The CAO determines who is eligible for MAWD using the rules in this chapter and the following chapters:
Medical Assistance Eligibility Handbook
Application - Chapter 304
Identity - Chapter 320
Citizen/Alien - Chapter 322
Residence - Chapter 323
Resources - Chapter 340
Income - Chapter 350
Self-Employment - Chapter 352
Reporting Changes - Chapter 370
Renewal - Chapter 376
Notices - Chapter 377
Appeal and Fair Hearing - Supplemental Handbook Chapter 870
Overpayment Recovery - Supplemental Handbook Chapter 910
Reimbursement -Supplemental Handbook Chapter 915 Reimbursement
Enumeration -Supplemental Handbook Chapter 950
For a MAWD Worker with a Disability (PW), an individual is considered disabled if he or she meets one of the following conditions:
The individual receives Social Security Disability Insurance (SSDI) benefits.
NOTE: Individuals applying for MAWD do not need to apply for SSI or SSDI in order to receive MAWD.
The individual previously received SSI or SSDI benefits and the SSA disability verification is still valid. If SSI or SSDI benefits were stopped for a reason other than a change in disability, the disability determination may be considered valid. The CAO must look at how much time has passed between the termination of SSI or SSDI benefits and the individual’s application for MAWD; if it is more than 12 months, the individual must be referred to the Medical Review Team (MRT).
NOTE: The SSA decision is binding unless the individual’s condition has changed because of a recent hospitalization, a new diagnosis, or another reason. If the individual was denied for SSI or RSDI before and the CAO believes that the SSA decision is outdated, the CAO can ask for new proof of the individual's condition.
The individual is certified as permanently and totally disabled by the MRT.
NOTE: MAWD applicants are not referred to the SSA because of employment. For the MAWD eligibility determination, Substantial Gainful Activity (SGA) requirements are not considered. MRT considers only the individual’s medical condition when reviewing the case for disability.
For a Worker with a Medically Improved Disability (PI), the individual is considered to have a “severe medically determinable disability” (as described in (Section 316.1) if a medical professional (a doctor, nurse practitioner, or psychologist) gives proof of one or more of the following health conditions:
Disability limits the individual’s ability to work or conduct daily life activities.
The individual has a mental health or physical health problem that has been stabilized by medication and monitoring by medical professionals. The individual’s health could get worse without medical services.
Loss of medical care could result in the individual not being able to work, or the health problem could get worse to the point where the individual would meet the SSA definition of disability and be eligible for Social Security Disability Income (SSDI) payments.
These conditions apply to the following individuals and others:
Individuals who use motorized vehicles or other durable medical equipment to perform daily activities.
Individuals who have had organ transplants and require medication for the rest of their lives so that they don’t reject the transplant.
Individuals with mental health problems who require medication to keep working.
Individuals such as those with AIDS/HIV who need medical monitoring and medication to help them live longer.
Individuals with diseases that last a lifetime, such as epilepsy, multiple sclerosis, and rheumatoid arthritis.
Individuals receiving treatment because their kidneys have stopped working.
NOTE: An individual must have medical proof showing that he or she continues to have a disability. Worker with a Disability (PW) coverage may continue for up to two full calendar months while the CAO is determining eligibility for Worker with a Medically Improved Disability (PI) benefits. This allows time for obtaining proof and assessing the disability.
NOTE: If someone who receives MAWD has his or her Title II SSDI benefits terminated (either permanently or for a while) the CAO must first find out why they were stopped. If benefits stopped because the individual is in a trial work period and not because of a change in his or her disability, MAWD PW coverage should continue.
NOTE: The individual must have had ongoing coverage in the Worker with a Disability group to be eligible for Worker with a Medically Improved Disability coverage. Retroactive Worker with a Disability coverage will not be considered.
MAWD provides individuals with disabilities the chance to return to work or enter the work force without losing medical coverage. Many of them can only work a few hours a month, but they should still be paid at normal levels. To make sure this happens, individuals with disabilities should be encouraged to charge a reasonable amount for their work. Examples of specific situations involving employment and self-employment are found later in this section.
