Government Assistance Programs
The Social Security Administration (SSA) offers disability benefits under two programs: the Social Security Disability Insurance program (SSDI), for people who are “insured” (you worked long enough and paid Social Security taxes), and the Supplemental Security Income (SSI), which is based on financial need. Both programs require medical and other information in order to decide if you meet the SSA’s definition of disability.
Requirements for a Medically Determinable Impairment
- The inability to engage in any substantial gainful activity (SGA) by reason of a medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a period of not less than 12 months.
- The impairment must result from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.
- An impairment must be established by medical evidence that consists of signs, symptoms, and laboratory findings.
Your clinical records reflecting ongoing medical assessment and treatment from your physician and other healthcare professionals are extremely helpful in documenting the clinical findings. Make every reasonable effort to secure all relevant evidence to ensure appropriate and thorough disability evaluation.
Generally, you must have the evidence for the 12-month period before you apply. Despite the rule that the disability must be expected to last a year, you should apply for benefits as soon as the condition becomes disabling and your doctor is willing to state in writing that it is expected to last at least a year.
Where to Apply
You can go to your local Social Security Office, apply online www.ssa.gov/ or call the office and apply over the phone. Make sure to ask for extra copies of all documents you sign.
The Role of the Healthcare Provider
The Treating Source is your own physician or other medical professional who can provide the most complete documentation of the nature and severity of your impairment. This physician is not asked or expected to decide if you are disabled. However, he or she will be asked to provide a statement about your ability, despite your impairments, to do work-related physical or mental activities.
Consultative Examiners (CE) are licensed medical professionals hired by SSA to perform an additional examination. CEs have a clear understanding of SSA disability programs and their evidentiary requirements as well as responsibilities and obligations regarding confidentiality.
Program Medical Professionals are physicians in all specialties who perform paper reviews of claims in the State DDS or SSA regional office.
Medical Experts are healthcare professionals who are paid for their testimony when administrative law judges request expert testimony on complex medical issues.
Evaluations of the Claim
Once a medically determinable impairment has been found, the severity of your impairment must be established. If the claim adjudicator finds that the affects of the brain aneurysm cause a limitation or restriction having more than a minimal effect on your ability to do basic work activities, the adjudicator must find that the impairment is severe and proceed to the next step-determining your residual functional capacity (RFC).
Just because you can’t do your present job doesn’t mean you can’t do any job.
SSA will look at your age, education, and past work experience, including any skills you have acquired during your work history. It will look at your duties at your old jobs to see if you learned any skills you might be able to use in another, easier kind of job and then decide whether you can physically and mentally do that kind of work. The younger and more educated you are, the easier SSA thinks it will be for you to adjust to a new job.
Social Security will pay benefits if there is a medical reason why you cannot do any work for which you might quality. Whether you can actually get a job doesn’t count.
The SSA has a website that provides employment support for people with disabilities, at disability.gov www.disability.gov/employment/work_incentives/ticket_to_work
Kinds of Benefits
Disability Insurance Benefits (DIB)
In order to qualify, you must have paid enough Social Security tax to be covered (generally pay five years out of the previous 10 before disability begins). The monthly benefit is set by your income. In some cases, your dependent children may also qualify.
Supplemental Security Income (SSI)
This program doesn’t require you to have paid social security tax. It is a needs-based federal welfare program providing benefits to those with little income and resources. The initial application can take between three and six months to process. In order to qualify, you must have:
- A physical or mental impairment that prevents you from working for at least 12 months
- Little or no income and less than $2,000 in resources ($3,000 if a couple), not including your home and car
- If your claim is denied, a notice of appeal rights will accompany the denial notice. You must file an appeal within 60 days of the notice. Then SSA will reconsider your application and consider new and updated medical evidence.
- You may be asked to see a physician for an evaluation. If the reconsideration application is denied, you may request a hearing within 60 days of the denial.
