H. B. 2841
(By Delegates Leach, Beane, Campbell, Mezzatesta,
Michael, R. M. Thompson and Ashley)
February 3, 2003
; referred to the
Committee on Health and Human Resources then Finance.]
A BILL to amend article four-a, chapter nine of the code of West
Virginia, one thousand nine hundred thirty-one, as amended, by
adding thereto a new section, designated section three,
related to the creation of a medicaid buy-in program for
working individuals with disabilities.
Be it enacted by the Legislature of West Virginia:
That article four-a, chapter nine, of the code of West
Virginia, one thousand nine hundred thirty-one, as amended, be
amended by adding thereto a new section, designated section three,
to read as follows;
ARTICLE 4A. MEDICAID UNCOMPENSATED CARE FUND.
§9-4A-3. Medicaid buy-in program for working individuals with
(a) The Legislature finds that establishing a medicaid buy-in
program for certain individuals with disabilities will assist these people in becoming independent of public assistance by enabling
them to enter the workforce without fear of losing essential
(b) The medicaid buy-in program for working individuals with
disabilities is established to provide, beginning July one, two
thousand three, medicaid to individuals who are disabled and
employed, as authorized under Section 201 of the federal Ticket to
Work and Work Incentives Improvement Act of 1999 (P.L. 106-170, 42
U.S.C. 1396 et seq.).
(c) As used in this section:
(1) "Basic Coverage group" means an optional coverage group as
defined by the Ticket to Work and Work Incentives Improvement Act
of 1999. An individual with a disability who is at least sixteen
but less than sixty-five years of age whose income and resources do
not exceed a standard established by the state;
(2) "Copayment" is a fixed fee to be paid by the patient at
the time of each office visit, outpatient service, or filling of
(3) "Cost-sharing" means the eligible person will participate
in the cost of the program by paying the enrollment fee, monthly
premiums and co-payments if established by the department;
(4) "Countable resources" includes earned and unearned income
but does not include: liquid assets of up to five thousand dollars
for an individual and ten thousand dollars for a family; retirement accounts; and independence accounts;
(5) "Department" means the department of health and human
(6) "Disability" means that a covered individual must be
determined to have a disability as defined by the Social Security
Administration criteria. They can be determined to have a
disability by either the Social Security Administration disability
determination process or the department's process. For purposes of
this program, disability will be defined as a medically
determinable physical or mental condition which can be expected to
result in death, or has lasted or can be expected to last, for a
continuous period of not less than twelve months, and renders a
person unable to engage in substantial gainful activity. The
person must also meet the requirements of limited income and
(7) "Enrollment fee" means a one time fee to participate in
(8) "Federal benefit rate" is the amount of monthly benefits
paid to persons with limited income and resources who are age
sixty-five or older, blind, or disabled;
(9) "Federal poverty level" means the level of personal or
family income below which one is classified as poor according to
governmental standards. Also known as the federal poverty
guidelines which are issued each year in the Federal Register;
(10) "Income" means money earned from employment wages or
earnings from self-employment and unearned which is money received
from any source that is not earned;
(11) "Independence accounts" are department approved accounts
established solely by funds from a buy-in recipient's earned income
to cover expenses necessary to enhance or maintain a person's
independence and/or increase employment opportunities. Approved
expenditures from such funds may include: educational expenses,
work-related expenses, home purchase/modification, transportation,
medical expenses, assistive technology and related services, or for
short-term living expenses in times of qualified emergencies as
determined by the department;
(12) "Liquid assets" are those which are cash or payable in
cash on demand, including financial instruments that can be
converted to cash within twenty working days. National, state, and
local holidays are not working days;
(13) "Premium" is a monthly fee paid to continue participation
in the program;
(14) "Resources" are possessions that the eligible person owns
which could be changed to cash and used for food, clothing, or
shelter while using social security rules for treatment of
(15) "Retirement accounts" are moneys invested in approved
retirement funds and accounts that are disregarded as an asset. Approved accounts include private retirement accounts such as
individual retirement accounts and other individual accounts, and
employer sponsored retirement plans such as 401(k) plans, Keogh
plans and employer pension plans.
(c) To participate in the buy-in program beginning July one,
two thousand three, an individual must meet the following
(1) The individual has a disability as determined by the
social security administration disability determination process or
(2) The individual must be at least sixteen years of age but
not more than sixty-four years of age.
