SUPPORTING CAREER DEVELOPMENT AND EMPLOYMENT BENEFITS PLANNING, ASSISTANCE AND OUTREACH (BPA&O) AND PROTECTION AND ADVOCACY FOR BENEFICIARIES OF SOCIAL SECURITY (PABSS) 2005 Edition SSA Publication No. 63 - 003 T.P. Golden, S. O'Mara, C. Ferrell, J. Sheldon, L. Axton Miller Benefits Planning, Assistance and Outreach (BPA&O) and Protection for Beneficiaries of Social Security (PABSS) T.P. Golden • S. O'Mara • C. Ferrell • J. Sheldon • L. Axton Miller 2005 Edition SSA Pub. No. 63 - 003 Acknowledgments This training curriculum is dedicated to increasing knowledge and understanding of the Social Security Administration's disability and return to work programs and work incentive provisions as prescribed in the Social Security Act and Ticket to Work and Work Incentives Improvement Act of 1999 as well as other federal benefit programs. These informational resources were compiled and edited to provide continuing education and print materials for benefits specialists and protection and advocacy personnel on the interplay of these benefit programs and impact or employment. Materials contained within this manual have been reviewed by the Social Security Administration, Health Care Finance Administration, Housing and Urban Development, Internal Revenue Service, and Department of Labor for accuracy. However, the opinions about programs administered by these entities expressed in these materials are those of the authors, and do not necessarily reflect the viewpoint of individual agencies referenced above. The information, materials, and technical assistance are intended solely as informal guidance and are neither a determination of legal rights or responsibilities, nor binding on any agency with implementation and/or administrative responsibilities. Materials contained within this manual are exclusively the work of the referenced authors and other contributors. The authors would like to recognize and extend their sincere appreciation to Mark Lassiter who contributed a great deal to some of the original conceptualization of content upon which chapters one through thirteen have evolved. In addition, the following individuals played an important role in providing editorial support and effort which contributed to the production of this manual: The National Materials Development Workgroup consisting of the primary authors and Diana Beckely, University of Missouri at Columbia; and, Mary Ridgely, Employment Resources, Inc. Staff of the Program on Employment and Disability including Alexis C. Falise, Debbie Fisher, and Shelia Smith. Technical editors from the federal agencies referenced above. TABLE OF CONTENTS Acknowledgments Table of Contents Contact Information INTRODUCTION A Framework for Benefits Planning, Assistance and Outreach Benefits Planning, Assistance and Outreach as an Emerging Field Definition Major Practice Domains Benefits Planning, Assistance and Outreach Construct Benefits Planning Benefits Assistance Outreach Counseling Implications for Staff Preparation and Service Delivery BPA&O Job Functions and Domains BPA&O Driving Values The P&A System: A Brief Summary Description of the Individual P&A Programs PABSS Priorities PABSS Staffing P&A Standards SECTION ONE: OVERVIEW OF SSA DISABILITY PROGRAMS CHAPTER 1: OVERVIEW OF SSA AND DISABILITY DETERMINATION Frequently Used Acronyms and Definitions Organizational Structure and History of SSA Work Incentives Adult Definition of Disability Sequential Evaluation Process Childhood Definition of Disability for SSI Disability Determination Service (DDS) Continued Disability Review (CDR) Continuing Disability Review (CDR) for Children Redetermination of Eligibility at Age 18 Continued Payment of Benefits for Children and Those Turning Age 18 Who Medically Recovered and are Participating in an Approved VR Program Continued Payment of Benefits to Those Who Medically Recovered and are Participating in an Approved VR Program Supporting Forms and Documentation CHAPTER 2: OVERVIEW OF Title II Disability Programs Additional Social Security Eligibility Requirements Credits Social Security for Disabled Adult Children (SSDAC) Disabled Widow(er) Benefits Supporting Forms and Documentation CHAPTER 3: OVERVIEW OF SSI Additional SSI Requirements Income Test Federal Benefit Rate (and state supplements) SSI Income Exclusions Earned and Unearned Income Deemed Income Deeming Chart 2005 (Federal) Living Arrangements In-Kind Support Resource Test SSI Resources (counted/not counted) Property Essential to Self-Support (PESS) SSI Redetermination Review Benefits for the Homeless Eligibility Case Study CHAPTER 4: APPLICATION PROCESS SSA Contact Information Application Process and Information Needed Types of Information Needed Other Eligibility Information Emergency Advance Payments and Immediate Payments Presumptive Eligibility Representative Payee SSI/Social Security Comparison Chart CHAPTER 5: APPEALS PROCESS Level I: Reconsiderations Level II: Administrative Law Judge Hearing Level III: Appeals Council Review Level IV: Federal Court Review BPA&O and PABSS Role During Appeals Waivers Supporting Forms and Documentation SECTION TWO: IMPACT OF EMPLOYMENT ON SOCIAL SECURITY DISABILITY TITLE II BENEFITS CHAPTER 6: SOCIAL SECURITY TITLE II BENEFITS Introduction Trial Work Period (TWP) Substantial Gainful Activity (SGA) Determination Income Averaging SGA Determination Process Unsuccessful Work Attempt TWWIIA CDR Protections Extended Period of Eligibility (EPE) Expedited Reinstatement of Benefits Medicare Coverage Two Part Medicare Medicare Premiums Extended Medicare Coverage Pre-TWWIIA Extended Medicare Coverage Under TWWIIA The Medicare Wizard TWWIIA Extended Medicare Coverage Decision Tree Examples/Exercises Medicare Buy-Back Option Exercise Questions Flowchart of Social Security/TWP Flowchart of Extended Period of Eligibility CHAPTER 7: SUBSIDIES AND SPECIAL CONDITIONS Introduction Employer Subsidies Special Conditions Unincurred Business Expense Indicators of Possible Subsidy Example: Subsidy Impact on Social Security Worksheet: Calculating Effect of Specific Subsidy Determining Subsidy SSA Work Activity Questionnaire CHAPTER 8: IMPAIRMENT-RELATED WORK EXPENSE AND SSDI Effects of IRWE on Benefits Allowable IRWE Deductions Sample Deductible and Non-Deductible IRWE Expenses Supported Employment Attendant Care Services Transportation Costs SSA Approved Mileage Allowances Medical Devices Prosthesis Work-Related Equipment and Assistants Residential Modifications Routine Drugs and Medical Services Diagnostic Procedures Nonmedical Appliances and Devices Similar Items and Services IRWE Computation Participant Exercise Example: IRWE Calculations - Impact on Social Security Benefits IRWE Summary SECTION THREE: IMPACT OF EMPLOYMENT ON SUPPLEMENTAL SECURITY INCOME CHAPTER 9: SUPPLEMENTAL SECURITY INCOME Impact of Income on SSI Participant Exercises: Example: Unearned Income and General Income Exclusion Worksheet: Calculating Unearned Income and General Income Exclusion Example: Earned Income and Exclusions Worksheet: Calculating Earned Income Only Example: Earned and Unearned Income Worksheet: Calculating Earned and Unearned Income Example: Eligible Couple Example: In-Kind Support and Maintenance (VTR) Worksheet: Calculating In-Kind Support and Maintenance Example: In-Kind Support and Maintenance (PMV) Student Earned Income Exclusion (SEIE) SEIE Reporting Example: Computing SEIE Worksheet: Computing SEIE SSI Eligibility for Students Temporarily Abroad Overview of 1619 Special Provision Statuses 1619(a) Break-Even Point (BEP) Participant Exercise: Example: Break-Even Point Without State Supplement 1619(b) Medicaid Covered Services Medicaid "Needs" Test Medicaid Administration Medicaid Buy-in Importance of the 1619(b) Provision Continuing Disability Review (CDR) CDR Protection Under TWWIIA Expedited Reinstatement of Benefits (EXR) Flowchart of SSI Benefits CHAPTER 10: IMPAIRMENT-RELATED WORK EXPENSE AND SSI Effects of IRWE on SSI Benefits Allowable IRWE Deductions Sample Deductible and Non-Deductible IRWE Expenses Employment Services Attendant Care Services Transportation Costs SSA Approved Mileage Allowances Medical Devices Prosthesis Work-Related Equipment and Assistants Residential Modifications Routine Drugs and Medical Services Diagnostic Procedures Nonmedical Appliances and Devices Similar Items and Services Participant Exercises Example: IRWE Calculations - Impact on SSI Worksheet: IRWE Calculations - Impact on SSI Example: IRWE Calculations - Impact on SSI and Social Security Benefits Worksheet: IRWE Calculations - Impact on SSI and Social Security Benefits IRWE Summary CHAPTER 11: BLIND WORK EXPENSE AND SSI Definition Allowable Expenses Exercises and Examples Example: Calculating Effect of BWE Worksheet: Calculating Effect of BWE CHAPTER 12: PLAN FOR ACHIEVING SELF-SUPPORT (PASS) Purpose for a PASS Effect of PASS on Benefits PASS Summary Earned and Unearned Income Resources PASS Approval Requirements Examples of Possible PASS Expenditures Non-Approvable Expenditures Supported Employment as an Excludable Expense PASS Candidates Developing a PASS Starting a Business Under a PASS Components of a Business Plan Calculating PASS Participant Exercise: Examples: Effect of PASS on Unearned and Earned Income Worksheet: Effect of PASS on Unearned and Earned Income Two Factors Effecting PASS and SSI Check Amount Participant Exercises: Example: Expense Exceeds FBR Worksheet: PASS Comparison Example: Expense Exceeds Total Countable Income Worksheet: PASS Exceeds FBR Effect of the One-Third Reduction Rule (Full In-Kind Support) Participant Exercise: Example: Calculating PASS with In-Kind Support (VTR) The Presumed Maximum Value Rule (Partial In-Kind Support) Participant Exercise: Example: Calculating PASS with In-Kind Support (PMV) Deciding Between PASS or IRWE Participant Exercise: Example: Calculating PASS and IRWE Concurrent PASS and IRWE Participant Exercise: Example: Calculating Concurrent PASS and IRWE PASS and Social Security Participant Exercise: Example: Example Without PASS Applied Example: SSI Example with PASS Applied Final Comments on PASS PASS Case Study PASS Format PASS Review Process Exhibit 1 - Initial PASS Checklist Exhibit 2 - PASS Progress Review SSI/Social Security Comparison Chart Concurrent Exercise SECTION FOUR: IMPACT OF EARNINGS ON OTHER SUPPORT PROGRAMS CHAPTER 13: TEMPORARY ASSISTANCE FOR NEED FAMILIES AND FOOD STAMPS Temporary Assistance for Needy Families (TANF) Characteristics of Each State Program Funded Under TANF TANF and SSI TANF and SSDI State TANF TANF Financial Eligibility Food Stamp Program State Food Stamp Information/Hotline Numbers CHAPTER 14: FEDERAL HOUSING SUBSIDIES Introduction Eligibility for Federally Subsidized Housing Calculating Rent Payments in Federally-Subsidized Housing Definition of Family in Federally-Subsidized Housing Section 504 Requirements Federal Preference Rules Public Housing Programs The Family Self-Sufficiency Program Section 8 Housing Choice Voucher Program Section 8 Project-Based Assistance Section 811 Supportive Housing for the Elderly and Persons with Disabilities Housing Opportunities for People with AIDS (HOPWA) Pilot Program for Homeownership Assistance for Disabled Families Other Project-Based Subsidy Programs Helping People with Disabilities Determine the Impact of Employment on Housing Costs Income Exclusions and Disallowances Setting Aside Rent Increase for Family Use Federally-Subsidized Housing Resources CHAPTER 15: UNEMPLOYMENT INSURANCE PROGRAM Introduction Covered Employment Eligibility for Unemployment Insurance Benefits Unemployment Benefit Amount Duration of Unemployment Insurance Benefits Application Process Right to Appeal Affect of Unemployment Benefits on SSI and SSDI North American Free Trade Agreement (NAFTA) and Trade Adjustment Assistance (TAA) CHAPTER 16: WORKERS' COMPENSATION General Provisions Coverage Workers' Compensation for Federal Government Employees Effect of Workers' Compensation Benefits on SSDI and SSI CHAPTER 17: EARNED-INCOME TAX CREDIT Introduction Eligibility Rules for Everyone Rules to Determine if there Are Qualifying Children Rules if There Are No Qualifying Children Rules for Computing and Claiming the EITC Calculating EITC Advance Payment of EITC Impact of EITC on Certain Welfare Benefits EITC Eligibility Checklist CHAPTER 18: MEDICAID AND STATE CHILD HEALTH INSURANCE PROGRAMS Introduction Services Covered by Medicaid Eligibility for Medicaid Using SSI as the Conduit to Automatic Medicaid Eligibility Four Provisions Allow Former SSI Recipients to Retain Medicaid Obtaining Medicaid Through the Medically Needy or Spend Down Program Home and Community-Based Waivers The Medicaid Buy-in Program Appealing Medicaid Decisions Medicaid Resources on the Internet Introduction to State Child Health Insurance Program Program Overview: The Basics of SCHIP SCHIP Eligibility Criteria Available SCHIP Services Cost Sharing Conclusion SECTION FIVE: BENEFITS PLANNING CHAPTER 19: EFFECTIVE COMMUNICATION STRATEGIES Introduction Active Listening Skills "Values-Free" Communication Expressive Communication Body Language Voice Tone/Inflection Words Interviewing Skills Negotiation Skills Six Rules of Successful Negotiation Mediation Final Thoughts CHAPTER 20: INFORMATION GATHERING, ANALYSIS, ADVISING, AND REPORTING BPA&O Decision Tree Data Collection and Profiling Gathering Personal Demographic Information Gaining Understanding of Personal Directions and Future Outlook Completing a Summary of Personal Demographics and Future Outlook/Exercise Describing and Reporting Disability Collecting Information On and From Other Service Providers the Person May be Involved With Summarizing Monthly Income Reporting Monthly Income Preparing a Monthly Budget/Exercise Identifying and Summarizing Resources Identifying Property Essential to Self Support Developing and Reporting Employment History Conducting a Trial Work Period Analysis Conducting an Extended Period of Eligibility Analysis Applying Expedited Reinstatement of Benefits Formulating Health Insurance Needs Reviewing, Projecting and Documenting Health Insurance Needs Identifying and Reporting Impairment-Related Work Expenses Identifying and Recommending Use of Blind Work Expenses Analyzing, Projecting, and Documenting Subsidy Exploring Plan for Achieving Self Support: History and Potential Use Ticket to Work Keeping Comprehensive Notes Verifying the Profile Data Collection Exercise Profile Scripts Developing a Comprehensive Report Documenting Scenario Analysis and Providing Computation of Useable Income/Example Scenario Computation/Exercise Making Closing Comments and Final Scenario Recommendations Verifying Soundness of Advise to be Given Using the Profile for Counsel Short-Term Advisement and Counsel SECTION SIX: BENEFITS ASSISTANCE CHAPTER 21: SUPPORT PLANNING Introduction Support Plans Comprehensive Benefits Support Plan Completed Comprehensive Benefits Support Plan Additional Thoughts on Support Planning Introduction to Other Support Systems History of SSA and Vocational Rehabilitation Ticket to Work and Self-Sufficient Program Ticket Eligibility The Ticket Continued Disability Review (CDR) Protection and Use of a Ticket Ticket Termination Program Manager Employer Network(s) (ENs) State Vocational Rehabilitation Agencies The Individualized Support Plan Employment Network Payment Systems Election of an EN Payment System Payment Under the Two EN Payment Systems Payment to State VR Agencies Limitations on Payments to ENs Dispute Resolution Disputes Between Beneficiaries and State VR Agencies Disputes Between Beneficiaries and ENs Representation of Beneficiaries in Ticket Disputes Dispute Between ENs and Program Managers Questions and Answers on the Ticket to Work Integrated Benefits Planning and Assistance Supports Into Existing Service Delivery Constructs The IEP and Transition Planning Statement of Needed Transition Instruction Developing the IEP Coordinated Set of Activities Continued Payment of Benefits The IPE and State VR The ISP and Other State Programs Support Plan Case Study CHAPTER 22: LONG-TERM BENEFITS ASSISTANCE Introduction Benefits Assistance Characteristics Proactive Benefits Monitoring and Assistance Strategies Benefits Assistance Meetings Critical Transition or Touchpoints SSI Touchpoints SSDI Touchpoints Touchpoints Applying to Both the SSI and SSDI Programs Notice of Action from SSA Information and Referral Problem Solving and Crisis Management Problem Solving Strategies Do's and Dont's of Crisis Management Crisis Intervention Plan Crisis Management Case Studies Case-Load Management Strategies Establishing and Maintaining a Case Record Importance of Consistent and Accurate Reporting to SSA SECTION SEVEN: OUTREACH CHAPTER 23: OUTREACH AND NETWORK BUILDING Introduction What is a Network Important Stakeholders Beneficiaries and Recipients Family Members Advocates Service Providers Planners/Case Managers Support Personnel SSA Stakeholder Analysis/Exercise Strategies for Network Building Important Steps in Developing a Network Creating Mutual Gains Establishing Trust Building Collaboration Maintaining an Effective Network SECTION EIGHT: ETHICS CHAPTER 24: ETHICAL CONSIDERATIONS Applying the Information in This Handbook Ethical Considerations Examples of Ethical Dilemmas Faced by Benefits Specialists Code of Professional Conduct Next Steps SECTION NINE: STATE SPECIFICS This section has been provided to insert state-specific information you may collect. SECTION TEN: SUPPLEMENTAL MATERIALS This section has been provided to incorporate materials distributed at the training or other support materials relevant to this program. APPENDICES A. Sample Job Descriptions B. Work Incentive Resources, Publications, and References C. State SSI Supplements D. 1619(b) Thresholds by State E. Accessing SSA Information and Other Resources Online F. Data Collection: A Model Questionnaire (Blank and Completed) G. Data Collection: A Series of Sample Reporting Formats/Templates H. Stakeholder Analysis I. Contact Log J. BPA&O Self-Assessment Checklist K. Standard Release of Information Forms L. Field Assignment/Practicum M. Training Evaluation Form CONTACT INFORMATION Cornell University's Employment and Disability Institute Work Incentive Support Center ILR Extension Bldg., Rm. 201 Ithaca, New York 14853-3901 607-255-7727 (voice) 607-255-2891 (TTY) 607-255-2763 (fax) ilr_edi@cornell.edu (email) www.edi.cornell.edu University of MO-Columbia Tri-Regional BPAO Training and Technical Assistance Center C. David Roberts #98 Corporate Lake Drive Columbia, MO 65203 Phone: 573-882-3807 Fax: 573-882-1727 robertsc@missouri.edu Virginia Commonwealth University Benefits Assistance Resource Center Susan O'Mara 1314 West Main Street Richmond, Virginia 23284-9063 Phone: 804-828-1851 Fax: 804-828-2193 soevans@rols.com This training program has been conducted under the sponsorship of the Social Security Administration through contract with the above institutions to serve as regional training and technical assistance centers. INTRODUCTION: A Framework for Benefits Planning Assistance and Outreach Objectives 1. Understand the history and evolution of BPA&O services in the U.S. and context of TWWIIA in promoting further expansion. 2. Define BPA&O services and supports and a framework for service delivery. 3. Recognize the breath and comprehensiveness of the benefits specialists' roles and responsibilities. 4. Articulate the values, which drive the delivery of BPA&O services and supports. A FRAMEWORK FOR BENEFITS PLANNING, ASSISTANCE AND OUTREACH Footnote Reference 1 Footnote 1: This chapter is excerpted in part from Golden, T. P., O'Mara, S., Ferrell, C. and Shelden, J.R. (in press). A Theoretical Construct for Benefits Planning and Assistance. The Journal of Vocational Rehabilitation. The last 15 years have seen an expansion of benefits planning and assistance services and supports being provided to Social Security Administration (SSA) disability program beneficiaries and recipients. With the growth in integrated employment service delivery and increased national emphasis on the employment of persons with disabilities the need for access to these types of services and supports has become essential to promoting successful employment outcomes and attachment of beneficiaries and recipients to work. With this increased focus on benefits planning and assistance comes the need to further articulate the service delivery construct for this growing field as well as identify the essential knowledge and skills required of practitioners to competently work within this specialized area. Important to this discussion is recognition that the field of benefits planning and assistance has grown from existing roles and functions of practitioners in diverse fields. These related fields and professions have included rehabilitation counselors; an insurance rehabilitation specialist, transition planners, advocates and peer counselors, supported employment personnel, vocational evaluators, and others. While these fields and professions have not focused solely on the delivery of benefits planning and assistance services and supports, they have been a valued activity within the context of their existing responsibilities, contributing to the employment success of consumers they have worked with. BENEFITS PLANNING, ASSISTANCE AND OUTREACH AS AN EMERGING FIELD The last five years have seen a growth in the number of practitioners that exclusively provide benefits planning, assistance and outreach (BPA&O) support and services as the primary role of their job. This increase has been partly in response to SSA's inception of state partnership initiatives focusing on the removal of barriers to employment for beneficiaries and recipients as well as anticipation of the recent passage of the Ticket to Work and Work Incentives Improvement Act of 1999. However, prior to these initiatives a few states did have existing benefits planning and assistance infrastructures for select groups of beneficiaries and recipients. For example, since the early '90s the New York State Office of Vocational and Educational Services for Individuals with Disabilities (VESID) has had an established network of 38 independent living centers statewide that state vocational rehabilitation counselors can access to deliver benefits advisement as prescribed in an Individual Plan for Employment (IPE). A formal referral process is utilized to secure this service and centers are paid under contract with VESID to deliver benefits planning as outlined in the IPE. In addition, a cadre of approximately 700 work incentive specialists have been trained and equipped in New York to provide benefits planning and assistance under the auspices of their existing professions. This cadre includes: educators, community rehabilitation practitioners, advocates, peer counselors, parent trainers and mentors, state agency personnel and other stakeholders. Other states have also equipped similar types of cadres although services and supports provided using this approach have been rather informal and not been the primary job responsibility of the practitioner delivering the service. This is of particular relevance to the discussion of quantifying and qualifying framework for how benefits planning and assistance services and supports are delivered. DEFINITION For our purposes we define benefits planning and assistance as... a set of benefits counseling strategies, services and supports that seek to promote work preparation, attachment, and advancement focusing on the enhancement of self-sufficiency and independence of Social Security Administration beneficiaries and recipients with disabilities through informed choice, which may result in decreased reliance on public benefit programs and increased financial well being. The knowledgeable reader will immediately recognize that the definition provided above does not encompass other situations under which benefits planning and assistance might be applied (i.e., supporting the movement of beneficiaries and recipients from institutions to community living and other areas such as health care and insurance planning). While the arena of benefits planning and assistance is larger than is narrowly defined here, for our purposes we are looking at its application in supporting successful employment outcomes for beneficiaries and recipients with disabilities. Given the diversity in training backgrounds of practitioners providing benefits planning and assistance and percentage of time and efforts allocated to these roles, any service and support delivery construct must be flexible in its design and able to be accessed on a variety of levels given the unique and heterogeneous employment support needs of beneficiaries and recipients as they consider work preparation, attachment, maintenance, and advancement. MAJOR PRACTICE DOMAINS To begin looking at a framework for major practice domains within the arena of benefits planning and assistance Cornell University's Program on Employment and Disability convened a workgroup of leading national experts in the field to outline an initial framework and set of associated knowledge areas and job functions. The work group identified several primary practice domains or function categories including: * Outreach; * Information and referral; * Data collection and profiling; * Benefits analysis; * Scenario advisement and counsel; * Support planning; and, * Benefits assistance. These domains within the BPA&O construct continue to be refined. For example, the Institute on Rehabilitation Issues convened by the Rehabilitation Services Administration as coordinated by the University of Wisconsin-Stout is currently addressing the implications of benefits planning and assistance on the roles of rehabilitation counselors. This Institute, comprised of experts from the Social Security Administration, Rehabilitation Services Administration, state vocational rehabilitation agencies, specific universities, and private service providers, initially seems to further support the flexibility of a service delivery construct that provides for easy access and delivery of services and supports from a broad array of practitioners based on the inherent capacities of these practitioners to deliver specific services. Virginia Commonwealth University, worked with state projects in Federal Region V to further refine a taxonomy of benefits planning and assistance services that included five service categories: information and referral; problem-solving and advocacy; benefits counseling; long-term benefits assistance; and follow-up services. These service categories and stemming