PUBLIC BENEFITS. What are disability benefits? How is disability determined for SSDI and SSI?

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1 PUBLIC BENEFITS Public benefits are government programs that are set up to help people who need health care, cash assistance, food stamps, housing assistance, and other programs. Determining which programs may apply to you may not be easy. It is wise to get help to make sure you receive the right benefits. Each of the Wisconsin AIDS service organizations have case managers who are experts in helping individuals apply for and maintain benefits. Free legal services may also help you to appeal denials of benefits. Look in the Resources chapter for a list of AIDS service organizations and free legal services. What are disability benefits? The Social Security Administration (SSA) oversees Social Security Disability Insurance (SSDI) and Supplement Security Income (SSI), programs that provide a monthly benefit to persons who can t work because they are disabled. To be eligible for disability benefits, a person must have a mental or physical health condition that is likely to prevent that person from earning Substantial Gainful Work Activity (SGA) for more than 12 months and/or will end in death. 1 SGA in 2013 is $1040, so a person who is earning more than $1040 a month is ordinarily considered to be engaging in SGA and thus not disabled. 2 The SSDI and SSI programs have different financial eligibility requirements, but evaluate disability in the same way. You can get applications for both programs at your local Social Security office, by calling SSA s toll-free number, (for the deaf or hard of hearing, call the TTY number, ) to request an appointment, or you can apply online at For either program, you can ask for your application to be processed faster than normal if you have AIDS. How is disability determined for SSDI and SSI? Persons diagnosed with HIV are not automatically disabled by SSA rules. If you have HIV, you must usually also meet one of the following medical criteria to be considered disabled: 1. You have certain HIV-related opportunistic infections; 3 OR 2. Your HIV-related symptoms, including fatigue and side effects of medication, prevent you from working full-time; OR 3. You have other health conditions like asthma or depression, and the combination of all your impairments prevent you from working full-time. Your doctor s role. Your doctor s opinion helps to convince SSA that you are disabled and your symptoms are real. The opinion of your doctor is important to SSA in making a disability determination. It is crucial to track your HIV symptoms and how they affect you on a daily basis, and to report this to your doctor.

2 Your role. Take notes about your symptoms, keep track of them on a calendar, and bring these with you when you see your doctor. Inform your doctor that you have applied for disability benefits and ask that notes about your symptoms be put in your medical records. You must be able to show SSA that your symptoms are frequent and severe enough that you have been or are expected to be unable to work full-time. What is Social Security Disability Insurance (SSDI)? SSDI is a disability insurance program for people who (1) are disabled, (2) have a work history, and (3) have had Social Security taxes deducted from past paychecks or have paid taxes from self-employment. 4 Generally, you need to have worked five of the ten years before the year you become disabled. Applicants 30 years old or younger need fewer years of work. See for more information on SSDI eligibility work requirements. The amount of your monthly SSDI benefit is based on the amount of income you earned while working and the number of years you worked. NOTE: After you have received SSDI for 24 months, you will be eligible to receive Medicare. 5 What is Supplemental Security Income (SSI)? SSI is a needs-based program for people with little income and resources who are disabled, blind, or elderly. For more information on income and asset requirements, see and Unlike SSDI, no work history is necessary. 6 For more information on eligibility requirements for SSI, see The monthly maximum federal SSI amount for 2013 is $710 for an eligible individual. You may be able to get both SSI and SSDI, if your SSDI is low enough and you meet the SSI program asset requirements. NOTE: If you receive SSI and you live in Wisconsin, you will also receive SSI-related Medicaid. A separate Medicaid application is not necessary. Wisconsin also offers a State Supplement for individuals receiving SSI. In 2012, the state supplement was $ If you are HIV-positive and meet the SSI financial requirements, you may be able to get what are called presumptive disability benefits. 7 This means that for up to six months while you wait for your SSI application to be processed, you may receive SSI payments. If SSA later determines you are not disabled, you will not have to pay back any money received. If you are facing a financial emergency, you may also ask for a one-time-only

