |   | · Change independent personal  |
|      |      |                      |   | assistance services programs   |
|      |      |                      |   | to self-directed approach.     |
+------+------+----------------------+---+--------------------------------+
| **A  | Ala  | · Exercise BBA       |   | · Create a workgroup of        |
| laba | bama | Medicaid coverage    |   | individuals with disabilities, |
| ma** | Medi | option for income    |   | consumer and advocacy groups,  |
|      | caid | below 250% FPL.      |   | potential employers, and other |
|      | Ag   |                      |   | stakeholders.                  |
|      | ency | · Design program to  |   |                                |
|      |      | people who have a    |   | · Through the Homeward Bound   |
|      |      | potentially severe   |   | Waiver Services, provide       |
|      |      | physical impairment. |   | personal assistance service    |
|      |      |                      |   | benefits for daily living on   |
|      |      | · Design a Medicaid  |   | and off the job.               |
|      |      | buy-in for the       |   |                                |
|      |      | eligibility groups   |   | · Assist in identifying        |
|      |      | described in section |   | solutions to problems related  |
|      |      | 1902                 |   | to employed disabled           |
|      |      | (a)(10)(A            |   | individuals in integrated      |
|      |      | )(ii)(XIII)(XV)(XVI) |   | working environments.          |
|      |      | of the Social        |   |                                |
|      |      | Security Act.        |   | · Hold public forums with      |
|      |      |                      |   | employers describing outcomes  |
|      |      |                      |   | that encourage the employment  |
|      |      |                      |   | of disabled individuals in     |
|      |      |                      |   | integrated work settings.      |
|      |      |                      |   |                                |
|      |      |                      |   | · Educate disabled individuals |
|      |      |                      |   | and the general public about   |
|      |      |                      |   | the TWWIIA provisions and how  |
|      |      |                      |   | they are being utilized in     |
|      |      |                      |   | Alabama.                       |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop a focus group of     |
|      |      |                      |   | disabled working individuals   |
|      |      |                      |   | to identify services needed to |
|      |      |                      |   | maintain employment.           |
+------+------+----------------------+---+--------------------------------+
| **   | De   | · Conduct outreach   |   | · Create a project steering    |
| Cali | part | to individuals with  |   | committee to oversee the       |
| forn | ment | disabilities and     |   | Health Incentive Improvement   |
| ia** | of   | provide training for |   | Project                        |
|      | He   | consumers,           |   |                                |
|      | alth | employers, service   |   | · Evaluate the adequacy of     |
|      | Serv | providers and State  |   | personal assistance services   |
|      | ices | and local agency     |   | to support competitive         |
|      |      | staff on the         |   | employment. The project will   |
|      |      | California Working   |   | authorize Medicaid services to |
|      |      | Disabled program and |   | be used in the workplace.      |
|      |      | other work           |   |                                |
|      |      | incentives and       |   |                                |
|      |      | employment supports. |   |                                |
+------+------+----------------------+---+--------------------------------+
| **Co | De   | · Plan and implement |   | · Improve personal assistance  |
| lora | part | a Medicaid Buy-In    |   | services.                      |
| do** | ment | program.             |   |                                |
|      | of   |                      |   | · Train staff professionals    |
|      | He   | · Appoint a Medicaid |   | about work-incentive programs. |
|      | alth | Buy-In ombudsman.    |   |                                |
|      | Care |                      |   | · Conduct outreach and         |
|      | Po   |                      |   | training for disability        |
|      | licy |                      |   | community on work incentives.  |
|      | and  |                      |   |                                |
|      | F    |                      |   |                                |
|      | inan |                      |   |                                |
|      | cing |                      |   |                                |
+------+------+----------------------+---+--------------------------------+
| **C  | De   | · Conduct outreach.  |   | · Explore the programmatic and |
| onne | part |                      |   | fiscal impact of expanding     |
| ctic | ment | · Report on status   |   | personal assistance services   |
| ut** | of   | of Medicaid buy-in   |   | within Medicaid waiver program |
|      | He   | program, including   |   | and state plan to individuals  |
|      | alth | utilization data.    |   | who have chronic mental        |
|      | and  |                      |   | illness, mental retardation,   |
|      | H    |                      |   | or developmental disabilities. |
|      | uman |                      |   |                                |
|      | Serv |                      |   | · Explore options for          |
|      | ices |                      |   | developing a competent,        |
|      |      |                      |   | flexible, culturally           |
|      |      |                      |   | sensitive, adequately          |
|      |      |                      |   | compensated long-term care     |
|      |      |                      |   | workforce.                     |
|      |      |                      |   |                                |
|      |      |                      |   | · Establish Connect to Work    |
|      |      |                      |   | Center at the Department of    |
|      |      |                      |   | Social Services to research    |
|      |      |                      |   | and evaluate mechanisms to     |
|      |      |                      |   | increase competitive           |
|      |      |                      |   | employment.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Train individuals and agency |
|      |      |                      |   | staff on services and          |
|      |      |                      |   | programs.                      |
|      |      |                      |   |                                |
|      |      |                      |   | · Explore methods of peer      |
|      |      |                      |   | support networks and benefit   |
|      |      |                      |   | counseling.                    |
+------+------+----------------------+---+--------------------------------+
| **De | He   | · Assess the need    |   | · Analyze agency policy to     |
| lawa | alth | for recruitment and  |   | determine personal assistance  |
| re** | and  | retention strategies |   | services related disincentives |
|      | So   | for the buy-in and   |   | to employment and ways to      |
|      | cial | develop elements for |   | extend PAS benefits.           |
|      | Serv | a buy-in program.    |   |                                |
|      | ices |                      |   | · Design a service delivery    |
|      |      |                      |   | system around consumer needs.  |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop an emergency back-up |
|      |      |                      |   | system of qualified            |
|      |      |                      |   | attendants.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Form an Infrastructure       |
|      |      |                      |   | Advisory Committee to examine  |
|      |      |                      |   | safety and medical issues and  |
|      |      |                      |   | solutions.                     |
+------+------+----------------------+---+--------------------------------+
| **   | Med  | · Design a Medicaid  |   | · Establish a leadership       |
| Dist | ical | buy-in program that  |   | council to develop an          |
| rict | As   | includes broad range |   | integrated system for disabled |
| of   | sist | of needed services.  |   | residents to access care and   |
| Co   | ance |                      |   | services under the Medicaid    |
| lumb | Ad   | · Assess a range of  |   | program.                       |
| ia** | mini | options for the      |   |                                |
|      | stra | implementation of a  |   | · Develop informational        |
|      | tion | buy-in program.      |   | materials.                     |
|      |      |                      |   |                                |
|      |      |                      |   | · Expand personal assistance   |
|      |      |                      |   | services that are provided     |
|      |      |                      |   | under the State plan to        |
|      |      |                      |   | include services provided      |
|      |      |                      |   | outside the home.              |
|      |      |                      |   |                                |
|      |      |                      |   | · Amend existing Elderly       |
|      |      |                      |   | Waiver to include the under 65 |
|      |      |                      |   | years of age population.       |
|      |      |                      |   |                                |
|      |      |                      |   | · Analyze data related to      |
|      |      |                      |   | persons with disabilities in   |
|      |      |                      |   | need of personal assistance    |
|      |      |                      |   | services and supports that     |
|      |      |                      |   | would enable them to work.     |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop strategy to collect  |
|      |      |                      |   | and monitor the number of      |
|      |      |                      |   | disabled residents willing and |
|      |      |                      |   | able to work.                  |
+------+------+----------------------+---+--------------------------------+
|      | \    | · Expand Medicaid    |   |                                |
|      | *Med | for                  |   |                                |
|      | ical | de                   |   |                                |
|      | As   | monstration-eligible |   |                                |
|      | sist | District residents   |   |                                |
|      | ance | with HIV.            |   |                                |
|      | Ad   |                      |   |                                |
|      | mini | · Assess the         |   |                                |
|      | stra | effectiveness of an  |   |                                |
|      | tion | \"early              |   |                                |
|      |      | intervention\"       |   |                                |
|      |      | Medicaid model in    |   |                                |
|      |      | maintaining the      |   |                                |
|      |      | health and           |   |                                |
|      |      | well-being.          |   |                                |
|      |      |                      |   |                                |
|      |      | . Evaluate the       |   |                                |
|      |      | feasibility of wider |   |                                |
|      |      | implementation of    |   |                                |
|      |      | early intervention   |   |                                |
|      |      | model for persons    |   |                                |
|      |      | with other           |   |                                |
|      |      | potentially          |   |                                |
|      |      | disabling            |   |                                |
|      |      | conditions.          |   |                                |
+------+------+----------------------+---+--------------------------------+
| **G  | De   | · Design a Medicaid  |   | · Survey potential workers for |
| eorg | part | buy-in for the       |   | their knowledge and            |
| ia** | ment | working disabled.    |   | satisfaction of the current    |
|      | of   |                      |   | work incentives.               |
|      | C    |                      |   |                                |
|      | ommu |                      |   | · Design outreach and training |
|      | nity |                      |   | programs using a peer support  |
|      | He   |                      |   | model.                         |
|      | alth |                      |   |                                |
|      |      |                      |   | · Determine how frequently     |
|      |      |                      |   | current Medicaid Waiver        |
|      |      |                      |   | recipients use personal        |
|      |      |                      |   | support services for           |
|      |      |                      |   | employment.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Survey Medicaid Waiver       |
|      |      |                      |   | recipients to assess desire    |
|      |      |                      |   | for employment.                |
|      |      |                      |   |                                |
|      |      |                      |   | · Analyze agency policies to   |
|      |      |                      |   | determine disincentives to     |
|      |      |                      |   | employment.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Amend policies to offer      |
|      |      |                      |   | providers greater incentives   |
|      |      |                      |   | for employment outcomes.       |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop incentives for       |
|      |      |                      |   | providers to use waiver-funded |
|      |      |                      |   | personal support services for  |
|      |      |                      |   | employment.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Conduct focus groups to      |
|      |      |                      |   | determine the effectiveness of |
|      |      |                      |   | the current personal           |
|      |      |                      |   | assistance services provided.  |
|      |      |                      |   |                                |
|      |      |                      |   | · Create a jobs hot line, peer |
|      |      |                      |   | support networks, and          |
|      |      |                      |   | marketing material.            |
|      |      |                      |   |                                |
|      |      |                      |   | · Design and develop a data    |
|      |      |                      |   | base to track outcomes for     |
|      |      |                      |   | workers.                       |
|      |      |                      |   |                                |
|      |      |                      |   | · Expand personal assistance   |
|      |      |                      |   | services through a State plan  |
|      |      |                      |   | amendment..                    |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Hire and train     |   | · Issue State Plan and HCBS    |
