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 allowable 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, with the same level as MAWD benefits in that month, then he or she does not have to pay the MAWD premium for the affected 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 ServiceNow.
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, after allowable deductions.
NOTE: Income of other household members, including a spouse, is not counted when determining premium amount.
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. |
|
The http://dhhsintra.dpw.state.pa.us/MAWD/ website is the MAWD Payments Due/Payment History Search Website. It is in real time and has the most current premium information. The CAO must review the information on this website prior to taking action on a MAWD budget.
Premium payments are due in full each month. They cannot be paid in advance for future months. The individual or the representative payer can pay the monthly premium through the following methods:
Credit cards and e-checks may be used for online payments.
Payments can be made online even if the case has been closed due to non-payment of their premium.
By mail with check or money order
When paying with a check or money order, premium payments must be mailed with the premium statement containing the Recipient Identification (RID) number
This mailing address must be used when the individual is sending their check or money order in the Business Reply Envelope (ENV 24) that is provided:
Commonwealth of Pennsylvania
Department of Human Services
Medical Assistance for Workers with Disabilities
P.O. Box 8052
Harrisburg, PA 17105-9933
This mailing address must be used when the individual is sending their check or money order with the premium statement in their own envelope:
Commonwealth of Pennsylvania
Department of Human Services
Medical Assistance for Workers with Disabilities
P.O. Box 8052
Harrisburg, PA 17105-8052
CAO Responsibilities:
The CAO is responsible for providing the initial premium statement and pre-addressed MAWD premium business reply envelope, if a premium is required to be paid. Appendix D has guidelines on completing and mailing the initial premium statement.
The CAO is responsible for entering correct information into CIS/e-CIS on premium begin dates, end dates, and amounts. The Central Office will collect premiums based on this information. If the information is entered incorrectly and the CAO cannot correct the case record, the CAO must request a correction through ServiceNow.
The CAO is responsible to have the MA Ombudsman work with the Central Office on premium payment issues. The Central Office can be reached by email at RA-PWMAWD@pa.gov.
The CAO is responsible for reviewing the http://dhhsintra.dpw.state.pa.us/MAWD/ website, which has a current record of premium payment information, prior to taking action on a MAWD budget.
NOTE: The CAO is NOT responsible for collecting premiums. If a MAWD recipient comes to the CAO with their MAWD premium payment, the CAO should direct the individual to the MAWD Online Payments website or provide the individual with a pre-addressed MAWD premium business reply envelope (BRE). If the individual is paying by mail, the PA 1755 payment voucher needs to be included with each premium payment. The voucher contains the RID number the Central Unit needs when applying the payments to each account. If the individual does not have their voucher, the CAO should provide them with the RID number to include on their check/money order.
Central Office Responsibilities:
The Central Office is responsible for collecting, processing, and tracking premiums. The Central Office mails on going 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.
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. |
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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 with a SAR or Renewal 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.
When information reported on a SAR or Renewal form leads to the premium increasing, the individual must receive an Advance Notice of the increase.
E-CIS notifies the CAO about premiums that have not been paid through an 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 by telephone or written correspondence 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 their own, the individual’s job ends in March and so they do 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 60 days after the closure date. (Section 379.2, Reopening Closed Benefits).
NOTE: SAR and Renewal dates must be updated to the original dates established prior to re-opening benefits.
The eligibility begin date will be the first day of the calendar month after the budget close date.
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 comments and scanned into imaging. 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 in case processing.
Example: An individual presents good cause in April for the previous March. Good cause cannot be granted for March in case processing. It must be processed through COPPMT.
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:
01 Unable to work, ill health
02 Lay off/Reduced hours
03 Job loss, not fault of client
04 Quit with good cause
05 Administrative Processing
This code may be used only when there is confusion over the first month of benefits, a payroll deduction issue, appeals or other related issue.
06 Delay in premium begin date.
07 Eligible for other MA category/overlapping eligibility.
The overlapping MA category must cover the same level of medical coverage as the MAWD category; if not, this code may not be used.
08 Death of the MAWD recipient.
09 Delay in closing. The CAO did not close MAWD timely.
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 and submit a request through ServiceNow for the correct code be entered in e-CIS for that time 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. When the CAO receives an alert for an unpaid premium, the CAO will review the case to determine if there is good cause for the unpaid premium by contacting the MAWD recipient. If good cause does not exist and the premium remains unpaid, the caseworker will close the case and send an Advance notice.
If 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)
Delay in closing.
If the case should have been closed earlier, use good cause code 09, delay in closing, 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 by contacting the recipient. 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.
54—Administrative error.
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 April 17, 2024, Replacing July 27, 2023