Healthcare for Workers with Disabilities (HWD)

FREQUENTLY ASKED QUESTIONS

General background information

Who is eligible for HWD?

How do I apply for HWD?

What services are covered under HWD? 

How much do I have to pay monthly to get coverage?

What happens if I don't pay my premiums?

Miscellaneous information about HWD

 

1. What is the Healthcare for Workers with Disabilities (HWD) program?

   The Healthcare for Workers with Disabilities (HWD) program recognizes the employment potential of people with disabilities, and represents Washington State’s response to the landmark "Ticket to Work" legislation passed by Congress in 1999.

   Note: In order to participate in the HWD program, an individual must pay a monthly premium that is based on his/her income. See Monthly Premium for additional information.
    

2. What is the Ticket to Work Program?

   The "Ticket to Work and Work Incentives Improvement Act of 1999" (Public Law 106-170) provides States with new options and flexibility to make it possible for people with disabilities to join the workforce without fear of losing their Medicare and Medicaid coverage.
    

3. What benefits does Ticket to Work make available to people with disabilities?

The Ticket to Work legislation has a section that covers employment and a section that covers health care.

Title I of the Act establishes the "Ticket to Work and Self Sufficiency Program." This voluntary program provides improved access to employment training and placement services for people with disabilities who want to work.

Title II of the Act establishes the optional Medicaid program, which enabled Washington State to implement the HWD Program. The Centers for Medicare and Medicaid Services administers the health care provisions at the federal level. 

4. How may I get more information about the Ticket to Work and Self-Sufficiency program now?

   You may contact MAXIMUS on their toll-free number at 1-866-968-7842 (Voice) or 1866TDD2WORK (TDD) or view comprehensive information on their web site at http://www.yourtickettowork.com/program_info.

   You may also contact the Social Security Administration (SSA) on their toll-free number at 1-800-772-1213 or contact your local SSA office. Comprehensive information is also available on the SSA web site at http://www.ssa.gov/work.
    

5. How will my employment affect my Supplemental Security Income (SSI) or my Social Security Disability Insurance (SSDI) benefit?

   You may contact SSA or access the SSA Redbook on Work Incentives at http://www.ssa.gov/disabilityresearch/redbook.htm.  

   If you live outside of King or Kitsap County, you may contact a Community Work Incentives Coordinator (CWIC) - previously known as a Benefits Planner - by calling 1-866-497-9443 (Voice) or 1-877-846-0775 (TTY).  If you live in Spokane, you may call 444-3087 (Voice) or 777-0776 (TTY).  Online information is available by clicking on Plan to Work at http://www.community-minded.org/.

   If you live in King County, you may contact Positive Solutions at 206-322-8181, or in Kitsap County at 360-373-5206 and ask for an intake specialist.  You may also access information about their Benefits Resource Center's Planning Assistance at www.psbrc.org/.
     

6. Does Ticket to Work legislation affect individuals receiving Medicare?

Yes. Ticket to Work extends premium free Medicare Part A benefits to SSDI beneficiaries who lose cash payments because they return to work, effectively extending coverage from 4 to 8½ years.  SSA determines whether an individual qualifies for this extension.

1. How do I know if I qualify for the HWD program?

• You must be a Washington State resident;

• You must be at least 16 and under 65 years old;

• You must meet the income requirements – have monthly net income* that does not exceed 220% of the federal poverty level (FPL). This is $1,986 for a single person or $2,672 for a married couple.

• You must meet federal disability requirements; and

• You must be employed full or part time (including self-employment)

Note: Once approved, you must pay your monthly premium to continue to qualify for the HWD program.

2. Which income standard does the department use when determining if I qualify - the one-person or two-person standard?

If you are single, we use the one-person standard.

If you are married, we use either the one-person or two-person standard, depending upon whether we must count your spouse’s income. See below for information on whether we must count it and which standard we use when determining if you qualify.

If your spouse’s income is equal to or less than ½ of the federal benefit rate (FBR), we do not count it and we use the one-person standard.  (The current FBR amount is $674).

• If your spouse’s income is more than ½ of the FBR, we count it and use the two-person standard.

