The CAO will tell the individual who is eligible for MAWD that he or she must pay a monthly sum of money, called a premium, to receive MAWD. The monthly premium is 5 percent of the individual’s earned and unearned income, after deductions.
The premium does not have to be paid, when:
The monthly premium is under $10.00.
The individual shows good cause why he or she should not have to pay it (Section 316.66).
Reminder: If an individual receives MAWD and another MA category in the same month, then he or she does not have to pay the MAWD premium for that month. The CAO must use good cause code 07 (Eligible for other MA category/overlap coverage) to show that the premium payment for the current and future calendar months does not have to be paid. Corrections to premiums for past calendar months must be requested through the CIS Hotline.
Here are guidelines for the CAO to use when determining the monthly premium:
Count the earned and unearned income of the applicant in the month of application, and remove any allowed deductions.
NOTE: Income of other household members, including a spouse, is not counted.
If both spouses are approved for MAWD, determine the monthly premium separately for each spouse, using only the income each receives.
NOTE: Both spouses can receive a $20 earned or unearned deduction.
Multiply the net income by .05 and round the result down to the nearest dollar to set the monthly premium.
Set the premium for a six-month period.
To set premiums for retroactive eligibility periods, see Section 316.7, Retroactive Eligibility.
Example: The month of application is June. The individual has $700 earned income and $800 unearned income for the month. The total Gross income is $1,500. The individual has impairment-related work expenses (IRWE) of $100.
|
Earned Income |
Unearned Income |
|
$700.00 |
$ 800.00 |
|
$635.00 |
$ 780.00 Net unearned income |
|
$ 535.00 |
$ 267.50 Net earned income |
|
Add net earned and net unearned income together to arrive at the net countable income for the premium. |
$ 267.50 (net earned income) |
|
Multiply the result by .05 and round down to arrive at the premium amount. |
$ 1047.50 X .05 = $ 52.38 |
|
The monthly premium amount is $ 52.00. |
|
Premium payments are due in full each month. They cannot be paid in advance for future months. The individual can pay the monthly premium or choose to have it deducted from pay checks.
Self-payment: The individual pays DHS by check or money order. No cash is accepted.
NOTE: The CAO staff is not responsible for collecting premiums.
Payroll deduction: If the employer allows payroll deductions, the individual can have the monthly premium deducted directly from their salary. If this method is used, then:
The individual signs a form allowing payroll deduction. The CAO must give a copy of this form to the individual and instruct him or her to give it to the employer. (Appendix E.)
The Central Office will set up the payroll deduction
.
NOTE: The CAO must enter the employment information on CIS/e-CIS, because the Central Office uses the information to set up the payroll deduction. The CAO must enter the recipient’s workplace name, address, and telephone number. The “payroll office” information must be left blank.
The individual will receive a letter from the Central Office letting him or her know whether the employer participants in payroll deduction. (Appendix G.)
The applicant must complete the “How To Pay The Premium” section on the application form and check the “Request Payroll Deduction” block on the initial premium statement.
The CAO is responsible for providing the initial premium statement and self-addressed stamped envelope, if required. (Appendix F) has guidelines on completing and mailing initial premium statements.
Premium payments must be mailed to the following address:
Commonwealth of Pennsylvania
Department of Human Services
Medical Assistance for Workers with Disabilities
P.O. Box 8052
Harrisburg, PA 17105-8052
The Central Office is responsible for collecting, processing, and tracking premiums. The Central Office mails ongoing premium statements to the recipient or the employer. Information is provided to the Central Office by a batch file process between CIS/e-CIS and the Central Office.
The Central Office uses CIS/e-CIS alerts to let the CAO know about past-due premiums and changes in address or employment. (See the CIS/e-CIS manual for information about CIS/e-CIS alerts.)
NOTE: The http://dhhsintra.dpw.state.pa.us/MAWD/ Website is in real time and has the most up-to-date current premium information. The information on this Website must always be reviewed prior to taking action on a MAWD budget.
NOTE: Information entered into CIS/e-CIS on premium begin dates, end dates, and amounts must be correct. The Central Office will collect premiums based on this information. If the information is entered incorrectly into CIS/e_CIS and the CAO cannot correct the case record, the CAO must call the CIS Hotline to report the situation and ask Headquarters to correct it.