3 advance payment from SSI while your SSI application is pending. However, if you receive payments while SSA processes your application and it is later denied, you will be required to pay back the advance payment you received. What can I do if I am denied benefits? Even if you are HIV-positive or have AIDS, SSA may deny your application. Do not assume that you are not eligible for benefits if you are denied after you first apply. Many applicants are successful after appealing. Under both SSDI and SSI, you have the right to appeal the denial of your claim for disability benefits. 8 Usually, appeals must be made within 60 days of receiving a first denial. You may appeal at your local Social Security office, by calling , or online at If you are denied benefits when you first apply, continue keeping track of your symptoms and follow up with your doctor. This will be important if you appeal. If your appeal is denied, you can always re-apply later. It is important to appeal if your disability claim is rejected. In 2009, more than 62% of initial SSDI/SSI claims were rejected, but 77% of cases that reached the hearing level were decided favorably. 9 Because of the high rate of reversals on appeal, it is important that you appeal within the time frame the SSA sets. For a list of free or low cost legal services to help you appeal a denial of Social Security benefits, see the Resources chapter. What is Medical Assistance (also called MA, Medicaid, Title 19)? Medical Assistance is a free health insurance program for disabled, blind, or elderly individuals who have little or no income or resources. 10 In Wisconsin, it is often called Title 19. Medical Assistance may pay for prescription drugs, doctor services, hospital care, skilled nursing care, nursing home care, dental care, and more. NOTE: If you receive SSI, you will automatically receive Medical Assistance. 11 If you receive SSDI, you may apply for Medical Assistance. If you earn more than Medical Assistance allows, but you meet the other eligibility requirements for this program, you may still qualify for the medically needy program. Under this program, you must pay or receive medical bills during a six-month period until you spend down to the qualifying income level. You can use old, unpaid bills to meet your deductible. At this point, Medical Assistance pays for any remaining medical bills during that six-month period. Every six months a new spend down amount is determined and the process repeats. 12

4 How do I apply for Medical Assistance? If you are on SSI, you should automatically receive Medical Assistance and do not need to apply. If you are not on SSI, call the Wisconsin Division of Health Care Financing at (608) or your AIDS service organization (phone numbers are in the Resources chapter) to learn how to apply. What is the Community Options Program? This program pays for your home care if the home care could keep you out of a nursing home. Funding is limited and based on financial need. Call (608) for more information. What is Medicare? Medicare is a federal government health insurance plan for disabled and elderly people. 13 Eligibility is not based on financial need. NOTE: If you have been receiving SSDI benefits for 24 months, you are also entitled to receive Medicare. However, under Medicare, you must pay deductibles, co-payments, and premiums out of your own pocket. If you have a low income or are not working, you may be eligible for state Medical Assistance to help pay for Medicare expenses. 14 If you can afford them, you may also buy Medicare supplemental policies, described below, which cover many of these expenses. There are four main parts to Medicare: Hospital Insurance (Part A), Medical Insurance (Part B), Medicare Advantage (Part C), and Prescription Drug Coverage (Part D). Part A automatically comes with Medicare. Everyone receiving Part A and Part B is also eligible to choose Part C, for which you must pay a monthly premium. For a description of the differences between the four parts of Medicare, see custhelp.ssa.gov/app/answers/detail/a_id/167/~/differences-between-medicare-parts-a,-b,- c-and-d. Medicare Hospital Insurance (Part A) Medicare hospital insurance covers some of the cost for hospitalization, home health, nursing home, and hospice care. 15 There is no monthly premium for Part A. Medicare Supplementary Insurance (Part B) Medical supplementary insurance covers 80% of reasonable charges for your doctor s fees and services provided outside of the hospital. 16 If you receive Part B, you will have to pay a monthly premium. 17 Part B covers you for certain services that Part A does not cover. These services can include doctor visits, home health care, durable medical

