Disability state insurance vs SSI

[Munchkin]

My friend's two year old son was recently diagnosed with autism. At 3 (this summer) he will age out of home based early intervention provided by the state and transition to school based therapies. My friend has also looked into various private play based, applied behavior and cognitive behavior therapies. She works full-time earning a low middle class salary. Her husband also works and makes less than she.

She and I have insurance through the same employer. We have great coverage but every visit to a specialist or therapy session has a $45 copay. My husband and I probably make double what my friend and her husband do, and I can tell you the financial burden of bringing our son to routine visits with 3 specialists, multiple top-tier scripts and weekly speech, PT and OT nearly cost us our house. We literally had to borrow against my retirement account to stay afloat.

Given his diagnosis I suggested she apply for disability so he could have state insurance as secondary to absorb the copay costs. She applied and she was told she and her husband make too much money for her son to be considered. She told them she wasn't looking for SSI payment/support but rather that he be eligible for state health insurance. She was again told their finances would disqualify them.

Is this true? If a person has a valid diagnosis which will inevitably incur routine, long-term care and therapies, do finances still affect eligibility? It boggles my mind that a better financial choice for them may be having her NOT work and go on state support for everything! She wants to work. She wants to have her son receive as many early interventions as possible. Yet, they may not be able to afford both.

Does anyone have any advice or experience with this?

Thanks in advance!

 

[AGBF]

I am not up to date on Medicaid because I have not been practicing social work recently. I do know that it has always been granted only to people with low incomes, however. One of the aims of the Universal Health Care reform was to work towards having more people, people like the family you mentioned, got medical insurance. In the past far too many of the working poor were the people who fell through the cracks (so to speak) since the very poor could get Medicaid.

Now at least the insurance companies cannot deny people with prior conditions insurance. Middle class people are gaining some small rights. But the insurance companies are, unfortunately, still the big winners. They can charge two arms and a leg for services and no one needs to help to reimburse the people who are supposedly "insured" to make sure that they can afford the services that they need. In fact there was an article in the paper recently about a movement to get physicians to offer only less expensive options to patients even if some of them were less effective whereas in the past they offered all options. To me this is a harrowing thought. I will look for the article.

Deb/AGBF

PS-Do you have any questions about SSI or SSD? If so, I can answer those. SSI does not come with medical insurance.

 

[Munchkin]

ABGF-

I must admit I don't really know the difference. It was my understanding that one needed to be declared "disabled" by social security which would then qualify a person for benefits due to a disabled status, be it insurance, payouts, etc. Is this not the case?

 

[AGBF]

ABGF-

I must admit I don't really know the difference. It was my understanding that one needed to be declared "disabled" by social security which would then qualify a person for benefits due to a disabled status, be it insurance, payouts, etc. Is this not the case?

I am not sure what you are saying you do not know the difference between. Is it the difference between SSI and SSD or between SSI and Medicaid? I would be happy to explain what I can, but I am not sure about what-if anything-you have questions!

One has to be permanently and totally disabled to be eligible for SSI or SSD. The difference between which you will receive if you have been deemed permanently and totally disabled (which one is rarely deemed upon his first application) is based on income and work history. In the case of a child, it is based on his parents' income and work history. In order to receive SSI the person (or parents of the child who is permanently and totally disabled) must have an income below what the Social Security Administration considers the poverty level . In order for the person (or child) to be eligible for SSD (Social Security Disability) which pays more, the person or family must have a substantial work history including during the past ten years (if I recall correctly). After having been on SSD for five years one is eligible for Medicare, the health insurance program. One is not eligible for Medicare just because he has been on SSI, however.

Many people who are eligible for SSI, because they have low incomes, are also eligible for Medicaid because it serves the poor. If a family has applied for medicaid and been found to have an income or assets that make them ineligible for it, then there is no federal health insurance program to aid them. President Obama has been trying to get better health coverage for the middle class, but it seems that the insurance companies are winning.

I found the article to which I was referring above. A link to it is below. I find it very frightening, because it basically says that our doctors are going to start making choices to give us cheaper medicines even if they are not as helpful to us without telling us.


April 17, 2014 "The New York Times"...http://www.nytimes.com/2014/04/18/business/treatment-cost-could-influence-doctors-advice.html

AGBF
Diamonds Are A Girl's Best Friend

 

[FrekeChild]

She's not going to get disability benefits for her child. Obviously I'm not able to diagnose him myself, since I do not have the credentials or access to do so, but it's very difficult for a child to get it.