| *Ida | part | benefit              |   | Waiver Amendments to increase  |
| ho** | ment | representatives.     |   | the availability of personal   |
|      | of   |                      |   | assistance services.           |
|      | He   | · Develop, design    |   |                                |
|      | alth | and seek legislative |   | · Bring together a steering    |
|      | and  | approval for a       |   | committee to address           |
|      | Wel  | Medicaid buy-in      |   | transportation.                |
|      | fare | program with         |   |                                |
|      |      | wrap-around          |   | · Strengthen inter-agency and  |
|      |      | coverage.            |   | intra-governmental             |
|      |      |                      |   | cooperation.                   |
|      |      | · Create steering    |   |                                |
|      |      | committees, public   |   | · Hold employer symposiums     |
|      |      | input forums, and    |   | statewide to discuss           |
|      |      | educational          |   | concerns/issues. Disabilities. |
|      |      | materials.           |   |                                |
|      |      |                      |   |                                |
|      |      | · Enhance Medicaid   |   |                                |
|      |      | data systems to      |   |                                |
|      |      | track, report and    |   |                                |
|      |      | evaluate individuals |   |                                |
|      |      | in the Basic         |   |                                |
|      |      | Coverage Group.      |   |                                |
+------+------+----------------------+---+--------------------------------+
| **Il | De   | · Enable persons     |   |                                |
| lino | part | with disabilities to |   |                                |
| is** | ment | buy into Medicaid    |   |                                |
|      | of   | coverage.            |   |                                |
|      | \*Pu |                      |   |                                |
|      | blic | · Design and         |   |                                |
|      | Aid  | implement a Medicaid |   |                                |
|      |      | buy-in               |   |                                |
|      |      | administrative       |   |                                |
|      |      | process.             |   |                                |
|      |      |                      |   |                                |
|      |      | · Design and         |   |                                |
|      |      | implement an         |   |                                |
|      |      | educational and      |   |                                |
|      |      | informational        |   |                                |
|      |      | dissemination        |   |                                |
|      |      | system.              |   |                                |
+------+------+----------------------+---+--------------------------------+
| **Io | De   | · Assure that the    |   | · Add personal care as an      |
| wa** | part | State\'s Medicaid    |   | option under the State         |
|      | ment | Buy-in program is    |   | Medicaid Plan.                 |
|      | of   | efficient and        |   |                                |
|      | H    | accessible.          |   | · Revise the State\'s waiver   |
|      | uman |                      |   | to be more supportive of       |
|      | Serv |                      |   | people with disabilities who   |
|      | ices |                      |   | are working.                   |
+------+------+----------------------+---+--------------------------------+
| **   | De   | · Design, develop,   |   | · Draft person/family of       |
| Kans | part | and seek legislative |   | choice centered standards for  |
| as** | ment | approval for a       |   | a wrap-around service approach |
|      | of   | Medicaid buy-in      |   | and a voucher program that     |
|      | So   | program.             |   | allows the consumer to         |
|      | cial |                      |   | purchase services.             |
|      | and  | · Provide personal   |   |                                |
|      | Re   | assistance services  |   | . Initiate advisory and        |
|      | habi | within the State     |   | interagency groups to help aid |
|      | lita | plan.                |   | in policy development.         |
|      | tion |                      |   |                                |
|      | Serv |                      |   | · Initiate communication with  |
|      | ices |                      |   | private sector employers.      |
|      |      |                      |   |                                |
|      |      |                      |   | · Design a software program    |
|      |      |                      |   | for managing premium           |
|      |      |                      |   | collection and necessary       |
|      |      |                      |   | changes in the State\'s        |
|      |      |                      |   | information systems.           |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Review the         |   | · Create advisory groups to    |
| *Lou | part | feasibility and      |   | assist in the development,     |
| isia | ment | fiscal impact of a   |   | delivery and modification of   |
| na** | of   | Medicaid Buy-in      |   | Medicaid benefits and services |
|      | He   | program, in order to |   | needed.                        |
|      | alth | seek legislative     |   |                                |
|      | and  | approval.            |   | · Develop informational        |
|      | H    |                      |   | materials on services and      |
|      | ospi | · Identify           |   | supports.                      |
|      | tals | infrastructure       |   |                                |
|      |      | improv               |   | · Provide outreach and         |
|      |      | ements/modifications |   | training about TWWIIA Medicaid |
|      |      | needed to support a  |   | provisions.                    |
|      |      | Medicaid Buy-in      |   |                                |
|      |      | program..            |   |                                |
|      |      |                      |   |                                |
|      |      | · Design a system    |   |                                |
|      |      | for managing premium |   |                                |
|      |      | billings and         |   |                                |
|      |      | collections.         |   |                                |
|      |      |                      |   |                                |
|      |      | · Enhance            |   |                                |
|      |      | information systems  |   |                                |
|      |      | to track key         |   |                                |
|      |      | enrollee data,       |   |                                |
|      |      | evaluate outcomes    |   |                                |
|      |      | and impact of the    |   |                                |
|      |      | buy-in.              |   |                                |
+------+------+----------------------+---+--------------------------------+
| *    | Medi | · Improve existing   |   | · Review long-term care        |
| *Mai | caid | Medicaid buy-in      |   | assessment tool to ensure that |
| ne** | Bu   | program.             |   | it captures the service needs  |
|      | y-In |                      |   | of employed persons.           |
|      | Ac   | · Conduct survey of  |   |                                |
|      | tivi | (1) workers with     |   | · Conduct time study of people |
|      | ties | disabilities         |   | with disabilities who work, or |
|      |      | participating in     |   | are likely to work, to gain    |
|      |      | Medicaid buy-in      |   | greater understanding about    |
|      |      | program, (2) workers |   | service needs.                 |
|      |      | with disabilities    |   |                                |
|      |      | not participating in |   | · Implement an action plan to  |
|      |      | the buy-in program,  |   | increase consumer              |
|      |      | and (3) SSDI         |   | participation via the          |
|      |      | beneficiaries whose  |   | Internet.                      |
|      |      | earned income is too |   |                                |
|      |      | high to qualify for  |   | · Disseminate information..    |
|      |      | buy-in program.      |   |                                |
|      |      |                      |   | · Conduct key informant        |
|      |      | · Expand Medicaid    |   | interviews with employers.     |
|      |      | Buy-In Advisory      |   |                                |
|      |      | Group.               |   | · Coordinate outreach with     |
|      |      |                      |   | SSA.                           |
+------+------+----------------------+---+--------------------------------+
| *    | \*   | . Conduct evaluation |   |                                |
| *Mas | Divi | and research         |   |                                |
| sach | sion | projects of the      |   |                                |
| uset | of   | Medicaid buy-in      |   |                                |
| ts** | Med  | program.             |   |                                |
|      | ical |                      |   |                                |
|      | As   | . Evaluate the       |   |                                |
|      | sist | advantages and       |   |                                |
|      | ance | disadvantages of     |   |                                |
|      |      | continuing the       |   |                                |
|      |      | CommonHealth program |   |                                |
|      |      | as it is versus      |   |                                |
|      |      | taking advantage of  |   |                                |
|      |      | Medicaid buy-in      |   |                                |
|      |      | options.             |   |                                |
|      |      |                      |   |                                |
|      |      | . Assess the impact  |   |                                |
|      |      | of the health care   |   |                                |
|      |      | services on          |   |                                |
|      |      | participants\'       |   |                                |
|      |      | ability to seek and  |   |                                |
|      |      | sustain competitive  |   |                                |
|      |      | employment .         |   |                                |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Evaluate the       |   | · Revamp the State Medicaid    |
| *Min | part | personal outcomes,   |   | website and establish a        |
| neso | ment | funding impacts, and |   | disability phone link to       |
| ta** | of   | the integrated       |   | enhance employment -related    |
|      | H    | database of the      |   | information resources.         |
|      | uman | Medicaid buy-in      |   |                                |
|      | Serv | option.              |   | · Issue mini-grants to local   |
|      | ices |                      |   | organizations to train them on |
|      |      | · Create a web-based |   | incorporating consumer         |
|      |      | tool kit for         |   | assistance activities into web |
|      |      | potential users and  |   | technologies.                  |
|      |      | buy-in recipients    |   |                                |
|      |      |                      |   | · Develop in-person and        |
|      |      |                      |   | web-based training materials,  |
|      |      |                      |   | and conduct training and other |
|      |      |                      |   | educational opportunities.     |
|      |      |                      |   |                                |
|      |      |                      |   | · Identify, develop, and       |
|      |      |                      |   | implement a strategic outreach |
|      |      |                      |   | plan to educate employers on   |
|      |      |                      |   | accommodations and assistive   |
|      |      |                      |   | technologies.                  |
|      |      |                      |   |                                |
|      |      |                      |   | · Interact with the business   |
|      |      |                      |   | community and grantees of      |
|      |      |                      |   | local infrastructure grants to |
|      |      |                      |   | address assistive technology   |
|      |      |                      |   | devices and services.          |
|      |      |                      |   |                                |
|      |      |                      |   | · Train local workers,         |
|      |      |                      |   | consumers, job counselors,     |
|      |      |                      |   | case managers, businesses, and |
|      |      |                      |   | vocational counselors on work  |
|      |      |                      |   | incentives                     |
+------+------+----------------------+---+--------------------------------+
| **M  | \*   | . Use the grant      |   |                                |
| issi | Divi | award, in            |   |                                |
| ssip | sion | conjunction with     |   |                                |
| pi** | of   | State funds, to      |   |                                |
|      | Medi | cover 500 persons    |   |                                |
|      | caid | with a diagnosis of  |   |                                |
|      |      | HIV/AIDS who work.   |   |                                |
|      |      |                      |   |                                |
|      |      | . Offer full         |   |                                |
|      |      | Medicaid benefits    |   |                                |
|      |      | and services as well |   |                                |
|      |      | as case management   |   |                                |
|      |      | to the demonstration |   |                                |
|      |      | participants         |   |                                |
|      |      |                      |   |                                |
|      |      | . Implement the      |   |                                |
|      |      | project in nine      |   |                                |
|      |      | counties in the      |   |                                |
|      |      | Mississippi Delta.   |   |                                |
|      |      |                      |   |                                |
|      |      | . Measure the        |   |                                |
|      |      | participants\'       |   |                                |
|      |      | reliance on cash     |   |                                |
|      |      | benefits, employment |   |                                |
|      |      | status, changes in   |   |                                |
|      |      | health status, and   |   |                                |
|      |      | quality of life.     |   |                                |
+------+------+----------------------+---+--------------------------------+
| **Mi | De   | · Research potential |   | · Develop training material    |
| ssou | part | costs of a Medicaid  |   | and resources for consumers    |
