Social Security Title II Basics. PABSS prerequisite February 2016

Transcription

1 Social Security Title II Basics PABSS prerequisite February 2016

2 Who Can be Served by PABSS? People who receive disability benefits from Social Security - Supplemental Security Income (SSI) based on disability. - Social Security Disability Insurance (SSDI). 2

3 Who Else Can be Served by PABSS? - Recipients of Title II dependent or survivor benefit that is based on disability - some individuals who receive Medicare as a former SSDI recipient or those receiving 1619b Medicaid. 3

4 Cash Benefits Administered by SSA The Social Security Administration (SSA) is a federal agency that administers two federal cash benefit programs: Social Security (Title II) Supplemental Security Income (Title XVI) Both pay benefits to those who meet the agency s disability standard. Each includes a different set of detailed work incentives and rules about work. 4

5 Disability Definition The inability to engage in any substantial gainful activity (SGA) by reason of medically determinable physical and/or mental impairment(s) which can be expected to last for a continuous period of not less than 12 months or result in death. 20 CFR , Statutory Blindness. 20 CFR et seq., et seq. 5

6 Establishing Disability The 5 Steps of Sequential Evaluation Engaging in SGA? Severe impairment or combination of impairments? Does impairment(s) meet or equal a Listing? Does impairment(s) prevent PRW? Does impairment(s) prevent other work? 20 CFR ,

7 Eligibility Requirements: Disability Benefits from Social Security SSDI Meet disability or blindness criteria and have worked long enough in jobs covered by Social Security taxes. SSI Meet disability or blindness criteria and have limited income and resources (needs based) (more on this in the second webinar). 7

8 How and when do you get a Title II benefit (SSDI)? File an application and provide evidence of diagnoses and functional limitations. SSA determines disability and the onset date 5 month waiting period 12 month duration rule SSA calculates the benefit rate based on the applicant s work history in FICA covered work. 8

9 Distinctive Features SSDI - Social Security Disability Insurance SSDI - Funded by FICA taxes and is not needs based or based on living arrangement. Benefit amount is based upon level of earnings over working years Paid on 3rd of month or on a Wednesday based on the day of birth. Medicare coverage starts after 24 months of entitlement 9

10 More distinctive features The Social Security program is compulsory for most workers, and based on insurance principles. It is designed to partially replace earnings lost due to the retirement, disability or death of an insured person. To qualify, the disabled person must have a recent work history. 10

11 The amount of work one needs to qualify depends on their age Before age /2 years of work in a three-year period before becoming disabled Age work during half the time between age 21 and the time the disability began Age 31 or older - work during five out of the 10 years before the disability began 20 CFR

12 When you pay Social Security taxes you earn work credits You can earn up to a maximum of 4 work credits each year. The work credits are based on the total amount of your wages or self-employment income during the year. In 2016, for each $1,220 in gross earnings you get one credit, max. of 4 credits per year Earn $4,880 to earn 4 credits in

13 Amount of SSDI Benefit Benefits are calculated based on work history Monthly benefit payment amounts depend upon the worker s work/wage history and are unique to each worker. Maximum benefit payable is $2639 per month in If the Social Security benefit amount is lower than the full SSI payment, one may be eligible to receive both Social Security and SSI. More on this later. 13

14 Disability Onset Date SSA will determine the disability onset date for SSDI benefits. It is the first day the applicant meets the definition of disability The 5 month waiting period counts from the month of disability onset. The 12 month duration of disability requirement counts from the month of disability onset. 14

15 Disability Onset Date Substantial Gainful Activity during either of these periods may result in a denial of the application for SSDI. 15

16 Retroactive Payments SSDI benefits may be paid retroactively for up to 12 months prior to the date of application. The actual amount of retroactivity depends on the disability onset date and where that falls in relationship to the date of application. For Example: Disability onset was 09/10/2012. Five month waiting period makes the first month of eligibility 03/2013. However, beneficiary doesn t file until 01/22/2015. If approved, benefits are only paid back one year to 01/2014, not back to 03/

17 Five Month Waiting Period Payment begins the sixth full month after the date SSA determines the disability began. In other words the first 5 months after disability onset are nonpayment months. For example, if the disability began on June 15, 2014, the earliest a benefit could be paid would be for the month of 12/2014. Benefits are paid a month behind. So, the December benefit would be paid in January