I used to work in a social security disability office, and we primarily worked with adults, reason being that child guidelines are very different from adult guidelines. What I do know is that she would absolutely, without a doubt, prove to SSA that she cannot work because she has to take care of him full time. In the event that happens, once the child turns 18, the requirements change, because it's assumed that the child can care for itself, it's now being treated as an adult, where the rules are different and become work based.

SSI is a poverty based program. Last time I checked, SS will pay out roughly $661 per month (I think this number has gone up finally, after I no longer worked there). If you have any kind of income, your SSI benefits will be reduced. Because her husband works, she would get denied for financial reasons, not medical reasons.

Also, it's not permanently and totally disabled. There are lots of people who are sick/depressed/physically unable to work for periods at a time, but they CAN and DO get better and are able to go back to work. The person applying has to prove that they are unable to work at ANY JOB for 12 months or more. There was one sick BLEEP (rhymes with truck) adjudicator who once denied a person with a terminal cancer diagnosis because "They aren't going to live for 12 months." That is legal by the way, with the way that the rules are written.

Typically people applying for SSI/SSDI are unable to work for much longer than that - the first application can take several months to get rejected (which the vast majority are rejected, based on our clients, I'd bet 95+%), then you have to do the appeal within 60 days, it goes through the adjudication process, and usually people get rejected again, appeal again, and then with that third denial, appeal once more, which is when things get complicated, and it's really better to go to an attorney, because odds are, you're going to have to stand in front of a judge and prove to them that you're disabled. In our office, it would typically take 2+ years from initial application to getting to the hearing stage. The hearing stage would typically take a year or two past that.

People who have been approved at the initial application level included: a young engineer with cancer (SSI, not enough work history to build up to SSDI), a higher up for a delivery company that was paralyzed and "of advanced age" (SSDI), a person with extensive psychological care who weighed 80 pounds at 5'8 and was unable to leave their house alone or care for themselves in any meaningful way (SSI), etc. These are very extreme cases.

There are several things to consider when applying for SSI/SSDI:
1. Age of the person applying.
2. Education of the person applying.
3. Work history of the person applying.
4. What is preventing that person from working? i.e. What problem do they have that keeps them from working?
5. Financial situation of the person's household.
6. Is the person currently getting care, from who and for how long?
7. Can they work at ANY job? Even one that they aren't necessarily trained for, but could learn? (This is the MOST IMPORTANT QUESTION!)

Also, having dealt with Medicaid personally, if you make too much money, you're not going to get it. I was attempting to get it for pregnancy only care, because my health insurance didn't cover pregnancy care at the time, and my husband and I, with him as a graduate student and me as a legal assistant, made almost double the maximum amount required.

Given his diagnosis I suggested she apply for disability so he could have state insurance as secondary to absorb the copay costs. She applied and she was told she and her husband make too much money for her son to be considered. She told them she wasn't looking for SSI payment/support but rather that he be eligible for state health insurance. She was again told their finances would disqualify them.

Is this true? If a person has a valid diagnosis which will inevitably incur routine, long-term care and therapies, do finances still affect eligibility? It boggles my mind that a better financial choice for them may be having her NOT work and go on state support for everything! She wants to work. She wants to have her son receive as many early interventions as possible. Yet, they may not be able to afford both.

This is correct. Financial eligibility is a must for government programs. There are possible other programs that might be able to help, your friend should try doing a google search in her state, and ask the EI people for help.

After having been on SSD for five years one is eligible for Medicare, the health insurance program.

The above is not entirely accurate - it's actually from the date that they apply for SSDI.

As far as SSI and SSDI, when you are applying for disability, you should ALWAYS apply for both, although you can apply for one or the other. Here are the big differences:

SSI:
-Poverty based program, any income will reduce your benefits. SSA keeps tabs on income and their bank accounts.
-This is typically awarded to people who have never worked, people who haven't worked within the last ten years, or people who haven't worked enough during the past ten years.
-Can be awarded past due benefits, but they will be paid in three payments, 6 months apart, in addition to monthly payments going forward.

