Medicaid Buy-In Program

By Gracie Davis – Deputy Executive Assistant at West Virginia Senior Legal Aid

So, you found the job of your dreams that makes you feel empowered and secure. Suddenly, a dark storm creeps in and is about to sweep up your Medicaid benefits! Do not fear the storm, disabled West Virginians, for there is the Medicaid buy-in program. The West Virginia Legislature has realized Medicaid is crucial for disabled citizens because of needed medical care, and that the income cap discourages these citizens from working. W.Va. Code §9-4D-1. If you are disabled and earn above the Medicaid cap, the Medicaid buy-in program may allow you to keep your healthcare insurance by “buying into” the Medicaid system. This article will summarize the program and process for you with ease.

You may be wondering what the point of this program is and why someone would want to enroll in the Medicaid buy-in program. Well, an eligible buy-in participant can continue to keep their health coverage they would otherwise lose with an income increase, without additional stress on their pockets or the stress of finding new medical providers. The buy-in program has the same benefits (as well as obligations and requirements) as regular Medicaid, which includes at-home healthcare services. W.Va. Code §9-4D-7.

There are a couple eligibility requirements: (1) West Virginia residency; (2) “Disabled” as determined by the Social Security Administration or the Department of Human Services; (3) 16 to 64 years old; (4) Hold a paying job in a competitive setting (including self-employment and non-traditional work); (5) Have measurable resources that do not surpass the supplemental security income program’s resource limit; (6) Have measurable income that does not surpass 250% of the federal poverty level; (7) Have total measurable unearned income (using the social security program methodology) that does not surpass the federal benefit rate plus the general income inclusion; (8) Not have measurable resources that surpass the federal supplemental security income program’s resource limit, unless an exception applies. W.Va. Code §9-4D-4.

As noted, there are some exceptions to the eligibility requirements for those who have improved their medical condition. First, the individual still has a “severe medically determinable impairment” as determined by the Department of Human Services or federal law. Second, the individual is employed and has a monthly wage over the federal minimum hourly wage multiplied by 40. Third, the individual does not have measurable resources and income that surpass limits set for the basic coverage group as defined by the Ticket to Work and Work Incentives Improvement Act of 1999. Fourth, the individual is 16 to 65 years old. Fifth, the individual pays any required premiums or other cost-sharing. Sixth, all other eligibility requirements are met. W.Va. Code §9-4D-3; §9-4D-5.

Furthermore, there are some exceptions for those enrolled in the program who cannot keep employment for involuntary reasons (e.g., involuntary termination and temporary leave caused by health issues). These individuals must meet the following 2 requirements: (1) The individual (or an authorized representative) must submit a written request to continue Medicaid coverage within 30 days of unemployment; (2) The individual must maintain a workforce connection during their eligibility period. To maintain a workforce connection, an individual may partake in any of the following activities: (1) State/federal vocational rehabilitation program enrollment; (2) Enrollment/registration with the office of workforce development; (3) Transition from school-to-work program participation; (4) Participation with an approved employment services provider; (5) Provision of employer documentation of temporary leave; (6) The individual’s measurable resources/income does not surpass the limit; (7) The individual is 16 to 65 years old; (8) The individual pays any required premiums or other cost-sharing; (9) all other eligibility requirements are met. If these requirements are met, the Department of Human Services must continue coverage for up to 6 months after unemployment due to involuntary reasons. If the requirements are unmet and/or the individual has already continued eligibility for 12 months, one must meet the eligibility requirements of another Medicaid program to receive benefits. W.Va. Code §9-4D-5.

The enrollment fee is $50. After that payment, coverage commences. Also, the first month’s premium payment is waived. The Department of Human Services has a sliding scale of premium prices for the buy-in program which is and does the following: (1) Based on yearly gross income; (2) Provides minimum premiums for $15 per month and maximum monthly premiums that do not surpass 3.5% of the individual’s gross monthly income; (3) Contingent on the minimum and maximum premiums, the Department of Human Services may adjust the scale of premiums yearly; (4) Requires the Department of Human Services must review the premium amount the individual must pay biyearly; (5) Before raising the premium, the Department of Human Services must conduct an interview; (6) Requires the Department of Human Services lower the premium if the individual notifies the department when there is a change in income or family size and the sliding scale indicates the income is not high enough for the current premium; (7) Has administrative procedures for premiums, including the effect of nonpayment and the collection of premiums; (8) Requires the Department of Human Services to review an individual’s disability biyearly based on medical evidence (not ability to work, earned income, or self-employment income). W.Va. Code §9-4D-6.

The Department of Human Services Secretary is tasked with developing an advisory committee for the Medicaid buy-in program. The advisory committee is comprised of West Virginia Medicaid agency representatives, the West Virginia Rehabilitation Agency, the West Virginia Office of Family Support, the West Virginia Statewide Independent Living Council, the West Virginia Rehabilitation Council, the West Virginia Developmental Disabilities Council, the West Virginia Mental Health Planning Council, and the West Virginia University Center for Excellence in Disabilities. W.Va. Code §9-4D-9.

Moreover, the Department of Human Services Secretary is tasked with developing a method of providing notice of availability and the related and necessary forms and notices (e.g., application forms, notices on costs, notices on expectations). W.Va. Code §9-4D-4. Here is the link to the printable version of the application form: https://dhhr.wv.gov/bcf/Services/familyassistance/Documents/726/726%20DFA_QSQ_1.pdfFA_QSQ_1 (wv.gov).

Hence, the Medicaid buy-in program is a great program to join as a working disabled person who wants to keep Medicaid healthcare benefits. For further aid, please get in touch with a licensed attorney, the Social Security Administration, or the Department of Human Services. West Virginia Senior Legal Aid is dedicated to defending seniors' rights.