210-RICR-40-15-1. “Medicaid Code of Administrative Rules, Section 1373: Medicaid for Working People with Disabilities Program” (version Adoption, 01/01/2012 to 01/01/2012)

Rhode Island Executive Office of Health and Human Services The Sherlock Plan - Medicaid for Working People with Disabilities Program January 1, 2012 Rhode Island Executive Office of Health & Human Services The Sherlock Plan - Medicaid for Working People with Disabilities Program Rules and Regulations TABLE OF CONTENTS Section One OVERVIEW 1 I. Program Description 1 II. Program Eligibility 1 III. Income Limits 1 IV. Resource Limits 2 Section Two RETROACTIVE COVERAGE 2 Section Three ACCESS TO EMPLOYER-BASED 3 HEALTH INSURANCE Section Four PREMIUM RATE SETTING 3 I. Premium Calculation 3 II. Premium Collection Methods 3 III. Non-Payment of Premiums 4 Section Five LOSS OF EMPLOYMENT OR ELIGIBILITY 4 Section Six AVAILABLE SERVICES 4 The Sherlock Plan – RI Medicaid for Working People with Disabilities Program Rules and Regualations 1/1/2012 1 Rhode Island Executive Office of Health and Human Services The Sherlock Plan – Medicaid for Working People with Disabilities Program Section One OVERVIEW I. PROGRAM DESCRIPTION The Sherlock Plan – Medicaid for Working People with Disabilities Program is an SSI-related categorical eligibility group comprised of working adults with disabilities pursuant to the Balanced Budget Act of 1997 (42 USC section 1396a(a)(10)(ii)(XIII)). Those eligible under this category will be entitled to the full scope of Categorical Medical Assistance benefits, Home and Community Based services, and services needed to facilitate and/or maintain employment, but will be required to pay a premium in order to remain active on the program. II. PROGRAM ELIGIBILITY To be found eligible within the program of Working People with Disabilities, a person must: • Be at least eighteen (18) years of age; and • Currently meet the Medical Assistance requirement for disability. Those individuals meeting the disability requirement are not required to meet the provision that a person be unable to engage in substantial, gainful employment; and • Have proof of active, paid employment such as a pay stub or current quarterly IRS tax statement (for those who are self-employed). III. INCOME LIMITS Financial eligibility is defined as countable net income equal to or less than two hundred fifty percent (250%) of the Federal Poverty Level (FPL). Countable income for purposes of establishing program eligibility excludes any unearned income and is defined as the total earned income remaining after all SSI-related disregards are applied. The SSI-related disregards listed in DHS Code of Code of Rules, Section 0364 are applied, including impairment related work expenses as defined in the Code of Federal Regulations, 20 CFR, Section 416.976. Participants in this program will be defined as a family size of one (1) for financial eligibility purposes. Only the individual’s income will be reviewed and counted in income calculations. The Sherlock Plan – RI Medicaid for Working People with Disabilities Program Rules and Regualations 1/1/2012 2 IV. RESOURCES LIMITS The following resource limits apply to applicants and recipients of the Working People with Disabilities Program: RESOURCE LIMITS Individual $10,000 Couple $20,000 When calculating available resource amounts for a married couple, the resources of both the individual accepted into the program and their spouse must be determined available as a resource and applied to the resource limit of $20,000. The following resources are not countable for this program: 1. IRS recognized medical savings accounts or retirement accounts. 2. Items necessary for an individual to remain employed and/or independent (such as a specially adapted vehicle). Section Two RETROACTIVE COVERAGE As an SSI-related coverage group, participants in the Working People with Disabilities Program are eligible for retroactive coverage. Eligibility for retroactive coverage will be determined in accordance with the rules established in DHS Code of Rules Section 0310 with the following exception particular to this coverage group: • Premiums must be paid in full before retroactive eligibility can be instituted. Individuals may deduct premium amounts from the total amount of any unpaid medical bills in the retroactive eligibility period. The Sherlock Plan – RI Medicaid for Working People with Disabilities Program Rules and Regualations 1/1/2012 3 Section Three ACCESS TO EMPLOYER-BASED HEALTH INSURANCE Individuals with disabilities who have access to employer-based health insurance are required to enroll in the plan as a condition of participation in the Medicaid buy-in program, provided that enrollment in the employer-based health insurance plan is cost-effective and its benefits are comparable to the benefits provided by the Medicaid program. If coverage meets Medicaid requirements, Medicaid will pay the employee’s share of the monthly premium. Enrollment of the individual in the employer-based health insurance plan is without regard to any enrollment season restrictions. Section Four PREMIUM RATE SETTING I. PREMIUM CALCULATION Once a person has been found eligible as a working person with a disability, a premium will be calculated using the following methodology. For the purposes of premium calculation the individual’s and spouse’s earned income will be counted. The total earned income will be income remaining after all SSI-related disregards are applied: Countable earned income will be assigned premiums in the following amounts: Total Countable Income: Premium: Between 100% and 149% FPL $ 54.00 Between 150% and 184% FPL $ 91.00 Between 185% and 199% FPL $ 113.00 Between 200% and 250% FPL $ 122.00 II. PREMIUM COLLECTION METHODS A. Electronic Funds Transfer (EFT) The eligible individual requests that their bank allow the state to withdraw the monthly premium directly from the family’s savings or checking account by an electronic transfer to Medicaid. The person is given an EFT form to fill out. The funds will be withdrawn by the state on the third (3rd) day of the month prior to the month of coverage. The person will be notified by letter if the EFT premium payment was not successful. B. Wage withholding The recipient may request that their employer withhold the monthly premium. The employer will then pay the monthly premium to Medicaid through an EFT. The employed person is given a special form requesting wage withholding and deposit or transfer to take to his or her employer to be completed and mailed. The Sherlock Plan – RI Medicaid for Working People with Disabilities Program Rules and Regualations 1/1/2012 4 C. Direct Pay The individual pays the premium to Medicaid by check or money order every month. A premium payment coupon and pre-addressed envelope will be provided to the family before the premium is due. The check or money order and the premium payment coupon are mailed or delivered to the Medicaid fiscal agent. III. NON-PAYMENT OF PREMIUMS Non-payment of premiums is treated in the same manner as for RIte Care and RIte Share participants as detailed in the DHS Code of Rules, Section 0349.10.20.15.05. Section Five LOSS OF EMPLOYMENT OR ELIGIBILITY A person who loses employment may retain eligibility, under this group, for up to four (4) months by paying a premium. If the person is still unemployed at the end of the four (4) month period, he/she will no longer qualify as a working adult with a disability. A person no longer eligible as a working adult with a disability may retain approved medical savings accounts and retirement account assets in the amount held on the last full day of eligibility as a working adult with a disability. These medical savings account and/or retirement account assets will be considered non-countable assets for purposes of Medicaid eligibility under any other coverage group. The individual is responsible for providing verification of these account balances as of the last date of eligibility as a working adult with a disability if it is to be disregarded for future Medicaid eligibility. Section Six AVAILABLE SERVICES Services include the full scope of Categorical Medical Assistance benefits, Home and Community Based services, including personal care services provided through an agency or through a self-directed program, and services needed to facilitate and/or maintain employment. The applicant/beneficiaries services are coordinated through the Medicaid Office and the Office of Rehabilitation Services (ORS). Long-term care services and supports are listed in DHS Code of Rules, Section 0399. Services to maintain and support employment shall be determined and approved through an assessment of need utilizing a state approved assessment instrument. Authorized personal care services may be provided in the home, workplace or other necessary setting (i.e. physician office).