Disabled Widow/Widower Benefit (DWB)
If you are a widow or widower who is currently disabled but your spouse was covered under Social Security at the time of death, you might be eligible for benefits. You must be between the ages of 50 and 60 and have been married for at least 10 years to the person covered. You must be able to prove your disability was severe enough to meet the requirements within seven years of your spouse’s death.
The Consolidated Omnibus Reconciliation Act (COBRA)
Social Security provides two types of disability benefits:
- Social Security Disability Insurance (SSDI) and
- Supplemental Security Income (SSI).
To be eligible for SSDI benefits, a claimant must have contributed to the Social Security Trust Fund (through payroll deductions) long enough and sufficiently enough. If approved, claimants receive monthly income immediately and Medicare after a 24-month waiting period. In the case of SSDI, award letters would not advise claimants to notify COBRA within 60 days, because claimants would need to keep their COBRA insurance during the waiting period until Medicare coverage begins. In some cases, benefits are awarded retroactively. Since the waiting period for Medicare starts as of the award date, a retroactive award date effectively reduces the wait for Medicare coverage but usually not by more than six months, so claimants would still need to keep their COBRA coverage until Medicare coverage takes effect.
SSI is for very low income/almost no assets/indigent elderly and disabled Americans, regardless of their contribution to the Social Security Trust Fund. If approved, claimants are immediately eligible for monthly income benefits and Medicaid insurance. Once Medicaid coverage is established (the claimant should verify that coverage is in effect) and the claimant wants to discontinue COBRA coverage, he/she should notify COBRA.
COBRA premiums are payable on a month-to-month basis and can be terminated at any time by notifying COBRA.
Special rules for disabled individuals and certain family members may extend the maximum periods of coverage. If a qualified beneficiary is determined to be disabled under the Social Security Act within the first 60 days of COBRA coverage, then the qualified beneficiary and all of the qualified beneficiaries in his or her family may be able to extend COBRA converge for an additional 11 months. However, you may lose all rights to the additional COBRA coverage, if the Notice of the Determination is not provided to the COBRA carrier within 60 days of the date of the determination and before the expiration of the 18 month COBRA period. The qualified beneficiary who is disabled or any qualified beneficiaries in his or her family may notify the plan administrator of the Social Security Determination.
The Office of Management and Budget and the Department of Labor recently added 25 citizen-focused benefit programs to the www.benefits.gov
Do You Need a Lawyer?
- For any of the federal programs, a lawyer isn’t necessary, but can do the following:
- Know what medical proof is necessary and how to get it
- Counsel you before the hearing
- Explain the government’s decisions and how to appeal
Most lawyers work on a contingency fee, meaning they will take a certain percentage (25% is common) of any back pay the government owes you by the time you finally win the case. Go to the National Organization of Social Security Claimants’ Representatives for attorneys experienced in Social Security. Make sure fees are established and understood before you begin the process.
If your claim is approved, your benefits cannot begin before the sixth full month of disability. Your Social Security benefit may be reduced if you receive worker’s compensation or other public disability payments or a pension from a job where you did not have to pay Social Security taxes. Some benefits are taxable. This health insurance program serves everyone over 65 years of age and people with disabilities under 65 years of age who: have been entitled to receive Social Security disability benefits for a total of 24 months, or need dialysis treatments or a kidney transplant because of permanent kidney failure. The program is available regardless of financial need.
Medicare Part A covers hospitalization. Certain deductibles and coinsurance amounts apply. Medicare Part B is voluntary medical insurance with a monthly premium that helps pay doctor bills and other approved medical services.
Medicaid is a joint federal/state program to provide physical and related healthcare services to persons with low incomes. People with disabilities may be eligible for Medicaid on the basis of their income. Medicaid services are available in all states. However, each state establishes its own eligibility requirements for Medicaid based on federal guidelines.
