NCSL LegisBrief
Briefing Papers On the Important Issues of the Day
Medicaid Buy-In Programs for Workers with Disabilities
By Donna Folkemer
Nov./Dec. 2002
Volume 10, Number 46
Congress gave states, in 1997 and 1999, opportunities to extend Medicaid coverage to working people with disabilities, with the Medicaid buy-in program. Disabled workers who have sufficient income share in the cost of the program-that is, "buy in" to Medicaid-through monthly premium payments or service co-payments. Twenty-four states are operating these programs as of July 1, 2002. Massachusetts was granted a waiver to operate a similar program.
Although some disabled individuals who work are eligible for Medicaid, many others risk losing coverage because of additional earnings. With this loss, disabled workers risk losing their independence. Even with private insurance at work, those without Medicaid may lose access to personal care, technology or other specialized health services essential to their success in the workplace. Medicaid buy-in programs offer a response to some of these concerns.
States have a great deal of flexibility in designing income and asset limits and cost sharing requirements under the Balanced Budget Act of 1997 and the Ticket to Work and Work Incentives Act of 1999. Under the '97 act, states may extend coverage to working disabled people with incomes of up to 250 percent of the poverty level. Under the work incentives act, a state may design its own income standards and is limited to covering people between the ages of 16 and 64. The state decides whether to impose cost sharing and the type and amounts of payments, within very broad guidelines.
No two Medicaid buy-in programs have the same eligibility rules. Some states seek broad participation. Minnesota, for example, extends eligibility to any disabled worker between the ages of 16 and 64 without regard to income. Individuals pay income-related premiums to enroll. Other states limit the program to a smaller group of people. In Maine, people who receive unearned income (usually Social Security disability payments) in an amount higher than the federal poverty level (about $740 per month for a single person) are not eligible for the buy-in. And to provide an additional incentive for work, some states do not count the income of other family members when determining eligibility.
Most states allow buy-in enrollees to retain higher assets than allowed in other Medicaid categories. In Iowa, buy-in enrollees can retain $12,000 in assets as compared with $2,000 in other Medicaid categories. Several states allow individuals to keep additional money in accounts set up for special purposes, such as retirement accounts or medical savings accounts. To foster greater independence, many states encourage disabled workers to save money for community living expenses or for items that will help them get a job. Under traditional Medicaid rules, such savings are not allowed.
Although 24 states now have programs, it is too early to say whether they have been successful in promoting employment among the disabled. Most state programs have been in operation for less than 18 months, and standardized data collection by the federal government began only recently.
Some states hoped that most buy-in enrollees would enroll in employer-sponsored private health insurance, with Medicaid serving as wrap-around coverage. To date, enrollment in private coverage is very low, due in part to individuals working fewer hours than are necessary to qualify for coverage.
To increase opportunities for disabled people, states are providing them with Medicaid personal assistance services in the workplace, a setting where services traditionally have not been delivered. States are working together to address common problems and develop ways to tackle issues requiring federal action. To date, 39 states, including some without Medicaid buy-in programs, have received Medicaid infrastructure grants from the Department of Health and Human Services to help them expand options for employment of the disabled. All of these states are using a portion of their grant to plan, implement or evaluate Medicaid buy-in programs.
Please view the Adobe Acrobat version for illustration on "States with Medicaid Buy-In Programs for Workers With Disabilities."
Selected References
Folkemer, D., A. Jensen, R. Silverstein, T. Straw. The Medicaid Buy-In Program: Lessons Learned from Nine 'Early Implementer' States. Washington, D.C.: U.S. Department of Health and Human Services, May 2002, http://aspe.hhs.gov/daltcp/reports/EIlesson.htm
Jensen, A., R. Silverstein, D. Folkemer, T. Straw. Policy Frameworks for Designing Medicaid Buy-In Programs and Related State Work Incentive Initiatives. Washington, D.C.: U.S. Department of Health and Human Services, May 2002, http://aspe.hhs.gov/daltcp/reports/polframe.htm
States and Territories Disability and Aging Issues. Baltimore, Md.: Centers for Medicare and Medicaid Services, August 2002, http://www.cms.gov/states/dis-aging.asp
Contacts for More Information
Donna Folkemer
NCSL-Washington , D.C.
(202) 624-8171
donna.folkemer@ncsl.org
Melissa Wittman
National Consortium for Health
Systems Development
(312) 925-3040
melwittman@mindspring.com
Allen Jensen
Work Incentives Project at
George Washington University
Ihoacj@gwumc.edu
Michael Cheek
Center for Workers with Disabilities
at the American Public Human Services Association
(202) 682-0100
mcheek@aphsa.org
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