Medicaid Buy-In for Workers with Disabilities in Ohio: A Valuable Program

Transcription

1 Medicaid Buy-In for Workers with Disabilities in Ohio: A Valuable Program A Nisonger Center LEND Leadership Project Isaac Aziramubera, Thalia Farietta, Jessica Middaugh, Gena Moore, and Laine Rothgeb

2 Medicaid Buy-In for Workers with Disabilities in Ohio History of advocacy for MBIWD implementation in Ohio Medicaid Buy-In was included in the Balanced Budget Act of Greater flexibility in designing Buy-In plans came with the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in This federal legislation has allowed people with disabilities to become employed without foregoing Medicaid, while increasing income allowances and providing protection for assets and resources. TWWIIA authorized funding for Medicaid Infrastructure grants to encourage states to develop Medicaid Buy-In programs. A workgroup created by the Ohio Rehabilitation Services Commission explored this policy initiative. In 2001, a joint House-Senate committee recommended Medicaid Buy-In to members of the General Assembly, and members of Advocates in Action (AIA) began promoting the policy initiative. A year later, several AIA members joined the Ohio Olmstead Task Force (OOTF) and formed a committee to actively promote adoption of enabling legislation for MBIWD. An Ohio Medicaid Infrastructure grant was drafted. The Ohio Developmental Disabilities Council played a pivotal role, funding three studies of MBIWD (2001, 2004, and 2013). Council also provided financial support to several entities involved in MBIWD advocacy (including AIA), and Council members advocated across the state, visiting newspaper editorial boards to make the case for Ohio s participation. Starting in autumn 2003, advocates traveled to disabilities advocacy organizations throughout the state to speak about MBIWD with hopes of garnering support. They succeeded in receiving endorsements from over 40 Ohio community organizations A Medicaid Buy-In recommendation was included in Governor Robert Taft s 2004 Ohio Access Report for People with Disabilities. In 2005, Medicaid Buy-In was the only Medicaid expansion recommendation put forth by the Ohio Commission to Reform Medicaid. Meanwhile, while taking a Statehouse tour, self-advocate Melissa Day met then state Senator Steve Stivers (now a member of the United States House of Representatives). In June 2003, Stivers offered Day a position as an intern. Day agreed to the position, but only as a nonpaid intern because, as she explained, she couldn t jeopardize her medical benefits. While working for Senator Stivers, she spent a portion of her time conducting research regarding existing MBIWD policies in other states. Over the next few years, Stivers and Representative Jon Peterson championed legislation that received bipartisan support in the Ohio Senate and Ohio House. Following the final push in 2007 through the DD Council funded Advocacy for Medicaid Buy-In, led by the talented Beverly Johnson, MBIWD was adopted via an amendment to the biennium budget, House Bill 119. It was implemented in Ohio became the 35 th state to offer MBIWD. During an interview with Legislative Assistant Adam Warren from State Senator Nina Turner s office regarding Ohio s willingness to support MBIWD, Warren indicated that Ohio s support of individuals with disabilities means that, Medicaid Buy-In services can now assist 2

3 more disabled Ohioans in becoming self-sufficient as well as productive citizens in their communities (A. Warren, Personal Communication, March 12, 2013). Determining Eligibility To qualify for Medicaid Buy-in for Workers with Disabilities, one must be an Ohio resident who is a US citizen or qualified alien and 16 to 64 years of age. The individual must be determined to be disabled by the Social Security Administration or Ohio Medicaid. Alternatively, disability status can also be obtained by eligibility under the MBIWD medically improved category. The individual must be employed in part-time or full-time taxed work and also faces financial criteria and a possible premium. Financial eligibility criteria are determined by income and resources. Two financial criteria must be met. The first condition is an $11,148 cap on resources (Ohio Department of Jobs and Family Services, 2012). Two current recipients of MBIWD indicated to a benefits and support professional that since participating in MBIWD, they have been able to maintain the minimum allowed savings of $11,148 which has helped to enhance their lives tremendously (Anonymous Personal Communication, March 7, 2013). The second requirement is an income limit. The annual income of the individual must be less than or equal to 250% of the federal poverty level ($28,728 in 2013) after income deductions (ODJFS, 2013; Medicaid, 2013). The applicant is eligible for up to $20,000 in income deductions each year. Even if annual income exceeds 250% FPL, certain deductions may still be given. A professional benefits analyst working with two MBIWD recipients commented, MBIWD has allowed them to achieve goals of independent living within their communities by allowing participants to earn a living in competitive employment (Anonymous Personal Communication, March 7, 2013). Premiums are required for individuals who earn more than 150% FPL ($17,237 (Medicaid, 2013). MBIWD consumers are sent monthly statements with the premium amount (ODJFS, 2012). The full amount must be received on the due date or it is considered a nonpayment. After two non-payments, the participant is subject to termination from MBIWD program. In order to re-enroll, one must pay delinquent premiums and still meet eligibility criteria. 3