(3) The individual must be engaged in competitive employment,
including self-employment, or nontraditional work. Work results in
remuneration at or above minimum wage in an integrated setting.
(4) The individual must have countable resources that do not
exceed the resource limit for the supplemental security income
program except the following:
(A) Countable resources of less than five thousand dollars
for the individual or ten thousand dollars for the individual and
(B) The individual's retirement accounts; and
(C) The individual's independence account, established under
(5) The individual has countable income that does not exceed
two hundred fifty percent of the federal poverty level. In
determining an individual's income under this subdivision, the
department may not consider the following:
(A) The income of the individual's spouse; and
(B) Income disregarded under the state medicaid's plan's
financial methodology, including income disregarded under the
federal Supplemental Security Income program (42 U.S.C. 1382) as
impairment related work expenses;
(6) The individual has total countable unearned income, using
social security income program methodology, that does not exceed
the federal benefit rate plus the general income exclusion.
(7) The individual does not have countable resources that
exceed the resource limits for the federal Supplemental Security
Income program except for the following:
(A) An individual who is enrolled in the buy-in program and
who no longer meets the eligibility requirements of the basic
coverage group due to an improvement in the individual's medical
condition continues to be eligible for medicaid coverage under the
buy-in program if the individual meets the following requirements:
(i) The individual continues to have a severe medically
determinable impairment, as determined by the department and as
allowed by federal law.
(ii) The individual is employed and earning a monthly wage that is not less than the federal minimum hourly wage times forty
(iii) The individual does not have income or countable
resources in excess of the limits established for the basic
(iv) The individual is at least sixteen years of age and less
than sixty-five years of age.
(v) The individual pays any premiums or other cost sharing
required under this chapter.
(vi) The individual meets all other eligibility requirements
under this section.
(B) An individual who is enrolled in the buy-in program and
who is unable to maintain employment for involuntary reasons,
including temporary leave due to a health problem or involuntary
termination, continues to be eligible for Medicaid coverage under
the buy-in program if the individual meets the following
(i) Within thirty days after the date on which the individual
becomes unemployed, the individual, or an authorized representative
of the individual, submits a written request to the office that the
individual's medicaid coverage be continued.
(ii) The individual maintains a connection to the workforce
during the individual's continued eligibility period by
participating in at least one of the following activities:
(I) Enrollment in a state or federal vocational rehabilitation
(II) Enrollment or registration with the office of workforce
(III) Participation in a transition from school to work
(IV) Participation with an approved provider of employment
(V) Provision of documentation from the individual's employer
that the individual is on temporary involuntary leave.
(C) The individual does not have income or countable resources
in excess of the limits established under this section.
(D) The individual is at least sixteen years of age and less
than sixty-five years of age.
(E) The individual pays any premiums or other cost sharing
required under this section.
(F) The individual meets all other eligibility requirements
under this section.
(e) The department shall continue medicaid coverage under the
buy-in program for an individual described in subsection (B) for up
to six months from the date of the individual's involuntary loss of
(f) If an individual is ineligible for continued coverage
under the buy-in program because the individual:
(1) Fails to meet the requirements of subsection (B); or
(2) Has already met twelve months of continuing eligibility
under this section; the individual must meet the eligibility
requirements of another available medicaid program to continue to
be eligible for medicaid.
(g) The department shall charge a fifty dollar enrollment fee
to all participants. Upon payment of the enrollment fee, the first
month's premium payment is waived. Medicaid coverage begins on the
first day of the month following payment of the enrollment fee.
(h)(1) The department shall develop a sliding scale of
premiums for individuals participating in the buy-in program.
(2) The sliding scale of premiums required under subsection
(A) Be based on the annual gross income of the individual; and
(B) Provide for a minimum premium of fifteen dollars ($15) and
a maximum monthly premium not to exceed three and one half percent
(3.5%) of the individual's gross monthly income.
(3) Subject to the minimum and maximum amounts described
above, the department may annually adjust the scale of premiums
adopted under this section.
(i) The department shall bi-annually review the amount of the
premium that an individual is required to pay under this section.
(j) The department may increase the premium required only
after conducting a review.
