New York Work Exchange

Critical Issues > The Medicaid Buy-In Program

Updated October 20, 2004

Introduction

The Medicaid Buy-In Program was designed for working individuals receiving SSDI/SSI to purchase Medicaid benefits on a sliding scale despite earnings over the allowable limits set up under Medicaid. Recent statistics show that only 30% of individuals on SSDI or SSI are employed. Out of this 30%, only 15% of individuals with a psychiatric disability are employed. An overwhelming and consistent reason for these individuals not returning to work is fear of losing their essential medical benefits under SSDI and SSI. Medicaid has a much more comprehensive medical coverage than most private health insurance. As a result, it is the preferred medical coverage. Medicaid covers the medical costs of prescriptions, long-term care, and ongoing medical supplies. For these reasons, applying for the Medicaid Buy-In is favorable.

The Medicaid Buy-In Program has been offered in several states. In New York State the program began in July 2003. New Yorkers can now apply for the program at their local County Social Services office. The Albany Central Office staff process all New York City Applications. According to the State Health Department, over 700 individuals have applied for the program and about 350 have been approved so far.

There has been a particular problem in getting the word out in New York City where the enrollment is noticeably less than the people proportionately who are out there. As of this date,2000 applications have come in within New York State; in New York City 209 applications have been received, 140 processed and 132 accepted with approximately 5 in the Medical Improvement Group. Approximately 20,000 individuals are eligible for the Buy-In in New York State. There also appears to be some confusion between the Medicaid Buy-In program and a similarly named offering for Medicare recipients. The official acronym for the Medicaid Buy-In is MBI-WPD. It also appears that some local social services workers have not been properly informed about the program and how to enroll beneficiaries in it. Some confusion has come up for SSI recipients in particular.

If a SSI recipient is working and earning between $34,765 and $47,580, they can apply for the Buy-In. This is strongly suggested especially if this same recipient has been receiving Medicaid through the 1619b program after the loss of their SSI due to a working status. The Buy-in would provide better coverage than the 1619b program.

Questions and Tips for Consumers

Some basic questions to ask and tips for consumers to know in terms of eligibility and applying for the Medicaid Buy-In are the following:

Are you currently working or would you like to work without losing your Medicaid benefits?
Have you been working but you have not been on any benefits for some time?
Would you like to save more money and keep your benefits?
Are you presently paying a spenddown and would rather pay a premium for healthcare coverage?

If you have answered yes to any of the above questions, the following are some tips to keep in mind when applying for the Medicaid Buy-In:

Bring proof of your working status, proof of your current resources and your last 4 bank statements
Fill out the green and white form only (LDSS-2921) -- not the QMB Medicare form or Medicare Savings Program form and label it as the Medicaid Buy-In program as well as MBI-WPD; this form can be obtained by calling 212-630-1571 or 1572
Ask for the disability interview form or the LDSS-1151 form so you can start to fill it out in advance (this is a lengthy form)
When applying, attach to form LDSS-2921 any "Medicaid Buy-In At A Glance" fact sheet and the Administrative Directive from the State of New York Department of Health on the Medicaid Buy-In, dated June 9, 2003 -- both are obtainable from the web sites listed below
Make sure to get the name of the worker assisting you as well as that worker’s supervisor
Expect the application process to take 30-45 days; an appeal can be made after 60 days if your application is held up

Benefits of the Program

Earn more and keep coverage
Pay a premium on a monthly basis
Earn up to $47,580 as an individual or $63,492 as a couple
Increase countable resources up to $10,000
Covers deductions from a paycheck for Medicare costs for SSDI recipients
Option to choose managed care if income is below 150% of the poverty guideline

Premiums

Currently a moratorium exists on premium collection until the Department of Social Services completes the automated payment system currently estimated to be completed in late November 2004. The following is an explanation as to how premiums will function once this moratorium is lifted.

Premiums apply to all Net Available Monthly Income (NAMI), are paid monthly, and are based on the poverty guideline or federal poverty level (FPL). Here is an example:

If NAMI falls below 150% of the poverty guideline or is $1,164 or less in 2004 — NO PREMIUM APPLIES
If NAMI falls between 150% - 250% of the poverty guideline, a premium from 3% of NAMI and 7.5% of NAMI applies
Individuals with NAMI above 250% of the poverty guideline or earning above $1,940 per month gross income for 2004 may not purchase Medicaid coverage
Premiums range from $0 to $698 yearly assuming all income is earned in a household of 1
The poverty guideline in 2004 for the 48 contiguous states and D.C. is the following:

One person household $9,310
Two person household $12,490
Three person household $15,670
Four person household $18,850
(add $3,180 for each additional person)

To put this simply, a single individual with a disability could return to a job that could earn $47,580 annually by paying a Medicaid premium of less than $60 per month (at the top level).

New York’s Two Coverage Groups

New York’s program is quite unique as it establishes two eligibility groups: the Basic Coverage Group and the Medical Improvement Group.