| ri** | ment | buy-in.              |   | and others.                    |
|      | of   |                      |   |                                |
|      | So   | · Develop the        |   | · Build a resource base, which |
|      | cial | legislation and      |   | directs information to         |
|      | Serv | fiscal note          |   | employers regarding available  |
|      | ices | \[justification\]    |   | supports for persons with      |
|      |      | for a Medicaid       |   | disabilities.                  |
|      |      | Buy-in option.       |   |                                |
|      |      |                      |   | · Develop a workgroup of       |
|      |      |                      |   | persons to remove/reduce       |
|      |      |                      |   | barriers to employment.        |
|      |      |                      |   |                                |
|      |      |                      |   | · Assure the system meets the  |
|      |      |                      |   | needs of consumers through use |
|      |      |                      |   | of consumers as advocates and  |
|      |      |                      |   | by conducting focus groups and |
|      |      |                      |   | surveys.                       |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop a report of          |
|      |      |                      |   | \"lessons learned\" based on   |
|      |      |                      |   | Missouri\'s experience.        |
+------+------+----------------------+---+--------------------------------+
| **Ne | De   | · Improve the        |   | · Develop and actively utilize |
| bras | part | Medicaid Buy-in      |   | the information capacity of    |
| ka** | ment | program.             |   | the Nebraska\'s Statewide      |
|      | of   |                      |   | Consumer Network.              |
|      | He   |                      |   |                                |
|      | alth |                      |   | · Undertake a goal-setting     |
|      | and  |                      |   | process.                       |
|      | H    |                      |   |                                |
|      | uman |                      |   | · Improve the provision of     |
|      | Serv |                      |   | personal assistance services.  |
|      | ices |                      |   |                                |
|      |      |                      |   | · Improve services for youth   |
|      |      |                      |   | transitioning to work.         |
|      |      |                      |   |                                |
|      |      |                      |   | · Improve integration with     |
|      |      |                      |   | existing employment services   |
|      |      |                      |   | and other programs.            |
|      |      |                      |   |                                |
|      |      |                      |   | · Improve communication to     |
|      |      |                      |   | stakeholders about the         |
|      |      |                      |   | opportunities for competitive  |
|      |      |                      |   | employment.                    |
|      |      |                      |   |                                |
|      |      |                      |   | · Investigate improvement to   |
|      |      |                      |   | State\'s internal capabilities |
|      |      |                      |   | to manage data.                |
+------+------+----------------------+---+--------------------------------+
| **   | De   | · Analyze the cost   |   | · Provide Personal Assistance  |
| Neva | part | effectiveness of a   |   | Services provider education    |
| da** | ment | Medicaid buy-in.     |   | and workplace assistance       |
|      | of   |                      |   | training.                      |
|      | H    | · Hire and train     |   |                                |
|      | uman | staff and form an    |   | · Develop and distribute       |
|      | R    | advisory board to    |   | pamphlets, brochures, and      |
|      | esou | review other         |   | other informational materials  |
|      | rces | state\'s buy-in      |   | on available Medicaid          |
|      |      | structures.          |   | programs.                      |
|      |      |                      |   |                                |
|      |      | · Develop a request  |   |                                |
|      |      | for including the    |   |                                |
|      |      | buy-in program into  |   |                                |
|      |      | the Executive        |   |                                |
|      |      | budget.              |   |                                |
|      |      |                      |   |                                |
|      |      | · Design and develop |   |                                |
|      |      | the buy-in program.  |   |                                |
|      |      |                      |   |                                |
|      |      | · Establish a        |   |                                |
|      |      | strategy for         |   |                                |
|      |      | consumer/provider    |   |                                |
|      |      | involvement in       |   |                                |
|      |      | educating key        |   |                                |
|      |      | legislators.         |   |                                |
|      |      |                      |   |                                |
|      |      | · Make computer      |   |                                |
|      |      | programming changes  |   |                                |
|      |      | to fully implement   |   |                                |
|      |      | buy-in enrollment.   |   |                                |
|      |      |                      |   |                                |
|      |      | · Formalize          |   |                                |
|      |      | partnerships needed  |   |                                |
|      |      | to implement         |   |                                |
|      |      | outreach,            |   |                                |
|      |      | r                    |   |                                |
|      |      | eferral/information, |   |                                |
|      |      | service delivery,    |   |                                |
|      |      | case management, and |   |                                |
|      |      | early intervention.  |   |                                |
|      |      |                      |   |                                |
|      |      | · Provide education  |   |                                |
|      |      | on Medicaid          |   |                                |
|      |      | guidelines,          |   |                                |
|      |      | eligibility, buy-in  |   |                                |
|      |      | process, procedures  |   |                                |
|      |      | and access.          |   |                                |
|      |      |                      |   |                                |
|      |      | . Improve Medicaid   |   |                                |
|      |      | services.            |   |                                |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Complete the       |   | · Develop rules to implement   |
| *New | part | design for the       |   | new personal assistance        |
| Ham  | ment | Medicaid buy-in      |   | services legislation and       |
| pshi | of   | program, get         |   | provide seed money to local    |
| re** | He   | legislative          |   | communities to create the      |
|      | alth | authorization and    |   | infrastructure, including      |
|      | and  | implement the        |   | intermediary functions, to     |
|      | H    | program.             |   | support enhanced personal      |
|      | uman |                      |   | assistance services with a     |
|      | Serv | . Support One-Stop   |   | consumer-directed option.      |
|      | ices | Centers so that they |   |                                |
|      |      | can counsel people   |   | · Provide supports to          |
|      |      | with disabilities    |   | consumers that will allow them |
|      |      | about the buy-in     |   | to participate fully in all    |
|      |      | program.             |   | aspects of grant               |
|      |      |                      |   | implementation.                |
|      |      | . Contribute the     |   |                                |
|      |      | presence of a health |   | · Develop and implement        |
|      |      | insurance expert at  |   | outreach strategies to train   |
|      |      | each One-Stop        |   | and educate the public,        |
|      |      | location.            |   | persons with disabilities,     |
|      |      |                      |   | their families, businesses,    |
|      |      | . Develop system for |   | providers and state staff on   |
|      |      | premium billing and  |   | buy-in and TWWIIA programs.    |
|      |      | collection services, |   |                                |
|      |      | including tracking   |   | · Provide education and        |
|      |      | premium data.        |   | training to all field staff    |
|      |      |                      |   | working with consumers, key    |
|      |      | . Make improvements  |   | stakeholders and local and     |
|      |      | to facilitate        |   | state agencies.                |
|      |      | personal assistance  |   |                                |
|      |      | services for         |   | . Coordinate efforts of CMS,   |
|      |      | consumers.           |   | Dollars and Sense, Department  |
|      |      |                      |   | of Labor, and SSA grantees on  |
|      |      |                      |   | work incentives under the      |
|      |      |                      |   | Governor's Task Force for      |
|      |      |                      |   | Employment and Economic        |
|      |      |                      |   | Opportunity for People with    |
|      |      |                      |   | Disabilities.                  |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Develop            |   | · Develop more effective       |
| *New | part | regulations to       |   | public transportation          |
| Jers | ment | provide Medicaid     |   | services.                      |
| ey** | of   | coverage to working  |   |                                |
|      | H    | individuals with     |   | · Modify and expand existing   |
|      | uman | disabilities.        |   | personal assistance services.  |
|      | Serv |                      |   |                                |
|      | ices | · Develop a system   |   | · Undergo a public relations   |
|      |      | for case management  |   | campaign to assist individuals |
|      |      | to assist            |   | with disabilities in           |
|      |      | individuals and      |   | understanding the existing and |
|      |      | professionals in     |   | new work incentives programs.  |
|      |      | understanding the    |   |                                |
|      |      | buy-in program.      |   | · Disseminate information      |
|      |      |                      |   | about Personal Care Services.  |
|      |      |                      |   |                                |
|      |      |                      |   | · Hold educational forums as   |
|      |      |                      |   | part of outreach to consumers  |
|      |      |                      |   | with disabilities.             |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop a management         |
|      |      |                      |   | information system to monitor  |
|      |      |                      |   | Medicaid infrastructure.       |
+------+------+----------------------+---+--------------------------------+
| *    | He   | · Design, administer |   | · Form consumer groups to      |
| *New | alth | and monitor the      |   | assist in the development,     |
| Mexi | and  | infrastructure for   |   | delivery and fine-tuning of    |
| co** | H    | an effective         |   | work incentives activities.    |
|      | uman | Medicaid buy-in      |   |                                |
|      | Serv | program.             |   | · Create advisory groups       |
|      | ices |                      |   | comprised of consumers,        |
|      | De   | · Conduct outreach   |   | service providers, parents,    |
|      | part | and educational      |   | advocates, and state agency    |
|      | ment | efforts on the       |   | personnel to oversee the       |
|      |      | Medicaid buy-in      |   | project.                       |
|      |      | using peer           |   |                                |
|      |      | presenters with      |   | · Provide training and         |
|      |      | disabilities.        |   | technical.                     |
|      |      |                      |   |                                |
|      |      | · Create a data      |   | · Expand linkages between      |
|      |      | collection upgrade   |   | Medical Assistance Division of |
|      |      | and reporting system |   | Human Services Department and  |
|      |      | for implementation   |   | the Comprehensive Health       |
|      |      | of the Medicaid      |   | Insurance Pool (CHIP) a        |
|      |      | buy-in.              |   | private health insurance plan  |
|      |      |                      |   | for individuals with           |
|      |      |                      |   | pre-existing disabling         |
|      |      |                      |   | conditions.                    |
|      |      |                      |   |                                |
|      |      |                      |   | ·                              |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Implementation of  |   | · Implement outreach,          |
| *New | part | the State\'s         |   | education and training         |
| Yo   | ment | proposed Buy-in      |   | programs for State staff.      |
| rk** | of   | program.             |   |                                |
|      | He   |                      |   | · Develop a program evaluation |
|      | alth | · Development of an  |   | component.                     |
|      |      | automated Medicaid   |   |                                |
|      |      | Buy-in premium       |   |                                |
|      |      | payment and data     |   |                                |
|      |      | collection system.   |   |                                |
+------+------+----------------------+---+--------------------------------+
| **N  |      | · Develop a Medicaid |   | · Assess existing Medicaid     |
| orth |      | buy-in program.      |   | systems.                       |
| Dako |      |                      |   |                                |
| ta** |      |                      |   | · Perform a outreach           |
|      |      |                      |   | activities to employers,       |
|      |      |                      |   | consumers and Medicaid staff.  |
|      |      |                      |   |                                |
|      |      |                      |   | · Establish a stakeholder      |
|      |      |                      |   | network to guide development,  |
|      |      |                      |   | consideration, implementation, |
|      |      |                      |   | and evaluation of grant        |
|      |      |                      |   | projects.                      |
+------+------+----------------------+---+--------------------------------+
| **Oh | Job  | · A Study            |   | · Study the Implications of    |