4 Graphic representation of enrollment numbers 9,000 Estimates of Ohioans Enrolled in MBIWD Estimated Number of Ohioans 8,500 8,000 7,500 7,000 6,500 January April July August September October November December 2012 Estimate of those who could be enrolled but have not been/glitches From 2008 to 2011, approximately 12,000 working disabled adults were enrolled in the Medicaid-Buy-In Program for Workers with Disabilities (Government Resource Center, 2012). Approximately 20% of these participants were new enrollees in the Medicaid program. The MBIWD program aims to make health insurance more accessible to and affordable for working adults with disabilities. This program has shown beneficial outcomes. Research has shown that even after controlling for several factors that influence employment participation, the program improved the percentage of working disabled adults (GRC, 2012). There are many Ohioans who would be eligible for the program. The Budget for the MBIWD program assumed that at least 7,000 people would be enrolled (GRC, 2012). Despite having a slower than expected take-up rate, by June of 2011 the program had an estimated 6,369 participants (GRC, 2012). However, these numbers do not represent the potential of enrolled 4

5 workers. In Ohio during 2010, there were approximately 45,100 disabled individuals who fell between 138% and 140% FPL and only roughly 20,900 of these individuals reported that they were working (GRC, 2012). These numbers show a potential for the MBIWD program. Chuck Beatty, Chair of the Ohio Olmstead Task Force MBI Advisory Committee, has pointed out two potential flaws in the MBIWD program. These weaknesses surround an asset cap after re-enrollment and consideration of family income in assessing Medicaid eligibility. Participants are encouraged to save money in case of disenrollment. However, if participants are dis-enrolled, they are required to spend down to the Medicaid asset cap of $1,500 before being eligible for Medicaid benefits. This flaw would lead to a disincentive to save money. Another flaw in determining eligibility is consideration of another family member s income (e.g., a spouse) when applying for Medicaid benefits. A family member s income can skew the individual s family income and make the person with a disability ineligible for services he or she needs. If Ohio participates in Medicaid expansion, the Affordable Care Act may impact MBIWD. MBIWD participants earning less than 138% of FPL would be able to become part of the Medicaid Community Adult Program. This program has no employment requirements (GRC, 2012). Those above 138% FPL would have to face cost-sharing requirements if electing to choose an ACA plan. Researchers believe that individuals eligible for MBIWD who are over 138% of FPL will elect to take part in the MBIWD program because of the cost-sharing requirements associated with the ACA. Service and Support Adminstrator (SSA) Survey Results Purpose: To gather information regarding SSAs opinions of factors related to the MBIWD policy in its current configuration. Method: An electronic, optional survey, consisting of three yes/no questions, was disseminated to thirty-three county boards of developmental disabilities across Ohio. Participants: Forty-nine SSAs (34%) from thirty-one counties of varying geographical location and population demographics responded within the alloted timeframe. This sample s population distribution was fairly proportional to that of the state. Population Estimated percentage of counties (sample) Estimated percentage of counties (state) 50,000 52% 44% 50, ,000 16% 24% 100, ,000 19% 22% 250, ,000 3% 4.5% 500,000-1,000,000 3% 3.5% 1,000, % 2% 5

