Volume 1, Number 2
October, 2001
Behind the Scenes at SRS
SRS staff members have formed an Implementation Team for the Working Healthy program that has been meeting on a regular basis for several months now. Team members are working hard on amending contracts with vendors, establishing eligibility criteria, adjusting all necessary database systems, identifying who will be eligible for the program and designing conversion techniques, training SRS EES area office and central office staff on the new program, establishing and drafting contracts with vendors to provide personal care services, etc. In addition, they are working with CMS (previously HCFA) to review and approve the amendments to the state Medicaid plan, a process that will take at least three months.
Despite these efforts, the Working Healthy program staff members regret to report that because of the complexity of getting this new program up and running, the January 1, 2002 start up date is not realistic. Another issue adding to the equation is that Howard Moses has been under the weather for the last couple of months and is expected to undergo surgery in the near future which will put him out of commission for several months. Because Howard is the program director and so critical to this program, work that he would have done to bring the program up by January 1, 2002 has been put on hold temporarily. Marianne Deagle and Sharon Johnson will be helping with his work while Howard is gone. Also, a new program staff person (and maybe two) will be hired in the next month or so. Although Marianne and Sharon cannot make any promises at this time because so much has to happen before the program begins, they are hoping to get Working Healthy up and running sometime between April and July 2002.
Other Activities
Benefits Specialists
The Infrastructure grant will be funding 11 new Benefits Specialist positions. A Specialist will be on staff at each of the SRS Area offices to work with consumers who might be eligible for Working Healthy. The Specialists will help consumers determine how going to work will affect all of their benefits such as Section 8 housing, food stamps, HCBS services, net income, etc. Qualified people with disabilities will be encouraged to apply for these positions.
Outreach
SRS, Breakthrough Club, Comcare and Connectcare hosted an outreach conference about the Working Healthy Program on August 23 and 24th at the Wichita Hyatt. About 200 people attended the first day of the conference, which was designed to provide information about the program to consumers, especially persons with HIV or persons with a mental illness diagnosis. The second day’s sessions were targeted at service providers and how they can assist the people with whom they work take advantage of Working Healthy. About 80 people attended this part of the conference. Barb Small from Small and Associates, who has been involved in the Buy-In program in New York, was a featured speaker. Working Healthy staff also provided a training and information for consumers at the 7th Kansas Disability Caucus in Topeka August 8th-10th and at the Region 7 CMS Conference on September 7th.
Future outreach efforts already planned include the Interhab conference in October. Also, be watching this space for information about a major Working Healthy statewide outreach conference planned for April, 2002.
What Has Happened with Similar Programs in Other States?
Vermont initiated a Medicaid buy-in program in January, 2000. The Vermont program is called the Vermont Work Incentive Initiative, with a Medicaid Buy-In for Working Disabled component.
Eligibility for the Vermont program is similar to that for Working Healthy. Participants must be working, satisfy the other SSI-related Medicaid eligibility criteria, and meet a two-step income test, demonstrating family income under 250 percent of the federal poverty level, and moderate amounts of unearned income. To encourage a working disabled person to move toward greater independence from publicly funded programs, only those with income more than 185 percent are charged a premium on a sliding scale basis.
As of May, 2001, the Vermont program had 390 people enrolled. A breakdown of the types of disabilities enrollees had is shown in Figure 1. Figure 1 information: pie chart showing Physical disability, 38%; Brain injury 3%; MR/DD, 10%; Mental illness, 46%; Other 3%.
Consumers Needed!