| io** | and  | administrative       |   | adding \"personal care\" as an |
|      | Fa   | changes required to  |   | optional Medicaid state plan   |
|      | mily | Implement the        |   | service.                       |
|      | Serv | Medicaid buy-in      |   |                                |
|      | ices | program.             |   | · Convene a consumer advisory  |
|      |      |                      |   | group to provide input on      |
|      |      |                      |   | these studies.                 |
+------+------+----------------------+---+--------------------------------+
| **Ok | He   | · Work with advocacy |   | · Review personal assistance   |
| laho | alth | groups to educate    |   | services policies,             |
| ma** | Care | the State            |   | availability, service delivery |
|      | A    | legislature on a     |   | mechanisms. Survey             |
|      | utho | Medicaid buy-in.     |   | stakeholders to determine how  |
|      | rity |                      |   | to expand personal assistance  |
|      |      | · Research and       |   | services outside of the home.  |
|      |      | evaluate premium     |   |                                |
|      |      | collection and       |   | · Study the positive and       |
|      |      | tracking systems     |   | negative impacts of using      |
|      |      | used by other        |   | non-emergency transportation   |
|      |      | states.              |   | programs for job               |
|      |      |                      |   | transportation.                |
+------+------+----------------------+---+--------------------------------+
| **   | De   | · Develop a data     |   | · Initiate opportunities to    |
| Oreg | part | tracking mechanism   |   | enhance social support         |
| on** | ment | for the Medicaid     |   | services.                      |
|      | of   | buy-in program.      |   |                                |
|      | H    |                      |   | · Initiate information         |
|      | uman | · Improve Medicaid   |   | dissemination opportunities    |
|      | Serv | services.            |   | through website links and      |
|      | ices |                      |   | clearinghouse.                 |
|      |      |                      |   |                                |
|      |      |                      |   | · Expand consumer involvement  |
|      |      |                      |   | by increasing consumer         |
|      |      |                      |   | participation, developing      |
|      |      |                      |   | training activities, and       |
|      |      |                      |   | increasing advocacy group      |
|      |      |                      |   | involvement.                   |
|      |      |                      |   |                                |
|      |      |                      |   | · Improve consumer choices and |
|      |      |                      |   | benefits counseling networks,  |
|      |      |                      |   | develop outreach programs and  |
|      |      |                      |   | strengthen links to employers. |
|      |      |                      |   |                                |
|      |      |                      |   | · Identify new methods to      |
|      |      |                      |   | enhance and expand personal    |
|      |      |                      |   | assistance services.           |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop options for          |
|      |      |                      |   | effective medical              |
|      |      |                      |   | transportation.                |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop access to emergency  |
|      |      |                      |   | backup services for needs of   |
|      |      |                      |   | workers.                       |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop monitoring plan for  |
|      |      |                      |   | infrastructure.                |
|      |      |                      |   |                                |
|      |      |                      |   | · Develop a research component |
|      |      |                      |   | for infrastructure building    |
|      |      |                      |   | efforts.                       |
|      |      |                      |   |                                |
|      |      |                      |   | · Design and develop an        |
|      |      |                      |   | enhanced Medicaid              |
|      |      |                      |   | benefit/services packages.     |
+------+------+----------------------+---+--------------------------------+
| **Pe | De   | · Support consumer   |   | · Establish a one-stop service |
| nnsy | part | input into the       |   | model for persons with         |
| lvan | ment | implementation of    |   | disabilities to learn about    |
| ia** | of   | the buy-in program.  |   | and obtain information on      |
|      | Pu   |                      |   | services related to finding    |
|      | blic | · Develop            |   | employment.                    |
|      | Wel  | educational and      |   |                                |
|      | fare | outreach efforts for |   | · Develop a back-up delivery   |
|      |      | the new program.     |   | system for attendant care      |
|      |      |                      |   | services.                      |
|      |      |                      |   |                                |
|      |      |                      |   | · Establish Statewide Advisory |
|      |      |                      |   | Council on Employment.         |
+------+------+----------------------+---+--------------------------------+
| **R  | De   | · Convene workgroups |   | · Improve dissemination about  |
| hode | part | to develop action    |   | programs currently available   |
| Isla | ment | plans for the        |   | to consumers.                  |
| nd** | of   | passage of Medicaid  |   |                                |
|      | H    | buy-in legislation.  |   | · Provide benefit counselors   |
|      | uman |                      |   | to one-stops, train Medicaid   |
|      | Serv | · Develop a policy   |   | eligibility workers, and       |
|      | ices | to more closely      |   | develop a web site and         |
|      |      | mimic 1619(b) rules  |   | linkages to relevant sites.    |
|      |      | for the medically    |   |                                |
|      |      | needy.               |   | · Facilitate a joint planning  |
|      |      |                      |   | effort with stakeholders to    |
|      |      |                      |   | bring together the work on     |
|      |      |                      |   | developing one-stop career     |
|      |      |                      |   | systems and the feasibility of |
|      |      |                      |   | replicating this effort on the |
|      |      |                      |   | health benefits side.          |
|      |      |                      |   |                                |
|      |      |                      |   | · Work with employers to       |
|      |      |                      |   | encourage hiring people with   |
|      |      |                      |   | disabilities.                  |
+------+------+----------------------+---+--------------------------------+
| **S  | De   | · Conduct a survey   |   | · Determining the costs        |
| outh | part | of states which have |   | associated with expanding      |
| Dako | ment | buy-in programs.     |   | personal assistance service    |
| ta** | of   |                      |   | programs.                      |
|      | H    | · Determine the      |   |                                |
|      | uman | systems              |   | · Engage the disability        |
|      | Serv | considerations,      |   | community across the state.    |
|      | ices | requirements, and    |   |                                |
|      |      | costs associated     |   | · Develop training materials   |
|      |      | with a buy-in        |   | for consumers, providers,      |
|      |      | program.             |   | employers and state and local  |
|      |      |                      |   | staff.                         |
+------+------+----------------------+---+--------------------------------+
| *    | He   | · Plan, design, and  |   | · Plan, design and model the   |
| *Tex | alth | model the costs of a |   | costs of expanding personal    |
| as** | and  | Medicaid buy-in      |   | assistance services.           |
|      | H    | program.             |   |                                |
|      | uman |                      |   |                                |
|      | Ser  |                      |   |                                |
|      | vice |                      |   |                                |
|      | Co   |                      |   |                                |
|      | mmis |                      |   |                                |
|      | sion |                      |   |                                |
+------+------+----------------------+---+--------------------------------+
|      | \*S  | · Target working     |   |                                |
|      | tate | individuals with     |   |                                |
|      | Age  | schizophrenia,       |   |                                |
|      | ncy: | bipolar disorder or  |   |                                |
|      | He   | major depression,    |   |                                |
|      | alth | ages 18 to 64, who   |   |                                |
|      | and  | are not yet able to  |   |                                |
|      | H    | meet the SSI         |   |                                |
|      | uman | disability test.     |   |                                |
|      | Serv |                      |   |                                |
|      | ices |                      |   |                                |
|      | Co   |                      |   |                                |
|      | mmis |                      |   |                                |
|      | sion |                      |   |                                |
+------+------+----------------------+---+--------------------------------+
| **Ut | De   | · Evaluate the       | · |                                |
| ah** | part | impact of the        | E |                                |
|      | ment | State\'s Medicaid    | x |                                |
|      | of   | Buy-in program.      | p |                                |
|      | He   |                      | a |                                |
|      | alth |                      | n |                                |
|      |      |                      | d |                                |
|      |      |                      | p |                                |
|      |      |                      | e |                                |
|      |      |                      | r |                                |
|      |      |                      | s |                                |
|      |      |                      | o |                                |
|      |      |                      | n |                                |
|      |      |                      | a |                                |
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|      |      |                      | l |                                |
|      |      |                      | a |                                |
|      |      |                      | n |                                |
|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
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|      |      |                      | a |                                |
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|      |      |                      | s |                                |
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|      |      |                      |   |                                |
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|      |      |                      | P |                                |
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|      |      |                      | m |                                |
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|      |      |                      | t |                                |
|      |      |                      | h |                                |
|      |      |                      | i |                                |
|      |      |                      | r |                                |
|      |      |                      | i |                                |
|      |      |                      | n |                                |
|      |      |                      | g |                                |
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|      |      |                      | r |                                |
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|      |      |                      | n |                                |
|      |      |                      | s |                                |
|      |      |                      | w |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | h |                                |
|      |      |                      | d |                                |
|      |      |                      | i |                                |
|      |      |                      | s |                                |
|      |      |                      | a |                                |
|      |      |                      | b |                                |
|      |      |                      | i |                                |
|      |      |                      | l |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | i |                                |
|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | . |                                |
+------+------+----------------------+---+--------------------------------+
| **V  | De   | · Study the Medicaid | · |                                |
| ermo | part | buy-in.              | D |                                |
| nt** | ment |                      | e |                                |
|      | of   | · Support Medicaid   | v |                                |
|      | A    | systems programming  | e |                                |
|      | ging | and administrative   | l |                                |
|      | and  | structures necessary | o |                                |
|      | Disa | to allow for the     | p |                                |
|      | bili | administration of    | a |                                |
|      | ties | the buy-in and new   | n |                                |
|      |      | personal assistance  | e |                                |
|      |      | services option.     | w |                                |
|      |      |                      | M |                                |
|      |      | · Conduct outreach   | e |                                |
|      |      | to consumers,        | d |                                |
|      |      | providers and        | i |                                |
|      |      | employers on the     | c |                                |
|      |      | Medicaid buy-in and  | a |                                |
|      |      | personal assistance  | i |                                |
|      |      | services option.     | d |                                |
|      |      |                      | S |                                |
|      |      |                      | t |                                |
|      |      |                      | a |                                |
