ENTITLEMENT
PROGRAMS:
An
Overview for Mental Health Consumers and Their Families
Compiled
March 2004 by:
Tammy
Pesenti
Assistant
Executive Director
NAMI
of Greater Chicago
1536 West Chicago Avenue , Chicago , IL 60622
Phone:
312.563.0445
Website:
www.namigc.org
TABLE
OF CONTENTS
Pages
Social
Security (SSI, SSDI, The Ticket to Work 3
and
Self-Sufficiency Program)
Medicare 8
Medicaid for Adults 12
The Qualified Medicare Beneficiary Program (QMB) 16
Medicaid for Children/KidCare 17
Comprehensive Health Insurance Plan (CHIP) 23
Temporary Assistance for Needy Families (TANF) 28
Transitional
Assistance, Family and Children Assistance, 30
and
Earnfare
Aid to the Aged, Blind or Disabled (AABD) 34
General Assistance 36
Food Stamps 39
Access Numbers and Internet Resources 41
Social Security Disability Benefits
(SSDI)
and Supplemental Security Income (SSI)
What Is It? Social Security is an insurance program that provides income to workers who become "disabled" (or who retire), and to their dependents and survivors. SSI is a needs-based program that provides a basic income for people with disabilities who meet specific low-income guidelines.
Where to Apply? The Social Security Administration local office in your area, or by calling toll-free 1-800-772-1213.
Who May Be Eligible? Social Security: workers who become "disabled" (or who are at least 62 years old), and their spouses, and dependents of workers who are "disabled" (or retired or deceased). SSI: People of any age who are needy and are blind or "disabled" (or who are at least 65 years old).
The Differences Between SSDI and SSI
The Social Security Administration
The Social Security Administration (SSA) is a federal government agency that
administers benefits for people with disabilities. Although SSA also runs
programs for people of retirement age, the focus of this section is on people
with disabilities.
People with disabilities may be eligible under either the "Social Security Disability Insurance" (SSDI) program, or the "Supplemental Security Income" (SSI) program. When you apply for benefits, the Social Security Administration will inform you whether your benefits will come from SSI, SSDI or both.
Social Security Disability Insurance (SSDI) is an Insurance Program
Most workers pay into Social Security while they are working. To become
eligible for SSDI disability benefits, you must have worked for a minimum
length of time before claiming benefits. The amount of time depends on your age
at the time you become "disabled." If you become "disabled"
before reaching age 22, you may be able to receive SSDI benefits based on the
earnings record of your parent, stepparent, or adoptive parent, if they receive
Social Security disability or retirement benefits or if they are deceased.
The amount of SSDI benefits you receive is based on the amount of your
contributions. If you became "disabled" before age 22 and are
receiving benefits based on the earnings record of a parent, stepparent, or
adoptive parent, your SSDI benefit will be one half of their benefit amount.
If you are found eligible for SSDI, you may be entitled to a retroactive benefit. In general, you are entitled to receive benefits going back to the first month following the end of a "waiting period."
The waiting period is the 5 month period starting with the first month in which you were both insured for disability and "disabled." However, the waiting period can start no earlier than the 17th month before the month you apply, no matter how long you were "disabled" before then.
Supplemental Security Income (SSI) is a Financial Aid, or "Needs
Based" Program
You can receive SSI benefits even if you have never been employed and
regardless of your age when you become "disabled." However, the amount
of benefits you can receive under SSI usually is less than what you can receive
if you qualify for SSDI.
If you are eligible for SSI, you also may be entitled to receive a retroactive benefit. In general, you are entitled to receive benefits going back to the first full month following the month in which you filed your application for SSI.
Income and Asset Limits for SSI
Income
Limits.
Because SSI is a needs-based program, your benefits may be reduced or you may
not be eligible at all if you have other sources of income. Social Security
considers many types of resources to be "income."
"Income" includes the following things, among others:
- Money that you earn from employment;
- Pensions, alimony, and interest;
- Food, clothing, or shelter that is given
to you on a regular basis;
- An amount of money that Social Security
assumes is given to you by your parent (if you are a minor child) or by
your spouse if they live with you and have their own income.
