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OSIP Program Manual

WG.11 Employed Persons with Disabilities

Effective 3/1/14

1. Program overview
2. Non-financial eligibility
3. Financial eligibility
4. Certification period
5. Participant fee
6. Eligibility vs. participant fee calculation
7. EPD and ICP
8. Reporting changes
9. Coding
10.Eligibility summary
11.Forms
12.EPD Referrals from 5503


1. Program overview

The Employed Persons with Disabilities Program (EPD) is designed to help people who have a disability go to work. Often, a person who has a disability is hesitant to go to work and risk losing Medicaid.  The cost of paying for a provider or adaptive equipment by oneself can use up most of a person’s paycheck.  The purpose of this program is to allow people who have a disability to work and not lose Medicaid coverage.

To be eligible for EPD, a person must meet the following:

The person may be eligible for a full OHP Plus benefits package and long-term care services. These may include:

Determining eligibility for EPD is similar to determining eligibility for other OSIPM programs. EPD is an OSIPM program and can be found in policy as OSIPM-EPD.

OSIPM-EPD policy is found in chapter 461 of the Oregon Administrative Rules.  When used alone in the administrative rules, the acronyms OSIPM cover EPD as well, since EPD is an OSIPM program. 

In instances where there is an exception for EPD, the rule will note the distinction.  Usually, the parenthetical statement “except OSIP-EPD or OSIPM-EPD” will appear, and later in the rule (often the last item) the EPD policy will be written.  Examples include 461-125-0370 and 461-155-0250.

2. Non-financial eligibility

The client will be the only person in any of the eligibility groups (household group, filing group, financial group, need group, and benefit group).  This is consistent with the current policy regarding a waivered service client (461-110-0410).

Clients must meet all current OSIPM non-financial eligibility requirements, unless otherwise noted. Non-financial eligibility requirements include:

Age. This program is available to clients who are at least 18 years old or legally emancipated, but there is no upper age limit (461-120-0510).

Basis of Need. The basis of need must be disability or blindness.  The basis of need cannot be age.  However, a person who is age 65 or older can be eligible for EPD, if the person has a disability that meets the definition below or is blind.

Disabled means having a physical or mental impairment, or a combination of these impairments, which meets the definition of disability used by the Social Security Administration (461-125-0370). They need not currently be receiving SSA benefits, but they need to meet the Listing of Impairments.

If they are not currently receiving SSA benefits based upon their disability, a presumptive Title XIX determination will need to be conducted by PMDDT (see OSIP WG.4).

PMDDT does not look at the current employment as part of the client’s Past Relevant Work.  PMDDT also looks at Substantial Gainful Activity (SGA) differently than the SSA.  They do not consider a working client to be earning above SGA unless their adjusted earned income is in excess of the EPD Adjusted Earned Income Standard, which is 250% of the Federal Poverty Level (461-001-0035, 461-125-0370, and 461-155-0250).

Pursuing Assets. EPD applicants and recipients are required to pursue assets unless good cause exists.  EPD applicants and recipients must pursue cost-effective employer-sponsored health insurance, as well as medical support when applicable.  EPD applicants are not required to pursue SSI.  EPD applicants and recipients are considered to have good cause to not pursue SSDI or Medicare because SSA will consider their current work as part of the Past Relevant Work calculation and they will be ineligible.  EPD clients can and should be encouraged to apply for SSDI and Medicare, but cannot be disqualified for failure to do so. (461-120-0330)

Employment Requirements. Employment means an on-going work activity for which the client provides DHS with one of the following:

The definition of “employment” does not include bartering or trading. Clients, particularly DD clients, who work for organizations that are not required to pay FICA under federal tax laws are considered to meet the definition of employed even if the employer does not file FICA.

Self-Employed clients often file or pay SECA payments.  These payments are often made on a quarterly basis.  However, clients are not required to do so to meet the definition of employed for EPD purposes.   

