A Brief Guide to Public Benefits: Medicare, Medicaid, and Social Security Disability Insurance

Many people do not understand the difference between Medicare and Medicaid and fewer still don’t understand the relationship between these programs and Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). This is not surprising given the similarities and complexity of these programs. Simply put, both Medicare and Medicaid help cover costs for qualified individuals’ medical expenses.

Medicaid is administered by individual states. The District of Columbia, Guam, Puerto Rico, United States Virgin Islands, American Samoa, and Commonwealth of the Northern Mariana Islands also have Medicaid programs, bringing the total to 56 separate Medicaid Programs. These programs are funded by a combination of state/territory taxes and federal taxes. Because each of these programs is independent, the requirements to qualify for Medicaid varies from state to state. Generally speaking, to qualify for Medicaid you must have limited income and limited financial resources. Additional requirements may include, being 65 years of age or older, being disabled, or being younger than 19 years of age. Medicaid can cover doctor visits, hospital stays, prenatal and maternity care, mental health care, and medications, as well as vision and dental care for children.

In Massachusetts, the Medicaid program is called MassHealth. For individuals under the age of 65, there are three Medicaid programs available through MassHealth:  1) Standard; 2) CommonHealth; and 3) Long-Term Care. See Table 1 for the general requirements for these programs. It is important to note that this table only includes the general requirements.

Table 1:  General Standards for MassHealth for Individuals 21-64 Years of Age.

  Standard CommonHealth Long Term Care
Disability Requirement ·       Legally Blind, Determined by Massachustts Commission for the Blind

·       Disabled, Determined by Social Security Administration

·       Disabled, Determined by MassHealth Disability Determination Unit

·       Legally Blind, Determined by Massachustts Commission for the Blind

·       Disabled, Determined by Social Security Administration

·       Disabled, Determined by MassHealth Disability Determination Unit

·       Be eligible for MassHealth Standard as a disabled person or pregnant; AND

·       Determined to require long-term care by MassHealth

Assets Requirement ·       Assets are NOT considered ·       Assets are NOT considered ·       Less than $2,000 in countable assets
Income Requirement ·       Less than or equal to 133% of the Federal Poverty Line ·       Less than or equal to 133% of the Federal Poverty Line; OR

·       Have income above 133% of the Federal Poverty Line, and pay a one-time detuctible

·       Is currently working 40 hours a week or more; OR

·       Is currently working and has worked at least 240 hours over the 6 months preceding the application

·       Less than or equal to 100% of the Federal Poverty Line.

Medicare is administered by the federal government and funded by federal taxes. It is available to individuals 65 years of age and older, individuals under 65 years of age with certain disabilities, and individuals with end-stage renal disease (ESRD). It is a large program with four main components, parts A through D. Part A, Hospital Insurance covers inpatient stays at hospitals, skilled nursing facilities, hospice care, and home health care. This is typically available for free provided you or your spouse paid Medicare taxes while working. Part B, covers doctor care, outpatient care, home health care, durable medical equipment, and some preventative care. This is typically available for a set premium. Part C, covers all the benefits in Parts A and B, and may cover the benefits of Part D and additional benefits, for additional fees. Part C is run by Medicare-Approved, private insurance companies.  Part D helps cover prescription drug costs and is also run by Medicare-Approved, private insurance companies.

It is possible to qualify for both Medicare and Medicaid.  Individuals who qualify for both programs are called “duel eligibles.” Between the two programs, most medical expenses are probably covered.

SSDI and SSI are distinct and separate programs from Medicaid and Medicare, but qualifying for one of the former may allow you to qualify for one of the latter sooner. Often individuals who apply for SSDI and SSI either already receive Medicaid or begin to receive Medicaid after they are awarded benefits. Individuals who receive SSI are automatically eligible for MassHealth. Individuals under 65 years of age who are awarded SSDI are eligible for Medicare Part A, at no cost, 24 months from the date when they were entitled to receive SSDI benefits. Individuals may begin receiving SSDI benefits as early as one year before their application date. There is always a 5-month waiting period from the onset date of a disability to the date that an individual in entitled to receive SSDI. Also, individuals are only entitled to SSDI benefits for a maximum of 12 months prior to the application date. Therefore, the earliest individuals can qualify for Medicare via SSDI is 24 months after their application date. That is assuming they were found to be disabled at least 17 months prior to their application date. Since Medicare is often an important benefit to disabled individuals, it is important to file SSDI claims earlier rather than later.

