SCI Forum Reports
Income and Medical Benefits after SCI
October 8, 2002
Understanding the state and federal medical and income benefits programs for persons with disabilities can be a challenge, said Norma Cole, MSW, social worker for the Northwest Regional SCI System. "Each program has unique guidelines, and these tend to change frequently."
Medical Coverage
Medicare is a health insurance program administered by the Federal Social Security Administration. "As most of you know, you need to be 65 or older or have a disability to get on the Medicare program," Cole said. People pay Medicare taxes while they are working, and the benefit they collect will depend on their lifetime earnings. "Every situation is a little different," she added, "but if you have paid into the system over the years, you are eligible for Medicare."
Medicare offers two types of plans. Fee-for-service plans allow beneficiaries a wide choice of physicians and facilities. Managed care plans limit the choice of providers they will pay for, "and these can get a little tricky," Cole said. "If you are established with a physician or a hospital, you should make sure you can still go to them if you choose a managed plan."
Medicare Part A coverage pays for hospital expenses, and most people are automatically enrolled in this plan without cost when they turn 65. Part B is optional and helps pay for physicians and medically necessary outpatient services and supplies. The Part B premium costs $54 per month in 2002, but will increase in January 2003. "This can be a lot of money if you're on limited income," Cole noted. "But if it's the only medical coverage you have, it's well worth it."
A visit to the Medicare Web site ( www.medicare.gov ) is "a great way to keep on top of what's happening with Medicare," Cole said. "It's a good idea to check it periodically because the coverage changes yearly, and it's really important to stay informed about your coverage."
Medicaid is the state's health benefits program, funded jointly by the state and federal governments and operated by the Washington State Department of Social and Health Services (DSHS). Eligibility is based on income, and people with disabilities who are also financially needy may receive a combination of Medicare and Medicaid benefits.
DSHS also manages the COPES (Community Options Program Entry System) program, which is designed to help low income adults with disabilities live independently by providing chore services and attendant care in the home. For information about DSHS programs, call 800-737-0617, or visit the DSHS Web site ( www.wa.gov/dshs ). Cole suggests checking the Web site frequently because "Medicaid changes even more frequently than Medicare."
Cole noted that people often don't realize how much (or how little) their Medicare Part A covers. "If you were hospitalized today, year 2002, and you're on Medicare, you would have an immediate deductible of $812. That's how much you would owe just by being admitted to the hospital. The first 60 days are covered 100%, but for days 61-90-hopefully you wouldn't be in the hospital that long-you would be responsible for $203 a day. After 90 days, you pay $406/day."
Because Medicare Part A leaves such big holes in hospital coverage, "one lengthy hospitalization could be financially devastating if you only have coverage under Part A," Cole said. A supplement, like Regents or Medicaid, would pick up the copays and deductibles not covered by Medicare Part A.
When purchasing medically necessary equipment, Cole recommended asking the equipment vendor to check with Medicare and Medicaid to find out what's covered. "And if you're with a vendor that's not willing to do that, I suggest looking at another company."
Cole warned against neglecting anything that comes in the mail from Medicare or Medicaid. "Sometimes they just need you to sign something and send it back. But if you don't respond, you're in danger of losing your coverage. If you don't understand what it says, ask the hospital social workers to explain it to you."
"If you have private insurance it's very important to know what it covers, especially if you want to change your insurance," Cole said. "Look closely at those plans. Make sure you know what inpatient rehab is covered. Is durable medical equipment covered? Long term care? The social worker in your hospital or clinic would be happy to talk with you about those options. Sometimes you just don't know what you're supposed to be looking for."
Employees who leave the job are eligible for at least 18 months of continued insurance coverage through a program called COBRA (Consolidated Omnibus Budget Reconciliation Act) by paying the monthly premium themselves. "The costs vary depending on the company you're with," Cole said. "But if you're going to have a lag in coverage, it's really important that you look into that option." "After the 18-month COBRA period, if you are not able to get other insurance, the State of Washington offers the Basic Health Plan," a low-cost program for low-income adults and families (800-826-2444; http://www.basichealth.hca.wa.gov/).
Individuals who are injured on the job may be eligible for Worker's Compensation benefits under the Washington State Department of Labor and Industries (800-547-8367; www.lni.wa.gov ). A case manager handles each case individually. The benefit covers all medical expenses plus a monthly stipend.