6 Limitations: Of the 49 responses, 22 (45%) were single responses (1 SSA s opinion representing the entire county); 27 (55%) of the responses included an additional 1-5 SSA s opinion(s) per county. The number of responses per county did not correlate with county population, so responses were not evenly nor proportionally representative. Question #1: Do you, as an SSA, feel that you are equipped with a comprehensive understanding of Medicaid Buy-In for Workers with Disabilities (e.g. restrictions, eligibility, etc.) in order to thoroughly explain and promote its use? 47% 53% Yes No Question #2: Is it your opinion that SSAs generally discuss this topic with potential applicants on a regular basis? 53% 47% Yes No Question #3: Do you think that more Medicaid Buy- In for Workers with Disabilities awareness activities would be beneficial to representatives and recipients? 4% 96% Yes No 6

7 Conclusions: Nearly half of the SSA respondents do not feel comprehensively knowledgeable about MBIWD to adequately educate potential consumers. Almost half of the SSA respondents do not feel that fellow colleagues (perhaps themselves included) regularly discussed MBIWD with potential applicants. Nearly all SSA respondents believe that increasing MBIWD awareness activities would be beneficial to representatives and recipients. Comparison to Other Great Lakes Region States Ohio s Medicaid Buy-In for Workers with Disabilities (MBIWD) program was implemented in 2008, and gave Ohioans with disabilities the option to work and still qualify for healthcare benefits under Medicaid. Other Great Lakes Region states that have Medicaid buy-in programs for those with disabilities include Illinois (enacted in 2002), Indiana (2002), Michigan (2003), Minnesota (1999), Pennsylvania (2002), and Wisconsin (2000). There are similarities and differences between the state programs, which include benefits and limitations for each program. There are upper and lower boundary age limit requirements for eligibility. The lower age boundary for eligibility is 16 years of age in Ohio, Indiana, Illinois, and Pennsylvania. However, the upper age boundary for eligibility is 64 years of age in each of the states except for Wisconsin, which does not have an upper age limit. Thus, when a recipient reaches 65 years of age, in the other Great Lakes Region states recipients will have to decide if they want to continue working, but lose Medicaid benefits, or if they will become unemployed to retain benefits. If a Medicaid recipient loses his or her job, or must discontinue working due to a medical issue, in the state of Ohio the recipient can remain on the Medicaid Buy-In program for up to six months. In addition, because premiums are based on income, the premium that the recipient is paying based on income will no longer be owed. Other states have similar clauses that vary in terms of length of unemployment. In Minnesota, a recipient who is unemployed or medically incapable to work for a period of time may remain in the Medicaid Buy-In program for up to four months. Similarly, in Illinois, people are no longer Medicaid Buy-In eligible if they are unemployed for 30 days or more, or they are unable to work due to a medical issue for 90 days or more. In the state of Michigan, if the Medicaid recipient is laid off from his or her job, or is unable to work due to a medical issue, the individual is protected from losing Medicaid insurance for up to 24 months. However, if the job loss is voluntary, this rule is not applicable. For MBIWD in Ohio, the first $20,000 of income is not included when determining financial eligibility. When comparing income eligibility limits to other states in the Great Lakes Region, Illinois s limit is capped at 350% of the federal poverty level (FPL) for the household 7

