Classic (non-MAGI) based programs manual

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Apple Health for Workers with Disabilities

Revised Date: 
January 1, 2020

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.

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.

  1. The HWD program provides categorically needy (CN) scope of care as described in WAC 182-501-0060.
  2. 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.
  3. 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.
  4. A person who is eligible for another medicaid program may choose not to participate in the HWD program.
  5. 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.

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.

  1. To qualify for the HWD program, a person must:
    1. Meet the general requirements for a medical program described in WAC 182-503-0505(3)(a) through (f);
    2. Be at least age sixteen;
    3. Meet the federal disability requirements described in WAC 182-511-1150;
    4. Be employed full or part time (including self-employment) as described in WAC 182-511-1200.
  2. The HWD program does not require a resource test.
  3. Once approved for HWD coverage, a person must pay the monthly premium in order to continue to qualify.
    1. The agency calculates the premium for HWD coverage according to WAC 182-511-1250.
    2. 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.
    3. 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: 
      1. The job less results from an involuntary dismissal or health crisis; and 
      2. 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.

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.

  1. Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program.
  2. To qualify for retroactive coverage under the HWD program, a person must first: 
    1. Meet all program requirements described in WAC 182-511-1050 for each month of the retroactive period; and
    2. Pay the premium amount for each month requested within one hundred twenty days of being bullied for such coverage. 
  3. 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.

Clarifying information

HWD allows enrollees to earn and save more money and to purchase health care coverage with monthly premium based on a sliding scale. 

Some people may be eligible for HWD, who are not eligible for other SSI-related medical programs, due to their having: 

  1.  Monthly earnings at or above the Substantial Gainful Activity (SGA) level after deducting any impairment related or blind work expenses that have caused any Title II benefit to stop; or
  2. Countable income or resources that exceed other program standards including coverage groups that use "institutional" rules to determine eligibility.

For more information go to the Apple Health SSI-related overview

HWD option for DDA and HCS waiver services

HWD  functionality eligible and approved for services from the Developmental Disabilities Administration (DDA) or Home and Community Services (HCS), they pay a monthly premium for all services and do not participate in the cost of services under "institutional" rules. If residing in an alternate living facility, they continue to pay room and board; room and board cannot be paid for with Medicaid funds. As a result, the individual who is working may be able to keep more of his/her earned income. A monthly premium amount is most likely less than the participation amount when using institutional rules. One exception applies to DDA clients who live at home, who may be working, but do not have income and/or resources that require them to enroll in HWD to keep their coverage. They can keep up to the income standard for services at home for their personal needs allowance. DDA resource case managers review client circumstances on an individual basis to determine which option is better for them and communicate this information to designate HWD staff, using the DSHS 15-345 CSO/DDA Communication.

Note: HCB waiver services received under HWD are subject to transfer of asset, annuity declaration, and excess home equity provisions that are specific to institutional programs. MPC and CFC program services are not subject to those provisions.

For additional information about HWD and DDA/HCS services, go to Working Clients and LTC

HWD and other insurance coverage

Like clients approved for coverage under other Apple Health programs, HWD clients may have access to other health insurance coverage. Some may even pay for such coverage out-of-pocket or have it taken out of their earnings. These costs may not be used to reduce countable income for determining eligibility or the monthly premium amount. However, the agency may be able to reimburse the monthly premium for the other insurance after HWD is approved. For related information, see Third Party Liability (TPL).

Worker responsibilities

  1. It is critical to compare the options and determine which program costs less when an individual meets the requirements for more than one program.
  2. 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:
    1. Apple Health Adults
    2. Apple Health for Kids (the minimum age for HWD is 16 years)
    3. Apple Health for Pregnant Women
    4. The CN disability program (S02) for a disabled adult child (DAC)
    5. CN programs (L22 or G03) depending upon financial and functional requirements and place of residence
  3. 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: 

  1. CN provides more extensive coverage than MN; and 
  2. 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.

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.

  1. A person age sixteen through age sixty-four must meet the requirements of the Social Security Act in section 1902 (a) (10) (A) (ii):
    1. (XV) for the basic coverage group (BCG); or
    2. (XVI) for the medical improvement group (MIG).
  2. The BCG consists of individuals who:
    1. Meet federal disability requirements for the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) program; or
    2. 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.
  3. The MIG consists of individuals who:
    1. Were previously eligible and approved for the HWD program as a member of the BCG; and
    2. 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.
  4. 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).
  5. When completing a disability determination for the HWD program, DDDS will not determine a person not disabled based only on 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.

