Benefits Verification: Considerations and Strategies

Transcription

1 Benefits Verification: Considerations and Strategies Why verify benefits The cornerstone of work incentive planning services is to provide accurate information about the impact of earnings on the various benefits an individual receives. Given the myriad benefits a person may be receiving, individualized advisement (whether through a written BSA or provided verbally) should only occur after verifying all of a beneficiary s benefits from an authoritative source. The alternative, trying to offer benefits advice based on unverified information, is extremely dangerous business. The risk of error is quite high and the consequences can be severe for the beneficiary. It is very common for beneficiaries to have inaccurate, incomplete, or out-of-date information about what benefits they receive and how much the payments are. Admittedly, benefits verification can take time and does slow down the advisement process. There will be times when beneficiaries will push CWICs for an immediate answer to a question, but CWICs must resist being rushed. It is far better to move slowly and dispense correct information than to respond quickly with incorrect advice. It may be necessary to explain this clearly to beneficiaries to help them understand why services take time. When to verify benefits When working with a newly enrolled beneficiary, you should verify benefits prior to giving any individualized advisement. That means, before you write a BSA, you should have verified all benefits. Before you tell a beneficiary what they can expect to have happen to each of their benefits given a specific work goal, you should have verified benefits. In some circumstances, it may be necessary to re-verify benefits as well. If a beneficiary returns for additional individualized services several months later, you will need to review their benefits to determine if changes may have occurred and if updated verification is necessary. The rule of thumb is that if it has been 6 months since you last verified benefits; plan to reverify all of them. If it s been less than 6 months since you last verified benefits, talk through with the beneficiary whether they have gone through a redetermination process and what may have changed with each benefit. If there has only been a change in one of their benefits, then you only need to re-verify that one. If there is ever a doubt as to whether a change has occurred, re-verify. What to verify When it comes to verification, a CWIC must verify all public benefits the beneficiary receives, which includes: SSDI/SSCDB/SSDWB, SSI, state supplement, Ticket assignment, Medicare Parts A/B/C/D, Medicaid, Medicaid Home and Community Based Services (HCBS) waiver, Medicare Savings Program, Low Income Subsidy, SNAP, low income housing, worker s compensation, unemployment insurance, Veteran s Pension/Compensation, Black Lung benefits, and Railroad Retirement benefits. If an individual is receiving a private benefit, such as a private long-term disability or private health insurance, and they 1

2 have concerns about how work will affect that benefit, then a CWIC must work with the beneficiary to contact the benefit administrator and verify the benefit and impact of working. It is not enough to verify the receipt of benefits only. Be prepared to verify all pertinent information, such as entitlement date, amount of benefit, time-limited income exclusions, and use of special programs within a benefit program. For example: some eligible beneficiaries receiving housing assistance have an earned income disregard for specific amounts over specific periods of time; it is imperative that the CWIC knows if any or all of the income exclusion months have already been used prior to offering advisement about the impact of earnings. Since each benefit program is unique in so many ways, what you need to verify will differ from one program to another. A detailed list of what is recommended to verify for each benefit is noted on Appendix A of this paper, titled Benefit Verification Quick Reference Guide. In the majority of situations, the benefits you are verifying are those of the beneficiary you are serving. In some situations, though, it may be necessary to verify their spouse s benefits and/or children s benefits. If a beneficiary s spouse or children are receiving public benefits and the beneficiary has concerns about how those will be impacted by working, a CWIC must verify those benefits as well. How to verify benefits The first step in verifying benefits is to explain to the beneficiary the need for verification and obtain signed releases of information. You will need to have a release of information to verify each benefit the person receives. To obtain verification from SSA, they require you use their specific release of information. You may find other benefit agencies also require you use their release of information form, while others may be fine with you using your agency s general release of information. As you establish a protocol for how to verify each benefit, you will want to clarify any specific release of information requirements and keep a list handy about what type of release is appropriate for each agency. The second step in verifying benefits is to contact the benefit agency. How and in what way you contact and communicate with the agencies will differ from one to another. The following section provides some details on how to communicate with the federal benefit programs to obtain verification of common federal benefits. Since there are numerous state benefits that you must also verify, you will need to identify the process for verifying these state specific benefits for your state or region. Establishing the means for verifying in your state may require a concerted effort of networking and relationship building on your part. In most benefit agencies, the personnel have substantial workloads and may be slow or non-responsive to your request for benefit verification. In these situations, it will be critical to build and use your network to find alternate avenues or approaches for obtaining verification. The third step in verifying benefits is to clarify any abnormalities or inconsistencies. With every agency you obtain verification from, you want to be certain your process not only allows you to obtain the verification, but also allows you to get clarification on any abnormalities or inconsistencies you find regarding the beneficiary s benefits. You should scrutinize all verifications to determine if there are any inconsistencies with what the beneficiary shared with you about their situation. In many situations, the verification information you receive may generate as many questions as it does answers. It is a critical part of the CWIC s job to identify these abnormalities as well as the appropriate course of action to correct them, if any correction is needed. 2