Once individuals qualify for Medicare Part A at no cost, they will be eligible for Parts B, C, and/or D. These will typically require a monthly premium for coverage; however, some states have programs which will help low-income individuals pay these costs.

Medicaid and Medicare can help you obtain vital medical care at little or no cost. All of these programs are much too complex to cover comprehensively in a blog post. There are numerous exceptions and caveats to the rules and requirements covered in this blog. If you are considering applying for SSDI or SSI, it is important to discuss the details of your particular case with an experienced attorney or a representative from the Social Security Administration so that you understand when and how you will qualify for these programs. The important thing to remember is that each day you delay in applying for SSDI and/or SSI, not only are you potentially losing cash benefits, you are also increasing the time you will have to wait to qualify for Medicaid and/or Medicare.

A few links with more information about these programs:

https://www.medicare.gov/Pubs/pdf/11306.pdf

http://www.mass.gov/eohhs/consumer/insurance/masshealth-coverage-types/masshealth-commonhealth.html#Income standards

http://www.mass.gov/eohhs/docs/masshealth/membappforms/aca-1-english-mb.pdf

http://www.benefits.gov/benefits/benefit-details/1282

http://www.mass.gov/eohhs/docs/masshealth/regulations/member-eligibility/130-cmr-520-000.pdf

https://www.ssa.gov/pubs/EN-05-10043.pdf

The Stigma of Public Assistance

Disability Stigma

The question of whether to apply for Social Security Disability Insurance or Supplemental Security Income is a tough one for many people with a number of personal, social, political, religious, etc. elements to be considered. In reading about social assistance programs you encounter people who believe that everyone living with some form of  social assistance is very excited and happy to be doing so, others that note that there is still a stigma and that there are those out there trying to enhance it, and, generally, the middle ground.

It turns out, unsurprisingly, that many of the people harboring extreme opinions about social assistance programs are the least informed about them. Very often, these people are ignorant of programs like work incentives for people collecting disability or even the general eligibility requirements for people to even qualify for, let alone collect benefits. Unfortunately, these less than educated opinions have very much worked their ways into the national political discourse and really colored the way people choose to pursue benefits to which they may be entitled.

The reality of the situation is that most people collecting benefits do not want to be on any form of public assistance, but need to be. Think of this objectively: in order to qualify for SSDI you must be out of work for twelve months or more, have a severe condition or conditions, not be able to physically or mentally (or both) maintain any work in your old field or a new one, and not have any substantial income. Earnings over $1,130, or $13,560 for the year, are considered “substantial” for 2016. You can have severe conditions and still not be approved. Not being able to find a job is not the same as being unable to maintain one and will not be considered the same way, if at all.

So, with an objective look at the eligibility requirements, we see that a person’s situation would already have to be pretty dire in order for them to qualify for SSDI, let alone actually collect it. Who has ever lived a full adult life without any real income, let alone with no earnings for multiple years? And this is even considering that SSDI is a type of insurance that anyone who has been gainfully employed has paid for themselves through their contributions to payroll taxes. A person would probably not be shamed for collecting on a renter’s policy for thefts from an apartment or billing healthcare costs to their health insurance, so why is it that they should be ashamed for attempting to collect SSDI?

The simple answer is that they should not. However, this is the way such benefits are often regarded in the United States.

But this is also a good reason to have a representative for your SSDI claim. Attorneys and direct-pay advocates have a number of responsibilities that should help anyone thinking of applying with the stigma aspect of the application. Most importantly, representatives are responsible for only representing individuals with legitimate claims for benefits. Doing otherwise may substantially prejudice an individual’s rights down the line which ultimately is a form of malpractice. Representatives can actually also help make the system more efficient by presenting completed files to the agency, making sure claimants stick to claim-related appointments, and concisely stating an individual’s case to the Agency, thereby eliminating administrative waste. And those are only a few of the advantages of having a representative for your SSDI  (or SSI!) claim.

If you are thinking about applying for benefits, or if you have received a denial and contemplating what to do next, use our contact form or give us a call at 1-866-262-8595.