Apple Health for Workers with Disabilities
The Apple Health for Workers with Disabilities program policy and procedures described here are effective January 1, 2020.
Purpose: This section describes the Apple Health for Workers with Disabilities (HWD) program. HWD recognizes the employment potential of people with disabilities. The enactment of the federal Ticket to Work and Work Incentives Improvement Act or the Ticket group of 1999 and the Balanced Budget Act (BBA) of 1997 enable many people with disabilities to work and keep their health care.
As a categorically needy (CN) Medicaid program, HWD provides access to Medicaid Personal Care services (MPC), Community First Choice (CFC), Medicaid Alternative Care (MAC) and Home and Community Based (HCB) waiver programs administered by the Developmental Disabilities Administration (DDA) and Home and Communities Services (HCS). To be approved for services, an individual must meet functional requirements as determined by DDA and HCS.
For more information see the Apple Health for workers with disabilities (HWD) fact sheet.
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WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.
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WAC 182-511-1000 Health care for workers with disabilities (HWD) -- Program description.
Effective January 1, 2020
This section describes the apple health for workers with disabilities (HWD) program.
- The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
- The HWD program also provides long-term services and supports described in chapters 182-513 and 182-515 WAC for a client who meets the functional requirements for those programs, are approved for those services, and choose to enroll in HWD.
- The medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC 182-511-1100 for retroactive coverage for months before the month of application.
- A person who is eligible for another medicaid program may choose not to participate in the HWD program.
- A person is not eligible for HWD coverage for a month in which the person received benefits under the medically needy (MN) program.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
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WAC 182-511-1050 Health care for workers with disabilities (HWD) -- Program requirements.
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WAC 182-511-1050 Health care for workers with disabilities (HWD) -- Program requirements.
Effective January 1, 2020
This section describes requirements a person must meet to be eligible for the apple health for workers with disabilities (HWD) program.
- To qualify for the HWD program, a person must:
- Meet the general requirements for a medical program described in WAC 182-503-0505(3)(a) through (f);
- Be at least age sixteen;
- Meet the federal disability requirements described in WAC 182-511-1150;
- Be employed full or part time (including self-employment) as described in WAC 182-511-1200.
- The HWD program does not require a resource test.
- Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify.
- The agency calculates the premium for HWD coverage according to WAC 182-511-1250.
- If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again.
- Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:
- The job less results from an involuntary dismissal or health crisis; and
- The person continues to pay the monthly premium.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
- To qualify for the HWD program, a person must:
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WAC 182-511-1100 Health care for workers with disabilities (HWD) -- Retroactive coverage.
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WAC 182-511-1100 Health care for workers with disabilities (HWD) -- Retroactive coverage.
Effective January 1, 2020
This section describes requirements for retroactive coverage provided under the apple health for workers with disabilities (HWD) program.
- Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.
- To qualify for retroactive coverage under the HWD program, a person must first:
- Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and
- Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.
- Payment must be received for each month requested of retroactive coverage before such coverage is approved.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Worker responsibilities
- It is critical to compare the options and determine which program costs less when an individual meets the requirements for more than one program.
- Since HWD requires a monthly premium payment, the program of choice for someone eligible for both HWD and another CN program is the one that costs less. Compare HWD to the following programs to determine the most advantageous to the individual:
- Apple Health Adults
- Apple Health for Kids (the minimum age for HWD is 16 years)
- Apple Health for Pregnant Women
- The CN disability program (S02) for a disabled adult child (DAC)
- CN programs (L22 or G03) depending upon financial and functional requirements and place of residence
- People who are eligible for both HWD and MN may prefer to receive Medicaid under the MN program. They do not have to enroll in HWD; enrollment is their choice. The HWD Award Letter provides people eligible for both with a comparison of their spenddown amount.
For most people, HWD is the preferred program because:
- CN provides more extensive coverage than MN; and
- The HWD monthly premium is likely to be less than the monthly amount used to determine a three or six month spenddown liability.
A person who is approved for MN (in active status) cannot be opened for HWD CN coverage until the first of the month after MN coverage is closed.
Note: Follow ACES procedures to screen for S03 and S05 when the individual is entitled to Medicare. Remember to review for resources for S03 and S05 eligibility.
