sb338 intr

Senate Bill No. 338
(By Senators Plymale, Bailey, Prezioso, Unger, Boley, Hunter, Rowe, Jenkins, Caldwell and Kessler)
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[Introduced January 24, 2003; referred to the Committee on Health and Human Resources; and then to the Committee on Finance

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A BILL to amend article four-a, chapter nine of the code of West Virginia, one thousand nine hundred thirty-one, as amended, by adding thereto a new section, designated section three, relating to the creation of a medicaid buy-in program for working individuals with disabilities.

Be it enacted by the Legislature of West Virginia:

That article four-a, chapter nine, of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new section, designated section three, to read as follows;
ARTICLE 4A. MEDICAID UNCOMPENSATED CARE FUND.

§9-4A-3. Medicaid buy-in program for working individuals with disabilities.

(a) The Legislature finds that establishing a medicaid buy-in program for certain individuals with disabilities will assist these people in becoming independent of public assistance by enabling them to enter the workforce without fear of losing essential medical care.

(b) The medicaid buy-in program for working individuals with disabilities is established to provide medicaid to individuals who are disabled and employed, as authorized under Section 201 of the federal Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170, 42 U.S.C. 1396 et seq.) It is to begin on the first day of July, two thousand three .

(1) "Basic Coverage group" means an optional coverage group as defined by the Ticket to Work and Work Incentives Improvement Act of 1999. An individual with a disability who is at least sixteen but less than sixty-five years of age whose income and resources do not exceed a standard established by the state;

(2) "Copayment" is a fixed fee to be paid by the patient at the time of each office visit, outpatient service, or filling of prescriptions;

(3) "Cost-sharing" means the eligible person will participate in the cost of the program by paying the enrollment fee, monthly premiums and copayments if established by the department;

(4)"Countable resources" includes earned and unearned income but does not include: liquid assets of up to five thousand dollars for an individual and ten thousand dollars for a family; retirement accounts; and independence accounts;

(5) "Department" means the department of health and human resources;

(6) "Disability" means that a covered individual must be determined to have a disability according to the Supplemental Security income definition of disability. They can be determined to have a disability by either the Social Security Administration process or the department's process. For purposes of this program, disability will be defined as a medically determinable physical or mental condition which can be expected to result in death, or has lasted or can be expected to last, for a continuous period of not less than twelve months, and renders a person unable to engage in substantial gainful activity. The person must also meet the requirements of limited income and resources;

(7) "Enrollment fee" means a one-time fee to participate in the program;

(8) "Federal benefit rate" is the amount of monthly benefits paid to persons with limited income and resources who are age sixty-five or older, blind, or disabled;

(9) "Federal poverty level" means the level of personal or family income below which one is classified as poor according to governmental standards. Also known as the federal poverty guidelines which are issued each year in the Federal Register;

(10) "Income" means money earned from employment wages or earnings from self-employment and unearned which is money received from any source that is not earned;

(11) "Independence accounts" are funds saved in a specified account to cover expenses necessary to enhance or maintain a person's independence or increase employment opportunities. Approved expenditures from such funds may include: educational expenses, work-related expenses, home purchase or modification, transportation, medical expenses, assistive technology and related services, or for short-term living expenses in times of qualified emergencies as determined by the department;

(12) "Liquid assets" are those which are cash or payable in cash on demand, including financial instruments that can be converted to cash within twenty working days. National, state, and local holidays are not working days;

(13) "Premium" is a monthly fee paid to continue participation in the program;

(14) "Resources" are possessions that the eligible person owns which could be changed to cash and used for food, clothing, or shelter while using social security rules for treatment of resources;

(15) "Retirement accounts" are moneys invested in approved retirement funds and accounts that are disregarded as an asset. Approved accounts include private retirement accounts such as individual retirement accounts and other individual accounts, and employer sponsored retirement plans such as 401(k) plans, Keogh plans and employer pension plans.