The CAO must use the following employment rules when determining eligibility:
Worker with a Disability: There is no minimum work hours requirement.
Worker with a Medically Improved Disability: An individual must work at least 40 hours a month and earn at least minimum wage. For self-employed individuals, divide the gross monthly receipts by 40 to determine if he or she meets the minimum wage requirement.
Proof of employment is required for individuals in both groups. The CAO must use the following rules when determining if employment or self-employment qualifies an individual for MAWD:
NOTE: The applicant is the primary source of information in proving eligibility for MA. However, the CAO must help the applicant, when necessary, to obtain the required proof.
Employed: The individual must be employed full or part-time and get paid for working. The individual must provide proof such as pay stubs or a letter from the employer. The CAO will explain the earned income deductions that allow individuals to work and continue to be eligible for MAWD coverage.
NOTE: Income in-kind satisfies the MAWD work requirement when a value is attached to the work that was performed. A statement from the individual paying for work to be done would need to identify the work being completed, how it was compensated, and a monetary value assigned to it. When processing this income, use an exemption code for SNAP and Cash Assistance on the wage screen.
Self-employed: The individual must provide proof of self-employment. The CAO will give the applicant a MAWD Self-Employment Form (PA 1762) and explain that the individual has the option to use the form to verify self-employment. The PA 1762 is available on DocuShare. Other proof includes, but is not limited to the following:
Self-employment business records and ledgers.
Proof that the individual paid taxes, including FICA, state, federal, and local taxes.
NOTE: Records must provide specific information, such as days worked, number of hours worked, hourly wage, and where employment took place.
NOTE: Self-employed individuals who have been running their own business for less than three months and have not filed tax forms must use proof such as the MAWD Self-Employment Form, a business plan, a log of hours, or an account book. The individual can submit proof of filing tax forms for future employment reviews.
For individuals who are self-employed and do not earn enough income to file quarterly taxes, use other proof to verify self-employment efforts. The CAO worker should discuss the advantages of filing taxes if his or her income increases. ( Appendix H.)
The Internal Revenue Service (IRS) requires individuals to file Schedule SE (Form 1040) and pay self-employment taxes if either one of the following applies:
Net earnings from self-employment (excluding church employee income) are expected to be $400 or more a year.
Church employee income is $108.28 or more a year.
An individual says she receives $5 a week to drive someone on shopping trips or to medical appointments.
Although the individual is probably not earning enough to file taxes, she needs to show some proof. For example, she might show some type of business plan that proves that she is trying to set up a real business. The plan could include records that show the following:
When the self-employment began.
The dates and times the trips took place.
The hourly rate earned.
The reason for the trips (for example, “Went to Giant from 10:00 a.m. to 12:00 noon on 5/1/20).
How many hours she worked to get $5 (1 hour or 5 hours).
The names and addresses of individuals she worked for.
Whether she is being paid back for the cost of gas.
An individual is watching a child on the first Thursday evening of each month and is being paid $50 each month to take a friend shopping.
See situation #1.
An individual receives a lump sum to carry out the terms of his cousin’s will.
The lump sum can be counted as either a resource or income. If the individual wants it counted as income, it must be treated as unearned income, not earned income. If there is no other earned income, the individual does not qualify for MAWD.
An individual is walking a neighbor’s dog, babysitting, and repairing things.
See situation #1.
An individual does ironing for $5 a month.
See situation #1.
An individual earns $1 an hour babysitting.
See situation #1. Also, the CAO must find out whether the $1 per hour payment for babysitting is an amount that babysitters get in the area. This amount seems extremely low and does not seem to be a reasonable payment. If she is trying to set up a childcare business, she must ask for fair pay for her services.
An individual earns $50 a month for building maintenance.
See situation #1. Also, the CAO must obtain proof of where the work takes place, the name and address of the customer, the number of hours worked per week, and the number of hours that the $50 covers.
An individual completes work for the landlord and in turn the landlord deducts an amount of money from the rent. This is an example of income in-kind. The landlord is assigning a value to the completed work and deducting it from the monthly rent.
Here are guidelines for determining the MAWD applicant/recipient group:
The MAWD individual is someone who meets the requirements for one of the MAWD eligibility groups.