• If both you and your spouse apply for HWD, we add your income together and use the two-person standard.

NOTE: If you have children, we will deduct up to ½ of the FBR from your or your spouse’s income for each child in the home.

When determining if you qualify for HWD, we must use a net income standard (220% FPL), which after the deductions described below, is the same as the gross income standard (450% FPL), if you are no longer receiving unearned income.  Federal regulations require use of a net income standard.   See examples below for determining net income.* 

We do not count the following amounts as part of your income before comparing it to the 220% FPL limit:

• $20 from unearned income, e.g., Social Security Disability Insurance (SSDI) benefit, Veterans benefit and pension

• $65 and ½ the remainder of earned income

• Impairment-related work expenses (IRWE), e.g., expenses that allow you to work

• Other amounts excluded by federal statute

Note: Your financial worker must approve an IRWE before we may deduct it from your income. An IRWE is a service you pay for that Medicaid does not cover, e.g., payment for vehicle modification to accommodate your disability (plus installation, maintenance, and associated repair costs). An IRWE may be either a one-time or an ongoing cost.

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*Examples for determining net income:

Example 1 - Unearned income (SSDI) of $885; Earned income of $1,865.

Deduct $20 from $885 (885 - 20) for a net amount of $865.

Deduct $65 from $1,865, then one-half of the remainder [(1,865 - 65) - 900] for a net amount of $900.

Add amounts together to calculate total net income. 

In this example, the individual has a net income of $1,765, which is below the income limit.

Example 2 - No unearned income**; Earned income of $3,685.

Deduct $20 and $65, then one-half the remainder from $3,685 [(3,685 - 85) - 1,800] for a net amount of $1,800.

In this example, the individual has a net income amount of $1,800, which is below the income limit. 

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**The individual is no longer receiving SSDI because of earnings at or above the "substantial gainful activity" (SGA) level of $980 (or $1,640 if statutorily blind) for 3 months after completion of the "Trial Work Period," but continues to meet federal disability requirements. 

4. How current does my disability determination have to be?

   HWD enrollees must have a current disability determination on file with the Social Security Administration (SSA). If you are receiving SSI or SSDI benefits, you have a current disability determination. If you do not have a current disability determination, your financial worker will help you start the process to obtain one.

   Note: If you are referred to SSA for a disability determination for the HWD program, they will not look at whether your earnings exceed the "substantial gainful activity" (SGA) level.  For 2009, the monthly SGA amount for statutorily blind individuals is $1,640. For non-blind individuals, the monthly SGA amount is $980.
    

5. What is the definition of employment?

To be eligible for HWD, you must be employed full or part time. Employment means that you are engaged in a reasonable work effort. You must:

• Get paid for working; and

• Have earnings that are subject to federal income tax; and

• Have payroll taxes taken out of your wages, unless you are self-employed.  If you are self-employed, you must provide tax forms such as the Internal Revenue Service Schedule SE form and/or legitimate business records.

6. What if I lose my job after enrolling in the HWD program?

You may choose to continue your enrollment in the HWD program through the end of your current certification period (up to 12 months), if:

• Your loss of employment is due to a health crisis or involuntary dismissal; and

• You intend to return to work after the health crisis has passed or continue looking for new employment; and

• You continue paying your monthly premium based on your remaining income.

7. What are the reporting requirements for this program?

You must report changes in your personal status, such as income or employment, to your financial worker by the 10th day of the following month. Reporting these changes as soon as possible will enable your worker to adjust your premium as quickly as possible. Any change in your premium amount will take effect the first of the following month in which the change is reported and processed.

1. How do I apply for the HWD program?

   To apply for HWD, call one of the numbers below, which also work for TTY users.  For submitting requested information by fax machine, enter 206-298-4453.

   Local:  (206)-341-7433  or  Toll Free:  1-800-337-1835

   Then choose option 2 for "family or adult medical" and tell the Customer Service Specialist you are calling about HWD.

   All HWD cases are administered at a single location in the Seattle area with the following exception.  Those accessing services administered by the department's Division of Home and Community Services (HCS) need to contact their local HCS Office.  Click here for information regarding the HCS Office that serves your area. 
    

