316.2 Determining Eligibility

The CAO determines who is eligible for MAWD using the rules in this chapter and the following chapters:

316.21 Disability Groups

316.211 Worker with a Disability (PW)

For a MAWD Worker with a Disability (PW), an individual is considered disabled if he or she meets one of the following conditions:

NOTE:  Individuals applying for MAWD do not need to apply for SSI or SSDI in order to receive MAWD.

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 If the individual was denied for SSI or RSDI before and the CAO believes that the SSA decision is outdated, the CAO can ask for new proof of the individual's condition.

NOTE:   MAWD applicants are not referred to the SSA because of employment.

NOTE:  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.

NOTE:   A MAWD applicant can be authorized benefits before a disability is proven, as long as he or she gives information about the disability. The information can come from many types of sources, including the following:

After authorizing presumptive eligibility, the CAO must obtain medical proof of the disability from the individual’s doctor. The presumptive eligibility period is three months from the date of authorization.  It can be extended for three more months to provide time to gather information for the MRT review. The CAO worker must explain the reason for the   extension in the case notes.

316.212 Worker with a Medically Improved Disability (PI)

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:

These conditions apply to the following individuals and others:

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.

316.22 Employment

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:

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.

NOTE:  It is important for individuals to understand the earned income deductions that allow them to earn a good income and continue to be eligible for MAWD coverage.

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:

316.221 Examples of Job Situations

Situation #1.

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:

Situation #2.

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.

Situation #3.

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.

Situation #4.

An individual is walking a neighbor’s dog, babysitting, and repairing things.

See situation #1.

Situation #5.

An individual does ironing for $5 a month.

See situation #1.

Situation #6.

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.

Situation #7.

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.

316.23 Determining the MAWD family

Here are guidelines for determining the MAWD applicant/recipient group:

Here are guidelines used in determining eligibility for other family members for other MA groups:

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.

Updated February 14, 2012, Replacing October 17, 2008