Once found eligible, a client remains "engaged in employment" while not working if the employer treats the client as an employee, such as when the client is absent from the job under the provisions of the Family Medical Leave Act (461-135-0725).

If an EPD client becomes unemployed and meets all eligibility requirements for the other OSIPM sub-programs except for resources, the client can remain eligible for EPD up to 12 months or until his or her resources are below the OSIPM resource limit (461-135-0725).

Protected eligibility. Generally, clients with protected eligibility (Pickle or DAC) status are not in the EPD program.  Pickle and DAC clients will not have a liability or DD offset if they are eligible for waivered services, therefore an EPD participant fee would be an increase in costs to the client.

Assumed eligibility. Assumed eligibility for OSIP applies only to recipients of SSI benefits and people deemed eligible for SSI under Sections 1619(a) or 1619(b) of the Social Security Administration. Clients who are eligible for SSI or are in 1619(b) status are not eligible for EPD.

3. Financial eligibility

Calculating countable income. Countable income is gross income minus exclusions.  Income exclusions can include self-employment business expenses under OAR 461-145-0920 and the Earned Income Tax Credit under OAR 461-145-0140. Example: Biff receives $1000 per month in earned income and $100 per month in Earned Income Tax Credit (EITC). So, we would exclude $100 from his gross income, which would leave $900 in countable earned income.  For EPD, this amount would be coded with the ECE N/R code.

Calculating adjusted income. Adjusted income is determined by doing the following:
  1. Exclude all unearned income.

  2. Determine countable earned income as described above.

  3. From countable earned income, deduct one standard income deduction of $20.

  4. Deduct one standard earned income deduction of $65, or $85 for individuals whose disability is based on blindness.

  5. Divide the remainder by two.

  6. Deduct any costs allowed as EIEs, Impairment Related Work Expenses (IRWEs), or Blind Work Expenses (BWEs) as defined in 461-001-0035

  7. The remainder is adjusted income (461-160-0780).
Employment and Independence Expenses.

The EPD program offers three income deductions that allow the client to retain eligibility for Medicaid although he or she is employed. Impairment-Related Work Expenses (IRWEs), Employment and Independence Expenses (EIEs), and Blind Work Expenses (BWEs) allow clients’ costs to be taken into account for Medicaid eligibility.  IRWEs, EIEs, and BWEs do not offer the client more benefits; they merely allow the client to have their eligibility for Medicaid judged on realistic values.  Money that the client uses, or plans to use on independence and employment expenses will not be counted when eligibility is determined. 

Impairment-Related Work Expenses (IRWEs)

The Social Security Administration (SSA) allows reductions to income known as Impairment Related Work Expenses (IRWEs).  Under the SSA definition, an IRWE is A payment for a service or an item that is excluded for SSI eligibility/payment purposes when the severity of the impairment is such that the individual must purchase or rent items and services in order to work.  To be allowed as an IRWE, the expense must be directly related to work and it must be necessary, due to the individual’s disability.  However, it can meet the criteria for an IRWE even if the item is used for daily activities other than work.

Employment and Independence Expenses (EIEs) 

EIEs are very similar to IRWEs. They are expenses that contribute to the person’s ability to work and enhance independence.  Any expense that can reasonably be expected to enhance the individual’s independence and facilitate employment will be allowed as an EIE deduction.  Example can include, but are not limited to, any of the following:

To be counted as an IRWE or an EIE, the cost must be incurred and paid for by the client.  It cannot be a cost or item that is paid for by a third party, such as an employer under the Americans with Disabilities Act (ADA) or Vocational Rehabilitation.  Expenses that a person without a disability would also incur and pay as a result of being employed (taxes, car insurance, routine vehicle maintenance) cannot count as IRWEs or EIEs.

It will be the responsibility of the client to justify why the expense can be expected to enhance their independence and employment opportunities.  The local branch will make the decision as to whether the expense is consistent with the policy. 