5 equipment, diagnostic tests, and even the hepatitis B vaccine. Some doctors accept Medicare s payment as payment in full for their services. If a doctor does not accept Medicare as payment in full, Medicare supplementary insurance may pay for the part of the bill that Medicare does not cover. If you rely on Medicare, when choosing a doctor be sure to ask if he or she takes Medicare as partial payment, payment in full, or not at all. You may choose to go to any doctor so long as he or she will take Medicare payment. Medicare Advantage (Part C) Some HMOs currently offer Part C Medicare plans that will provide you with their own Medicare package that you may choose to join instead of enrolling in Original Medicare Part A and B. 18 You must be enrolled in Part A and Part B to purchase Part C. 19 Under this type of plan, you would not be able to go to any doctor you would have to use the doctors, hospitals, and nursing homes within that Part C HMO package. Each Part C plan is different, but most include prescription drug coverage. Currently in Wisconsin, there are Part C plans available in Milwaukee, Racine, and select areas in the state. There may not be one in your area. Only choose a Part C plan if you have weighed all the factors and decided that it is better than the regular Part A and B plan. If you are thinking about a Medicare Advantage plan, take the time to study the plan s rules, its providers, and whether you can easily get out of the plan if you decide it is not right for you. If you want help, call your AIDS Service Organization (see the Resources chapter for phone numbers). Medicare Prescription Drug Coverage (Part D) Medicare prescription drug coverage is stand-alone prescription drug coverage insurance. 20 Most people have to pay a premium for this coverage. Plans vary and cover different drugs, but all medically necessary drugs are covered. Part D is provided only through private insurance companies that have contracts with the government it is never provided directly by the government. Part D is optional for most people; whether you should take it depends on your current drug coverage and needs. NOTE: If you do not choose Part C, you will automatically receive Part A and Part B, unless you expressly opt out of Part B. 21 Can I get coverage for health care costs not covered by Medicare? Yes. If you enroll within six months of becoming eligible for Medicare, you can get a Medicare supplement policy to fill in the gaps of coverage in Original Medicare insurance (Medicare supplement policies are not available to those enrolled in Part C). These Medicare supplemental policies are often called Medigap policies. There are several Medigap policies that provide different amounts of coverage. Enrollment in these policies is optional. If you choose this coverage, you will pay a monthly premium for it. If you receive SSDI, the premium is deducted from your SSDI check. It is a good idea to get help when deciding whether to choose this coverage. For more information about

6 Medicare supplement policies, see or call the Medigap helpline at (800) Are there other kinds of public health insurance that I can get aside from Medical Assistance and Medicare? Yes. Below is a list of other public health insurance plans. Your local AIDS service organization can help you figure out the plans for which plans you are eligible. HIRSP. The State of Wisconsin offers the Health Insurance Risk Sharing Plan (HIRSP). 22 You may be eligible for HIRSP if you have been diagnosed with HIV in the last nine months, your health insurance was cancelled, or the payments became much more expensive, or there was a big decrease in what your health insurance could cover. HIRSP covers basic in-patient and out-patient services, prescription drugs, home health care, and durable medical equipment. You will have to pay a yearly deductible, monthly premiums, and insurance co-payments. HIRSP offers premium and deductible reductions if your household income is below $34,000 per year. See for more information about lowincome subsidies. For more information, call (800) or visit Wisconsin HIRSP pays secondary to any other coverage available to the individual. Wisconsin also offers a HIRSP Medicare Supplement Plan for individuals who are on Medicare because of a disability or for current HIRSP members who turn 65 while enrolled in HIRSP. For the HIRSP Plan, applicants must be residents of Wisconsin under the age of 65 who fail to qualify for employer-offered group health insurance coverage, comprehensive Wisconsin Medicaid, or the BadgerCare Plus Standard Plan. To be eligible for HIRSP, you must also meet either one of the medical uninsurability criteria OR the loss of employer-sponsored coverage criteria. To be eligible under the medical uninsurability criteria, an applicant either: must be eligible for Medicare due to a disability; OR have received one of the following in the past nine months: o documentation confirming a diagnosis of, or treatment for, HIV; OR o a notice of rejection from an insurer; OR o a notice of reduction or limitation in coverage, including restrictive riders; OR o a notice of an increase in premium of 50% or more; OR o two or more offers for insurance with premiums at least 50% higher than a standard risk would be charged for the coverage. To be eligible under the loss of employer-sponsored coverage criteria, the applicant must: have exhausted continuation coverage, AND