definitions were based largely on the work of the Minnesota and Wisconsin state partnership initiatives. BENEFITS PLANNING, ASSISTANCE AND OUTREACH CONSTRUCT BENEFITS PLANNING Information Gathering, Profiling, Analysis and Advisement: An important first step in the benefits planning process is that of information gathering and profiling. Inevitably, at some point, a request for support will come in pertaining to an individual's benefit status. It is at this point that the benefits specialist will need to make a decision as to the complexity of the issue at hand and depth of information that will be needed to provide solid guidance. Often, requests will be short-term in nature and counsel needed provided through problem solving and advocacy. In more complex cases requiring indepth data collection, a customized profile of an individual's personal demographics, history, benefit status, work status, and other relevant information may need to be developed which will provide a base upon which to give guidance that will support the consumer in making a decision based on their initial request. This profile is an important tool in understanding the individual's current status so that it can be used as a springboard in proposing future alternatives and scenarios that the consumer may want to consider. Based on this and goals, aspirations, interests and support needs expressed by the individual the benefits specialist will conduct a comprehensive analysis of how the consumer's current situation may be effected by their purported goals and changes in other variables such as income, resources, living arrangements, supports and subsidies, etc. This analysis culminates in a comprehensive summary of information collected and presents options and recommendations for the consumer's consideration. An important element of counsel at this point is making sure the individual and their key supporters and stakeholders understand the options report generated and are provided with or connected with other resources to support them in making informed choices as to employment plan development and resulting need for benefits assistance. Counsel should result in informed choice leading to the possible development of actual employment goals. Information and Referral: Information and referral services and supports really cut across each of the three BPA&O domains. Information may include both spoken and print materials pertaining to SSA and other federal benefit programs. This may also include information on other community rehabilitation and employment programs and federal/state resources that may be available. It is important to recognize that the benefits specialist will not be able to be all things to all people. For example, a consumer may need to access rehabilitation counseling services or special evaluative services to assist them in making an employment decision. In those types of cases, and situations where the consumer's needs exceed the skills and expertise of the benefits specialist, referral to other community service providers or federal/state agencies for these supports may be appropriate. A comprehensive BPA&O program will have a diverse network of providers to whom they can refer. Problem Solving and Advocacy: As requests and referrals come in for the benefits specialist, information and counsel will inevitably need to be provided. This type of support is typically classified as either short- or long-term in nature. Most problem solving and advocacy is short-term in nature and consists of questions and needs for information pertaining to eligibility for various benefit programs, utilization of work incentives, and community referral. However, in some cases there may be a need for ongoing or long-term support with problem solving and advocacy. In this type of case, these services and supports are much more of a benefits management nature that will be discussed later in this introduction. BENEFITS ASSISTANCE Benefits assistance is critical for individuals who may require long-term BP&O services and supports and picks up where initial planning may end. That is, actually supporting the individual in establishing a plan and developing long-term supports that may be needed to ensure success. Support Planning: Whether deciding to prepare for employment, attach to work, maintain employment, or advance in work, planning is a core function of a benefit specialist's duties. It requires the practitioner to be skilled in existing service plan delivery mechanisms and understand how each is designed, implemented, and evaluated across an array of systems. For example, transition-aged youth may often have an Individual Education Program (IEP) and an Individual Transition Plan (ITP) that provides a mechanism by which management goals may become a part of the child's education program. Individuals currently in the vocational rehabilitation system may have an Individual Plan for Employment (IPE) or individuals in the mental retardation / developmental disabilities system may have an Individual Service Plan (ISP) both of which provide additional mechanisms for integrating benefits management and long-term support into existing service delivery constructs. Should the individual not be attached to a current service delivery system or goals not be appropriate to integrate into existing service delivery plan, the practitioner may need to consider the development of a benefits support plan that outlines support areas, activities, responsibilities, timeframes, and criteria/ indicators for successful outcomes. Benefits Assistance: Proactive benefits monitoring is the key to success at this level of support potentially focusing on regular intermittent contact with individuals, consistent communication, crisis management, information and referral, problem solving and advocacy, and assistance with management of the individual's benefit status. Benefits assistance is known by the long-term nature of services and supports needed by the consumer that may include ongoing data collection, analysis, counsel, and benefits reporting. Follow-Up: In many cases, some individuals may not need benefits assistance, but rather intermittent spot-checking to maintain their financial well being. Proactive benefits monitoring may also serve as a key to success at this level of support as well. OUTREACH This domain provides several important tools for recruiting and securing referrals of beneficiaries and recipients with employment interests. Marketing and network building are an important aspect of outreach, essential to developing a customer base. Many effective BPA&O providers offer community education programs and group counsel as an outreach tool. Others, target their outreach and education campaigns at a systems level hoping to in effect change specific systems. Whatever the approach, the key to effective outreach is securing a solid referral base. While an individual who is considering employment for the first time may come in through the outreach process and enter the construct more linearly as they make a decision as to whether or not to enter employment (e.g. proceeding through planning and assistance), the construct proposed does not require linear movement. For example, an individual may be referred who is already attached to work and simply requires long term management supports in managing a specific work incentive or reporting earnings. Another scenario may include a referral of someone who is already working and needs assistance in considering whether or not a job advancement should be taken and what its impact on benefits might be. In that case, the individual may only need initial problem solving and advocacy. COUNSELING Counseling is a vital cross cutting skill for the effective benefits specialist. It is the tool by which the benefits specialist gleans information, shares expertise, supports problem solving, provides advocacy, fosters the development of self-determination, and supports informed choice and decision making. Critical to counseling are effective communication skills that include: receptive listening; values-free communication; and expressive communication that include body language, voice tone, and inflection, and words. Interviewing and negotiation skills are also important. IMPLICATIONS FOR STAFF PREPARATION AND SERVICE DELIVERY As the field of benefits planning and assistance continues to grow and evolve, it will place an increasing need on continued and consistent development of human resources. This development will require both pre- and post-service development with a focus on the measurement of individual competency. In addition, sustainability of current and future planning and assistance efforts will need to be addressed. Critical to this emerging field will be the more rigorous identification and certification of a minimum set of standards and competencies for the profession and those practitioners that comprise it. However, equally important will be how success of practitioners in providing these essential services and supports will be measured and the extent to which customer feedback continues to enhance the quality improvement of planning and assistance services and supports provided. BPA&O JOB FUNCTIONS AND DOMAINS Major job and practice domains provide a clear differentiation of how job functions and critical knowledge will vary depending on the level, extent and comprehensiveness of support provided by a specific practitioner. Some practitioners may only provide outreach, profiling, analysis, and advisement, while another provides a broader scope of services and supports. This requires the major job/practice domains to be further refined into a flexible service delivery construct or framework for how services and supports might be provided while at the same time configuring for extent and level to which a benefits specialist may be engaged in service and supports delivery. The framework discussed and outlined in TWWIIA clearly sets forth the three primary domains under which job functions and critical knowledge can begin to be identified. It is important to note though that further extensive qualitative and quantitative analysis of these domains and stemming job functions is needed. In addition, information pertaining to minimum credentials in terms of education and work experience that a practitioner should have need to be identified. Given the breadth of backgrounds, disciplines, agency placement, and percentage of time devoted to providing services a more rigorous research protocol will need to consider and possibly control for these variables. The framework proposed also delineates the level and competency at which a practitioner will need to be equipped based on types of services provided under each domain. A first step for the benefits specialist or agency providing related services and supports is to consciously be aware of the extent and breadth of benefits planning services and supports that are being provided and available. A sample job description is provided in Appendix A. BPA&O DRIVING VALUES Individualized BPA&O services. Each individual served must be viewed as an individual and not as a member of some disability group. Each consumer will have unique interests and goals that are based upon their own individual values and preferences, which have nothing to do with the disabling condition or label. Services planned for and then delivered must be based upon the individual's personal preferences and must not be offered in a "on size fits all" manner. Consumer choice. It is within sound BPA&O practice to provide consumers with the information necessary to make informed choices. It is also appropriate to explain why one course of action may be preferable to another. It is important to remember, however, that the ultimate decision about the path or action to be taken must be made by the consumer. Non-judgmental approach. While benefits specialists may offer advice based upon benefits expertise, it is completely inappropriate to make value judgments about the choices consumers make. For example, it is not the benefits specialists place to tell a consumer that the "should" work or are somehow wrong to choose not to work. While the benefits specialists should advice consumers when they are about to pursue a course of action that is against SSA laws, regulations, or policies, they must be careful not to assume a judgmental tone. THE P&A SYSTEM: A BRIEF SUMMARY Footnote Reference 2 Footnote 2: For a more detailed description of the individual P&A programs, their mandates, eligibility criteria, and representative services, contact the National Association of Protection and Advocacy Systems (NAPAS) in Washington, D.C. at 202-408-9514 or visit their web site at www.protectionandadvocacy.com. The web site contains links to web sites of the state P&A programs. An excellent article on this subject was written by Gary Gross, Senior Public Policy Counsel, NAPAS. See, The Protection and Advocacy System and Collaboration with Legal Services Programs, published in Management Information Exchange Journal, vol. XII, No. 2, July 1998, p. 28. An updated version of the article will soon be published and appear on the NAPAS website. We acknowledge that article as a primary reference in preparing these materials and thank Mr. Gross and Cheryl Bates-Harris of NAPAS for editorial assistance. The Protection and Advocacy (P&A) system is the one longstanding and institutionalized system of disability-related advocacy services that is available, free of charge, in every state. The P&A system has the capacity to provide a wide range of advocacy services to persons with disabilities through several specific federally-funded P&A grants. Each P&A grant establishes a program with its own unique mandate. Each state has a designated state P&A agency. Typically, this is an independent, not-for-profit agency, such as Advocacy, Inc. in Texas, or Protection and Advocacy, Inc. in California. In some states, the designated P&A agency will be part of the state government, such as the Indiana Protection and Advocacy Services program or the State Commission on Quality of Care in New York. Most P&A systems deliver services through employees of the state-designated P&A agencies. However, some state P&A agencies will provide grants or subcontracts to other agencies to provide all or part of the services mandated under a particular P&A program. For example, in New York, the Commission on Quality of Care has provided grants to a range of Legal Services programs, law schools, Centers for Independent Living, and other agencies to deliver advocacy services under various P&A programs. All state P&A agencies employ, directly or through subcontractors, attorneys and other advocates to deliver services to eligible individuals with disabilities. The non-attorney advocates typically carry the title of advocate; some carry the title of paralegal. The ratio of attorneys to advocates varies greatly from state to state, since the P&A funding sources provide individual discretion regarding how to design a state P&A system to serve eligible individuals. The sections below describe the P&A programs that exist in each state. These include: * Protection and Advocacy for the Developmentally Disabled (PADD) * Protection and Advocacy for Individuals with Mental Illness (PAIMI) * Protection and Advocacy for Individual Rights (PAIR) * Protection and Advocacy for Assistive Technology (PAAT) * The new Protection and Advocacy for Beneficiaries of Social Security (PABSS) * The Client Assistance Program (CAP) Although CAP does not carry the P&A name, most consider CAP a part of the P&A family of programs. Like the P&A programs, it is a federally funded advocacy program that exists in every state to serve persons with disabilities. In many states, CAP is found in the same agencies that deliver services under the other P&A grants (i.e., within the state-designated P&A or within one of its subcontractors). The services of the five P&A programs and the CAP program will, in all states, typically fall under one of the following categories: * information and referral services * individual representation, including pursuit of client objectives through negotiation, mediation, administrative appeals, and court actions * investigation of allegations of abuse and neglect (primarily a function of the PADD and PAIMI programs) * outreach and community education (e.g., speaking, dissemination of print and web-based materials) In addition, many P&As dedicate some staff time to activities such as sitting on boards and committees where decisions are made concerning disability service delivery and policy within a state, or region of a state. In he descriptions below, some of the more typical P&A services are outlined with an emphasis on the type of services that would most likely help an SSI or SSDI beneficiary overcome a barrier to employment. Although typical services or advocacy cases are discussed by individual P&A program, there is great overlap among the P&A programs regarding the types of services offered to eligible individuals. (For example, each of the four traditional P&A programs, as well as the new PABSS, may become involved with Americans with Disabilities Act issues.) Each state P&A system develops its own set of priorities on how best to use its limited resources and some state P&A programs do not provide the full range of services described. In addition, many P&A agencies provide valuable services other than those described, including services provided through additional, non-P&A sources of funding. DESCRIPTION OF THE INDIVIDUAL P&A PROGRAMS The Protection and Advocacy for Persons with Developmental Disabilities (PADD) Program was created by the Developmental Disabilities Assistance and Bill of Rights (DD) Act of 1975. P&A programs are required by the Act to pursue legal, administrative and other appropriate remedies to protect and advocates for the rights of individuals with developmental disabilities under all applicable federal and state laws. The governor in each state designated an agency to act as the P&A system, and provided assurance that the system was and would remain independent of any service provider. 1994 amendments to the DD Act expanded the system to include a Native American P&A program. Administration for Children Youth and Families, Administration on Developmental Disabilities (ADD) administers the PADD program. The Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program was established in 1986. Each state has a PAIMI program, which receives funding from the national Center for Mental Health Services. Agencies are mandated to (1) protect and advocate for the rights of people with mental illness and (2) investigate reports of abuse and neglect in facilities that care for or treat individuals with mental illness. Agencies provide advocacy services or conduct investigations to address issues, which arise during transportation or admission to, the time of residency in, or 90 days after discharge from such facilities. The system designated to serve, as the PADD program in each state and territory is also responsible for operating the PAIMI program. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (CMHS) administers the PAIMI program. The Protection and Advocacy for Individual Rights (PAIR) Program was established by Congress as a national program under the Rehabilitation Act in 1993. PAIR programs were established to protect and advocate for the legal and human rights of persons with disabilities. Although PAIR is funded at a lower level than PADD and PAIMI, it represents an important component of a comprehensive system to advocate for the rights of all persons with disabilities. The system designated to serve, as the PADD program in each state and territory is also responsible for operating the PAIR program. Office of Special Education and Rehabilitative Services, Rehabilitation Services Administration (RSA) administers PAIR. The Client Assistance Program (CAP) was established as a mandatory program by the 1984 Amendments to the Rehabilitation (Rehab) Act. Every state and territory, as a condition for receiving allotments under Section 110 of the Rehab Act, must have a CAP. CAP services include assistance in pursuing administrative, legal and other appropriate remedies to ensure the protection of persons receiving or seeking services under the Rehab Act. Rehabilitation Services Administration also administers CAP. The Protection & Advocacy for Assistive Technology (PAAT) Program was created in 1994 when Congress expanded the Technology-Related Assistance for Individuals with Disabilities Act (Tech Act) to include funding for P&As to "assist individuals with disabilities and their family members, guardians, advocates and authorized representatives in accessing technology devices and assistive technology services" through case management, legal representation and self advocacy training. Originally passed by Congress in 1988, the Tech Act set up a lead agency in each state to coordinate activities to facilitate access to, provision of and funding for assistive technology devices and services for individuals with disabilities. Office of Special Education and Rehabilitative Services, National Institute on Disability and Rehabilitation Research (NIDRR) administers PAAT. The Protection and Advocacy for Beneficiaries of Social Security (PABSS) Program was established pursuant to the Ticket to Work and Work Incentives Improvement Act of 1999. Footnote Reference 3 It is administered by the Social Security Administration (SSA) through direct grants to each state-designated P&A agency. As stated by SSA, these new grants are made for two specific purposes: 1) to provide information and advice about obtaining VR and employment services; and 2) to provide advocacy or other services that a beneficiary needs to secure or regain gainful employment. PABSS programs can serve any individual who is entitled to SSI or SSDI benefits based on disability or blindness. Footnote Reference 4 Footnote 3: See TWWIIA § 1150, 42 U.S.C. § 1320b-21. Footnote 4: We believe, but it is not clear from SSA's written grant conditions, that a person no longer eligible for SSI or SSDI cash benefits is eligible for PABSS services if the person receives continuing Medicaid benefits through the 1619(b) program or extended Medicare benefits for former SSDI recipients. Both 1619(b) and extended Medicare benefits are a derivative of the cash benefit programs, with a requirement that the person continues to be disabled. PABSS PRIORITIES PABSS programs are to provide the following services in the order of priorities listed below: i. Investigate and review any complaint of improper or inadequate services provided to a beneficiary with a service provider, employer or other entity involved in the beneficiary's return to work effort. ii. Provide information and referral to SSI and SSDI beneficiaries about work incentives and employment, including information on the types of services and assistance available to them in securing or regaining gainful employment, particularly services and assistance through employment networks under the Ticket to Work and Self Sufficiency Program. Provide information and technical assistance on work incentives to individuals, attorneys, governmental agencies, employment networks and other service providers, and advocacy organizations. iii. Provide consultation to -- and legal representation on behalf of -- beneficiaries when such services become necessary to protect the rights of such beneficiaries. To the extent possible, alternative dispute resolution procedures should be used. iv. Assist beneficiaries with disabilities in disputes before SSA involving work related program decisions and benefits overpayments that are clearly a barrier to obtaining employment. PABSS personnel may not receive legal fees for these services. v. Advocate to identify and correct deficiencies in entities providing VR services, employment services, and other support services to beneficiaries with disabilities, including reporting to the program manager on identified deficiencies related to employment networks and other concerns related to the Ticket to Work and Self Sufficiency program. Within these priorities, it appears that PABSS programs can provide any advocacy services that fall within a P&A's traditional categories of service. One exception is that PABSS programs cannot use this new grant money to pursue appeals or litigation against SSA, its commissioner, or any SSA official. See discussion of condition four below. Footnote Reference 5 PABSS programs may pursue appeals and litigation against other federal agencies for issues directly related to securing or regaining employment. Footnote 5: The extent of SSA-related advocacy and appeals done through the other P&A programs will vary from state to state. A number of state P&A agencies have established priorities, within their PADD, PAIR and PAIMI programs, to pursue SSI and SSDI issues on behalf of persons with disabilities. Within priority category one, SSA clearly envisions that PABSS programs will represent beneficiaries in disputes with the new employment networks under the Ticket to Work and Self Sufficiency program. This will involve the Ticket's dispute resolution system as set forth in regulations expected to become final later this year. Footnote Reference 6 The Ticket program will be implemented in 13 states during the latter part of 2001, Footnote Reference 7 with the remaining 37 states to be phased in during 2002 and 2003. PABSS programs could also handle beneficiary disputes with state and private VR programs under this priority, but many of those cases are expected to be referred to CAP programs. Footnote 6: The proposed Ticket regulations were published on December 28, 2000, with comments received by SSA through February 26, 2001. 