Glossary of SSA Disability Programs and Related Terms
Thomas P. Golden M.S., C.R.C.
K. Lisa Yang and Hock E. Tan Employment and Disability Institute
Raymond A. Cebula, Esq.
K. Lisa Yang and Hock E. Tan Employment and Disability Institute
Edwin J. Lopez-Soto, Esq.
K. Lisa Yang and Hock E. Tan Employment and Disability Institute
Any person who was found eligible for SSI as a child in the month before they turned 18 must have their eligibility for SSI re-determined as an adult.
Individuals have the right to appeal any “initial determination” made by the SSA. Initial determinations include appealing denial of benefits, reduction of benefits, termination of benefits, and overpayments. There are four levels of the appeals process with certain time restrictions for each. Individuals generally have 60 days from the time they receive a notice from the SSA to file appeals.
Other federal and state benefits programs will all have different appeals processes and different appeal periods.
Any SSI beneficiary whose primary diagnosis is blindness, and who receives earned income is entitled to exclude from that income any ordinary and necessary expenses attributable to the earning of income. This results in earned income not being counted in determining SSI eligibility and monthly cash payments.
While a reduction in the SSI cash payments will occur as a beneficiary’s earnings increase, an SSI beneficiary will continue receiving cash payments until total countable income increases to the point where their SSI payment is reduced to zero.
Adults with disabilities who do not have sufficient Social Security-covered work history for insured status may receive Social Security benefits based on their parents’ insured status. To be eligible for Social Security as a disabled adult child, an individual must be: 18 years of age or older; disabled by SSA’s definition before age 22; and the child of insured workers who are disabled, retired or deceased. (If adult child marries, benefits end unless marriage is to another Title II beneficiary.)
The Social Security Act requires that SSA periodically update records and review the disability status of beneficiaries to ensure that they continue to be disabled and thus eligible for disability payments. These reviews are called Continuing Disability Reviews (CDRs) and apply to persons receiving SSDI or SSI.
Effective January 1, 2001, SSA is no longer able to initiate a Continuing Disability Medical Review while an SSI beneficiary or Title II beneficiary is using a “Ticket” under the Ticket to Work and Self-Sufficiency program. Extending CDR protections further, effective January 1, 2002, work activity by a Title II beneficiary who has received Title II cash payments for at least 24 months cannot be used as the sole basis for conducting a medical CDR.
The amount of combined earned and unearned income remaining after SSA has subtracted all allowable income exclusion and deductions from gross countable income. This will determine the amount of the SSI eligibility and the amount of payment.
When determining the eligibility and amount of SSI payable to an SSI beneficiary, the income and resources of certain people responsible for the beneficiary’s welfare will also be considered. This concept is called “deeming.” It is based on the idea that those who have a responsibility for one another share their income and resources. It does not matter if money is actually provided to an eligible individual for deeming to apply. There are three main situations where income and resources are “deemed”: from an ineligible spouse to an eligible individual; from an ineligible parent(s) to a child; or, from a sponsor to an alien.
“The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”
Earned income is: wages paid; net earnings from self-employment; payments for participating in a sheltered workshop or work activity center; sickness or temporary disability payments received within the first six months of stopping work; royalties earned in connection with any publication of the individual’s work or any honoraria received for services rendered. Earned income may be paid in cash or in-kind. If it is in-kind and in exchange for labor, its full current market value is the amount used to determine countable income.
This HUD program allows any increased, or new, earned income to be excluded for the first 12 months of the increased earnings, for the purpose of determining rent. During the following 12 months, 50% of the new or increased earnings are disregarded when determining tenant rental liability.
This federal program provides low income workers with increased take home pay or increased tax returns in order to ease the cost of basic needs and encourage work. The benefit provided is determined by the earned income level of the participant as well as the number of eligible children, if any, in the household. EITC amounts are likely to increase each year.
An Employment Network is a qualified public or private organization that has entered into an agreement with SSA to function as an EN under the Ticket to Work program and take responsibility for the coordination and delivery of employment services, vocational rehabilitation services, and/or other support services.
