2015 basic benefits information network (bin) training understanding social security and federal,...

2015 Basic Benefits Information Network (BIN) Training

UNDERSTANDINGSOCIAL SECURITY AND FEDERAL, STATE, AND LOCAL BENEFITS

UNDERSTANDINGSOCIAL SECURITY AND FEDERAL, STATE, AND LOCAL BENEFITS

1CENTER ON COMMUNITY LIVING AND CAREERS

2

Welcome! Four days of information At-home testing with an 80% passing grade required for BIN certification

Homework assignment between Days 2 and Day 3

Guest Speakers: IRS, IN Works, and ASPIN On Day 4 you write a Complete Strategic Plan based on your homework assignment

Your Strategic Plan will be “quality reviewed” by a BIN CWIC (Kathy, or Kelley)

CENTER ON COMMUNITY LIVING AND CAREERS

Certification Process1. Full attendance at Day 1, 2, 3 and 4 (8:30 am – 4:30 pm)

2. Achieving at least an 80% passing grade on at home testing

3. Completion of homework assignment prior to Day 3

4. The BIN CWIC “quality review” of your Strategic Plan for completeness and accuracy


https://sites.google.com/site/bindocuments/ http://www.socialsecurity.gov/redbook/

Resources


http://www.choosework.net/index.html

Introductions• Name• Organization• One Interesting Fact


7

Why are you here?

What are our clients’ concerns?

Why is going to work difficult for our clients?


Client Video

https://youtu.be/zuc0cnYRkjY

8CENTER ON COMMUNITY LIVING AND

CAREERS

Fear of the impact employment will have on various benefits

◦ Education surrounding work incentives is the most effective way to combat fears

◦ Much to learn and understand: eligibility requirements, operational details, work incentive rules


10

The Office of Vocational Rehabilitation Services (VRS), the Indiana Institute on Disability and Community (IIDC), and the Social Security Administration (SSA) are developing capacity building throughout Indiana to engage providers and community advocates in supporting work incentive planning and assistance services.

“The Benefits Information Network is funded by Indiana Vocational Rehabilitation Services” http://www.VRS.in.gov


What is the Benefits Information Network (BIN)?

Employment providers

Annual certification

166 certified BIN Liaisons (as of 03/2015)

19 Tier 2s, 12 Tier 3s (CWICs)

BIN TA reviewed 1,407 plans in 2014


What kinds of activities will people in the BIN do?

BIN Liaisons will receive information and training on:◦ how to complete valuable profiling information, ◦ how to access important information for beneficiaries and ◦ help beneficiaries plan how to use work incentives while they are pursuing

employment goals

BIN Liaisons receive training on how to help beneficiaries understand the impact of employment on local, state and federal benefits

BIN Liaisons will be able to support beneficiaries over the course of their employment to understand the changes and implement work incentives


What programs will the BIN Liaisons learn?

Social Security Programs and Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) work incentives

Healthcare (including Medicare and Medicaid)

The Ticket to Work Program

Housing and HUD Work Incentives

Earned Income Tax Credit (IRS)


14

What information will the BIN Liaisons learn?

• Asset Development and Individual Development Accounts

• Supplemental Nutrition Assistance Program (Food Stamps) and TANF

• Verifying federal, state and local benefits + assistance

• Completing a thorough intake and Benefits Screening Profile, and planning for benefits Supports

• Collaborate with federal, state and local partners to increase financial outcomes of individuals served


Why is the Benefits Information Network Important?

•Expect improved employment outcomes when information is applied

•Liaison will be able to provide long term supports over the course of the beneficiaries employment


What is required to participate as BIN Liaison?

Annual certification

Read and study the 2015 BIN Manual, Work Incentives Fact Sheets, Strategic Plan examples, website resources, etc. throughout the year

Participate in the interviewing process needed for benefits analysis and advisement, including accessing information with releases from the Social Security Administration (such as the Benefits Planning Query and other SSA information)

Collaborate with federal, state and local agencies to support beneficiaries’ understanding and implementing work incentives that pertain to their individual situations


Chapter 2Overview of Social Security Programs

President Franklin D Roosevelt signed the Social Security Act in 1937

Since then it’s been amended several times

Different sections of the law provide authority to pay Social Security benefits (authorized by Title II), Supplemental Security Income or SSI (authorized by Title XVI), Medicaid (authorized by Title XIX), Medicare (authorized by Title XVIII), and other programs


18

The Social Security Administration (SSA) has over 65,000 employees

Central office is in Baltimore, with 10 regional offices

IN is in SSA Region V

The next level down in authority includes the Area Director’s offices of which

there are currently 58. For the most part, an Area Office corresponds to a state.

For really populous states like California or Florida, there may be more than one

Area Office


Office of Employment Support Programs (OESP)

The Office of Employment Support Programs (OESP) - oversees the Ticket to Work initiative, SSA’s Vocational Rehabilitation program and the WIPA projects (Work Incentives Planning and Assistance)

OESP is one office within the larger component of SSA known as the Office of Disability and Income Support Programs (ODISP) which manages all components of the Retirement and Survivors Insurance (RSI), Disability Insurance (DI), Supplemental Security Income (SSI) and international SSA programs


Understanding Eligibility for SSA Disability Benefits

Disability Defined:

Definition of disability under the Social Security Act for cash benefit purposes, ◦ Must be unable to engage in any substantial gainful activity (SGA) by reason of any

medically determinable physical or mental impairment 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 12 months.”

SGA Means:

“the performance of significant physical and/or mental activities in work for pay or profit, or in work of a type generally performed for pay or profit, regardless of the legality of the work.”


Three (3) CriteriaThe definition of disability under the Social Security Act has three (3) criteria

First, the person must have an impairment accepted by SSA

SSA Listing of Adult Impairments: http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm ]

Second, the person must be unable to perform SGA (Substantial Gainful Activity… 2015 = $1,090 / month / non-blind or $1,820 statutory blind) because of that impairment

Third, the condition must meet the duration requirement (12 months or result in death)

In order to receive benefits, the person must meet all criteria


State Disability Determination Services (DDS)

Fully funded by the Federal Government, are state agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law.

1.Uses information from claimant’s medical sources

2.If needed will arrange for a consultative exam

3.Disability determination


The Sequential Evaluation Process

A 5-step process is used to make disability determinations in the SSA system. The first step is conducted by SSA personnel.

1.Is the applicant performing SGA?

2.Is the medical condition “severe” / significantly limits the ability to do basic work activities?

3.Is the medical condition on the List of Impairments?http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm4.Can the applicant do the work the applicant did before?

5.Can the applicant make an adjustment to any other type of work?


Continuing Disability Reviews (CDRs)

The local Social Security field office gathers the medical information and sends it to the DDS

Once people are entitled to benefits DDS looks for evidence that the disability is better

If there is sufficient medical improvement, the person’s benefits are terminated


25

DDS sets a date, called a “diary”, of which there are 3:

Medical Improvement Expected (reviewed less than 3 years )

Medical Improvement Possible (reviewed every 3 years)

Medical Improvement Not Expected (reviewed 7 years but no more frequently than once every 5 years)


Protection from Medical CDRs

The Ticket to Work and Work Incentive Improvement Act (TWWIIA) of 1999 created two provisions:

1. Actively using a Ticket to Work

2. Effective January 2012, SSA will not initiate a review if the beneficiary has received benefits for 2 years just because they return to work


Age 18 Redeterminations in the SSI (Supplemental Security Income) Program

The adult definition of disability for SSI is different than that for children, individuals who are found eligible for SSI under the childhood disability definition are required to go through a full disability “redetermination” after reaching the age of 18. The SSA calls this process the “age 18 redetermination”

The age 18 redetermination occurs at some point after the 18th birthday, generally within 12 months of the 18th birthday


28

The age 18 redetermination is treated like a new application for disability benefits. Based on the fact that the individual has turned 18, the adult disability criteria for SSI are applied for the first time

Focus of the evaluation shifts to assessing whether the individual’s impairment(s) meets or equals any of the adult listings, and, if not, whether he or she has the ability to perform past or other work at a substantial level

Adult standard is more stringent – some children may no longer qualify


Applying for SSA Disability Benefits

Individuals can apply for disability benefits in three ways.

They can (SSA encourages online applications):

1.Apply at the nearest SSA field office, or

2.Call SSA’s toll-free number, 1-800-772-1213, to make an appointment to file a disability claim at the local Social Security office or to set up an appointment for someone to take the disability claim over the telephone. The disability claims interview lasts about one hour. Individuals who are deaf or hard of hearing may call SSA’s toll-free TTY number, 1-800-325-0778, between 7 a.m. and 7 p.m. on business days.

3.Initiate an online application by visiting www.socialsecurity.gov.


Application Information

• Social Security number

• Birth or baptismal certificate

• Names, addresses and phone numbers of the doctors, caseworkers, hospitals and clinics that would have information about the disability

• Names and dosage of all the medicines

• Medical records from doctors, therapists, hospitals, clinics and caseworkers

• Laboratory and test results

• A summary of work history and

• A copy of the most recent W-2 Form (Wage and Tax Statement) or, for self-employed individuals, a copy of the federal tax return for the past year


31

Retired worker — Beneficiary who worked enough in Social Security covered employment to be due benefits and who is at least 62 years old (benefits are reduced if applicant is under full retirement age when entitled)

Disabled worker - Beneficiary who had recent and sufficient work in Social Security covered employment or self-employment long enough to be insured and who had been working recently in covered employment or self-employment prior to disability onset

Spouse of retired or disabled worker (1) they are taking care of a child entitled on the worker’s record who is under age 16 or disabled, or (2) is at least 62 years old. Entitlement applies also to an unmarried divorced spouse who is at least 62 if the marriage(s) to the worker lasted at least 10 years. In some situations, he or she may get benefits even if the worker is not receiving them (SSA determines this)

Child of retired, disabled, or deceased worker must be under age 18, or between 18 and 19 and in primary or secondary school

Beneficiary Categories


Earning Entitlement to Social Security Benefits

Social Security taxes paid on work are somewhat like insurance premium payments. Benefits are earned by paying Social Security taxes on wages, or on the net-profit from a trade or business

The amount of wages previously taxed determines eligibility and the amount of payments


33

To determine eligibility on a worker’s history of earnings, SSA counts calendar quarters in which a minimum amount of wages were taxed under the Social Security Act. SSA calls these periods of work “Quarters of Coverage” (QCs) or credits

◦ Quarters of Coverage and credits are terms that SSA uses interchangeably and which mean the same thing

◦ If you were born in 1929 or later, you need 40 credits (10 years of work)

Note: In the year 2015, you must earn $1,220 (gross) in covered earnings to get one Social Security or Medicare work credit

http://www.socialsecurity.gov/retire2/credits1.htm


Three types of disability benefits authorized under Title II of the Social Security Act

Disability Insurance Benefits (DIB), also called Social Security Disability Insurance (SSDI), are payable to a worker insured under the Act

Childhood Disability Benefits (CDB) are payable to a disabled adult child of an insured worker who has retired or become disabled, or has died

The child must have a disabling condition that began prior to the time the child attained age 22. The disabled child must be 18 years of age or older to access Childhood Disability Benefits

Those under age 18 may be eligible for child’s benefits not based on disability

Disabled Widow(er) s Benefits (DWB) are payable to the widow, widower, or surviving divorced spouse of an insured worker

The widow, widower, or surviving divorced spouse must be at least age 50, be found to be disabled before the end of a specified period of time called the “prescribed period,” and must meet other requirements regarding relationship


Effect of Marriage on CDB and DWB

A Childhood Disability Beneficiary’s benefits will terminate when he or she marries unless the marriage is to someone entitled to a Social Security benefit (Title II), other than a minor child

Effective January of 1984, re-marriage will not terminate benefits for a Disabled Widow(er) or a disabled surviving divorced spouse if the individual was already entitled as a DWB at the time of the marriage


Waiting Period for Title II Disability Benefits

Before entitlement a beneficiary must wait 5 full calendar months (date of entitlement)

The waiting period begins the first full month the person is disabled (date of onset) and meets requirements for entitlement, such as having worked enough under the Social Security system


Important Concepts Affecting Entitlement to Title II Disability Benefits

• Date of Onset - is the date that evidence demonstrates the disability is severe and prevents SGA. This is a date established by DDS when the individual first applies and is found eligible. The waiting period follows the Date of Onset

• Filing Date, or Date of Application - is the earlier of either the date a valid application is received by SSA or the protective filing date.