3 Verifying benefits from federal entities The following is a list of common federal benefit programs and the specific steps you can take to verify them. A detailed list of how to verify various benefits is provided in Appendix A of this paper, titled Benefit Verification Quick Reference Guide. Benefit Planning Query (BPQY): The Social Security Administration s BPQY (SSA-2459) contains comprehensive information about an individual's disability benefits and work status. This includes the status of the beneficiary's Social Security administered disability cash benefits, Medicare, Medicaid (in some situations) scheduled medical reviews, representative payee, last work review date and work history. In essence, the BPQY provides a snapshot of the beneficiary's benefits and work history as stored in SSA's electronic records. A beneficiary can request their own BPQY or they can have a representative obtain one for them by signing the appropriate releases of information. SSA and IRS rules require two SSA-3288 Release of Information forms (found in the CWIC Manual, Module 6 Unit 2) be submitted when requesting a BPQY. The completed forms should be sent to the beneficiary s local SSA office with a specific request for the BPQY. Some SSA offices require WIPA projects to submit all releases to a central point of contact (such as the WIL or Office Manager). Other offices allow the releases to be sent directly to Claims Representatives. Be sure to follow the proper procedure for that particular local SSA office. The BPQY is generated by pulling from several different data sources at SSA including; the Master Beneficiary Record (MBR), the Disability Control File (DCF), the Supplemental Security Income Display (SSID), the Summary Earnings Query (SEQY), and the Inquiry Response (QRSL). If any of the information in those data systems is outdated, the information on the BPQY will be outdated or inaccurate. For example, if the beneficiary did not report earnings or if SSA has not yet processed work reports, the work incentive information on the BPQY will likely be outdated. You can help identify discrepancies or errors in any item on the BPQY by bringing this to the beneficiary s attention and helping them resolve this through the local Social Security office to avoid future misunderstandings and/or overpayments. A subsequent BPQY should confirm that correction(s) were made. It is important to keep in mind that the BPQY, as with all verifications, is a starting point. It must be scrutinized for inconsistencies or missing information. The process of scrutinizing a BPQY is a critical step in the benefit verification process. You will find in Appendix B of this paper a list of tips for how to scrutinize each of the key sections of the BPQY. Additionally, SSA has created a BPQY Handbook, available at which explains the details of each section of the BPQY. To become familiar with the basics of the BPQY, CWICS should read and use this handbook. In general, when scrutinizing the BPQY, here are the steps we recommend CWICs take to try to answer questions or resolve concerns: 1. Contact the beneficiary or his/her representative and ask questions about the information on the BPQY. The CWIC needs to know if it matches what the beneficiary is experiencing or what he/she remembers about work history. In some cases, this simple step will provide the information the CWIC needs to resolve the mystery at hand. If no, the CWIC should move on to the next step. 3