An individual who has had his or her disability benefits terminated as a result of work and earnings and have had to subsequently reduce his or her work or stop work as a result of his or her impairment, may request reinstatement of benefits within five years of their termination date. Up to six months of provisional benefits can be paid while a disability determination is made.
At the conclusion of the nine-month TWP, as long as individuals continue to have their original disabling condition, a 36-month EPE will begin. During these 36 consecutive months, individuals will receive benefit checks when their earnings are below SGA. During the EPE, individuals are due payment of their disability benefits for any month they do not work, or when work and earnings fall below the SGA level. During this period, it is not necessary to file a new application for benefits to resume.
FSS is a public housing program that allows the resident to establish a self sufficiency contract. Increases in earned income will not result in a rent increase during the term of the contract and “matching” deposits into a savings account may be made by the housing authority. Please see local rules and regulations to determine the exact administration of the FSS.
SSI is an economic “need-based” program and is intended to supplement any income individuals already possess, to ensure that they are afforded a minimum level of income. Therefore, the dollar amount of SSI benefits received on a monthly basis varies from person to person. The Federal Benefit Rate (FBR), is the maximum dollar amount that individuals or couples can receive in SSI cash benefits in a month.
When conducting the SGA determination, or work CDR, SSA may average income when monthly earnings are typically under the SGA level but there are one or two months in which the reported earnings are above the SGA limit. Averaging must always involve income from the same or similar jobs and must only be completed during a time period in which the SGA level remains the same.
SSA grants individuals a $20 general income exclusion, which is subtracted from their income. The general income exclusion is first applied to unearned income received. Any portion of the general income exclusion remaining is then applied to earned income. In addition to the general income exclusion, a $65 earned income exclusion is subtracted from earned income. For SSI beneficiaries, earned income is the gross amount received in the calendar month, regardless of when it was earned. After the earned income exclusion is applied, SSA counts one-half of the remaining earned income. The remaining amount of earned and unearned income after exclusions is combined to give the countable income; this is the dollar amount that SSA uses to determine the SSI payment.
The cost of certain impairment-related items and services required by individuals in order to work are deducted from gross earnings in calculating SGA, even if these items and services are also needed for non-work, daily activities. The purpose of the IRWE is to allow beneficiaries to reduce income below SGA levels until they can work at a level of self-sufficiency, which decreases reliance on benefits. The cost of IRWE expenses can also be deducted from gross earnings during initial application processes, enabling individuals to meet the SGA requirement.
For SSI beneficiaries, deducting the cost of the IRWE from monthly gross wages increases the SSI cash payments they can receive. The cost of IRWE expenses can also be deducted from gross earnings during initial SSI application processes, enabling individuals to meet the SGA requirement.
As a means tested program, SSI will consider the income and resources of all applicants and beneficiaries. In determining SSI eligibility, individuals may exclude many types of income such as including parents’ income/resources once a child reaches the age of 18, any portion of student’s grants, scholarships, or fellowships used to pay the cost of tuition, books, and other education related expenses; and/or food and shelter provided “in-kind” by a non-profit organization as income if the assistance is based on need and is certified by the state. This is only a partial list of possible exclusions.
Medicaid is a means tested health care program providing benefits to individuals with low income and who meet other state specific eligibility criteria. Medicaid is a federal/state partnership. The federal government provides basic guidelines for eligibility and services and allows a state agency to administer the specifics of the program. The financial partnership varies from state to state but is generally a 50/50 cost split. Due to the variances in each state’s rules and regulations, there are essentially 50 different Medicaid programs and the individual must comply with the rules and regulations administered by the agency within the state of residence.
States can extend Medicaid coverage to certain individuals with disabilities who work under a provision known as the Medicaid Buy-In. The Medicaid Buy-In first appeared as an option for States under Section 4733 of the Balanced Budget Act of 1997. The Buy-In is designed to provide Medicaid to working people with disabilities who, because of relatively high earnings, cannot qualify for Medicaid under one of the other statutory provisions. The Medicaid Buy-In program allows working individuals with disabilities to “buy into” their state’s Medicaid program by paying a premium and/or cost share amount similar to the manner in which they would purchase health coverage on the private market. Working individuals with a disability who meets their state’s specific eligibility requirements for the Buy-In may enroll in the program. SGA is not a considered when determining disability for Buy-In purposes.