• Date of Entitlement - is the first month for which benefits are payable. Title II disability benefits may be paid retroactively, which means that SSA can pay benefits for months prior to the date of the application


Retirement When Title II disability beneficiaries reach retirement age (FRA), their disability benefits automatically convert to Retirement Insurance Benefits (RIB)

A disability beneficiary’s last month of entitlement to disability benefits is the month before their FRA


Title II Disability Payments

Social Security benefits are paid each month, generally based on the birth date of the person on whose work record the benefits are paid

Example: individuals who receive benefits as retired or disabled workers have their benefit payment date determined by their own birth date. Individuals who receive benefits on a spouse’s or parent’s work record will have a payment date based on that person’s birth date


Overpayments?If the beneficiary agrees that he or she was paid too much and that the overpayment amount is correct:

1.If the Title II beneficiary is in current pay status, Social Security will withhold the full amount of the benefit each month, unless a lesser withholding amount is requested and Social Security approves the request

2.Full withholding begins 30 days after notification of the overpayment


SSI and Overpayment

SSI - generally Social Security will withhold 10% of the maximum Federal Benefit Rate (FBR) ($73.00, 2015) each month in order to recover the overpayment. If the beneficiary cannot afford this, he/she may ask that less be taken from their monthly benefit


Appeal and Waiver Rights Process?

An appeal can be filed by completing form SSA-561. The form can be obtained online at www.socialsecurity.gov or by calling or visiting the local Social Security office. The appeal must be in writing, and should explain:•Why the beneficiary thinks he/she has not been overpaid; or

•Why he/she thinks the amount is incorrect

•Have 60 days from overpayment notice to file an appeal

•Can file a waiver (SSA-632) if they feel they shouldn’t have to repay the money


Conclusion Individuals receive Social Security Disability Insurance benefits because someone worked and paid into the Social Security system

The benefits partially replace wages or self-employment income lost because that person died, or stopped working due to disability or age

Benefits eligibility is determined based on the number of years a person worked and paid Social Security taxes, and the amount of earnings that the person has.

Entitlement for dependent family members is based on their relationship to and dependence on the person who worked and paid Social Security taxes. If a dependent family member is entitled on the work history of a living worker, the family member will usually not be paid benefits if the worker isn’t due benefits


Chapter 3

Social Security Disability Insurance (SSDI)


Entitlement – Review

Entitlement – waiting period of 5 full calendar months after Date of Onset

The waiting period begins the first full month the person is disabled and meets requirements for entitlement, such as having worked enough under the Social Security system

CDB beneficiaries never serve a waiting period


Trial Work Period

The Trial Work Period (TWP) effectively suspends the “able to perform Substantial Gainful Activity” part of the disability definition so that beneficiaries may attempt to work without immediately losing their cash benefits

The Trial Work Period provides beneficiaries an opportunity to test work skills while maintaining full benefit checks, no matter how much the beneficiary earns

Only months that would count as TWP months by the SSA are those in which: (1) an individual earns pre-tax wages of more than $780 in 2015; or, (2) works over 80 hours in self-employment

The Trial Work Period ends only when a beneficiary performs nine months of work over the TWP guideline within a rolling period of 60 consecutive months


46

Determining Wages in a Month

The Title II disability program is interested in work ability or effort in a month, and thus counts wages when they were EARNED, not when

they were PAID

47

Beneficiaries are entitled to one Trial Work Period (TWP) per period of disability.


What is a Trial Work Period Service Month?

When determining if work activity is considered “services” for TWP purposes, SSA is only concerned with income that is performed for

compensation (pay for work) and produces earnings that exceed the applicable Trial Work Period (TWP) Service amount

$780.00 per month in 2015


Completing the TWP

The Trial Work Period ends when an individual has completed (9) nine service months within a rolling five year (60 month) period – don’t need to be consecutive

To do this, the SSA marks all of the possible months that could be TWP service months. They count forward to nine, then count back 60 consecutive months to see if all nine service months were completed within that period

If not: • The service months that fall before the 60-month period are disregarded• The service months that fall within the 60-month period are counted and • The TWP continues


SGA is a DecisionSGA is NOT simply a number – an objective concrete dollar figure ($1,090.00 per month in 2015 or $1,820.00 per month if the beneficiary is statutory blind) that SSA establishes each year as the upper limit that a beneficiary can earn before benefits are ended

SGA determinations require that SSA personnel gather the applicable facts, apply the appropriate rules and procedures and use their best judgment to render a decision about the “value” of an individual’s work


Understanding Substantial Gainful Activity

During an SGA determination, SSA attempts to determine the value of work activity as compared to the current SGA guideline

Once all applicable work incentives are applied, SSA compares the “countable” income to the applicable SGA level for the year

If countable income is consistently above the applicable SGA guideline, the work activity is SGA. If the countable income is consistently below the SGA guideline, the work is unlikely to be considered Substantial Gainful ActivityOnly the SSA Claims Rep can make this determination!


What are Earnings ?

Anything a beneficiary receives in exchange for work performed may count during an SGA determination

Pay (wages) for work may be received in cash or in-kind

In-kind payments (such as room and board) may be in lieu of or in addition to cash

SSA only counts wages or self-employment income that represents the beneficiary’s work effort. Thus reimbursements for travel expense, pay for vacation or sick leave, etc., would generally not be counted during an SGA determination.


Continued Disability Review

SSA regulations state that work CDRs are to be conducted immediately after the conclusion of the Trial Work Period (TWP)

When work is not reported monthly, or CDRs are not completed in a timely fashion, there is a risk that the beneficiary will be overpaid by SSA


SGA Determination “Tools” available to the SSA claims representative

1. Unsuccessful Work Attempt (UWA)

2. Income Averaging

3. Subsidy and Special Conditions

4. Impairment Related Work Expenses (IRWEs)


Unsuccessful Work Attempts (UWA) – SSA only

A significant break in the continuity of a person’s work could occur if the person: • Discontinued or reduced work activity to the non-SGA level

because of the impairment, or the removal of special conditions related to the impairment that are essential to the further performance of the work;

• Discontinued or reduced work activity to the non-SGA level prior to the alleged onset date of the impairment for reasons unrelated to the impairment (e.g., retirement, or layoff)

Discontinued: Was out of work for at least 30 consecutive days, or forced to change to another type of work or another employer

Only if SGA level work was 6 months or less


Income Averaging – SSA only

Averaging is applied by SSA when earnings after the Trial Work Period (TWP) fluctuate above and below the Substantial Gainful Activity (SGA) guideline and in situations where the Unsuccessful Work Attempt (UWA) criteria do not apply

56

The purpose of income averaging is to allow SSA to analyze an individual’s earnings in a consistent period of work effort to

determine if the work effort represents the ongoing ability to perform SGA. Remember, the local SSA field office will make the

formal SGA determination


Work Incentives

Work incentives are a way for the SSA to encourage work activity by limiting the impact of work on benefits

These incentives are not really in existence until the SSA claims representative decides that the work incentives are applicable to that individual’s situation


Subsidy and Special Conditions

SSA recognizes that sometimes a person’s disability results in the need for extra assistance, a reduced production rate, frequent breaks, or fewer job duties than co-workers in a similar job – accommodations!

The individual’s wages represent not only pay for their work product or effort, but also either direct help from someone else, or full pay for lower productivity or lower quality work than other employees


Employer Subsidy

Employer subsidies happen when the beneficiary’s employer provides extra accommodations, supervision, or other special assistance because of the beneficiary’s disability. Specific subsidies are those in which employers are able to designate a specific dollar amount of subsidy after calculating the reasonable value of the worker’s services

Non-specific subsidies are established when the employer determines the value of the subsidy by comparing the individuals work in terms of time, skills, and job responsibilities at the workplace with that of coworkers without disabilities who are performing similar work. The proportional value of the work must then be estimated according to the prevailing wage for such work


Special Conditions

Another type of subsidy is called “special conditions.”

Special conditions exist when a worker receives supports or services from someone other than the employer, potentially subsidizing the worker’s ability to perform SGA. Special conditions may be provided by any third party. Most often they are provided by a State Vocational Rehabilitation agency, a community rehabilitation agency or another service provider.

Employment in a sheltered workshop or job coach services provided to workers are both strong indications that the work is being subsidized.


Impairment Related Work Expenses (IRWE)

For an IRWE deduction to be allowable, 5 criteria have to be met:

1.The expense must be directly related to enabling the beneficiary to work

2.The expense has to be related to a medically determinable impairment that is being treated by a health care provider rather than being something that anybody would incur by working. This means that things like FICA deductions are not permissible as IRWEs


3. The expense must be paid for out of pocket by the individual and not reimbursable from another source (VR)

4. The expense must be paid for in a month during which the individual was working. Under some circumstances, costly durable goods purchased during the 11-month period preceding the month work started may be deducted as an IRWE. Expenses incurred in a month of work but paid for after work stopped also can be considered

5. The expense must be “reasonable” which SSA generally defines as “usual and customary” or the typical cost for that item or services in the persons community


Extended Period of Eligibility (EPE)

Extended Period of Eligibility (EPE) begins the month immediately following completion of the trial work period and ends 36 months later, regardless of work status

The beneficiary must continue to have a disabling impairment to access the Extended Period of Eligibility


64

If a beneficiary is not performing Substantial Gainful Activity (SGA) at the time the 36- month re-entitlement period ends, benefits may continue.

The Extended Period of Eligibility re-entitlement period is a safety net. Some beneficiaries may never know they have used it if their earnings are consistently below SGA.

If a beneficiary’s payments are “ceased” after the Trial Work Period, and the person needs to receive benefits again during the 36-month reinstatement period of the Extended Period of Eligibility, they do not have to file an application. Instead, they must simply establish with the SSA that their work activity is below SGA – report earnings!


65

If the beneficiary performs Substantial Gainful Activity during the Extended Period of Eligibility, benefits are suspended, not terminated

Cessation and Grace Months may or may not occur during the Extended Period of Eligibility (EPE)

Cessation happens the first time after the Trial Work Period (TWP) that a person performs SGA

(dependent on the SSA claims reps evaluation)

Cessation is not dependent on the EPE and the grace period is a separate and distinct work

incentive


Cessation Month and Grace Period

When a beneficiary performs sustained SGA level work for the first time after the TWP, this first month where this pattern begins is called the cessation month

SSA allows a payment to be made in this month and the two succeeding months, called the grace period, for a total of three (3) months. Even though the months have different names, they are really one work incentive and they are always applied together as one 3-month block

These are sometimes referred to collectively as the Grace Period

This all occurs once the claim rep has established a pattern and has spoken to the working individual.


