Current through March 25, 2025
A. The Ticket to
Work Program is an SSI-related eligibility pathway for working adults with
disabilities established pursuant to
42 U.S.C. §
1396a(a)(10)(A)(ii)(XV) and
R.I. Gen. Laws §
40-8.7-1 et seq.
B. Adults with disabilities eligible through
the Ticket to Work Program are entitled to the full scope of Medicaid benefits
and home and community-based services and supports necessary to facilitate
and/or maintain employment. This is the same scope of coverage available to all
Medicaid-eligible adults with disabilities who work, without regard to
eligibility pathway. Financial eligibility for the Ticket to Work pathway is
determined in accordance with the SSI methodology as described in Subchapter 00
Part 3 of this Chapter.
C. The
Ticket to Work eligibility pathway is open to adults with disabilities who are
working and seeking Medicaid coverage, either with or without LTSS HCBS
benefits:
D. To qualify through the
Ticket to Work pathway, a person must be determined disabled by a State or
Federal government authority using the criteria established for the SSI program
except for the provisions related to substantial gainful activity.
1. General eligibility requirements -To be
Ticket to Work-eligible, a person must:
a.
Meet the non-financial eligibility requirements set forth in Part 10-00-3 of
this Title;
b. Be age between the
ages of sixteen (16) and sixty-four (64); and
c. Have proof of active, paid employment such
as a pay stub or current quarterly U.S. Internal Revenue Service (IRS) tax
statement (for those who are self-employed).
2. Financial eligibility - Applicants for
Ticket to Work eligibility are subject to the SSI methodology for counting
income and resources set forth in Subchapter 00 Part 3 of this Chapter.
However, there are no income or resource limits for the program. Nonetheless,
income and resources must be reported for the purposes of calculating cost
sharing amounts and, if applicable, determining if disqualifying transfers of
assets have been made according to Part 50-00-6 of this Title.
3. Retroactive coverage - As an SSI-related
coverage group, applicants may be eligible for up to ninety (90) days of
retroactive coverage. Eligibility for retroactive coverage is determined in
accordance with Subchapter 05 Part 2 of this Title once the premium or cost of
care requirements set forth below in § 1.10.1 of this Part have been
met.
1.10.1
Types
of Cost Sharing
A. Depending on their
countable income from all sources, both LTSS and non-LTSS Ticket to Work
beneficiaries may be required to pay a share of the cost of coverage. Non-LTSS
Ticket to Work beneficiaries subject to a cost share are required to pay a
premium; LTSS Ticket to Work beneficiaries who have a cost share generally have
the choice of paying a portion of income or premium.
1. Ticket to Work Premium -To calculate a
premium, the earned income of the Ticket to Work beneficiary and their spouse,
if applicable, are added together and then all SSI-related disregards are
applied. The remaining earned income is added to the unearned income of the
beneficiary or couple (after unearned income disregards are applied) and are
assigned a premium as follows:
a.
|
Income |
Monthly Premium |
|
Less than 150% FPL |
No premium |
|
At least 150% and less than 185%
FPL |
$ 61.00 |
|
At least 185% and less than 200%
FPL |
$ 77.00 |
|
At least 200% and less than 250%
FPL |
$ 92.00 |
|
At least 250% and less than 300%
FPL |
$ 110.00 |
|
At least 300% and less than 350%
FPL |
$ 130.00 |
|
At least 350% and less than 400%
FPL |
$ 150.00 |
|
At least 400% and less than 450%
FPL |
$ 170.00 |
|
At least 450% and less than 500%
FPL |
$ 190.00 |
|
At least 500% and less than 550%
FPL |
$ 210.00 |
|
At least 550% and less than 600%
FPL |
$ 230.00 |
|
At least 600% and less than 650%
FPL |
$ 250.00 |
|
At least 650% and less than 700%
FPL |
$ 270.00 |
|
At least 700% and less than 750%
FPL |
$ 290.00 |
|
At least 750% and less than 800%
FPL |
$ 310.00 |
|
At least 800% FPL and less than 850%
FPL |
$ 330.00 |
|
At least 850% FPL and less than 900%
FPL |
$ 350.00 |
|
Greater than 900% FPL |
$ 370.00 |
b.
Premiums must be paid in full before retroactive coverage for allowable health
care expenses is made available by the State.
2. LTSS Ticket to Work Cost of Care - The
State bases its calculation of a LTSS Ticket to Work beneficiary's liability
for the cost of care in accordance with the post-eligibility treatment of
income rules set forth in Part 50-00-8 of this Title. A LTSS Ticket to Work
beneficiary is entitled to all the allowances set forth therein when
determining the amount of income available to pay toward the cost of care. The
LTSS cost of care option is available only if the beneficiary's countable
income is less than or equal to the private pay rates established in Part
50-00-2 of this Title.
3. Ticket to
Work LTSS beneficiary choice - The State calculates both the monthly premium
and the LTSS cost of care, if applicable, for Ticket to Work LTSS
beneficiaries. An LTSS eligibility specialist is responsible for informing the
beneficiary of the premium versus the LTSS cost of care costs and assisting the
beneficiary in making an appropriate choice if they qualify for both options.
The State does not impose or collect a cost share until a Ticket to Work LTSS
beneficiary has been so informed and made a choice. Coverage may not be delayed
or denied pending the beneficiary's decision.
1.10.2
Non-Payment Ticket to Work Cost
Share
A. Absent a hardship exemption,
EOHHS will terminate eligibility after a beneficiary fails to pay their premium
for ninety (90) days.
B. The
provisions governing non-payment of LTSS cost of care are set forth in the LTSS
post-eligibility treatment of income rule contained in Part 50-00-8 of this
Title.
1.10.3
Hardship Exemption
A. If
circumstances arise that prevent a beneficiary eligible through the Ticket to
Work pathway from paying their premium in a given month, the beneficiary may
apply for a hardship exemption as described at 1.9.3(A)(1) of this Part.
1. If the hardship exemption request is
approved for a given month, that month's premium invoice will be
cleared.
2. If the hardship
exemption request is denied, the beneficiary will be required to pay the
premium.
1.10.4
Loss of Employment or
Eligibility
A. A Ticket to Work
beneficiary who loses employment may retain eligibility for up to four (4)
months by continuing to pay the applicable cost share, whether a premium or
LTSS cost of care payment. If the person is still unemployed at the end of the
four (4) month period, Ticket to Work eligibility is terminated. Prior to
taking this action, the State evaluates the Ticket to Work beneficiary for all
other forms of Medicaid eligibility as well as for coverage for a commercial
plan through HSRI, the State's health insurance marketplace.
1.10.5
Available
Services
A. Services include the full
scope of categorical Medicaid benefits, including home and community-based
services if eligible for LTSS, including personal care services provided
through an agency or through a self-directed program and services needed to
facilitate and/or maintain employment, as described in Chapter 50 of this
Title. Services are coordinated through the appropriate unit in EOHHS, DHS or
BHDDH or a contractual designee of the agency.
B. Services to maintain and support
employment are determined when developing a service plan, or through an
assessment of need utilizing a state approved assessment instrument or an EOHHS
approved prior authorization plan. Authorized personal care services may be
provided in the home, workplace or other necessary setting (such as a physician
office).