The MBI-WPD is a program that allows eligible working people with disabilities to purchase Medicaid.
To qualify for the MBI-WPD you must:
· Be a resident of New York State;
· Be at least 16 years of age (coverage up to 65 years of age);
· Have a disability as defined by the Social Security Administration (SSA);
· Be engaged in paid work (includes part-time and full-time work);
· Have a gross income in 2009 that may be as high as $55,188 for an individual and $73,884 for a couple;
· Have countable income below $2,257 in 2009; and
· Have non-exempt resources that do not exceed the Medicaid resource level of $13,800 for an individual and $20,100 for a couple.
Applications must be completed and submitted to your local Department of Social Services office.
These two special Medicaid eligibility criteria allow for the state Medicaid agency to pay Medicare Part B premiums on behalf of the eligible individual.
A Medicaid Spend Down is an option in many states that allows an individual with excess income, who is otherwise eligible, to incur the cost of care equal to the excess income. Spend Down amounts can be determined on a one month or six month basis in accordance with that state’s regulations. Once the otherwise eligible individual has incurred allowable health care costs within the Spend Down period, Medicaid coverage will commence to provide health care protection.
A program particular to a state or region of a state, that has been sanctioned by HHS that will provide services different from those provided by the state’s regular Medicaid program. Waiver programs are essentially experiments in service delivery that will allow a state to determine if cost savings can be derived from alternative delivery.
A waiver administered by the NYS Office of Mental Health (OMH) allows children and adolescents with mental illness to receive a range of services not otherwise available through the traditional Medicaid program.
Medicare is a federal health care program provided to retirees and insured individuals with disabilities meeting the SSA medical standards. Medicare is provided to retirees at full retirement age and to individuals with disabilities after the receipt of 24 monthly cash, Title II payments. Exclusions to this 24-month waiting period are provided for individuals with end stage renal disease and ALS. Premium assistance may be available for low income Medicare beneficiaries through the state Medicaid program. Medicare comes in four parts:
Provides for hospital coverage and is free to the individual.
Provides for doctor’s office visits and is a premium-based service provided at the option of the individual. Premiums may be collected from retirement or disability benefits, if payable. Premiums are likely to increase each year.
The Medicare Advantage Program is similar to an HMO. Individuals who have Parts A & B are not covered by Part C. Individuals who have Part C are not covered by Parts A & B. This is also a premium-based service.
Prescription Drug Coverage. This service is premium-based and services are from various providers depending upon the area of the country in which the individual resides. Full or partial subsidies may be available.
Beneficiaries who continue to work can generally continue to receive Medicare for 78 months with the first month of SGA occurring after the 15th of the month of the EPE. Medicare coverage extends for at least 93 months after the end of the TWP.
Beneficiaries of SSDI and SSI may incur overpayments of benefits when they receive more benefits than they were entitled to receive. Overpayments are initial determinations and can be appealed through the reconsideration process if the beneficiary disagrees that the overpayment occurred or disagrees with the amount assessed. If the overpayment is correct, the beneficiary can request a waiver of recoupment if he or she was not at fault in causing the overpayment and if repayment will jeopardize the ability to meet basic needs.
PASS is an SSI work incentive under which persons with disabilities can set aside income and/or resources to be used to achieve specific work goals. A PASS can be established to cover the costs of obtaining an education, receiving vocational training, starting a business, or purchasing support services which enable individuals to work and result in reduction/cessation of benefits.
This SSI provision allows individuals to exclude certain resources which are essential to their means of self-support. Properties that are used in trades or businesses by individuals for work as employees are totally excluded as of May 1, 1990. Up to $6,000 of the equity value of non-business properties that are used to produce goods or services essential to daily activities are excluded.
Re-determinations are non-medical reviews which occur annually. During the re-determination reviews, the SSA updates information on the individual’s income, resources and living arrangement.
It is the policy of the SSA that every legally competent beneficiary has the right to manage his or her own cash benefits. However, when there is evidence that an individual is not able to manage or direct the management of benefit payments in his or her best interests, representative payment may be made. As a result, payments are made to a third party, called a representative payee, to be used for the benefit of the beneficiary.