The U.S. Social Security Administration (SSA) operates two income benefits programs for persons with disabilities: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Eligibility for SSDI is based on the number of years a person has worked and paid into the social security system. To receive benefits, a person must be over age 65 or have a disability that lasts longer than 12 months. Payments begin six months after onset of disability. SSDI beneficiaries are eligible to receive Medicare coverage after they have been disabled for 24 months. (For SSA information: 800-772-1213; www.ssa.gov )
"How much you receive (from SSDI) each month is dependent entirely on how much you paid into the system over the years," Cole added. "If you haven't worked long enough yet -and a lot of young people haven't-you may not qualify for that program."
SSI benefits are available to people who are low income and have a disability expected to last more than 12 months. "That again is something that is very individual," said Cole. "You sit down with (SSI personnel) and they will figure out if you qualify for that program." SSI beneficiaries are eligible for Medicaid coverage.
Income and Work Issues after SCI
"People work for many reasons, however when you're not working, a lot of structure, interactions and meaning goes out of your life," said Karen Ball, rehabilitation counselor at the University of Washington. "That can be pretty devastating. Work offers a lot of things for people."
She recommends working with a rehabilitation counselor. "That way you're really going to pick a career goal that's realistic, and you can get a good understanding of how work can impact your disability benefits."
Ball cited a recent survey in which 75% of people receiving some sort of disability benefit said they would like to work. "A primary barrier to returning to work is the fear of losing disability benefits. Things have improved since the 1980s when the income rules were very strict. Back then once you got past your nine-month trial work period, your disability and medical benefits stopped and you were on your own. So people who could have worked part time or with medical benefits, didn't go to work." Now there are several incentives for getting back to work. However, the Social Security Administration has very stringent definitions of disability, and 60% of first-time applications for SSDI benefits are denied, Ball said.
Some employers offer long-term disability benefits, and employees can usually add to the standard benefit by paying an additional monthly premium. "For instance, as a state employee I pay about $10 per month, and if I were disabled, I would get about 60% of my salary," Ball explained. Often, a disabled person can continue to receive at least some part of a disability benefit while working, depending on the person's salary, number of hours working per week, and the formula the disability carrier uses for determining the benefit after an employee returns to work.
Most long-term disability carriers now have return-to-work incentives that benefit both the insurance company and the policyholder. Ball gave a case example of a gentleman who had a stroke and received $2000 per month in long-term disability benefit, 60% of his pre-stroke salary. "He had been in the trades and could no longer do that kind of work. Rehabilitation counseling with funding from his long term disability carrier and DVR assisted him to find a part-time job here at the UW, which paid $1,000 a month," she said. The disability carrier's formula reduced his benefit by 50% of his new salary. "So they gave him a check for $1,500. But he was collecting a paycheck of $1,000, so he was ahead $500 by working, plus he got the full health care benefits from his employer. He also had the long term benefits of getting out of the house every day, interacting with people and feeling good about himself."
For Armed Services personnel who become disabled while in the service, the Veterans Administration also offers a comprehensive rehabilitation program. They can pay a monthly stipend in addition to the costs of going to school and any other training or equipment necessary to find a job or start a new career. "Their program is really the Cadillac of vocational rehabilitation in terms of the comprehensive guidance, financial support and assistance that they can provide to someone who is eligible for that service" People who receive a pension from the Department of Labor and Industry, however, jeopardize their pension if they return to work. The Washington State Division of Vocational Rehabilitation is the primary resource for people with disabilities to get retraining and help finding work ( www1.dshs.wa.gov/dvr/index.htm ), Ball said. "They have many resources available to help individuals select a career goal, find training, and assist with job placement. It's important to find a counselor you like and can work with." DVR clients who are having problems with their counselors can contact CAP (Client Assistance Program), an independent advocacy service that helps with problem solving, communication and administrative proceedings (800-544-2121).
A local organization called Positive Solutions Benefits Resource Center ( www.psbrc.org ) offers services to people with disabilities who want to find out how they can return to work without jeopardizing their other benefits. This organization started five or six years ago primarily for HIV patients. Recently they have received a grant from the SSA to serve all person who are receiving SSI or SSDI understand their benefits. "They offer seminars with in-depth information about return-to-work incentives and work-related expenses," Ball explained. "They also meet with individuals to find out what your specific benefits are and how they would be impacted by work. I highly recommend them." Positive Solutions services are free.