Note: HWD enrollees receiving Medicare get help with their Part D expenses; they receive "full subsidy" benefits. People with income above 135 percent FPL who choose MN instead of HWD receive only partial help with their Part D expenses, unless they meet their spenddown.
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WAC 182-511-1150 Apple health for workers with disabilities (HWD) -- Disability requirements.
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WAC 182-511-1150 Apple health for workers with disabilities (HWD) -- Disability requirements.
Effective January 1, 2020
This section describes the disability requirements for the following groups of individuals who may qualify for the apple health for workers with disabilities (HWD) program.
- A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):
- (XV) for the basic coverage group (BCG); or
- (XVI) for the medical improvement group (MIG).
- The BCG consists of individuals who:
- Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or
- Are determined by the department of social and health services (DSHS), division of disability determination services (DDDS), to meet federal disability requirements for the HWD program.
- The MIG consists of individuals who:
- Were previously eligible and approved for the HWD program as a member of the BCG; and
- Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1) (b). For these people, a continuation of HWD coverage is provided to help them maintain their employment.
- A person sixty-five or older, must meet federal disability requirements as determined by the DSHS DDDS. Coverage under the MIG is not available under federal law for persons age sixty-five or older. Coverage for this age group is authorized under the Balanced Budget Act of 1997 as described under section 1902 (a)(10)(A)(ii)(XIII).
- When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on earnings or the performance of substantial gainful activity (SGA). (See SSA POMS Section DI 10501.001, https://secure.ssa.gov/apps10/poms.nsf/Home?readform).
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
- A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):
Worker responsibilities
HWD designated staff responsibilities
For an individual receiving HWD benefits who appears to no longer meet the disability requirements for the BCG, follow procedures below.
Example: #1 - An HWD individual receives a letter from SSA that states he/she no longer meets the disability requirement to receive SSDI cash after completing his/her Trial Work Period (TWP) and has earnings at or above the substantial gainful activity (SGA) level for one subsequent month.
He/she will be eligible for and receive the SSDI benefit for that one month and the following two months. However, during any month in which earnings fall below the SGA level, the individual remains eligible for his/her SSDI cash benefit during the Extended Period of Eligibility (EPE). The EPE begins the month after the TWP ends. The individual should contact the Social Security Administration (SSA) to confirm when their TWP ended once their SSA cash benefit ends because of earning at or above the SGA level. To receive SSDI for a month in which earnings fall below SGA, the client must call SSA and document for them the amount of earnings; no application is necessary.
When an individual receives this letter from SSA, it might appear he/she does not continue to meet disability requirements for coverage under the HWD Basic Coverage Group (BCG). This is not true, since the client remains eligible for coverage under the BCG during the EPE. Staff need to recalculate the monthly premium amount and send proper notification. Staff should email the HWD program manager in Olympia, if they have questions about the client's coverage during the EPE.
For more information about this SSDI work incentives​, see the SSA Red Book Extended Period of Eligibility.
Example: #2: An individual completes the EPE and remains enrolled in HWD. If medical improvement has occurred, the client's coverage continues until the completion of a disability determination for the Medically Improved Group (MIG) is completed. Email the HWD program manager to request a determination of eligibility under MIG and continue coverage until one is completed. .
To approve HWD coverage for a member of the MIG, use the new "Disability Source" (CD) code to indicate the client has a medically improved disability as determined by the HWD program manager.
For an individual receiving HWD benefits that no longer meets the eligibility requirements for BCG or MIG, continue HWD coverage until you redetermine eligibility for other medical programs.
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WAC 182-511-1200 Health care for workers with disabilities (HWD) -- Employment requirements.
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WAC 182-511-1200 Health care for workers with disabilities (HWD) -- Employment requirements.
Effective January 1, 2020
This section describes the employment requirements for the basic coverage group (BCG) and the medical improvement group (MIG) for the apple health for workers with disabilities (HWD) program.
- For the purpose of the HWD program, employment means a person:
- Gets paid for working;
- Has earnings that are subject to federal income tax; and
- Has payroll taxes taken out of earnings received, unless self-employed.
- To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.
- To qualify for HWD coverage as a member of the MIG, a person must be:
- Working at least forty hours per month; and
- Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).