2. What if I have other health insurance?

   We will ask you about any health insurance you have when completing your application. After your application is approved, you will need to contact the Coordination of Benefits Section at HRSA (1-800-562-6136) to see if we can pay for the cost of your health insurance. HRSA may pay for employer-related and private health insurance for persons who qualify for Medicaid only when it determines it would be cost effective to do so.

   Note: You must continue to pay in full your monthly HWD premiums to continue receiving HWD coverage, even if you continue paying for other health insurance benefits.
    

3. What if I disagree with your decision about my application or any action you take regarding my HWD coverage?

For all benefits administered by DSHS, you will receive written notice of your fair hearing rights at the time of application, denial, termination, suspension, grant reduction or notification of overpayment.

1. Will HWD provide all Medicaid services?

   HWD provides the same scope of coverage as other Medicaid Categorically Needy (CN) programs. See CN Scope of Care.

2. Will HWD provide Medicaid coverage to other members of my family?

   No.  HWD covers individuals only; it is not family coverage. If more than one family member has a disability, each person with a disability may qualify for HWD, if he/she meets all program requirements.
    

3. Are mental health services and substance abuse treatment services covered under HWD?

   Yes.  HWD enrollees may receive mental health services, if they meet medical necessity requirements for such treatment.  HWD enrollees may receive substance abuse treatment services, if they meet requirements set by the Division of Alcohol and Substance Abuse (DASA).

   HWD enrollees obtain mental health and substance abuse treatment services through the same systems as other Medicaid recipients.  Mental health services may be obtained from providers who contract with the local Regional Support Network.  Substance abuse treatment services may be obtained from providers who contract with DASA.
    

4. What if a patient wants a medical service not covered under the Medicaid program? Can the doctor (provider) bill the client for this service?

   Medicaid policy requires all program participants to sign an agreement to pay for non-covered services prior to services being delivered. If you have questions regarding Medicaid scope of care, call the customer service line at 1-800-562-3022.
    

5. Will HWD cover medical bills that I had before I apply for HWD?

If you meet all program requirements, you may apply for Medicaid coverage for up to three months prior to the month of application, with the following exception. 

Note: If you want to apply for retroactive coverage and have paid providers for services received during those months, you need to talk to those providers before purchasing this coverage. Providers are not required to reimburse you for services that you already paid for, even if you show them a medical ID card for those previous months. Make sure your provider will reimburse you for those services before you purchase retroactive coverage.

1.  What type and amount of premium will I pay to purchase Medicaid coverage under the HWD 
    program?

We follow a two-step process to determine the amount of your premium, which will be billed to you on a monthly basis. 

First, we use the following formula to calculate the monthly premium.  We add the following together for a total amount:

• 50% of your unearned income above the Medically Needy Income Level (MNIL); the MNIL is equal to $674; plus

• 5% of your total unearned income; plus

• 2.5% of your earned income after first deducting $65

Then we compare that amount to 7.5% of your total income and take the lesser amount.

Example: A person earns $736 per month and receives $859 SSDI.

In this example, you would pay $119 per month or 7.5% of your total income. When calculating premiums, we do not include cents, so the premium is $119 per month.

Note: We do not count income of a spouse when determining the HWD premium amount.  If two spouses receive HWD, we determine their monthly costs separately.

      After you are approved for the HWD program, you will receive your first bill (with a
      return envelope) from the Financial Services Administration (FSA) around the 5^th of
      the month. If you do not send full payment by the end of the month in which you
      receive your bill, your next bill will indicate you are behind on your account.

  3.   What if my application is not approved until after the 
         month in which I apply?

If you apply in one month, but your application is not approved until the next month, the first bill for your monthly premium will include costs for both the first and second month.

Example: You apply for HWD on July 10 and provide the information we need to complete your application on August 6.  FSA receives information from us about your monthly premium on the last business day of August and bills you on September 5. Your first monthly premium includes charges for both July and August for HWD coverage that begins July 1.

