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Appendix II 233C. Defining “Medically Improved Disability”For purposes of determining eligibility under the Medical Improvement Group, an individual with amedically improved disability is one who:• Was eligible for Medicaid under the Basic Coverage (subsection (XV)) Group discussed above;• Continues to have a medically determinable severe impairment, but• Whose disability, impairment, or condition has, by reason of medical improvement, improved tothe point where the individual has lost eligibility under the Basic Coverage (subsection (XV))Group because it was determined, at the time of a regularly scheduled continuing disabilityreview, that he or she no longer met the definition of disability under the SSI and SSDI programs.It is important to emphasize that the loss of eligibility under the Basic Coverage Group must be thedirect and specific result of loss of disability status because of medical improvement. Loss of disabilitystatus for a reason unrelated to medical improvement would not qualify as loss because of medicalimprovement.Under the statute, the Secretary is required to define the term “medically determinable severe impairment.”Information concerning how that term is defined, as well as information on other related disabilityissues in the context of the work incentives legislation, will be forthcoming in a separate letter toState Medicaid Directors.NOTE: See section III below for information concerning State options for requiring payment of premiumsor other cost-sharing charges. See section IV below for information on maintenance of effortrequirements.III. PREMIUMS AND COST-SHARING CHARGESUnder the existing eligibility group created by section 4733 of the BBA (section 1902(a)(10)(A)(ii)(XIII) ofthe Act), States may (but are not required to) require eligible individuals to pay premiums or other costsharingcharges. If States require such payments, the amount must be set on a sliding scale based onincome.TWWIIA also permits States to require payment of premiums or other cost-sharing charges by individualseligible under both the Basic Coverage Group and the Medical Improvement Group. While someaspects of the premium and cost-sharing requirements under TWWIIA are similar to those under theBBA, many are different.A. Key Elements of TWWIIA Premiums and Cost-SharingThe rules applicable to payment of premiums or other cost-sharing charges under TWWIIA are discussedbelow. The same basic rules apply to both the Basic Coverage (subsection (XV)) Group and theMedical Improvement Group, and your requirements for payment of premiums or other cost-sharingcharges must apply equally to all individuals eligible under either of the two groups.It should also be emphasized that while you have the option to require payment of premiums or othercost-sharing charges, you are not required to do so. A State can elect to impose no premium or cost-sharingcharges at all on individuals eligible under either or both of these groups.For individuals eligible under the Basic Coverage (subsection (XV)) Group and the MedicalImprovement Group you may, in a uniform manner for all individuals eligible under those groups:
234 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERa. Require individuals to pay such premiums or other cost-sharing charges, set on a sliding scale basedon income, as the State may determine;b. For any individual whose annual family income is less than 450 percent of the Federal poverty level,you can require payment of premiums only to the extent that the amount of the premiums does notexceed 7.5 percent of the individual’s income.c. For any individual whose (IRS) adjusted gross income exceeds $75,000 annually, you must charge100% of premiums.B. Sliding Scale Based on IncomeThe requirement under (a.) above that payments be on a sliding scale based on income applies to bothpremiums and other cost-sharing charges. While the degree to which such premiums and chargesincrease with increasing levels of income is up to the State, the underlying principle is that individualswith higher levels of income should contribute more toward the cost of services they receive than thosewith less income. A percentage premium or cost-sharing charge (e.g., 5 percent of income) is, by definition,on a sliding scale based on income because the actual amount paid increases as income increases.For purposes of this provision, premiums are defined as fees (usually monthly) that are charged tosecure coverage under one of the work incentives Medicaid eligibility groups. Premiums would normallybe paid by the individual directly to the State Medicaid agency. By contrast, cost- sharing chargesare defined as any other charges that the State may establish through which an individual eligible underone of the work incentives groups shares in the cost of the care and services provided to him or herunder the Medicaid program. Cost-sharing charges can either be paid by the individual directly to theState Medicaid agency, or paid by the individual to providers of services in the form of co-pays,deductibles, or co-insurance payments.A flat cost-sharing or co-payment charge (e.g., $5.00 for each doctor’s visit) does not, if applied alone,meet the requirement that charges be on a sliding scale based on income. However, you can use a flatcost-sharing charge system provided that premiums charged to eligible individuals rise with increasingincome, either because the premium is a percentage of income or the specified dollar amount of the premiumincreases as the individual’s income increases. A flat cost-sharing charge in conjunction with asliding scale premium produces an aggregate premium/cost-sharing charge that would meet therequirement that such charges be on a sliding scale based on income.This means, for example, that a State’s normal cost-sharing requirements, when used in conjunction witha sliding scale premium structure, would meet the sliding scale based on the income requirement. Solong as there is a sliding scale premium structure, there is no need for a State to incur the added administrativeexpense of establishing a cost-share system which is different from that used in the rest of itsMedicaid program.It is important to emphasize that while under (a.) above you may require payment of premiums andother cost-sharing charges, the limitation of 7.5 percent of annual income described in (b) above appliesonly to premiums. The restrictions and requirements outlined in items (b.) and (c.) do not apply to costsharingcharges that are not premiums.Regardless of whether or not you exercise your option to require payment of premiums and other costsharingcharges for the individuals described above you are required, under the statute, to charge 100percent of premiums for certain other individuals. Individuals subject to payment of 100 percent of premiumsare those whose adjusted gross annual income (as determined under the IRS statute) exceeds$75,000. This amount will increase each year after 2000 by the percentage of the annual Social Securitycost-of-living increase.
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Understanding MedicaidHome and Comm
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Gary Smith, the Primer’s principa
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viiiUNDERSTANDING MEDICAID HOME AND
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IntroductionPeople of all ages with
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Introduction 31998—is the group m
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Introduction 5This Primer has been
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CHAPTER 1Medicaid Coverage of Home
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Medicaid Coverage of Home and Commu
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CHAPTER 2Financial Eligibility Rule
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Financial Eligibility Rules and Opt
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CHAPTER 3Health and Functional Crit
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Health and Functional Criteria for
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CHAPTER 4Options for Designing Serv
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Options for Designing Service Cover
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as barriers to coverage (i.e., comp
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Factors to Consider When Choosing C
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Factors to Consider WhenChoosing Co
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Transitioning People from Instituti
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Guide to Chapter 7Consumer Directio
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Supporting Informal Caregiving 1Inf
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under an HCBS waiver program. This
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