IM-67 July 16, 2013, IM-77 August 28, 2007IM-75 July 11, 2005IM-78 June 28, 2002

Senate Bill 236 (2001) enacted the Medicaid provision from Section 201 of the federal Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170). The program was called Medical Assistance for Workers with Disabilities (MA-WD) and was funded effective July 1, 2002. The program had a gross income limit of 250% of the federal poverty level, but had a liberal disregard of the spouse's income. Persons with income above 150% FPL paid a premium. The available resource limit was $999.99. The MA-WD program was eliminated effective August 28, 2005, after passage of Senate Bill 539 (2005).

A new version of the Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170), RSMo 208.146, was authorized by Senate Bill 577 (2007) and effective August 28, 2007 for a period of six years. The program was named Ticket to Work Health Assurance (TWHA) program. Senate Bill 127 (2013) extended the TWHA program for another six years. The TWHA program will end August 28, 2019, unless reauthorized by the General Assembly.

The purpose of the Ticket to Work Health Assurance (TWHA) program is to provide medical care for persons with disabilities, age 16 through 64, who are employed. The gross income limit for this program is 250% of the federal poverty level (FPL), excluding any earned income between 250% and 300% of the federal poverty level of the worker with a disability. This results in an actual gross income limit of 300% FPL. The net income limit is 85% FPL. Participants with income above 100% FPL will pay a premium to receive coverage. The income of the spouse is included when determining eligibility for the TWHA program.

TWHA has two components, a Basic Coverage Group and a Medically Improved Group. The Basic Coverage Group is for persons who have earnings but are determined to be permanently and totally disabled. The Medically Improved Group is for persons who have lost their eligibility for the Basic Coverage Group solely due to medical improvement. Both groups provide full Medicaid benefits.


IM-77 August 28, 2007

To qualify for TWHA, the following eligibility criteria must be met:

  1. Age
  2. Citizenship/Alien Status
  3. Social Security Number
  4. Residence
  5. Disability
  6. Employment
  7. Resources
  8. Income
  9. Premium Payment

0855.005.05 AGE

IM-77 August 28, 2007

Participants must be age 16 through age 64. This includes the month the person turns age 16 or 65.


IM-77 August 28, 2007

Citizenship/Alien status requirements are the same as for the Medical Assistance for Families program. Refer to Section 0905.010.30.


IM-77 August 28, 2007

Social Security number requirements are the same as for Medical Assistance programs for the aged, blind and disabled. These requirements apply only to the applicant/participant, not their spouse or child. Refer to Sections 0905.010.05 and 0905.010.05.05.

0855.005.20 RESIDENCE

IM-77 August 28, 2007

Residence requirements are the same as for Medical Assistance programs for the aged, blind and disabled. These requirements are found in Sections 1015.000.00 through 1015.020.25.

0855.005.25 DISABILITY

IM-77 August 28, 2007

The following disability criteria must be met for each TWHA eligibility group:

Request a determination of disability from MRT by submitting the Social Information Summary (IM-61), the Disability Questionnaire (IM-61B), and gathered medical evidence (refer to Section 1060.005.05 ). whenever a participant has earnings, write in or check Basic Coverage Group in the Application or Redetermination box of the IM-61.

NOTE: An individual may lose eligibility for Social Security based on disability due to having earned income above the Substantial Gainful Activity (SGA) limit. The SGA requirement does not apply to TWHA. If an individual loses disability status due to SGA, redetermine disability status through the MRT process as noted above. Do not close TWHA until MRT's assessment is complete.

0855.005.30 EMPLOYMENT

IM-15 February 21, 2017, IM-77 August 28, 2007

The following employment criteria must be met for each eligibility group:

NOTE: Effective February 1, 2017, participants will be considered in compliance with the statutory requirement to pay Medicare and Social Security taxes if they work in a medically related caregiver or homemaker/chore services position and

the payment received is through a government agency such as DMH or DHSS where no such taxes are paid because the wages are specifically exempt and no such taxes are due.

If an individual's earnings cease, ex-parte review procedures (refer to Section 0840.015.05 ) must be followed to determine eligibility under Medical Assistance PTD rules.


IM-#69, 06/15/2017 , IM-77 August 28, 2007

The resource considerations and limits are the same as Medical Assistance for Permanently and Totally Disabled Individuals (refer to Section 1030.000.00 )


0855.005.40 INCOME LIMIT

IM-77 August 28, 2007

The TWHA Program includes both a gross and net income limit.