4 2. Many of the resolutions to BPQY problems will come from contact with the WIL in the local office or possibly the AWIC. These SSA employees will have access to the computer files and may be able to look up the question and answer it in a matter of minutes. The CWIC should make sure there is a signed release of information before making a request of this nature. The important thing to understand is that in some cases, the BPQY is merely a starting place in the information gathering process. Further inquiry is typically necessary to present accurate advisement on the impact of employment on benefits. Medicare Part D and Low Income Subsidy: Since the BPQY can t verify Medicare Part D or the Low Income Subsidy program reliably, you can instead use Medicare s call center to provide you that information. In using this process, you do not have to get another release of information, but you will need to collect the person s Medicare number (listed on their Medicare card). The following steps outline how to obtain this verification: Approximate time to verify: 5-10 minutes 1. Call Say the Medicare number when prompted to do so 3. Say "other choices" when prompted to do so 4. Say "my monthly premium" when prompted to do so 5. Say "drug coverage" when prompted to do so 6. An operator will come on the call, let them know you are a social worker and are calling to verify a client's Part D enrollment information. The operator will ask you for the following information about the beneficiary; Medicare number, name, date of birth, if enrolled in Part B, and then your name. 7. Ask the operator to verify if the person is enrolled in Part D, at which time the operator will let you know what prescription drug plan they are enrolled in and when they enrolled. 8. Ask the operator to verify if the person is enrolled in the Low Income Subsidy Program or Extra Help. If they say yes, make sure to clarify if it is partial subsidy or a full subsidy. You can also verify Medicare Part D enrollment by going to the following website: Ticket Assignment: In advising beneficiaries about their Ticket to Work and the medical continuing disability review protection, there is some key information you need to verify. You need to confirm when the beneficiary s Ticket was assigned (Month/Year), who their Ticket is currently assigned to, when their last Timely Progress Review occurred, and if their Ticket is considered in active status. This information can be verified by contacting the Ticket Call Center at when you have the beneficiary with you (or on conference call). Veteran s Benefits: You may verify Veteran s benefits by reviewing a copy of an award letter. If a veteran does not have a copy of their award letter but they have or are willing to set up a password to access their VA benefit information through the online portal, ebenefits you can verify benefits that way as well ( Another option is for the veteran, or you and the veteran together, to call the Veterans Administration at When the automated phone system begins you ll need to press 1, then press 1 again, then press 0 to speak with an operator. The veteran will need to ask the operator for a letter stating what their disability percentage is and their monthly compensation rate. The letter will be mailed out generally that day and should be received in 2-3 business days. 4

5 Railroad Retirement Benefits: You may verify Railroad Retirement Benefits by reviewing a copy of an award letter or by requesting a copy of verification at the Railroad Retirement Board s website: Black Lung Benefits: You may verify Black Lung Benefits by reviewing an award letter or by request verification through the DOL Division of Coal Mine Worker s Compensation: Documenting verifications For any beneficiary receiving intensive services, it is required that CWICs maintain documentation of verification in the beneficiary s file. This documentation could include copies of BPQYs, statements of benefits or other correspondence that verifies public benefits received, current benefits status, payment amounts, and work incentives used. When obtaining verification through a conversation with an agency representative (such as when calling the Medicare hotline), you should record the conversation at the very least in a case note. The case note should include the date you had the conversation, who you spoke to, and details about what you verified. Additionally, copies of relevant releases of information should be on file to verify that the beneficiary granted permission to obtain information from agencies. Summary As previously mentioned, it is imperative that ALL benefit information is verified BEFORE offering specific advisement. Providing benefit information or advice without verifying the benefit status is extremely dangerous and can have severe negative consequences for the beneficiary. While the BPQY can verify a substantial amount of information, most beneficiaries have additional benefits that provide critical support. These benefits must also be verified, which means the process for obtaining verification generally involves more than just obtaining the BPQY. While you may run into some challenges finding timely or efficient ways to verify some benefits, you must be persistent in finding solutions. Establishing an effective and efficient manner for verifying benefits is essential for WIPA projects to provide the quality and depth of services beneficiaries need. 5