|      |      |                      | t |                                |
|      |      |                      | e |                                |
|      |      |                      | P |                                |
|      |      |                      | l |                                |
|      |      |                      | a |                                |
|      |      |                      | n |                                |
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|      |      |                      | t |                                |
|      |      |                      | i |                                |
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|      |      |                      | f |                                |
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|      |      |                      | c |                                |
|      |      |                      | o |                                |
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|      |      |                      | s |                                |
|      |      |                      | u |                                |
|      |      |                      | m |                                |
|      |      |                      | e |                                |
|      |      |                      | r |                                |
|      |      |                      | - |                                |
|      |      |                      | d |                                |
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|      |      |                      | s |                                |
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|      |      |                      | r |                                |
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|      |      |                      | c |                                |
|      |      |                      | e |                                |
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|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
|      |      |                      | P |                                |
|      |      |                      | r |                                |
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|      |      |                      | e |                                |
|      |      |                      | r |                                |
|      |      |                      | v |                                |
|      |      |                      | i |                                |
|      |      |                      | c |                                |
|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
|      |      |                      | F |                                |
|      |      |                      | u |                                |
|      |      |                      | n |                                |
|      |      |                      | d |                                |
|      |      |                      | a |                                |
|      |      |                      | n |                                |
|      |      |                      | e |                                |
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|      |      |                      | a |                                |
|      |      |                      | l |                                |
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|      |      |                      | a |                                |
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|      |      |                      | n |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | . |                                |
|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
|      |      |                      | D |                                |
|      |      |                      | i |                                |
|      |      |                      | s |                                |
|      |      |                      | s |                                |
|      |      |                      | e |                                |
|      |      |                      | m |                                |
|      |      |                      | i |                                |
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|      |      |                      | r |                                |
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|      |      |                      | n |                                |
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|      |      |                      | e |                                |
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|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
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|      |      |                      | n |                                |
|      |      |                      | a |                                |
|      |      |                      | c |                                |
|      |      |                      | t |                                |
|      |      |                      | i |                                |
|      |      |                      | v |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | i |                                |
|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | t |                                |
|      |      |                      | o |                                |
|      |      |                      | r |                                |
|      |      |                      | a |                                |
|      |      |                      | i |                                |
|      |      |                      | s |                                |
|      |      |                      | e |                                |
|      |      |                      | e |                                |
|      |      |                      | m |                                |
|      |      |                      | p |                                |
|      |      |                      | l |                                |
|      |      |                      | o |                                |
|      |      |                      | y |                                |
|      |      |                      | m |                                |
|      |      |                      | e |                                |
|      |      |                      | n |                                |
|      |      |                      | t |                                |
|      |      |                      | r |                                |
|      |      |                      | a |                                |
|      |      |                      | t |                                |
|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | f |                                |
|      |      |                      | o |                                |
|      |      |                      | r |                                |
|      |      |                      | p |                                |
|      |      |                      | e |                                |
|      |      |                      | o |                                |
|      |      |                      | p |                                |
|      |      |                      | l |                                |
|      |      |                      | e |                                |
|      |      |                      | w |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | h |                                |
|      |      |                      | d |                                |
|      |      |                      | i |                                |
|      |      |                      | s |                                |
|      |      |                      | a |                                |
|      |      |                      | b |                                |
|      |      |                      | i |                                |
|      |      |                      | l |                                |
|      |      |                      | i |                                |
|      |      |                      | t |                                |
|      |      |                      | i |                                |
|      |      |                      | e |                                |
|      |      |                      | s |                                |
|      |      |                      | s |                                |
|      |      |                      | t |                                |
|      |      |                      | a |                                |
|      |      |                      | t |                                |
|      |      |                      | e |                                |
|      |      |                      | w |                                |
|      |      |                      | i |                                |
|      |      |                      | d |                                |
|      |      |                      | e |                                |
|      |      |                      | . |                                |
+------+------+----------------------+---+--------------------------------+
| **Vi | De   | · Develop and        | · |                                |
| rgin | part | implement a Medicaid | I |                                |
| ia** | ment | buy-in program.      | n |                                |
|      | of   |                      | v |                                |
|      | Med  |                      | o |                                |
|      | ical |                      | l |                                |
|      | As   |                      | v |                                |
|      | sist |                      | e |                                |
|      | ance |                      | s |                                |
|      | Serv |                      | t |                                |
|      | ices |                      | a |                                |
|      |      |                      | k |                                |
|      |      |                      | e |                                |
|      |      |                      | h |                                |
|      |      |                      | o |                                |
|      |      |                      | l |                                |
|      |      |                      | d |                                |
|      |      |                      | e |                                |
|      |      |                      | r |                                |
|      |      |                      | s |                                |
|      |      |                      | i |                                |
|      |      |                      | n |                                |
|      |      |                      | t |                                |
|      |      |                      | h |                                |
|      |      |                      | e |                                |
|      |      |                      | d |                                |
|      |      |                      | i |                                |
|      |      |                      | r |                                |
|      |      |                      | e |                                |
|      |      |                      | c |                                |
|      |      |                      | t |                                |
|      |      |                      | i |                                |
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|      |      |                      | n |                                |
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|      |      |                      | f |                                |
|      |      |                      | g |                                |
|      |      |                      | r |                                |
|      |      |                      | a |                                |
|      |      |                      | n |                                |
|      |      |                      | t |                                |
|      |      |                      | p |                                |
|      |      |                      | r |                                |
|      |      |                      | o |                                |
|      |      |                      | j |                                |
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|      |      |                      | . |                                |
+------+------+----------------------+---+--------------------------------+
| **   | De   | · Design and         | · |                                |
| Wash | part | implement a buy-in.  | P |                                |
| ingt | ment |                      | i |                                |
| on** | of   | · Change information | l |                                |
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|      |      |                      | . |                                |
|      |      |                      |   |                                |
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|      |      |                      | l |                                |
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|      |      |                      | . |                                |
|      |      |                      |   |                                |
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|      |      |                      | a |                                |
|      |      |                      | m |                                |
|      |      |                      | . |                                |
|      |      |                      |   |                                |
|      |      |                      | · |                                |
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+------+------+----------------------+---+--------------------------------+
| **   | Divi | · Design, implement  | · |                                |
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|      |      |                      | . |                                |
+------+------+----------------------+---+--------------------------------+
| *    | De   | · Evaluate the       | · |                                |
| *Wis | part | disability           | H |                                |
| cons | ment | determination        | i |                                |
| in** | of   | process to assess    | r |                                |
|      | He   | the outcomes of case | e |                                |
|      | alth | adjudication.        | s |                                |
|      | and  |                      | t |                                |
|      | Fa   | · Automate the       | a |                                |
|      | mily | Medicaid purchase    | f |                                |
|      | Serv | plan eligibility     | f |                                |
|      | ices | system.              | p |                                |
|      |      |                      | e |                                |
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+------+------+----------------------+---+--------------------------------+
| **W  | Wyo  | · Revise existing    | · |                                |
| yomi | ming | State statute in     | D |                                |
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+------+------+----------------------+---+--------------------------------+

