This fact sheet is intended to give Navigators and Enrollment Specialists answers to the questions that people with disabilities may have about possible Medicaid Buy-In for Working People with Disabilities as a coverage option when they are looking into purchasing private insurance in the Marketplace.*
Q1. What is the Medicaid Buy-In -for Working People with Disabilities?
A. Many people with disabilities are interested in working. Health insurance coverage can have an important relationship to employment for people with disabilities. For example, persons with disabilities on Medicaid may be concerned that they will lose their Medicaid coverage if they enter or return to the workforce. Commercial or employer-based health insurance might not provide coverage for services and supports that enable people with disabilities to work and live independently such as personal assistance services. The purpose of the Medicaid Buy-In program is to allow persons with disabilities to purchase Medicaid coverage that helps enable them to work.
The Medicaid Buy-In program offers health care coverage to people with disabilities who are working, and whose earnings and resources might otherwise make them ineligible for Medicaid. The package of benefits is the same as regular Medicaid’s.
Q2. What services and benefits are covered in a Medicaid Buy-In program?
A. The Medicaid Buy-In program provides “traditional” Medicaid (regular Medicaid state plan benefits), which generally includes doctor’s visits, prescription medications, hospitalization, and additional home and community-based services. Medicaid co-payments are no more than $3, except inpatient hospital stays, which are $25. Services cannot be denied if you are unable to pay the co-pay.
Q3. How is disability determined for the Medicaid Buy-In program?
A. Disability determination for the Medicaid Buy-In program uses the same medical definition for having a disability or blindness that the Social Security Administration (SSA) uses for its disability benefits programs (the Social Security Disability Insurance and Supplemental Security Income programs). This means that you will need to have a physical or mental impairment that causes significant functional limitations and that has or is expected to last for at least 12 consecutive months, or result in death. However, because the Medicaid Buy-In program is intended to provide health coverage to working individuals with disabilities, disability determination for this Medicaid program does not consider your employment. In other words, you can have a disability, work and have earnings, and participate in this health coverage program.
While disability determination for the Medicaid Buy-In program uses SSA’s medical criteria, you do not need to receive federal disability benefits to participate in a Medicaid Buy-In program. If you do receive federal disability benefits, you will already have a disability determination through SSA, and your award letter is sufficient proof of your disability. And keep in mind that you can receive Medicare through the Social Security Disability Insurance program and still participate in a Medicaid Buy-In program.
If you do not have a disability determination through SSA, but would like to apply for the Medicaid Buy-In, you may be able to receive a disability determination through the Medicaid office. This disability determination would be done for the purpose of Medicaid eligibility. Additionally, you can be enrolled in other health coverage while your disability determination is being conducted. If you qualify, you may be able to receive other coverage, such as subsidized coverage through the Health Insurance Marketplace, while your disability-related Medicaid eligibility is being determined.
Q4. Can I have other health insurance such as Medicare or employer-based coverage and enroll in a Medicaid Buy-In program?
A. Yes, you may enroll in the Medicaid Buy-In even if you have Medicare and/or employer-based health insurance coverage. If you have significant health care costs, the Medicaid Buy-In would help by providing wrap-around coverage to your Medicare or employer coverage. Additionally, this program may be able help you with Medicare and/or employer insurance costs. Medicaid can also cover some services and supports, such as personal assistance services, that other health insurance either does not cover at all or covers with restrictions.
Q5. How much do I have to work to participate in a Medicaid Buy-In program?
A. Medicaid Buy-In does not require a minimum number of hours of work to be eligible, but there must be some work each month. Individuals may work part-time or be self- employed. However, unpaid activities such as volunteer work do not count as employment. You must provide proof of earnings and employment.
Q6. Do I have to pay a premium?
A. Currently, there is no premium for Medicaid Buy-In, but New York may implement premiums in the future. Copays are the same as for regular Medicaid.
Q7. How do I apply for a Medicaid Buy-In program?