The CAO will also assign a staff individual to be the MA Ombudsman. This individual works with the Central Office on premium payment issues. The Central Office can be reached by e-mail at MAWD@.pa.gov
Here’s the premium-collection timeline for the Central Office. Note that the CAO data-entry deadline is the last calendar day of the month.
|
Date |
Action |
|
10th of the month |
Premium statements generated by Central Office. |
|
11th of the month |
Premium statements mailed. |
|
15th of the month |
Estimated date premium statements received by recipients and employers. |
|
End of the month |
Premium due at Central Office. |
|
10th of the month |
Premium statement generated by Central Office. Premium statement will show the current month’s premium and any premiums that are overdue. |
|
20th of the month |
If the premium for the preceding month is not received, Central Office sends a CIS/e-CIS alert to the CAO. |
|
End of the month |
Estimated date that the CAO takes action on late premiums. Actions may include good cause or issuing a notice to close the budget. |
The premium amount is set for six months. Here are guidelines for the CAO to follow if a change in income is reported in that period:
Increase in income
The premium must not be increased during the six-month period if the recipient’s countable income continues to be below 250% of the FPIG limit. If countable income is more than 250% of the FPIG limit, the CAO will close the MAWD budget after appropriate notification.
Decrease in income
The premium must be reviewed and reduced if the decrease in income is expected to continue for the rest of the six-month period.
NOTE: Premiums must not be reduced when the decrease in wages is due to a temporary absence from work, such as days missed because of illness.
The CAO will:
Review income every six months to determine the monthly premium amount for the next six-month period.
Inform the individual by letter to send proof of income to the CAO.
NOTE: Unearned income that is adjusted once a year does not require proof every six months.
Review the premium at the twelve-month renewal.
Schedule one of the six-month premium reviews and the renewal at the same time.
Send notices to the individual to let him or her know of changes to the premium amount.
NOTE: When information reported on an SAR form leads to an increase in the MAWD monthly premium, an Advance Notice is needed to let the individual know about the premium increase.
CIS/e-CIS notifies the CAO about premiums that have not been paid through alert. When an alert comes that a monthly premium is overdue and not paid:
The CAO must review the budget and take appropriate action.
Before sending notification to close the budget, the CAO must try to contact the individual to determine if good cause exists. (Section 316.67.)
NOTE: The individual is responsible for payment of premiums for earlier months. He or she has until the end of the good cause period to pay overdue premiums.
Example: Through no fault of his or her own, the individual’s job ends in March and so he or she does not pay the March premium. In April, the individual reports a loss of employment. Good cause is granted for April and May. The March premium is due by the end of May. By June 11, the CAO reviews the information on the MAWD Intranet page to see if overdue premiums have been paid. (Appendix B.) If the premiums have not been paid, the CAO sends an advance notice to close the budget on the last day of June. The reason for the closing is nonpayment of premiums.
Benefits will be reinstated with no break in coverage if the MAWD individual pays the overdue premiums within 30 days after the closure date. The eligibility begin date will be the first day of the calendar month after the budget close date.
An application is not required if this is the first reinstatement in the six-month period. The CAO will allow reinstatement benefits once every six months.
All additional reinstatements of benefits due to late payment in a six-month period, require a complete application.
The CAO will not require premium payment for up to two months if the individual shows good cause and provides written proof. The individual must be planning to go back to their former job or be making a real effort to find new employment.
Good cause includes, but is not limited to, the following situations that the individual does not have control over:
The individual has medical problems that are expected to last longer than two weeks.
The individual had a job that is beyond what he or she can do.
The individual gets fired.
The individual is let go from a job through no fault of his or her own.
The working conditions are below standard. That is, the place of employment has dangers that may cause death or serious physical harm or pays wages that are below the minimum wage (if applicable for that type of job).
The individual has reason to make a claim of discrimination by an employer or fellow employees based on age, race, sex, color, disability, religious beliefs, national origin, political beliefs or other unlawful discrimination.
In determining whether there is good cause, the CAO will consider all facts and situations. Good cause must be proven to be true and shown in writing in the case record. Proof includes, but is not limited to, the following:
Good cause granted for health reasons.
A written statement from a medical or mental health provider, such as a medical doctor, psychiatrist, or psychologist, that identifies the health problem and time period in which the individual cannot work.
Good cause granted for employment loss.