In general, Social Security does not count the first $65 per month in earned income and the first $20 per month of unearned income. They also do not count certain types of income, such as the value of food stamps, energy assistance, Pell grants or other federally funded student assistance programs, and federally subsidized housing assistance.
Asset Limits. You may have no more than $2,000 in assets ($3,000 in the case of a married couple where both receive SSI). Social Security does not count some types of property in determining whether you meet the asset limit. These assets are considered "exempt." Exempt assets include:
- The home in which you live;
- Your household goods and personal
effects (to the extent that their equity value is less than $2,000);
- The value of your car or truck, if it is
necessary for medical care, employment, or essential daily activities for
you or any household member, or if the car is modified for a person with
disabilities. If the car is not totally excluded for one of the above
reasons, then one car may be excluded to the extent that its market value
is under $4,500. Social Security counts the market value in excess of
$4,500 toward the asset limit. They also count the equity value of any
additional cars toward the asset limit.
Income and Asset Limits for SSDI
There are no asset limits under the SSDI program. There also are no limits
under the SSDI program on the amount of unearned income you may receive.
However, employment earnings can affect eligibility for SSDI.
Disability Requirements
Who is Considered "Disabled" for SSI or SSDI benefits?
To receive disability benefits under either program, you must meet the Social
Security Administration's definition of "disability."
The term "disability" under Social Security law means that you are unable to work because of a physical or mental impairment which has lasted or is expected to last for at least 12 months, or is expected to result in death.
Proving Disability for Adults
In deciding whether you have a disability, SSA uses a five-step analysis:
Step One: If you are working and performing substantial gainful activity, then you are considered able to work and therefore not "disabled." If your average monthly earnings are over $800 per month, you are probably not eligible. If you are not earning significant income, proceed to step two.
Step Two: You must have a "severe impairment." This means that you must have a medical problem which significantly limits your physical or mental ability to perform basic work activities. If you have a severe impairment, proceed to step three.
Step Three: Social Security has determined that certain medical conditions are automatically disabling. Social Security describes these conditions in a part of their regulations called the "Listing of Impairments." To be considered "disabled" under the Listings, you need to have the required type of medical proof and the indicated level of severity for your particular illness.
If you have impairments that are similar but not identical to those included in the Listings, or if you have a combination of illnesses, SSA will consider you "disabled" if your condition is considered to be "comparable" to those included in the listings, and is of equal severity.
If your condition does not meet or equal one of the conditions in the Listings, proceed to step four.
Step Four: If you are physically and mentally able to return to a job that you have held within the last fifteen years, then SSA considers you "not disabled." If you cannot perform any of your past jobs, proceed to step five.
Step Five: If you cannot perform your past work, then Social Security decides whether you are able to perform other types of work.
At step five, SSA will consider your physical limitations, your age, education, the type of work skills you have acquired, and any mental limitations on work activities.
Proving Disability for Children's SSI Disability Benefits
As with adults, Social Security has a process for determining whether a child
has a disability and whether that child is eligible for benefits. But, the
evaluation process for children is different from the evaluation process for
adults. In deciding whether your child has a disability, SSA uses a three-step
analysis:
Step One: If your child is working and performing substantial gainful activity, then SSA considers the child to be "not disabled." SSA considers the child to be performing substantial gainful activity if the child is earning at least $800 per month. If your child is not earning at that level, proceed to step two.
Step Two: Your child must have a "severe impairment." This means that your child must have a medical problem which causes more than minimal problems with respect to the child's ability to perform basic physical or mental activities. If your child has a severe impairment, proceed to step three.
Step Three: As with adults, SSA has determined that certain medical conditions are automatically disabling for children. These conditions are set forth in a part of the Social Security regulations called the "Listing of Impairments for Children." The Listings indicate the type of medical proof needed and the level of severity required for a particular illness to be considered disabling. SSA considers your child to have a disability if the child has an impairment of the severity indicated in the Listing.
SSA can also find children to be "disabled" if their impairments are "medically equal" in severity to a listed impairment.
The term "medically equal" means that your child's medical findings are equal in severity and have lasted as long as those in the Listing of Impairments for Children.