Spouses who are applying for MAWD who live together and who both meet the MAWD requirements are included in the same applicant/recipient group. Each spouse is authorized as a separate budget group.
A spouse who is living with a MAWD individual and does not meet MAWD requirements or chooses not to apply for MAWD must be included in the MAWD eligibility decision.
Other family members or relatives who meet MAWD requirements and who are applying for MAWD are included in separate applicant/recipient groups.
Here are guidelines used in determining eligibility for other family members for other MA groups:
NMP and MNO: When considering NMP and MNO for other family members, do not count the income or resources of the MAWD-eligible member.
Modified Adjusted Gross Income (MAGI): When considering MAGI for other family members, follow the steps in Chapter 312, ACA/MAGI.
Healthy Horizons: When considering Healthy Horizons for other family members, follow the steps in Chapter 319, Healthy Horizons.
MAWD and HCBS: Count income of a spouse under MAWD using the income guidelines in this chapter.
NOTE: If an individual is eligible for HCBS under the special income limit (300 percent of the federal benefit rate), do not count the spouse’s income when determining eligibility under the special income limit. However, spousal impoverishment provisions will apply when figuring countable resources of the couple.
316.24 Presumptive Eligibility
For a MAWD worker with a disability (PW), an individual can be authorized benefits before a disability is proven. If the County Assistance Office (CAO) receives some type of disability information and all other conditions of eligibility are met, the CAO will authorize ongoing presumptive MAWD without delay.
Disability information may be provided verbally or in a written format and can come from various sources. Examples of these sources include, but are not limited to:
Employability Assessment Form (PA 1663)
Health-Sustaining Medication Assessment Form (PA 1671)
A medical provider
A Mental Health or Intellectual Disability Agency
A Center for Independent Living (CIL)
An agency that serves the applicant, such as the Office of Vocational Rehabilitation (OVR)
NOTE: Individuals diagnosed solely with an alcohol or drug addiction are not eligible for SSI or SSDI. Medical documentation that shows only alcohol or drug addiction cannot be used to authorize MAWD presumptively. However, often with alcohol or drug addiction, there may be another medical condition present. The CAO should ask the individual if they can provide evidence of another medical condition. If the CAO is unsure, they should authorize presumptive eligibility and wait for the Medical Review Team’s (MRT) decision.
After presumptive eligibility is authorized, the CAO will request proof of the disability to complete an MRT referral. The initial ongoing presumptive eligibility period is three months from the date of authorization. It may be extended an additional three months if more medical information is needed for the MRT review. The CAO must provide the reason for the extension in the case comments.
316.241 Presumptive Eligibility in the Retroactive Period
The CAO may authorize presumptive MAWD in the retroactive period if:
There is a need for retroactive coverage (Section 368.2, Retroactive NMP).
A medical assessment form indicates a permanent disability or a disability lasting 12 months or more beginning on or prior to the retroactive MAWD requested effective date (Section 305.26, Presumptive Eligibility).
MAWD eligibility requirements are met, including the work requirement (Section 316.7, Retroactive Eligibility).
The MAWD premium is paid for the retroactive month(s) before authorization (Section 316.7, Retroactive Eligibility).
EXAMPLE: The CAO receives an application for MAWD on December 5, 2020 and the individual has requested that MAWD benefits begin that month. An Employability Assessment Form (PA 1663) is provided and shows the applicant has a disability that lasts 12 months or more with a disability begin date of October 10, 2020. The applicant provides medical expenses for September, October and November 2020, and requests retroactive coverage for each of these months. The CAO will authorize ongoing presumptive MAWD with a December 1, 2020 start date without delay. The CAO may authorize presumptive MAWD for retroactive months October and November prior to the MRT certification if all MAWD conditions of eligibility are met and the premiums for those months are paid. Since the PA 1663 shows that the applicant’s disability did not begin until after September, presumptive eligibility is not relevant for September and retroactive coverage for September cannot be authorized until the MRT certifies that the applicant was disabled for that retroactive month.
Updated March 10, 2021, Replacing November 30, 2016