An individual who becomes disabled is confronted with a host of problems beyond the physical limitations of the disability itself, not the least of which is the inability to earn a living. Because s/he is not able to work, a disabled individual must find not only another source of income, but also some form of health care coverage to pay for much-needed medical care.
Fortunately, the federal Social Security Act allows a disabled individual to receive both a monthly income benefit and health care coverage under Medicare and/or Medicaid.
A Few Basics. As we told you in the fall issue of Social Security Disability Update, the Social Security Administration (SSA) administers two income benefit programs for disabled individuals, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). The two programs use the same medical criteria to evaluate whether a person is disabled. However, different standards apply in determining whether a disabled person is eligible for SSDI or SSI (or both) and in calculating benefits under each program.
For SSDI, a disabled applicant's eligibility for the program and calculation of the monthly income benefit are based upon the applicant's prior participation in the Social Security system (i.e., working and paying Social Security taxes). Eligibility and benefit calculation for SSI, on the other hand, are based upon financial need.
A disabled person who is found eligible for either of the two main Social Security disability benefit programs will also be eligible for federal health benefits. Specifically, a disabled person found eligible to receive SSDI will automatically qualify for Medicare after s/he has received SSDI payments for two years. A disabled person found eligible to receive SSI payments will qualify for Medicaid.
More about Medicare. As you may know, Medicare has two parts - Part A, which provides hospital insurance coverage (including inpatient care and certain follow-up services), and Part B, which provides supplemental coverage for certain other medical expenses (such as physician services and certain other medical services not covered under Part A).
Eligibility. Once a disabled person has been receiving SSDI benefits for a period of 24 months, s/he will automatically qualify for both Part A and Part B of Medicare.
Cost. Coverage under Part A is free to SSDI recipients, while coverage under Part B requires payment of a small monthly premium (currently, $42.50), which is deducted from the recipient's Social Security check. Because Part B requires payment of a premium, an SSDI recipient may choose to retain Part A coverage but decline Part B coverage. However, if the recipient has a low income and few resources, s/he may be eligible to apply for state assistance in paying the Medicare Part B premium (and, in some cases, paying any out-of-pocket expenses, such as deductibles and coinsurance payments).
Enrollment. Shortly before an SSDI recipient becomes eligible for Medicare, SSA will contact the recipient and provide information that the recipient will need to enroll in Medicare. While SSA handles Medicare enrollment, another federal agency, the Health Care Financing Administration (HCFA), is responsible for administering the program. Among other things, HCFA sets the standards that health care providers must meet in order to receive payment for any Medicare-covered services that they provide. HCFA is also responsible for processing provider claims for payment. An appeal process is available for providers whose claims are denied or who are not satisfied with the amount they have been paid.
Services. While Medicare provides basic health care protection, it does not cover all medical expenses. For example, Part A does not cover long-term or custodial care or personal convenience services (such as televisions, telephones, private duty nurses or the extra cost of private rooms when not medically necessary). And Part B generally does not cover routine doctor visits (with the exception of pap smear tests and mammograms in certain instances), preventive care, or prescription drugs.
More about Medicaid. The Medicaid program is a joint effort between the federal government and the states to provide health insurance coverage for certain low-income individuals. Although each state is permitted to establish its own rules for determining who is eligible for coverage and the nature of the services that will be covered, the state's rules must fall within broad federal guidelines in order for the state to qualify for federal funding.
Eligibility. Unlike Medicare eligibility, which is based upon an individual's prior contribution to the Social Security system (through Social Security payroll taxes), Medicaid eligibility is based solely on financial need. Each state has some discretion in determining which individuals their Medicaid program will cover. However, to be eligible for federal funds, the states must provide coverage for certain groups, including disabled individuals who qualify to receive SSI payments (although, in some states, the eligibility requirements for Medicaid are more restrictive than the criteria for SSI).
Cost. Coverage under Medicaid is free to eligible recipients.
Enrollment. In most states, enrollment in Medicaid is automatic for SSI recipients. However, in some states, SSI recipients must apply for Medicaid benefits through a state agency.
Services. In order to receive federal funding, each state Medicaid program must provide certain basic services. Examples of mandatory services include inpatient and outpatient hospital care, rural health clinic services, laboratory and X-ray services, physician services, and, in some cases, home health care. States may place appropriate limits on a service based upon criteria such as medical necessity or utilization control.
In determining whether or not you are disabled under Social Security's rules, the Social Security Administration considers five questions.
Are you working? If you are and your earnings average more than $500 per month, you cannot generally be considered disabled.
Is your condition so severe that it interferes with basic work related activities?
Is your condition found on the Social Security Administration's list of "disabling impairments?" If so, you are automatically considered disabled. If not, Social Security compares your disability to those on the list to determine if it is of equal severity to a listed condition. If it is, then your claim is approved; if not, the process goes on to the next question.
Can you continue to do the work you did during the last 15 years? If the answer is yes, your claim is rejected. If the answer is no, the evaluation process goes on to ask the final question.
Can you do any other type of work, when your age, education, past work experience and transferable work skills are taken into account? If you can, no benefits are awarded. But if you can't, you will be entitled to receive disability payments
It seems that part of the inflated cost of health care is associated with bilking insurance companies and as a result drives up all of our premiums.
I do feel for you though and I will pray for you.
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The Land of the Free is dying.