6 Appendix A: Benefit Verification Quick Reference Guide Benefit What to Verify Ways to Verify Title II Disability (SSDI, SSCDB, Current benefit amount(s) (full, net, and reason for difference if BPQY, TPQY, Recent letter from SSA noting updated check amount (within last 6 months) SSDWB) any) Dependent benefits (if any) BPQY Date of Onset and Date of BPQY, SSA award letter Entitlement Next scheduled medical CDR, BPQY SSI Representative Payee status Work incentive information (current and previous use) and work history Current benefit amount(s) (full, net, and reason for difference if any) Date of Onset and Entitlement Next scheduled medical CDR, Representative Payee status Work incentive information (current and previous use) and work history BPQY, Recent work review decision (within last 6 months, older if no work activity since review) BPQY, TPQY, Recent letter from SSA noting updated check amount (within last 2 months) BPQY, SSA award letter BPQY BPQY State Supplement Current benefit amount Federally administered: BPQY State administered: Medicaid agency (i.e., case worker, centralized verification process, etc.), recent award or redetermination letter (within last 6 months) Ticket Assigned or In Use Medicare Is Ticket assigned, who is Ticket assigned to, when the Ticket was assigned, when the last Timely Progress Review was done, and if have Timely Progress Requirements been met Part A: Is beneficiary enrolled (yes/no) and enrollment date Part B: Is beneficiary enrolled (yes/no), enrollment date, premium beneficiary is paying Part C: Is beneficiary enrolled (yes/no), enrollment date, premium beneficiary is paying Part D: Is beneficiary enrolled (yes/no), premium beneficiary is paying EPMC: If Cessation has occurred, number of EPMC months remaining Ticket Call Center: BPQY, copy of Medicare card, Medicare # BPQY, copy of Medicare card, Medicare # Medicare # Medicare # Contact SSA representative (WIL, Claims Representative, etc.) 6

7 Benefit What to Verify Ways to Verify Medicare Savings Program (QMB, SLMB, Currently eligible (yes/no), which group enrolled in State Medicaid agency (case worker, centralized verification process), recent award or redetermination letter (within last 6 months) QI) Medicare Part B State Buy-In Currently eligible (yes/no) Medicaid agency (case worker, centralized verification process) Low Income Subsidy (Extra Help) Medicaid Medicaid Home and Community Based Services (HCBS) Waiver Currently eligible (yes/no), which group enrolled in, is any additional premium being deducted from T2 check? (when they select a better plan than the subsidy covers) Currently eligible (yes/no), which Medicaid eligibility group enrolled in Currently eligible (yes/no), which waiver enrolled in Medicare #, for those in full subsidy-medicaid agency (case worker, centralized verification process) For those SSI eligible in 1634 states: BPQY All others: Medicaid agency (case worker, centralized verification process) Medicaid agency (case worker, centralized verification process), award letter SNAP Current amount Agency administering SNAP (caseworker, centralized verification process), recent (within last 3-6 months, depending on frequency of state recertification) award or redetermination letter. Housing Assistance Veteran s Benefits Department of Defense Disability Retirement Unemployment Insurance Which housing subsidy program enrolled in and rent or subsidy amount Number of EID months available and involvement in FSS Type of VA cash benefit, benefit amount, VA medical priority group Benefit amount Weekly benefit amount, number of weeks left of payment Type and amount of benefit Type and amount of benefit Housing program staff (case worker, centralized verification), recent award, redetermination letter, or rental agreement (within last 12 months). Housing program staff Award letter, Veterans Administration ( ), or ebenefits: Award letter or ebenefits: Agency administering Unemployment benefits (case worker, centralized verification process) Railroad Benefits Award letter, request copy of verification at RRB website: Worker s Award letter Compensation Black Lung Amount of benefit Award letter, request verification through DOL Division of Coal 7