(d) To participate in the buy-in program beginning the first day of July, two thousand three, an individual must meet the following eligibility requirements:

(1) The individual has a disability as determined by the social security administration disability determination process or the department;

(2) The individual must be at least sixteen years of age but not more than sixty-four years of age;

(3) The individual must be engaged in competitive employment, including self-employment, or nontraditional work. Work results in remuneration at or above minimum wage in an integrated setting;

(4) The individual must have countable resources that do not exceed the resource limit for the Supplemental Security income program except the following:

(A) Countable resources of less than five thousand dollars for the individual or ten thousand dollars for the individual and spouse;

(B) The individual's retirement accounts; and

(5) The individual has countable income that does not exceed two hundred fifty percent of the federal poverty level. In determining an individual's income under this subdivision, the department may not consider the following:

(A) The income of the individual's spouse; and

(B) Income disregarded under the state medicaid's plan's financial methodology, including income disregarded under the federal Supplemental Security Income program (42 U.S.C. 1382) as impairment related work expenses;

(6) The individual has total countable unearned income, using social security income program methodology, that does not exceed the federal benefit rate plus the general income exclusion.

(7) The individual does not have countable resources that exceed the resource limits for the federal Supplemental Security Income program except for the following:

(A) An individual who is enrolled in the buy-in program and who no longer meets the eligibility requirements of the basic coverage group due to an improvement in the individual's medical condition continues to be eligible for medicaid coverage under the buy-in program if the individual meets the following requirements:

(i) The individual continues to have a severe medically determinable impairment, as determined by the department and as allowed by federal law;

(ii) The individual is employed and earning a monthly wage that is not less than the federal minimum hourly wage times forty;

(iii) The individual does not have income or countable resources in excess of the limits established for the basic coverage group;

(iv) The individual is at least sixteen years of age and less than sixty-five years of age;

(v) The individual pays any premiums or other cost sharing required under this chapter;

(vi) The individual meets all other eligibility requirements under this section.

(B) An individual who is enrolled in the buy-in program and who is unable to maintain employment for involuntary reasons, including temporary leave due to a health problem or involuntary termination, continues to be eligible for Medicaid coverage under the buy-in program if the individual meets the following requirements:

(i) Within sixty days after the date on which the individual becomes unemployed, the individual, or an authorized representative of the individual, submits a written request to the office that the individual's medicaid coverage be continued;

(ii) The individual maintains a connection to the workforce during the individual's continued eligibility period by participating in at least one of the following activities:

(I) Enrollment in a state or federal vocational rehabilitation program;

(II) Enrollment or registration with the office of workforce development;

(III) Participation in a transition from school to work program;

(IV) Participation with an approved provider of employment services;

(V) Provision of documentation from the individual's employer that the individual is on temporary involuntary leave;

(D) The individual is at least sixteen years of age and less than sixty-five years of age;

(E) The individual pays any premiums or other cost sharing required under this section;

(F) The individual meets all other eligibility requirements under this section.

(e) The department shall continue medicaid coverage under the buy-in program for an individual described in subsection (B) of this section for up to twelve months from the date of the individual's involuntary loss of employment.

(f) If an individual is ineligible for continued coverage under the buy-in program because the individual:

(1) Fails to meet the requirements of subsection (B) of this section; or

(2) Has already met twelve months of continuing eligibility under this section; the individual must meet the eligibility requirements of another available medicaid program to continue to be eligible for medicaid.

(g) The department shall charge a fifty dollar enrollment fee to all participants which includes the first month's premium payment.

(h)(1) The department shall develop a sliding scale of premiums for individuals participating in the buy-in program.

(2) The sliding scale of premiums required under subsection (1) of this section must:

(A) Be based on the annual gross income of the individual and, if married, the individual's spouse; and

(B) Provide for a minimum premium of fifteen dollars and a maximum monthly premium not to exceed three and one half percent of the individual's gross monthly income.

(3) Subject to the minimum and maximum amounts described above, the department may annually adjust the scale of premiums adopted under this section.

(i) The department shall review the amount of the premium that an individual is required to pay under this section, bi-annually .

(j) The department may increase the premium required only after conducting a review.