If your child's condition does not meet or medically equal one of the conditions in the Listings, SSA can find the child to be eligible if the child's condition is "functionally equal to the listings."
The term "functionally equal" means that the child's impairment or combination of impairments causes "marked and severe" limitations in the child's level of functioning.
Applying for Disability Benefits
You should apply for benefits at your local Social Security Administration
office. To locate that office and for other information, you can call Social
Security toll free at 1-800-772-1213.
When you apply for disability benefits, you will be asked to explain why you have a disability. You also will be asked to name the doctors, hospitals and other medical providers who have treated you. SSA will contact them to obtain your medical records to confirm how serious your impairments are.
If you have not received medical care recently or your records do not contain the necessary information, SSA may pay to send you to a doctor for a "consultative examination."
Following this review of your medical records, SSA will then send you a notice telling you whether or not they find that you are "disabled." The notice will explain whether or not you will receive benefits, and if so, in what amount.
If you disagree with the decision made by Social Security, you can appeal.
“The Ticket to Work
and Self-Sufficiency Program”
The SSA implemented “Ticket to Work
and Self-Sufficiency Program” in 2001.
The Ticket to Work Program provides Social Security disability
beneficiaries and disabled or blind Supplemental Security Income beneficiaries
with expanded access to employment services, vocational rehabilitation
services, or other support services.
This program will enable these beneficiaries to obtain, regain or
maintain employment and to reduce their dependency on cash assistance. Under this program, SSA will pay the
providers of those services, called employment networks (ENs), after the beneficiaries
achieve certain levels of work and earnings.
Most Social Security and
Supplemental Income (SSI) disability beneficiaries will receive a “ticket” they
may use to obtain vocational rehabilitation, employment or other support
services from an approved provider of their choice to help them go to work and
achieve their employment goals. This
program is voluntary.
Expanded Availability of Health Care
Services
Starting
States may provide Medicaid coverage
to more people who are still working.
States also may permit working individuals with income above 250 percent
of the federal poverty level to purchase Medicaid coverage. This provision creates an experiment in which
medical assistance will be provided to workers with impairments who are not yet
too disabled to work. In addition, a
Medicaid infrastructure Grant program is available to support State efforts to
increase employment options for people with disabilities. To find out if these provisions are available
in your state, call the State Medicaid office or check the State Chart of Work
Incentives Activity at http://www.ssa.gov/work/Beneficiaries/activity.html. This law also expands Medicare coverage to
people with disabilities who work. It
extends Part A premium-free coverage for at least four and a half years beyond
the current limit (39 months) for most Social Security disability beneficiaries
who work. This is a minimum for eight
and a half years for most Social Security disability beneficiaries who
work.
Expedited Reinstatement of Benefits
Effective January 1, 2001, when a person’s Social Security or SSI disability
benefits have ended because of earnings from work, he or she would be able to
request reinstatement of benefits, including Medicare and Medicaid, if
applicable, without filing a new application.
Beneficiaries must be unable to work because of their medical
condition. They must file the request
for reinstatement with Social Security within 60 months from the month their
benefits are terminated. In addition,
they may receive temporary benefits- as well as Medicare or Medicaid- for up to
six months while their case is being reviewed.
If they are found not disabled, these benefits would not be considered
an overpayment.
Deferral
of Medical Disability Reviews
Effective
For
More Information
If you have questions about the Ticket to Work program, you should call the
Ticket Program Manager, MAXIMUS Inc., at 1-866-968-7842 (TTY
1-866-833-2967). For information about
other work incentives, you should also visit www.socialsecurity.gov/work. You also may request a copy of the work
incentives publication, Working While Disabled:
How We Can Help, by calling 1-800-772-1213 (TTY 1-800-325-0778).
It is fairly common for SSI and SSDI recipients to receive a notice that they have received benefits to which they were not entitled. This is called an "overpayment." Usually, SSA will require you to pay back any overpaid benefits, and they will reduce your current benefits until the money is paid back. Overpayments commonly occur when recipients acquire new sources of income and their benefits are not promptly reduced. Overpayments can also occur when SSA is not promptly informed of changes in living arrangements, marital status, or employment changes.