Source: Center for Medicare and Medicaid Services, Demonstration and
Infrastructure Grant Activities,
<http://www.cms.hhs.gov/twwiia/inf_dmap.asp> \<Accessed April 1, 2003.\>

Note: Stars (\*) Indicates a demonstration description. Nonstarred
programs refer to Medicaid Infrastructure related grant activity. The
District of Columbia and Texas are the only entities with both grants
and demonstrations.

# 

# 

# 

# 

# 

# [APPENDIX 2:]{.underline}

# 

# [STATE CASE STUDIES]{.underline} 

# 

# [NEW HAMPSHIRE]{.underline}

# BBA or TWWIIA Basic Coverage Group

TWWIIA. The state wanted a higher income cut off than is available under
the BBA.

**Medical Improvement Group:**

No. The state wanted to see how the basic coverage group worked out
first.

# Background 

Governor's Task Force on Employment and Economic Opportunity argued that
TWWIIA coverage would support economic development. Federal grants
helped with the design work. The governor was very supportive and the
Medicaid coverage expansion unanimously passed the legislature. The
fiscal impact was estimated to be small.

**Eligibility Requirements**

-   General: One-year grace period if beneficiary loses employment and
    intends to return to work. Individual must meet New Hampshire's
    definition of disability.

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-   Income levels: Net income may not exceed 450 percent of FPL. Spousal
    income is included. Unearned income, impairment-related work
    expenses, and PASS disregarded. (Net income is approximately half of
    gross income.)

-   Resource levels: \$20,000 for individual and \$30,000 for a married
    couple. These amounts excludes retirement accounts, medical savings
    accounts, individual development accounts, and accounts to enhance
    employability. Liquid resources accumulated from earnings while
    eligible and kept in a separate account will be excluded when
    determining future eligibility for non-buy-in Medicaid categories.

**Premiums**

There is no monthly premium if the net income is below 150 percent of
the FPL. Premiums ranging from \$80 to \$210 per month in FY 2001 are
charged if net income is between 150 percent and 450 percent of FPL.
7.5% of income is charged for persons with income over \$75,000. Spousal
income is included in the premium calculation.

**Private Insurance**

Employer-sponsored insurance premiums are deducted from the buy-in
premiums, as are Medicare premiums.

**Long-Term Care**

Noninstitutional long-term care services are covered through three home
and community-based services waivers. The Medicaid state plan covers
personal care for people who must use wheelchairs.

**Outreach and Education**

The state has made a major outreach effort, including radio spots,
brochures and posters. They plan to connect with Chambers of Commerce.
Benefit specialists provide counseling services. Grants to independent
living centers provide outreach. The Governor's Task Force for
Employment and Economic Opportunity provides a forum for state and local
agencies, advocacy organizations, and consumers to coordinate Medicaid
infrastructure grant activities with other grantees (Dollars and Sense,
Department of Labor, SSA). Training and outreach efforts have included
statewide district offices, SSA offices, area agencies serving consumers
with developmental disabilities and acquired brain disorders, mental
health agencies, One-Stop centers (offering employment-related services
to both employees and employers), advocacy groups, and other local and
state agencies.

**Experience**

-   Participants: 1,017 beneficiaries, only a few of which were not
    previously eligible for Medicaid. Approximately 70 percent of
    participants are dually eligible for Medicare and Medicaid.

-   Premiums: The state has the State Children's Health Insurance
    Program collect the premiums for the buy-in program. Premium
    collection has gone smoothly. Premiums are not believed to be a
    significant bar to participation. About 18 percent of beneficiaries
    pay premiums. Of those paying premiums, 75 percent have net incomes
    between 150-200 percent of FPL. In addition, of those paying
    premiums, 90 percent are eligible for Medicare.

**Outlook and Issues**

-   The program benefits the state because it encourages people to work.
    Consumer advocates argue that there would be considerable opposition
    if the state tried to cut the Medicaid buy-in coverage.
    Community-based services may be at risk in the current budget
    environment.

-   The state believes that improvements could be made to the TWWIIA
    legislation regarding the definition of work and the age limitation.
    The definition of work is problematic, as it does not allow the
    states to specify the number of hours worked or minimum level of
    earnings. Some people on the buy-in program may work for only a few
    hours. In addition, the state believes that people age 65 and over
    should be able to participate in the buy-in program.

-   Consumer advocates argue that there needs to be more home and
    community-based services, perhaps with a higher Medicaid match.
    Personal care workers are said to be underpaid and typically do not
    have health insurance. Workforce issues need to be addressed.

-   The Medicaid Infrastructure Grant is overseen by the Governor's Task
    Force for Employment and Economic Opportunity for People with
    Disabilities. Representation from the Governor's Office allows
    recommendations to be made to the Governor to promote the
    advancement of employment for adults with disabilities.

# [IOWA]{.underline}

# BBA or TWWIIA Basic Coverage Group

Chose BBA because it was the first legislation that provided for this
coverage group.

**Medical Improvement Group**

Not applicable.

# Background

The Department of Human Services approached business groups to support
work incentives for people with disabilities as a way to address the
personnel shortage. The Iowa Business Council, consisting of the 25
largest businesses in the state, perceived people with disabilities as
an untapped pool of potential employees. Business groups were heavily
involved in helping get the legislation enacted.

**Eligibility Requirements**

-   General: Limited to people under age 65.

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-   Income levels: Iowa has a two-step test. First, monthly net income
    levels must be less than 250 percent of FPL for family size. The
    second step is to determine if the individual meets the disability,
    assets and unearned income standards to receive an SSI benefit. Iowa
    disregards all unearned income at this step. Eligible individuals
    who end their employment for any reason may remain eligible for six
    months if she or he intends to return to work.

-   Resource levels: Resources must be less than \$12,000 for
    individuals and \$13,000 for couples. Retirement accounts, assistive
    technology accounts and medical savings accounts are disregarded.

**Premiums**

Premiums are required when gross monthly income is above 150 percent of
the FPL. The highest premium is the average full cost of health
insurance for state employees. Maximum premium is 7.5 percent of gross
income. Above \$35,028, premium is constant and there is no state
subsidy.

**Private Insurance**

If an individual has employer-sponsored health insurance and it is cost
effective, the state will pay the premium. Thee are 26 persons in this
category.

**Long-Term Care**

Noninstitutional long-term care services are available through a home
and community-based services waiver. A total of 59 people in the
Medicaid buy-in receive waiver services. Personal care is not available
as an optional service under Medicaid.

**Outreach and Education**

The state has provided outreach efforts through Medicaid. They have
provided informational meetings throughout the state.

**Experience**

-   Participants: 5,048 individuals. This enrollment is about 10 percent
    of population with disabilities on Medicaid. Approximately 20
    percent are new Medicaid enrollees. Early data suggested that
    participants generally were coming from the medically needy coverage
    group.

-   Average earned income is \$210 per month; average unearned income is
    \$779 per month; average total income is \$956 per month.

-   Not including persons who are unemployed, 42 percent of participants
    work less than 10 hours per month; 10 percent work 80 hours a month
    or more. A total of about 4 percent of participants earn \$750 a
    month or more; 57 percent earned \$100 a month or less.

-   Premium collection: Approximately 27 percent of beneficiaries pay
    premiums. Failure to pay premiums has not been a significant
    problem.

**Outlook and Issues**

-   Despite a sluggish economy, the number of enrollees continues to
    increase at about 100 Medicaid beneficiaries a month.

-   Many people are working for just a few hours a month for
    individuals. State officials would like to require more hours of
    work.

-   Given the state fiscal problems, the legislature is looking at the
    Medicaid program as a whole for possible savings. Nothing specific
    has been proposed that would affect the Medicaid buy-in program.

-   The ability to provide prescription drug coverage for persons with
    mental illnesses is particularly important.

# CONNECTICUT

# 

# BBA or TWWIIA Basic Coverage Group

TWWIIA. The state chose TWWIIA because it allowed higher income
thresholds.

**Medical Improvement Group**

Yes. The state saw this as a logical extension of the basic coverage
group. However, there are no "medically improved" people in the program.
It seems that people have stable disabilities.

# Background 

Although the state agency had been working with disability advocacy
groups for a number of years, enactment of legislation was largely the
result of a few committed state legislators who worked with consumer
advocates. There is broad political support for initiatives to help
people to work. The law passed unanimously in the legislature.

**Eligibility Requirements**

-   Income levels: Individual may have income up to \$75,000 per year.
    Earned and unearned income considered. Spouse's income is not
    considered. Impairment related work expenses are disregarded. While
    the state wanted a high level of eligibility, they did not want the
    perception that "millionaires" could get free health care.

-   Resource levels: Individual may have resources up to \$10,000 and
    couples may have resources up to \$15,000. Retirement accounts,
    medical savings accounts, and accounts for employability-related
    expenses are also excluded for this as well as other eligibility
    categories. The state did not want to discourage savings. Liquid
    resources accumulated from earnings while eligible will be excluded
    when determining future eligibility for non-buy-in Medicaid
    eligibility categories.

-   Persons receiving benefits who temporarily lose employment may
    continue Medicaid eligibility as an employed person for up to one
    year if the loss of employment is due to involuntary dismissal or
    temporary health problem, and the individual intends to return to
    work or is looking for new employment.