67

The cessation and grace months, like the Trial Work Period, are only available once during a period of disability

Once paid for the grace period, the individual’s work incentive disappears

The beneficiary only has access to another grace period if the beneficiary is re-entitled

Entitled = qualified for by right according to law


Self EmploymentTo make this determination, the SSA asks the

following questions about self-employment:

• Is there a good faith intention of making a profit or producing income?

• Are similar transactions repeated over time?

• Is the beneficiary holding himself out to others as being engaged in the selling of goods or services?


69

Net Earnings from Self-Employment

To understand how the SSA views income from a business, the following three terms must be understood: Gross Receipts, Net Profit and Net Earnings from Self-Employment (NESE)

• Gross receipts are any money the business takes in

• Gross receipts – applicable expenses = Net Profit

• Once net profit has been established, the Social Security Administration uses IRS rules to determine Net Earnings from Self-employment (NESE).

Once the SSA determines the NESE for a given month, they will use that number as the starting point for SGA decisions.


Self-Employment Issues

Determinations about whether income is “earned” as opposed to “unearned” and subsequent decisions about whether earned income represents “wages” or should be counted as “net earnings from self-employment” (NESE) can get very complicated

Both the U. S. Department of Labor (DOL) and the Internal Revenue Service (IRS) have a stake in these matters and often have overlapping laws and regulations


70

SSA’s Termination of Title II Benefits

Termination, under Social Security rules, does not just mean that cash payments have stopped. It means that the computer record that maintains payments has been terminated. Once a person has been terminated, it takes a formal re-entitlement or re-instatement decision to reopen the computer record in order for payments to begin again.

REMEMBER: Termination is more than just stopping payments. Termination is more than cessation, suspension, non-payment, or any other term Social Security uses to denote merely the loss of cash payment. It means that no more benefits are payable based on that application


Expedited Reinstatement of Benefits (EXR)

•Benefits ended (were terminated, not suspended) due to work•Work activity falls below SGA within 60 months of termination•Same disability or impairment related to original disability•Short application•6 months of provisional payments


73

SSDI Activity


Chapter 4

Understanding Medicare


75

MedicareCountry’s health insurance program for people age 65 or older, certain people with disabilities who are under age 65 and people of any age who have permanent kidney failure

It provides basic protection against the cost of health care, but it does not cover all medical expenses or the cost of most long-term care

The Medicare program is financed by a portion of the Federal Insurance Contributions Act (FICA) taxes paid by workers and their employers. It also is financed in part by monthly premiums paid by beneficiaries

The Centers for Medicare and Medicaid Services or CMS is the federal agency in charge of the Medicare program

Social Security Administration determines who is eligible for Medicare, enrolls people in the program, and disseminates general Medicare information


76

There are two parts of Medicare.

Medicare Part A (also known as Hospital Insurance or HI) helps pay for care in a hospital and skilled nursing facility, home health care and hospice care.

Medicare Part B (also known as Supplemental Medical Insurance or SMI) helps pay for doctors, outpatient hospital care and other medical services.

Anyone who is eligible for premium-free Medicare hospital insurance (Part A) can also enroll in Medicare supplemental medical insurance (Part B) by paying a monthly premium.

Additional Cost: ◦ monthly premiums, there are other out-of-pocket costs for Medicare (deductibles

and co-insurance)◦ The current Medicare charges can be found at http://www.medicare.gov or by

calling the Medicare toll free number at 1-800-633-4227


Medicare vs. Medicaid Many people think that Medicaid and Medicare are two different names for the same program. THAT IS FALSE!

Medicaid is a state-run program designed primarily to help those with low income and little or no resources

Medicare is an entitlement earned by someone who has paid into the Medicare trust fund through taxes on earned income; it is not needs based


78

The federal government helps pay for Medicaid, but each state has its own rules about who is eligible and what is covered under Medicaid

Medicare is a federally run program that has the same eligibility standards and coverage rules across all 50 states.

Medicaid coverage is typically free (with some exceptions in some states) while Medicare coverage involves premiums, co-payments and deductibles


79

Who is eligible for Medicare?

• Individuals age 65 and older who are insured for retirement benefits under the Social Security program either through their own work, or through a spouse’s work

• Individuals receiving Social Security Disability Insurance (SSDI) who have met the 24-month qualifying period for Medicare

• Individuals receiving benefits as a Childhood Disability Beneficiary (CDB) who have met the 24-month qualifying period that begins no earlier than the person’s eighteenth birthday

• Individuals who meet the Social Security disability standards and who are either entitled to disabled Widow(er)s benefits (DWB) or Medicare on a deceased worker’s record and who have met the 24-month qualifying period


80

• Individuals with disabilities who have worked beyond their Extended Period of Medicare Coverage (EPMC) and are eligible to purchase Medicare Parts A and B coverage as a Qualified Disabled and Working Individual (QDWI)

• Individuals who have End-Stage Renal Disease (ESRD) who have been receiving dialysis for three months, or who have been performing self-dialysis for one month or who have received a kidney transplant

• Government employees who paid only Medicare taxes and meet any of these above categories

• People who are age 65 or older, are not insured for Social Security retirement benefits, and pay a premium for both parts of Medicare

• Individuals who lost cash Title II disability benefits due to work and are in the Extended Period of Medicare Coverage (EPMC)


The Medicare Qualifying Period (MQP)

The Medicare Qualifying Period (MQP) is different from the 5

month Social Security disability benefit waiting period

The 24-month Medicare Qualifying Period begins with the first month for which the person is entitled to SSDI payments, after the five-month waiting period. Coverage generally begins the first day of the 25th month of benefit entitlement with one notable exception:

◦ Beneficiaries with ALS (Lou Gehrig’s Disease) qualify for Medicare when their disability insurance benefits start


Medicare and Other Health Insurance

When individuals have multiple forms of insurance, Medicare may pay medical expenses first in some circumstances and second under other circumstances

When Medicare and Medicaid are both received, Medicare almost always pays first and Medicaid pays for expenses that are left


Medicare Supplements or Medigap Plans

Since Medicare involves deductibles and coinsurance payments, some people end up with large out-of-pocket expenditures to manage

Medicare supplemental insurance policies, also called “Medigap Plans”, may help to meet a beneficiary’s medical insurance needs. These private insurance policies are optional for Medicare beneficiaries to purchase, but which are mandated to exist in each State


Medicare/Medicaid Dual Eligible programs or Medicare Savings Programs

Indiana Medicaid may help by providing special limited Medicaid

coverage that is mandated and regulated by the federal government

CMS refers to this assistance as Medicare/Medicaid Dual Eligible programs or Medicare Savings Programs

These special Medicaid programs are for certain eligible Medicare

beneficiaries who have little income and few resources. This coverage may help pay for all or part of the Medicare premiums, deductibles and coinsurance

NOTE: Medicare Savings Programs are not the same as regular Medicaid coverage. These programs do NOT pay for services or items that Medicare

Part A and B would not cover, such as prescription medications


85

To qualify for one of the Medicare Savings Programs, the beneficiary must have:◦ Medicare Part A (hospital insurance)◦ limited income◦ countable resources such as bank accounts, stocks and bonds, must not be more than twice the SSI limit

($4,000 for a single person or $6,000 for a couple)

There are numerous dual eligibility categories such as:◦ Qualified Medicare Beneficiary (QMB)◦ Special Low-Income Medicare Beneficiary (SLMB)◦ Qualifying Individuals (QI)◦ Qualified Disabled and Working Individuals (QDWI)

Each of these programs has different eligibility criteria and each pays for different types and amounts of Medicare out-of-pocket expenditures


Qualified Medicare Beneficiaries

A Qualified Medicare Beneficiary, sometimes referred to as QMB or “quimby”, is someone receiving Medicare who has countable income equal to or less than 100% of the current federal poverty standard

The QMB program provides limited Medicaid coverage to pay for Medicare premiums, deductibles, and coinsurance payments


Specified Low – Income Medicare Beneficiaries (SLMB)

Someone eligible under SLMB (also referred to as “slimby”) has Medicare Part A and countable income of more than 100% but less than 120% of the federal poverty level, as calculated using SSI exclusion rules

For SLMB, the state will pay the Medicare Part B premiums for these individuals, but does not pay anything toward coinsurance or deductibles

It is possible for SLMB beneficiaries to have full Medicaid coverage, but only if they meet the criteria for Medicaid eligibility under another program, like a state Medicaid buy-in program (MED Works)


Qualifying Individuals (QI)

A QI has Medicare Part A and countable income of 120% to less than 135% of the Federal poverty level, as calculated using SSI exclusion rules

QI is a Federal block grant program, so funding is based on availability of grant funds

It is possible for QI beneficiaries to have full Medicaid coverage, but only if they meet the criteria for Medicaid eligibility under another program, like a state Medicaid buy-in program (MED Works)


Qualified Disabled and Working Individuals (QDWI)

Certain individuals are entitled to purchase Medicare Part A after premium-free Part A coverage ends because Medicare benefits were lost due to return to work at a substantial level

To be eligible for QDWI, the individual must have countable income of up to 200% of the federal poverty level, countable resources not exceeding twice the SSI limit ($4,000 for an individual and $6,000 for a married couple), and not otherwise be eligible for Medicaid


Medicare Prescription Drug Program (Medicare Part D)

Under the provisions of Part D voluntary prescription drug coverage, Medicare beneficiaries entitled to or enrolled in Part A and/or beneficiaries enrolled in Part B may also enroll in the voluntary prescription drug program

Unlike with Parts A and B, SSA does not process Part D enrollments. Beneficiaries must enroll directly with a participating approved Medicare Part D Prescription Drug Provider (PDP) or a “Medicare Advantage Plan” that offers prescription drug coverage (MA-PD)


Extended Period of Medicare Coverage (EPMC)

If you are a Medicare beneficiary, if you continue to have a disability as defined by the Social Security Administration, and you return to work, you can keep your Medicare coverage for at least 93 months after you return to work

During this Extended Medicare Coverage, you will receive Part A (premium-free hospital insurance) and Part B (elected medical insurance coverage with a monthly premium), and Medicare prescription drug coverage if applicable


How EPMC Works:

This Medicare coverage applies to you if you are: oJust starting work oUsing Trial Work Period months right now oHave used up your Trial Work Period and are currently in your

36 months Extended Period of Eligibility oHad not completed the 36 months Extended Period of

Eligibility before 6/1/2000

Exactly when the Extended Medicare Coverage begins and ends is determined by when you consistently reach Substantial Gainful Activity (SSA determines when your 93 months start)


State Health Insurance Counseling and Assistance Program (SHIPs)

The State Health Insurance Counseling and Assistance Program (SHIP) provides free, one-on-one Medicare counseling to seniors and people with disabilities

SHIPs help beneficiaries make informed choices about their Medicare, and can answer questions about Medicare bills, appeals, and Medicare consumer rights

SHIP websites can be found at: http://www.in.gov/idoi/2495.htm


Chapter 5

HUD and Housing Programs


The three main types of federal housing assistance programs sponsored by the Department of Housing and Urban Development (HUD) are:

Public housing

Tenant-based Section 8 vouchers and

Project-based housing subsidy programs


Public Housing• Public housing is owned and operated by local public housing

authorities (PHAs)

• Housing units take many forms from high-rise apartment buildings to detached single-family dwellings, and may be located at one site or scattered over several sites


Section 8 Housing Choice Voucher

Assists very low income, elderly, and people with disabilities afford housing in the private market

Administered by Public Housing Agencies (PHAs)

PHA pays a subsidy directly to a private landlord and the renter pays the difference between the subsidy and the actual rent

Some PHAs allow voucher payments to be applied to a mortgage


Section 8 Project-Based-Assistance

• Low-income families in subsidized units

• Assistance generally ends when the family moves

• In any fiscal year, 40% of all new project admissions vouchers must go to very low-income families


Section 8 SubsidiesHUD pays rental subsidies so that eligible families can afford safe, decent and sanitary housing.