The SSI benefit program has specific resource limitations that are set by statute and include real or personal property (including cash). This must not exceed the specified amount at the beginning of each month. The resource limits are not subject to regular cost-of-living increases, and the current limit is $2,000 for individuals and $3,000 for federally married couples.
Section 8 (Housing Choice Voucher Program) is the main housing assistance program in the United States providing housing assistance to low income individuals. While rental liability is based upon an individual determination, it is generally around 30% of the tenant’s countable income. Please contact the local housing authority for income and rental determination rules.
The Social Security Act provides for continuation of SSI and/or Title II benefits to individuals who have medically recovered but who are participating in a program consisting of the Ticket to Work and Self-Sufficiency Program or another program of vocational rehabilitation services, employment services or other support services. These provisions allow individuals who have medically improved and are no longer considered disabled to continue receiving SSDI and SSI benefits if they are participating in approved vocational rehabilitation programs at the time their disability ceases and SSA has determined that continued participation in the vocational rehabilitation programs will increase the likelihood of permanent removal from the disability benefit rolls.
1619(a) enables individuals who continue to be disabled to receive special SSI cash benefits in place of their regular SSI payments when earnings exceed the SGA level. To be eligible for 1619(a) benefits, individuals must continue to have the original disabling impairment under which eligibility for SSI was initially determined, and must currently meet all other eligibility rules, including the income and resource test. If all eligibility requirements continue to be met, when earnings exceed the SGA level but remain lower than the break-even point, SSI beneficiaries will automatically move into 1619(a) status.
$19,284 ($1607 monthly) is for 2010 and 2011.
1619(b) provides continued Medicaid eligibility for individuals whose incomes are too high to qualify for SSI cash payments, but are not high enough to offset the loss of Medicaid or publicly funded attendant care. Individuals will be eligible only for the 1619(b) protected Medicaid status if the sole cause for SSI payments cessation is increased earnings over the break-even point. If cessation is a result of anything other than earnings (e.g. determination of medical recovery or excess resources and/or excess unearned income) individuals will not be eligible for 1619(b). A second criterion for 1619(b) status requires that individuals’ gross earnings fall below certain limits called the threshold amount which will vary from state to state.
$43,957 is for 2010 and 2011.
Formerly known as Food Stamps, this federal program provides nutrition assistance in the form of an electronic benefits transfer (EBT) card. The amount of benefit is directly related to the composition of each household and the state, or region of a state, of residence. The SNAP program is administered by the U.S. Department of Agriculture.
In NY, the shelter allowance will depend on the size of the household and whether the family receives HEAP, has rent obligations, lives in a domestic violence shelter, etc., and whether the individual is elderly or disabled.
Social Security Disability Insurance is a federal insurance program authorized under Title II of the Social Security Act.
To be eligible for Social Security Disability Insurance, individuals must have insured status as former employed workers: that is, they have been employed for a specified minimum period in Social Security-covered employment. To establish insured status for disability benefits, individuals need 20 credits in the 10 years prior to the onset of disability. Those disabled before age 31 need less work to qualify. It is possible to earn up to four credits of coverage yearly based on annual earnings. In 2010 and 2011, employees earn one credit for every $1,120 of earnings. This amount is automatically increased each year under a formula that takes into account increases in average wage levels nationally. To be eligible for Social Security, individuals must be determined medically disabled, out of work or earning less than SGA.
Supplemental Security Income is a means tested program authorized under Title XVI of the Social Security Act.
To be eligible for SSI an individual must fit into one of the following categories: disabled (as defined earlier); blind: 20/200 or less in better eye with glasses, or field of vision less than 20 degrees; or aged (65 or older). In addition, they must meet the Income and Resource Test and other SSI eligibility requirements.
Only earnings that represent the real value of the work performed are used to determine SGA. A subsidy is support a person receives on the job which could result in more pay than the actual value of the services the person performs. SSA makes a determination of the value of the work, after subsides are subtracted. The dollar amount of these is subtracted from gross monthly earnings during the initial eligibility process for both SSI and Social Security, potentially reducing gross earnings below the SGA level. They are applicable to the SSI program only during initial eligibility. For the Social Security program, however, they are considered in ongoing SGA determinations.