**Premiums**

Premiums are imposed on persons with income above 200 percent of the FPL
based on family size. The premium is 10 percent of income above 200
percent of the FPL based on family size. For persons between 250 percent
and 450 percent of the FPL, the premium may not exceed 7.5 percent of
income. Spouse's income is considered when determining the premium
charge. A credit is given for other health insurance premiums paid.

**Private Insurance**

If it is cost-effective, Medicaid will pay employer-sponsored health
insurance premiums.

**Long-Term Care**

Personal care services are available through the home and
community-based services waiver. It is a consumer-directed model and
services can be provided at work. Many people receive home health
benefits, which are available outside of the waiver. There was a
state-funded personal care program, but beneficiaries have been
transferred to the Medicaid waivers. The state program has basically
been eliminated. Despite the requirement that people have a nursing home
level of care in order to qualify for the waivers, the state has not had
a problem getting people onto the waivers.

**Outreach and Education**

The Medicaid buy-in program is integrated into a broader employment plan
that includes benefits counseling. The Connect to Work program in the
Division of Rehabilitation Services tries to encourage disabled persons
to return to work, utilizing Medicaid. There has been heavy marketing,
including mailings to disabled people on SSI with earned income and
disabled individuals who have ended Medicaid eligibility within the last
two years. The state provides information to people earning less than
the SGA that they can earn more and still maintain Medicaid. The state
has five benefits counselors in the field. There have been talks to
groups providing services to people with disabilities, such as the
Multiple Sclerosis Society.

**Experience**

-   Participants: Connecticut has 2,512 beneficiaries in the Medicaid
    buy-in program, almost half of whom are aged 30-44. Approximately 16
    people have excluded retirement accounts. Approximately 27 percent
    of beneficiaries are earning \$5,000 a year or less; 43 percent are
    earning \$5,000 to \$9,999 a year. Thus, approximately 70 percent of
    beneficiaries are earning less than the SGA. Approximately 9 percent
    of the caseload is involuntarily unemployed and seeking work. Fully
    82 percent of beneficiaries are dually eligible for Medicare and
    Medicaid, primarily SSDI only. In percentage terms, the program has
    grown rapidly, from 651 beneficiaries in 2001 to 2513 beneficiaries
    in 2003. State officials are uncertain if the program is topping
    out.

-   Premium collection: 12% of beneficiaries pay premiums, of which the
    average amount is \$52 a month. The state does not believe that
    premiums have been a barrier to participation. The state sends a
    bill, which is supposed to be paid by the end of the month. If the
    client is more than 30 days in arrears, then the case is closed.
    Payment of premiums has not been a major issue. Programming the
    computers for the premium payment was more of the issue.

-   The Medicaid infrastructure grant from CMS is combined with the
    benefits and outreach planning grant from SSA. The grants are housed
    within Vocational Rehabilitation, which is part of the Department of
    Social Services. State officials believe that having Medicaid and
    Vocational Rehabilitation in the same agency greatly improves
    coordination. Changing attitudes regarding work for people with
    disabilities is a major task.

**Outlook and Issues**

-   The state was originally going to have a more restrictive definition
    of employment, but CMS did not allow states to do that. However,
    there is also a view that many people need to start working a little
    before they can work a lot.

-   With the current downturn in the economy, the caseload has not
    grown, but it has not shrunk. So far, the economy does not seem to
    be a major factor in the size of the program.

-   With the current state fiscal crisis, there is some possibility that
    the premiums may increase. However, the basics of the program are
    not being considered for budget cuts.

-   State officials would propose removing the limitation in eligibility
    to the population under the age of 65.

-   The Medicaid buy-in is most effective when it is well integrated
    with other work programs for people with disabilities.

-   Press releases about the program emphasize that the Medicaid buy-in
    program can also benefit Connecticut employers by helping them
    attract and retain workers. The state recognizes that many employers
    do not provide the comprehensive health insurance that people with
    disabilities need and Medicaid is, therefore, needed.

### SOUTH CAROLINA

**BBA or TWWIIA**

BBA

**Medical Improvement Group**

Not applicable.

**Background**

The South Carolina Department of Health and Human Services made the push
for this legislation. Given the small enrollment, there has been no
particular push to switch to TWWIIA.

**Eligibility Requirements**

-   Income: An individual's income must be below 250 percent of the FPL.
    South Carolina uses SSI methodologies in determining income.

-   Resources: Resources must be below \$2,000 for individuals and
    \$3,000 for couples. South Carolina uses SSI methodologies in
    determining resources.

**Premiums**

South Carolina does not charge premiums for its Medicaid buy-in program.
It also does not charge premiums for its State Children's Health
Insurance Program.

**Private Insurance**

The Medicaid program will pay private health insurance premiums if it is
cost effective.

**Long-Term Care Benefits**

Personal care is covered through home and community-based services
waivers, which have more exclusions from resources. Personal care is not
covered as a state plan benefit.

# Outreach

The state provides an overview of Medicaid to all prospective
beneficiaries. There are linkages with the Department of Vocational
Rehabilitation.

**Experience**

-   Participants: Approximately 770 beneficiaries are participating.
    Most beneficiaries were previously on Medicaid.

**Outlook**

-   Despite the state's fiscal crisis, there are no plans for cutting
    the Medicaid buy-in program.

**[PENNSYLVANIA]{.underline}**

# BBA or TWWIIA

TWWIIA

**Medical Improvement Group**

Yes. It seemed to be the logical next step beyond covering the basic
coverage group. It was also felt that if this group was not covered,
then individuals could have a recurrence of their disabilities due to a
lack of health coverage.

**Background**

The state liked the flexibility available in TWWIIA. The expanded
eligibility was funded with funds from the tobacco settlement, as part
of "Pennsylvania's Health Investment Plan." Medical Assistance for
Workers with Disabilities was implemented in January 2002. They expect
short-term costs, but savings in the long run because people will stay
healthier longer. The initial cost estimate was nearly \$25 million,
which was based on an initial estimate of 10,000 enrollees, far more
than currently enrolled.

**Eligibility Requirements**

-   Income: Net countable income must be less than 250 percent of the
    FPL. The income of children and siblings is excluded.

-   Resources: Countable resources must be less than \$10,000. This
    resource level allows individuals to save and still maintain their
    Medicaid coverage. Family Savings Accounts (established by the
    Department of Community and Economic Development) are excluded.

**Premiums**

All participants must pay a monthly premium based on 5% of their net
countable income. Premiums of less than \$10 per month are waived. This
level was established as a fair and reasonable payment for coverage.

**Private Insurance**

The Medicaid program will pay private insurance premiums if it is cost
effective.

**Long-Term Care**

Noninstitutional long-term care services are available through home and
community-based services waivers. Personal care is not an optional
benefit for the Medicaid program.

# Outreach and Education

Pennsylvania received a Ticket to Work infrastructure grant. It has used
that funding to establish an advisory committee on employment. It has
also developed outreach programs and CareerLink, a pilot job information
and training program, which provides information on the Medicaid buy-in
program.

**Experience**

Participants: There are 1,374 beneficiaries, less than the 10,000
originally budgeted. State officials believe that the SSA Ticket to Work
initiative (which is slated to begin in Pennsylvania in late 2003) has
the potential to have a positive impact on enrollment. Fully 73 percent
of individuals in the buy-in program were enrolled in a different
Medicaid eligibility group within the past year. Approximately 24
percent of people with some other Medicaid coverage were enrolled in a
state-funded general assistance category. By using the buy-in program,
the state moved working people with disabilities from a state-funded
eligibility group to a federally-funded eligibility group. Over half of
participants are between the ages of 30 and 49. A third of beneficiaries
worked either part time or part-time for more than 100 hours per month;
half worked 100 hours per month or less; and, one-seventh were
self-employed. Higher income working people with disabilities may
receive employer-paid health insurance and do not feel the need to
obtain insurance through Medicaid. Many disabled individuals may feel
that if they work too many hours, they will lose their benefits and
therefore limit what they earn. Average monthly Medicaid costs are
\$529. A little over half of beneficiaries are dually eligible for
Medicare and Medicaid.

Private insurance: Approximately 13 percent of participants had private
insurance. The general lack of private insurance may reflect the broader
Medicaid benefits, the failure of employers to offer insurance, and the
high cost of private coverage.

Premiums: All but one percent of beneficiaries are required to pay
premiums. Approximately a quarter of premium-paying beneficiaries are
delinquent in their premium payments, at least temporarily. Many
individuals are unable to pay the premiums due to layoffs and other
reasons beyond their control. Under these circumstances, they are
allowed to claim "good cause," which is granted for up to two months
when the problems are reported and verified in a timely manner. The
premium is waived during the good cause period.

**Outlook**

-   If the economy worsens, the state expects jobs generally to become
    less available, including those for persons with disabilities.

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-   The state expects to cut Medicaid this year. Despite the state's
    fiscal crisis, the Medicaid buy-in program is unlikely to be cut.

-   Some state officials would like a clearer definition of "work."

###### 

[^1]: Congressional Budget Office, "Fact Sheet for CBO's March 2003
    Baselines: Medicaid and State Children's Health Insurance Program,"
    (Washington, DC: Congressional Budget Office, March 2003).

[^2]: Kaiser Family Foundation, "Medicaid's Role for the Disabled
    Population Under Age 65," (Washington, DC: Kaiser Family Foundation,
    2001).

[^3]: Chad Newcomb, Suzanne Payne, and Mikki Waid, "What Do We Know
    About Disability Beneficiaries' Work and Use of Work Incentives
    Prior to Ticket," in Kalman Rupp and Stephen H. Bell, *Paying for
    Results in Vocational Rehabilitation,* (Washington, DC: The Urban
    Institute, 2003), pp. 31-69.

[^4]: Enrollment estimates from Congressional Budget Office, *op. cit.*;
    expenditure estimates from the Urban Institute (unpublished), based
    on data from the Centers for Medicare and Medicaid Services (Form
    64).

