Understanding federal benefits


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  • Remember it is the INability to perform SGA
  • SSA has tools they use to decide if SGA is happening: see “how does work affect my benefits” Income averaging, IRWEs, Unsuccessful Work Attempts
  • Rental Assistance? How does this affect SSI max/calculation. Rental Assistance/HOC does not affect SSI in any way
  • SSI can be retroactive to the first of the month after the month of applicationTitle II can be retroactive for up to 12 months prior to the application (if all qualifications are met)
  • SEIE = exclude income if working and regularly attending school (monthly cap 1640, yearly cap 6600)IRWE =
  • BWE = lunches consumed at work, federal state and local taxes“regularly attending school” = college for at least 8 hrs per week, or grades 7-12 and 12 hours per weekPASS plan – excludes income/resources used for approved PASS expenses, allows for continues eligibility for SSI or higher SSI payment due to money excluded
  • Understanding federal benefits

    1. 1. Entitlements Training: The Basics Adrian Wicker 301-493-4200 ext 411 240-429-9298 wickera@stlukeshouse.com
    2. 2. Social Security Administration (SSA)1,300 local field offices (New Hampshire Ave or Rockville)10 regional officesOver 60,000 employeesState contracted Disability Determination Service (DDS) makes disability decisionLocal field offices make ALL OTHER decisions (including work incentives)
    3. 3. 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: MedicareTitle XIX: Medicaid
    4. 4. Overview of SSA Benefits Programs Based on Disability Title II Title XVI Funded by the SSA trust  Funded by federal tax fund dollars Entitlement program based  Welfare program based on on work history financial eligibility Assumes 3 forms: SSDI,  Assumes 1 form: SSI CDB, & DWB  Comes with Medicaid Comes with Medicare health coverage (no waiting health coverage (after 24 period) months)
    5. 5. SSA Disability DefinitionThere 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)
    6. 6. 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)*
    7. 7. 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
    8. 8. Eligibility for Title II DisabilityMust have a disabilityMust be unable to perform SGAMust 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)
    9. 9. Important Things to Remember About Title II Disability… Title II is a form of insurance – not welfare Title 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
    10. 10. Title II Disability Work Incentives: Safety Nets Trial Work Period (TWP)  Extended Period Medicare  9 months in 60 month period Coverage (EPMC)  Months can be consecutive, but do not have to  At least 93 months after TWP  $720/mo is benchmark  Receive health care whether receiving check or not Extended Period of Eligibility (EPE)  Expedited Reinstatement  36 month period (EXR)  Easy back on benefits  5 years after date of termination  Up to 6 months of provisional Grace period benefits  1st time at SGA after TWP  Can lose Medicare coverage if found  3 months of checks while at or above no longer disabled SGA  4th month at SGA check suspended if in EPE or terminated if not in EPE
    11. 11. Title II Disability Work Incentives: DeductionsImpairment Related Subsidy and Special Work Expenses Conditions (IRWE)  Extra help on the job  Related to an impairment  Subsidy = out of employers pocket  Necessary for work  Special Condition = out of a  Out of pocket, not 3rd party pocket (e.g. SLH) reimbursed  EXAMPLE: job coaching, extra  EXAMPLE: co-payments for supervision, subsidized medications or doctor’s visits productivity
    12. 12. Eligibility for SSIIndividuals: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
    13. 13. 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 shelter2012 Rates Individual: $698.00/mo Couple: $1,048.00/mo
    14. 14. Types of IncomeEarned Income Unearned Income Wages Title II benefits Self employment Veteran’s benefits Commissions/fees Worker’s comp Tips Sheltered workshop Unemployment earnings Interest income Royalties (e.g. from book Alimony/child support sales) Pensions Americorps living stipends
    15. 15. Examples of Income and Resource ExclusionsIncome not counted: Resources not counted:  Value of food stamps  Home in which beneficiary  Income tax refunds lives in  Earned income tax credits  1 car per household  Home energy assistance  Retroactive SSI/Title II  Assistance based on need payments (for up to 9 funded by state/local months) government  Small amounts of income  PASS protected income and received irregularly or resources infrequently  Whole life insurance (face  Food, clothing, shelter based value less than $1,500) on need provided by private  Some trusts non-profit agencies  Cash that is loaned and must  Some student financial be repaid assistance
    16. 16. 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
    17. 17. SSI Work Incentives: Safety Nets1619a Expedited allows earnings to go Reinstatement (EXR) above SGA without  5 years after date of termination  Up to 6 months of provisional checks being stopped benefits1619b 12 month Suspension keep MA when SSI check Period = $0, until earnings are  SSI suspended if resources go above state threshold over limit ($38,660/year)  12 months to go back below, then terminated