8 size, and includes the income of a spouse if applicable. However, in the state of Indiana, which also has an income limit of 350% FPL, spouse or parental income is not considered when determining income eligibility. For income eligibility, the gold standard states are Michigan and Minnesota which do not have an income eligibility limit. Thus, there is not a cap on income that can be accumulated annually. The current resource limit in Ohio is $11,148 (ODJFS, 2013). Although other Great Lakes Region States have slightly higher resource limits, again the gold standard would be the state of Michigan, which has a resource limit of $75,000. Federal law permits the establishment of Individual Development Accounts. In the state of Wisconsin, Medicaid buy-in recipients can set up Independence Accounts, defined as any new financial account set up through a financial institution, such as a bank or credit union, and registered with a county/tribal human or social services department (Wisconsin Medicaid Fact Sheet, p. 1-2). These accounts can include pensions, retirement accounts, or accounts that can be used to purchase assets such as a home or vehicle. The Independence Accounts are not included when calculating the asset resource limits for Medicaid eligibility. The state of Indiana has a similar program for saving to increase independence and employment opportunities; however, prior to opening an account, the recipient must get approval through specification of goods that will be bought, how these goods will increase independence or employment, and an estimated time period in which the goods will be bought. This opportunity is rarely mentioned in Ohio, and the state does not appear to associate it with potential MBIWD recipients. Further information is available at and jfs.ohio.gov/owf/prc/guidance/prc28.pdf. Other differences in Ohio s MBIWD compared to other Great Lakes Region states include the use of co-pays for specific services. In Ohio, a co-pay scale has not been implemented in the MBIWD program; however, in Minnesota, there may be co-pays for some recipients for items such as prescription medications. Additionally, when comparing other insurance options outside of the Medicaid buy-in for workers with disability programs, Wisconsin allows recipients to receive insurance benefits through their employer, or spouse s employer, and Medicaid will cover the expense if the alternate insurance is less expensive than their current Medicaid coverage. In this program, the recipient will pay a premium for Medicaid, and Medicaid will cover other insurance-related expenses. In the state of Ohio, premiums are determined based on income, household size, and other deductions. Other states in the Great Lakes Region have other methods of calculating a premium. For example, in Pennsylvania all recipients pay a premium, which is 5% of monthly income. Additionally, in Minnesota a sliding fee scale determines premiums for Medicaid recipients. Recipients must pay the determined fee, or a minimum of $35.00, per month. Thus, the recipient will pay the amount that is higher. However, Native Americans are not required to pay a premium. Lastly, in Michigan premiums are based on five tier-levels, not percentage of income above the set FPL. Recommendations The main recommendation for improvement that could be implemented the MBIWD in Ohio is to not set an upper boundary for age when determining eligibility. By having the 8

9 eligibility criterion set at 64 years of age, people with disabilities who want to contribute to the workforce while earning an income are no longer eligible for Medicaid if they continue to work once reaching 65 years of age. If continuing to work and receive Medicaid benefits, recipients will have to spend down to remain under the income eligibility criteria. This would potentially allow for greater employment opportunities for workers with disabilities. Acknowledgements: A special thanks to State Senator Nina Turner s office (Adam Warren) and staff for their time to assist in this leadership project A special thanks to Dustin McKee and fellow Ohio Association of County Boards staff for their time and energy submitting, retrieving, and compiling the MBIWD survey. References DD Quarterly (Summer, 2004) 9. Family and Social Services Administration.(2010). M.E.D. Works. Retrieved from Forum, Ohio Coalition for the Education of Children with Disabilities (January 2, 2000)6. Government Resource Center. (2012). Evaluation of the Medicaid Buy-In Program for Workers with Disabilities. Health Benefits for Workers with Disabilities.(2012). Health Benefits for Workers with Disabilities. Retrieved from Information to assist citizens in advocating for a Medicaid Buy-In Program in Ohio, Ohio Olmstead Task Force & Ohio Developmental Disabilities Council (2006). Medicaid. (2012) poverty guidelines. Retrieved from CHIP-Program-Information/By-Topics/Eligibility/Downloads/FederalPovertyLevelRates.pdf Michigan Department of Community Health.(2013). Medicaid State Plan. Retrieved from: Minnesota Department of Human Services. (2013). Medical Assistance for Employed Persons with Disabilities (MA-EPD). Retrieved from 9

10 onselectionmethod=latestreleased&ddocname=id_ Ohio Department of Job and Family Services. (2011).Medicaid buy-in for workers with disabilities (MBIWD). Retrieved from Ohio Department of Job and Family Services. (2000) OWF/PRC Guidance Letter No. 28. Retrieved from Ohio Department of Job and Family Services. (2013) Income Guidelines for Ohioans: Medicaid for Workers with Disabilities (MBIWD). Retrieved from Pennsylvania Department of Public Welfare.(2011). Medical Assistance Benefits for Workers with Disabilities. Retrieved from erswithdisabilities/index.htm United States Census Bureau.(2012). US Department of Commerce.State & County Quick Facts. Retrieved from Using Individual Development Accounts to save and build assets (2010). Retrieved from Wisconsin Department of Health Services. (n.d.) Wisconsin Medicaid Fact Sheet. Retrieved from 10

11 Funded by Maternal and Child Health Bureau Grant T73MC