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Keeping Medicare and Medicaid When You Work: Medicaid Buy-in Programs online version

Under federal law, states have the option of creating Medicaid buy-in programs that enable employed individuals with disabilities who make more than what is allowed under Section 1619(b) to obtain Medicaid coverage at a low or no cost. A state has 3 distinct ways that it can create and offer a Medicaid buy-in under two separate federal laws – the Balanced Budget Act (the BBA) and Ticket to Work and Work Incentives Improvement Act (TWWIIA). In brief, these provisions provide for the following:  

The BBA Medicaid Buy-In – Allows a state to offer Medicaid coverage to any employed person with a disability who has a net family income below 250 percent of the Federal poverty level for a family of the size involved.

TWWIIA Medicaid Buy-In Provisions – TWWIIA allows a state to offer Medicaid coverage to individuals who fall into one of the following groups:  

(1) Basic Coverage Group. States have the option to offer Medicaid to working individuals who are at least 16 but less than 65 years of age who, except for their income and resource levels, are eligible to receive SSI. States are free to establish their own income and resource standards. Individuals who have never received SSI benefits can be eligible.

(2) Medical Improvement Group. States have the option to offer Medicaid to employed individuals with a medically improved disability who lose Medicaid eligibility under the group described above because they no longer meet the SSI definition of disability.

States offering coverage to the second group must also cover the first group. States may impose premiums or other cost-sharing charges on a sliding scale based on income for individuals eligible for either of the new eligibility groups.

As of September 2004, a total of 25 states offered a Medicaid buy-in to working age people with disabilities who are eligible for coverage under one or more of the 3 options just described. For information about eligibility policies in specific states, go to http://www.cms.hhs.gov/twwiia/statemap.asp. If you have determined that there is buy-in program in your state for which you may qualify, you should contact the Medicaid program in your state for more information. Back to the Top

What rules apply to states implementing the BBA eligibility group?  

The following rules must be adhered to in each state that offers this form of Medicaid buy-in:  

  • Family Income Standard – Net family income below 250 percent of the Federal poverty level for a family of the size involved. 
  • Except for earned income (which is completely disregarded) the individual must meet all SSI eligibility criteria, including: 
    • Unearned income not exceeding the SSI income standard (currently $599 a month for an individual; $889 for a couple in 2005). 
    • Resources not exceeding SSI resource standard ($2,000 for an individual; $3,000 for a couple in 2005). 
    • Disabled as defined under the SSI program. 
    • SSI income and resource methodologies are used to determine eligibility. Back to the Top

Can a state impose additional requirements?  

Yes. A state with a BBA Medicaid buy-in can also:  

  • Use more liberal income and resource methodologies than are typically used by SSI. 
  • Use more restrictive eligibility criteria than are used by SSI (209(b) States). 
  • Require payment of such premiums or other cost-sharing charges, on a sliding scale based on income, as the State may determine. Back to the Top

What are the basic Medicaid buy-in provisions in TWWIIA?  

These provisions were approved by Congress to build and expand on the buy-in option available under the BBA. TWWIIA created two additional optional categorically needy Medicaid buy-in eligibility groups: (1) the Basic Coverage Group; and (2) the Medical Improvement Group. Back to the Top

Who qualifies for coverage under the basic coverage group?  

The Basic Coverage Group is similar to the BBA group, however states can establish their own income and resource standards (or choose to not have any income or resource standards), and there is an age limit (at least 16 but not more than 64 years of age). Back to the Top

What rules apply to states implementing the TWWIIA basic coverage group?  

States implementing this provision must ensure that:  

  • Individuals covered must be between 16 and 64 years of age. 
  • Individuals covered must meet the SSI definition of disability. 
  • Earned income is not automatically disregarded. 
  • No federally required income and resource standards. 
  • If States establish income and resource standards, SSI income and resource methodologies are used to determine eligibility. Back to the Top

Who qualifies for coverage as part of the medical improvement group?  

Under this option, a state can offer Medicaid to employed individuals with a medically improved disability who lose Medicaid eligibility under the group described above because they no longer meet the SSI definition of disability. It is important to note that States offering coverage to the second group must also cover the first group. Back to the Top

What rules apply to states implementing the medical improvement group?

States implementing this provision must ensure that:  

  • Individuals covered must be between 16 and 64 years of age.
  • Individual covered must have a medically improved disability. 
  • Individual covered must have been eligible under the Basic Coverage Group but lost that eligibility because his or her medical condition has improved to the point where it is determined at the time of a regularly scheduled continuing disability review that he or she is no longer disabled as SSI defines the term. 
  • Earned income is not automatically disregarded. 
  • No federally required income and resource standards. 
  • If States establish income and resource standards, SSI income and resource methodologies are used to determine eligibility. Back to the Top

Can a state that has a TWWIIA Medicaid buy-in impose additional requirements?  

Yes, it can:  

  • Establish their own income and resource standards, or have no income and resource standards if they choose. 
  • Use more liberal income and resource methodologies than are typically used by SSI. 
  • Use more restrictive eligibility criteria than are used by SSI (209(b) States). 
  • Require payment of such premiums or other cost-sharing charges, on a sliding scale based on income, as the State may determine. 
  • Impose premiums or other cost-sharing charges on a sliding scale based on income for individuals eligible for either of the new eligibility groups.

To obtain information on TWWIIA Medicaid buy-in requirements that have been set by your state, you can contact your state Medicaid agency (see the table on the next page or consult the Centers on Medicare and Medicaid Services website at http://www.cms.hhs.gov/twwiia/statemap.asp. Back to the Top

Can a person resume receiving SSI cash benefits if you are not able to work any longer?     

Yes. If you have not been eligible for an SSI benefit for 12 months or less, you do not have to file a new application to reinstate your SSI cash payments or Medicaid coverage. If you stop working after more than 12 months you will have to apply for the benefits again but provided that your disability has not improved regaining them should not be an issue. Back to the Top

How to Contact Medicaid in Your State