If you or someone you know is seriously planning to enroll in Working Healthy when it begins, we would like to talk with you as part of a research study to help us make the program as effective as possible. Please call or email Jean Hall for more information 785-864-7083 or jhall@ukans.edu)
Acronym Assistant
SSI : Supplemental Security Income
SSDI : Social Security Disability Insurance
TW-WIIA : Ticket to Work, Work Incentives Improvement Act
HCBS : Home and Community Based Services
EES : Economic and Employment Support
CMS : Centers for Medicare and Medicaid Services
PAS : Personal Assistance Services
MMIS : Medicaid Management Information Systems
Case Studies -- How Working Healthy May Work for People with Various Disabilities
The Working Healthy program is designed to be beneficial to people with different disabilities and different circumstances. The following case studies are provided as general examples of how the program might work for some people.
Case Study 1-- Person with Severe and Persistent Mental Illness
Tom is a 34-year old male who has a severe and persistent mental illness. The onset of his illness was in his mid 20’s. He was able to work full time in a general labor job before his illness became so severe that he was unable to concentrate, became very paranoid and started hearing voices. He was not able to continue employment. He finally applied for Social Security Disability and was approved for SSDI benefits and receives $660.00 a month. Having been on SSDI for more than two years, Tom is Medicare eligible.
After several years of isolated existence, Tom’s psychiatrist referred him to Breakthrough Club, where he started doing volunteer work in the clubhouse. After several months, Tom decided he wanted to work. He first tested his job capabilities doing some temporary employment before taking his current job.
Totaling income from his job and SS cash benefits, Tom had a spend down of $2,500 every six months. He usually did not meet his spend down and had to pay for his medications out of pocket. Often, he could not meet those costs. Consequently, Tom had a relapse six weeks ago and immediately needed mental health case management services. Tom must take a leave of absence from his job, which means his spend down will be reduced to an amount he can more easily meet. After his spend down is met, his medical card will pay for the $110 hourly cost for case management services. Tom will probably need extra services such as medication management, attendant care or psycho-social activities, paid by the Medicaid card, for another six months. His goal is to return to work in six to eight weeks.
How Working Healthy could assist Tom
Working Healthy is designed to help people like Tom who have an episodic illness. These illnesses often require medications or medical care that is costly. Additionally, their illness may keep people from maintaining employment because they require periodic time away from work. Because of necessary medical services, most people in this situation who are Medicaid eligible strive to maintain that eligibility. They may not be supported in finding employment, or, consciously work just under allowable levels of income, turning down additional hours or wage increases out of fear of losing benefits.
By virtue of Medicaid and Social Security eligibility, Tom would be eligible for Working Healthy. His case manager from the local mental health center refers him to the benefits specialist for consultation. He meets age and income requirements, and can verify income. The specialist tells Tom that should he choose to work full time, he could retain his Medicaid services under the Working Healthy program through payment of a monthly premium. In addition, participation in the program means that Tom’s $2500.00 spend down will be eliminated.
Case Study 2 -- Person with a Physical Disability
Carmen is 38 years old. She has a spinal cord injury, and is a high-level (T-3) paraplegic. Vocational Rehabilitation assistance and student financial aid allowed her to attend and finish college. After college graduation, VR helped purchase equipment in order for Carmen to obtain employment. Carmen became employed full time, in a salaried teaching position, which she maintained for eight years.
During that time, her wheel chair and cushion wore down and Carmen developed ulcers and other health problems. Her employer’s insurance would cover only a small portion of the cost of a new power chair. Carmen applied to VR for assistance but was turned down because she did not meet order of selection criteria and for various other reasons. Consequently, Carmen lost her teaching job. High COBRA payments precluded her from continuing her employers health insurance. Carmen was determined eligible for SSDI, and began receiving a check for $1100.00 each month. It took Carmen 8 months to spend down her limited assets and obtain Medicaid coverage during this time of unemployment. Carmen was forced to relinquish her apartment, and access Section 8 low-income housing assistance.
Carmen obtained 4 hours a week in Personal Assistance Services (PAS) for shopping, housecleaning, and laundry, and concentrated on improving her health and returning to work. She was deemed eligible again for VR services, and was able to obtain a substitute teaching position within a trial work period. She was unable to obtain employer health insurance coverage.