Note: In this example, if you do not pay this bill in full by the end of September, you will be one month behind in making your premium payments.

Yes, but your monthly billing statement can be sent only to your address, unless you sign papers to make someone your authorized representative and provide the necessary information to HWD staff.  Otherwise, you are responsible for making sure that the person (or entity) knows when the premium is due, that your identifying information is indicated on the payment, and that payment is made on time.

      We will apply payments received to any past due charges first.

      Example: You send in a payment on September 15 and have not yet paid for the
      months of June, July or August.  Your payment will first be applied to enrollment costs
      for the month of June. You would still owe for July and August and remain two months
      behind on your premiums.

  6.  How do I pay premiums for "retroactive" coverage  
        described in Covered Services #5?

       You must pay the premium for each month for which you are requesting retroactive
      coverage before HWD benefits can be approved for those months. You will receive
      your bill for retroactive coverage (with a return envelope) in the mail from FSA after
      completing the application process.

      To be approved for retroactive coverage, you must pay in full the premium for each
      month requested within 120 days of receiving your bill.

       When processing your application, we will ask you to identify each of the months in
      the retroactive period for which you want to purchase HWD coverage.  If we receive
      only partial payment within the 120 days, we will deny coverage for the retroactive
      period and refund the partial payment.
 

1. What happens if I do not pay my premiums?

   If you do not pay your premium for four consecutive months, your Medicaid coverage under the HWD program will end. If this happens, you will not qualify again for HWD until four months after your coverage ended. If after those four months you want to re-enroll, you must pay any unpaid premiums for the months before your coverage ended.

   Note: We will determine whether you qualify for the Medically Needy (MN) program or another medical program, if your HWD coverage ends for non-payment of premiums. We will not use unpaid premiums to reduce your spenddown amount for MN coverage.
    

2. Is there "good cause" for my HWD coverage not to end because of non-payment of my premiums?

   Good cause is limited to situations that are beyond your control, e.g., a premium processing error. Good cause does not include a lack of money to make premium payments required for HWD coverage.
    

3. What if my premium costs more than medical services I receive in one or more months?

   You must continue to pay your premiums in full to continue your HWD coverage – as you are required to do to maintain other types of insurance, e.g., home or automobile insurance.
    

4. What if I have difficulty accessing care, e.g., finding a provider that accepts Medicaid payment?

You must continue to pay your premiums in full to continue your HWD coverage. You should talk to your physician or pharmacist before purchasing HWD coverage, if you are not certain they will accept Medicaid payment.

1. What does HWD offer me, if I receive free Medicaid under the Supplemental Security Income (SSI)?

   You may be interested in purchasing Medicaid through the HWD program, since it allows you to earn income above the SSI 1619(b) threshold and does not have an asset test.  In Washington State the 1619(b) threshold amount for 2009 is $28,080 annual income (gross income minus IRWE).  You may not enroll in HWD, however, if you are eligible for Medicaid under the SSI program.
    

2. What if I have already applied for or am currently receiving Medicaid under the Medically Needy (MN) program – the "spenddown" program?

• If you prefer to receive Medicaid under the MN program, you do not have to enroll in the HWD program, unless you want to do so.

• If you have applied for the MN program and have not yet met your spenddown, you may enroll in the HWD program instead, if you meet program requirements.

• If you have met your spenddown, you can enroll in the HWD program beginning the first of the month after MN coverage can be closed.

Note: The HWD program is a Categorically Needy (CN) Medicaid program. This means that HWD pays for certain services not covered under the MN program, such as physical therapy and Medicaid personal care services.

If in the future SSA determines you no longer meet federal disability requirements, you may continue to qualify for Medicaid under the HWD program. At that point, the HWD Program Manager would determine if you have a "severe medically determinable impairment" (SMDI). We would continue your HWD coverage while we make that determination.

Note: To qualify for a continuation of HWD coverage after an improvement in your medical condition, you must:

• Have had a disability determination on file with SSA; and

• Have been approved for and receiving HWD benefits; and

• Have an SMDI as determined by the HWD Program Manager; and

• Be working at least 40 hours per month, earning at least minimum wage.