(k) The department shall decrease the premium that an
individual is required to pay under subsection (h) of this section
(1) The individual notifies the office of a change in income
or family size; and
(2) The sliding scale adopted by the department applied to the
individual's changed circumstances prescribes a premium for the
individual that is lower that the premium the individual is paying.
(l) The department shall establish administrative procedures
regarding premiums for the buy-in program, including:
(1) The effect of nonpayment of a premium; and
(2) The collection of premiums.
(m) The department shall establish criteria to base the bi-
annual redetermination of disability required for an individual
participating in the buy-in program on the individual's medical
evidence, including evidence of physical or mental impairment.
(n)In conducting the bi-annual redetermination described in
subsection (l), the department may not determine that an individual
participating in the buy-in program is no longer disabled solely on
(1) Participation in employment;
(2) Earned income; or
(3) Income from self-employment.
(o) Except as otherwise provided in this section, an individual participating in the buy-in program:
(1) Shall receive the same benefits, including home health
care services; and
(2) Is subject to the same requirements, including cost
sharing; as an individual receiving regular medicaid coverage.
(p) (1) The department shall establish criteria to determine
the effectiveness of:
(A) The buy-in program; and
(B) Continued medicaid coverage through Section 1619 of the
federal Social Security Act (42 U.S.C. 1382h).
(2) The criteria required under subdivision (o) must include
(A) The number of individuals with disabilities who are:
(i) Enrolled in the buy-in program; or
(ii) Receiving medicaid through Section 1619 of the federal
Social Security Act (42 U.S.C. 1382h).
(B) State revenues resulting from premiums paid by
participants in the buy-in program.
(C) State costs incurred as a result of implementing the buy-
in program, including administrative costs and costs of providing
(3) In addition to the criteria required under subsection (2)
of this section, the department may establish criteria to determine
(A) Comparative costs of medicaid funded services for
participants in the buy-in program and work incentives created
through Section 1619 of the federal Social Security Act (42 U.S.C.
1382h) before and after employment.
(B) The number of Supplemental Security Income and Social
Security Disability Insurance recipients in West Virginia who are
no longer dependent on, or who have reduced dependence on, public
assistance or health care entitlement services, other then Medicaid
or the children's health insurance program, due to participation in
the buy-in program or work incentives created through Section 1619
of the federal Social Security Act (42 U.S.C. 1382h).
(C) The number of individuals with severe disabilities who are
no longer dependent on, or who have reduced dependence on, public
benefits or services, other than medicaid or the children's health
insurance program, due to income or support services received
through participation in the buy-in program or work incentives
created through Section 1619 of the federal Social Security Act (42
(D) The change in the number of buy-in program participants or
participants in work incentives created through Section 1619 of the
federal Social Security Act (42 U.S.C. 1382h) who have health care
needs and related services covered through employer based benefit
(4) In evaluating the effectiveness of the state's work incentives initiatives for individuals with disabilities, the
(A) Shall collaborate with other state agencies on data
(B) May consult with an independent contractor to collect data
on the criteria listed under subsection (2).
(5) The department shall provide an annual report of its
evaluation under this section to the Legislature no later than the
last day of December of each year, beginning in two thousand four.
(p) Funding for the buy-in program shall be from funds
appropriated by the legislature, premiums paid, enrollment fees and
any federal matching funding available to the program.
(q) Notwithstanding any other provisions of this article, the
state agency shall promulgate emergency rules pursuant to the
provisions of section fifteen, article three, chapter twenty-nine-a
of this code by the first date of September, two thousand three, to
implement this program.
(r) In adopting rules under this section, the department
(1) Establish an advisory council with representation from the
state medicaid agency, the state rehabilitation agency, the state
office of family support, the West Virginia Statewide Independent
Living Council, the West Virginia State Rehabilitation Council, the
West Virginia Developmental Disabilities Council, the West Virginia Mental Health Planning Council, and the Center for Excellence in
Disabilities at West Virginia University;
(2) Submit proposed rules for review and input to the advisory
council prior to release for public comment; and
(3) Consider any recommendations of the advisory council
before adopting final rules.
NOTE: The purpose of this bill is to establish a medicaid
buy-in program for certain individuals with disabilities to allow
those individuals to work and maintain their medicaid coverage.
This section is new; therefore, strike-throughs and
underscoring have been omitted.