Blind Work Expenses (BWEs)

BWEs are expenses incurred by blind individuals that facilitate employment and independence.  They are very similar to IRWEs and EIES, except that:

Examples of BWEs include:

Specific assets. Treat specific assets according to existing OSIP(M) policy.

Resource Limits. The countable resource limit is $5,000.  The EPD Program also allows exclusions from the resource limit, which other OSIP(M) programs do not.  EPD participants may exclude resources from this limit if they are in a qualified Approved Account.

Approved Accounts. Funds in an Approved Account must be designated for a disability-related purpose or in a retirement account. Examples of appropriate retirement accounts include those regulated by the Internal Revenue Code and used for retirement planning, such as IRAs, 401Ks and Keogh accounts (461-001-0035).

The account must be segregated from other accounts and must have only the client’s name on it.  Additionally, funds deposited into Approved Accounts must be from the person’s earnings or from an employer, based upon earnings (461-145-0025).  Payments from SAIF are considered to originate with an employer, and are considered valid to fund an Approved Account.

Money in an Approved Account, and assets purchased from these moneys and assets purchased as EIE’s are not counted towards the $5,000 resource limit. 
(461-145-0025).

Many individuals with disabilities incur expenses that are directly related to the disability. These expenses are necessary to increase or maintain the individual’s level of independence and employment.

An example of such an expense is transportation costs. An individual who uses a motorized wheelchair may require a van with a lift, hand controls or other vehicle modifications. The total cost can easily exceed $30,000. A worker with a disability should be able to save for the purchase or replacement of such an expense without being penalized by losing needed Medicaid benefits.

Each disability causes the need for certain types of expenses. For a person who is blind, the expenses may include an electronic reading machine or a laptop Braille recorder.  Many necessary items, such as a van equipped for accessibility or assistive technologies have finite life spans. Workers with disabilities need to be able to save for their replacement. The EPD Program will exclude from countable resources any monies that are in segregated accounts with the purpose of saving for future expenditures. These segregated accounts will be known as Approved Accounts.

Also included in this category are retirement savings accounts (IRAs, TSAs, 401[k]s, KEOGHs, etc.) and Medical Savings Accounts (MSAs). Monies in these accounts will be available when the working disabled individual retires or to pay for qualified medical expenses and should decrease the individual’s reliance on governmental assistance.  Savings for retirement or for potential medical expenses should be promoted. By having these monies excluded from the resource limit, the individual is not penalized for saving.

Money deposited in an Approved Account must be from earnings that originate from employment or from an employer. For example, most of the time EPD clients will deposit money from earnings in their Approved Account.  Sometimes, money that originated from employment (such as retirement money in a PERS account) can be deposited in an Approved Account or can become an approved account. Money that does not originate from earnings or employment, such as SSDI or gifts from friends or relatives, cannot be deposited in Approved Accounts. 

The clients will seek approval of these accounts, thereby ensuring accountability. As with EIEs, these accounts will be approved if it can be shown that the future purchases can be reasonably expected to enhance the independence and employment opportunities for the individual, and if they are related to the person’s disability. If a client uses money in an approved account for items other than those included on the agreement, the money used to purchase the item and money remaining in the clients Approved Account will count toward the $5,000 resource limit for EPD.  Example: an EPD client is saving for a new wheelchair, which is listed on the Approved Account agreement. The client then decides to withdraw the money to purchase a video game system.  The money used for the system, and any money remaining in the account afterwards, count toward the EPD resource limit.

APD has a form that contains the purpose(s) of the account, account information (name of the institution, account number, date the account was opened, balance, etc.), and the signatures from the client and the local office worker. This form also informs the client that they are responsible for keeping records, which may be used to determine future eligibility.

The EPD Program allows any payment made to an Approved Account to be used as an EIE, thereby reducing income. By using this reduction, the individual maintains Medicaid eligibility while saving for their future disability-related needs.