    18. 18. SSI Work Incentives: DeductionsImpairment Related  Student Earned Work Expense (IRWE) Income Exclusion  Related to an impairment (SEIE)  Necessary for work  under age 22  Out of pocket (not reimbursed)  “regularly attend school”Blind Work Expense  working (BWE)  Plan for Achieving Self  Necessary for work  Out of pocket (not reimbursed) Support (PASS)  Does not have to be related to  way to set aside income blindness and/or resources for achieving work goal
    19. 19. Title II Disability vs. SSITitle II Disability SSI  Disability Insurance  Poverty program  Family Benefit  SSI recipient only  Medicare  Medicaid  IRWE  IRWE  SGA  SGA (only when applying)  No resource limit  Resource limit (2k/3k)  EXR  EXR  Monthly check depends on  FBR of $698/$1,048 the workers earnings  Amount of check varies  All or nothing check  BWE (SSI only)  TWP, EPE, Subsidy/Special condition (SSDI only)
    20. 20. 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%. 20
    21. 21. Medicaid (Medical Assistance)• How Can I Get It? – You are automatically (categorically) eligible if you receive: • Supplemental Security Income (SSI) • Temporary Cash Assistance (TCA) 21
    22. 22. Medicaid (Medical Assistance)• How Can I Get It? – 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) 22
    23. 23. Medicaid (Medical Assistance)• How Can I Get It? – You may also be eligible through: • 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 23
    24. 24. Medicaid (Medical Assistance)• How Can I Get It? – You may also be eligible through: • Maryland Children’s Health Program (MCHP) • MCHP Premium • Medicaid for Families Program • Various other categories 24
    25. 25. Medicaid (Medical Assistance)• 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. 25
    26. 26. Medicaid (Medical Assistance)• 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 26
    27. 27. Medicaid (Medical Assistance)• 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 27
    28. 28. Medicaid (Medical Assistance)• What It Pays For: – 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 28
    29. 29. Medicaid (Medical Assistance)• What It Pays For: – 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 29
    30. 30. Medicaid (Medical Assistance)• What It Pays For: – Transportation to covered services (through local health departments) – Vision care services (eye exams every two years; eyeglasses for individuals under age 21) 30
    31. 31. Medicaid (Medical Assistance)• 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. 31
    32. 32. Medicaid (Medical Assistance)• 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 32
    33. 33. 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 33
    34. 34. 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. 34
    35. 35. 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 35
    36. 36. 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 36
    37. 37. 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 37
    38. 38. 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 38
    39. 39. Employed Individuals with Disabilities (EID)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. 39
    40. 40. Employed Individuals with Disabilities (EID)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. 40
    41. 41. Employed Individuals with Disabilities (EID)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. 41
    42. 42. Employed Individuals with Disabilities (EID)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 42
    43. 43. Employed Individuals with Disabilities (EID)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) 43
    44. 44. Employed Individuals with Disabilities (EID)– 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 44
    45. 45. Employed Individuals with Disabilities (EID)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. 45
    46. 46. Employed Individuals with Disabilities (EID)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 46
    47. 47. Medicare vs. MedicaidMedicare Medicaid  Eligible after 24 month  In Maryland automatically waiting period when eligible if receiving any receiving Title II Disability amount of SSI  Pays 80% of many medical  Pays 100% of most medical expenses expenses  Medicare while working: if  Medicaid while working: if you loose Title II Disability you lose SSI due to you can keep MC up to 93 earnings you can keep MA months after end of TWP until earnings exceed state threshold
    48. 48. 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) 48
    49. 49. 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 49
    50. 50. 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 illness 2) 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.
    51. 51. 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
    52. 52. 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, eid@mdod.state.md.us) 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
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