8 Benefits Mine Worker s Compensation: Appendix B: Tips for Reviewing a BPQY Type of Benefit: This row of the BPQY verifies the type of benefit the beneficiary is receiving. Under the Title II column it will indicate Disabled Worker if the person is receiving SSDI, Disabled Widow if the person is receiving SSDWB, and Disabled Adult Child if the individual is receiving SSCDB (formerly SSDAC). IMPORTANT NOTE: If the beneficiary is receiving more than one Title II benefit, you will need to get a BPQY for each Title II benefit. A BPQY can only show information about one Title II benefit, so you need to be sure to request a BPQY for each. Regarding SSI, this section will give you clues as to whether the individual is part of a SSI couple (Disabled Spouse), is being treated as a child in the SSI system (Disabled Child), or is being treated as an adult in the SSI system (Disabled Individual). Sample BPQY: Type of Benefit CASH Type of Benefit Disabled Widow Disabled Individual You will see on this sample BPQY this beneficiary is receiving a Social Security Disabled Widower benefit, and is eligible for SSI as a disabled adult. Statutory Blindness: If you are working with someone who experiences a visual impairment that appears to meet SSA s definition of statutorily blind, then you will want to check to see that this is marked Yes. If this is marked No, you will need to check with SSA to see if it is coded incorrectly or if SSA has not determined the person is statutorily blind. Sample BPQY: Not considered statutorily blind Current Status Current Pay Terminated Statutory Blindness No You will see on this BPQY SSA considers this beneficiary to not be Statutorily Blind, as it indicates No on the Statutory Blindness row. Date of Disability Onset and Date of Entitlement: For SSDI/SSDWB beneficiaries there will generally be a 5-month difference from Date of Disability Onset and Date of Entitlement. If you have a BPQY for a SSDI or SSDWB beneficiary and there is no 5-month difference, it is an indication that the person was previously entitled, terminated and has been re-entitled, either through Expedited Reinstatement or through reapplication. Additionally, if the date of entitlement on the BPQY is later than the dates listed for TWP usage, this typically indicates a new period of entitlement, via either EXR or reapplication. If they used Expedited Reinstatement, you will need to clarify if they are still in their Initial Reinstatement Period. Sample BPQY: No 5-month waiting period Date of Disability Onset 02/01/2009 Date of Entitlement 02/2009 $0.00 Full Amount $ On this BPQY this person did not serve a 5-month waiting period when they became entitled to this Title II cash benefit, the Date of Disability Onset is 02/01/2009, and the Date of Entitlement is 02/2009. Full Amount and Net Amount: When evaluating the SSDI column, anytime there is a difference between the full and the net amount you will need to clarify what is causing the difference. In some cases, you can look at other information on the BPQY to determine why the deduction occurs. The difference could be due to: 8

9 The Medicare Part B premium deduction: You can crosscheck that by subtracting the full and net amount to see if it equals the current year s Part B premium amount. Then check the Health Insurance-Buy-In Subsidy section of the BPQY. If the Buy-In or Subsidy section indicates a No under Part B, then that tells you the person is responsible for paying the Part B premium, which makes sense that the net amount is less than the full by the Part B premium amount. An overpayment deduction: You can crosscheck that by subtracting the full and net amount. If the amount is the same as the Monthly Amount Withheld section of the BPQY, then you know the reduction is due to the overpayment. Child Support, other garnishments, voluntary tax withholding: The only way you can determine the deduction is due to child support, other garnishments, or a voluntary tax withholding is if you contact SSA and ask them to clarify that for you. Sample BPQY: Title II Reduction Full Amount $1, Net Amount $1, Others Paid On This Record Yes Total Family Cash Benefit $2, Not Applicable Overpayment Balance $0.00 Monthly Amount Withheld $0.00 You will see on this page that the difference between the full and the net amount is $96.90, which is close to the same amount as the Medicare Part B premium ($96.40/month at the time this BPQY was generated). That is a clue that the reduction in the Title II cash benefit may be due to the Medicare Part B premium. You will also see there is no overpayment or monthly amount withheld, so the reduction cannot be due to that. HEALTH INSURANCE MEDICARE MEDICAID Type PART A PART B No Medicaid Eligibility Start 07/ /2005 Stop Buy-In No No On the second page of the BPQY, your suspicions are proven true. Under the Medicare Part B column it indicates there is No Buy-In, which means the beneficiary isn t getting any help from the state in paying the Part B premium, so they are covering that cost all on their own, which is why the Title II check is being reduced. Under the SSI column, whenever the SSI is not the full Federal Benefit Rate, you will need to determine what is causing the reduction. The difference could be due to: Entitlement to SSDI/SSCDB/SSDWB: If the full amount on the SSDI column and the full amount on the SSI column add up to the FBR plus $20 (or higher if in a state with a federally administered state supplement), then you know the reduced SSI is due to the Title II benefit. Earned income: Look for current monthly earnings listed on the Recent Earnings on Record section of the BPQY. That can confirm the reduction is due to earnings. In the SSI calculation worksheet plug in the monthly earning amount listed and see if you get the SSI amount listed on the BPQY. If so, you have verified the reduction is due to earnings. In-Kind Support and Maintenance: If the SSI payment is exactly 1/3 rd less than the Federal Benefit Rate, that is an indication that ISM is being applied. You will need to clarify from SSA whether they are applying the Value of One- Third Reduction or the Presumed Maximum Value rule, since that can t be confirmed by looking at the BPQY. If you find the beneficiary is actually paying their fair share of room and board, you will want to support them in correcting that information with the local SSA office. Other income: If the reduction amount cannot be identified by looking at the indicators noted above, you will need to contact SSA to clarify if the have on record some other sort of income the beneficiary is receiving. Sample BPQY: SSI reduction amount is one-third of SSI Federal Benefit Rate 9