- For a person who is self-employed, the examples described in the Social Security Administration Program Operations Manual System (POMS) provide guidance when determining whether someone meets the HWD work requirements. (See SSA POMS Section SI 00820.200, https://secure.ssa.gov/apps10/poms.nsf/lnx/0500820200). The guidelines described in POMS for determining the existence of a trade or business may also be used when making this determination. (See SSA POMS Section RS 01802.010, https://secure.ssa.gov/apps10/poms.nsf/lnx/0301802010).
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
- For the purpose of the HWD program, employment means a person:
Workers responsibilities
- Do not use a personal check or pay stub that does not indicate tax withholdings as evidence of earnings gained through employment for HWD eligibility requirements.
- Contact the individual’s employer when necessary to verify tax withholdings.
- For individuals who are self-employed, but have not been in business long enough to file a tax return, accept business documents as evidence of self-employment. Advise them to maintain business records and provide a copy of their federal tax return.
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WAC 182-511-1250 Health care for workers with disabilities (HWD) -- Premium payments.
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WAC 182-511-1250 Apple health for workers with disabilities (HWD) -- Premium payments.
Effective January 1, 2020
This section describes how the Medicaid agency calculates the premium amount a person must pay for apple health for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.
- When determining the HWD premium amount, the agency counts only the income of the person approved for the program. It does not count the income of another household member.
- When determining countable income used to calculate the HWD premium, the agency applies the following rules:
- Income is considered available and owned when it is:
- Received; and
- Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC 182-512-0600(5), 182-512-0650, and 182-512-0700(1).
- Certain receipts are not income as described in 20 C.F.R. Sec. 416.1103.
- Income is considered available and owned when it is:
- The HWD premium amount equals the lesser of the two following amounts:
- A total of the following (rounded down to the nearest whole dollar):
- Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus
- Five percent of total unearned income; plus
- Two and one-half percent of earned income after first deducting sixty-five dollars; or
- Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
- A total of the following (rounded down to the nearest whole dollar):
- When determining the premium amount, the agency will use the currently verified income amount until a change in income is reported and processed, unless good cause for delay in verifying changes exists.
- A change in the premium amount is effective the month after the change in income is reported and processed.
- For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
- For retroactive coverage, the agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information that establishes eligibility is received by the agency.
- If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following months that have passed during determination of eligibility.
- As described in WAC 182-511-1050 (3)(b), the agency will close HWD coverage if premiums are not paid in full for four consecutive months.
- The person must pay the monthly premium in full to avoid losing HWD coverage. If a person makes a partial payment, the payment does not count as a full payment toward the premium.
- Payments received are applied to premiums owed in the following order:
- If retroactive coverage is requested, the retroactive coverage month(s);
- Past due months, beginning with the most delinquent month;
- The current coverage month that has been invoiced; then
- Future coverage months.
- A person must pay a premium for any month that HWD coverage is provided. This includes months when a redetermination of coverage is made, and months when continued coverage that is requested, pending the outcome of an administrative hearing.
This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.
Worker responsibilities
Initial premium amount
Explain to the individual they are not obligated to purchase coverage each month back to the date of application.
Retroactive coverage
- Encourage the individual who has paid for services received in the retroactive period that providers are not obligated to accept Medicaid reimbursement for those months.
- Explain to the individual that premiums for retroactive coverage must be paid in advance. Premiums must be paid within 120 days or the retroactive coverage will be denied.
Note: If the premium billing invoice is sent to a Protective Payee, a copy will not be sent to the client. Add free form text in a letter to the individual to let them know this.
Note: Members of an American Indian/Alaska Native (AI/AN) population are exempt from HWD premiums. By entering the appropriate valid value for race, ACES automatically bills for a payment of $0.
Premium payment questions are managed by the CSO. Do not refer individuals to OFR or to HCA MACSC.
Note: if the individual states they did not get the premium bill, check for returned mail.
Undelivered premium billings are returned to the HCA Imaging and Mail Services, not to OFR.
If the individual has lost the premium notice and asks where to send the payment, tell the individual to:
Make the check or money order out to DSHS:
- Include the billing coupon that detaches from the monthly statement, or a written statement if the coupon has been lost, which states the payment is for Health Care for Workers with Disabilities or HWD premium; and
- Include their account number (the CLID of the head of household); and
- Mail the payment to:
Office of Financial Recovery
PO Box 9501
Olympia, WA 98507-9501
Note: Individuals may pay their premium directly from their bank account. To set up an account or for more information about this option go to My Secure DSHS.