How Working Healthy could assist Carmen
Carmen would like to increase her work hours and income. Carmen meets with a Benefits Specialist who determines that she meets the requirements for Working Healthy and has verified income. Carmen is currently receiving Medicaid and SSDI benefits. Her income remains below the 300% FPL ($2168/month gross countable income) level, making her financially eligible. Carmen and the Benefits Specialist also discuss the following issues:
1) how working would affect her SSDI after reaching substantial gainful activity (SGA);
2) Home and Community Based Services (HCBS) versus Working Healthy PAS services;
3) Section 8 eligibility; and
4) whether her work will provide her the income necessary to weather the transition period between SSDI income and employment income.
Under the Buy In, Carmen will receive the full range of basic Medicaid services and can access employment PAS services as needed. Carmen also learns she can establish an Individual Development Account (IDA) to begin to save for additional training required to maintain her teaching license. Any assets accumulated in the training IDA would be disregarded.
Finally, when she becomes eligible for employer-based health insurance, Carmen is required to report this information to SRS. If Carmen’s private insurance offered by her employers is more cost effective, then Medicaid will begin to pay that premium, as provided for under the Health Insurance Portability and Accountability Act (HIPAA).
Case Study 3 -- Person with a Developmental Disability
Diane is a 26 year old woman with Down Syndrome. She receives SSDI income of $800 per month and, since the age of 19, has lived in her own apartment. She volunteers about 20 hours per week at a local women’s shelter, performing routine office tasks and helping clean the living areas the shelter maintains. Recently, the shelter has offered her a full time job at $7.50 per hour, but without health care benefits.
Diane would very much like to accept the job, but is concerned that she will not be able to maintain a full-time work schedule without some help with her personal care. Under the Working Healthy program, Diane would qualify for personal attendant services to help support her work activities. In addition, she would qualify for Medicaid coverage to augment the Medicare coverage she receives under her SSDI benefits.
Case Study 4 -- Person with HIV
Tony is 42 years old and has been HIV positive for 10 years. He ran a successful business until his illness forced him to quit and go onto SSDI four years ago. Over the years, Tony accumulated personal assets of about 14,000 in savings and mutual funds. He also owns a house and car. He currently has too much income and assets to qualify for Medicaid coverage. Some, but not all, of the cost of his medications are covered through the AIDS Drug Assistance Program (ADAP).
Tony began using the Internet extensively from home to keep abreast of the newest AIDS research. Eventually, he developed his own web site and then began designing web sites for friends and family members. He is now contemplating beginning a home-based web design company but is worried about how the income from his business would affect his benefits.
Tony meets with a Benefits Specialist and learns that his assets can be disregarded for the Buy-In program. Further, under Working Healthy, he would qualify for Medicaid coverage for prescription drugs, including those not covered by ADAP. Under the Ticket to Work legislation, he would also be able to maintain Medicare coverage for eight and a half years after completing his trial work period.
"Working Healthy" is the new name of the Kansas Medicaid Buy-In Program.
All future reference to the Buy-In Program will be under this new title, "Working Healthy."
Working Healthy is published quarterly by the KU Department of Health Policy and Management, in cooperation with the KU Division of Adult Studies and the Kansas Department of Social and Rehabilitation Services.
Additional copies and copies in alternate formats are available upon request by writing the University of Kansas Department of Health Policy and Management, c/o Division of Adult Studies, Attn: Noelle, 1122 West Campus Rd.. JRP Hall Rm. 517, Lawrence, KS 66045,
by phone 785-864-7085, by email: pixie@ukans.edu
KU Research Team
Michael Fox, Principal Investigator
Jean Hall, Project Director
Noelle Kurth, Editor
Erin Rink, Research Assistant
SRS, Division of Health Care Policy Staff
Marianne Deagle, Communications Director
Howard Moses, Program Administrator
Sharon Johnson, Program Analyst