10 Full Amount $ Net Amount $ Others Paid on This Record No Total Family Cash Benefit Not Applicable Overpayment Balance None On this BPQY the Full Amount and the Net Amount for the SSI check is $449.34/month, which is exactly 1/3 less than the Federal Benefit Rate. This amount generally indicates that ISM is being applied, but you will need to check with SSA to clarify if it is PMV or VTR. Sample BPQY: Beneficiary not receiving full SSI Current Status Current Pay Non Pay-Excess Income Statutory Blindness No No Date of Disability Onset 12/01/ /01/2002 Date of Entitlement 05/ /2002 Full Amount $ $0.00 Net Amount $ $0.00 Others Paid On This Record Yes No Total Family Cash Benefit $1, Not Applicable Overpayment Balance $0.00 Monthly Amount Withheld $0.00 This part of the BPQY shows the beneficiary is in Non Pay Excess Income status, which means they are not receiving an SSI check due to too much income. You can see they have SSDI of $509/month, but if that was their only income they would be due $185 in SSI ($509 - $20 = $489, $674 - $489 = $185). Therefore, there must be some other income. Now look turn to the Recent Earnings on Record section of the BPQY (see below). RECENT EARNINGS ON RECORD YEAR EARNINGS YEAR EARNINGS MONTHS EARNINGS MONTHS EARNINGS 1999 $1, $1, /08-01/08 $1, (V) 05/08-05/08 $ (V) 2001 $2, $1, /08-06/08 $ (V) 07/08-07/08 $ (V) 2003 $ $ /08-08/08 $ (V) 09/08-09/08 $ (V) 2005 $ $ /08-10/08 $ (V) 11/08-11/08 $ (V) 2007 $3, $4, /08-12/08 $ (V) 01/09-01/09 $1, (V) 02/09-02/09 $ (V) 03/09-03/09 $ (V) 04/09-04/09 $ (V) 05/09-05/09 $ (V) 06/09-06/09 $ (V) 07/09-07/09 $1, (V) 08/09-12/09 $1, (E) 01/10-01/10 $1, (E) 02/10-06/10 $1, (E) 07/10-07/10 $1, (E) 08/10-Cont. $1, (E) On this section, you will see the beneficiary has some earnings right now (the date this BPQY was generated was August 2010). The earned income, combined with the SSDI is so much that the SSI has been reduced to $0. Other s Paid on this Record and Total Family Cash Benefit: When Other s Paid on this Record is marked Yes that means other people are entitled to benefits on this same work record. If the Type of Benefit is listed as Disabled Worker that means there are others paid on this beneficiary s work record. That s very important to catch because if the Disabled 10