[^5]: The U.S. Territories (American Samoa, Guam, Northern Mariana
    Islands and U.S. Virgin Islands) and the Commonwealth of Puerto Rico
    are not included in this analysis.

[^6]: Congressional Budget Office, *op. cit.*

[^7]: Author's calculations based on Congressional Budget Office data.

[^8]: Kaiser Family Foundation, "Medicaid's Role for the Disabled
    Population Under Age 65," (Washington, DC: Kaiser Family Foundation,
    2001).

[^9]: Centers for Medicare & Medicaid Services, *Medicaid Eligibility
    Groups and Less Restrictive Methods of Determining Income and
    Resources: Questions and Answers,* May 11, 2001, available at:
    <http://cms.hhs.gov/medicaid/eligiblity/elig0501.pdf>., accessed
    February 11, 2003.

[^10]: 42 U.S.C. 1396a(a)(10)(A)(i)(II); 42 U.S.C. 1396v(a)(2).

[^11]: The provisions in federal law \[42 U.S.C. 1396a(a)(10)(E)(ii)\]
    authorizing premium assistance up to 135% of the FPL (the QI-1
    program) and 175% of the FPL (the QI-2 program) expired on December
    31, 2002. Congress extended the QI-1 program as part of an Omnibus
    appropriations act passed in January 2003 (P.L. 108-7). At the time
    of this writing, legislative staffers believe that the QI-1 program
    likely will be reauthorized for five years sometime during the 108th
    Congress. The QI-2 program was allowed to expire at the end of 2002
    and is unlikely to be reauthorized.

[^12]: Ellen O'Brien and Diane Rowland, *Medicare and Medicaid for the
    Elderly and Disabled Poor,* (Kaiser Family Foundation, 1999).

[^13]: 42 U.S.C. 1396a(a)(10)(E)(i) and 1396a(a)(10)(E)(iii); states are
    required to pay only premiums (not deductibles and co-payments) for
    those individuals between 100 and 120 percent of the FPL.

[^14]: 42 U.S.C. 1382c(3).

[^15]: The substantial gainful activity level for 2003 is \$1,330 per
    month for blind individuals.

[^16]: 20 CFR 416.1201 to 416.1266 (Subpart L).

[^17]: 42 U.S.C 1382h(b); 42 U.S.C. 1396d(q).

[^18]: Julie Scales, Donna Folkemer and Alan Jensen, *Ticket to Work:
    Medicaid Buy-In Options for Working People with Disabilities,*
    (Washington, DC: National Conference of State Legislatures,
    undated), available at
    <http://204.131.235.67/programs/health/Forum/tickettowork.htm>.

[^19]: Chad Newcomb, Suzanne Payne, and Mikki D. Waid, "What Do We Know
    About Disability Beneficiaries Work and Use of Work Incentives Prior
    to Ticket?," *Paying for Results in Vocational Rehabilitation: Will
    Provider Incentives Work for Ticket to Work?*, Kalman Rupp and
    Stephen H. Bell, editors, (Washington, DC: The Urban Institute,
    2003), pp. 31-69.

[^20]: Ibid, p. 46.

[^21]: Unpublished data, Centers for Medicare & Medicaid Services.

[^22]: Center for Workers with Disabilities, *Working for Tomorrow,*
    (Washington, DC: Center for Workers with Disabilities, July/August
    2001).

[^23]: Greg Von Brehen and Nick Samuels, "The Fiscal Survey of States,
    November 2002," (Washington, DC: National Association of State
    Budget Officers, 2002); National Governors' Association, "Governors
    to Meet with President, Cabinet Officials and Congressional Leaders
    During NGA Winter Meeting," February 22, 2003, available at:
    http://www.nga.org/nga/newsRoom/1,1169,C_PRESS_RELEASE\^D_5079,00.html.

[^24]: NGA, ibid.

[^25]: National Association of State Budget Officers, "NASBO Analysis:
    Medicaid to Stress State Budgets Severely into Fiscal 2003,"
    (Washington, DC: National Association of State Budget Officers,
    2002).

[^26]: Vernon Smith, Kathy Gifford, Rekha Ramesh and Victoria Wachino,
    *Medicaid Spending Growth: A 50-State Update for Fiscal Year 2003,*
    (Washington, DC: Kaiser Family Foundation, 2003); and, John Holahan,
    Joshua M. Wiener, Randall R. Bovbjerg, Barbara A. Ormond and Stephen
    Zuckerman, *The State Fiscal Crisis and Medicaid: Will Health
    Programs Be Major Budget Targets?* (Washington, DC: Kaiser Family
    Foundation, 2003).

[^27]: John Holahan, Alan Weil and Joshua M. Wiener, editors, *Health
    Policy and Federalism,* (Washington, DC: The Urban Institute, in
    press).

[^28]: National Association of State Budget Officers, *NASBO Analysis:
    Medicaid to Stress State Budgets Severely into Fiscal Year 2003,*
    (Washington, DC: National Association of State Budget Officers,
    2002); Holahan et al., op. cit.; and, Smith et al., op. cit.

[^29]: Matthew Broaddus, Shannon Blaney, Annie Dude, Jocelyn Guyer,
    Leighton Ku, and Jaia Peterson, *Expanding Family Coverage: States'
    Medicaid Eligibility Policies for Working Families in the Year
    2000,* (Washington, DC: Center on Budget and Policy Priorities,
    2002).

[^30]: Allen J. LeBlanc, M. Christine Tonner and Charlene Harrington,
    "State Medicaid Programs Offering Personal Care Services," *Health
    Care Financing Review,* 22(4): 155-73, 2001.

[^31]: Joshua M. Wiener, Jane Tilly and Lisa Maria B. Alecxih, \"Home
    and Community-Based Services for Older Persons and Younger Adults
    with Disabilities in Seven States,\" *Health Care Financing Review*,
    23(3): 89-114, 2002.

[^32]: Janet O'Keeffe Janet, *Determining the Need for Long-Term Care
    Services: An Analysis of Health and Functional Eligibility Criteria
    in Medicaid Home and Community Based Waiver Programs*, (Washington,
    DC: AARP, 1996); and, Janet O'Keeffe*, People with Dementia: Can
    They Meet Medicaid Level-of-Care Criteria for Admission to Nursing
    Homes and Home and Community-Based Waiver Programs*? (Washington,
    DC: AARP, 1999).

    ^?^ Pat Johnson, "Issue Brief on Medicaid Provider Reimbursement,\"
    National Conference of State
    Legislatures.http://www.hpts.org/hpts97/issueb2001.nsf., 2000,
    accessed January 30, 2001.

[^33]: Liu, Korbin, Kenneth G. Manton, and Cynthia Aragon, "Changes in
    Home Care Use by Disabled Elderly Persons: 1982-1994," *Journal of
    Gerontology:Social Sciences,* 55B(4):S245-S253, 2000.

[^34]: Joshua M. Wiener, Jane Tilly and Lisa Maria B. Alecxih, \"Home
    and Community-Based Services for Older Persons and Younger Adults
    with Disabilities in Seven States,\" *Health Care Financing Review*,
    23(3): 89-114, 2002; and, Allen J. LeBlanc, M. Christine Tonner, and
    Charlene Harrington, "Medicaid 1915(c) Home and Community-Based
    Services Waivers Across the States," *Health Care Financing Review,*
    22(2): 159-174, 2000.

[^35]: Donna Folkemer, Allen Jensen, Robert Silverstein, and Tara Straw,
    *The Medicaid Buy-In Program: Lessons Learned from Nine "Early
    Implementer" States,* (Washington, DC: Office of the Assistant
    Secretary for Planning and Evaluation, U.S. Department of Health and
    Human Services, 2002), available at:
    [http://aspe.hhs.gov/daltcp/reports/EIlesson.htm](http://aspe.hhs.gov/daltcp/reports/Eilesson.htm).

[^36]: The medically needy option allows states to set slightly higher
    income limits---called the medically needy income level
    (MNIL)---than were allowed under the Aid to Families with Dependent
    Children (AFDC) program. In addition to meeting the income standard,
    individuals can also qualify under the medically needy option by
    incurring out-of-pocket medical expenses that, when subtracted from
    regular income, put them below the MNIL, a process known as
    "spending down," or depleting their incomes paying for medical care.
    In addition, as a condition of electing to use more restrictive
    eligibility criteria, states using the section 209(b) option also
    must allow applicants to qualify for Medicaid by "spending down."
    These mechanisms make it possible for applicants with incomes that
    are too high to qualify for Medicaid, but who have significant
    medical expenses, to become eligible by deducting incurred medical
    expenses from their incomes.

[^37]: Larry Levitt, Erin Holve, and Jain Wang, "Employer Health
    Benefits: 2001 Annual Survey," (Menlo Park, CA and Chicago: Kaiser
    Family Foundation and Health Research and Educational Trust, 2001).

[^38]: Leighton Ku and Teresa A. Coughlin, "Sliding Scale Premium Health
    Insurance Programs: Four States' Experiences," *Inquiry,* 36(4):
    471-80, 1999-2000; M. Susan Marquis and Stephen H. Long, "Worker
    Demand for Health Insurance in the Non-group Market," *Journal of
    Health Economics,* 14(1): 47-63, 1995; and, Peter J. Cunningham,
    Elizabeth Schaefer, Christopher Hogan, "Who Declines
    Employer-Sponsored Health Insurance and is Uninsured?" *Issue Brief
    22*, (Washington, DC: Center for Studying Health Systems Change,
    1999); Elizabeth Shenkman, Donna Hope Wegener, Jane Pendergast, and
    Traci Hartzel, *Premium Subsidies and 'Adverse Retention' in a
    Children's Managed Care Program,* (Gainesville, FL: Institute for
    Child Health Policy, 1996).