Returned Medical Assistance for Workers with Disabilities (MAWD) Premium payments due to Temporary Mailbox Closure, PMA18980-316 (Published June 15, 2018)
Medical Assistance Program Changes due to the Introduction of Enhanced Federal Medical Assistance Percentage, OPS160305 (Published March 10, 2016)
Medical Assistance for Workers with Disabilities (MAWD) helps individuals with disabilities work while receiving MA coverage. Each individual receiving MAWD must pay a monthly premium to the Department of Human Services (DHS).
Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170)
Act 2001-77 of June 26, 2001 (P.L. 755)
MAWD gives benefits to individuals who meet the eligibility rules in the following groups:
Worker with a disability (category PW). Individuals in this group must:
Be at least age 16 but under age 65.
Be employed and getting paid.
Be disabled according to the Social Security Administration (SSA) or the DHS rules (except for earnings).
Have countable monthly income, after any deductions, below 250% of the Federal Poverty Income Guidelines (FPIGs).
Have countable resources of $10,000 or less.
NOTE: Everyone between the ages of 16 and 65 who has a permanent disability should be evaluated for MAWD.
Worker with a medically improved disability (category PI). Individuals in this group must:
Meet the age, income and resource requirements of the worker with a disability group.
Work at least 40 hours a month and earn at least minimum wage.
Have a medically improved disability that no longer meets the SSA’s disability rules.
NOTE: The individual must continue to have a severe impairment, as determined by medical professionals.
Have received ongoing MA coverage in the workers with a disability group in the past and have had benefits discontinued because of medical improvement.
NOTE: Begin eligibility the month after coverage ends under the worker with a disability group. There cannot be a break in coverage.
HCBS is in-home, Long-Term Care services designed to help individuals with disabilities live independently in their homes and communities.
Individuals enrolled in MAWD can apply for HCBS, and those in HCBS programs can apply for MAWD. Also, individuals not enrolled in either MAWD or HCBS can apply for both.
NOTE: This applies to all HCBS for which individuals receiving MAWD can qualify. This does not include the infants, toddlers, and families waiver (for children birth through age 2).
Use category PW for MAWD and HCBS.
The CAO must let individuals enrolled in MAWD know that they can apply for HCBS and that there are pros and cons to enrolling in MAWD, HCBS, or both. Each individual must meet the functional eligibility requirements for HCBS. Also, individuals ages 55 and older who receive HCBS are subject to MA estate recovery requirements. The benefit of HCBS to MAWD enrollees is access to HCBS.
Resource limits are higher for MAWD than for other MA eligibility groups. Individuals enrolled in both MAWD and HCBS can earn more income and keep their HCBS services. To be eligible for MAWD, an individual must:
Meet MAWD age and disability requirements.
Be employed.
Pay a premium.
When an individual is functionally eligible for HCBS, the CAO must consider all other MA categories before allowing MAWD. A PA 600L form is used for HCBS. Individuals taking part in HCBS do not need to complete a PA 600WD to apply for MAWD. A page with information about the MAWD premium will be attached to the PA600L. A page explaining HCBS eligibility rules will be attached to the PA 600WD.
When looking at resource and income limits for combined MAWD and HCBS eligibility, the CAO must use the MAWD resource and income limits to determine eligibility. (See Appendix A.)
Use the following guidelines when looking at disability for combined MAWD and HCBS eligibility.
Age: The individual must meet the MAWD age requirement (age 16 through 64), as well as the age requirement for the appropriate HCBS program.
Disability: The individual must meet the disability criteria for MAWD and be functionally eligible for HCBS.
Employment: Individuals enrolled in MAWD must be employed.
Premium: Individuals enrolled in MAWD must pay a monthly premium. The CAO must tell them about this rule.
HCBS participants enrolled in MAWD have a higher resource limit than waiver participants enrolled in other MA groups. The CAO must tell waiver program participants about this when they apply for MAWD.
Resource limits: The CAO must use the MAWD resource eligibility limit of $10,000.
Look-back: Look-back requirements do not apply for MAWD.
NOTE: A spouse’s countable resources must also be included in determining resource eligibility.
HCBS recipients enrolled in MAWD benefit from higher income limits than HCBS individuals in other MA groups. The CAO must let HCBS individuals applying for MAWD know of the different limits.
Income: Use the MAWD income eligibility guideline of 250 percent of the Federal Poverty Income Guidelines.