11 Worker s cash benefit stops due to working, the benefits of the others paid on the work record will stop too. The Total Family Cash Benefit includes the full amount of cash benefits paid to the individual with a disability, as well as other entitled family members on work record. This section is not applicable to SSI since SSI entitlement doesn t extend to dependents. Sample BPQY: Others Paid on this Record Type of Benefit Disabled Worker Current Status Current Pay Statutory Blindness No Date of Disability Onset 01/07/2003 Date of Entitlement 07/2003 Full Amount $1, Net Amount $1, Others Paid on This Record Yes Total Family Cash Benefit $2, Not Applicable Notice on this BPQY, the Type of Benefit is a Disabled Worker, meaning this individual is receiving SSDI. There are also Others Paid On This Record, as you can see this row is marked Yes. The Total Family Cash Benefit is $2,326.30, which means the others paid on the record are receiving a total of approximately $ ($2, $1, = $775.40), rounding may affect actual payment. Health Insurance-Medicare Type, Start, Stop, and Buy-In or Subsidy: This section of the BPQY can be used to verify Medicare Part A and Part B enrollment. If the person is enrolled Part A or Part B then a Start date will be listed. If the beneficiary unenrolled from Part A and/or B, a date will be listed under Stop. SSA does not have access to reliable information about Medicare Part D, so the BPQY will no longer show that information. The Buy-In or Buy-In or Subsidy row denotes whether the beneficiary is receiving help from the state in paying the Part B premium. If the state is paying their Part B premium, under the Part B column it would note Yes. Sample BPQY: Medicare enrollment HEALTH INSURANCE MEDICARE MEDICAID Type PART A PART B State determination Start 05/ /2007 Stop Buy-In No Yes On this BPQY this person is enrolled in Medicare Part A and B. On this BPQY, you will also see that on the Buy-In row, for the Part B column a Yes is listed. That means this person is getting help in paying their Part B premium. Health Insurance-Medicaid: This section of the BPQY can only verify Medicaid eligibility for SSI beneficiaries who live in a 1634 state. For everyone else, the BPQY will indicate that eligibility for Medicaid is State determined, which means CWICs must ask those beneficiaries if they receive Medicaid and then get verification of Medicaid eligibility through the state or other means. Sample BPQY: Medicaid eligibility HEALTH INSURANCE MEDICARE MEDICAID Type PART A PART B State determination Start 05/ /2007 This is a BPQY for a SSI recipient in a 209(b) state. You will see it does not verify Medicaid, instead it clarifies Medicaid eligibility is a State determination. When State determination is listed, CWICs must verify Medicaid eligibility through the state or other means. SSI Work Exclusions-BWE, IRWE, SEIE, and PASS: If a beneficiary is currently using or has previously used an SSI work incentive, it is listed here. The amount of the exclusion and the months it was approved for are listed here. Remember that 11

12 SSA will only make these deductions if the person reports them. That means a beneficiary might actually have costs that meet the criteria for these work incentives even though there is no indication on the BPQY. SSDI Work Activity-TWP, Cessation, Current SGA and Last Work Review: This section of the BPQY provides information about what SSA has on record regarding SSDI work activity and work incentive use. The TWP and cessation information noted in this reflect the findings from the last work continuing disability review (CDR) determination that was done. The date of that review was either initiated or completed will be listed under the Last Work Review Action. In some cases, a work CDR may be pending or needed so the information provided may be outdated. You should ALWAYS review this section carefully for accuracy. To determine if the information is outdated, compare the Date of Entitlement to the earnings listed under the Recent Earnings on Record and ask the beneficiary to clarify their recollection of their monthly earnings during those years. If it looks like there has been either Trial Work Period level work or SGA level work since entitlement or the last work review, and it s not reflected on the BPQY, you will need to let the beneficiary know a work CDR needs to be done and support them in working with SSA to get that completed. Remember, if a beneficiary has more than one Title II benefit (such as SSDI and SSCDB) they get a set of Title II disability work incentives for each. Therefore, a BPQY must be obtained for each benefit to verify which work incentives they have available. The Current SGA Level should reflect the current SGA for the beneficiary; if the beneficiary is statutorily blind it should list the blind SGA and if their disability on record is not statutory blind, it should list the non-blind SGA. If this amount is outdated, it is because the BPQY software that was used to generate the BPQY has not been updated. Sample BPQY: SSDI work incentives information SSDI WORK ACTIVITY Trial Work Months Start: End: Used: Months of Cessation Current SGA Level Last Work Review Action DEMONSTRATION PROJECT INFORMATION None RECENT EARNINGS ON RECORD YEAR EARNINGS YEAR EARNINGS MONTHS EARNINGS MONTHS EARNINGS 1981 $2, $4, $4, $4, $9, $12, $14, $14, $16, $18, $18, $20, $23, $27, $27, $29, $33, $32, $29, $37, $42, $35, $15, $5, $4, $8, $10,439, $6, Notice this beneficiary has nothing listed under TWP, Cessation, SGA or Last Work Review Action. This beneficiary became entitled in 12/2005. You will see under the Recent Earnings on Record section that this beneficiary had earnings of $8, in 2006, $10, in 2007, and $6, in The beneficiary clarifies they worked at the same job all these years, working 12 months during each of the years, and earning about the same amount each month. You estimate that average monthly earnings appear to be above TWP level in numerous months, but below SGA all months: $712/month in 12