These Section 8 subsidies take the form of tenant-based or project-based assistance

Tenant-Based Subsidies

Tenant based subsidies allow recipients to rent housing in the private market and the subsidy moves with the tenant


Project-Based Subsidies

•Attached to specific units in privately owned and operated buildings

•Rental assistance generally ends for the tenant when the tenant moves except in the Section 8 Project-Based Voucher program

•A single building may receive housing assistance under several federal housing subsidy programs


101

Housing programs listed by numberNumber Who this is for ?

Section 8 Project Based For low-income renters who want to live in privately owned and managed properties

Section 8 Housing Choice Voucher

For low-income renters who want to live in private market housing

Section 42 For income-qualifying renters who want to live in private market housing


Number Who is this for?

Section 202 For low-income seniors age 62 and older

Section 236 For low-income renters

Section 515 For low-income renters who live in a rural area

Section 811 For low-income renters with disabilities who are over the age of 18

Information obtained from: www.housinglink.org


HUD Earned Income Disregard

The Department of Housing and Urban Development (HUD) has an Earned Income Disregard that applies to people in certain

types of housing. Public housing authorities will disregard 100% of earnings from employment when calculating your rent for the first

year in which you are employed. In the second year of your employment, only half of your earnings will be counted in figuring

your rental payments.


How it Works If you live in the following types of HUD-subsidized housing, you may be eligible for the Earned Income Disregard (also known as the Earned-Income Disallowance):

Public housing, operated by the Public Housing Authorities The Section 8 Housing Choice Voucher Program The Home Investment Partnerships Program The Housing Opportunities to Persons with AIDS Program

For the purpose of this work incentive, you must not have been working during the previous 12 months or if you have worked, you can’t have

worked, on average, more than 10 hours per week at minimum wage.


Individual Savings Accounts (An Alternative to Earned Income Disregard)

Housing authority will deposit the total amount that would have been calculated as increased tenant rent employment income into an interest-bearing savings account

The tenant family may only withdraw the monies deposited in the account for:

• Purchasing a home

• Paying the education costs of a family member

• Moving from public or assisted housing or

• Paying other expenses approved by the housing authority that promote economic self-sufficiency


106

The Family Self Sufficiency Program (FSS)


Chapter 6

Asset Building and Individual Development Accounts (IDA)

How Does it Fit Into Your Work as a BIN Liaison?


CAREERS

Individual Development AccountsHave any of you either had an IDA or helped someone with an IDA?


CAREERS

IDA Premise

“Few people have ever spent their way out of poverty. Those who escape do so through saving and investing for the long-term.”

Michael Sherraden

Center for Social Development

109

Reference: Sherraden, M. (2005). Inclusion in Asset Building.


Individual Development Accounts

Individual Development Accounts (IDAs) are matched savings accounts that help people with modest means to save toward the purchase of a lifelong asset, such as a home.

It is called a match and is usually three to four times the size of each deposit the person makes.

◦ For example, if you receive a 3:1 match, each time you deposit $25, you will get an additional $75 toward your savings goal


CAREERS

Indiana Code 4-4-28

Indiana Code 4-4-28 requires that the State must provide at least a 3:1

match. In other words, while we typically match in excess of 3:1,

pending any change to the legislation, the State must always provide a

3 to 1 minimum.


CAREERS

Short-term or Long-term

An IDA program can be as short as six months or as long as several years from beginning to end (3 Years)

IDA participants are allowed to withdraw money as soon as they have reached their savings goal, but they must first get approval from their IDA program sponsor


CAREERS

What is Asset Development?Asset Development is accumulating things that

increase in value.

•Asset development is a savings account, a trust, buying a home, investing in a business, learning a new skill, or putting aside money in a PASS or IDA account.•Assets provide long-term benefits.•A home, a business, a computer, or a savings account is an asset.


113

Why is Asset Development important for People with Disabilities• According to the U.S. Census, there are 50 million

people in the U.S. living with a disability

• More than 34% of adults with disabilities live in households with total income of $15,000 or less

• Only 10% of people with disabilities own homes compared to 71% of those without disabilities

• More likely to be asset poor

Sources: The White House, Executive Summary: Fulfilling America's Promise to Americans with Disabilities. (http://www.whitehouse.gov/news/freedominitiative/freedominitiative.html.) April 2001 and National Disability Institute


114

What question on the Profile indicates that the beneficiary is a Good Candidate IDA?

(Demographic Information)


115

Are you interested in saving money?“Are you interested in saving money for a home, starting a business, or paying for an education for yourself or family member and would benefit from information about the work incentives that apply to these situations?” Yes or No

•IF YES, DISCUSS IDA


CAREERS

Good Candidate Profile Checklist

• Employed and Earning enough to put some into savings

• Individuals with income less than 175% of Federal poverty guidelines

• Has goals beyond immediate employment◦ Buy or rehab a home◦ Start or expand a business◦ Post secondary education for themself or an IRS defined dependent

• Willing to participate or has support network that is willing to participate in the education component of an IDA

117


Ways to Develop IDA & Assets

Indiana Housing and Community Development Authority

Take the extra money gained through the Social Security Work Incentives and set it aside in an Individual Development Account (IDA). The money saved in these accounts is not counted against the income and resource limits of SSDI, SSI, Medicaid, Medicare, TANF, Food Stamps, HUD (anything that has Federal funding)

Families can put money away in a Special Needs trust fund for use after their death. It can be arranged through a private attorney, or it can be part of a pooled trust such as the ARC Special Needs Trust


CAREERS

Once Accepted Into the Program

• You open a savings account at a bank that is tied to the IDA organization.

• You sign a contract that lays out how much money you plan to deposit each month.

• You attend a financial literacy training.

• You will also likely have regular meetings with the other participants in the IDA program who will offer peer support.

• Once you reach your savings goal, your IDA caseworker will confirm the purchase (or investment) and your savings will be released


CAREERS

Interested in setting up an IDA savings account?

Local Community Action Agencies or United Ways

Indiana Housing and Community Development

Authority

(800) 872-0371 (317) 232-7777

http://www.in.gov/ihcda/2341.htm


CAREERS

Additional Asset Development Resources

Indiana United Way

(317) 923-2377

Community Action Program (CAP)

(317) 638.4232 or 1.800.382.9895

Purdue Extension office(765) 494-8491

Contact the Indiana Housing and Community Development Authority

(800) 872-0371


CAREERS

Chapter 7

Supplemental Security Income (SSI)


Understanding the SSI Program

Supplemental Security Income, often referred to simply as SSI (Title XVI of the Social Security Act ), is another disability benefits program managed by the Social Security Administration

SSI is a benefit paid to people who are disabled, blind, or age 65 or older who have few resources and low income, and meet certain citizenship or residency requirements

The funds used to pay SSI benefits do not come from the Social Security trust fund, but are paid out of general federal tax dollars


SSI is a means-tested program

SSA has to determine what income or resources people have available in order to know whether or not SSI payment is possible, and how much to pay in benefits

Even after initial eligibility for SSI is established, SSA continues to assess the countable income and resources of all SSI recipients on a monthly basis

Individuals with countable income and resources over the allowable limits are not eligible for an SSI cash payment or associated Medicaid coverage


125

In the SSI program, an individual applying for benefits must meet the same definition of disability or blindness as individuals applying for Title II disability benefits

Applicants who have a disability (other than blindness) will not be awarded SSI benefits if performing Substantial Gainful Activity (SGA),$1,090 in 2015, at the time of application.

Individuals who meet SSA’s definition of being statutorily blind, however, may be awarded SSI even if they are performing SGA

The SGA test is waived for individuals who are blind per the SSA definition.

Statutory/legal blindness is defined as best corrected visual acuity of 20/200 or less in the better eye; or a visual field limitation such that the widest diameter of the visual field, in the better eye, subtends an angle no greater than 20 degrees.


Basic Eligibility Requirements

Age 65 or older, blind, or disabled

Reside in one of the 50 States, the District of Columbia, or the Northern Mariana Islands, except for a child of military parent(s) assigned to permanent duty anywhere outside the United States, or certain students temporarily abroad

Citizen or national of the U.S or an alien who meets the applicable requirements

Have income and resources within specified limits


Additional Requirements

Not be absent from the U.S. for a calendar month unless he/she is a child who is a U.S. citizen and lives outside the U.S. with a parent in the U. S. armed forces, or is a student who is temporarily abroad for the purpose of conducting studies

Files for any other benefits for which he or she is potentially eligible

Not be a fugitive felon

Not be violating a condition of parole or probation

Give SSA permission to contact any financial institution at any time and request any financial records that financial institution may have about the individual. Other people who are responsible for the individual’s support must also give SSA their permission to contact any financial institution at any time and request financial records that financial institution may have about them

File an application


Retroactivity

Unlike the Title II disability programs, there is no waiting period and no retroactivity under the SSI program

In the SSI program, payments are not made until the first full month following the application


Federal Benefit Rate (FBR) The Social Security Administration counts an individual’s or SSI eligible couple’s income on a monthly basis. To determine the SSI payment amount, income not excluded through work incentives or other provisions is subtracted from the SSI Federal Benefit Rate (FBR)

The FBR is a monthly amount that (usually) changes in January of each year, and is the highest Federal payment an individual or eligible couple (two SSI beneficiaries married, or holding out to the community as if married) may receive

2015 (Individual) $733.00

2015 (Couple) $1,100.00


Eligible Couples SSA defines an eligible couple as two SSI-eligible individuals who are:

1.Legally married under the laws of the state where they have a permanent home

2.Living together in the same household and holding themselves out as husband and wife to the community in which they live or

3.Determined by SSA to be entitled to either husband’s or wife’s Social Security benefits as the spouse of the other.

130

The term “eligible couple” only applies to SSI recipients, not beneficiaries of the Title II disability benefit programs.


How Income is Defined in the SSI Program The SSI program considers income to be anything an individual receives in cash or in-kind that can be used to meet the basic needs for food or shelter.

◦ In-kind income isn’t cash, but is actual food or shelter provided to an eligible individual or SSI eligible couple by someone else.

Under this definition, income also includes the receipt of anything that can be used, either directly or by sale or conversion, to meet basic needs of food or shelter

All income is categorized either earned or unearned income and treated very differently.


132

What is NOT Considered to be Income?

• Medical and social services

• Food and shelter received during a medical confinement

• Personal services performed for an individual

• Rebates, refunds, or other returns of money

• Income tax refunds

• Proceeds of a loan

• Payment of an individual’s bills

• Replacement income after a loss, theft, or destruction

• Weatherization assistance

• Miscellaneous fringe benefits

• Clothing


Income Exclusions Not all earned income counts:

1.Earned income tax credit (EITC) payments (effective January 1, 1991) and child tax credit payments

2.Up to $30 of earned income in a calendar quarter if it is infrequent or irregular

3.Earned income of a blind or disabled student regularly attending school, who is under the age of 22, up to the Student Earned Income Exclusion (SEIE)


134

4. Any portion of the $20 monthly General Income Exclusion (GIE), which has not been excluded from unearned income in the same month

5. $65 of the Earned Income Exclusion (EIE) in the month

6. Earned income of disabled individuals that is used to pay Impairment Related Work Expenses (IRWE)

7. One-half of remaining earned income in a month

8. Earned income of individuals with blindness that is used to meet any expenses the person has related to working-whether or not it is related to blindness - called Blind Work Expenses (BWE)

9. Any earned income used to fulfill an approved Plan for Achieving Self-Support (PASS)


How SSI Treats Unearned Income

SSA describes unearned income as any cash or in-kind item a person receives which is NOT earned income.