The SSA Web site ( www.ssa.gov ) includes a section on Employment Support for People with Disabilities called The Work Site ( www.ssa.gov/work ) and a booklet called Working While Disabled-How We Can Help ( www.ssa.gov/pubs/10095.html ). Most SSA offices have staff designated to help with return to work cases. SSDI and SSI have different return-to-work rules, which Ball summarized below.
SSDI allows a nine-month trial work period during which you may collect all of your benefit and all of your paycheck. Any month in which you earn more than $550 is considered a trial work month. The nine months don't need to be consecutive.
After the nine-month period, if you continue working and your earned income falls below what SSA calls "substantial gainful activity" or SGA, you will get your SSDI benefit back. The SGA dollar amount changes from year to year. The 2002 cut-off is $708 per month.
During the first 36-month period after returning to work, if you lose your job for reasons unrelated to your disability-e.g., the company went out of business- you can get your disability benefits reinstated without a waiting period or new application, Ball explained. "You also get to keep Medicare Part A for up to 8½ years, and if after that you still don't have other coverage, you can keep the benefit by paying a premium."
SSA allows you to deduct Impairment Related Work Expenses (IRWE) from your income for disability-related equipment or services you need in order to work, such as a specialized workstation or keyboard, service dog, or transportation.
Ball provided an example. A young woman receiving SSDI benefits of $557 a month started a part time job in a laundry, which paid her $857 a month. For nine months she received both the paycheck and the benefit, which totaled $1,414 a month. After nine months the company relocated and was no longer accessible by bus. Since her disability prevented her from driving, she had to hire a neighbor to drive her to work and a coworker to drive her home. This cost her $125, which the SSA allowed as an IRWE, along with $75 a month for a wheelchair. Subtracting the $200 in IRWE from her $857 paycheck gave her a "countable income" of $657. Since this was below the SGA, she was eligible to continue receiving her SSDI check, bringing her total income up to $1214. Eventually she got a pay raise and stopped making payments on the wheelchair, which raised her income above the SGA and made her ineligible for continued SSDI benefits.
Since benefits can be complicated and each person's situation is unique, Ball highly recommends meeting with an SSA or Positive Solutions representative. "Some people are receiving long-term disability, social security and SSI all mixed together," she said. "How are you going to figure out what the impact of work will be on that? You need somebody to look at your situation specifically and carefully plan for return to work activity."
SSI requires beneficiaries to develop a PASS (Plan for Achieving Self Support) with a vocational counselor. The PASS includes goals for getting back to work and money needed to achieve those goals. Ball's example: A woman collecting SSI developed a PASS with a goal of owning and operating her own home-based t-shirt business. Her PASS allowed her to set aside money for t-shirts, office supplies, computer, file cabinets, software, modem, scanner, camera, and an 800- number. This came to $2000 per year for three years, or $6,000, which was subtracted from her SGA.
"Getting a job can be a lot harder that having a job," Ball acknowledged. "You have to treat the job search as a job in itself, get organized, and be really persistent. In the end, it's usually well worth it."
Resources
Social Security Administration (for SSI and SSDI)
800-772-1213;
www.ssa.gov
Medicare
800-633-4227;
www.medicare.gov
State of Washington Department of Social and Health Services (DSHS, for Medicaid and COPES.
800-737-0617;
www.wa.gov/dshs
Basic Health Plan (State of Washington)
800-826-2444;
http://www.basichealth.hca.wa.gov/
Division of Vocational Rehabilitation
360-438-8000; Toll Free: 800-637-5627
www1.dshs.wa.gov/dvr/index.htm
Division of Labor and Industries
800-547-8367;
www.lni.wa.gov
Positive Solutions Benefits Resource Center ("To assist individuals to make educated choices, remove disability-related barriers, and enhance their lives through self-advocacy.")
318 First Ave. So. Suite 300
Seattle, WA 98104-2597
206-322-8181 (King County)
877-561-8181 (Kitsap County)
general@psbrc.org
www.psbrc.org
Disability Resources Monthly Guides to Resources on the Internet ( www.disabilityresources.org ) has a long listing of Internet resources on its Employment page for people with disabilities looking for employment and for employers who want to know more about hiring people with disabilities. www.disabilityresources.org/employment.html
VOCATIONAL COUNSELING
Division of Rehabilitation Counseling
University of Washington Medical Center
Box 356490
1959 NE Pacific St.
Seattle, WA 98195
206-543-3677
Rehabilitation Counseling
Harborview Medical Center
325 Ninth Ave.
Seattle, WA 98104
206-731-4614