SGA is defined as the performance of significant physical or mental duties for pay or profit and in 2010 and 2011 is generally determined to be gross earnings in excess of $1,000 a month for an individual with a disability other than blindness and $1,640 for a person who is blind.
When individuals have accumulated nine months of trial work, a work CDR is conducted by SSA. The purpose of the review is to determine whether or not the individual can work at SGA levels. A decision of SGA implies that individuals are performing significant mental or physical duties for profit, and are, therefore, demonstrating the ability to work in spite of their disabling impairment. If individuals are determined to be engaging in SGA they will receive full benefit checks for an additional three months (the first month of SGA after the end of TWP [cessation month] and the two following months), and then the cash benefits will cease. This three-month period is called the “cessation month and grace period” and may occur at any time after the end of the TWP when the individual’s income is at SGA levels. If individuals are determined not to be engaging in SGA, they will continue to receive full benefit checks.
SEIE is an SSI work incentive program which allows individuals under age 22 who regularly attend school to exclude (as of January 2011) up to $1,640 of earned income per month (up to a maximum of $6,600 per year). This exclusion is applied before any other exclusion. The exclusion amount will be automatically adjusted on an annual basis based on the cost of living. The exclusion is only applied to the earned income and consecutively to months in which there is earned income until either the exclusion is exhausted or the individual no longer meets the definition of a student.
The federally based program provides cash assistance to help meet basic needs to low income families. The program is administered by HHS in cooperation with an agency in each state. As a result, the program may have an operational name different than TANF. The amount of benefits is dependent upon the size of the household and will differ in each state, or region of a state.
NYS’s FA resource exclusions are similar but not identical to the federal SSI exclusions. The following resources are exempt and do not count toward eligibility for Family Assistance:
· $2,000 (or $3,000 for households with a member over 60);
· A home that is the household’s usual place of residence;
· A car with a fair market value of $4,650, unless the car is needed to seek or maintain employment, in which case the car can have a fair market value of $9,300;
· One burial plot per household member;
· Funeral agreements worth up to $1,500 per household member;
· Funds in an Individual Development Account;
· For six months, real property that the household is making a good-faith effort to sell;
· Personal property necessary for business or employment; and
· State and Federal earned income tax credit refunds.
An amount up to $4,650 will be disregarded if set aside in a separate bank account for the sole purpose of enabling the individual to purchase a first or replacement vehicle for the recipient to seek, obtain or maintain employment, so long as the funds are not used for any other purpose.
With few exceptions, FA requires adults receiving assistance to work or participate in work activities within 24 months of FA startup. The following types of work activities will count toward the recipient’s work requirements:
· Unsubsidized employment (when a recipient has his or her own job);
· Subsidized private sector employment (when a business receives money or tax incentives to hire a FA recipient);
· Subsidized public sector employment (when a non-profit organization receives money or tax incentives to hire a FA recipient);
· Work experience program (WEP) in the public or non-profit sector if sufficient private sector employment is not available;
· On the job training;
· Job search and job readiness;
· Community service;
· Vocational educational training (but not more than 12 months);
· Job skills training directly related to employment – including up to 12 months of vocational education.
In NY, a recipient shall not be required to participate in work activities if he or she:
· Is a child under 16 years of age or under 19 years of age and attending a full-time secondary, vocational or technical school;
· Is a person whose presence in the home is required because of the illness or incapacity of another member of the household;
· Is a pregnant woman after the eighth month of pregnancy;
· Is a person who is physically or mentally unable to engage in work activities for up to three months;
· Is 60 years of age or older;
· Determined to be disabled after a disability determination done by the New York State Office of Disability Determinations. NYSODD uses the SSA standard for disability but is much more lenient when making determinations for the FA rather than SSA.
Public Law 106-170 directed the Commissioner of Social Security to establish a Ticket to Work and Self-Sufficiency program (section 1148), which expands the universe of service providers available to SSDI and SSI disability beneficiaries and provides them with a “ticket” they may use to obtain vocational rehabilitation services, employment services, and/or other support services from an employment network of their choice.