Unearned income would include the following:

•Periodic public payments or private annuities or pensions

•Income of a spouse or parent (for SSI recipients under the age of 18)

•Alimony and child support payments

•Rental payments

135

The Most Common Form of Unearned Income – Title II Disability Payments


Important SSI is considered to be the payer of absolute last resort!

If an individual is eligible for any other SSA benefit, that benefit must be accessed first, before SSI is considered.

Unearned income is counted when the individual receives it, when it is credited to the individual’s account, or set aside for the individual’s use.


Income Limits When countable income exceeds the Federal Benefit Rate (FBR) for the current month, ineligibility for SSI cash payments will result for that month.

137

2015 - $733.00 (individual) or $1,100.00 (couple)


Deemed Income

When SSA determines eligibility; the income and resources of people responsible for the recipient’s welfare are also considered.

This concept is called “deeming” and is based on the idea that those who have a responsibility for one another share their income and resources.


Three Types of Deeming

1. Parents to a child

2. Spouse to spouse

3. Sponsor to an alien


Parent-to-Child Applies to deeming of income and resources from an ineligible parent (or parents) to an SSI eligible child below the age of 18

◦ If one or both of the parents also receives SSI, then deeming does NOT apply

Once the child reaches age 18, deeming of income and resources from the parent(s) no longer applies under any circumstances

Generally, the child needs to be living with the parent(s), but there are some exceptions to that rule (e.g. a child away at school but under parental control)


Spouse-to-Spouse Applies to the deeming of income and resources from a spouse that is not eligible for SSI to a spouse that is eligible for SSI

If both are SSI eligible, another set of rules governing eligible couples would apply

141

Under some limited circumstances, individuals who are not legally married may be treated as a married couple for the purposes of deeming. SSA will make this determination


Sponsor-to-Alien

Applies to deeming the income and/or resources of an ineligible individual (and the individual’s ineligible spouse if the individual is married) who sponsors an alien’s legal entry into the United States

Deeming applies whether or not the alien lives with the sponsor

142

Deeming determinations are made by SSA at initial application, and during the annual redeterminations.


In-kind Support and Maintenance (ISM)

SSI is intended to cover the basic costs of food and shelter, if an SSI recipient is given food or shelter by another person, SSA will consider these gifts to be a specific type of unearned income.

Example: Parent to child


Determining the Value of ISMSSA applies one of two basic rules:

• The Value of the One-Third Reduction (VTR) rule is applied when the eligible individual lives in another person’s household for a full calendar month, receives both food and shelter from that person and pays NOTHING toward his/her pro-rata share of household expensesWhen the VTR rule applies, SSA reduces the SSI payment by a full one-third (1/3) of the current federal benefit rate (FBR).

•Presumed Maximum Value (PMV) - When a claimant or couple receives in-kind support and maintenance (ISM), but does not receive both food and shelter from the household in which the claimant or couple lives, the value of the one-third reduction (VTR) rule does not apply and the ISM is valued under the PMV rule.

When ISM is valued under the VTR rule, it actually results in a reduction in the beneficiary’s base SSI rate


Reporting Income in the SSI Program SSI recipients are required to report any and all income to the Social Security Administration when the income is received

This requirement applies equally to earned income such as wages and unearned income such as child support or Workers’ Compensation payments


Information which should be reported to SSA: 1. Unearned income (any other cash received that is NOT wages)

2. Any gross wages/earnings and net earnings from self-employment. This includes in-kind items received in lieu of wages (like room and board)

3. In-kind support and maintenance received from others

4. Change of address

5. Changes in living arrangements

6. Changes in marital status

7. Resources or assets received that cause total countable resources to be over the $2,000 limit

8. Use of any specific work incentives


How Income is Verified – Annual Redeterminations

A redetermination is a review of a beneficiary’s/couple’s non-medical eligibility factors such as income, resources, and living arrangements

SSI recipients can expect to have a redetermination conducted at least once per calendar year


OverpaymentWhen SSA recovers an overpayment from an individual, they will typically withhold it from future SSI payments

By Federal statute, SSA is not permitted to withhold more than 10% of the SSI FBR for recovery of overpayments without consent


Retrospective Monthly Accounting

1. The income eligibility test, which is based on the individual’s or couple’s income, in the month for which the payment calculation is made and

2. The payment computation, which is generally based on the income in the second month before the month for which payment is being computed

Stated more simply, eligibility is for the current month, but an individual or couple’s SSI benefit is usually based on the income received two months earlier


EXAMPLE:

Stella works and receives SSI. In June, she earns $860.00 gross wages.

In August she earns $435.00 gross wages.

Because of RMA (Retrospective Monthly Accounting), Stella’s August payment is based on her June, not August earnings.

In this situation, SSA would call June the “budget month” for Retrospective Monthly Accounting.


Practice Ginger is working at the Indianapolis Zoo she makes $9.00 an hour.

◦ August she worked 15 hours a week. ◦ Sept. she worked 25 hours a week ◦ Oct. she worked 10 hour a week

What would SSI count as her earned income in September?


CAREERS

How Resources Affect SSI SSI is a means-tested program intended for aged, blind or disabled people who have little income and few resources

Both income and resources affect SSI eligibility, but unlike income, resources do NOT affect the amount of SSI payment an individual receives.


153

Resources are defined as cash and any other personal property, including any real property, that an individual (or spouse): • owns

• has the right, authority, or power to convert to cash (if not already cash) and

• is not legally restricted from using for his/her support and maintenance

SSI eligibility with respect to resources is a determination made as of the first moment of each calendar month and applies to the entire month

Subsequent changes in resources within the month have no effect until the following month’s resources determination


Resource LimitsCountable resources must not exceed $2,000 as of the first moment of a given month.

If an eligible couple; the couple’s combined countable resources must not exceed $3,000.

There are some resource exclusions.


Common Resource Exclusions

•Household goods and personal effects •Medical devices and adaptive equipment•Some life insurance policies •The home in which the beneficiary lives •One automobile per household •Some burial funds, burial spaces, and life insurance assigned to funeral provider

•Student financial assistance received under Title IV of the Higher Education Act of 1965 (HEA) or Bureau of Indian Affairs (BIA including Pell grants and Work-Study grants

•Certain individual Development Accounts (IDAs) •Specific trust frunds (i.e. Special Needs Trust)


Earned Income Exclusions in the SSI Program

1. General Income Exclusion (GIE) – $20.00 exclusion of any kind of income—earned or unearned—that an SSI beneficiary has. If the SSI beneficiary has no unearned income, or has less than $20.00 in unearned income, the remainder of the $20.00 exclusion may be deducted from the person’s gross earnings

2. Earned Income Exclusion (EIE) – SSA excludes the first $65.00 of earnings after the applicable Student Earned Income Exclusion (SEIE) or General Income Exclusion (GIE) are subtracted

3. Student Earned Income Exclusion (SEIE) – Exclusion of income for individuals who are under age 22 and regularly attending school

4. Impairment Related Work Expenses – IRWEs are defined the same way under the SSI program that they are defined under the Title II program.


157

5. The ½ earnings exclusion or the “one-for-two offset”– The “1/2” exclusion permits SSA to exclude half of the earnings that remain after applicable deductions for the exclusions listed above have been made

6. Blind Work Expenses (BWE) – If the SSI beneficiary meets the definition of statutory blindness, he/she may deduct any items that meet the IRWE definition listed above as Blind Work Expenses, instead of under the Impairment Related Work Expense provisions.

7. Plan to Achieve Self-Support (PASS) – A PASS permits individuals to deduct countable income, or exclude resources that would otherwise reduce or eliminate the SSI payment.


Student Earned Income Exclusion

The Student Earned Income Exclusion (SEIE) is a work incentive that allows certain SSI beneficiaries who are under age 22 and regularly attending school to exclude a specified amount of gross earned income per month up to a maximum annual exclusion

The Student Earned Income Exclusion (SEIE) decreases the amount of countable earned income, thus permitting SSI recipients to keep more of the SSI check when they work

To qualify for the SEIE an individual must be:

•under the age of 22

•regularly attending school, college or training to prepare for a paying job and

•working


158

159

Regularly Attending SchoolRegularly attending school means that the person takes one or more courses of study and attends classes:

•In a college or university for at least 8 hours per week

•In grades 7 through 12 for at least 12 hours per week

•In a training course to prepare for employment for at least 12 hours per week (15 hours a week if the course involves shop practice)

•For less time than indicated above for reasons beyond the student’s control (such as illness)

A person who is homebound because of a disability may be a student when he or she studies a course or courses given by a school (grades 7-12), college, university, or government agency; and has a home visitor or tutor from school who directs the study or training

New Revision: Online School - An online school is one that offers Internet-based courses to students. Online schools vary considerably in the methods used to provide education to students.


Applying the Student Earned Income Exclusion (SEIE) The SEIE is applied to a student’s gross earnings before any other allowable exclusion

The Social Security Administration (SSA) will exclude all gross earnings up to a maximum amount per month until the full annual SEIE exclusion is exhausted, or the individual becomes ineligible for the SEIE by reaching the age of 22 or stops attending school.

2015 = $1,780 per month / maximum $7,180.00 year


161

Scenario 1: Scenario 2: Scenario 3:

Step One Scenario 1 Scenario2 Scenario3Unearned Income Subtract General Income Exclusion - -$20.00 -$20.00 -$20.00Equals Countable Unearned income =

Step Two Gross Earned Income

Student Earned Income Exclusion -

Subtract Earned Income Exclusion - -$65.00 -$65.00 -$65.00Subtract GIE (if not used above) - Remainder = Impairment-Related Work Exp. - Remainder = Divide by 2 /2 /2 /2 /2Remainder = Blind Work Expenses - Equals Countable Earned Income =

Step Three Total Countable Unearned Income Total Countable Earned Income + Countable Income = PASS Deduction - Equals Total Countable Income =

Step Four Base SSI Rate Deductions: (e.g., Overpayment) - Total Countable Income - Equals Adjusted SSI Payment =

Before/After Work Illustration Unearned Income (if any) + Gross Earned Income + New SSI Payment + Equals Total Income From All Sources = Minus cost of IRWE (if applicable) - Equals Total Adjusted Monthly Income =

Countable Income Formula Worksheet Pertaining to SSIPlease indicate for all scenarios the anticipated amount of hours to work each week multiplied by 4.3 multiplied by the monthly wage


IRWE and SSI Impairment Related Work Expenses (IRWEs) for SSI recipients permit the deduction of the value of goods or services that are:

•Related to the disability or to an impairment for which the person is receiving treatment from a health care provider

•Necessary for work

•Paid out of the beneficiary’s pocket and not reimbursed by any other source

•Reasonable and

•Paid in the month earnings were received


163



Step Two Gross Earned Income Student Earned Income Exclusion - Subtract Earned Income Exclusion - -$65.00 -$65.00 -$65.00Subtract GIE (if not used above) - Remainder =

Impairment-Related Work Exp. -

Remainder = Divide by 2 /2 /2 /2 /2Remainder = Blind Work Expenses - Equals Countable Earned Income =






Blind Work Expenses (BWE)

•Must be stat blind per SSA

•Blind Work Expense (BWE) provisions allows exclusion of any work related items that are paid out of pocket and not reimbursed In addition to goods or services that would normally be deducted under the

IRWE provisions outlined above

164

The biggest difference between BWE and IRWE is that Blind Work Expenses do not need to be related to any

impairment.