65 Federal Register 82843. Final regulations are expected to be published in late 2001. Footnote 7: The 13 states are Arizona, Colorado, Delaware, Florida, Illinois, Iowa, Massachusetts, New York, Oklahoma, Oregon, South Carolina, Vermont and Wisconsin. See SSA's Office of Employment Support Programs web site, www.ssa.gov/work. Priority two creates a mandate similar to what is expected of the newly created BPA&O projects; that is, to provide information and technical assistance to beneficiaries, advocates, and a range of provider agencies regarding the SSI and SSDI work incentives and related provisions. What PABSS programs do under this mandate may depend, in part, on previous expertise in doing similar work under existing grants, work currently done by only a few P&As. It may also depend on collaborative agreements they negotiate with the BPA&Os in their states. In many states, we expect that PABSS programs will collaborate with BPA&Os to maximize their combined resources and jointly embark on efforts to provide training, disseminate materials, and provide technical assistance to beneficiaries and the providers that serve them. Priority three provides authority for PABSS programs to provide consultation and legal representation to beneficiaries, when necessary to protect their rights. As long as the issues involved have a connection to employment, we can expect PABSS attorneys and advocates to be potentially available to provide consultation or representation on the following types of cases: special education; vocational rehabilitation; enforcement of the ADA or section 504 as related to employment, training, college programs, transportation, or anything else that stands as a barrier to employment; and denials of funding for goods and services (including AT) through Medicaid, Medicare or private insurance companies. In all their advocacy work, PABSS programs are required to first pursue administrative remedies, where available, before initiating litigation in a state or federal court, unless doing so would compromise the rights of the beneficiary. Priority four allows PABSS programs to represent cash beneficiaries who encounter adverse, work related decisions from SSA concerning their benefits, such as work related continuing disability reviews and work related overpayments. PABSS activities permitted under this condition include, but are not limited to, assisting and/or representing a beneficiary during the pursuit of a waiver or reconsideration of an overpayment assessed due to excess earnings (up to and including the Administrative Law Judge hearing), explaining the SSA appeal process to beneficiaries and assisting with the completion of necessary paperwork, assisting continuing disability review, and providing advice and information to assure complete consideration by SSA of potential employment subsidies, impairment related work incentives, and plans for achieving self support. Priority four, as mentioned above, does not allow the pursuit of any litigation, e.g., the filing of a Federal Court Complaint for Judicial Review, using PABSS fund. There is no prohibition that will prevent the use of alternative P&A funding streams to bring this type of claim however. Priority five is best described as performing a watchdog function over the existing and new VR and employment systems that are available to serve individuals with disabilities. Under this priority, we can expect PABSS programs to: monitor the existing state and private VR systems; monitor the new one-stop agencies established pursuant to the Workforce Investment Act; and monitor the employment networks serving beneficiaries under the Ticket program, reporting concerns to the program manager who will oversee that program. Here again, we expect that many PABSS programs will collaborate with BPA&Os to identify how best to accomplish this priority. We expect that in many states, the PABSS program will seek to address this priority by attending public meetings or seeking appointments to boards that oversee the functions of the systems described above. In addition, individual complaints from beneficiaries about these systems can be regularly referred by the BPA&Os to the PABSS staff. PABSS STAFFING PABSS Programs have been typically staffed with a Project Coordinator, a lead staff person with program reporting responsibilities, PABSS Specialists who provide direct line services, and other administrative support personnel. A sample composite job description, detailed by the NAPAS, is provided for reference in Appendix A. P&A STANDARDS The following is taken from the NAPAS Standards for Advocacy Programs Serving People with Developmental Disabilities and People with Mental Illness. Originally developed by a workgroup, these standards were later adopted by the NAPAS Board of Directors for use by all P&A agencies. Principles The following principles govern the way in which advocacy services are organized and delivered: 1. People with disabilities share with all citizens of the United States and its territories, basic human, legal, and civil rights. 2. The primary role of advocates is to establish, expand, protect and enforce the human, legal and civil rights of people with disabilities. 3. The role of the advocate is to inform the client about options, to assist the client to express preferences, and to ensure that these preferences are heard and vigorously pursued within the scope of the law. 4. Advocacy efforts are sensitive and responsive to the unique needs of individuals from diverse ethnic, racial, and cultural backgrounds. 5. Advocates appreciate the realities that confront clients and take meaningful direction from clients. 6. Advocacy programs are accessible and reasonably available to the places where people live and work. 7. The availability of advocacy services is known to potential clients, the location of services is physically accessible and the program possesses the resources necessary to communicate with its clients. 8. When a decision or meaningful choice cannot be or is not expressed by a client, or when consent is not available from or provided by a client or legally authorized substitute, advocates safeguard and advance the human, legal and civil rights of the person with a disability in a way that does not limit the client's options for choice. 9. Advocates assist people with disabilities to speak for themselves regarding their personal, programmatic and service goals and desires. 10. Advocates seek access to, and participate in forums such as state rule making, state planning, legislative and policy development processes that affect the rights and opportunities for people with disabilities. 11. Advocacy programs are accountable to the people whom they represent and such accountability is reflected in the policies and practices of the program as well as in the ethnic, racial, cultural, and consumer composition of the governing authority and staff. 12. Advocates employ multiple means of action and redress such as individual and class representation, legislative and other systemic advocacy, training and consumer education. 13. Advocacy programs are administratively independent and physically separate from service providers and state agencies responsible for the provision of services to persons with disabilities. 14. Advocacy priorities include the special concerns of people in segregated settings and promote opportunities for integration in work, education, leisure, and housing. 15. Advocacy resources and priorities address the human, legal, and civil rights of those individuals in the greatest jeopardy and with the greatest needs. 16. Advocacy efforts recognize and promote the right to a range of appropriate and humane treatment and habilitation. Values and Philosophy Advocacy for persons with disabilities is based on the following values: Equality, Equity and Fairness People with disabilities are full and equal citizens under the law. They are entitled to equal access to the same opportunities afforded to all members of the society. People with disabilities are entitled to be free from abuse, neglect, exploitation, discrimination, and isolation, and to be treated with respect and dignity. Meaningful Choice and Empowerment People, regardless of age, type and level of disability have the right to make choices and to have their choices acted upon. These choices are exercised both with respect to daily routines and major life events. Supports and Participation Services and supports are shaped by the unique needs and preferences of each individual, and assure and enhance opportunities for integration in all aspects of life. Services are age appropriate and premised on the fact that people with disabilities, continue to learn, grow and develop throughout their lives. For children, such growth is best accomplished within families, and for adults, within integrated communities rather than institutions. Independence Advocacy services are based on a philosophy of equal access, peer support and self-determination to be achieved through individual, professional and system advocacy. Services are delivered in a manner that maximizes leadership, independence, productivity and integration of individuals with disabilities. Cultural Competency Advocacy services reflect, and are responsive to, the diverse cultural, ethnic and racial composition of society. SECTION ONE: OVERVIEW OF SSA DISABILITY PROGRAMS Objectives 1. Understand general rules that apply to both the SSI and SSDI program. 2. Articulate the size and scope of SSA. 3. Explain how work incentive provisions promote work and employment outcomes. 4. Define disability according to SSA's standards. 5. Maneuver and understand the sequential evaluation and disability determination process. 6. Understand the continuing disability review and redetermination process for youth. 7. Explain circumstances under which benefits can continue in light of medical recovery. 8. Knowledge of SSDI eligibility rules. 9. Knowledge of SSI eligibility rules. 10. Understand SSA's benefit application process. 11. Maneuver and negotiate the SSA appeals process. CHAPTER 1: OVERVIEW OF SSA AND DISABILITY DETERMINATION Frequently Used Acronyms and Definitions The following acronyms and abbreviations will be used repeatedly throughout the text of this manual. They may be commonly accepted in the rehabilitation and education community, but these acronyms and abbreviations may have limited use with personnel in the Social Security Administration or with individuals with disabilities and their families. ALJ - Administrative Law Judge BPA&O - Benefits Planning, Assistance and Outreach BPQY - Benefits Planning Query BWE - Blind Work Expense CDB - Childhood Disability Benefits CDR - Continuing Disability Review CMS Centers for Medicare and Medicaid Services (formerly HCFA) CSA - Civil Service Annuity DD - Developmental Disabilities DWB - Disabled Widow(er) Benefits EAP - Emergency Advance Payments EPE - Extended Period of Eligibility ESR - Employment Support Representative EXR - Expedited Reinstatement of Benefits FBR - Federal Benefit Rate FICA - Federal Insurance Contribution Act HCFA - Health Care Financing Administration HUD - Housing and Urban Development IEP - Individualized Education Plan IRS - Internal Revenue Service IRWE - Impairment-Related Work Expense IPE - Individual Plan for Employment ISM - In-kind Support and Maintenance IWP - Individual Work Plan MH - Mental Health MIE - Medical Improvement Expected MINE - Medical Improvement Not Expected MIP - Medical Improvement Possible MRTW - Modernized Return to Work MSSICS - Modernized Supplemental Security Income Claims System NPRM - National Proposed Rule Making ODD - Office of Disability Determination ODO - Office of Disability Operations OHA - Office of Hearing and Appeals OASDI - Old Age Survivors Disability Insurance P&A - Protection and Advocacy PABSS - Protection and Advocacy for Beneficiaries of Social Security PASS - Plan for Achieving Self-Support PESS - Property Essential to Self-Support PMV - Presumed Maximum Value POMS - Procedural Operations Manual System RFC - Residential Functional Capacity SCHIP - State Child Health Insurance Program SEIE - Student Earned Income Exclusion SGA - Substantial Gainful Activity SS# - Social Security Number SSA - Social Security Administration SSDI - Social Security Disability Insurance SSO - Social Security Office SSI - Supplemental Security Income TANF - Temporary Assistance for Needy Families Title II - Legislation outlining Social Security Disability Insurance Title XVI - Legislation outlining Supplemental Security Income TWWIIA - Ticket to Work and Work Incentives Improvement Act TWP - Trial Work Period UWA - Unsuccessful Work Attempt VA - Veterans Administration VB - Veterans Benefits VR - Vocational Rehabilitation VTR - Value of the Reduction Organizational Structure and History of SSA The Social Security Administration (SSA) is a federal agency that administers two benefit programs for people with disabilities known as Supplemental Security Income (SSI) and Title II (SSDI; CDB; DWB). Social Security benefits are paid to individuals, and their dependents, which have been employed and have paid Social Security taxes. When individuals work, the employees and their employers contribute Social Security taxes that are reflected on the paychecks as Federal Insurance Contributions Act (FICA). Social Security tax contributions for 2004 are 7.65 percent of an individual's wages, which is then matched by employers and submitted to the Internal Revenue Service (IRS). For individuals who own their own business, the contribution is not shared and they are solely responsible for submitting both shares to the IRS (15.3 percent of their earned wages). The 7.65 percent tax rate is the combined rate for Social Security and Medicare (6.20% for OASDI and 1.45% for the Medicare portion). As contributors, individuals and their dependents/family members may receive benefits when they retire, become disabled, or die. Social Security provides benefits as follows: • Retirement benefits to those 62 or older; • Disability benefits to those who cannot perform substantial work and meet SSA disability criteria; and/or • Dependent benefits to spouses and children of deceased, disabled, or retired workers. The Supplemental Security Income program, or SSI, was established in 1974 to provide benefit assistance to individuals who demonstrate economic need and who are 65 or older or have a disability. The primary goals of Congress in establishing the SSI program include the following: 1. To provide a uniform, minimum income level that is at or above the poverty line; 2. To establish uniform, national eligibility criteria and rules; 3. To provide fiscal relief to the states; and 4. To provide efficient and effective administration (U.S. Congress 1971; U.S. Congress, 1972). Prior to 1974, states provided public assistance to individuals with disabilities to varying degrees depending on the state. Unlike the Title II program, SSI is funded through the general revenues of the Federal Treasury. As a result, to be eligible for SSI cash benefit it is not necessary for a person to have a past history of employment and payroll tax contributions. Instead, eligibility for SSI is based solely on meeting specific income, resource and disability eligibility criteria. Eligible individuals can receive both Title II and SSI. The legislative history pertaining to both the SSI and Title II programs shows that Congress expresses a "...desire to provide every opportunity and encouragement to the blind and individuals with disabilities to return to gainful employment." While SSA has frequently promoted SSI and Title II as "stepping stones or springboards to employment and greater economic self-sufficiency," reports on employment outcomes for beneficiaries and/or recipients indicate that limited numbers of individuals have actually opted to return to work once disability benefits are awarded. In an effort to encourage employment for beneficiaries, the federal government and the SSA have responded during the past 20 years with legislative and regulatory changes in the SSI and Title II disability programs. These changes, or work incentives, are aimed at reducing the risks and costs associated with the loss of benefit support and medical services as a result of returning to work. The headquarters of the Social Security Administration is located in Baltimore, Maryland and provides management and computer support to an organization of over 60,000 employees. In addition to the headquarters site, there are: • 10 regional offices, • 6 processing centers, • 3 data operations centers, and • about 1300 local Social Security offices located throughout the country. • 130+hearing offices nationwide. • Office of Hearing Appeals in Falls Church, VA. The Office of Employment Support Programs (OESP) was established in 1999. The mission of OESP is: 1. To plan, implement, and evaluate Social Security Administration (SSA) programs and policies related to the employment of the Social Security Disability programs (Title II) and Supplemental Security Income (SSI) beneficiaries with disabilities. 2. To promote innovation in the design of programs and policies that increase employment opportunities for Social Security beneficiaries. 3. To educate the public about the SSA and other public programs that support employment and about organizations that provide employment-related services. 4. To join with other public and private entities to remove employment barriers for people with disabilities. The Division of Employment Policy is comprised of three teams: 1. Employment Policy Team: Leads operational policy development and implementation for all work-related provisions under the Title II and SSI programs. 2. Employment Support Service Delivery Team: Manages pilot, evaluation and implementation of a new field position. It leads testing of new service delivery software, procedures, materials and related outreach materials and leads crafting of communications plans, forums and materials in coordination with SSA's Office of Communications. 3. Program Innovations Team: Manages research and demonstration projects under section 234 and 1110 of the Social Security Act, grants and cooperative agreement programs. It evaluates and makes recommendations about requests for SSA to waive title II and title XVI requirements; evaluates unsolicited grant and cooperative agreement proposals; SSI youth with disabilities. The Division of Employment Support and Programs Acquisitions is comprised of four teams. They are: 1. Communications and Training Team: This team works with the Office of Communication to produce written products and other material related to internal and external communications efforts for the Ticket to Work Program, concentrating on the 120-day period leading up to and following the release of the first tickets. It is responsible for assessing training needs related to the Ticket program and crafting appropriate training material. 2. Legislative Implementation Team: This team is responsible for coordinating the implementation of the Ticket to Work program, including developing policy, negotiating systems support, preparation of regulations, development of notices, and training on the program. 3. Program Acquisitions Team: This team provides technical support and oversight in the development, solicitation, award, administration, and evaluation of program contracts and interagency agreements entered in to promote and/or support SSA's employment support/return-to-work initiatives. 4. Provider Operations Team: This team is responsible for administering the Vocational Rehabilitation (VR) Reimbursement Program affecting both State VR agencies and alternate participants. This includes writing policy and procedures and reviewing and paying reimbursement claims. This team is also responsible for developing regulations and policies and procedures for some aspects of the Ticket to Work Program including activities relating to Employment Networks and State VR agencies. The claims unit will also be involved in the Employment Network payment process. Communicating with the SSA regarding individual benefits, work incentives and employment efforts largely involves interactions with SSA personnel at the local field office or through the SSA 1-800 telephone service. Claims Representatives, are located in the local field offices and provide an array of services related to establishing entitlement to benefits under Social Security programs and dealing with issues related to benefit payment amounts. In most cases, the local Social Security Offices have access to designated, specially trained work incentive liaisons. This is not an actual job title, but it does imply that these individuals have additional training and duties related to work incentive information and development. To identify the work incentive liaisons in a geographic area, contact the local Social Security Office or regional office. The SSA Web Site (www.socialsecurity.gov) contains information on location of the offices. In addition, beneficiaries and/or recipients also have access to a cadre of PASS specialists who can support use of the Plan for Achieving Self Support (PASS) work incentive. Work Incentives Work incentive provisions can help people with disabilities in two significant ways. First, they can help individuals pay for services or items that they need in order to work and to maintain, or even increase, their cash benefits until they are stable in employment. Second, in addition to the 1619(b) work incentives, the PASS, Impairment Related Work Expense (IRWE), and Blind Work Expense (BWE) are incentives that enable people with disabilities to recover expenses they incur while working towards greater economic self-sufficiency. The goals of the work incentive programs are to assist individuals to achieve gainful employment, increase independence, facilitate empowerment, and acquire self-support. A decision by a beneficiary or recipient to work and use the work incentives available to them should involve thorough up-front evaluation and planning to ensure an overall positive impact. First, projections should be made on the immediate effect of the earnings and the work incentives plan on cash benefits and the overall financial situation. Second, the long-term impact of changes in both earnings and work incentive utilization must be investigated. Some very basic questions to be addressed should include the following: What happens if earnings increase or decrease? If the vocational goal is reached, will benefits cease altogether? What will be the impact on medical coverage? Successful utilization of the work incentives and smooth benefit transitions ultimately depend on a cooperative effort between beneficiaries and recipients, families, advocates and the SSA. Proactive communication with the SSA will help to ensure that decisions made regarding employment and work incentive use are based on sound, accurate information and projections. A listing of work incentive resources and publications is provided in Appendix B. Adult Definition of Disability The criteria and process used to establish an individual's disability status for initial eligibility is the same for the SSI and Title II. It is critical to keep in mind, however, that for the SSI program, the disability eligibility requirements and process for determining eligibility based on those requirements differ slightly for individuals who are under the age of 18 versus those who are 18 years of age and older. The following information outlines the criteria and process for adults who are 18 years of age and older. The childhood requirements that apply to individuals under the age of 18 are described later in this section. The key to understanding the adult criteria lies in understanding how disability is defined for the adult program. Section 223(d) of the Social Security Act defines the disability requirements for this program in the following manner: "The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. An individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work." The basic conditions for the disability requirement include the following: • Individuals must have a disability that can be documented by a qualified medical examiner. Individuals must also meet or equal a certain level of disability; • The disability must be expected to last 12 or more months or be expected to result in death; • Individuals cannot be working at the time of application or, if working, can not be earning more than the SGA level of $830 for individuals with a disability other than blindness or $1,380 if they are blind; and • Per separate statutory definition, individuals who are blind and applying for SSI do not need to meet an SGA test but rather a test to ascertain level of blindness. Sequential Evaluation Process Based on this definition of disability, a sequential evaluation process involving five distinct steps is applied by the Disability Determination Service in making the disability decision. The Social Security regulations pertaining to the sequential evaluation process require that the steps of the process be followed in specific order and allow for the process to terminate if at any step a determination of "disabled" or "not disabled" can be made. 1. Is the person working at a substantial level? Step one of the sequential evaluation process addresses whether the person is engaging in substantial gainful work activity, or SGA. SGA is defined as the performance of significant physical or mental duties for pay or profit and in 2005 is generally determined to be gross earnings in excess of $830 a month for individual with a disability other than blindness and $1,380 for a person who is blind. Individuals engaging in work at or above the SGA level are considered to be demonstrating the ability to do substantial work in spite of their disabling condition and are consequently determined to be not disabled under Social Security law. Prior to January 2001, earnings between $300 and $700 per month may have been considered a gray area and deemed to be SGA - known as the secondary SGA level. This was based on comparison of the earnings of workers with disabilities to that of their non-disabled peers performing similar jobs. Also, prior to these changes the $700 SGA level established in July of 1999 was not automatically adjusted annually as was the case for individuals who were blind. Effective January 2001, SGA eliminated the secondary SGA level of $300. In addition, the new rules adjust annually the SGA amount for people with impairments other than blindness. The guideline would be the larger of the previous year's amount or an increased amount based on the Social Security national average wage index. Individuals who are blind and applying for SSI do not have to meet an SGA standard. There are several work incentive provisions that can help individuals earning over the SGA level to establish eligibility. Income averaging can possibly result in a current month's wages above SGA being considered non-SGA when averaged with previous lower-wage months. This is explained in more detail in Chapter 6. The dollar amount of impairment-related work expenses (IRWE) and subsidies are subtracted from the gross monthly wages before the SGA determination is made. Individuals may be earning over the SGA level and still meet the disability criteria if the dollar amount of their IRWEs and/or subsidies is significant enough to reduce their gross monthly earnings below the SGA level. The provisions are explained in greater detail later in this manual. Earnings set aside under a PASS cannot be deducted from gross monthly wages to meet the SGA criteria. 2. Is the individual's medically determinable impairment or combination of impairments "severe?" Key to the disability determination process is the requirement that a person have a physical or mental impairment that can be documented by a qualified medical examiner and that the disability is severe in terms of rendering the person incapable of performing substantial work. Social Security policy requires that for an impairment or combination of impairments to be considered severe, it must significantly limit the individual's physical or mental ability to perform one or more basic work activities needed to do most jobs. Examples of such basic work activities include walking, standing, seeing, hearing, following simple instructions, and the use of judgment. Based on consideration of the medical factors and evidence alone, a decision is made as to whether the person's disability is severe. Impairments of only a slight abnormality, which have no more than a minimal impact on the person's ability to perform basic work activity, result in a determination of "non severe." A non-severe determination at this step translates into a determination of not disabled and results in a cessation of benefits. If a determination is made that the person's impairment is severe, the evaluation will move to the next step of the sequential evaluation process. 3. If the impairment is determined to be severe, does it meet or medically equal the severity of a listing in the SSA's Listing of Impairments? At this step of the evaluation process, the individuals' medical evidence is reviewed to determine if they meet or equal one of the impairments as described in the SSA's Listing of Impairments. The Listing of Impairments provides for each of the major body systems a description of medical conditions that are considered severe enough to prevent an individual from performing work at a substantial level. If the medical evidence available supports the fact that a person has an impairment that is of the same level of severity as described in the Listings, and the impairment has lasted or is expected to last for a continuous period of at least 12 months or to result in death, that person will be determined to be disabled based on the medical considerations alone. Individuals are also found to be disabled if they are determined to have a medical condition that is the equivalent of an impairment described in the Listings. The Social Security Regulations specify that for an impairment to be found to be equivalent in severity to a listed impairment, the symptoms, signs, and laboratory findings in the individual's medical evidence must be equivalent in terms of severity and duration to the symptoms, signs and findings for a listed impairment. In addition, the DDS physician must document that in their medical judgment, the individual's disability equals a listed impairment. The disability evaluation process ends at this point for individuals who are found to be disabled based on a decision that they meet or equal the medical listing of impairments. A determination that a person does not meet or equal the Listings requires that the disability evaluation process continue to the next step. 4. If the impairment is severe, but does not meet or equal the severity of listing, does the individual retain the capacity to do his or her past relevant work, considering his or her residual functional capacity? Both the physical and mental demands of past relevant work and the individual's capacity to meet these demands are evaluated at this step of the sequential evaluation process. Past relevant work refers to any work that the individual has performed at the substantial gainful activity level within the past 15 years. Work that did not result in SGA level earnings may also be considered if it is determined that the person had the capacity to perform that work at a substantial level. However, work that was performed for less than six months may be determined to be an Unsuccessful Work Attempt and would then be discounted as past relevant work. See Chapter 6 for more detail about UWA. The process of determining a person's ability to perform past work involves an assessment of their Residual Functional Capacity (RFC). RFC is defined as the work-related abilities that a person retains in spite of their medical impairment. The DDS physician is responsible for determining an individual's RFC, and bases this determination on the medical and non-medical evidence in the case file. For persons with mental impairments, the Mental Residual Functional Capacity Assessment form is used by the physician to rate the degree of limitation that exists in four categories of mental activity. These categories include understanding and memory; sustained concentration and persistence; social interaction; and adaptation. The ratings are then considered as a whole in reaching a determination of the individual's residual functional capacity. The Residual Physical Functional Capacity Assessment form is utilized to rate the degree of limitation that exists for persons with physical disabilities. Exertional, postural, manipulative, visual, communicative, and environmental limitations are rated separately by the DDS physician, and then considered in their totality in the assignment of a person's overall residual functional capacity. 5. If past relevant work is precluded, does the individual retain the capacity to do any other kind of work (which exists in significant numbers in the national economy), considering the individual's residual functional capacity and the vocational factors of age, education, and work experience? In determining whether an individual has the capacity to perform other work that exists in the national economy, both residual functional capacity and the vocational factors of age, education and work experience are taken into consideration. Individuals with impairments, which are strictly physical or exertional, are assigned a range of work based on their assessed residual functional capacity. The range of work defines the person's maximum sustained work capability for sedentary, light, medium, heavy, or very heavy work. A corresponding table exists for each of the range of work categories. The table provides a list of SSA medical/vocational rules indicating "disabled" or "not disabled" based on variances in age, education and work experience. In cases where these factors coincide with all of the factors of a medical/vocational rule represented on the table, a finding of disabled or not disabled can be reached without further evaluation of the person's ability to perform other work. The tables and medical/vocational rules described above apply only to situations in which the person's impairment is strictly physical or exertional in nature. For individuals with a mental impairment or combination of physical and mental impairments, the tables are used as a source of guidance in the determination process only. The ultimate decision of "disabled" or "not disabled" for these disability categories requires that the person's vocational factors of age, education and work experience first be assessed. Based on the assessment of both the vocational factors and residual functional capacity, a review of jobs in the Dictionary of Occupational Titles is conducted to determine which, if any, of the jobs that exist in the national economy would be indicated for the individual. A determination of "not disabled" must cite three jobs, at minimum, that the individual possesses the residual functional capacity to perform at a substantial level. A determination that an individual is not able to perform other work at a substantial level will conclude with a decision that the individual is disabled. Childhood Definition of Disability for SSI Disability... "An individual under the age of 18 shall be considered disabled for the purposes of the SSI program if that individual has a medically determinable physical or mental impairment which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." SSA has clearly stated that they will no longer discuss disability in terms of a child's ability to function independently, appropriately, and effectively in an age-appropriate manner. The new definition of disability has four main parts which guide the sequential evaluation process: 1. Medically determinable impairment 2. Impairment results in "marked and severe" functional limitations 3. Duration requirement 4. No current SGA Substantial Gainful Activity (SGA) for Children Under 18 The law is clear that no individual under the age of 18 who engages in SGA at the point of initial application will be considered disabled. However, once a child turns 18, as well as during any "redetermination," an SGA test will not be conducted as part of the redetermination process as SSA is applying the 1619 work incentive provisions in these cases. Medically Determinable Impairment An important part of the sequential evaluation process is to determine whether the child has a medically determinable impairment or combination of impairments that is severe. The term "severe" at this step differs from its use in the definition of disability, as it refers during this step as a "term of art" and means that an impairment, or combination of impairments, has more than minimal impact on a child's functioning. SSA stipulates that they must be very careful in considering the combined effects of all of an individual's physical or mental impairments, and associated symptoms (Office of Disability, 1997). Marked and Severe Functional Limitation The new phrase "marked and severe functional limitation does not refer to a "marked" limitation plus a "severe" impairment. Instead, it refers to listing-level severity, which means that a child's impairment must meet, medically equal, or functionally equal the severity of the listing. SSA also defines listing-level severity as marked limitations in two areas of functioning or an extreme limitation in one area. A child's functioning is still considered and still developed the same way as it was under the prior definition, but the level of severity is greater than under the "Individualized Functional Assessment" process used prior to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. In addition, these limitations must be expected to result in death or be expected to last for a continuous period of not less than 12 months. Disability Determination Service (DDS) Disability Determination Services (DDS) are state agencies that are fully funded by the federal government to develop and review the medical and non-medical evidence and render a determination on whether an individual is, or is not, disabled under the law (SSA, Publication No. 64-039). The state DDS makes the disability decision for the SSA. Once an application for the SSI or Title II program is completed at the SSA office, it is sent to DDS. In making the disability determination, DDS workers will ask individuals' doctors and other treatment sources for a medical history of their condition: • What is wrong; • When did it begin; • What do medical tests indicate; and • What treatment has been given. A team of trained people in the DDS office, including a doctor and a disability examiner, review the completed forms, as well as the medical records and work history, to decide if individuals are disabled. If they are unable to make a decision based on this information, the DDS will pay for a specific medical examination. In deciding if individuals are disabled, the DDS will determine if the condition is as severe as that described in the SSA's listing of specific impairments. If it is not, the DDS looks at the individual's physical and mental capabilities in combination with other factors, such as age, education, and work experience. Continuing Disability Reviews (CDR) The Social Security Act includes a requirement that the SSA periodically update records and review the disability status of beneficiaries and recipients to ensure that they continue to be disabled and thus eligible for disability payments. These reviews are called Continuing Disability Reviews (CDRs) and apply to persons receiving both SSDI as well as SSI. At the point when an individual is determined eligible for disability benefits or at the time of the last full CDR, a date (or diary) for the next review, is established by the DDS Disability Adjudicator. Generally, a CDR can be expected based on classification of disability, namely: • Medical Improvement Not Expected (MINE): CDR every five to seven years; • Medical Improvement Possible (MIP): CDR every three years; • Medical Improvement Expected (MIE): CDR every six to eighteen months; or • Vocational Re-examination Cases: CDR pending training/rehabilitation program completion. Prior to 1993, all beneficiaries and recipients diaried for a CDR in any given year were subject to a full medical review. In an effort to increase efficiency, a new process was implemented in 1993 that included use of a computerized statistical analysis and CDR Mailer to predict the probability of medical recovery and need for a full medical review to be conducted. On an annual basis, SSA on-line data for all current beneficiaries and recipients are run through the computerized statistical analysis and assigned a score. This process is referred to as "profiling" and all beneficiary/recipient records are subject to the analysis regardless of an individual's CDR diary. Once the profiling process is complete, beneficiaries and recipients with a diary that will mature during the current fiscal year are essentially divided into two groups: those whose profile score indicates a high probability of medical recovery and those whose profile score indicates a low probability. Full medical CDRs are initiated immediately for individuals with a score indicating high probability. Beneficiaries/recipients with a low probability score are sent a CDR Mailer also know as the Disability Update Report, (SSA 455-ocr-sm). The purpose of the CDR mailer is to gather additional information directly from the individual and to consider this information along with current records to determine if a more detailed medical review is needed. The following questions are asked of beneficiaries/recipients on the mailer: 1. Have you received medical treatment during the last two years? 2. As compared to two years ago, do you feel the same, better, or worse? 3. Have you discussed your ability to work with your doctor? Has your doctor cleared you for work? 4. Within the last two years, have you participated in, or completed, an educational program? 5. Have you engaged in any work activity during the last two years? In many cases, depending on the answers provided, the SSA can avoid doing the much longer full medical review that used to be done in every case, and is still done in about half of the cases they process each year. Once the mailer is returned and the screening process completed by the Data Operation Center, a determination is made to either defer the case or to initiate the process for a full medical review (CDR). If a case is referred for a CDR, an electronic flag is sent to the location where the file is housed, and the file is then forwarded to the local SSA office. The local SSA office generates a CDR notice to the beneficiary/recipient and contacts them for an interview. The information is then forwarded to the State DDS for a determination of disability. Cases that are deferred as a result of the mailer will not undergo a CDR. Instead, no further disability evaluation will take place at this time and a new diary will be established for the next CDR. The diary will be set for the same duration as was established for the previous CDR. All CDR mailers are processed through the Wilkes-Barre Data Operation Center in Pennsylvania. During the mailer process, beneficiaries/recipients may be contacted via phone or mail from the Data Operation Center to assist in the gathering of complete and accurate information. Additionally, if the mailer is not returned, a second mailer will be sent. A fact sheet accompanying the mailer indicates that failure to submit the form will not automatically result in benefits stopping. Extensive development (including generating the second mailer, Data Operations Center and/or field office contact) and due process notification takes place before consideration is given to suspending or terminating benefits. It is important to keep in mind that the CDR mailer process does not apply to the Title II CDR conducted at the end of the trial work period for the purpose of determining SGA, or to CDRs triggered by SSI recipients moving into 1619 status. Current mandates require that full medical CDRs be conducted on individuals in both of these categories. CDRs as they apply specifically to the SSI and SSDI program will be detailed in more depth later in this manual. Effective January 1, 2001, the SSA will not be able to initiate a Continuing Disability Medical Review while an SSI recipient or SSDI beneficiary is using a "Ticket" under the Ticket to Work and Self-Sufficiency program. This protection is discussed in greater detail in Chapter 21. Extending CDR protections further, effective January 1, 2002, work activity by an SSDI beneficiary who has received SSDI for at least 24 months cannot be used as a basis for conducting a medical CDR. However, as in the prior protection, earning at or above the SGA level may make the individual's benefits subject to termination. However, work CDRs will still be conducted. Also, any previously scheduled medical CDRs will still be conducted unless the beneficiary is exempt due to participation in the ticket program. Continuing Disability Review (CDR) for Children A CDR must be done at a minimum of every three years for recipients of SSI under age 18 whose conditions are likely to improve. CDRs must be done not later than 12 months after birth for babies whose disability is based on their low birth weight. The Social Security Administration may also do CDRs for recipients under age 18 whose conditions are not likely to improve. Redetermination of Eligibility at Age 18 Any person who was found eligible for SSI as a child in the month before they turned 18 must have their eligibility for SSI redetermined as an adult. The redetermination will be done following the individual's 18th birthday using rules for adults filing a new benefits application. In 1997, the 12-month rule for conducting "age 18" redeterminations was repealed; now, SSA may conduct the redetermination at any point following the individuals 18th birthday. This could be done during a CDR or conducted at other points at SSA's discretion. Once completed, an individual who is not determined eligible for benefits as an adult will receive two more months of cash benefits from the date of the determination. However, overpayment may be considered after the ineligibility date for adult benefits is determined, should the individual continue to receive cash benefits beyond the two-month grace period in certain situations. Continued Payment of Benefits for Children and Those Turning Age 18 Who Medically Recovered and Are Participating in an Approved Vocational Rehabilitation Program Section 5113 of the Omnibus Budget Reconciliation Act of 1990 extended eligibility for "Section 301" payments to individuals whose disability ceased because of medical recovery during participation in an approved VR program expecting to result in employment. On August 10, 1999, the Office of Employment Support Programs of the Social Security Administration provided further clarification in field memorandum file number EM-99079. This stated that the procedure for determining continued payment of benefits under "Section 1631(a)(6)" of the Social Security Act applies to all "age 18" redetermination and continuing disability review cases. The field memorandum clearly articulates that "Section 1631(a)(6)" does apply to an individual age 18 and older whose impairment is determined to be no longer disabling, as a result of a disability redetermination conducted to redetermine a SSI recipient for benefits as an adult (as long as they are participating in an approved VR program). This further clarification strongly supports the movement and connection of students prior to school exit into approved VR programs. Inadvertently, connecting students to VR programs could potentially result in more transition-aged youth becoming attached to employment as a result of this provision. Continued Payment of Benefits to Those Who Medically Recovered and are Participating in an Approved Vocation Rehabilitation Program Sections 225(b) and 1631(a)(6) provide for a continuation of SSI and/or Title II benefits respectively to individuals who have medically recovered but who are participating in approved vocational rehabilitation programs. Note that section 101(b) of the Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170) amends the sections of the Social Security Act referenced above by removing "vocational rehabilitation program" language and replacing it with "a program consisting of the Ticket to Work and Self-Sufficiency Program under section 1148 or another program of vocational rehabilitation services, employment services or other support services." The information below pertaining to this provision has not yet been amended to reflect these new changes. However, the proposed rules to implement this expanded definition will be published in the Federal Register at a later date and incorporated into a later edition of this curriculum. These provisions allow individuals who have medically improved and are no longer considered disabled to continue receiving SSDI and SSI benefits if: • They are participating in approved vocational rehabilitation programs at the time their disability ceases; and • SSA has determined that the beneficiaries' continued participation in the vocational rehabilitation programs will increase the likelihood of permanent removal from the disability benefit rolls. Because of a law effective November 1, 1991, individuals can be participating in public or private approved vocational rehabilitation programs, not just state programs, to have benefits continued. Medicare, Medicaid, and state supplement eligibility also continue. To establish eligibility, beneficiaries should work with their SSA claims representatives and vocational rehabilitation counselors. Form SSA-4290 or the Individual Plan for Employment (formerly IWRP) will be used to gather the necessary information. Information considered includes: current vocational rehabilitation status; specific vocational objectives; the programs progress toward completion; and when the program will be completed. If SSA determines that continued participation in rehabilitation programs will not increase the likelihood that individuals will be permanently removed from the disability rolls, benefits will be terminated the month following this decision. Additionally, if individuals stop participating in the program for more than 30 days, benefits will cease and will not resume. Supporting Forms and Documentation Form/No# SSA-4290 Claimants Recent Medical Treatment Used by SSA to collect information from State VR units or alternative providers of VR services regarding program participation. Copies can be obtained from your local SSA office. Form/No# SSA Publication No. 64-039 A program circular defining disability evaluation under Social Security. Available at SSA.GOV under the publications link or at you local SSA office. CHAPTER 2: OVERVIEW OF TITLE II DISABILITY PROGRAMS Additional Social Security Eligibility Requirements To be eligible for Social Security, individuals must have insured status as former employed workers; that is, they have been employed for a specified minimum period in Social Security-covered employment. To establish insured status for disability benefits, individuals need 20 credits in the 10 years prior to the onset of disability. Those disabled before age 31 need less work to qualify. It is possible to earn up to four credits of coverage yearly based on annual earnings. In 2005, employees earn one credit for every $920 of earnings. This amount is automatically increased each year under a formula that takes into account increases in average wage levels nationally. In summary, to be eligible for Social Security individuals must: • Be determined medically disabled; • Not be working or earning less than SGA; and • Have insured status as former workers. Credits If a person is self-employed, they earn credits the same way employees do. The following chart shows the number of credits a person needs to be eligible for disability benefits, depending on age. Disability Benefits The number of credits required for disability benefits depends on age and onset of disability. If disabled before age 24, a person generally needs six credits during the three-year period, ending when the disability begins. If 24 through 30, a person generally needs credits for half of the period between age 21 and the onset of disability. If disabled at age 31 or older, a person needs the number of credits shown below. Also, they must have earned at least 20 of the credits in the 10 years immediately before they became disabled. Disabled at Age 31 through 42 Credits Needed: 20 Disabled at Age 44 Credits Needed: 22 Disabled at Age 46 Credits Needed: 24 Disabled at Age 48 Credits Needed: 26 Disabled at Age 50 Credits Needed: 28 Disabled at Age 52 Credits Needed: 30 Disabled at Age 54 Credits Needed: 32 Disabled at Age 56 Credits Needed: 34 Disabled at Age 58 Credits Needed: 36 Disabled at Age 60 Credits Needed: 38 Disabled at Age 62 or older Credits Needed: 40 Social Security for Disabled Adult Children (Childhood Disability Benefits) Adults with disabilities who do not have sufficient Social Security-covered work history for insured status may receive Social Security benefits based on their parents' insured status. To be eligible for Social Security as a disabled adult child, individuals must be: • 18 years of age or older; • disabled by SSA's definition before age 22; and • the child of insured workers who are either disabled, retired or deceased. (If adult child marries, benefits end unless marriage is to another social security beneficiary.) Disabled Widow(er) Benefits To qualify for disability benefits, a widow(er) (including certain surviving divorced spouses) must be found disabled before the end of a certain period prescribed in the law. The prescribed period begins with the latest of the following: • The month of the spouse's death, or • The last month of entitlement to mother's benefits, or • The last month of previous entitlement to DWB. The prescribed period ends with the earliest of the following: • The month before the month in which a widow(er) attains age 60, or • The close of the 84th month (7 years) following the month in which the period began. Disabled widow(er) benefits are not payable prior to age 50, even though the disability onset occurred earlier. Disability Eligibility For a widow(er): • The individual must have a physical or mental impairment(s) that meets or equals the level of severity in the Listing of Impairments. When the impairment does not meet or exceed the listing, the individual will not meet the definition of disabled for the purpose of these benefits. In determining eligibility SSA does not consider vocational factors, i.e., age education, and experience, as is done in the case of DIB or CDB. • The impairment must result from anatomical, physiological, or psychological abnormalities, verifiable by medically acceptable diagnostic techniques. • The individual must not have demonstrated (or be demonstrating) an ability to engage in substantial gainful activity. NOTE: The 1980 amendments extended the trial work period (TWP) provisions to disabled widow(er)s effective December 1980. (See DI 13010.035) The disability must have lasted or be expected to last for a continuous period of not less than 12 months, unless, of course, as in DIB and CDB cases, the impairment is expected to result in death within 12 months. A DWB is subject to a waiting period of 5 full consecutive calendar months. There is no waiting period if the claimant again becomes disabled before age 60 and the new disability began within 84 months following the month in which prior entitlement to DWB terminated. Benefits will begin with the first month in which the claimant is disabled for the entire month. Supporting Forms and Documentation Form/No# SSA Publication No. 05-10022 If You're Self Employed Explains how credits may be computed for an individual who is self employed. Available at SSA.GOV under the publications link or your local SSA office. CHAPTER 3: OVERVIEW OF SSI Additional SSI Requirements Individuals must fit into one of the following categories: • Disabled (as defined earlier); • Blind: 20/200 or less in better eye with glasses, or field of vision less than 20 degrees; or • Aged 65 or older. AND They must meet the Income and Resource Test and other SSI eligibility requirements. Income Test Income includes both earned income (monthly gross earnings) and unearned income, such as Social Security or any other type of benefits, monetary support, or in-kind support received. To compute the dollar amount of SSI cash benefits that individuals qualify for, the SSA uses a standardized formula that accounts for earned and unearned income. This formula is applied during the initial eligibility determination and individuals must qualify for some dollar amount of SSI to meet the income test. Federal Benefit Rate (FBR) SSI is an economic "need-based" program and is intended to supplement any income individuals already possess, to ensure that they are afforded a minimum level of income. Therefore, the dollar amount of SSI benefits received on a monthly basis varies from person to person. The Federal Benefit Rate (FBR), is the maximum dollar amount that individuals or couples can receive in SSI cash benefits on a monthly basis. In January of each year, the FBR is adjusted for changes by the Department of Labor. The amount of the FBR actually received in a given month depends on the following factors: • Earned income (work); and • Unearned income (Social Security benefits, VA, deemed income, etc.); • Living arrangement and in-kind support; • Use of available work incentives such as IRWE and PASS. In addition, some states may opt to supplement the FBR to some extent. These states include: Alabama* Alaska* Arizona* California Colorado* Connecticut* Delaware District of Columbia Florida* Hawaii Idaho* Indiana* Iowa Kentucky* Louisiana* Maine* Maryland* Massachusetts Michigan Minnesota* Missouri* Montana Nebraska* Nevada New Hampshire* New Jersey New Mexico* New York North Carolina* North Dakota* Ohio* Oklahoma* Oregon* Pennsylvania Rhode Island South Carolina* South Dakota* Texas* Utah Vermont Virginia* Washington Wisconsin* Wyoming* Effective January 2005, the FBR for a single person living independently is $579 per month and $869 for a couple. Appendix C has been provided as a place to insert your own state's benefit payment schedule. If a state has an asterick that means they do not offer a federally administered state supplement. They do however offer some type of supplement, which can be identified by contacting a local SSA office. SSI Income Exclusions In determining SSI eligibility, individuals may exclude any of the following: • Parent's income/resources once a child reaches the age of 18, regardless of their student status; • Any portion of student's grants, scholarships, or fellowships used to pay the cost of tuition, books, and other education related expenses; and/or • Food, clothing, and shelter provided "in-kind" by a non-profit organization as income if the assistance is based on need and is certified by the state. Earned and Unearned Income The reduction in SSI payments due to earned income and unearned income is based on the dollar amount of the types of income. In each case, the more earned/unearned income received, the greater the reduction in SSI payments. Keep in mind that the SSA provides income exclusions, which are available to individuals who receive SSI. These will be discussed in much greater depth in Section Three, Chapter 9. Some examples of earned and unearned income follow: Earned Income Earned income may be paid in cash or in-kind. If it is in-kind and in exchange for labor, its full current market value is the amount used to determine countable income. Earned income is: • wages paid; • net earnings from self-employment; • payments for participating in a sheltered workshop or work activity center; • sickness or temporary disability payments received within the first six months of stopping work; • royalties earned in connection with any publication of the individual's work or any honoraria received for services rendered. Unearned Income Unearned income is all income that is not earned. Some common types include: • in-kind support and maintenance; • private pensions and annuities; • periodic public payments such as SSDI, VB, railroad retirement benefits, workers' compensation, unemployment compensation, etc.; • life insurance proceeds and other death benefits; • gifts and inheritance (except those to be used for school expenses within 9 months); • support and alimony; • prizes and awards; • dividends and interest; • rents and royalties (except those defined as earned income); • certain payments not considered wages for social security purposes: in-kind payments to agriculture and certain domestic workers; tips under $20 per month; jury fees, monies paid to individuals who are residents, but not employees of institutions; and military pay and allowances, excepts base pay. Deemed Income When the SSA determines the eligibility and amount of payment for an SSI recipient, the income and resources of people responsible for the recipient's welfare are also considered. This concept is called "deeming." It is based on the idea that those who have a responsibility for one another share their income and resources. It does not matter if money is actually provided to an eligible individual for deeming to apply. There are three main situations where income and resources are "deemed": A. From an ineligible spouse to an eligible individual B. From an ineligible parent(s) to a child C. From a sponsor to an alien Spouse-to-Spouse Deeming: When individuals who are eligible for SSI live with spouses who are not eligible for SSI, SSA will count some of the spouse's income in determining SSI eligibility and calculating the benefit payment of the eligible spouse. Deductions, or "allocations" are allowed for children under age 21 who reside in the household and for the ineligible spouse. In addition, certain types of income are excluded when determining the income to be deemed from the ineligible spouse and there are additional exclusions provided based on whether the ineligible spouse receives earned or unearned income. Under spouse-to-spouse deeming, an individual can never receive a higher payment with deeming than would be received if deeming did not apply. If deeming does apply, the ineligible spouse's income is combined with the income of the eligible individual and compared to the FBR for a couple. It is important to remember that resources are also counted in the deeming process. The resources of the eligible individual and the ineligible spouse are counted together and compared to the resource limit for an eligible couple, which is currently $3,000. Certain resources are excluded from the deeming process. Pension funds owned by an ineligible spouse are excluded from resources for deeming purposes. Pension funds are defined as funds held in Individual Retirement Accounts (IRA's) or in work-related pension plans. Parent(s)-to-Child Deeming: Deemed income from the parent(s) will be considered for a child when the following conditions are met: * The child is under 18; * The child is unmarried; * The child is living with the parent(s) (or away at school but subject to parental supervision); and * The parent(s) do not receive SSI. The same exclusions that apply to the income of an ineligible spouse, apply to the ineligible parent(s). Just as with spouse-to-spouse deeming, there are also deductions or "allocations" each parent and for each ineligible child under age 21 living in the household. Any income of an ineligible child reduces the amount of the allocation. The type of calculation used to figure the amount of deemed income for the child depends on the type of income the parent(s) have after allocations are made for ineligible children. Deeming does not apply if the eligible child does not live in the same household as the parent(s), unless the absence is temporary (e.g., the child is away at school). Keep in mind resources are also counted in the parent(s)-to-child deeming process. The young person may have up to $2000 while at the same time their parents could have up to $3000. That would make the countable resource limit actually $5000 in a two-parent family and $4000 in a one-parent family. Once again, some resources may be excluded entirely. Pension funds owned by an ineligible parent or spouse of a parent are excluded from resources for deeming purposes. Pension funds are defined as funds held in Individual Retirement Accounts (IRA's) or in work-related pension plans. Sponsor-to-Alien Deeming: When aliens have sponsors, SSA may count the sponsor's or sponsor's spouse's income in determining the SSI benefit amounts. The exclusions that apply to the income of an ineligible spouse or parent listed in above do not apply to a sponsor, except for certain types of income excluded by other Federal laws. Allocations are provided for the sponsor, the sponsor's spouse in the same household, and the sponsor's dependents as defined by the Internal Revenue Service. These allocations are subtracted from the income of the sponsor and the living-with spouse to determine the amount of income to deem to the alien. Resources excluded from the resources of an eligible individual are also excluded from the resources of a sponsor. Currently, the balance of countable resources above $2,000 (or $3,000 for a sponsor with a living-with spouse) are deemed to an alien. Other Deeming Information: When deeming is involved, the eligible recipient, representative payee, or the legal guardian is responsible for making sure that all income (earned and unearned) and resources of ineligible parties are promptly reported to the SSA. Changes in income/resources experienced by the ineligible spouse, ineligible parent(s) and siblings, or ineligible sponsor may affect the recipients SSI payment amount or eligibility status. Deemed income calculations are complex are must be performed by the SSA claims representative. BPA&O and PABSS staff should not attempt to make deeming calculations without assistance from Social Security personnel. Deeming Chart 2005 (Federal) The following is for those states in 2005 that do not supplement the FBR. Contact a local SSA office and request the State's current Deeming Chart. Number of Ineligible Children: 0 Parent-to-Child Earned Income 1 Parent: $1283-$2441 Parent-to-Child Unearned Income 1 Parent: $619-$1198 Parent-to-Child Earned Income 2 Parents: $1863-$3021 Parent-to-Child Unearned Income 2 Parents: $909-$1488 Spouse-to-Spouse Earned Income: $665-$1823 Spouse-to-Spouse Unearned Income: $310-$889 Spouse-to-Spouse-To-Child Earned Income: $1863-$3021 Spouse-to-Spouse-To-Child Unearned Income: $909-$1488 Number of Ineligible Children: 1 Parent-to-Child Earned Income 1 Parent: $1573-$2731 Parent-to-Child Unearned Income 1 Parent: $909-$1488 Parent-to-Child Earned Income 2 Parents: $2153-$3311 Parent-to-Child Unearned Income 2 Parents: $1199-$1778 Spouse-to-Spouse Earned Income: $955-$2113 Spouse-to-Spouse Unearned Income: $600-$1179 Spouse-to-Spouse-To-Child Earned Income: $2153-$3311 Spouse-to-Spouse-To-Child Unearned Income: $1199-$1778 Number of Ineligible Children: 2 Parent-to-Child Earned Income 1 Parent: $1863-$3021 Parent-to-Child Unearned Income 1 Parent: $1199-$1778 Parent-to-Child Earned Income 2 Parents: $2443-$3601 Parent-to-Child Unearned Income 2 Parents: $1489-$2068 Spouse-to-Spouse Earned Income: $1245-$2403 Spouse-to-Spouse Unearned Income: $890-$1469 Spouse-to-Spouse-To-Child Earned Income: $2443-$3601 Spouse-to-Spouse-To-Child Unearned Income: $1489-$2068 Number of Ineligible Children: 3 Parent-to-Child Earned Income 1 Parent: $2153-$3311 Parent-to-Child Unearned Income 1 Parent: $1489-$2068 Parent-to-Child Earned Income 2 Parents: $2733-$3891 Parent-to-Child Unearned Income 2 Parents: $1779-$2358 Spouse-to-Spouse Earned Income: $1535-2693 Spouse-to-Spouse Unearned Income: $1180-$1759 Spouse-to-Spouse-To-Child Earned Income: $2733-$3891 Spouse-to-Spouse-To-Child Unearned Income: $1779-$2358 Number of Ineligible Children: 4 Parent-to-Child Earned Income 1 Parent: $2443-$3601 Parent-to-Child Unearned Income 1 Parent: $1779-$2358 Parent-to-Child Earned Income 2 Parents: $3023-$4181 Parent-to-Child Unearned Income 2 Parents: $2069-$2648 Spouse-to-Spouse Earned Income: $1825-2983 Spouse-to-Spouse Unearned Income: $1470-$2049 Spouse-to-Spouse-To-Child Earned Income: $3023-$4181 Spouse-to-Spouse-To-Child Unearned Income: $2069-$2648 Number of Ineligible Children: 5 Parent-to-Child Earned Income 1 Parent: $2733-$3891 Parent-to-Child Unearned Income 1 Parent: $2069-$2648 Parent-to-Child Earned Income 2 Parents: $3313-$4471 Parent-to-Child Unearned Income 2 Parents: $2359-$2938 Spouse-to-Spouse Earned Income: $2115-$3273 Spouse-to-Spouse Unearned Income: $1760-$2339 Spouse-to-Spouse-To-Child Earned Income: $3313-$4471 Spouse-to-Spouse-To-Child Unearned Income: $2359-$2938 Number of Ineligible Children: 6 Parent-to-Child Earned Income 1 Parent: $3023-$4181 Parent-to-Child Unearned Income 1 Parent: $2359-$2938 Parent-to-Child Earned Income 2 Parents: $3603-$4761 Parent-to-Child Unearned Income 2 Parents: $2649-$3228 Spouse-to-Spouse Earned Income: $2405-$3563 Spouse-to-Spouse Unearned Income: $2050-$2629 Spouse-to-Spouse-To-Child Earned Income: $3603-$4761 Spouse-to-Spouse-To-Child Unearned Income: $2649-$3228 Parent-to-Child Deeming: These figures are correct only if the eligible child has no countable income; and the ineligible children (if any) have no countable income; and the deemor(s) has either earned or unearned income (but not both); and there is only one eligible child in the household. Spouse-to-Spouse Deeming: These figures are correct only if all income of the ineligible spouse and the eligible individuals is either earned or unearned (but not both); and the ineligible children (if any) have no countable income; and the eligible individual's own countable income is less than the FBR. Spouse-to-Spouse to Child: These figures are correct only if the eligible child has no countable income; and deeming the ineligible children (if any) have no countable income; and there is only one eligible child in the household. Living Arrangements Social Security carefully assesses an SSA recipient's living arrangement to determine whether in-kind support and maintenance (ISM) is being received, and subsequently, if ISM is being received, whether the ISM is to be valued under the VTR rule or the PMV rule described later in this manual. Because of this, an SSI recipient's living arrangement can be a critical factor in determining both eligibility and cash payment amount. The first step in determining the type of living arrangement is to determine whether it is one of a "household" or non-household". A non-household situation exists if the recipient is either a transient or a resident of an institution. Residence in an institution (as defined for SSI purposes) can affect an SSI recipient's eligibility and/or payment amount. Residents of public institutions generally are ineligible for SSI. Residents of Medical facilities (public or private) may be eligible, but are generally limited to a maximum Federal payment of $50 a month. However, there are many exceptions to these generalizations. The POMS defines terms and provides the policies and procedures for determining the specific effect of various forms of institutionalization on SSI eligibility and payment. A household situation exists when an individual is not a transient or a resident of an institution. For SSI purposes, a household is defined as a personal place of residence in which the individuals share common living quarters and who function as a single economic unit. For purposes of living arrangement determination and ISM, members of a household need not be related by blood or marriage, but must live together in a single dwelling and function as an economic unit. A person who is temporarily absent from a household is still a member of the household. Below is a list of the primary household living arrangement designations used in SSI cases: 1. Non-institutional care - An individual is in a non-institutional care situation when all of the following conditions exist: * The individual has been placed by a public or private agency under a specific program of protective placement. * The placement is in a private household that is licensed or otherwise approved by the State to provide protective care. * The placing agency retains responsibility for continuing supervision of the need for placement and of the services provided. * The individual, the placing agency, or some other party pays for the services provided, or has a written agreement to pay for the services provided. When an individual is in a non-institutional care situation such as a group home, the individual is considered to be in a household of one and the individual is subject to the PMV rule rather then the VTR rule. 2. Home ownership (or ownership interest) - For SSI purposes, this living arrangements exists if an individual (or the individual's living-with spouse or a person whose income is deemable to the individual) has specified forms of ownership interest in the home in which he /she lives as a permanent resident. A finding of home ownership means that any ISM from within the household received by the individual must be subject to the PMV rule rather than the VTR. 3. Rental Liability - Rental liability is an oral or written agreement between an individual (or the individual's living-with spouse or a person whose income may be deemed to the individual and a landlord that the landlord will provide shelter in return for rent.) An individual is living in his own household when he or she has liability to the landlord for payment of any of the rental charges on the part of: * the individual; * the living-with eligible spouse; * any person whose income may be deemed to the individual. The PMV rule is used to determine ISM for an individual who has rental liability. The VTR never applies when an individual is in his/her own household. There are various types of rental liability including a flat fee for room and board and room rental within a private dwelling. These various rental liability types vary in terms of how ISM is applied. Rental subsidy (reduced rent) is a type of outside ISM, subject to the PMV rule. The value of the subsidy is the difference between the current market value of the shelter and the actual rent charged by the landlord. Rent-free shelter is a type of ISM from outside a household. It is ISM in the form of shelter, subject to the PMV rule, which is received by an individual living in a household in which no household member has an ownership interest or rental liability. 4. Public Assistance (PA) Households - A public assistance household is a household in which each member receives cash or vendor payments (i.e., direct or indirect payments) from one or more specified public income maintenance programs (i.e.: TANF, SSI, General Assistance etc.). An individual who lives in a PA household does not receive any ISM from other household members and so cannot be subject to the VTR. If the household receives outside ISM or if the individual receives ISM-to-one from a source outside the household, it is subject to valuation under the PMV rule. 5. Separate Consumption - this living arrangement exists when an individual (or at least one member of an eligible couple) eats all meals during a month outside the household in which he/she lives. A finding of separate consumption means that any ISM received from within the household by the individual/couple is in the form of shelter and subject to the PMV rule. 6. Separate purchase of food for oneself - This living arrangement exists when an individual (or at least one member of an eligible couple) buys all of his/her own food (excluding certain items such as condiments) apart from the food of other household members even though the food is consumed inside the household. A finding of separate purchase of food means that any ISM received from within the household by the individual/ couple is in the form of shelter and is subject to the PMV rule. 7. Sharing - This living arrangement exists when an individual contributes his/her pro rata share of household operating expenses or an eligible couple contributes their combined pro rata share. A finding of sharing means that the individual/couple does not receive ISM from anyone else in the household. 8. Earmarked sharing - This living arrangement exists is when an individual designates, or earmarks, all or a portion of his/her contribution specifically for food or for shelter. If the earmarked contribution equals or exceeds a pro rata share of the household operating expenses (i.e., the food expenses or the sum of the shelter expenses), the individual's living arrangement is earmarked sharing and he/she is not subject to the VTR. As is the case with deeming, the process of determining living arrangement and any subsequent ISM valuation (VTR or PMV) is multi-faceted and complex. Living arrangement determinations may only be made by SSA personnel, and are of course, subject to the appeals process. However, it is imperative that a Benefit Specialist consider a recipients' living arrangement before offering advice about the effect of employment on SSI benefits as ISM in the form of either VTR or PMV may be involved. Recipients must be advised to promptly report any and all changes in living arrangements to the SSA. In-Kind Support and Maintenance The One-Third Reduction Rule (Full In-Kind Support) In-kind support and maintenance is unearned income in the form of food, clothing, or shelter that is given to an eligible individual or is received because someone else pays for it. Whether someone else pays a living expense in full or just in part has a bearing on the amount of SSI cash benefits individuals receive. Individuals who live in someone else's household and receive both food and shelter and do not pay their pro rata share of household expenses are subject to a full one-third reduction of their SSI benefits. In SSA lingo this is referred to as the Value of the One-Third Reduction (VTR). The VTR rule applies only if the individual receives both food and shelter in another's household. Individuals falling into this category will have their SSI cash benefit reduced by one-third of the amount of the FBR. In 2005, this translates into a reduction of $193 ($193 for a single person living alone and $286 for a couple). This reduction comes right off the top of their monthly benefit checks. The maximum amount of SSI that can be received by an individual who has a full in-kind support reduction is $386 ($579 - $193). The Presumed Maximum Value Rule (Partial In-Kind Support) When the VTR rule does not apply, ISM is determined using the Presumed Maximum Value Rule. For example, the PMV rule is used if the eligible individual has ownership interest or rental liability, separately purchases or consumes food, get only outside ISM, etc. The SSA presumes that the maximum value of the support and maintenance an individual gets is no more than $213. They arrive at this figure by adding $20 to the one-third-reduction amount of $193. After subtracting a $20 general exclusion from the PMV, the reduction in the SSI check is $193. But, if the actual value of the ISM is less than the PMV, only the actual value is counted as ISM. For example, if a third party pays the household's electric bill, which was $100, only $100 is counted as ISM. And the $100 is divided equally among all the household members. If the household has 4 members, only $25 of ISM is counted for the SSI eligible individual. Summary The SSA makes determinations of in-kind support based on data gathered on the MSSICS computer screens or the Statement of Living Arrangements, In-Kind Support, and Maintenance forms. If individuals are able to pay within $5 of their fair share of the household expenses, they will be determined not to be receiving in-kind support and will avoid reductions in SSI benefits. Any contributions individuals make towards these expenses should be reported to the SSA. Often, individuals with disabilities and their family members are leery of reporting that the SSI cash benefit is used for household expenses. The SSI was intended for this purpose and it should be reported, as in some instances, it might help individuals receive the full SSI benefit. Resource Test The SSI benefit program has specific resource limitations that are set by statute and include real or personal property (including cash). This must not exceed the specified amount at the beginning of each month. The resource limits are not subject to regular cost-of-living increases, and the current limit is $2,000 for individuals and $3,000 for couples. Resources in excess of these limits at the beginning of a month will render individuals ineligible for SSI cash benefits in that month. Ineligibility will continue through the next month that resources fall below the allowable limit. If ineligibility continues for 12 consecutive months, entitlement to SSI benefits will cease. A PASS may allow individuals to save more than the resource limits, while maintaining or increasing their SSI cash benefits. This will be discussed in further detail in the unit entitled Work Incentives. SSI Resources (Counted and Not Counted) For SSI purposes, resources are anything an individual owns which could be changed to cash and used for food, clothing, or shelter. This includes: • Cash, bank accounts, stocks; • Land; or • Personal property; Also: • The SSA sometimes counts a portion of deemed resources of a spouse, parent or sponsor of an alien and sponsor's spouse. • Most of the resource exclusions listed below also apply to a parent's resources. In addition, if a child lives with one parent, $2,000 of the parent's resources does not count. If the child lives with two parents, $3,000 does not count. Countable amounts over these limits are deemed to be the child's. The following is a partial list of resources not counted by the SSA: • The home lived in and the land it is on; • Household goods and personal property that do not exceed $2,000 in value; • Burial spaces for individuals and their immediate families; • Burial funds for individuals and their spouses valued at not more than $1,500 each; • Life insurance policies with a combined face value of not more than $1,500 per person; • Retroactive SSI or Social Security checks are not counted as resources for nine months after receipt; • Property essential to self support; • Resources needed for an approved PASS; • Money needed for school expenses is not counted for nine months; • For children under 18, retroactive SSI benefits that exceed six times the monthly FBR must be deposited into a dedicated savings account. These funds must be kept separate from any other funds. • Property in a trust that is set up according to state law - to which the SSI recipients have no access; • Replacement of lost, damaged or stolen excluded resources; and • Payments received by an individual (or spouse) from a fund established by a state to aid victims of crime and certain relocation assistance received from a state or local government. • Earned income tax credits excluded in month of receipt and following month. • One automobile, regardless of value, if there is a second automobile then $4,500 of its market value is excluded. Property Essential to Self-Support (PESS) This SSI provision allows individuals to exclude certain resources which are essential to their means of self-support. Properties that are used in trades or businesses by individuals for work as employees are totally excluded as of May 1, 1990. For example, the values of tools or equipment which individuals need for work are totally excluded. For periods prior to May 1, 1990, the total exclusion only applied to properties that were required by employers. Up to $6,000 of the equity value of non-business properties that are used to produce goods or services essential to daily activities are excluded (e.g., land used to produce vegetables or livestock solely for consumption by the individual's own household). Also, up to $6,000 of the equity value of non-business income-producing properties are excluded, provided that the property yields an annual rate of return of at least six percent. This $6,000/ six percent rule also applies to property used in trades or businesses for periods to May 1, 1990. SSI Redetermination Review RE-DETERMINATIONS are non-medical reviews, which occur annually. During the re-determination reviews, the SSA updates the individual's income, resources, and living arrangement. If individuals are married to someone not on SSI, or are receiving SSI as a child living with their parents, the SSA also reviews the income, resources, and living arrangements of the spouses or parents. It is during this review that changes in these non-medical areas are discussed, if individuals have failed to report them during the year. With this updated information, wages will be projected for the next 12 months and SSI cash benefit amounts will be adjusted accordingly. Re-determinations may be conducted in person, by telephone interview or by mail, and will include cross-referencing the Supplemental Security Record (SSR) with the records of other federal agencies and the State for income and resource information. Benefits for the Homeless Individuals living in a public shelter for the homeless may be eligible for up to six months of SSI benefits in any nine-month period. This is an exception to the standard rules to enable homeless people to plan for more permanent living arrangements. The Social Security Office (SSO) will make special arrangements to have the SSI check for homeless people sent to a third party. An organization may serve as a mail drop, permitting homeless people to pick up benefit checks at their convenience. Eligibility Case Study Mary is 25 years old, has had a label of serious mental illness for two years, one year of which she spent in a psychiatric hospital. She lives in her own home, which she inherited from her deceased parents. She has two renters and all three of the individuals receive residential supports and case management services from a mental health agency. Mary is working, earning $7 an hour, 20 hours per week. She has worked for four months, is receiving follow-along in Supported Employment. She drives her own, older car to work and takes Closaril each day to control her mental illness. What factors should you consider in predicting what she is eligible for? Title II: SSI: CHAPTER 4: APPLICATION PROCESS SSA Contact Information To apply for disability benefits, call the SSA toll-free number: 1-800-772-1213. When connected, you will hear an automated operator who will tell you how long you will hold for assistance. SSA's toll-free TTY number is 1-800-325-0778. You may also contact the local SSA office listed in your telephone directory. Basic information such as name, address, and telephone number will be taken when you call. A listing of work incentive liaisons in your catchment area can be requested from your local SSA office. However, some states may not maintain up-to-date records of these personnel. Application Process and Information Needed Remember the SSA's definition of disability when making an initial application. It contains two major eligibility requirements for both the SSI and Social Security programs. Individuals must have a medically determined disability and must be unable to earn above the SGA level As advocates for yourselves or others, the extent of the disability must be documented. Initially, a medical diagnosis should be provided. Also include reports from human service workers, friends, family or any support or services required by the individuals to maintain themselves in their residential and employment setting. The SSA has several application forms that are intended to help document the extent of an individuals' disabilities. The Social Security Disability Report was designed primarily for those with physical disabilities, while the Mental Impairments Report was created to assist people whose disabilities are primarily mental. Most of the benefit application forms are not designed for self-completion. Claims representatives interview individuals and complete the forms. Additional documentation required in the application process must establish how the disabling impairments prevent individuals from working and earning above SGA for any job in the nation's economy. If individuals with disabilities have been trained as nursery workers and there are no greenhouses available in the area, the lack of available work has no bearing on eligibility for benefits. Furthermore, individuals must not be able to engage in part-time paid work that would earn above SGA, if performed on a full-time basis. They must be unable to perform any work earning above SGA. Documentation of this inability to work must be specific. For instance, you should document whether individuals forget instructions quickly, don't understand directions, become easily frustrated, or react inappropriately to coworkers. Documentation of work difficulties from vocational rehabilitation counselors, job coaches, and other job training personnel is especially useful. Types of Information Needed It is helpful for individuals to have the following documents on hand when applying for Social Security benefits. • A summary of their work history, if applicable; • The latest tax bills (if a home or other property is owned); copies of the lease or rental agreements; copies of, or proof of, utility and food expenses; • Payroll stubs, insurance policies, bank books, care registration information, and other documents showing resources or assets; • Special records or the names of medical personnel and/or facilities where treatment or services have been provided; • Information about parent's or spouse's incomes if appropriate and applicable; • Names, addresses and telephone numbers of all treating physicians and the dates of treatments; • Names, addresses, telephone numbers and records of clinics and hospitals and the dates of treatments. Also, the patient or clinic numbers given; • Names, addresses and records of the schools attended. The names of the most recent teachers and/or counselors; • Consultative examinations authorized by the DDO. If individuals have filed for benefits previously and have attended examinations, let us know; • Non-physician healthcare professionals: dates of physical and occupational therapy with names and addresses of treatment centers; • Vocational rehabilitation records and the names of vocational rehabilitation counselors. Dates of testing, evaluations and training programs; • Statements by the claimants, relatives, and friends, including the names, addresses and telephone numbers of those who knows about the conditions of the individuals and can give additional information; • Social Security Numbers (SS#) of individuals as well as spouses and dependents; • Copies of legal documents such as marriage certificates, divorce papers, birth certificates and adoption papers; • Names of banks and credit unions with checking and savings accounts information (SSI only); and • Other information on benefits received such as, Veterans Assistance, Military Pensions, Unemployment Compensation, TANF, WIC, Medicaid, Energy Assistance, Workers Compensation, Food Stamps, etc. Please note that the SSA must see the original documents. Photocopies are not acceptable. Keep copies of anything that is sent to the SSA. Also keep track of the dates information is sent, conversations with the SSA personnel and the names of the SSA workers spoken to. Other Eligibility Information Individuals should apply for SSI benefits as soon as possible, even if all the information is unavailable. If individuals contact the SSA and indicate that they want to apply for SSI, the date of their inquiry will count as their application date if filed within 60 days of the call. If eligible for SSI, benefits will be paid as of the first of the month following the month of application. If individuals are institutionalized, they can apply before they leave so that SSI benefits can begin quickly. For individuals in this situation, applications should be filed under the "Pre-Release Program." Applications for Social Security should also be made as soon as possible. Individuals must complete a five-month waiting period from the month of disability onset before Social Security payments begin. Unlike the SSI program, the Social Security program allows for up to 12 months of retroactive payments once eligibility for benefits is determined. Retroactive payments are not made for the five-month waiting period after disability onset, but can begin the month following the completion of this five-month waiting period. It takes about three to four months to process claims, depending upon the time needed to verify the disabling condition with the required medical reports. If individuals are already receiving Social Security benefits, SSA can authorize immediate SSI payments without a new medical review. Once decisions are made, written notification is sent from the SSA. If the claims have been approved, the notices will show the amount of the payment and when payment will start. If the claims are denied, the notice will explain why. Individuals have the right to appeal these decisions. Applicants for SSI must apply for all other benefits they may be eligible for, such as pensions, Social Security, and so on. The cash income from other benefit programs is counted as unearned income in computing the dollar amounts of SSI benefits. Applicants for Social Security and SSI who have disabilities (including blindness) must be referred to appropriate rehabilitation agencies for service (under certain selection criteria). Accepting these services does not prevent benefits, but refusing services without good reason could. Emergency Advance Payments and Immediate Payments Emergency advance payments (EAPs) and Immediate Payments (IPs) are two ways to make payments to persons via Third Party Draft who are due SSI benefits and have a financial emergency. EAPs are made under statutory authority for SSI initial eligibility only. EAPs and IPs address the situation where certification to Treasury for regular payments, automated one-time payments (A-OTPs), or manual one-time payments (M-OTPs), cannot be made or would not be fast enough. See SM 01901.000 for discussion of A-OTPs and M-OTPs. The EAP and IP are advances against future SSI payments. These payments must be recovered; they are not additional money due the SSI recipient. EAP Verses IP Authority EAP-Section 1631(a) of the Social Security Act IP-Decision by the Commissioner Title XVI or Title II EAP-SSI IP-SSI and/or Title II When EAP-Initial Claims only IP-Initial Claims or post-eligibility Money Limit EAP-Federal benefit rate + State Supplementary Payment level IP-$999 total Title II and SSI Frequency EAP-One time per claim IP-One time in a 30-day period Recovery EAP-6 monthly installments; or ALL at once from a retroactive payment IP- From first regular payment Priority EAP-EAP before IP IP-EAP before IP Emergency Advance Payments The EAP is a one-time advance to only SSI claimants against their first month's payments made only if a financial emergency exists. A person must be due SSI benefits to receive an EAP. A person can receive an EAP if he/she will receive SSI benefits based on a finding of presumptive disability/blindness. Issuance of an SSI EAP does not preclude issuance of an IP (immediate payment). EAPs are available only to an initial claimant who has a financial emergency. The following conditions apply: 1. The SSI person is due SSI benefits. 2. The EAP will be made in an amount that is no more than the applicable FBR plus any federally administered state supplement. 3. If the person is due retroactive SSI benefits, the amount of the EAP will be recovered in full from the retroactive benefits. If the person is not due retroactive SSI benefits, the amount of the EAP will be recovered in up to six monthly installments. Immediate Payments IPs were set up to help individuals who do not qualify for EAPs. IPs can be made to either Title II or Title XVI (SSI) or concurrent cases. The IPs are payments made directly at the Field Office and not through the regular SSA payment centers. Only one IP may be made every 30 days regardless of the amount paid or concurrent Title II/SSI status. An IP can be made if: Payments are delayed or stopped; or An individual reports non-receipt of a payment. Immediate Payments in Concurrent Cases The IP payment is made from the program that can pay the full IP amount. IF... Both Title II and SSI can pay the full IP amount Then... Pay the IP from Title II funds IF... Title II equals or exceeds IP amount Then... Pay a Title II IP (see RS 02801.001) IF... Title II is less but SSI equals or exceeds IP amount THEN... Pay an SSI IP IF... Both Title II and SSI less than IP THEN... Pay the Title II IP first, and then the SSI IP up the IP maximum, or the amount of total unpaid benefits, whichever is smaller. The maximum IP amount for SSI, Title II or a combination SSI/Title II payment is $999.00 to an individual or each member of a couple, effective 8/23/99. Payment will be the smaller of the two following amounts: • $999.00 for an individual or each member of an eligible couple, or • The total unpaid benefits due at the time the FO makes the IP. NOTE: The recipient may request only the amount needed for the emergency that may be less than the total of unpaid benefits due or $999.00. Presumptive Eligibility Applicants for SSI benefits may request presumptive eligibility consideration. SSI benefits may be paid for a period of up to six months on the basis of presumptive disability or blindness, pending the final determination. The SSA can make presumptive disability or blindness decisions if individuals have one or more of the following conditions: • Amputation of two limbs; • Amputation of a leg at the hip; • Allegation of total deafness; • Allegation of total blindness; • Allegation of total bed confinement or immobility without wheelchairs, walkers, or crutches, allegedly due to a long-standing condition - excluding recent accidents and recent surgeries; • Allegation of cerebral palsy, muscular disability, or muscular atrophy and marked difficulty in walking (e.g. use of braces), speaking or coordination of the hands or arms; • Allegation of diabetes with amputation of a foot; • Allegation of Down's Syndrome; • Applicants filing on behalf of other individuals alleging severe mental deficiency for claimants who are at least seven years of age. Applicants alleging that individuals attend (or attended) special schools, or special classes in schools (or if beyond school age were unable to attend), and require care and supervision for routine activities; • Allegation of HIV infection; and/or • Allegation of a stroke (cerebral vascular accident) more than three months prior with continued marked difficulty in using arms or legs. If the SSA is unable to make presumptive disability decisions, the DDS can sometimes make one for other severe medical conditions, if it has medical proof that would most likely make its final decision an approval. If presumptive disability payments are granted and individuals are ultimately ineligible for SSI, they will not be asked to repay the money. Representative Payee It is the policy of the SSA that every legally competent beneficiary or recipient has the right to manage his or her own cash benefits. However, when there is evidence that individual's are not able to manage or direct the management of benefit payments in their best interests, representative payment may be made. An individual under age 18 is generally considered incapable of managing benefit payments, and a representative payee will be selected to receive payments on the individual's behalf. However, payments may be made directly to an individual age 15 or over if this will serve the individuals best interests, if they do not have a legal guardian, and if they are: • receiving SSDI based on their own earnings record; or • serving in the military services; or • self-supporting and living alone; or • a parent filing for themselves with experience in handling personal finances; or • capable of using the benefits to provide for their own current needs and no qualified payee is available; or • within seven months of attaining age 18 and filing an application for benefits for the first time. Payment is made directly to an individual over 18 unless the individual: • is adjudged legally incompetent; or • is mentally incapable of managing the benefit payments; or • is physically incapable of managing or directing the management of the benefit payment. The following are the factors where payees are considered most likely to promote the individual's best interest: • relationship of the person to the individual; • person's concern for the individual's well being; • ability of the person to act in the individual's best interest; • whether the potential payee has custody of the individual; and • whether the potential payee is in a position to know of and look after the needs of the individual. The Representative Payee is responsible for: • determining the individual's total needs and to use the benefits received in trust conforming to SSA regulations and policies, in the best interests of the individual; • applying the benefit payments only for the individual's use and benefit; • maintaining a continuing awareness of the individual's needs and condition, if the individual does not live with the representative payee, by contact such as visiting the individual and consultations with custodian; and • notifying SSA of any change in the individual's circumstances that would affect performance of the payee responsibilities; and • reporting to SSA any event that will affect the amount of benefits the individual receives or the right of the individual to Title II or SSI benefits; and • giving SSA written reports accounting for the use of the benefits, when requested to do so. SSI/Social Security Comparison SSI-Below Age 18 No waiting period SSI-Above Age 18 No waiting period Social Security-Above Age 18 Usually a five-month waiting period after onset of impairment required SSI-Below Age 18 Presumptive disability (up to six months) SSI-Above Age 18 Presumptive disability (up to six months) Social Security-Above Age 18 No presumptive payments SSI-Below Age 18 No retroactivity beyond the original date of application SSI-Above Age 18 No retroactivity beyond the original date of application Social Security-Above Age 18 Up to 12 months of retroactivity if applicable SSI-Below Age 18 Economic need-based SSI-Above Age 18 Economic need-based Social Security-Above Age 18 Must meet insured status SSI-Below Age 18 No duration of blindness requirement SSI-Above Age 18 No duration of blindness requirement Social Security-Above Age 18 12-month duration of blindness requirement SSI-Below Age 18 Must not be earning SGA at initial application. No SGA test after eligibility established. SSI-Above Age 18 SGA test to establish initial eligibility for non-blind; No substantial gainful activity SGA test after eligibility established. Social Security-Above Age 18 SGA determination required to establish and maintain disability status for individuals who are blind or non-blind. CHAPTER 5: APPEALS PROCESS Individuals have the right to appeal any "initial determination" made by the SSA. Individuals may also appeal denial of benefits, reduction of benefits, termination of benefits, and/or overpayments. There are four levels of the appeals process with certain time restrictions for each. Individuals generally have 60 days from the time they receive a notice from the SSA to file appeals. The SSA assumes that individuals receive the notice five days after the date shown, unless individuals can show that they received it later. Whenever the SSA sends a notice, they will indicate which step of the appeals process individuals may take. The four steps of the process must generally be taken in order. The levels of appeal are described below. Level I: Reconsiderations Reconsiderations are a complete review of the claims by someone who did not participate in the original decision. All the evidence originally submitted will be reviewed. Any additional evidence submitted will also be considered. Reconsideration can be requested by completing form-S61. If individuals are appealing a decision of medical improvement, they will have the opportunity to meet with a disability hearing officer and explain in person why they believe they are still disabled. They may also ask for benefits to continue while the decision is being made. If requests for reconsideration are made within 10 days, any payments currently being made will continue until a decision is made. If recipients lose the appeal, benefits may have to be paid back. Note: In some states the reconsideration step has been eliminated for individuals appealing a medical decision. In those states, the individual immediately can go to the next level of appeal, the hearing before an administered law judge. Level II: Administrative Law Judge Hearing If individuals disagree with the reconsideration decision, they may ask for a hearing by an administrative law judge. The administrative law judge has had no part in either the original or reconsidered decision. A hearing is requested by completing a form HA-501. Individuals may review their entire file prior to the hearing. The clerk of the ALJ records the hearings and copies of the tape may be requested. In a disability case, individuals may request further medical exams/tests be ordered if more medical information is necessary. The individuals and their representative(s), if any, will have the opportunity to attend the hearings and explain their case in person. They may question witnesses, give new information, submit a written statement about their case, and look at the information the ALJ will use to make the decision. Individuals will receive written notice of the hearing decision. Level III: Appeals Council Review If individuals disagree with the hearing decision, they may request a review by the Appeals Council. A request for an Appeals Council Review can be made by completing form HA-520. The Appeals Council considers all requests for review, but it may deny requests if it believes the decision by the Administrative Law Judge was correct. If the Appeals Council decides to review the case, it will either decide the case or return it to an Administrative Law Judge for further review. Generally, the Appeals Council Review is a paper process. Individuals are sent written notice of the Appeals Council decision. Level IV: Federal Court Review If individuals disagree with the Appeals Council decision or if the Appeals Council decides not to review their case, a lawsuit may be filed in a Federal District Court. The complaints must be filed in a U.S. District Court within 60 days of the date that the notice of the Appeals Council decision is received. The Federal Court will review the evidence and previously made decisions and will not conduct a new trial. Advocates may provide major assistance with best results during the time between initial determination notices and the requests for reconsideration. At this time, documentation must be gathered to support the claims to disability. Individuals should be assisted when contacting local advocacy groups with expertise in Social Security appeals. In addition to local advocacy groups and legal aid, some congressional offices have disability benefits specialists who are experienced in appeals. Remember, beneficiaries and recipients enrolled in SSA's Ticket or VR Reimbursement Program has access to advocacy and support services through state protection and advocacy programs. BPA&O and PABSS Role During Appeals It is critical for BPA&O and PABSS programs to understand and recognize their roles during the appeals process. While both are excluded from representing a beneficiary negotiating the appeals process, they can play a supportive role that could include, but not be limited to: • providing general information on the appeals process • information and referral to individuals/agencies that have the skill and ability to help with appeal • providing copies of forms need to appeal • providing support in making choices and understanding the appeals process Waivers When an individual receives a written notice from SSA, which states that he or she has been overpaid, the individual can file an appeal and/or seek a waiver of overpayment recovery. Many overpayment determinations relate to work activity and wages. The Request for Reconsideration is used to challenge the overpayment determination and must be filed within 60 days from the date of receiving the determination. By filing it, the individual is claiming either that he or she was not overpaid or that the overpayment amount claimed by SSA is too high. If the individual disagrees with the reconsideration determination, the individual may ask for a hearing before an Administrative Law Judge. Like all other appeals, appeals involving overpayments can eventually go to the Appeals Council and to the Federal District Court. Even if an individual agrees with an overpayment determination (or if he or she only disputes the amount of the overpayment), the individual may seek a Waiver of Overpayment Recovery. The request for waiver asks SSA to waive its right to collect any overpaid amount. Generally, SSA will waive recovery if the individual can show that he or she was "without fault" in causing the overpayment and that recovery would either cause an "undue hardship" or be "against equity and good conscience." A denial of a request for waiver is treated like any other initial determination. SSA must provide the individual with a written notice of the determination. The individual will have 60 days from the date of receiving the determination to challenge it through a request for reconsideration. Like all other appeals, appeals involving a request for waiver can be appealed to an administrative law judge, to the Appeals Council, and to the federal District Court. Supporting Forms and Documentation Form/No# SSA-1696-U4 Appointment of Representative This authorizes a person, in the place of any applicant or recipient, to communicate with SSA, represent a person before SSA on any appeal, receive notices generated by SSA, and otherwise obtain information about the applicant or recipient that is contained in SSA's website files. Can be obtained from any SSA field office or by visiting SSA's website. Form/No# SSA-561-U2 Request for Reconsideration An applicant or recipient or his/her authorized representative should use this to appeal any initial decision issued by SSA. Can be obtained from any SSA field office or by visiting SSA's website. Form/No# SSA-HA-501-U5 Request for Hearing by Administrative Law Judge An applicant or recipient or his/her authorized representative should use this to request a hearing before an administrative law judge. Generally, this would be used following an adverse decision on a request for reconsideration. Can be obtained from any SSA field office or by visiting SSA's website. Form/No# SSA-HA-520 Request for Appeals Council Review An applicant or recipient or his/her authorized representative should use this to request an appeals council review. Can be obtained from any SSA field office or by visiting SSA's website. Form/No# SSA-632-BK Request for Waiver of Overpayment Recovery or Change in Repayment Rate A recipient, or his/her authorized representative should use this to challenge SSA's rights to collect an over-payment of benefits. Generally, this would be used when the individual concedes that he or she was overpaid but is asking SSA to waive their right to collect over-payment. Can be obtained from any SSA field office or by visiting SSA's website. SECTION TWO: IMPACT OF EMPLOYMENT ON SOCIAL SECURITY TITLE II BENEFITS Objectives 1. Understand the impact of earnings on Title II benefits. 2. Understand and apply pre- and post-TWWIIA extended Medicare coverage. 3. Identify and apply subsidy and special conditions when determining SGA. 4. Identify and apply impairment-related work expenses when determining SGA. CHAPTER 6: SOCIAL SECURITY TITLE II BENEFITS Introduction The benefit program authorized under Title II of the Social Security Act enables individuals who have become disabled and are unable to work to receive monthly cash benefits and Medicare insurance. As explained in the first section, to qualify for Social Security benefits, individuals must be determined medically disabled, and must not be working or, if working, earning less than the SGA level. They must also have insured status (i.e., sufficient past work in Social Security covered employment), or are individuals who are 18 or older, who have become totally and permanently disabled before age 22, and who are dependents of insured workers who are disabled, retired or deceased, or be the disabled widow or widower (50 years of age or older) of a deceased spouse. The Social Security program is not based on economic need; therefore there are no restrictions on unearned income limitations to be entitled to it as there are for SSI. The dollar amount of income support received by Social Security beneficiaries on a monthly basis is dependent on the level of contributions made to the program, which varies significantly from person to person. There are no provisions for gradual reductions in Social Security cash benefits as earnings increase, as is the case with the SSI program. Social Security beneficiaries will either receive the full amount of their Social Security benefit per month or receive no income support at all. Please refer to Flowchart #1 on page 67 for a visual guide to Social Security. Trial Work Period (TWP) Unless medical recovery is an issue, individuals receiving Social Security based on disability are entitled to a nine-month TWP, which provides opportunities to test work skills while maintaining full benefit checks regardless of any income earned. The TWP is a work incentive and begins the first month that individuals are entitled to Title II benefits or file applications for disability benefits (whichever is later). Effective January 2005, only months during which an individual earns over $590 or works over 80 hours in self-employment are service months and count as TWP months. In 2004 $580, in 2003 $570, in 2002 $560, and in 2001, $530 per month counted as a TWP month. Prior to January 2001, months in which individual earned over $200 a month or worked more than 40 hours in self-employment counted as a TWP month. The TWP ends only if individuals have performed nine months (not necessarily consecutive) of trial work within a rolling period of 60 consecutive months. TWP months must be carefully tracked; as the 36-month extended period of eligibility (EPE) begins immediately after the nine-month TWP. For Title II beneficiaries, SSA counts the gross monthly income earned in the calendar month, rather than what was received, based on pay dates. Individuals are entitled to a TWP for each period of disability. Subsidy and IRWEs are not considered during the TWP. With the most recent rule changes annual increases to the amount of earnings that can count as a TWP, are linked to the national average wage index. Substantial Gainful Activity (SGA) Determination When individuals have accumulated nine months of trial work, a continuing disability review (work CDR) is conducted by SSA. The purpose of the review is to determine whether or not the work is SGA. Unlike the SSI program, work activity remains a major factor in considering whether disability under the law continues. A decision of SGA implies that individuals are performing significant mental or physical duties for profit, and are, therefore, demonstrating the ability to work in spite of their disabling impairment. This determination is made by the claims representatives and is based on the average monthly income. If individuals are determined to be engaging in SGA, they "cease" eligibility for cash benefits, they will receive full benefit checks for an additional three months (the first month of SGA after the end of TWP (cessation month) and the two following months), and then the cash benefits will stop. This 3-month period is called the "grace period" and may occur at any time after the end of the TWP. If individuals are determined not to be engaging in SGA, they will continue to receive full benefit checks. Income Averaging When conducting the SGA determination, or work CDR, the Claims Representative may average income when monthly earnings are typically under the SGA level but there are one or two months in which the reported earnings are above the SGA limit. For example, some months have twenty working days, while others have twenty-two. If the earnings are just below the SGA level, two extra days of work may result in earnings being over the level. If the average earnings are below SGA, the disability status will not be “ceased” and benefits will continue. In order to average, earnings levels must be fairly consistent over the period of work that is used. Large fluctuations in earnings may not be averaged together. Income can only be averaged for periods in which the SGA level is the same, which means that after the year 2000, earnings may not be averaged over more than one calendar year. Unsuccessful Work Attempt When work at the SGA level cannot be sustained by the individual for more than six months, a provision called “Unsuccessful Work Attempt,” or UWA, may apply in both initial determinations and for continuing disability. Termination or reduction of work must be due to the individual’s impairment or the removal of special conditions that are necessary because of the disability. Some examples of special conditions include: special assistance from other employees in performing the job, irregular work hours or frequent breaks, special equipment or work assignments that are suited to the impairment, tolerance of a lower standard of productivity, work opportunity is given because of family relationship, past association with an employer, or altruistic reasons. If SGA level work lasts three months or less and the reason it ended is related to the disability, UWA is allowed without verification or evidence of the reason. If substantial gainful activity lasts between three and six months, the Claims Representative is required to gather supporting documentation that there are other factors involved such as frequent absences from work, removal of special conditions (e.g. a job coach or extra support), unsatisfactory work performance, or temporary remission of the impairment. There may be more than one UWA as long as certain criteria are met. The beneficiary must be out of work or have earnings reduced to below the SGA level for at least thirty days, or be forced to change to a different type of work or another employer. There is no limit to the number of times UWA can be applied in one individual’s case, as long as the requirements are met. SSA will not count earnings during an unsuccessful work attempt when they make an SGA decision. This is true for the initial eligibility determination for SSI, and initial and ongoing eligibility for SSDI or Title II. The Claims Representative may reopen a previous cessation decision if they later receive documentation or evidence that UWA applies. SGA Determination Process In making SGA determinations, the SSA claims representative will contact Title II beneficiaries. In some cases, the review will be handled by mail or telephone, but in most cases it will be conducted in the local SSA office. The claims representative needs information from the individual's employer and/or may refer the case for a medical determination to determine whether the individual continues to have a disabling condition. The claims representative will request information from the individual and their employer regarding extra support and supervision supplied, and special accommodations and arrangements made, to enable individuals to obtain and maintain employment. This form is called the Work Activity Report and is available online or available at the local social security office. Communication should occur, with all parties submitting information to ensure accurate presentation of employment situations. Claims representatives handle scheduling of most work CDRs. Files for Social Security beneficiaries under SS are maintained at the Office of Disability Operations (ODO) in Baltimore, Maryland. NOTE: Some work CDRs are handled in ODO or PSCs. When a nine-month TWP concludes, ODO will forward files to the local SSA office. The case representatives must have the files in order to conduct the review. If the nine months of accumulated TWP have not been consistently reported, there will probably be a delay in conducting the CDRs, as SSA will be unaware that the TWP is ending. Implications of such a delay are as follows: * For individuals receiving only Social Security who are performing SGA, a delayed CDR may mean that their cash benefits are not terminated promptly, resulting in an overpayment. NOTE: SSA operates on a "no-fault" basis; even though an overpayment may be caused by them, the over-payment is still due to be repaid. NOTE: SSA notified beneficiaries of overpayments, but beneficiaries have a right to request waiver of overpayments due to no fault and inability to repay. Overpayment also occurs as a result of unreported earnings in some cases. * For individuals receiving Social Security and SSI who are performing SGA, a delayed CDR may mean that their Social Security is not terminated promptly, resulting in overpayment. Also, a delay in adjusting the dollar amount of SSI upward will occur due to the decrease in unearned income in the form of the ceased Social Security benefit. TWWIIA CDR Protections Effective January 1, 2001, the SSA will not be able to initiate a Continuing Disability Medical Review while an SSI recipient or Title II beneficiary is using a "Ticket" under the Ticket to Work and Self-Sufficiency program. This protection is discussed in greater detail in Chapter 21. Extending CDR protections further, effective January 1, 2002, work activity by a Title II beneficiary who has received benefits for at least 24 months cannot be used as a basis for conducting a medical CDR. However, as in the prior protection, earning at or above the SGA level may make the individual's benefits subject to termination. However, work CDRs will still be conducted. Also, any previously scheduled medical CDRs will still be conducted unless the beneficiary is exempt due to participation in the ticket program. Extended Period of Eligibility (EPE) At the conclusion of the nine-month TWP, as long as individuals continue to have their original disabling condition, a 36-month EPE will begin in the month following the ninth TWP month. During these 36 consecutive months, individuals will receive benefit checks when their earnings are below SGA (see Flowchart 2 on page 68). During the EPE, individuals are due payment (disability benefits) for any month they do not work, or when work and earnings fall below the SGA level. During this period, it is not necessary to file a new application for benefits to resume. Social Security cash benefits are paid during the EPE only for the months in which countable earnings are below the SGA level. For individuals who are self-employed, individual determinations of what quantifies SGA during EPE will be established. The claims representatives or ESR will make this individualized determination by considering: how many hours of work were performed; who performed the services; net and gross earnings; subsidies; and other particulars. Consistency and accuracy in reporting to SSA monthly fluctuations in earnings between SGA and non-SGA levels is critical in avoiding overpayment or underpayment of Social Security benefits. When the 36-month EPE ends, if the beneficiary is engaged in SGA, benefits are terminated and the case file is closed. This could occur immediately following the EPE or at any point thereafter, depending on when SGA occurs. Expedited Reinstatement of Benefits (excerpted from The Benefits Planner, Cornell University, Fall 2001) Under pre-2001 law, a person who performed SGA after the EPE would lose SSDI benefits. If the person later lost his or her job or had wages reduced below the SGA level, he or she would have to reapply to re-establish Title II eligibility. This prospect of a new application, with the uncertainty of whether a new decision maker would find the individual disabled (especially in light of recent work activity), made many individuals pause at the notion of taking a chance at work that might not be successful in the long term. The new expedited reinstatement (EXR) program should make more beneficiaries willing to try working, despite a severe disability, knowing they may re-establish eligibility if their work is not sustained because of their impairment(s). NOTE: Under EXR criteria, individuals must have become unable to continue performing SGA because of their impairment(s) and must be under a disability based on the application of the medical improvement review standard (MIRS). The EXR Criteria Effective January 2001, a person who performs SGA after the EPE and had his or her benefits terminated and later has wages reduced below SGA levels because of his or her impairment(s) or health condition will be reinstated to Title II, without a new application, if the individual: * was eligible for Title II benefits; * lost benefits due to performance of SGA; * requests reinstatement within 60 months of the last month of entitlement (the earliest that someone could have had benefits terminated and be eligible for reinstatement is February 1996), or, if the request is filed after 60 months, the individual establishes good cause for missing the 60-month deadline; * has a disability that is the same as (or related to) the physical or mental disability that was the basis for their original claim; and * that disability renders the individual incapable of SGA based on application of the medical improvement standard. If an individual believes he or she meets the EXR criteria, the individual should contact SSA and say that he or she wants to request reinstatement. This includes individuals who, in the last five years (since February 1996), stopped receiving benefits due to SGA and who, since their last month of Title II entitlement, also stopped performing SGA because of their impairment(s) or health condition... SSA has issued "Field Instructions," outlining the criteria and procedures to be followed by local offices. The instructions also include an EXR request form. If the beneficiary satisfies the EXR criteria, both his or her benefits and the benefits of dependents can be reinstated. Title II dependent's benefits, including benefits for dependent children and spouses, can be reinstated if the dependent satisfies all the eligibility criteria as a dependent (this includes having a new medical determination if the dependent's entitlement is based on being disabled.) A previously entitled dependent does not have to file a new application to qualify for reinstated benefits. New dependents will have to file an application to qualify for reinstated benefits. Provisional Benefits Pending Reinstatement Decision While the EXR request is pending, the individual is eligible for up to six consecutive months of provisional benefits. Provisional benefits are payable when EXR is requested. The individual may also be eligible for Medicare coverage while receiving provisional benefits, if not already covered for such benefits. Provisional benefits may be suspended under current rules (e.g., prisoner suspension), and performing SGA will terminate provisional benefits. Early reports are that SSA is processing these requests quickly and individuals have received provisional benefits within weeks of the EXR request. What happens if SSA later determines that the individual was not entitled to reinstatement? Must they repay the provisional benefits received? SSA's Field Instructions state that any resulting overpayment cannot be recovered unless SSA determines that the individual knew or should have known that he or she did not meet the EXR criteria. In the instance that the reinstatement decision has not been made before the 6-month provisional benefit period ends, the beneficiary can request EAPs. A New Trial Work Period and Extended Period of Eligibility For years, Title II beneficiaries were told they would get one TWP and one EPE. The TWP and EPE could be exhausted for good at very low levels of earnings. In fact, the EPE could be exhausted whether the person was working or not. This has changed under the new EXR program. After being paid 24 months (need not be consecutive) of reinstated benefits (including any months for which provisional and retroactive payments were actually received), the beneficiary gets: a new TWP; a new EPE; and another 60-month period in which to request EXR if benefits are terminated again due to SGA. As demonstrated in John's case, the chance for a new TWP and EPE, fortunately, allows the person to work through the peaks and valleys of their continuing disability. Application of the New TWP and EPE John's case: John was awarded SSDI benefits in 1990 based on a back injury. His monthly SSDI check was $600 in 1990 and higher in 2001 based on cost of living adjustments. In 1993, John goes to work part-time doing lighter work. He earns $400 per month between January and June 1993 when he re-injures his back and stops working. He does not work again until 1998. He starts work in October 1998 and works the remainder of 1998 through December 1999 earning $650 per month. In 2000, he gets a raise and earns $720 per month throughout all of 2000 and for the first four months of 2001. In late April 2001, John is laid off and earns no money between May and October 2001. In November 2001, he goes back to work and earns $1,000 per month between November 2001 and December 2002. On New Year's Day of 2003, John aggravates his injured back taking down holiday decorations. He must stop working and remains out of work for the entire year, January to December 2003. In January 2004, John returns to work on a lighter schedule. He has gross monthly earnings of $500 between January and December 2004. In January 2005, he increases his hours of work and has gross monthly earnings of $1,000 between January and December 2005. John worked his first TWP month in January 1993. This is the first month he worked as an SSDI beneficiary and earned more than the TWP services month amount ($200 in 1993). Between January and June 1993, he used up six TWP months. When John went to work in October 1998, he had no TWP months within the last 60 months (i.e., between November 1993 and October 1998). This means his TWP started over. Since he then earns at least $200 in gross wages for nine consecutive months, October 1998 to June 1999, John completes his TWP in June 1999. NOTE: Under pre-2001 rules, this would be John's only TWP. He would only get a second TWP if he lost SSDI, reapplied, and was awarded benefits on the new claim and had a new five-month waiting period. Effective 2001, the new expedited reinstatement provisions, discussed later in the article, allow John to qualify for a new TWP after he has received reinstated benefits for 24 months. John's EPE began in July 1999 (i.e., immediately following his ninth TWP month). His 36-month EPE will run from July 1999 though June 2002. John is clearly eligible for SSDI between July 1999 and December 1999. His gross wages of $650 per month were less than the SGA amount in effect at that time and his eligibility continued. (Remember: The monthly SGA level increased from $500 to $700 effective July 1999 and remained at that level through the end of 2000.) January 2000, when John gets a raise up to $720 per month, will be considered his "benefit cessation month." This is the first month of SGA during his EPE. (Again, the SGA amount of $700, effective July 1999, continued throughout 2000.) John is entitled to SSDI benefits for January, February and March 2000 the benefit cessation month and two more months. This is his three-month grace period. Starting in April 2000, John will get checks only when his countable wages are below the SGA amount. Since his gross earnings were $720 per month throughout the remainder of 2000 - more than the 2000 SGA amount of $700 - he will not receive an SSDI check during the April through December 2000 period. Starting in January 2001, John will start getting SSDI checks again. This is because the SGA amount was increased to $740 and John's monthly earnings remained at $720. He will get SSDI checks for January through April as his earnings remained below $740. He will also get checks for the months of May through October 2001 