Unless medical recovery is an issue, individuals receiving Social Security based on disability are entitled to a nine-month TWP, which provides opportunities to test work skills while maintaining full benefit checks regardless of any income earned. The TWP is a work incentive and begins the first month that individuals are entitled to Title II benefits or file applications for disability benefits (whichever is later). Effective January 2010 and 2011; only months during which an individual earns over $720 or works over 80 hours in self-employment are service months and count as TWP months.
Unearned income is all income that is not earned. Some common types may include: in-kind support and maintenance; private pensions and annuities; periodic public payments such as SSDI, Veteran’s Benefits, railroad retirement benefits, workers’ compensation, unemployment compensation, etc; and others.
The unemployment insurance program is a federal and state administered program providing cash benefits to those workers who have lost employment through no fault of their own. Workers must have met minimum work and earnings requirements set by each state, and be “no fault” as that term is defined by state regulations. The amount of income replacement cash provided will vary according to the last amount of earned income as well as any minimum and maximum payment level set by the state.
In New York State, almost all employees are under the Unemployment Insurance Law. Those not covered are because such earnings are not taxable and/or the worker is not entitled to unemployment benefits based on the services rendered. Included in this set:
· Babysitters under the age of 18;
· Casual laborers under the age of 21 doing yard work and household chores;
· Golf caddies;
· Independent contractors;
· Inmates of custodial or penal institutions;
· Out-of-state employees; and
· Licensed real estate brokers and sales associates.
The worker must file a claim either online for unemployment benefits with the New York State Department of Labor at www.labor.state.ny.us/ui/how_to_file_claim.shtm or at Telephone Claims Center at 1-888-209-8124.
The individual claiming benefits must report weekly either through the web or by using TEL-SERVICE (1-888-581-5812), must actively be seeking employment, and must also be readily available for work and willing to accept a suitable job if one is offered.
In New York State, the benefit formula computes a weekly benefit as a fraction of the wages a person received in one or more quarters of the base period. There is a maximum benefit amount of $405 weekly, plus a $25 federal supplement. No worker, regardless of his or her earnings level during the base period, receives more than this maximum. This maximum benefit amount is a flexible amount that is adjusted according to the weekly wages of covered employees.
Unincurred Business Expense is SSA’s term for self-employment business support that someone else gives to the working beneficiary without cost. Examples include: unpaid help, a third party buying a computer for your business.
When work at the SGA level cannot be sustained by the individual for more than six months, a provision called “Unsuccessful Work Attempt,” or UWA, may apply in both initial determinations and in continuing disability reviews. Termination or reduction of work must be due to the individual’s impairment or the removal of special conditions that are necessary because of the disability. UWA are considered different depending upon whether the work attempts lasted between 1 – 3 months or 4 – 6 months.
When an individual receives a written notice from SSA which states that he or she has been overpaid, the individual can file a waiver of overpayment recovery. If the individual agrees that the overpayment has occurred and that the amount assessed is correct but believes that he or she was not at fault in causing the overpayment and cannot repay without risking the ability to meet basic monthly needs, a request for a waiver of recoupment should be filed.
The Workers Compensation is a state administered program providing cash and medical benefits, among others, to workers injured “on the job.” Currently, 48 states require certain employers to participate in the program while Texas and New Jersey have voluntary programs. The worker receives replacement income and health care coverage in return for giving up the right to sue the employer. Programs vary greatly according to individual state regulations.
In NY, the Workers Compensation program is administered by the New York State Workers Compensation Board. http://www.wcb.state.ny.us/
The Social Security Act outlines several work incentives intended to help SSI beneficiaries and SSDI beneficiaries return to, or enter, the workforce and reduce the dependency on benefits. Work incentives can help individuals pay for services or items that they need in order to work and to maintain, or even increase, their cash benefits until they are stable in employment. In addition to the 1619(b) work incentives, the Plan for Achieving Self-Support (PASS), Impairment Related Work Expense (IRWE), and Blind Work Expense (BWE) are incentives that enable people with disabilities to recover expenses they incur while working towards greater economic self-sufficiency. The goals of the work incentive programs are to assist individuals to achieve gainful employment, increase independence, facilitate empowerment, and acquire self-support.