Basic Coverage Group

Most individuals who currently have SSDI or SSI will be eligible for the Basic Coverage Group. The minimum amount of working hours needed for eligibility can be as low as one hour a month as long as the individual is contributing to FICA. An individual must have a disability that meets the medical criteria established by the Social Security Administration (SSA) but have too much income to qualify for SSI. In addition to the usual Medicaid rules, the specific requirements are:

Disability–Certified disabled by SSA SSA (SGA, Substantial Gainful Activity, rule does not apply)
Age–Be at least 16 but not yet 65 years of age
Work–Be engaged in paid work and earn more than $810 per month in 2004 and still be eligible for the Buy-In(includes part-time and full-time work)
Income–Have a gross income that may be as high as $47,580 for an individual and $63,492 for a couple (as of January 1, 2004)
Resources–Have non-exempt resources that do not exceed $10,000 in categories such as automobile, homestead, pre-need funeral arrangements, Plan to Achieve Self-Support (PASS), and life insurance policies with a combined face value of $1,500 or less; other resources may be allowed

Medical Improvement Group

To be eligible for the Medical Improvement Group, an individual must meet all the criteria met by individuals in the Basic Coverage Group. Additionally, the individual must receive coverage through the basic group and be no longer determined disabled by SSA but continuing to have a severe medically determined impairment. Keep in mind that loss of eligibility under the Basic Coverage Group must be the direct and specific result of loss of disability status because of medical improvement. Finally, an individual in the Medical Improvement Group must be employed at least 40 hours per month and earn at least the federally required minimum wage.

Grace Period

In general and applicable for both groups is a grace period of up to six months. This is allowed if, for medical reasons the Medicaid Buy-In recipient is unable to continue working. Multiple grace periods are allowed as long as the sum does not exceed 6 months in a 12 month period. The local DSS office is responsible for determining grace periods. Medical verification is required if an individual should lose their job through no fault of their own (i.e. lay off). A grace period of up to six months will be allowed in this instance as well. Verification is required demonstrating that the individual is reasonably expected to return to work as it is a temporary lay off, or that the individual is actively seeking new employment. The local DSS office verifies that the recipient is actively seeking employment and is reasonably expected to return to work.

Other Information

NYAPRS (New York State Association of Psychiatric Rehabilitation) has been working closely with officials with the NYS Health Department and Office of Mental Health to explore ways to enhance awareness, overcome bureaucratic obstacles and increase enrollment in the state’s new Medicaid Buy-In work incentives program. The NYAPRS Training Collective is available to offer a broad array of trainings in several areas including basic information on the Medicaid Buy-In for free. More information: http://www.nyaprs.org/train_ed/train_info.htm.

The Ticket to Work and Work Incentives Advisory Panel has posted a briefing paper prepared for the Panel by the Urban Institute entitled "The Effectiveness of Medicaid Buy-In Programs in Promoting the Employment of People with Disabilities." The purpose of this paper is to provide the Panel with information about the features of the existing Medicaid Buy-in programs, and the potential effectiveness of these programs in promoting the employment of people with disabilities. Online:http://www.ssa.gov/work/panel/panel_documents/briefingpapers.html

Mathematica Policy Research, Inc. has put together a one year evaluation on the Medicaid Buy-In called "Extending Medicaid to Workers with Disabilities - A Look at the Medicaid Buy-in Program." This evaluation looks at emerging themes, participation information, and policy questions within 21 states in 2002. Some of the themes that emerged were increased enrollment and few participants with earnings over the SGA of $810. Participant numbers within the states evaluated were as low as 150 to as high as 8000. Policy questions addressed the promotion of employment for people with disabilities through the Buy-In program and the relationship between health expenditures and earnings. Specific information on this evaluation: http://www.mathematica-mpr.com/health/medicaidbuy-in.asp

The following are some helpful contacts:

The New York State Office of Mental Health Statewide Plan, Appendix 8 specifically on the Medicaid Buy-In:
http://www.omh.state.ny.us/omhweb/Statewideplan/appendix8.htm

The New York State Department of Health Informational page on the Medicaid Buy-In:
http://www.health.state.ny.us/nysdoh/medicaid/buy_in/buy-in_work_disabled.htm

The New York State Department of Health/Medicaid Management:
Medicaid Help Line at 1-800-541-2831 (TDD 800-662-1220)

The National Conference of State Legislatures website:
http://www.ncsl.org/programs/health/ttwork.htm

Social Security Administration:
http://www.ssa.gov/work

Benefits Planning Assistance & Outreach (BPAO)- community based planning and assistance programs:
http://www.ssa.gov/work/ServiceProviders/bpaofactsheet.html

Individual contacts to help troubleshoot and provide staff training:
Mr. Nash and Ms. Barnes of the NY State Department of Health, Office of Medicaid Management: 212-268-6855;
Brad Titus, Medicaid Buy-In for Working People with Disabilities, Office of Medicaid Management, 518-473-5330;
Ms. Jackson of the NYC HRA Medicaid Assistance Program: 212-630-1491

Neighborhood Legal Services, Inc. Medicaid/Medicare informational page:
http://www.nls.org/caidcare.htmand http://www.nls.org/ssassi/medicaid.htm

The Greater Upstate Law Project informational page on the Medicaid Buy-In:
http://www.gulpny.org/Disability/SSI%20-%20SSD/SSISSD/new_york_implements_medicaid_buy.htm