Blind Work Expense ONLY apply in the SSI program!


165

BWE Examples include, but are not limited to:

• State and federal taxes • Union dues • Mandatory pension contributions • Uniforms • Reader services • Driver services • Cost of service animal’s care • Childcare • Transportation • Meals consumed at work • Adaptive equip. purchased by beneficiary


166



Step Two Gross Earned Income Student Earned Income Exclusion - Subtract Earned Income Exclusion - -$65.00 -$65.00 -$65.00Subtract GIE (if not used above) - Remainder =

Impairment-Related Work Exp. -

Remainder = Divide by 2 /2 /2 /2 /2Remainder =

Blind Work Expenses -

Equals Countable Earned Income = Step Three

Total Countable Unearned Income Total Countable Earned Income + Countable Income = PASS Deduction - Equals Total Countable Income =





Work Incentives that Create

Excluded Resources The SSI program contains several special provisions that allow individuals to set aside resources for use in achieving an occupational goal, or to have resources that are used as part of a business or are necessary for self-support.

Plan to Achieve Self-Support (PASS)

Property Essential to Self-Support (PESS)


168

Plan to Achieve Self-Support (PASS) •Set aside income and/or resources for a specified period of time in order to pay for items or services needed to achieve a specific work goal

•Under an approved PASS an individual may set aside income and/or resources to pay for education or training, job coaching or other support services, transportation, job-related items, equipment needed to start a business, or just about anything else needed to achieve an occupational goal

•Income and/or resources set aside in a PASS are not counted when determining SSI eligibility or when determining the amount of SSI payment an eligible individual is due

•A person whose income or resources are too high to qualify for SSI may develop a PASS to set aside the excess income and/or resources for use in their work goal, thus establishing initial SSI eligibility


169

Individuals Who May Benefit from a PASS These characteristics include the following: •PASS reflects individual choice - Individuals choose their own work goal and develop their own plan for achieving that goal

•PASS is self-financed - Individuals use their own funds to pursue the plan. The receipt of, or an increase in SSI benefits up to the amount of the Federal Benefit Rate (FBR), and any applicable state supplement, replaces some or all of the funds that the individual uses for the PASS

•PASS is largely self-directed - Individuals decide what goods and services are needed to reach the work goal

•PASS is highly individualized - Each PASS is specifically designed to meet the needs of a unique individual


170

It is important to keep in mind that if a Title II disability beneficiary uses the PASS to establish eligibility for SSI and sets aside Social Security disability benefits, the goal must be likely to result in work above the SGA level and lead to the eventual loss of the Social Security disability benefit

By setting the Title II disability payment aside under an approved PASS, the SSI program essentially disregards this income when determining eligibility for SSI

If the PASS is approved, the Title II payment continues and is used to pay for the items or services needed to achieve the stated occupational goal. In return, the individual will receive SSI cash payments during the life of the PASS

PASS is typically 18 – 48 months


171

PASS: Important Points to Consider

PASS must have an occupational goal

Supported Employment Goals - An individual in a supported employment program may submit a PASS whose goal is to achieve stabilization in that job, to work more hours, or to work with less support (fewer hours of job coaching per week, for example). Such plans should specify the targeted level of performance in terms of the supports required, and how long it will take the individual to reach the goal

Self-Employment Goals - For individuals with a work goal of self employment, general small business start-up costs will be approved for a minimum of at least 18 months, if necessary for business operation. A PASS with a self employment goal must include a detailed business plan and this plan must meet very stringent requirements set by SSA

PASS Cadre: 866-575-4889 or 312-575-6505 http://www.socialsecurity.gov/online/ssa-545.html


172



Step Two Gross Earned Income Student Earned Income Exclusion - Subtract Earned Income Exclusion - -$65.00 -$65.00 -$65.00Subtract GIE (if not used above) - Remainder = Impairment-Related Work Exp. - Remainder = Divide by 2 /2 /2 /2 /2Remainder = Blind Work Expenses - Equals Countable Earned Income =

Step Three Total Countable Unearned Income Total Countable Earned Income + Countable Income =

PASS Deduction -

Equals Total Countable Income = Step Four

Base SSI Rate Deductions: (e.g., Overpayment) - Total Countable Income - Equals Adjusted SSI Payment =




Property Essential to Self-Support

PESS is a Social Security provision that lets you exclude counting certain properties (resources necessary for your self-support) when calculating your SSI benefits

How the PESS Works

Social Security will not count some of the following property when calculating your monthly SSI benefit amount:

173

• The full value of tools or equipment used for trade or business, for example,

(carpenter tools, mechanic tools, computers, wheelchairs, or inventory used

for a trade or business)

• Certain amounts of the value of non-business properties that are used to

produce goods, (i.e., land used to produce vegetables or livestock solely for consumption by the individual’s own household)

• Some amounts of non-business, income-producing properties, provided that the property yields a profit


SSI and Net Earnings from Self-Employment (NESE)

To determine a Net Earnings from Self-Employment or NESE, SSA deducts business expenses allowed by the IRS on Schedule C of the Federal income tax form 1040 from the gross receipts that the person received for the year

Once NESE is determined, SSA divides those net earnings equally among all 12 months in the individual’s taxable year (i.e. the calendar year). This is done even if the business is seasonal, did not operate for the entire year, or ceased operation prior to making application for SSI

Benefit payments are adjusted retroactively for the entire calendar year to reflect this NESE


Section 301Section 301 Continuation of Benefits after Medical Recovery

•The Section 301 provision allows continuation of disability or blindness benefit payments to certain individual’s disability or blindness medically ceases (medically improved) while he/she is participating in an appropriate program of vocational rehabilitation (VR) services, employment services, or other support services


Expedited Reinstatement of Benefits (EXR)If a SSI recipient works there way to the break even point of SSI ($0 cash benefits) for 12 months then their benefit is terminated. They would need to request an EXR.

The EXR request must be made within 60 months of termination.

Beneficiaries may receive provisional payments and have Medicaid while SSA is deciding if reinstatement is possible.

176

A request for EXR can be a complicated decision and many factors enter into it. The SSA is best equipped to

help someone make the EXR decision since they make the decision of what will be paid and whether benefits are

payable at all.


EXR Facts The use of SSI work incentives is immediately possible after reinstatement

Once someone receives SSI through Expedited Reinstatement, he or she must receive benefits for 24 months before again requesting EXR

If the entitlement ends before the 24 months have passed, the person would have to reapply to get SSI payments again


CAREERS

Countable Income Formula Worksheet (CIF)

178

When SSA calculates SSI payments, they use the exact amount of income received in past months

To avoid SSI overpayments in the future, SSA will also estimate future earnings by projecting amounts based on the beneficiary’s recent earnings


179



Step Two Gross Earned Income Student Earned Income Exclusion - Subtract Earned Income Exclusion - -$65.00 -$65.00 -$65.00Subtract GIE (if not used above) - Remainder = Impairment-Related Work Exp. - Remainder = Divide by 2 /2 /2 /2 /2Remainder = Blind Work Expenses - Equals Countable Earned Income =






180

Twelve (12)-months Suspension Period

When an SSI recipient loses eligibility for cash payments due to reasons other than medical improvement, ineligibility for SSI results. Ineligibility will begin as of the first day of the month in which income or resources exceeds statutory limits or another eligibility factor ceases to be met (i.e. person is incarcerated)

While beneficiaries are ineligible for SSI at this time, they are not “terminated” from the SSI program. Beginning with the first month of ineligibility, individuals begin a “suspension period” of up to 12 months


181

Emergency Advance Payments &Immediate Payments There are two ways to make payments to persons via Third Party Draft who have a financial emergency.

Emergency Advance payments are only available to persons who have been found eligible for SSI

Immediate payments may be made to SSI recipients, Title II beneficiaries, as well as to concurrent beneficiaries receiving both SSI and a Title II benefit

Both EAPs and IPs are considered to be advances against future SSI/Title II disability payments and must be recovered by SSA at a later date. They are not additional money due the individual. SSA personnel are directed to make EAPs and IPs when the criteria for them are met.


Activity


CAREERS

Chapter 8

Understanding Healthcare Programs

Medicaid


184

Understanding Medicaid Indiana used to be a 209(b) Medicaid state, and in June of 2014 it changed to a 1634 state, which is what most states are and brings us in line with SSAhttp://www.indianamedicaid.com/

Medicaid, also known as Medical Assistance, is a cooperative federal-state program authorized by Title 19 of the Social Security Act.

If a person is eligible for SSI they are AUTOMATICALLY eligible for Medicaid; there is no longer a separate determination process.

◦ This also means that IN Medicaid’s resource limit is the same as SSI’s: $2,000 and $3,000


Indiana Health Coverage Programs (ICHP)

The Office of Medicaid Policy and Planning and the Children’s Health Insurance Program (CHIP) have categorized all covered IHCP into distinct subprograms and include the following:

• Hoosier Healthwise

• Healthy Indiana Plan (HIP)

• Hoosier Care Connect

185

Care Select no longer available since July 1st, 2015


Traditional Medicaid Traditional Medicaid generally includes the aged, blind, and disabled population

Individuals receiving Traditional Medicaid services may also be participants (or members) in Hoosier Care Connect or the 590 Program

The 590 program provides Medicaid assistance for those who are residents of state-owned facilities under the direction of the Indiana Family Social Services Administration.


SSDI & SSI (dual eligible)DUAL ELIGIBLES: Federal law requires that state Medicaid programs pay Medicare premiums, co-insurance, and deductibles for certain elderly and disabled people

Medicaid members who are eligible for both Medicaid and Medicare are referred to as dually eligible. When Indiana pays for the Medicare premiums of individuals, it is referred to as Medicare Buy-In

Indiana and other states receive Federal Financial Participation (FFP) for premiums paid for members eligible as the following:

• Qualified Medicare beneficiaries (QMB) (Indiana’s only focus)• Qualified disabled working individual (QDWI) • Specified low-income Medicare beneficiaries (SLMB) • Qualified individual (QI-1)


187

Medicaid Waivers Special provisions allow states, with approval of the federal Centers for Medicare and Medicaid Services, to “waive” (or not follow) specific requirements of the Medicaid Act

HCBS (Home – Community Based Services) waivers are important for persons with disabilities because they allow states to extend Medicaid eligibility to individuals at risk of institutionalization who wish to remain in a community setting.

Aged and Disabled WaiverTraumatic Brain Injury WaiverCommunity Integration and Habilitation Waiver (formerly Developmental

Disability and Autism Waiver)Family Supports Waiver (formerly Support Services Waiver)


Community Mental Health Medicaid Rehabilitation Option: MRO

MRO services are clinical mental health services provided to members, families, or groups living in the community who need aid intermittently for emotional disturbances or mental illness.

Some mental health providers use this funding for extended services.