Clarifying information

Disability determination for Apple Health Non-Grant Medical Assistance (NGMA)

For information on procedures to obtain a determination of disability or blindness that enables adult not receiving federal cash benefits to be related to Medicaid, see the Non-Grant Medical Assistance (NGMA) overview and Non-Grant Medical Assistance (NGMA) examples

If the applicant is working and their income (gross income after deductions for impairment related work expenses or blind work expenses) is over the SGA standard or their resources exceed other program standards, forward the application, using the contact information below: 

ALTSA HIU: (All HCS and DDA financial documents)
Home & Community Services
PO BOX 45826
Olympia, WA 98504-5826
FAX: 1-855-635-8305

DDA HWD specialists (maintain HWD cases on DDA services and those not on HCS services)

Connie Sadler ACES ID: SDLR
Brandy Sanchez ACES ID: BJSA
Jill Hamilton back-up ACES ID: JIHA
Danielle Lopez Financial Sup of HWD team ACES ID: DANL
Linda Trimble FHC ACES ID: BHLY
800-871-9275
DDA LTC Pool: @HWD 17
Office #17

HCS HWD specialists (maintain HWD on HCS services and spouses of clients on HCS services)

Region 1 HCS - Pend Oreille, Grant, Adams, Lincoln, Okanogan, Ferry, Douglas, Whitman, Spokane, Klickitat, Yakima, Walla Walla, Franklin, Benton, Garfield, Columbia, Asotin, Kittitas
ATTN: Shaunna Martinez, Wenatchee HCS Office #78 A-C (ACES ID: HRSH) Phone: 509-886-6186
ATTN: Mary Aspen, Wenatchee HCS office #79 D-Z (ACES ID: POLM) Phone: 509-886-6140
Backup: Jacque Bruns, Supervisor Omak HCS (ACES ID: BRJQ) Phone: 509-846-8635 Alternative phone: 1-800-670-8874 Fax: 509-886-6221 TTY: 509-886-6223

Region 2 South HCS - King
ATTN: Ruby Pham, Holgate HCS Office #56 (ACES ID: PHHO), Phone: 206-341-7604
Alternative phone: 1-800-346-9257 TTY: 1-800-833-6384

Region 2 North HCS - Snohomish, Whatcom, Skagit, Island
ATTN: Hanh Nguyen, Lynnwood HCS Office #89 (ACES ID: HNGU), Phone: 425-977-6563 TTY: 425-977-6534
Backup: Kiona Stubbs, Lynnwood HCS Office #89 (ACES ID: STKJ), Phone: 425-977-6563

Region 3 North HCS - Pierce, Kitsap, Clallam, Jefferson
ATTN: Ciravegna Parramore (ACES ID: PRCI), Phone:  253-476-7160
Backup: Kathi DeVay, Tacoma HCS #66 (ACES ID: MNKT), Phone: 253-476-7266
Alternative phone: 253-476-7200
Alternative phone: 1-800-442-5129, TTY: 253-593-5471
PBS Supervisor: Jeremy Warren (ACES ID: WAJD), Phone: 253-476-7274

Region 3 South HCS - Thurston, Mason, Lewis, Cowlitz, Clark, Pacific, Grays Harbor, Skamania, Wahkiakum
ATTN: Roxanne LaRoy, Kelso HCS Office #97 (ACES ID: LROX), Phone: 260-501-2527
Backup: Nanette Sanders, Kelso HCS Office #97 (ACES ID: NASA), Phone: 360-501-2517
Alternative phone: 1-800-605-7322 TTY: 360-577-7591
Supervisor: Michael Asbury (ACES ID: ASMC), Phone: 360-742-9385

Disability determination for the HWD Medical Improvement Group

To continue eligibility for HWD as a member of the Medical Improvement Group (MIG), an individual must have been eligible and approved for the program as a member of the Basic Coverage Group (BCG). DDS program staff determine whether an individual meets HWD MIG requirements. DDS staff confer with HWD program staff before denying the medical improvement group status necessary for continued coverage.

Having the MIG option or coverage group ensures that an individual who continues to have a significant impairment may continue to receive health care services that support their employment. 

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 local procedures to obtain an ETR decision from the HWD program manager before terminating coverage. 

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 SSDI ends because of earnings and continues for 36 months. 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 is only beginning the EPE. The client remains eligible for coverage under the BCG during the EPE. Staff need to recalculate the monthly premium amount and send proper notification.