(k) The department shall decrease the premium that an individual is required to pay under subsection (h) of this section if:

(1) The individual notifies the office of a change in income or family size; and

(2) The sliding scale adopted by the department applied to the individual's changed circumstances prescribes a premium for the individual that is lower that the premium the individual is paying.

(l) The department shall establish administrative procedures regarding premiums for the buy-in program, including:

(1) The effect of nonpayment of a premium; and

(2) The collection of premiums.

(m) The department shall establish criteria to base the bi-annual redetermination of disability required for an individual participating in the buy-in program on the individual's medical evidence, including evidence of physical or mental impairment.

(n) In conducting the bi-annual redetermination described in subsection (l) of this section, the department may not determine that an individual participating in the buy-in program is no longer disabled solely on the individual's:

(1) Participation in employment;

(2) Earned income; or

(3) Income from self-employment.

(o) Except as otherwise provided in this section, an individual participating in the buy-in program:

(1) Shall receive the same benefits, including home health care services; and

(2) Is subject to the same requirements, including cost sharing; as an individual receiving regular medicaid coverage.

(p) (1) The department shall establish criteria to determine the effectiveness of:

(A) The buy-in program; and

(B) Continued medicaid coverage through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h).

(2) The criteria required under subdivision (o) of this section must include the following:

(A) The number of individuals with disabilities who are:

(i) Enrolled in the buy-in program; or

(ii) Receiving medicaid through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h).

(B) State revenues resulting from premiums paid by participants in the buy-in program.

(C) State costs incurred as a result of implementing the buy-in program, including administrative costs and costs of providing services.

(3) In addition to the criteria required under subsection (2)of this section, the department may establish criteria to determine the following:

(A) Comparative costs of medicaid funded services for participants in the buy-in program and work incentives created through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h) before and after employment.

(B) The number of Supplemental Security Income and Social Security Disability Insurance recipients in West Virginia who are no longer dependent on, or who have reduced dependence on, public assistance or health care entitlement services, other then Medicaid or the children's health insurance program, due to participation in the buy-in program or work incentives created through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h).

(C) The number of individuals with severe disabilities who are no longer dependent on, or who have reduced dependence on, public benefits or services, other than medicaid or the children's health insurance program, due to income or support services received through participation in the buy-in program or work incentives created through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h).

(D) The change in the number of buy-in program participants or participants in work incentives created through Section 1619 of the federal Social Security Act (42 U.S.C. 1382h) who have health care needs and related services covered through employer based benefit programs.

(4) In evaluating the effectiveness of the state's work incentives initiatives for individuals with disabilities, the office:

(A) Shall collaborate with other state agencies on data collection; and

(B) May consult with an independent contractor to collect data on the criteria listed under subsection (2) of this section.

(5) The department shall provide an annual report of its evaluation under this section to the Legislature no later than the last day of December of each year, beginning in two thousand four.

(q) Funding for the buy-in program shall be from funds appropriated by the Legislature, premiums paid, enrollment fees and any federal matching funding available to the program.

(r) Notwithstanding any other provisions of this article to the contrary, the state agency shall promulgate emergency rules pursuant to the provisions of section fifteen, article three, chapter twenty-nine-a of this code by the first day of September, two thousand three, to implement this program.

(s) In adopting rules under this section, the department shall:

(1) establish an advisory council with representation from the state medicaid agency, the state rehabilitation agency, the state office of family support, the West Virginia Statewide Independent Living Council, the West Virginia State Rehabilitation Council, the West Virginia Developmental Disabilities Council, the West Virginia Mental Health Planning Council, and the Center for Excellence in Disabilities at West Virginia University;

(2) Submit proposed rules for review and input to the advisory council prior to release for public comment; and

(3) Consider any recommendations of the advisory council before adopting final rules.

NOTE: The purpose of this bill is to establish a medicaid buy-in program for certain individuals with disabilities to allow those individuals to work and maintain their medicaid coverage.

This section is new; therefore, strike-throughs and underscoring have been omitted.