Behavioral and Primary Healthcare Coordination (BPHC)

Coordination of healthcare services to manage the healthcare needs of the individual. BPHC includes logistical support, advocacy and education to assist individuals in navigating the healthcare system. Must be at least 19 and have a BPHC eligible primary mental health diagnosis

Those in the program are eligible for Medicaid

Must apply at local community mental health centers

Individuals must have countable income of 300% of FPL or less

http://www.in.gov/fssa/dmha/2883.htm


Hoosier HealthwiseHoosier Healthwise is Indiana's health care program for children, pregnant women, and low-income families. It is a health care program administered by the Indiana Family and Social Services Administration.

The goals of Hoosier Healthwise are to:

1. Ensure access to primary and preventive care services

2. Improve access to all necessary health care services

3. Encourage quality, continuity and appropriateness of medical care

4. Provide medical coverage in a cost-effective manner

Individuals who enroll in Hoosier Healthwise are eligible for either Medicaid benefits or benefits through the Children’s Health Insurance Program (CHIP).


191

192

The member’s specific eligibility aid category determines their benefit package. Based on family income, children up to age 19 may be eligible for premium-free coverage, or low-cost coverage under the Children's Health Plan - Benefit Package C

Pregnant women can be eligible for full coverage under Package A, or for pregnancy-related coverage under Package B, depending on family income and assets

Low-income families can be eligible for Hoosier Healthwise Package A, if there are children under the age of 18 living with their parent(s) or other caretaker relative. Young adults 18, 19, and 20 who live with a caretaker relative who meet the financial requirements can be covered; however, their caretaker relative is not eligible


Healthy Indiana Plan 2.0

An affordable health insurance program from the State of Indiana for uninsured adult Hoosiers. The Healthy Indiana Plan pays for medical expenses and provides incentives for members to be more health conscious.

The Healthy Indiana Plan provides:◦ Coverage for qualified low-income Hoosiers ages 19 to 64, who are interested

in participating in a low-cost, consumer-driven health care program. ◦ Hoosiers with incomes of up to $16,436.81 annually for an individual,

$22,246.25 for a couple or $33,865.13 for a family of four are generally eligible to participate in the Healthy Indiana Plan.


193

HIP Plans ◦ HIP Plus - The preferred plan available to most HIP-eligible individuals; provides

the best value for members. HIP Plus members are required to pay affordable monthly contributions in a Personal Wellness and Responsibility (POWER) Account and receive a full commercial benefit package that includes coverage for vision and dental services.

◦ HIP Basic - Available only to HIP members with incomes at or below 100% of the federal poverty level (FPL), who lose HIP Plus eligibility because they did not make the required POWER Account contributions. HIP Basic members have a more limited benefit plan and most are assessed copayments for most services (no vision or dental).

◦ HIP Link - (Implementation pending) - HIP Link allows HIP-eligible individuals who have access to qualifying employer-sponsored insurance plans to enroll in their employers' plans and receive assistance with premiums and cost-sharing obligations.


CAREERS

195

Hoosier Care ConnectHoosier Care Connect was implemented to improve the quality of care and clinical outcomes for members eligible for the Indiana Health Coverage Programs (IHCP) on the basis of age, blindness, or disability.

Hoosier Care Connect members receive full Medicaid benefits, in addition to care coordination services and other FSSA-approved enhanced benefits through managed care entities contracted to manage the care of eligible members.

These services include:◦ Primary care ◦ Acute care ◦ Prescription drugs and certain over-the-counter drugs ◦ Behavioral health ◦ Emergency services ◦ Dental services ◦ Transportation services


Verifying MedicaidVery Important!!!

FSSA Benefits Portal https://www.ifcem.com/CitizenPortal/application.do#

Medicaid Eligibility Website ◦ If your agency bills Medicaid


Medicaid Work Incentive

1619(b): Continued Medicaid for Persons Who Lose SSI Due to Earned Income

Section 1619(a) permits eligible disabled SSI recipients to receive a reduced cash payment when earnings exceed the Substantial Gainful Activity amount (Countable Income Formula)

Part (b) of Section 1619 extended these protections, allowing eligible disabled or blind individuals to continue to be considered SSI recipients for the purposes of Title 19 or Medicaid eligibility, even though cash benefits actually ceased due to earned income.

◦ This only works until the 12 month suspension period

Individuals who are utilizing the Section 1619(b) work incentive provision do not receive SSI payments because their income is over the Break-Even Point (BEP) after all exclusions and deductions have been applied


197

Not everyone who loses eligibility for SSI cash benefits will be eligible for 1619(b). This provision is a work incentive intended for eligible individuals who have earned income

Although everyone who is eligible for Medicaid the month before their wages reach the BEP is entitled to Medicaid under 1619(b), it is not automatic

The SSI Claims Representative must enter a special code on the SSI record at the same time the SSI payment stops to begin 1619(b). This information is forwarded by SSA to the State Data Exchange (SDX)


199

Allows eligible 1619(b) recipients to receive a SSI cash payment in any month in which income falls below the break-even point.

Enables people who are ineligible for continued Medicaid coverage because earnings exceed the threshold amount to get SSI cash payments again if earnings fall below the break-even point within 12 months.

Allows people who are ineligible for continued Medicaid coverage because earnings exceed the threshold amount to regain Medicaid eligibility if earnings drop below the threshold amount within 12 months.

For Indiana in 2015 the state threshold is $37,087.00Enables people whose eligibility (including 1619(b) eligibility) is suspended for less than 12 months to be reinstated to cash benefits or 1619(b) status without a new application or new disability determination.


200

1619(b) for Eligible CouplesFor the purposes of SSI, an eligible couple exists when two SSI recipients are married to each other. If both members of the eligible couple have earned income, then all of that income is disregarded when considering 1619(b) eligibility for both members of the couple

It does not matter how much either person is contributing; one person may even be contributing less than the $65 earned income exclusion. If both members have earned income at some level, then both get 1619(b)

If only one member’s 1619(b) status is being considered, then the earned income is only disregarded for that one person, not the spouse

Since 1619(b) is considered a work incentive, it is only available to persons who are working


Medicaid Eligibility And The Pickle Amendment

Named after its Congressional sponsor and enacted in 1977, the Pickle Amendment created a separate category of Medicaid eligibility.

Under the Pickle Amendment, an individual who received both Social Security benefits (SSA) and Supplemental Security Income (SSI) benefits but became ineligible for SSI due to cost-of-living adjustments (COLA) in the SSA benefit will remain eligible for Medicaid if the individual would continue to be eligible for SSI benefits if the COLA increases in the SSA benefits were disregarded.


MED-WorksMED Works is Medicaid for Employees with Disabilities

MED Works is a program designed to allow disabled employees to work without fear of losing their Medicaid. MED Works offers the same coverage levels as regular Medicaid

There may be small monthly premiums based on the amount of money a worker earns

*Now that Indiana is a 1634 state, an individual must continue to meet SSA’s disability standard in order to keep his or her MED Works.


203

Family Size Income Guidelines

Income Range Premium

Single $1,472 to $1,716 $48

$1,717 to $1,962 $69

$1,963 to $2,452 $107

$2,453 to $2,943 $134

$2,944 to $3,433 $161

$3,434 $187

Married $1,992 to $2,323 $65

$2,324 to $2,655 $93

$2,656 to $3,319 $145

$3,320 to $3,983 $182

$3,984 to $4,647 $218

$4,648 $254

2015 Premium Chart*If gross income is less than $1,472 for a single person or $1,992 for a married couple, there is no premium.


Chapter 9

Benefits Planning Query

Handbook


BPQY Handbook

Who Can Get A BPQY?

Requesting a BPQY (SSA-3288) 2 forms

Understanding the BPQY

The handbook can be found on Larry Docs https://sites.google.com/site/bindocuments/home


Review BPQY Snapshoot of SSA record

Name, SS#, dates, benefits, etc.

Health insurance, SSI work exclusions, SSDI work activity, Earnings report (annual & monthly)

SSA release forms



CAREERS

Using the BPQY Effectively

Critical components of the BPQY that the BIN Liaison should pay close attention to are as follows:

◦ Recent earnings on record◦ Cessation month◦ Use of work incentives – SEIE, IRWE, PASS, BWE◦ Buy In or Subsidy participation◦ Payment amount◦ Date of entitlement◦ Others paid on record◦ Medical review date


209

It is important to remember that not all information a BIN Liaison might need will be shown on the BPQY. However, some of the items that are listed on the BPQY will trigger the BIN Liaison to ask further questions so that accurate advisement can be given. Some important information NOT found on the BPQY includes:

◦ Type of in-kind support and maintenance – VTR or PMV?

◦ Deemed income

◦ New period of entitlement via EXR or reapplication?


210

BIN Assignment Find a beneficiary (can be a VR referral but doesn’t have to be) Complete a profile Have beneficiary sign releases (your agency releases, IN Works releases, BPQY releases [both of them])

Fax BPQY releases to local SSA office and get BPQY Gather any other verification of benefits (Medicaid, Medicare, HUD, etc)

Bring all of this back with you next month Day 1 & 2 Quiz

DO NOT START WORKING ON THE PLAN!!!


Insurance Activity


CAREERS

Chapter 10

Ticket to Work Program


213

The 2008 Amendments to the Ticket Regulations

All title II disability and SSI adult disability beneficiaries who are between the ages of 18 and 64 and currently receiving cash benefits will be eligible for a ticket, including those who are classified as medical improvement expected (MIE)

The expectation of Social Security is that beneficiaries will participate in greater numbers and, over time, achieve earnings levels that will eliminate their dependence on disability benefits


Eligibility for a Second Ticket

An individual is eligible for only one Ticket during a period of entitlement to Title II disability or SSI based on disability or blindness. However, if entitlement to Title II disability or SSI ends or is terminated, and is later reinstated, a new Ticket will be issued

There is no limit to the number of new Tickets an individual can receive


Assigning a Ticket A beneficiary can assign a Ticket to an Employment Network (EN) or state Vocational Rehabilitation (VR) agency or otherwise use it with a state VR agency if the Ticket is valid and the beneficiary is receiving a cash payment.

To assign a Ticket, a beneficiary must first find an EN or state VR agency that is willing to accept it.

http://www.chooseworkttw.net/


Medical Continuing Review (CDR) Protection and Use of a Ticket

A medical CDR is the review conducted by SSA to determine whether or not a beneficiary continues to meet SSA’s disability standard.

SSA will not initiate a medical CDR when the beneficiary has a ticket assigned and in use.

However, this protection does not apply to work reviews SSA may conduct to determine whether or not a title II disability beneficiary is engaging in substantial gainful activity.


Using a Ticket SSA defines using a ticket as a specified period of time during which the beneficiary is actively making progress according to SSA’s Progress Review guidelines to become self-supporting.

The EN or state VR agency monitors the beneficiary’s progress, but the OSM (Maximus) actually decides if the beneficiary is using a ticket and making timely progress.

SSA cannot initiate a medical CDR while the beneficiary is using the ticket and making timely progress.


The Operations Support Manager - MaximusMAXIMUS: The Operations Support Manager is responsible for:

1. Serving as the “face of the Ticket Program” to ENs and SVRAs from the point of initial outreach and recruitment through active EN participation;

2. Recruiting experienced and highly qualified Employment Networks;

3. Facilitating and monitoring of active Ticket program participation by ENs;

4. Administering and supporting the Ticket assignment process; and,

5. Administering and supporting the Employment Network payment process.

http://www.yourtickettowork.com/


Employment Networks (ENs) An EN is any qualified entity that has entered into an agreement with the SSA to function as an EN under the Ticket to Work program

To serve as an EN an entity must meet and maintain compliance with both general and specific selection criteria.

An EN will serve a beneficiary, who has assigned his or her ticket to the EN, pursuant to a written Individual Work Plan (IWP)


CAREERS

EN Responsibilities Coordination and delivery of employment services

VR services

Case management

Benefits management

Extended Services Support

Other support services (As defined in the IWP)


221

The Ticket legislation provides a representative list of services available through the Ticket program.

It includes “case management, work incentives planning, supported employment, career planning, career plan development, vocational assessment, job training, placement, follow up services, and such other services as may be specified by [Social Security] under the Program.”

Although the law and regulations authorize a fairly open ended array of potential services, there are no criteria or test governing what services a beneficiary will get with a Ticket. Since the program is voluntary, there is no mandate for an EN (other than a state VR agency) to provide any specific service or serve any specific beneficiary, except as established by the IWP.


Individual Work Plan (IWP)

An IWP is a required written document signed by an EN and a beneficiary, or a representative of a beneficiary. It is developed and implemented in partnership when a beneficiary and EN have come to a mutual understanding to work together to pursue the beneficiary’s employment goal.

The IWP outlines the specific employment services, vocational services, and other support services that the EN and beneficiary have determined are necessary to achieve the stated employment goal.

The beneficiary and EN share responsibility for determining the employment goal and the specific services needed to achieve it.


Ticket Ends When…The period of using a Ticket ends with the earliest of the following:

•The date before the effective date of a decision that the beneficiary is no longer meeting timely progress requirements; or

•If the beneficiary’s Ticket was assigned, but is no longer assigned to an EN or state VR agency acting as an EN, the last day of the 90-day extension period if the beneficiary fails to reassign his or her Ticket within the extension period; or

•If the beneficiary’s Ticket was in VR cost reimbursement status, the 90th day following the date the state VR agency closes the beneficiary’s case if the beneficiary fails to assign his or her Ticket within that period; or

•The last day of the month before the month in which the Ticket terminates as a result of one of these events.


CAREERS

Ticket Termination The month in which entitlement to Title II disability benefits based on disability ends for reasons other than work activity or earnings, or the month in which eligibility for SSI benefits based on disability or blindness terminates for reasons other than work activity or earnings, whichever is later;

If the beneficiary is entitled to widow’s or widower’s insurance benefits based on disability, the month in which the beneficiary attains full retirement age;

If the beneficiary is eligible for SSI benefits based on disability or blindness, the month following the month in which he or she turns age 65; or

The month after the month in which the beneficiary’s outcome payment period ends;

The month in which the beneficiary dies.


225

•The Ticket program is an outcome-based employment program administered by the Social Security Administration

•The goal of employment service providers participating in the Ticket program should be to assist people receiving Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) benefits attaining self-sufficiency through sustained work at or above the Substantial Gainful Activity (SGA) level

•SGA for 2015 is earnings of $1,090/month for Ticket Holders with disabilities other than blindness and $1,820/month for Ticket Holders who are blind or visually impaired.

https://yourtickettowork.com/web/ttw/en-payments


Chapter 11

Overview of Self-Employment and Work Incentives


226

Self-Employment Earnings

Earnings are counted differently under self-employment:◦ Social Security considers Net Earnings from Self-

Employment (NESE) NOT gross earnings when counting income.

◦ NESE= (Gross receipts – expenses x .9235)◦ The self-employment tax, calculated on Schedule SE, is

applied to 92.35% (.9235) of the actual net earnings from self employment.

◦ SSA uses IRS rules and tax return to determine NESE.


227

Example of Determining NESE

$2000.00: monthly gross receipts

-$1000.00: business expenses

___________________________

1000.00 (IRS net income)

x.9235 (SSA’s exclusion for FICA)

___________________________

$923.50 NESE/month


228

Is it a Business? Consider the following in determining the existence of a trade or business:

◦ The good faith intention of making a profit or producing income

◦ Continuity of operations, repetition of transactions, or regularity of activities

◦ Regular occupation◦ Holding out to others as being engaged in the selling of

goods or services


229

Factors to Consider in a Business

Seasonal– Although length of time is usually an important factor, certain activities

are seasonal, e.g., selling ice cream during the summer months.

Illegality– An illegal activity may constitute a trade or business. Individuals

engaged in such activities are required to report their income and pay SE taxes.

Hobbies– The buying and selling involved with a hobby is generally done for the

purpose of improving or otherwise furthering the hobby. In these cases, the activities do not constitute a trade or business.


230

SSA Makes the Decision:

‘Is It a Business?’

The SSA makes the final decision of whether work effort is wage employment or self-employment

Have the consumer request a determination from the SSA


231

Self-Employment and SSDI BenefitsTWP months occur when NESE (Net Earnings from Self- Employment) are over $780 (in 2015) or when the beneficiary works for 80 hours or more, regardless of the amount they earn.

NESE is NOT averaged during TWP, but assessed on a month by month basis by examining income and expenses. This also applies in the EPE after cessation. NESE is averaged over the period of work when making SGA determinations.


232

Self-Employment and SSDI Benefits

The value of the work effort is what is most important

SSA is looking for a consistent pattern of work behavior

SSA uses numerous “tools” to assess the value of work:

◦ Income averaging◦ Unsuccessful Work Attempt (UWA)◦ Subsidy◦ IRWEs CENTER ON COMMUNITY LIVING AND

CAREERS233

Additional Work Incentives

234

Unincurred Business Expenses — If there is business support given to you at no cost (for example Vocational Rehabilitation pays for services or equipment you need in self employment), the cost of this support is deducted from your net earnings in determining when you have reached SGA.

Unpaid Help — If you receive help from friends, relatives, professionals or others in performing business-related tasks, and they are not paid for this assistance, the fair labor cost of this assistance is deducted from your net earnings in determining whether you have engaged in SGA.


Determining SGA for Self-Employment

“In determining whether a self-employed individual is engaging in SGA, consideration must be given to the individual's activities and their value to the business.

Self-employment income alone is not a reliable factor in determining SGA, since it is influenced not only by the individual's services but also by such things as market conditions, capital investments, the services of other people, and agreements on distribution of profits.”

(POMS DI 10510.001)


235

Earnings from Self-Employment and SSI

Social Security will average an individuals earnings over a taxable year’s period, rather than looking at each month’s earnings.

Averaging earnings results in the same adjusted SSI check each month. Therefore, it is VERY IMPORTANT to get a good estimate of what the year’s earnings will be and divide by 12.

If you underestimate, you may have an overpayment, if you overestimate, you will have an underpayment.

(see POMS SI00820.210)


236

SSI Work Incentives for Self-EmploymentOnce SSA determines the average earnings they will apply the countable income formula (by subtracting the GIE (general income exclusion) and the EIE (earned income exclusion) and then apply the 1 for 2 reduction). Then they will compare that to the Federal Benefit Rate.

If other SSI work incentives apply to the individual, they will include these in the countable income formula. You will need to evaluate if there are other available work incentives.


237

Chapter 13

Food Stamps

(Supplemental Nutrition Assistance Program)


239

Supplemental Nutrition Assistance Program (SNAP http://www.in.gov/fssa/dfr/2691.htm)•Federal program housed within the U.S. Department of Agriculture

•This program helps low-income people purchase food

•Those that may be eligible to receive SNAP are those who work for low wages, are unemployed or work part time, receive welfare or other public assistance payments, are elderly or disabled and live on a small income, or are homeless

•SNAP provides a type of credit card for food purchases


Basic Eligibility Requirements for SNAP

All members of the household, including children, must have a Social Security Number

There is a work requirement for most adults between the ages of 16 and 60, however people with disabilities are deferred from the work requirement

The USDA adjusts SNAP maximum allotments, deductions, and income eligibility standards at the beginning of each Federal fiscal year. The changes are based on changes in the cost of living adjustments (COLA) which are announced in October each year


SNAP FactsOne of the rules that applies only to persons with a disability has to do with living arrangement. Generally, people living in institutional settings in which the food is provided are not eligible for food assistance

However, under certain circumstances, people living in non-profit residential settings of 16 or fewer individuals can qualify for food assistance even if they need someone within that setting to help them prepare the food

Individuals who are already receiving SSI are considered “categorically eligible”. Basically, if any member of the household receives SSI the income test is met


242

SNAP benefits are based on financial need.

The first 20% of earned income is not counted when determining your new amount.

The remaining 80% of earned income usually results in just about a $1 for $3 reduction (approximately) in what you will receive.

DFR (Division of Family Resources) will do this calculation

Report all changes - benefit can also increase again if earnings should lessen for some reason.


Chapter 14

TANF

(Temporary Assistance for Needy Families)


244

Temporary Assistance for Needy Families (TANF)

TANF is a federal program that is state administered

TANF program is designed to allow states to receive block grants that have a few core federal requirements

The core federal requirements for TANF funds are: • Recipients are limited to 60 months of TANF funds in a lifetime per

family; and

• A parent or caretaker in the household must pursue work in order to continue receiving benefits.

The federal requirement states that within 24 months of receiving TANF, work activity should begin. That work activity could be job training, volunteer work or actual paid employment.

In Indiana, the work program associated with TANF is called IMPACT : (Indiana Manpower Placement and Comprehensive Training)


245

What is TANF? TANF is a program that provides cash assistance and supportive services to assist the family achieve economic self-sufficiency.

Who is eligible for TANF? Families with children under the age of 18.

May a family have any real or personal property? A family may not possess assets valued in excess of $1,000 at the time application for assistance is made. The house, which is the usual residence, is exempt.

Where do I apply?To apply to the local Division of Family Resources Office in your county of residence. - responsibility of processing applications - certifying eligible applicants for participation - issuing benefitsApplications may be taken to the local DFR office, mailed or faxed.

FSSA http://www.in.gov/fssa/dfr/2684.htm


TANF and SSISSI and TANF interrelate.

Eligibility for SSI is based on that person’s individual circumstance whereas TANF is a benefit to a family. These two programs are not based on the same types of income tests.

There may be one member of a family who is receiving SSI while the rest of the family is receiving TANF. This is often the case when a child receives SSI under the children’s eligibility test, and a TANF check comes to the household based on the entire family’s income.

If an individual applies for TANF and the caseworker suspects the individual may be eligible for Social Security benefits, they will refer the individual to the Social Security Administration.


TANF and Title II Disability Benefits

If Title II disability beneficiaries have dependents, in addition to the Social Security disability check coming into the household, there may also be receiving a child’s (or a child’s and young spouse’s) benefit.

If a family applies for TANF and there are several members of that family receiving Social Security benefits, many times the amount of the Social Security checks coming into the household will disqualify the family from TANF because the income is too high.

TANF counts every penny of unearned income, so it doesn’t take a great amount of Social Security benefits to make a person financially ineligible for TANF benefits.


248

Indiana TANFIndiana uses part of the TANF Block Grant to supplement the Child Care Development Fund and/or Social Services Block Grant in addition to funding the following programs:

Assisted Guardianship Program Children’s CHOICE Program TANF Child Care Assistance Domestic Violence Prevention/Treatment Emergency Assistance Emergency Assistance for Hurricane Katrina Evacuees Early Intervention - First Steps Healthy Families (A child abuse prevention strategy) Mitch’s Kids TANF Funded Low-Income Heating and Energy Assistance Program TANF and IMPACT


Housing Activity


CAREERS

BIN Manual Reference Material

250

Please read on your own!



251

Produced by:

iidc.indiana.edu/cclc

812-855-6508

2015 basic benefits information network (bin) training understanding social security and federal,...

Documents

community living

careers slide

community iidc

community advocates

careers http

federal benefits bin

kelley center

certified bin liaisons