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) by the Division of Disability Determination Services (DDS). Obtain an ETR decision from the HWD program manager and continue HWD coverage until a redetermination of eligibility for the MIG is completed. To facilitate the MIG determination, see instructions provided in the NGMA overview​.

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.

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.

  1. For the purpose of the HWD program, employment means a person:
    1. Gets paid for working;
    2. Has earnings that are subject to federal income tax; and
    3. Has payroll taxes taken out of earnings received, unless self-employed.
  2. To qualify for HWD coverage as a member of the BCG, a person must be employed full or part time.
  3. To qualify for HWD coverage as a member of the MIG, a person must be:
    1. Working at least forty hours per month; and
    2. Earning at least the local minimum wage as described under section 6 of the Fair Labor Standards Act (29 U.S.C. 206).
  4. 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.

Clarifying information

Employment - Basic Coverage Group (BCG)

Individuals do not have to work a certain number of hours or earn a minimum amount of income to be eligible for HWD coverage under the BCG. Individuals who want to participate in the HWD program must provide proof they have earned income.

To satisfy the program requirement of being employed or self-employed, a person must provide proof that the work activity they perform is generating income subject to federal income tax rules. Individuals can meet this requirement by providing evidence that FICA and payroll taxes are taken out of their earnings. 

Note: If a person works for an employer that by law is not required to withhold FICA or payroll taxes or is prohibited from doing so, such as tribal governments or certain sheltered workshops, HWD coverage may still be approved.

Self-employment 

Individuals who are self-employed can meet this requirement by providing business records and a copy of Internal Revenue Services (IRS) forms completed and filed, e.g. IRS Schedule SE or IRS Form 1040, Schedule C or Schedule F, showing entries for net earnings or losses. If the person hasn't been in business long enough to file a tax return, detailed records, such as a combination of ledger sheets, receipt books, self-employment worksheets for tracking potential tax liability must be provided. A business license does not in and of itself provide evidence of self-employment.

Self-employment tax

Self-employment tax (SE tax) is a social security and Medicare tax primarily for individuals who work for themselves. Payments of SE tax contribute to an individual's coverage under the social security system. Social security coverage provides retirement, disability, survivor, and hospital insurance (Medicare) benefits. All deductions allowed by the IRS, including depreciation, may be used.

An individual must pay SE tax and file Schedule SE (Form 1040), if the individual has: 

Net earnings from self-employment or $400 or more or church employee income of $108.28 or more.

Self-employment definition - examples

The following examples are taken from the Social Security Administration (SSA) Program Operations Manual System to help determine whether a person meets the program requirement of employment.

Example: #3 - Mrs. Bell reports she started babysitting for her grandchild while her daughter works. Sometimes the child comes to her home, but usually, she goes to her daughter's home because the child's toys and other items are there. She does not baby sit for anyone else. She receives about $20 a week from her daughter.

Although a caregiver is a recognized occupation, Mrs. Bell is not holding herself out as a provider of daycare services, nor does she have intent to produce income. Therefore, Mrs. Bell is not considered self-employed when determining whether she meets the program requirement of employment.

Example: #4 - Mrs. Simon files for SSA benefits. When asked about any income she receives, she says she does baby sit for various neighbors and friends, but does not consider herself as self-employed. She files no tax forms for this income. She began babysitting when her own children were young to make some extra money. She gets new business by word of mouth.

Although Mrs. Simon does not consider herself to be in the daycare business, she meets all of the factors indicating the existence of a trade or business. Therefore, Mrs. Simon is considered to be self-employed when determining whether she meets the program requirement of employment.

Example: #5 - Mr. Lyons, an SSDI recipient, reports that since he needed extra money to meet his rent and food expenses, he started collecting aluminum cans from the street. He redeems them at the recycle center for cash. Sometimes his neighbors or local organizations call him to pick up their cans. He does not file any tax returns, but he thinks he makes about $200 a month.

Since this is an ongoing, regular activity that includes some third party collection pickups and was established with the intent of producing income, it is determined that Mr. Lyons is self-employed. To establish and document this eligibility criteria, Mr. Lyons must provide completed IRS forms or legitimate business records as described above.

Example: #6 - Mr. Kent reports that he earned some money cutting the lawn for one of his neighbors. His car needed some repairs and he did not have the money. His neighbor told Mr. Kent that he could cut his lawn for the month of July for $80. Since he needed the cash to pay for the repair, he decided to cut the lawn. Mr. Kent is not holding himself out as a lawn service. Further, this is not an ongoing regular activity nor does Mr. Kent plan to do this activity to make a profit. He only did it to earn enough to pay for the car repair. Therefore, Mr. Kent is not considered to be self-employed when determining whether he meets the program requirement of employment.