13 2006, $869/month in 2007, and $564/month in Since there is no date listed under Last Work Review Action that means there has been no work review done since entitlement, therefore a work review is needed to establish TWP use. Recent Earnings on Record-Annual Amounts (left side): This section provides a breakdown of all the beneficiary s annual earnings, which are provided by the IRS. Annual earnings from the previous year will not show up on the BPQY until spring of the following year. The amounts listed reflect the gross earnings a beneficiary received in a given year. Sample BPQY: Recent Earnings on Record-annual amounts RECENT EARNINGS ON RECORD YEAR EARNINGS YEAR EARNINGS MONTHS EARNINGS MONTHS EARNINGS 1981 $2, $4, $4, $4, $9, $12, $14, $14, $16, $18, $18, $20, $23, $27, $27, $29, $33, $32, $29, $37, $42, $35, $15, $5, $4, $ $10, $6, You will see this beneficiary began working in This beneficiary became entitled in 7/03, which you can see is a year in which their earnings dropped substantially due to their disability. Recent Earnings on Record-Monthly Amounts (right side): This section provides a monthly breakdown of generally up to 2 years of earnings reported by the individual and posted on the SSI record. Since this only reflects earnings posted to the SSI record, it will only show information if the beneficiary has been eligible for SSI. Since SSI counts earnings when received, these monthly earnings cannot reliably be used to evaluate the impact on a Title II cash benefit because Title II counts earnings in the month they are earned. Next to each monthly amount there will be a (V), which clarifies the earnings were verified, or an (E) which clarifies the earnings were estimated. Sample BPQY: Recent Earnings on Record-monthly amounts RECENT EARNINGS ON RECORD YEAR EARNINGS YEAR EARNINGS MONTHS EARNINGS MONTHS EARNINGS 1999 $1, $1, /08-01/08 $1, (V) 05/08-05/08 $ (V) 2001 $2, $1, /08-06/08 $ (V) 07/08-07/08 $ (V) 2003 $ $ /08-08/08 $ (V) 09/08-09/08 $ (V) 2005 $ $ /08-10/08 $ (V) 11/08-11/08 $ (V) 2007 $3, $4, /08-12/08 $ (V) 01/09-01/09 $1, (V) 02/09-02/09 $ (V) 03/09-03/09 $ (V) 04/09-04/09 $ (V) 05/09-05/09 $ (V) 06/09-06/09 $ (V) 07/09-07/09 $1, (V) 08/09-12/09 $1, (E) 01/10-01/10 $1, (E) 02/10-06/10 $1, (E) 07/10-07/10 $1, (E) 08/10-Contd. $1, (E) You will see this BPQY was generated for someone who has been eligible for SSI, as there are monthly earnings listed on the right side of this section. At the time this BPQY was generated, the claims representative from SSA had verified monthly earnings through 8/09. The Claim Representative then entered estimated earnings for the next 12 months. As the earnings are verified and posted to the record, the E will be replaced with a V and the actual monthly earnings will be listed. 13

14 Posted SSDI Monthly Earnings (Last Five Years): This section provides a monthly breakdown of what SSA has verified of monthly earnings (wage and self-employment) and the total countable income for each month in regard to the Title II disability benefit. The information on this section is generated from the work review process; therefore the information only reflects work activity that was evaluated as of the last work review. Sample BPQY: Posted SSDI Monthly Earnings (Last Five Years) Posted SSDI Monthly Earnings (Last Five Years) DATE GROSS WAGES VERIFIED SELF-EMPLOYMENT VERIFIED TOTAL COUNTABLE EARNINGS 8/1/2006 9/1/ /1/ /1/ /1/2006 1/1/2007 7/1/2007 8/1/2007 9/1/ /1/ /1/ /1/2007 1/1/2008 2/1/2008 In this example, the beneficiary has not had a work review since entitlement, as a result there is no information provided here. 14