If you receive a notice of overpayment, you have the right to appeal. You should file an appeal if you believe that SSA is wrong in saying that you received an overpayment, or if you believe that the amount of the overpayment is less than they allege. You must file an appeal in writing within 65 days of the date of the notice of overpayment.
Even if you agree that you received an overpayment, you can ask that you not be required to pay the money back. This is called a "Request for Waiver of Recovery of Overpayment," commonly called a "waiver." You may request a waiver at any time, by completing a written form available at your local SSA office.
In order to qualify for a waiver, you must prove that you were not responsible for causing the overpayment. In other words, you must show that you did your best to properly report all necessary information to SSA, and that you did not accept benefits that you knew you were not entitled to receive. In addition, you must also show that it would be unfair to make you pay back the money, either because you cannot afford to do so, or because you have taken certain actions thinking that you were entitled to the overpaid benefits.
You should clearly explain your side of the story when you file a request for a waiver. Staff at the SSA office can help you complete the form. You are entitled to file an appeal if your request for a waiver is denied.
Where to Go for More Information
Other Information
To apply for benefits or to file an appeal, contact your local Social Security
office, or call (800) 772-1213(v) or (800) 335-0778 (TTY) for information and
assistance.
The Social Security Administration website can be found at http://www.ssa.gov
Medicare
What It Is: Medicare is a national health insurance program created by the Social Security Act for people with disabilities and the elderly.
Where To Apply: The Social Security Administration.
Who May Be Eligible: People who are age 65 or older, people of any age who Social Security says are "disabled," and people with kidney failure.
The Medicare Program in General
Medicare is a federal health insurance program for people with disabilities and the elderly. The Medicare program pays a portion of hospital and other medical bills. There are three parts to Medicare.
Medicare Part A (hospital insurance):
This covers inpatient hospital care, skilled nursing home care, hospice care, and some home health care.
Medicare Part B (medical insurance):
This covers doctors, outpatient hospital services, and various other medical services not covered under Part A.
Medicare Part C:
Also known as Medicare + Choice, it adds a variety of health care choices, such as Health Maintenance Organizations (HMOs), preferred provider organizations, medical savings accounts, and private fee-for-service. These are not available everywhere.
Medicare is not a comprehensive insurance program. There are many medical costs, which are not covered by Medicare.
Who is Eligible for Medicare?
You are eligible if you are in any of the following categories of individuals:
· You are age 65 or older, and you are eligible
to receive Social Security Retirement, Survivor's benefits, or Railroad
Retirement Board Benefits.
· You are under age 65 and you are entitled to
receive Social Security Disability benefits or Railroad Retirement Board
disability benefits, and have been entitled to those disability benefits for at
least 24 consecutive months.
· You are under age 65, you have kidney disease
requiring dialysis or kidney transplant, and you are insured for Social
Security benefits, or you are the spouse or dependent child of someone who is
insured for Social Security benefits.
What does Medicare Cost?
If you have contributed to the Social Security or Railroad Retirement plans long enough, Part A (hospital insurance) costs you nothing. If you have not contributed long enough to get Part A for free, you may still participate in Medicare Part A by paying a large monthly premium.
To receive Part B (medical insurance), you must pay a monthly premium which is deducted from your monthly Social Security check. Even if you have not worked long enough to get Part A for free, you may receive Part B benefits by paying the monthly premium.
How to Apply for Medicare
Automatic Enrollment
If you are already receiving Social Security Retirement or Railroad Retirement benefits before reaching age 65, you do not need to apply for Medicare. You will be automatically enrolled in both Part A and Part B upon reaching age 65.
If SSA determines that you are disabled, you will automatically be enrolled in both Part A and part B beginning with the 25th month that you are eligible for Social Security disability insurance (SSDI) benefits.
NOTE
If
you do not want Part B benefits, you must notify Social Security in writing to
prevent the premiums from being deducted from your benefits.
Services Covered By Medicare
Services Covered Under Part A
You do not need to file a claim for coverage of a Medicare Part A covered service. Instead, the provider submits the claim. You will then receive a Benefits Notice explaining how much was paid and the amount you are responsible for paying.
Services covered under Part A include: