The Ticket to Work and Self-Sufficiency Program Training for Employment Networks and State Vocational Rehabilitation Agencies January 2007 Unit 2 The Social Security Administration Title II and Title XVI Programs & Medicare/Medicaid Learning Objectives Define Social Security Disability Insurance (SSDI) Describe SSDI eligibility requirements Define Supplemental Security Income (SSI) Describe SSI eligibility requirements Define disability according to SSDI and SSI Define Substantial Gainful Activity Describe basic elements of Medicare Describe basic elements of Medicaid Social Security Disability Insurance Social Security Disability Insurance (SSDI) Definition Provides benefits to individuals with disabilities or blind individuals who are "insured" by workers' contributions to the Social Security Trust Fund Contributions are the Federal Insurance Contributions Act (FICA) taxes paid on the individual's earnings or those of a spouse or parents Authorized by Title II of the Social Security Act SSDI Eligibility The worker must have worked and paid Social Security taxes for enough years to be covered under Social Security insurance. Some of the taxes must have been paid in recent years, and the individual must be: The worker, the worker's adult child or widow(er) Considered medically disabled Not working or working but earning less than Substantial Gainful Activity (SGA) Worker's Adult Child To be considered for SSDI as a worker's adult child, an individual must: Be unmarried Be, or have been, dependent on the parent Must be 18 or older The disability must have begun before age 22 Substantial Gainful Activity (SGA) for 2007 Earnings guidelines used to evaluate an individual's work activity, and whether the person may be considered disabled under the law Non-blind beneficiaries = $900/month Blind beneficiaries = $1500/month Disability Defined Definition of Disability The inability to engage in any substantial gainful activity because of a medically determinable physical or mental impairment(s): That can be expected to result in death; or That has lasted or that can expect to last for a continuous period of not less than 12 months Critical Test for Disability Earnings guidelines are used to evaluate work activity to determine disability To meet disability guidelines, individual's earnings must be below the SGA level Note: SGA test is used differently for SSDI and SSI in regards to continuation of blind and disability eligibility Supplemental Security Income (SSI) What is SSI? Makes cash payments to aged, blind, and individuals (including children under 18) with disabilities who have limited income and resources Funded by the federal government through general revenues Financial Need based program Authorized by Title XVI of the Social Security Act SSI Eligibility Have little or no income (need based) Age - 65 yrs + Blind - 20/200 corrected vision Disabled (as previously defined) Not working, or working but not performing SGA SSI Eligibility (Continued) SGA is a factor in determining disability when applying for benefits SGA is not a factor for determining eligibility for blind individuals SGA is not used to determine if disability continues when the individual enters the SSI rolls. SSI eligibility continues until medical recovery or for a non-disability reason. Medicare Overview of Medicare Provides health care for the aged, individuals with disabilities, persons entitled to Social Security or Railroad Retirement, and persons with End-Stage Renal Disease Title XVIII of the Social Security Act Consists of Part A: Hospital Insurance Part B: Supplementary Medical Insurance Part C: Medicare + Choice program Services Covered Under Medicare Part A Inpatient hospital care Skilled nursing facility care Home health agency care Hospice care Benefit Periods for Part A Coverage Starts when beneficiary enters hospital and ends when there has been a break of at least 60 consecutive days No limit on number of benefit periods Inpatient hospital care is limited to 90 days with co-payment required for days 61-90 If the 90 days of inpatient care are exhausted, then a recipient can use days from a non-renewable "lifetime reserve" up to 60 additional days with co-payments Services Covered Under Medicare Part B Physicians' and surgeons' services Emergency room, outpatient clinic, and ambulance services Home health care services not covered under Part A Laboratory tests, x-rays, and diagnostic radiological services (continued on next slide) Services Covered Under Medicare Part B (continued) Ambulatory surgical center services Physical, occupational, and speech therapies Outpatient rehabilitative services Radiation therapy, renal dialysis and transplants, and heart and liver transplants Durable medical equipment Drugs that cannot be self-administered Medicare Financing Funded through two trust funds: Part A: Financed primarily through a mandatory payroll tax, with additional funds from income taxes Part B: Financed through premium payments and contributions from the U.S. Treasury Beneficiary Part A (HI) Payments and Liabilities No premiums as eligibility is earned through work experience For services not covered under Part A, liabilities are charged on a fee-for-service basis whereby beneficiary or other insurance covers the cost Beneficiary Part B (SMI) Payments and Liabilities Individuals enroll on a voluntary basis by payment of a monthly premium Beneficiary or other insurance carrier is responsible for fees not covered by Medicare Services must be either medically necessary or one of several prescribed benefits Medicaid Overview of Medicaid Developed as a Federal/State entitlement program to pay for medical assistance for certain individuals and families with low incomes and limited resources Does not provide services for all low income persons Title XIX of the Social Security Act Administered by Health Care Financing Administration (HCFA), now called the Centers for Medicare and Medicaid Services (CMS) State Medicaid Guidelines Within broad Federal guidelines, each state: Establishes its own eligibility standards; Determines the type, amount, duration, and scope of services; Sets the rate of payment for services; and Administers its own program. Federal vs. State Medicaid Guidelines Medicaid is a matched plan between Federal and State dollars Medicaid is implemented differently between states because of state plan variations Differences across states affect eligibility, coverage, and duration of services Medicaid Coverage Groups Federal government requires coverage of the "categorically needy" eligibility category Optional coverage can be extended to the "categorically related" eligibility category Medicaid Services Federal government requires the coverage of certain services, in order for states to receive federal matching funds States may also cover optional services that are not required by the federal government but for which they will receive federal matching funds Amount and Duration of Services Broad Federal guidelines States determine the amount and duration of services offered under Medicaid States are required to provide comparable amounts, duration, and scope of services to all categorically needy persons Reasons for Growth in Medicaid Expenditures Increase in size of Medicaid-covered populations resulting from Federal mandates and population growth Expanded coverage Disproportionate Share Hospital (DSH) payment program Increase in elderly and disabled population Results of technological advances that result in long term care Increase in payment rates to providers of health care Medicaid-Medicare Relationship Medicare beneficiaries who have low incomes and limited resources may be eligible for full Medicaid coverage and use Medicaid to supplement those services not covered under Medicare Certain Medicare beneficiaries may receive Medicare premium and cost sharing payments through their State Medicaid program The Ticket to Work and Self-Sufficiency Program Training for Employment Networks and State Vocational Rehabilitation Agencies January 2007