Employment - Medical Improvement Group (MIG)

When reviewing for continued HWD coverage under the MIG group, the 40 hours (per month) work requirement does not apply at this time. Enrollees must continue to meet the employment requirements of the Basic Coverage Group (BCG).

Workers responsibilities

  1. 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.

  2. Contact the individual’s employer when necessary to verify tax withholdings.

  3. 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.

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.

  1. 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.
  2. When determining countable income used to calculate the HWD premium, the agency applies the following rules:
    1. Income is considered available and owned when it is:
      1. Received; and
      2. 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).
    2. Certain receipts are not income as described in 20 C.F.R. Sec. 416.1103.
  3. The HWD premium amount equals the lesser of the two following amounts: 
    1. A total of the following (rounded down to the nearest whole dollar):
      1. Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC 182-519-0050; plus
      2. Five percent of total unearned income; plus
      3. Two and one-half percent of earned income after first deducting sixty-five dollars; or 
    2. Seven and one-half percent of countable income described in subsection (2) of this section, including both earned and unearned income.
  4. 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.
  5. A change in the premium amount is effective the month after the change in income is reported and processed.
  6. For current and ongoing coverage, the agency will bill for HWD premiums during the month following the benefit month.
  7. 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.
  8. 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.
  9. 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. 
  10. 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.
  11. Payments received are applied to premiums owed in the following order: 
    1. If retroactive coverage is requested, the retroactive coverage month(s);
    2. Past due months, beginning with the most delinquent month;
    3. The current coverage month that has been invoiced; then
    4. Future coverage months.
  12. 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.

Clarifying information

Countable income - premium amount

States have flexibility when determining the type and amount of cost sharing they require for enrollment in the HWD program with the following exception. States cannot require a premium amount that exceeds 7.5 percent of the enrollee's total income.

States have flexibility when determining the type and amount of cost sharing they require for enrollment in the HWD program with the following exception. States cannot require a premium amount that exceeds 7.5 percent of the enrollee's total income. Income used to calculate HWD premiums includes only that of the person enrolling in the program. If both spouses apply, their premiums are calculated separately using only the income of each spouse. ACES 3G calculates the HWD premium using the program formula and then compares that amount to 7.5% of the enrollee's total income. The lesser of the two is sent to the Office of Financial Recovery (OFR) for billing purposes.

Premium example: A person earns $1,065 per month and receives $1,083 SSDI.

Income

Premium calculation

Monthly earned income

$1,065

Monthly unearned income (Social Security) 

$1,083

Total monthly income

$2,148

Premium calculations - first

 

Subtract the MNIL ($783) from unearned income ($1083 - $783)

$300

Take 50% of the result (.5 x $300 = $150)

$150

Include the result as part of your premium

$150

Calculate 5% of unearned income (.05 x $1083 = $54.15)

$54.15

Include the result as part of your premium

$54.15

Subtract $65 from gross earned income ($1065 - $65 = $1000)

$1,000

Take 2.5% of the result (.025 x $1000 = $25)

$25

Include the result as part of your premium

$25

PREMIUM AMOUNT (rounded down) - using formula

$229.15

Premium Calculations - second

 

Calculate 7.5% of total income (.075 x $2148 = $161)

$161

PREMIUM AMOUNT (rounded down) - using formula

$161

ACTUAL PREMIUM (lesser of first and second calculation)

$161

 

Initial premium

If a person applies in one month for HWD coverage, but not approved until the next month, the first monthly premium include costs for both months. Purchasing the initial month is optional.

Example: #7 - An individual applies for HWD on July 10 and provides information on August 6. HWD is approved on August 7 for coverage beginning July 1. The individual receives a bill for the initial premium, which includes charges for July and August.

Changes in premium

Changes in the HWD premium takes effect the first of the following month in which the change is reported and processed as a change in circumstances. Individuals who experience a job loss may choose to continue HWD coverage as described in WAC 182-511-1050 (4)(c).

ACES - OFR interface

The interface between ACES and OFR is used to communicate information regarding premium payments. Nonpayment of premiums triggers the AU to close for Reason Code 342 - Termination/Denial Due to Nonpayment of Premium and imposes a four month sanction.

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

  1. 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.
  2. 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.