SSDI:
-Pay in-pay out program - basically, you get what you put into it. If you work at a really high paying job for a long time, you might be able to get $1800/month - that's about the highest amount I ever saw and it was for a VP for a bank.
-Family/household income doesn't make a difference to the amount of benefits they can get.
-Can get past due benefits in one large lump sum. (Sidenote: my absolute favorite part of my job was when someone would call me - I worked mostly with the financial end of things - and say, "Um, Liz, why do I have $40,000 in my bank account?" and we hadn't even gotten the paperwork to find out they'd been approved yet! What a great way it was to find out! They had to be signed up for direct deposit for this to happen though.)
-Able to work a part time job while on benefits.

You CAN get approved for both SSDI and SSI - if the person has worked and put in enough money to get a couple hundred dollars or so in SSDI, depending on their financial situation, they can also potentially collection SSI to the maximum amount. The back benefits will be paid via SSI, and the same three payments 6 months apart rule applies.


I know that this is more information than you asked for, but I figure if anyone else out there has questions, this might be helpful.

Feel free to ask more questions - if I can't remember/don't know the answer, I have a few people I could ask!

 

[AGBF]

SSI is a poverty based program. Last time I checked, SS will pay out roughly $661 per month (I think this number has gone up finally, after I no longer worked there).

It is now $721 per month. Thank you for correcting some of the errors in my posting including the definition of disability by the SSA.

Deb

 

[packrat]

I would have her check out AEA too. (Area Education Agency) Our preschool program has AEA reps that come in. Well, they actually go to all the schools as needed, not just ours. They evaluate kids and work w/them. We have two different speech therapists that come, each once a week, we have OT and PT, and we have an early outreach worker who goes into homes and evaluates kids (and she is also the one who comes to schools to evaluate as well), and she works w/them in the home setting, one on one and also works w/the parents, showing them how to work w/their child and helping them find other resources. But they won't show up on someone else's say so, the parents have to contact them. It's free of charge. They also work w/us, showing us what they've been doing w/them, and we experiment, see what works best in the classroom.

I can tell you that we had a boy last year w/severe apraxia, now talks non stop in his second year w/us. We have one suspected case of autism and MR, parents aren't real swift about getting him diagnosed, but he is leaps and bounds farther than he was last year. We had our own little happy-tears session when we looked at his scores. We have one autistic boy who started in February, and turned 3 shortly thereafter,w/no words and a profound fear of anything being different/any changes. He has a one on one, and we adapt what we can for him in the classroom. He can now handle small changes, like his one on one going into a different room, and he has several words.

Several of our parents are on Medicaid. They either don't work or they have very low income jobs-like working part time at McDonalds.

There are resources and programs out there that are free, need based, reduced etc, where they can get help. Special education programs at preschools can be very beneficial, Area Education Agency is another one to check out.

 

[Munchkin]

Thank you so much for all your replies!
I've learned quite a bit. Off to google AEA...

 

[FrekeChild]

SSI is a poverty based program. Last time I checked, SS will pay out roughly $661 per month (I think this number has gone up finally, after I no longer worked there).

It is now $721 per month. Thank you for correcting some of the errors in my posting including the definition of disability by the SSA.

Deb

Just filling in a few blanks. The thing is, it might as well be completely and permanently disabled for as hard as it is for people to get it. It's not often that people actually do heal (whether mentally or physically) enough to go back to work. The people that walked into our office were typically pretty downtrodden and had been basically told that they couldn't/shouldn't be working for the foreseeable future, obviously extending past that year marker. Which is good (and bad) because it typically takes 2-4 years to even get approved!

It's an incredibly complicated process, and maybe I'm just a bleeding heart liberal, but no one really wants to be looked down upon as worthless by others, and in America, jobs are a huge part of our identity. When you first meet someone, almost the first thing they ask is, "So, what do you do?" And people are ashamed of saying, "I sit at home and collect government benefits." It sucks for them. I can't tell you how many people I had sitting across the desk from me crying because they wanted to work to make money to be self sufficient, and they couldn't.

Don't get me wrong, there are free loaders too, but it's rare that a free loader will put in the effort to LOOK sick/disabled/etc enough to actually be awarded disability. In any typical case, to get awarded benefits at the hearings level, there will be at least 3 adjudicators looking at each case, combing over medical records, calling doctors, calling your friends and family members, getting any evidence they can to find that you AREN'T disabled. They have better BS meters than I'll ever have, that's for sure!

It's a messed up system, but I can't really think of a better way to do it.