18 What is Substantial Gainful Activity (SGA)? Work is substantial if it involves doing significant physical or mental activities or a combination of both. In 2016 SGA is presumed at earnings averaging over $1,130 gross a month for those eligible on the basis of disability. For those eligible on the basis of statutory blindness it s $1,820. [substantial] 18

19 Other benefits payable under Title II Benefits authorized under Title II of the Social Security Act can also be paid for Retirement, Dependent benefits for certain family members of retired or disabled workers, and Survivors benefits for certain family members of deceased workers (20 CFR ) These individuals ARE NOT PABSS eligible 19

20 Retirement Insurance Benefits Generally need 40 quarters of coverage to qualify. Receive full retirement (based on earning history at Full Retirement Age. Can elect retirement benefits as early as age 62 but this result in a permanently reduced benefit. Medicare eligibility starts at age 65. These beneficiaries are Not PABSS eligible 20

21 Child Disability Benefits (CDB), POMS DI , 20 CFR The child must: Be the child of a worker entitled to retirement or disability, or who died fully or currently insured Be a dependent of the worker and Be unmarried. (some exceptions) Be 18 or older and be under a disability which began before age 22. These beneficiaries are PABSS eligible. 21

22 Disabled Widow(er)s DWB, POMS DI , 20 CFR Applicant must be: Surviving spouse or surviving divorced spouse of worker who died with enough credits to be insured for benefits, Age 50 60, Disabled within specific time periods (called prescribed period) Unmarried These beneficiaries are PABSS eligible. 22

23 Other Dependent and Survivor Benefits There are other categories of dependent and survivor benefits payable on the wage record of a disability/retirement beneficiary or deceased wage earner. E.g., minor child benefits and spousal or widow/or benefits based on age. These beneficiaries are not PABSS eligible. 23

24 Medicare for SSDI eligible individuals Medicare coverage automatically begins after being entitled to disability benefits for 24 months. Exception: no wait for those with End Stage Renal Disease and ALS. Example: Month of eligibility is 01/2014 Medicare A&B effective 01/2016 [Title II] SSA will send information about Medicare several months before coverage starts. 24

25 Medicare Medicare has 4 parts. Part A - hospital insurance Part B - medical insurance Part C - Medicare Advantage (managed care) Part D Prescription drug coverage must be purchased from private insurer Recipients of early retirement benefits are not eligible for Medicare until age 65 and then they are automatically enrolled. 25

26 Sources of Law and Policy United States Code (U.S.C.). Contains the federal statutes that created the Title XVI (SSI) (42 U.S.C et. seq.) and Title II (42 U.S.C. 402 et. seq.) programs. Code of Federal Regulations (C.F.R.). Contains the federal regulations implementing for the Title XVI (20 C.F.R. 416 et seq.) and Title II (20 C.F.R. 404 et.seq.) Programs. 26

27 Sources of Law and Policy Case law. Decisions of the Federal District Courts, U.S. Circuit Courts of Appeals, and the U.S. Supreme Court. Social Security Rulings (SSR). Statements of policy and interpretations adopted by SSA based on federal court and administrative decisions, policy statements, and opinions of SSA s Office of General Counsel. Published in the Federal Register, they are binding on all components of SSA, but do not have the force and effect of law. 27

28 Sources of Law and Policy Acquiescence Rulings explain how SSA will apply decisions of the U.S. Circuit Courts of Appeals that are at odds with SSA s national policies. Program Operations Manual System (POMS). The POMS provides guidelines for day-to-day operations in SSA s district offices and at Disability Determination Services (DDS). The POMS does not have the force and effect of law and cannot be used where it conflicts with the statute or regulations. 28

29 Sources of Law and Policy Hearings, Appeals and Litigation Law Manual (HALLEX). Published by the SSA Office of Hearings and Appeals (OHA), the HALLEX conveys guiding principles to OHA staff, defines procedures for carrying out policy, and provides guidance for processing and adjudicating claims at the ALJ hearing, Appeals Council, and federal court levels. 29

30 Sources of Law and Policy On the home page Go to - Our Agency Then, in the drop down box, choose - Program Rules You can then choose to view statute provisions, regulations, Social Security Rulings, POMS, HALLEX, Emergency Messages, or Chief ALJ Bulletins. 30

31 Upon completion Send the spoken verification words to Subject line - pre-requisite training (If these are not received you will be denied entry to the onsite training) Please any questions/comments to Cheryl.Bates-Harris@ndrn.org 31