0855.005.40.01 Social Security Cost of Living Adjustment (COLA) Disregard

IM-#76 December 23, 2014, IM-#114 December 13, 2013, IM-#100 December 7, 2012, IM-3,  January 7, 2008

Senate Bill 577 (2007) amended Section 208.153 RSMo to specify that programs in which income eligibility is determined by Federal Poverty Level (FPL) will not be adjusted for annual Cost of Living Adjustment (COLA) changes in OASDI or SSI benefits until the next FPL adjustment.

FAMIS disregards the COLA amount entered for January's income for the MO HealthNet Ticket to Work Health Assurance (TWHA) program until the next FPL adjustment for April.  SSA and SSI incomes for individuals in any FAMIS EU entered after the adjustment must include the pre-COLA adjusted amount for December and the COLA-adjusted amount for January with a verification code of CO (COLA).

NOTE: The disregard of COLA increases for January through March applies to both the gross income test and net income test completed for TWHA.

Example 1: Applications Made After COLA Mass Adjustment (December)

On February 8, Ms. Foster applies for Food Stamps and TWHA benefits.  Ms. Foster has been receiving Social Security Disability Income (SSDI/SSA) for five years. Enter Ms. Foster's pre-COLA adjusted SSA income for the month of December with a verification code of HC or TC.  Enter her COLA-adjusted SSA income for the budget month of January and ongoing with verification code of CO.  The Food Stamp EU eligibility determination budgets the current (COLA-adjusted) SSA amounts; the TWHA eligibility determination budgets the pre-COLA adjusted SSA amount.

Example 2: Active EUs with Participants that Begin Receiving SSA/SSI Between COLA and FPL Mass Adjustments

The Jackson family is active in FAMIS, receiving TWHA and Food Stamp benefits. Mrs. Jackson reports that daughter, Jessie, begins receiving SSI February 1. Enter Jessie's new SSI income for the month of February with a verification code of HC or TC.  Continue to budget Mrs. Jackson's pre-COLA SSA income that she was receiving based on disability using a verification code of CO; do not change the verification code from CO to HC or TC.

Example 3: Exploring Prior Quarter for TWHA Applications Taken After the FPL Adjustments

On March 15, Ms. Ola applies for TWHA.  She requests prior quarter coverage for her emergency room visit.  Ms. Ola has been receiving SSDI for several years. Enter her pre-COLA SSDI received for December with the appropriate verification code of HC or TC and the COLA-adjusted income for the months of January-March with a verification code of CO.

NOTE:  FAMIS does not disregard the COLA amount entered for January's income for Blind Pension (BP), Vendor (VEND), Missouri Children with Developmental Disabilities (MOCDD), Home and Community Based (HCB) Waiver Services, Supplemental Aid to the Blind(SAB), and Supplemental Nursing Care (SNC) programs.

0855.005.40.05 GROSS INCOME LIMIT

IM-#30 April 19, 2018 IM-#30 March 29, 2017 IM-#26 May 9, 2016, IM-#22 March 20, 2015, IM-#17 March 21, 2014, IM-#26 March 11, 2013, IM-#20 March 13, 2012, IM-#16 March 14, 2011, IM-#13 March 5, 2009, IM-#22 March 7, 2008, IM-#77 August 28, 2007

The gross monthly income maximum is 300% of the Federal Poverty Level (FPL), adjusted annually. The gross income maximum is $3,035.00 for a single individual and $4,115.00 for a couple. Individuals cannot spend down to obtain this coverage. Individuals with income above this level are not eligible for TWHA.

Include as income:

To arrive at gross income, subtract overhead expenses of producing income and income exclusions allowed for the Medical Assistance program as outlined in Sections 0805.015.15 and 0805.015.10.

NOTE: Exclude any income earned by individuals eligible for certified extended employment at a sheltered workshop. The exclusion applies to income earned at both a sheltered workshop and a different employer when the individual is certified for extended employment at a sheltered workshop.

0855.005.40.10 NET INCOME LIMIT

IM-77 August 28, 2007

The individual's net income cannot exceed the limit for permanently and totally disabled individuals to receive non-spenddown Medical Assistance. To determine net income the following shall be disregarded: