understanding federal benefits

Entitlements Training:The Basics

Adrian Wicker301-493-4200 ext 411

[email protected]

mailto:[email protected]

Social Security Administration (SSA)

1,300 local field offices (New Hampshire Ave or Rockville)

10 regional officesOver 60,000 employeesState contracted Disability Determination

Service (DDS) makes disability decisionLocal field offices make ALL OTHER decisions

(including work incentives)

Benefits Under the Social Security Act

Title II: Retirement, Disability, Survivors and Dependents Insurance (SSDI, CDB, DWB)

Title XVI: Supplemental Security Income (SSI)Title XVIII: MedicareTitle XIX: Medicaid

Overview of SSA Benefits Programs Based on Disability

Title II Funded by the SSA trust

fund Entitlement program based

on work history Assumes 3 forms: SSDI,

CDB, & DWB Comes with Medicare

health coverage (after 24 months)

Title XVI Funded by federal tax

dollars Welfare program based on

financial eligibility Assumes 1 form: SSI Comes with Medicaid

health coverage (no waiting period)

SSA Disability Definition

There are 3 parts to the definition:1. Must have an impairment2. Must be unable to perform Substantial

Gainful Activity (SGA)3. Impairment must meet duration requirement

(result in death or lasted/will last at least 12 months)

Substantial Gainful Activity (SGA)

Definition:“the performance of significant physical and/or

mental activities in work performed for pay or profit, regardless of the legality of the work.”

Benchmark:SSA assigns a dollar figure to help them decide

whether SGA is being performed.*Benchmark for 2012: $1,010 (non blind), $1,690 (blind)*

SGA is a Decision Not a Number

SGA is based on a pattern of work behavior

SGA is a decision made by a Social Security employee

Social Security has various tools that they use to make the SGA decision

SGA uses countable income instead of actual income

Eligibility for Title II DisabilityMust have a disabilityMust be unable to perform SGAMust have worked recently enough and long enough

to qualify Measure this by counting amount of work credits earned (by paying

Social Security taxes on wages) Most people need at least 20 work credits in the 10 years prior to the

onset of their disability (this can vary based on the age you became disabled

Can earn a maximum of 4 credits per year (1 work credit = $1,130 gross wages in 2012)

Important Things to Remember About Title II Disability…

Title II is a form of insurance – not welfareTitle II benefits are NOT means tested and therefore

there are no limits on resources or assets (any income that is not earned)

The Title II check amount is determined by work history (amount of work credits earned)

SGA decision applies at initial application and forever onwards

There is a 5 month waiting period before benefits may begin

Title II Disability WorkIncentives: Safety Nets

Trial Work Period (TWP) 9 months in 60 month period Months can be consecutive, but do

not have to $720/mo is benchmark

Extended Period of Eligibility (EPE) 36 month period Easy back on benefits

Grace period 1st time at SGA after TWP 3 months of checks while at or above

SGA 4th month at SGA check suspended if

in EPE or terminated if not in EPE

Extended Period Medicare Coverage (EPMC) At least 93 months after TWP Receive health care whether

receiving check or not

Expedited Reinstatement (EXR) 5 years after date of termination Up to 6 months of provisional

benefits Can lose Medicare coverage if found

no longer disabled

Title II Disability Work Incentives: Deductions

Impairment Related Work Expenses (IRWE) Related to an impairment Necessary for work Out of pocket, not

reimbursed EXAMPLE: co-payments for

medications or doctor’s visits

Subsidy and Special Conditions Extra help on the job Subsidy = out of employers

pocket Special Condition = out of a

3rd party pocket (e.g. SLH) EXAMPLE: job coaching, extra

supervision, subsidized productivity

Eligibility for SSI

Individuals: with a disability OR who are 65+ AND have income/resources below specified limits

Income limit = below SGA when applying Resource limit = below $2,000 for individuals and $3,000 for couples

Federal Benefit Rate (FBR)

FBR = the maximum SSI check amount that someone can receive

Rate is set each year (January 1st)Receive full FBR when responsible for food

and shelter2012 Rates

Individual: $698.00/moCouple: $1,048.00/mo

Types of Income

Earned IncomeWagesSelf employmentCommissions/feesTipsSheltered workshop earningsRoyalties (e.g. from book sales)Americorps living stipends

Unearned IncomeTitle II benefits Veteran’s benefitsWorker’s compUnemploymentInterest incomeAlimony/child supportPensions

Examples of Income and Resource Exclusions

Income not counted: Value of food stamps Income tax refunds Earned income tax credits Home energy assistance Assistance based on need funded by state/local government Small amounts of income received irregularly or infrequently Food, clothing, shelter based on need provided by private non-profit

agencies Cash that is loaned and must be repaid

Resources not counted: Home in which beneficiary lives in 1 car per household Retroactive SSI/Title II payments (for up to 9 months) PASS protected income and resources Whole life insurance (face value less than $1,500) Some trusts Some student financial assistance

Important Things to Remember About SSI…

Same SGA definition applies to both SSI and Title II

SGA does not apply to SSI after initial application

SSI recipients can make more than SGA and still receive SSI (1619a)

SSI is a poverty program and therefore income and resources can cause checks to fluctuate, be suspended, or be terminated

SSI Work Incentives:Safety Nets

1619a allows earnings to go

above SGA without checks being stopped

1619bkeep MA when SSI check

= $0, until earnings are above state threshold ($38,660/year)

Expedited Reinstatement (EXR) 5 years after date of termination Up to 6 months of provisional

benefits

12 month Suspension Period SSI suspended if resources go

over limit 12 months to go back below,

then terminated

SSI Work Incentives:Deductions

Impairment Related Work Expense (IRWE) Related to an impairment Necessary for work Out of pocket (not reimbursed)

Blind Work Expense (BWE) Necessary for work Out of pocket (not reimbursed) Does not have to be related to

blindness

Student Earned Income Exclusion (SEIE)

under age 22 “regularly attend school” working

Plan for Achieving Self Support (PASS)

way to set aside income and/or resources for achieving work goal

Title II Disability vs. SSI

Title II Disability Disability Insurance Family Benefit Medicare IRWE SGA No resource limit EXR Monthly check depends on the workers earnings All or nothing check TWP, EPE, Subsidy/Special condition (SSDI only)

SSI Poverty program SSI recipient only Medicaid IRWE SGA (only when applying) Resource limit (2k/3k) EXR FBR of $698/$1,048 Amount of check varies BWE (SSI only)

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Medicaid (Medical Assistance)

• What Is It?

– A program that pays medical expenses for some people who meet income and resource (asset) limits. A partnership between the federal government and state governments, each party pays a percentage of program costs. In Maryland, the split is usually 50%-50%.

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• How Can I Get It?

– You are automatically (categorically) eligible if you receive:

• Supplemental Security Income (SSI)• Temporary Cash Assistance (TCA)

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– You may also be eligible through:

• The Employed Individuals with Disabilities (EID) Program

• Continuing Medicaid for people who lose SSI payments due to earnings (1619(b))

• Continuing Medicaid for people who lose SSI, but would be eligible if not for cost of living increases in some other cash benefits from Social Security (Pickle Amendment)

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• Continuing Medicaid for people who lose SSI due to Childhood Disability Beneficiary (CDB) benefits

• Medicaid Waiver programs• Public Assistance to Adults (PAA)• Medically Needy (“Spend down”) Program

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• Maryland Children’s Health Program (MCHP)• MCHP Premium• Medicaid for Families Program• Various other categories

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• Do I Need to Apply for Other Benefits to Get It?

– Yes. Medicaid is a benefit of last resort, and you must apply for any other benefits to which you may be entitled.

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• What It Pays For: Medicaid pays the recipient’s full cost for most

medical expenses, including:

– Ambulance and wheelchair van services and emergency medical transportation

– Ambulatory surgical care services– Clinic services– Dental services (including orthodontic care) for

individuals under age 21– Diabetic care services (covered by managed care

program)– Family planning services & supplies

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• What It Pays For:

– Health maintenance organization (HMO) services– Healthy Kids Program services– Home and community based services for people with

disabilities in Medicaid Waiver programs– Home health care– Hospice care– Hospital services– Kidney dialysis services– Lab and X-ray services

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– Medical day care services– Medical equipment– Medical supplies– Medicare premiums, deductibles and co-payments– Mental health treatment, case management and

rehab. services– Nurse anesthetist, nurse midwife and nurse

practitioner services– Nursing home services– Oxygen services and related respiratory equipment

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– Personal care services– Pharmacy services (small co-payment; for those

who receive Medicare Part D, Medicaid eliminates almost all out-of-pocket costs)

– Physical therapy– Physician services– Podiatry– Psychiatric rehabilitation services– Residential treatment facility services– Substance abuse treatment– Targeted case management for targeted groups

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– Transportation to covered services (through local health departments)

– Vision care services (eye exams every two years; eyeglasses for individuals under age 21)

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• How You Get Medical Care:

– Most recipients must join managed care organizations (MCO’s). They will receive information about their choices and must sign up. If they don’t sign up, a MCO will be chosen for them.

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• How You Get Medical Care:

– Some recipients do not have to join a MCO, and can receive “fee for service” care. These include those who:

• Also get Medicare• “Spend down” to qualify• Have “rare and expensive” illnesses or

disabilities• Enroll in EID

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Medicare

– Medicare provides medical coverage to people who are elderly or disabled. It’s a federal program.

– Most recipients become eligible by:• Receiving Social Security Disability benefits after a

two-year waiting period, or• Being age 65 and having worked (or having a

spouse who worked) at least 10 years in Medicare-covered employment (may qualify at age 65 without sufficient work history, but must pay Part A premium), or

• Having end stage renal disease

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Medicare

– Medicare Part A pays for hospitalization, some skilled nursing home care, some skilled home health care and hospice care.

– Most recipients receive Part A without paying premiums or co-payments. Some pay premiums of $248/month or $451/month in 2012.

– Most pay a deductible of $1,156 for the first 60 days of hospitalization, $289/day for days 61 - 90 and $578/day for days 91 – 150 in 2012.

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Medicare

– Medicare Part B pays for medical services.– Most recipients pay:

• A premium of $99.90/mo. (more for those with very high incomes) in 2012

• 20% coinsurance for most services; 50% for some psychiatric services

• Annual deductible - $140 in 2012

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Medicare

– Medicare Part D provides prescription coverage.– Most recipients pay:

• Monthly premium (varies according to chosen plan)• $320 deductible per year in 2012• 25% of costs between $321 and $2,930 per year in 2012 –

plan covers 75%• All drug costs from $2,931 to $6,657.50 per year in 2012

(“donut hole”)• In 2012, people in the donut hole receive discounts of 50% on

brand name drugs and 14% on generics• 5% co-payments – or co-pays of $6.50 for brand name drugs

and $2.60 for generics – for costs over $6,657.50 in 2012 – plan covers the rest

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Medicaid Rocks!

– Medicaid pays for almost all Medicare costs that the individual would otherwise have to pay:

• $99.90/mo.) Part B (medical insurance) premium• 20% co-payments for medical expenses (50% for

some psychiatric services)• Deductibles for Parts A and B• Premiums (up to $34.57/month in 2012) and

deductibles for Part D (prescription coverage)• Fills “donut hole” for Part D• Individual pays only $1.10 or $3.30 co-payment per

prescription in 2012

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Employed Individuals with Disabilities (EID)

Also known as the Medicaid Buy-In, EID is a work incentive that provides Medicaid, for a limited premium, to people who:

– Meet Social Security’s disability criteria after reaching age 18

– Are U.S. citizens or qualified aliens aged 18 – 64– Are working for pay– Meet income limits– Meet resource limits

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Disability

– You may be eligible for EID if you:

• Currently receive SSDI• Formerly received SSDI or SSI as an adult and lost

the benefit for reasons other than medical improvement (i.e., earnings, other income or resources)

• Meet Social Security’s medical disability standard, but are not eligible for SSDI or SSI due to non-disability criteria.

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Disability

If you have not received SSDI or SSI before• You may need to apply for SSDI when you apply for

EID. If you are denied SSDI for non-disability reasons (such as earnings), you will get a disability determination for EID.

• If you earn over $1,900/month from work (or, if you are blind, over $2,600/month), you will not need to apply for SSDI, and will get a disability determination for EID.