A written statement from a community agency with whom the individual is working to find a new job.
A written statement from the Office of Vocational Rehabilitation (OVR) or the local employment office.
Copies of job applications.
A written statement from the individual describing his or her efforts to obtain new employment.
A written statement from the former employer.
The good cause period will begin:
The first day of the calendar month in which the individual requests good cause.
The first day of the following month.
Good cause cannot be granted for previous months.
Example: An individual presents good cause in April for the previous March. Good cause cannot be granted for March.
NOTE: It is the individual’s responsibility to request good cause.
Good cause is limited to two months in any six-month premium payment period. The two months do not have to be in a row.
The good cause period will end on the last day of the calendar month for which good cause was requested. The good cause end date must be the last day of the current month or the last day of the next month.
The CAO must review the individual’s situation at the end of the good cause period.
If the individual does not meet the employment requirement by the 15th of the month following the month of the good cause period, the CAO must send a notice to close the MAWD budget on the last day of the month.
Reminder: Good cause begin and end dates and codes must be entered in CIS/e-CIS to let the Central Office know that a monthly premium is not due.
The CAO will grant good cause and stop premium payments for past months when review of MA eligibility, review of overdue premiums, or contact with the individual or an outside agency shows that good cause should have been granted for a past month. The CAO must use the following codes when stopping the premium payments:
06—Delay in premium begin date.
07—Eligible for other MA category/overlapping eligibility.
NOTE: The previous MA category would have to have covered the same medical expenses as the MAWD category; if not, good cause cannot be granted, and the premium must be paid.
08—Death of the MAWD recipient.
09—Delay in closing.
10—Other.
This code covers good cause that cannot be identified by any other code. This includes, but is not limited to, the following situations:
The recipient thought his or her employer was paying the premiums.
The recipient has overdue rent or utility bills, and suspension of premiums would help him or her pay them.
The recipient has a temporary health problem that is expected to last longer than two months.
The recipient is working with an agency to find new employment.
The CAO must note in the case comments the reason good cause was granted. The CAO must contact the CIS Hotline to request that the correct code be entered on CIS/e-CIS for the period.
NOTE: Good cause may be extended to periods longer than two months. However, good cause may only be entered up to two months at a time in CIS/e-CIS. When good cause is extended for longer than two months, the situation must be reviewed at the end of each two-month period and documented in the case record.
When the CAO cannot determine whether good cause exists, the CAO must ask the Bureau of Policy to decide what to do about the situation.
Individuals enrolled in MAWD must pay a monthly premium to be eligible. Because of this, failure to make premium payments can be a cause of overpayments.
NOTE: The CAO does not process overpayments for a failure to pay premiums; the Central Office handles this type of overpayment.
When a case is closed for failure to pay premiums, the CAO must explore the following options and give special consideration to granting good cause. (Section 316.67) for information on good cause.)
Delay in closing.
If the case should have been closed earlier, use good cause code 09, and do not file an overpayment.
Due process.
Review the case to see if the right steps were taken and enough time was allowed for the notice to expire before closing. If the right steps were taken, do not file an overpayment, and use good cause code 09 for a delay in closing.
Other good cause.
Determine whether there was another reason that good cause should be given for nonpayment. Use the appropriate good cause code, and do not file an overpayment.
The Automated Restitution Referral and Computation (ARRC) System codes for MAWD overpayments are as follows:
53—Failure to report.
This code is used when the client fails to report or fails to report all required items and reporting would have caused ineligibility for MAWD.
This code is used when the CAO has caused the overpayment because of an incorrect premium calculation.
Example: The CAO determines that the initial premium is $50, and this is what the individual pays for the first two months. The case is later reviewed and it is found that the premium should have been $55. Since the client only paid $50, this would be an underpayment of the premium. The individual would be ineligible for the two months that only $50 was paid, because he or she did not pay what was required to maintain eligibility. This would result in an overpayment. Since it was the agency’s error, the overpayment is filed but no action is taken.
The CAO must review the case for good cause before referring an overpayment The following good cause codes may be used:
05—Administrative processing.
This code may be used only when there is confusion over the first month of benefits, a payroll deduction issue, or a related issue.
09—Delay in closing.
This code may be used when the case must be left open in order for the advance notice period to expire or when the CAO is working with the individual on premium payments.
Updated February 14, 2012, Replacing October 17, 2008