0855.000.00 TICKET TO WORK HEALTH ASSURANCE (TWHA) PROGRAM

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.

0855.005.00 ELIGIBILITY REQUIREMENTS FOR TICKET TO WORK HEALTH ASSURANCE (TWHA) PROGRAM

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

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

0855.005.10 CITIZENSHIP/ALIEN STATUS

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

0855.005.15 SOCIAL SECURITY NUMBER

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

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

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

• Basic Coverage Group: The participant must meet the definition of Permanent and Total Disability. The definition is the same as for Medical Assistance (MA), except earnings of the participant are not considered in the disability determination. Disability for the Basic Coverage Group will be determined either by receipt of SSI or Social Security based on disability, or the Medical Review Team (MRT).

  Once a person is determined eligible as Permanently and Totally Disabled (PTD) under MA or TWHA Basic Coverage Group, persons who gain and lose employment may switch between these Medicaid categories without a new medical determination. Resubmit medical information at the scheduled medical redetermination period.

• Medically Improved Group: The participant must continue to have a severe medical impairment, but have lost eligibility in the Basic Coverage Group due solely to an improvement in his/her medical condition.

  Eligibility for the Medically Improved Group must be determined by MRT. MRT will make this determination whenever they find that a person being redetermined for the Basic Coverage Group has medically improved. A person receiving SSI or Social Security based on disability would not be in the Medically Improved Group, as they meet the disability requirement for the Basic Coverage 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

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

• Basic Coverage Group: An individual must have earnings from employment or self-employment. For income to be considered earned income it must be documented that Medicare and Social Security taxes are withheld from such income. Self-employed persons must provide proof of payment of Medicare and Social Security taxes for income to be considered earned. Self employed Individuals must provide copies of their tax records to verify taxes withheld or if it is a new self employment enterprise they must provide business records (i.e. business ledgers or gross profit statements) showing the taxes are being withheld for Social Security and Medicare. There is no minimum level of hours of employment or amount of earnings required.

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.

• Medically Improved Group: An individual must have earnings from employment equal to at least 40 hours per month at the federal minimum wage. For income to be considered earned income it must be documented that Medicare and Social Security taxes are withheld from such income. Self-employed persons shall provide proof of payment of Medicare and Social Security taxes for income to be considered earned.

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.

0855.005.35 AVAILABLE RESOURCES

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

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

0855.005.40.01 Social Security Cost of Living Adjustment (COLA) Disregard

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).

0855.005.40.05 GROSS INCOME LIMIT

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:

• The individual's gross income, both earned and unearned; and,
• The spouse's gross income, both earned and unearned.

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

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:

• All earned income of the disabled worker.
• The first $65 and one-half of the remaining earned income of a non-disabled spouse's earned income.
• A twenty dollar standard exemption.
• Health insurance premiums.
• A seventy-five dollar a month standard deduction for the disabled worker's dental and optical insurance when the total dental and optical insurance premiums are less than seventy-five dollars. If the total dental and optical insurance premiums exceed $75, allow the actual premium.
• All Supplemental Security Income (SSI) payments received.
• The first fifty dollars ($50.00) of the disabled worker's SSDI payments.
• A standard deduction for impairment-related employment expenses equal to one-half of the disabled worker's earned income. The disabled worker is entitled to this deduction even if the earned income is excluded from the gross income test as sheltered workshop income.