7 have had continuous insurance coverage for at least 18 months with no gaps in coverage greater than 63 days, AND not be eligible for Medicare. Individuals who qualify for HIRSP under the medical uninsurability criteria are subject to a six month waiting period for medical coverage of pre-existing conditions. The waiting period does not apply to prescription drug coverage. Individuals who qualify for HIRSP due to loss of employer-offered coverage are not required to serve a waiting period. Ryan White Part C. If you are HIV-positive and have no or not enough health insurance, you may be able to receive primary care from federally funded serviceproviders. 23 Ryan White Part C provides grants to medical facilities and agencies that provide primary medical care and early intervention services. It does not pay for hospitalizations or emergency room visits. It does cover: Diagnosis and treatment of HIV disease Early interventions and prophylaxis for HIV-related complications General medical care Psychological and psychosocial assessment and treatment Referrals to specialty clinics Screening for clinical trials Part C grantees in Wisconsin include The UW Health HIV Care Program, Milwaukee Health Services, AIDS Resource Center of Wisconsin, and Sixteenth Street Community Health Center. There may be a co-pay, depending on your income. For more information about UW Hospital s HIV/AIDS Comprehensive Care Program, call (608) BadgerCare Plus is a state program that uses Medicaid funds to provide health care for parents and their children who are not eligible for Medical Assistance. You may receive BadgerCare coverage if your family income is not more than 185% of the federal poverty level. 24 Once in the program, a family s income may increase to 200% of the federal poverty level before they become ineligible to remain in the program. Families with incomes above 150% must pay a monthly premium. For more information, call the state Medicaid hotline at (800) Wisconsin AIDS/HIV Health Insurance Premium Subsidy Program. This plan may pay all or most of your premiums to get insurance through COBRA, HIRSP, a Medicare supplement plan, or a private company. 25 To be eligible, you must be HIV-infected, meet the eligibility requirements, and your family income must not exceed 300% of the federal poverty level. You must also have a note from your doctor saying that, due to HIV, you cannot work, are on an unpaid leave from work, or would lose your group health insurance because you need to reduce your hours at work. Individuals with income between 201% and 300% of poverty are required to cover 3% of the cost of their annual premium. 26 If individuals are not eligible for premium subsidies under Wisconsin Statutes sections or because they are not on unpaid medical leave, are not

8 unable to continue employment, and have not had to reduce their employment hours because of an illness or medical condition arising from or related to HIV, they may be eligible for HIRSP premium and prescription drug co-payment subsidies under section (6). For more information, call the Health Insurance Premium Subsidy Program Administrator at (800) For more information, see How can I pay for my medications if I don t have insurance to cover it? The Wisconsin AIDS/HIV Drug Reimbursement Program will reimburse you for approved AIDS/HIV medications if your family income is not more than 300% of the federal poverty level. 27 For more information on the Drug Reimbursement Program or to see if you qualify, call the program at (800) or your AIDS service organization, or see Also, some drug companies provide their drugs free to patients with low incomes. For more information on these programs, ask your doctor, pharmacist or an AIDS service organization. These guides are not legal advice. Moreover, because the law is constantly changing, information contained in these guides may become outdated. If you need legal counsel or further information, please contact AIDS Network Legal Services. 1 See 20 CFR et seq.; 20 CFR et seq. 2 See CFR 404 Subpart P, Appendix 1, Listing available at 4 See 20 CFR 404 et seq U.S.C See 20 CFR 416 et seq CFR CFR d.; 20 CFR See (table 60 and 62). 10 See 42 U.S.C.A et seq.; WIS. STAT WIS. STAT (1)(a)(4). 12 WIS. ADMIN. CODE DHS See 42 U.S.C et seq; 42 CFR et seq. 14 WIS. STAT ,

9 15 See 42 U.S.C. 1395c-1395i See 42 U.S.C. 1395j-1395w USC 1395r U.S.C. 1395w w U.S.C. 1395w w See 22 Wis Stat See generally Pub.L , 104 Stat. 576, enacted August 18, Wis. Stat Wis. Stat. 252(16)-(17). 26 Wis. Admin. Code DHS (1)(d). 27 Wis. Stat