A. You must apply for Medicaid Buy-In at your local Medicaid office. You cannot apply through the NY State of Health Marketplace. If you try to apply through the Marketplace and check the box that you are interested in the program, you will be referred to the local Medicaid office. Navigators can assist by providing information on where and how to apply.
Q8. What happens if I stop working or lose my job?
A. Individuals may be concerned about what would happen to Medicaid Buy-In coverage if they lost their job or were unable to continue working. You may temporarily stay on the program following an interruption or loss of employment due to illness or involuntary earnings loss by requesting a grace period of up to six months in a year. For individuals who become ineligible for the program, Medicaid will determine if you are eligible for any other category of coverage such as regular Medicaid.
If you enroll in the Medicaid Buy-In, it is important that you report changes to your employment status such as loss of employment or change in earnings to a Medicaid worker at your local Medicaid office.
Q9. If you qualify for a Medicaid Buy-In program, you may have other health coverage choices as well, such as the Medicaid expansion program through the NY State of Health Marketplace You may be wondering how you can assess which program is better for you.
A. Medicaid coverage is identical in the Medicaid Buy-In and Medicaid through the Marketplace. You should consider a range of issues when assessing your health coverage options, including your health needs, whether you need long-term services and supports, provider networks, income and asset limits, and your employment status. You should take into account your unique needs and circumstances. If you are income eligible for expanded Medicaid through the Marketplace, it will be easier and faster to apply online through NY State of Health rather than submitting a paper application to the local Medicaid office. If your income is over the expanded Medicaid limit but you still qualify for the Medicaid Buy-In, then you would apply for it at the local Medicaid office. Click here for a chart with an illustrative comparison of three health insurance options: the Medicaid Buy-In program, the Medicaid expansion program (i.e., new adult Medicaid) and qualified health plans (QHPs) purchased through a Health Insurance Marketplace.
Q10. What types of resources and organizations should navigators and assisters know about that might help people with disabilities on employment issues?
A. While your primary role as a navigator or assister is to help consumers obtain health insurance coverage, you might also refer individuals to resources and organizations that help people with disabilities on employment issues. This will be especially true if you are informing consumers about the Medicaid Buy-In program as most require employment as part of the eligibility criteria.
There are a number of national employment services, which help both people with and without a disability. A one-stop location to find many resources is disability.gov. The Department of Labor and American Job Centers offer a range of employment-related services and resources. American Job Centers (AJCs) are located in communities across the country. The Department of Labor and AJCs offer resources to assess career interests and transferrable skills, and provide job leads.
Agencies or organizations tailored to disability-specific assistance include State Vocational Rehabilitation Services (SVR) (Acces-VR), the Employer Assistance and Resource Network (EARN), and the Job Accommodation Network (JAN). The Federal government funds programs to help individuals with disabilities reenter and start employment. These programs include services from counseling and guidance to job development and placement.
EARN is tailored to employers looking to hire people with disabilities. Additionally, EARN operates the Workforce Recruitment Program, a recruitment and referral program to increase employment of people with disabilities. The website for EARN is here. For consumers looking for help with job accommodations or their rights as employees with a disability, the Job Accommodation Network or JAN can be found here.
Lastly, most people receiving Social Security Disability Benefits (SSDB) between the ages of 18 to 64 have a Ticket to Work, which gives consumers more choices on seeking assistance with employment. The consumer can go to http://www.chooseworkttw.net and access information about Employment Networks, which are agencies that assist Ticket Holders who want to work. In addition, SSA has contracts for Work Incentive Planning and Assistance (WIPA) programs. These programs assist individuals with employment referrals and work incentives counseling to help consumers understand how work and benefits interact. You can find your WIPA by entering your zip code here.
Individuals needing help with self-employment may want to visit the Department of Labor’s Office of Disability Employment Policy, which has resources available here. The Service Corp of Retired Executives (SCORE) is another resource here. The Small Business Administration has both online and local services.
* Written for New York by Center for Independence of the Disabled, NY