Spousal income: Spousal income is counted under MAWD. If the individual is eligible for the HCBS under the Special Income Limit (300 percent of the Federal Benefit Rate), the CAO will not count the spouse's income.
Individuals age 55 and older are subject to the MA estate recovery requirements for the following types of services received:
Nursing Facility Care.
Home and Community-Based Services.
Any related hospital care and prescription drug services provided while receiving nursing facility care or care at home or in a community setting.
Individuals who are eligible for both MAWD and HCBS must meet MAWD rules for the following:
Eligibility period: The CAO must use a calendar month when determining the eligibility period. MAWD benefits are opened at the beginning of the month and are closed at the end of the month.
Renewal: Renewals are required every 12 months. The applicant must use the PA 600WD form for the yearly renewal for MAWD and HCBS services. MAWD renewals do not need to include a renewal of functional level-of-care eligibility so long as a current HCBS eligibility decision has been provided by the program offices. The decision could be shown on such forms as the MR 250 or 251 for individuals in the Consolidated or individual/Family Directed Support waivers.
MAWD or HCBS closure: When an individual’s eligibility for MAWD or HCBS ends (by choice or by eligibility requirements), review the case for continued MA eligibility under other categories.
MAWD and HCBS applications can be processed in CIS/e-CIS using the current PW and PI categories with the entry of the waiver code on CAMWAI in CIS or the Waiver screen in e-CIS, identifying the individual's appropriate HCBS eligibility.
MA benefits: Health care benefit packages 1, 2, and 8 apply. HCBS services for the appropriate HCBS must be based on the entry of the waiver code.
Tell current HCBS enrollees who expect to be employed (as defined in the MAWD state plan) about MAWD. Program offices need to let current HCBS individuals know about MAWD and to refer them to the CAO when the HCBS individual or his or her representative chooses to have a MAWD determination made by the CAO. Program offices will also have MAWD outreach information for individuals enrolled in the program, their families, and advocates
.
The Work Incentives Planning and Assistance (WIPA) program is another resource available to individuals interested in applying for MAWD. It is funded by the SSA. The WIPA program provides technical assistance to individuals with disabilities receiving SSI or RSDI who need assistance in understanding how earned income from employment affects benefits and how to access and manage work incentives.
The CAO must refer eligibility information for individuals who are already enrolled in MAWD or taking part in HCBS to the correct office (either the CAO or the HCBS provider). Individuals who are already enrolled in MAWD must fill out the supplement to the PA 600WD to apply for HCBS services. Individuals who are already in HCBS must complete the supplement to the PA 600L to apply for MAWD.
The HCBS provider will also make MAWD/HCBS referrals, and MAWD/HCBS applications will be generated by COMPASS.
PMW18583316 - Home and Community Based Services (HCBS) in a Medical Assistance for Workers with Disabilities (MAWD) Category, July 17, 2017
The CAO must use the following procedures when handling MAWD/HCBS applications and referrals. Use category PW for MAWD and HCBS.
When an individual applies for HCBS at the CAO, the CAO must follow these steps:
1. Explain the differences between MAWD requirements and HCBS requirements and review the information page.
2. Refer the individual to the right HCBS provider.
3. The HCBS provider will determine the individual’s functional eligibility and let the CAO know the decision. If the individual is functionally eligible, enter the correct HCBS code.
4. Update the case narrative to show combined MAWD/HCBS eligibility.
5. Send HCBS eligibility notices to the individual and the HCBS agencies.
When an individual uses COMPASS to apply for HCBS, the CAO must follow these steps:
1. Give the application to a CAO worker who handles HCBS to make sure that the HCBS provider received the information from the Health Care Services Information System.
2. Contact the applicant to explain the differences between MAWD requirements and HCBS requirements and to review the information page.
3. The HCBS provider will determine the individual’s functional eligibility and let the CAO know the decision. If the individual is functionally eligible, refer the individual to a CAO staff worker who handles HCBS.
4. Enter the appropriate HCBS code.
5. Update the case record to show that the individual has applied for combined MAWD/HCBS eligibility.
6. Send HCBS eligibility notices to the individual and the HCBS provider agencies.
When an individual applies for HCBS through the HCBS provider, the CAO must follow these steps:
1. After the HCBS provider contacts the CAO, review the information page with the applicant and explain the differences between MAWD requirements and HCBS requirements.