Disqualifying transfers. For clients in standard living arrangements, there is no disqualifying transfer of resources if an EPD client disposes of a resource for less than the fair market value. For clients in a non-standard living arrangement (receiving waivered services in community based care), there can be a disqualifying transfer of resources if a resource is disposed of for less than fair market value.

Motor Vehicles. If a vehicle was purchased as an EIE or with moneys from an approved account, the total value of the vehicle is excluded (461-145-0360).

4. Certification period

The certification period is usually 6 to 12 months, depending upon the stability of the client’s employment and income level (461-115-0540). The certification period will remain in effect, unless the client:

5. Participant Fee

As a condition of eligibility, every EPD client must pay a participant fee every month. This includes months in which the client receives retroactive OSIPM-EPD eligibility. The fee serves as a buy-in for Medicaid and any waivered services.

Clients approved for EPD should be given a number of EPD Business Reply Envelopes (SDS 0489, available on FBOS) equal to the number of months in their certification period. If the client does not have an envelope, they may return their payment to the local office or mail it themselves to PO Box 4263 Portland OR, 97208-9829.

The amount of the fee will be based on the client’s countable earned and unearned income. Calculate countable income by combining all earned and unearned income, reducing that amount by all excluded income (such as self-employment costs, Earned Income Tax Credit, etc.). The remainder is countable income. Use the following chart to determine the amount of the EPD participant fee.

Monthly Countable Income

Monthly Participant Fee

 

Under $730

$0

 

$730 - $972.99

$50

 

$973 - $2,431.99

$100

 

$2,432 and above

$150

 

EPD clients receiving community-based residential care will still be required to pay room and board.

If a client fails to pay the Participant Fee, EPD eligibility ends. Local office staff must evaluate for eligibility for other Medicaid programs.

6. Eligibility vs. Participant Fee Calculation

There are two income calculations that are critical for the client. The first is the eligibility calculation. This calculation determines if the client’s income is under the EPD income standard for eligibility purposes. The second is the EPD participant fee calculation, which determines how much the client will pay as a participant fee for the EPD program. These calculations are different. The chart below shows the differences between the two types of income calculation for EPD.

Deduction

Eligibility

Participant Fee

Unearned income

Excluded

Countable

Earned Income

Countable

Countable

Earned and Unearned Income Exclusions

Yes

Yes

$20 Income Deduction

Yes

No

$65/$85

Yes

No

½ earned income deduction

Yes

No

Deduct EIEs, IRWEs, and BWEs

Yes

No

Compare to 250% FPL Standard

Yes

No

Compare to FPL for Participant Fee Calculation

No

Yes

Example 1: Geoff receives $1000 per month in SSB and $5000 per month in earned income from his work.  He has $1000 per month in EIEs.

EPD Eligibility Calculation: $1000 SSDI is excluded.  All unearned income is excluded for EPD eligibility.

Earned income:

Total Countable Earned Income

$5000

- $20 Earned Income Deduction

$5000 - $20 = $4980

- $65 Earned Income Deduction

$4980 - $65 = $4915

- ½ Earned Income Deduction

$4915 / 2 = $2457.50

- EIEs, IRWEs, BWEs

$2457.50 - $1000 = $1457.50

Total Adjusted Earned Income

$1457.50

$1457.50 is less than the EPD adjusted income standard of $2,432.  Geoff is eligible for EPD.

EPD Participant Fee Calculation: Unearned Income $1000, plus $5000, equals $6000.  There are no earned income deductions like there are in the eligibility calculation.  Compare the $6000 to the participant fee income chart.

$6000 is greater than $2,395, so the client’s monthly participant fee is $150.

Example 2: Jo has $1000 in SSB/SSDI and $5000 per month in self-employment income.  She has $1000 per month in business related expenses, which can be excluded under OAR 461-145-0920.  She also has $1000 in EIEs.