That means that there are geographic differences between eligibility requirements and types of services covered. In general, persons may be eligible for Medicaid if they are receiving public assistance benefits or Supplemental Security Income, or are blind or disabled. Individuals with higher incomes may be eligible for Medicaid, Supplemental Medical Care Assistance, or their children may be eligible if medical expenses exceed a given percentage of their annual income.
Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process (PDF) From the Medicare Rights Center
Low income families may be eligible for housing assistance payments from the US Department of Housing and Urban Development (HUD). HUD payments are made directly to landlords to make up the difference between a HUD-approved rental amount and what the tenant is required to pay.
Other Disability Resources
The Office of Management and Budget and the Department of Labor has a full listing of over 100 programs at GovBenefits Website.
If you are seriously ill or disabled, in many states the utility companies will continue your service and let you pay when you are able. Each state utility system has different regulations, but generally you must enlist the aid of your physician’s office to verify your condition.
If you are unable to pay your phone bill, your physician must call the service representative and follow up with written verification of your illness within seven days. Phone companies will extend your service for 30 days. If the illness continues, you must repeat this process. Check the phone book for the number of your local representative. Note: You will be responsible for all overdue charges once you are no longer ill.
Heat and Electricity
Your gas and/or electric company cannot shut off your power if you or a member of your household has a serious illness and financial hardship. Each state has different requirements, but your physician must certify the illness in writing. If the utility company refuses to protect your accounts from shut off, contact your Department of Telecommunications and Energy Consumer Division immediately.
Emergency Food and Shelter Programs (EFS)
Applicants to Emergency Food and Shelter Programs must show evidence of a precipitating event that caused the emergency. These programs provide assistance to any needy individual who has received a notice of foreclosure, eviction, or termination of utility services if the ability to pay is compromised because of a sudden reduction in income. EFS can provide rent/mortgage assistance and supplemental utility assistance, but this is a one-time-only offer. These programs do not supplement SSI, Aid to Family with Dependent Children (AFDC), or other public assistance programs. Although criteria differ from state to state, some of the common items are:
- You must provide the basic proof of economic situation and family composition
- The agency will give you the amount which is required and appropriate to the case
- You must have had a verifiable economic or personal crisis
- The agency will not pay if you are paying more than 75% of your income on rent and have no prospects for increased income
- The agency will not pay rent if you do not have a regular income or prospect for one
- The agency does not assist people who are in a chronic situation
If you are completely and permanently disabled, you may obtain a conditional discharge by the U.S. Department of Education by filling out the Disability Discharge Form and submitting it to your loan holder. After three years, the Department will review the disability discharge and make a final determination on the discharge status of the applicable conditionally-discharged loans.
If you wish to regain student loan eligibility after having discharged your loans through permanent disability, will need to fill out the Physician’s Certification of Borrower’s Ability to Engage in Substantial Activity Form and submit it to the current loan holder. If you have had loans discharged through disability previously, you may be required to reinstate previously discharged loans.
Home-based Care for the Disabled
Attendant care of home-based care programs have been developed to allow physically disabled people to get the care they need in their own homes, rather than having to become a resident in a nursing home. To quality for this program, a person must need physical assistance to achieve some of their life skills (bathing, cooking, wound care, etc.). Each state has its own program and the client pays a portion of the cost of this care. The federal government has established a Medicaid Waiver program to help all states provide these services to those with a low income.
The National Association for Home Care and Hospice (NAHC)
NAHC is the nation’s largest trade association representing the interests and concerns of home care agencies, hospices, home care aide organizations, and medical equipment suppliers. NAHC believes that Americans should receive health care and social services in their own homes, so far as this is possible. Senior citizens and other vulnerable groups should be able to live in independence through the assistance of home care services, making institutionalization a last resort. NAHC seeks to reverse the current bias that places hundreds of thousands, possibly millions, of fragile children and chronically ill seniors in nursing homes or retained in hospitals when they could receive equal or better care at home. Here is a list of NAHC organizations in each state.