2. The HCBS provider will determine the individual's functional eligibility and let the CAO know the decision. If the individual is eligible, enter the correct waiver code, and update the case notes to show combined MAWD/HCBS eligibility.
3. Send HCBS eligibility notices to the individual and the HCBS provider agencies.
The CAO must take the following steps whether the individual uses a CAO application, a COMPASS application, or an HCBS program office application:
NOTE: When an application is made through the HCBS provider, the provider will contact the CAO.
1. Refer the individual to the CAO worker who handles HCBS.
2. Follow existing HCBS steps to let the program office know about the MAWD application.
3. Review the information page with the applicant and explain the differences between MAWD requirements and HCBS requirements.
Explain that individuals receiving MAWD have to pay a premium.
4. Review MA eligibility to determine whether the individual is still eligible for the current category or for another MA category. If the individual is eligible for HCBS under MAWD only, proceed to step 5.
5. Make sure the correct HCBS code is in CIS/e-CIS.
6. Update the notes in the case record to show combined MAWD/HCBS eligibility.
7. Send MA eligibility notices to the individual and the HCBS provider agencies.
8. Send HCBS eligibility notices to the individual and the HCBS provider agencies.
The CAO must take the following steps whether the individual uses a CAO application, a COMPASS application, or an HCBS program office application:
1. Determine the individual’s eligibility for MA. If the individual's eligible, open the case in the right MA category.
2. Follow existing CAO HCBS steps to let the program office know about the application. If the individual’s case is open in MAWD, proceed to step 3. If not, follow existing HCBS steps.
3. Review the information page with the applicant and explain the differences between MAWD requirements and HCBS requirements.
Explain that individuals receiving MAWD have to pay a premium.
4. The HCBS provider will determine the individual’s functional eligibility and let the CAO know the decision. If the individual is eligible, enter the correct HCBS code.
5. Update the notes in the case record to show combined MAWD/HCBS eligibility.
6. Send MA eligibility notices to the individual and the HCBS provider agencies.
7. Send HCBS eligibility notices to the individual and the HCBS provider agencies.
Each individual who is enrolled in MAWD receives a PA ACCESS card to show providers when obtaining medical services. MAWD includes the following benefits:
MA benefits provided by a managed care organization, if the individual lives in a Health Choices county
NOTE: Individuals living in counties with voluntary managed care organizations may choose to have MA coverage provided by a managed care organization.
NOTE: Individuals under age 21 living in counties with ACCESS Plus may choose to have MA coverage provided by ACCESS Plus.
HealthCare Benefits Package (HCBP) coverage:
HCBP #1 is for individuals ages 16 to 20.
HCBP #2 is for individuals ages 21 to 65 who do not have Medicare coverage.
HCBP #8 is for individuals ages 21 to 65 who have Medicare coverage.
Payment of the Medicare Part A and Part B premiums, if the individual is also eligible for Healthy Horizons Cost Sharing Benefits.
NOTE: Healthy Horizons is also known as Qualified Medicare Beneficiaries (QMBs).
Payment of the Medicare Part B premium, if the individual is also eligible for Specified Low Income Medicare Beneficiaries (SLMB). (Chapter 319, Healthy Horizons.)
NOTE: Individuals who are eligible for MAWD and also meet the income and resource limits for Qualifying Individuals Group 1 (QI-1) cannot receive both MA services under MAWD and payment of the Medicare Part B monthly premium.
Payment of group health insurance benefits provided by employers by the Health Insurance Premium Payment Program (HIPP), if DHS decides it is cost-effective. ( Section 338.22 for information about HIPP.)
Reminder: The CAO can refer individuals to HIPP on the basis of their data entry of answers to insurance and employment questions in CIS/e-CIS.
NOTE: MAWD eligible individuals who need accessible public transit beyond the terms of the Americans with Disabilities Act may be eligible for transportation at a reduced rate. This service is provided under the People with Disabilities (PwD) program.
The CAO must verify the following:
Age: This can be verified through SDX.
NOTE: Documentation of date of birth is not required if it has been proven and noted before. If there is a problem with information provided, proof of age is required within 30 days.
Disability: A individual's disability is shown to be true if he or she gets SSI or Social Security Disability Insurance (SSDI) or by DHS’s Medical Review Team (MRT).
Employment
The CAO will not deny eligibility if proof is not received as long as the individual cooperates in providing the information needed.
Act 2001-77 of June 26, 2001 (P.L. 755)
Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170)
Updated August 30, 2018, Replacing June 15, 2018