EPD Eligibility Calculation:

Total Earned Income

$5000

- Excluded Income (Business Expenses)

$5000 - $1000 =$4000

- $20 Earned Income Deduction

$4000 - $20 = $3980

- $65 Earned Income Deduction

$3980 - $65 = $3915

- ½ Earned Income Deduction

$3915 / 2 = $1957.50

- EIEs, IRWEs, BWEs

$1957.50 - $1000 = $957.50

Total Adjusted Earned Income

$957.50

Jo’s adjusted income is below the EPD adjusted income standard of $2,395.  Jo is eligible for EPD.

EPD Participant Fee Calculation: Jo’s unearned income is $1000.  Her earned income is $5000, but we would exclude the $1000 in business expenses, which are excluded under OAR 461-145-0920. This leaves a total of $4000 in countable earned income.  $1000 + $4000 = $5000, which is greater than $2,432, so she will owe $150 per month as an EPD participant fee.

7. EPD and Independent Choices (ICP)

EPD clients can be in ICP.  When an EPD client is eligible to receive APD in-home services and otherwise qualifies for ICP, the client may be enrolled in the program.  When in both EPD and ICP, a client will have both an EPD Participant Fee and an ICP payment, which are both calculated separately.  For example, Charlene receives in-home services and is employed and in EPD.  Her Participant Fee is $100 per month.  When she moves to ICP, her ICP payment is $1,500 per month. For DHS accounting and receipting purposes, Charlene will have to pay the Participant Fee to DHS, and she will receive the $1,500 to pay her provider separately. DHS will not deduct the $100 Participant Fee from her ICP cash benefit. EPD clients in ICP will not be in the pay-in system like other ICP clients.  ICP payments will need to be issued by the local office by use of the SDS 437 form.  For more information about the ICP program, please see 411-030-0100.

arrow right To link to the ICP program manual, click here.

 

8. Reporting Changes

Clients must report the following within 10 days (461-170-0011):

9. Coding

EPD cases must be coded on program _5, D4/4, B3/3, or A1/1.  Usually, cases will be coded on a D4 or B3 case. 

Although the basis of need for EPD cannot be age, EPD clients age 65 and older must be coded with A1/1 program codes.  In most instances, since SSI recipients are not eligible for EPD, EPD participants will rarely be coded on program 1, 3, or 4 program codes.  However, in some instances, where EPD participants receive cash payments from DHS (such as Health Insurance Premium [HIP] payments), they may need to be coded as program 1, 3, or 4 cases.  All EPD cases should be coded in Oregon ACCESS, and then integrated into CMS from ACCESS.

Presumptive cases. EPD clients going through the PMDDT process can be coded on a program _5 on CMS. Pending cases can be coded with a PEND incoming code, a PMP c/d. Approved cases can be coded on Oregon ACCESS/CMS with the PMA c/d.

Oregon ACCESS. EPD cases must be coded in Oregon ACCESS and integrated to the CMS system, as with all other OSIP(M) cases. All narration protocols need to be followed.  All EPD clients need to have the EPD tab (in the financial section) completed, as well as all other case data. The EPD tab contains four sections: EPD General Info, EIE, Approved Account, and Client Contribution. In the client contribution tab, after March 1 2008, staff should use “Manual”, “Extended Eligibility”, or “Nursing” calculation types for all EPD clients, as the situation calls for.

EEI and ECE coding. There are two Need/Resource codes that are essential to EPD coding. The first is the EEI code. The EEI code is for EPD adjusted income for EPD eligibility. Workers will code the amount of adjusted income for EPD (Countable Income – deductions = Adjusted Income) with the EEI N/R code. The ECE code is for the EPD client’s countable earned income. Workers will code the client’s countable earned income in the ECE field. The CMS system combines the amount of countable earned income in the ECE field with any unearned income to determine the amount of the client’s Participant Fee. Normally, the amount listed in the ECE field will be larger than the amount listed in the EEI field.