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Disability

If you have not received SSDI or SSI before• If your EID disability determination shows you meet

Social Security’s medical standards, you will be approved for EID.

• If your SSDI application is approved (and you meet the other EID eligibility conditions), you will be approved for EID.

• If a disability determination shows you don’t qualify for EID (or SSDI), you can appeal.

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Paid Work

– No minimum level of earnings – may be very small, but need to be verified

– Must result in income during enrollment period

– Must be subject to state and federal reporting and withholding or estimated tax payments

– May be employed or self-employed

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Countable Income

– “Countable” income must be below 300% of federal poverty level (FPL)

• $33,510/yr. ($2,793/mo.) for an individual (in 2012)

• $45,390/yr. ($3,783/mo.) for a married couple (in 2012)

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– Countable resources for individual or couple must be below:

• $10,000

– Use Aged, Blind and Disabled rules for resources, plus:• 401(k), 403(b), Keogh and pension plans are

excluded

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Premiums

– Monthly premiums on a sliding scale• Countable income up to 100% federal poverty level

(FPL) – premium = $0/mo.• Countable income = 101% - 200% FPL – premium =

$25/mo.• Countable income = 201% - 250% FPL - premium =

$40/mo.• Countable income = 251% - 300% FPL – premium =

$55/mo.

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Once You’re Enrolled

– If found eligible, Medicaid is retroactive to the 1st day of the month the application is received

– EID provides “fee for service” Medicaid – don’t join a managed care organization

Medicare vs. MedicaidMedicare

Eligible after 24 month waiting period when receiving Title II Disability

Pays 80% of many medical expensesMedicare while working: if you loose Title II Disability you can

keep MC up to 93 months after end of TWP

Medicaid In Maryland automatically eligible if receiving any amount of SSIPays 100% of most medical expensesMedicaid while working: if you lose SSI due to earnings you can

keep MA until earnings exceed state threshold

PRIMARY ADULT CARE (PAC)

• Provides primary care for adults age 19 or older with very low incomes and resources who do not have Medicaid or Medicare

• Basic medical coverage – including mental health, medications and other services – but not hospitalization

• Household includes the individual and spouse (if they live together)

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PRIMARY ADULT CARE (PAC)

• Countable income must be under 116% of FPL.

• Countable income must be under these limits in 2012:– $1,080/mo. for 1-person household– $1,463/mo. for 2-person

• Co-payments for medications - $2.50 - $7.50 per prescription in 2012

• No resource limit

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SSI/SSDI Outreach, Access and Recovery

SOAR allows clients without benefits who meet certain criteria to complete an expedited application process for SSI/Title II Disability benefits.

There are two main criteria:1) They must have a mental illness2) They must be homeless or “at risk” of homelessness

Completing the SOAR process allows a client to have their application go to a special group within DDS who will return a decision much more quickly than the traditional application process.

Ticket to Work Ticket to Work (TTW) is a program open to all clients that allows

them to assign their “Ticket” to an Employment Network (or agency) in exchange for services

While a Ticket is assigned a client is subject to Timely Progress Reviews (TPRs) to determine if they are meeting the outcomes schedule dictated by SSA.

While a client is meeting their TPRs, they are exempt from Continuing Disability Reviews (CDRs) which are periodic reviews conducted by SSA to determine if a client remains disabled.

When a client completes 9 months of work over SGA, the agency gets reimbursed for “reasonable costs” associated with providing rehabilitation services to the client

Resources Social Security Administration

www.ssa.gov 1-800-772-1213 (*only use 800 number to schedule appointments,

call local office for specific information) EID

Carla Bryant (443-514-5034, 1-800-637-4113, [email protected]) Medicare

http://www.medicare.gov/ 1-800-MEDICARE

Medicaid http://www.dhmh.state.md.us/mma/mmahome.html

SHIP (helpful for Medicare questions) http://www.medicarehelp.org/ 301-590-2819

http://www.ssa.gov/

mailto:[email protected]

http://www.medicare.gov/

http://www.dhmh.state.md.us/mma/mmahome.html

http://www.medicarehelp.org/

understanding federal benefits

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