Open CMS case

10. Eligibility summary

Basic Eligibility

Steps to Determine Eligibility

arrow STEP 1: Employment

Is the client employed? Does the client file or pay Federal Insurance Contribution Act (F.I.C.A.), Self-Employment Contribution Act (S.E.C.A.), or demonstrate clear and convincing evidence of self-employment?

YES, client is considered Employed.

NO, the client is not considered Employed and is not eligible for the EPD Program. Deny the case and send a Notice of Planned Action, SDS 540 and the DHS 462A as appropriate.

arrow STEP 2: Income

Is the total gross earned income less than $4,949 per month?

YES, client meets the Income Test.

NO, the total gross earned income is more than $4,949 per month.

Use the Adjusted Income Calculation Worksheet, SDS 850A to determine the adjusted income. Allow the earned income disregards and Employment and Independence Expenses (EIE’s) to see if the client is eligible, based on the deductions. (NOTE: EIE’s include IRWE’s and BWE’s.)

Is the adjusted income is equal to or less than $2,432?

YES, the client has met the Income Test using the allowable deductions and is eligible for the EPD Program. If there are Employment and Independence Expenses, complete form, Employment and Independence Expenses, SDS 850B (461-160-0090).

NO, the adjusted income is more than $2,432; the client is not eligible for the EPD Program. Send the client a Notice of Planned Action, SDS 540 and the DHS 462A as appropriate.

arrow STEP 3: Resources

Determine the total amount of resources. Is the total amount of resources under $5,000?

YES, client meets the Resource Test and is eligible based on resources.

NO, the resources are $5,000 or more.

Determine if client’s resources can be placed in an Approved Account (461-145-0025). Use form, Request for Approved Account SDS 850C, to capture those resources.

If resources over $5,000 can be placed in an Approved Account, they are excludable and the client is eligible for the EPD Program.

If the purpose and/or source of funds does not qualify for use as an Approved Account and the client has $5,000 or more in resources, the client is not eligible for the EPD Program, deny the case and send a Notice of Planned Action, SDS 540 and the DHS 462A as appropriate.

arrow STEP 4: Disability

Is the client currently receiving SSDI?

YES, client is considered to meet the disability criteria.

NO, the client is not receiving SSDI. If the client is not currently receiving SSDI, medical records must be submitted to the PMDDT team to determine if they meet the disability criteria.

Disability Decision –Was the case approved by PMDDT for EPD?

YES, the disability was determined to meet the criteria.

NO, the disability was not determined to meet the criteria and is not eligible for the EPD Program. Deny the case and send a Notice of Planned Action, SDS 540 and the DHS 462A as appropriate.

arrow STEP 5: OSIPM Eligibility Factors

As a sub-program of OSIPM, EPD clients must meet all other financial and non-financial eligibility factors for OSIPM. Does the client meet all other financial and non-financial eligibility factors for OSIPM, including protected eligibility status (Pickle, DAC, etc.)?

YES, client is eligible for the EPD Program.

Inform the client that he or she will be required to pay a participant liability fee every month to maintain eligibility in the EPD Program.

Add the case to Oregon ACCESS and integrate to UCMS.

NO, the client is not eligible for the EPD Program. Deny the case and send a Notice of Planned Action, SDS 540 and the DHS 462A as appropriate.

11. Forms

Forms commonly used in the EPD program include:

SDS 0539A Application
SDS 0539E EPD Application Supplement
SDS 0620 Request for Presumptive Medicaid Disability Decision
SDS 0850A EPD Adjusted Income Calculation Worksheet
SDS 0850B Employment and Independence Expenses
SDS 0850C Request for Approved Account (This form available on Oregon ACCESS only)
SDS 0850D Client Contribution Worksheet (Do not use this form until further notice)
SDS 0850E Participant Fee Agreement
DHS 2099 Authorization for Use and Disclosure of Health Information
   

 

 

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