when he was out of work and earned nothing. Starting in November 2001, John earned $1,000, which is more than the SGA amount. This means he will not get checks for November or December 2001. Since his wages remained over SGA throughout 2002, John will continue to be ineligible for SSDI through the end of his EPE (i.e., through June 2002). Since John stopped working for health reasons, he became eligible for EXR in January 2003, because his wages were now below the SGA amount, it was within 60 months of his last month of entitlement to SSDI (i.e., within 60 months of October 2001), and the other EXR criteria are met (i.e., has the same or related impairment and is disabled based on the application of the MIRS criteria). We assume that John would have applied for EXR as early as January 2001, or as soon as it became apparent that he would not return to work right away. We expect that John would be eligible for up to six months of provisional benefits while his EXR request was being processed. (NOTE: One can argue that the 60-month time limit for EXR applications begins after the last month of the EPE rather than after the last month John received an SSDI check. This issue should be clarified when SSA issues EXR instructions in its Program Operations Manual System or POMS.) The facts indicate that John had no earnings during 2003 and his wages during 2004 were $500 per month, well below the SGA level. In addition, having been found to meet the EXR medical criteria, John is eligible for EXR benefits for all of 2003 and 2004, a 24-month period. A new TWP and EPE: When John returns to work in January 2005 he will be entitled to a new TWP. This is because John received reinstated benefits for at least 24 months. Since he made at least the TWP amount each month, his new TWP would run from January through September 2005. His new EPE would start in October 2005 and run for 36 months through September 2008. The same EPE rules would apply as did in the earlier years. Medicare Coverage Medicare provides medical insurance coverage to Social Security beneficiaries. Individuals with disabilities must complete a five-month waiting period from the month of disability onset before Social Security benefits begin. An additional 24-month waiting period (Medicare Qualifying Period) after disability cash benefits begin is required before individuals are entitled to receive Medicare coverage. It is not required that the 24 months be accumulated consecutively. Individuals may accumulate 12 months of the 24-month period before losing Social Security entitlement due to medical recovery. If individuals re-establish entitlement for Social Security at a later date, they will need to complete only the final 12 months of the 24-month waiting period before Medicare coverage begins. In addition, if Social Security beneficiaries complete the 24-month period prior to losing Social Security and become entitled again for Social Security within five years (or seven years for childhood disability beneficiaries), a new 24-month period is not required. If entitlement for Social Security disability benefits is re-established after five years, but is based on the same or directly related disabling impairment, a new 24-month Medicare waiting period is not required. Two Part Medicare Medicare has two parts: hospital insurance and medical insurance. Hospital Insurance (Part A) Hospital insurance, like the Social Security program, is financed through part of the FICA payroll tax and helps pay for inpatient hospital care and certain follow-up care. This part of the Medicare program is automatic for Social Security beneficiaries upon completion of the 24-month waiting period. Medical Insurance (Part B) Medical insurance helps pay for doctor's services and a variety of other medical services and supplies that are not covered by hospital insurance. Unlike hospital insurance, medical insurance is voluntary and is financed in part by the monthly premiums of individuals who enroll. Enrollment occurs automatically for those receiving Social Security at the time when hospital insurance entitlement begins. Those choosing to buy medical insurance coverage will have their monthly premiums deducted from their monthly Social Security cash benefits. If beneficiaries' Social Security cash benefits are suspended for some reason (i.e. SGA month in the 36-month EPE period), they are billed on a quarterly basis for the Part B premium Medicare Premiums Excerpted from: www.medicare.gov/Basics/Amounts2004.osp Individuals who are disabled and working who have lost eligibility for premium free HI due to SGA may enroll in Medicare Part A (hospital insurance) by paying a monthly premium. Individuals who elect to purchase the hospital insurance (Part A), may enroll in Medicare Part B (medical insurance). The 2005 monthly premium for Medicare Part B is $78.20 per month. NOTE: The amount received each month is the net amount; the gross Social Security benefit is this amount plus the Part B premium.) Part A - Hospital Insurance Monthly Premium $0 if individual or spouse has 40 or more quarters of Medicare covered employment. Part B - Medical Insurance Monthly Premium $78.20 Part A - Hospital Insurance Monthly Premium $375 paid only by individuals who are not otherwise eligible for premium free hospital insurance and have less than 30 quarters of Medicare covered employment. Part B - Medical Insurance Monthly Premium $78.20 Part A - Hospital Insurance Monthly Premium $206 for those having 30-39 quarters of Medicare covered employment. Part B Medical Insurance Monthly Premium $78.20 Original Medicare Plan Deductible and Coinsurance Amounts Part A - Hospital Insurance Deductible - $912 per benefit period Part B - Medical Insurance Deductible - $110 per year Original Medicare Plan Deductible and Coinsurance Amounts Part A - Hospital Insurance Coinsurance - $228 per day for the 61st-90th day each benefit period. $456 per day for 91st-150th day for each lifetime reserve day. Part B - Medical Insurance Deductible - $110 per year Original Medicare Plan Deductible and Coinsurance Amounts Part A - Hospital Insurance Skilled nursing (coinsurance) $114 per day for the 21st-100th day each benefit period. Part B - Medical Insurance Deductible - $110 per year (You pay 20% of the Medicare approved amount for services after you meet the $110 deductible) Extended Medicare Coverage Pre-TWWIIA Social Security beneficiaries who lose benefit entitlement due to performance of SGA, but continue to be disabled, are eligible for extended Medicare coverage. The extended coverage is for a minimum of 39 months following the conclusion of the nine-month TWP. The 39-month period is derived from adding the original 15-month EPE reinstatement period (pre-1987) to the 24-month pre-TWWIIA extended Medicare coverage. Beneficiaries who are still in their Medicare 24-month qualifying period could have less than 39 months if they returned to work shortly after their month of entitlement. This is more the exception than the rule. Extended Medicare Coverage Under TWWIIA Section 202 of TWWIIA further extends Medicare coverage for most Title II beneficiaries who work. Beneficiaries will get an additional 4 1/2 years coverage beyond the current limit (for a total of 8 1/2 years including the TWP). This incentive became effective October 1, 2000. Under this provision, insurance can generally continue for 78 months with the first month of SGA occurring after the 15th of the month of the EPE. This is why under TWWIIA, Medicare coverage extends for at least 93 months (15 months of EPE and 24 months pre-TWWIIA extension and 4 1/2 years TWWIIA extension). Specifically, where Title II benefits end because of SGA following a TWP, Medicare coverage ends based on one of the following: 1. If the first month of SGA following the end of the TWP occurs prior to the 14th month of the EPE and the individual performed SGA in the 16th month of the EPE, D-HI extends for 78 months after the 15-month EPE. D-HI ends the last day of the 57th month following the end of the 36-month EPE. 2. If the first month of SGA following the end of TWP occurs prior to the 14th month of the EPE and the individual does not engage in SGA in the 16th month of the EPE, D-HI ends with the last day of the 77th month following the first month of SGA occurring after the 16th month, and terminates on the first day of the 78th month. 3. If the first month of SGA following the end of the TWP occurs after the 13th month of the EPE, D-HI ends with the last day of the 80th month following the first month of SGA occurring after the TWP, and terminates on the first day of the 81st month. Beneficiaries will be eligible for the extension under TWWIIA if they: * are starting to work for the first time since their entitlement; or * are in a TWP; or * are in an EPE that began after June 1997; or * are in an EPE that began prior to June 1997 and still has premium-free coverage that was not due to terminate until after 9/30/2000, and fraud or similar fault is not an issue. The Medicare Wizard The Medicare Wizard is designed to assist benefits specialists in determining when a Title II beneficiary’s Extended Medicare Coverage (post-implementation of the Ticket to Work and Work Incentives Improvement Act) will cease as a result of work and earnings. By way of history ... the Medicare Wizard was a software program created by the Social Security Administration for Claims Representatives to use in the field. Its purpose was to streamline and assist the Claims Representative in determining exactly at what point in time a Title II beneficiary’s Medicare would end in light of recent changes to continued Medicare coverage available to beneficiaries who work. During its initial use by Claims Representatives in the field, many SSA-sponsored benefits planners and advocates requested copies of the software to assist them in conducting their work with beneficiaries. SSA decided that the software would be useful to practitioners in the field but wanted to ensure that the software could be easily updated and that certain quality assurance measures were in place to ensure appropriate usage. Toward that end Cornell University worked with the SSA to create the Medicare Wizard Online. The website has three initial features—a tutorial, a practice quiz and a final quiz. Prior to receiving a personalized username to use the Wizard, an interested individual must complete and pass the final quiz. The tutorial was designed to aid you in passing the test and completing the registration process. Once you have passed the quiz and completed the registration process, Cornell will issue you a username that will allow you access to the fourth facet of the website which is the actual Wizard. To get started... 1. Go to www.medicarewizard.org. 2. Choose to either: take the Tutorial; take the Practice Quiz; or take the Final Quiz. 3. Before we can assign you a username you must take the Final Quiz and pass it with a score of 100%. 4. Once you have completed the Final Quiz (and passed it) we will issue you a username. 5. Once you have your username you can now access the fourth and final feature of the website—the Wizard. Enter your username and also the password you use to access the VCU BPA&O Database. We use the VCU password you were assigned to minimize the number of passwords you need to remember. TWWIIA Extended Medicare Coverage Decision Tree Did SGA occur prior to the 14th month of EPE after the TWP? - NO - Did SGA occur after the 13th month of the EPE? - YES - Start counting 80 months beginning with the month following the first month of the EPE to determine when the person's Medicare ends - or if later - The date of the benefit termination notice plus one month. Did SGA occur prior to the 14th month of EPE after the TWP? - YES - Did the individual perform SGA in the 16th month? - YES - Begin counting 57 months off starting the month following completion of the EPE to determine when the person's Medicare ends - or if later - The date of the benefit termination notice plus one month. Did SGA occur prior to the 14th month of EPE after the TWP? - YES - Did the individual perform SGA in the 16th month? - NO - Did SGA occur after the 16th month of the EPE? - YES - Start counting 77 months beginning with the month following the first month of SGA after the 16th month to determine when the person's Medicare ends - or if later - The date of the benefit termination notice plus one month. NOTE: In all three cases, Medicare would end the last day of the month as specified above and terminate the first of the following month. Examples/Exercises #1: Application of Rule #1 You just received a call from an individual who tells you that their TWP ended in 12/98. They reported working at SGA every month since their TWP ended and don't anticipate working at a lesser level. They want to know at what point their Medicare coverage will end. Begin by recording all the relevant and pertinent information below--making sure to record the TWP ending date, beginning of EPE and months in which the individual worked at SGA. December 1998 - TWP Ended January 1999 (Month 1) - EPE Starts SGA February 1999 (Month 2) SGA November 2001 (Month 35) December 2001 (Month 36) - EPE Ends/SGA January 2002 (Month 1) - Benefits End September 2006 (Month 57) - Medicare Ends You will note that the individual's TWP ended 12/98, putting the start date for their EPE in 1/99. They have earned SGA every month since 12/98 and if SGA were to continue the EPE would be expected to end 12/01, with cash benefits terminating on 1/1/02. (Benefit cessation cannot be earlier than the last day of the month with benefit termination occurring the first day of the next month.) Given that benefit termination would not occur until after 9/30/00, the TWWIIA provisions apply. Given that the individual earned SGA prior to the 14th month of the EPE and again in the 16th month, the first rule applies. The 15th month of the EPE is 3/00 and you should begin counting 78 months into the future to identify that this individual's Medicare coverage would cease on 9/30/06 with a termination on 10/1/06. #2: Application of Rule #2 If in Example #1 the individual did not earn at or above the SGA level in the 16th month of the EPE but did in the 18th month (6/00), the 77 count down would begin in 7/00 with benefits ceasing on 12/11/06 and terminating 1/1/07. The information below outlines this calculation. December 1998 - TWP Ended January 1999 (Month 1) - EPE Starts SGA February 1999 (Month 2) of SGA March 1999 (Month 3) of SGA April 1999 (Month 4) of SGA May 1999 (Month 5) of SGA June 1999 (Month 6) of SGA July 1999 (Month 7) of SGA August 1999 (Month 8) of SGA September 1999 (Month 9) of SGA October 1999 (Month 10) of SGA November 1999 (Month 11) of SGA December 1999 (Month 12) of SGA January 2000 (Month 13) of SGA February 2000 (Month 14) of SGA March 2000 (Month 15) of SGA April 2000 (Month 16) - No SGA May 2000 (Month 17) - No SGA June 2000 (Month 18) - SGA July 2000 (Month 1) of SGA through December 2000 (Months 2 through 6) January 2001 (Month 7) of SGA through December 2001 (Months 8 through 18) January 2002 (Month 19) of SGA through December 2002 (Months 20 through 30) January 2003 (Month 31) of SGA through December 2003 (Months 32 through 42) January 2004 (Month 43) of SGA through December 2004 (Months 44 through 54) January 2005 (Month 55) of SGA through December 2005 (Months 56 through 66) January 2006 (Month 67) of SGA February 2006 (Month 68) of SGA March 2006 (Month 69) of SGA April 2006 (Month 70) of SGA May 2006 (Month 71) of SGA June 2006 (Month 72) of SGA July 2006 (Month 73) of SGA August 2006 (Month 74) of SGA September 2006 (Month 75) of SGA October 2006 (Month 76) of SGA November 2006 (Month 77) Medicare Ends December 2006 (Month 78) Medicare Terminates #3: Application of Rule #3 If the individual had not earned SGA prior to the 13th month of their EPE, but earned SGA the 18th month, the individual's Medicare would continue until the last day of the 80th month following that first month of SGA. The information below details this rule. December 1998 - End TWP January 1999 (Month 1) - EPE Begins February 1999 (Month 2) Non SGA March 1999 (Month 3) Non SGA April 1999 (Month 4) Non SGA May 1999 (Month 5) Non SGA June 1999 (Month 6) Non SGA July 1999 (Month 7) Non SGA August 1999 (Month 8) Non SGA September 1999 (Month 9) Non SGA October 1999 (Month 10) Non SGA November 1999 (Month 11) Non SGA December 1999 (Month 12) Non SGA January 2000 (Month 13) Non SGA February 2000 (Month 14) Non SGA March 2000 (Month 15) Non SGA April 2000 (Month 16) Non SGA May 2000 (Month 17) Non SGA June 2000 (Month 18) SGA July 2000 (Month 1) of SGA through December 2000 (Months 2 through 6) January 2001 (Month 7) of SGA through December 2001 (Months 8 through 18) January 2002 (Month 19) of SGA through December 2002 (Months 20 through 30) January 2003 (Month 31) of SGA through December 2003 (Months 32 through 42) January 2004 (Month 43) of SGA through December 2004 (Months 44 through 54) January 2005 (Month 55) of SGA through December 2005 (Months 56 through 66) January 2006 (Month 67) of SGA through December 2006 (Months 68 through 78) January 2007 (Month 79) of SGA February 2007 (Month 80) Medicare Ends February 2007 (Month 81) Medicare Terminates Final Comments Be careful when assisting individuals in determining Medicare cessation/ termination. These rules are complex and the practitioner should always confirm their findings with SSA. Keep in mind; if the beneficiary's situation under the pre-TWWIIA policy results in termination of coverage prior to 9/30/00, the beneficiary would not get extended coverage. Also keep in mind use of IRWE or subsidy could result in an individual's earnings being lower than SGA, which might assist individuals who miss qualifying for TWWIIA extended coverage as a result of the ending of their EPE due to performance of SGA in the 36th month. Medicare Buy-Back Option It is possible for individuals with disabilities to buy into the Medicare program once the extended Medicare coverage is exhausted. Specifically, PL 101-239, effective April 1, 1990, provides disabled beneficiaries who are under 65 years of age with the option of purchasing Medicare coverage. They must no longer be entitled to Medicare because of having earnings in excess of the amount and time permitted having exhausted their extended period of Medicare eligibility. Individuals who lost entitlement to Social Security disability benefits due to SGA, and whose Extended Medicare coverage has also terminated, may opt to enroll in premium free Medicare Part A (know as Premium-HI). In order to get Premium HI, individuals must first file an application for Premium-HI, and then a determination regarding medical improvement will be made. Working individuals with disabilities must still meet SSA disability guidelines in order to qualify for Premium -HI. See chart on page 54 for Premium HI rates. Note: An individual who has earned at least 30 quarters of coverage will have a reduced rate. Also, individuals who have limited income and resources may qualify for payment by their State. This is known as the Qualified Disability Working Individual provisions (QDWI) and is available through the Medicaid office. * Social Security beneficiaries earning over 200 percent of the poverty level are required to pay the full premium; * For Social Security beneficiaries earning less than 200 percent of the poverty level, Medicaid is required to pay the entire Medicare premium (in most states). Exercise Questions Use the attached chart to answer the following questions: 1. In what month/year does the TWP begin? _____end?_____ 2. In what month/year does the EPE being? _____end?_____ 3. How much of his/her Title II check will the person receive in September 2004? _____None _____Half _____All 4. What month/year would his/her extended medicare coverage cease? _____ 5. What if the person were blind? What would the answers to the above questions be? Title II Exercise 1999 Countable Earnings January $0 Benefit Status February $0 Benefit Status March $150 Benefit Status April $205 Benefit Status May $210 Benefit Status June $190 Benefit Status July $300 Benefit Status August $150 Benefit Status September $170 Benefit Status October $220 Benefit Status November $225 Benefit Status December $0 Benefits Status 2000 Countable Earnings January $0 Benefit Status February $0 Benefit Status March $0 Benefit Status April $0 Benefit Status May $0 Benefit Status June $0 Benefit Status July $185 Benefit Status August $600 Benefit Status September $410 Benefit Status October $390 Benefit Status November $0 Benefit Status December $0 Benefits Status 2001 Countable Earnings January $0 Benefit Status February $0 Benefit Status March $0 Benefit Status April $0 Benefit Status May $210 Benefit Status June $150 Benefit Status July $500 Benefit Status August $620 Benefit Status September $590 Benefit Status October $340 Benefit Status November $330 Benefit Status December $400 Benefits Status 2002 Countable Earnings January $410 Benefit Status February $505 Benefit Status March $390 Benefit Status April $400 Benefit Status May $410 Benefit Status June $420 Benefit Status July $530 Benefit Status August $540 Benefit Status September $525 Benefit Status October $600 Benefit Status November $580 Benefit Status December $78 Benefits Status 2003 Countable Earnings January $100 Benefit Status February $120 Benefit Status March $100 Benefit Status April $170 Benefit Status May $180 Benefit Status June $165 Benefit Status July $220 Benefit Status August $0 Benefit Status September $0 Benefit Status October $0 Benefit Status November $0 Benefit Status December $0 Benefits Status 2004 Countable Earnings January $475 Benefit Status February $600 Benefit Status March $825 Benefit Status April $830 Benefit Status May $850 Benefit Status June $840 Benefit Status July $890 Benefit Status August $800 Benefit Status September $785 Benefit Status October $820 Benefit Status November $810 Benefit Status December $795 Benefits Status 2005 Countable Earnings January $830 Benefit Status February $805 Benefit Status March $790 Benefit Status April $840 Benefit Status May $810 Benefit Status June $785 Benefit Status July $820 Benefit Status August $825 Benefit Status September $0 Benefit Status October $0 Benefit Status November $0 Benefit Status December $0 Benefits Status Flowchart 1: Social Security/TWP An example of how an individual might proceed through the Social Security system Receive Benefits (Title II + Medicare) Goes to Work Trial Work Period (9 months within rolling 60 consecutive month period) * Receives wages + full benefits * Starts with first month earnings allowed limits. $200/40 hour rule January 2000 Regular Employment - $282 Self Employed - 41 hours October 2000 Regular Employment - $312 Self Employed - 48 hours November 2000 Regular Employment - $408 Self Employed - 59 hours December 2000 Regular Employment - $500 Self Employed - 67 hours $530/80 hour rule January 2001 Regular Employment - $535 Self Employed - 88 hours February 2001 Regular Employment - $540 Self Employed - 81 hours $560/80 hour rule March 2002 Regular Employment - $570 Self Employed - 95 hours April 2002 Regular Employment - $570 Self Employed - 91 hours $570/80 hour rule December 2003 Regular Employment - $700 Self Employed - 87 hours 2004 TWP = $580 9 months of earnings meeting TWP/income criteria End of TWP Extended Period of Eligibility Extended Medicare Coverage In the 10th month, continuing disability review. Look at SGA. Still medically disabled? Flowchart 2: Extended Period of Eligibility Extended period of Eligibility (for persons still medically disabled) 36 consecutive months * Begins the first month after the 9th TWP month * Receives no cash benefits for months earning over SGA (2005 = $830/$1,380) after the 3 month grace period * If work stops or earnings drop below SGA, receive benefits and any earnings. 36 months 2004 Month 1 - Wages: $500 (Not SGA) + Benefits: Social Security Month 2 (Grace Period) + Wages: $820 (Cessation Month SGA) + Benefits: Social Security Month 3 (Grace Period) + Wages: $815 + Benefits: Social Security Month 4 (Grace Period) + Wages: $880 + Benefits: Social Security Month 5 - Wages: $860 + Benefits: 0 Month 6 - Wages: $815 + Benefits: 0 Month 7 - Wages: $820 + Benefits: 0 Month 8 - Wages: $390 + Benefits: Social Security Month 9 - Wages: $500 + Benefits: Social Security Month 10 - Wages: $600 + Benefits: Social Security Month 11 - Wages: $650 + Benefits: Social Security Month 12 - Wages: $860 + Benefits: Social Security 2005 Month 13 - Wages: $840 + Benefits: 0 Month 14... Wages: $835 + Benefits: 0 Month 36 - Wages: $850 + Benefits: 0 End of EPE (36th month of EPE) No SGA Social Security Benefits Continue End of EPE (36th month of EPE) Earned SGA First month of SGA after EPE benefits discontinue If work cessation is because of disability within 60 months, can file for reinstatement of benefits Pursuant to Conley v. Bowen, 859 F.2d 261 (2d Cir. 1988), this is not true in New York, Connecticut and Vermont, the states within the jurisdiction of the U.S. Court of Appeals for the Second Circuit. Under the Conley holding, SSA cannot terminate benefits unless average monthly wages exceed SGA following the EPE. See Social Security Acquiescence Ruling (AR) 93-2(2), at 3-4; POMS DI 12718.001 et seq. CHAPTER 7: SUBSIDIES AND SPECIAL CONDITIONS Introduction A subsidy is support a person receives on the job, which could result in more pay than the actual value of the services the person performs. Only earnings that represent the real value of the work performed are used to determine SGA. SSA makes a determination of the value of the work, after subsides are subtracted. Subsidies and special conditions are applicable to both SSI applicants and Title II applicants and beneficiaries. The dollar amount of these is subtracted from gross monthly earnings during the initial eligibility process for both SSI and Social Security, potentially reducing gross earnings below the SGA level. They are applicable to the SSI program only during initial eligibility. For the Social Security program, however, they are considered in ongoing SGA determinations. Employer Subsidies Subsidies exist when employers pay workers more in wages than the reasonable value of the actual services performed. To qualify, individuals must have evidence of receiving subsidies such as extra support, supervision, or documentation of lower productivity compared to unimpaired workers performing the same or similar work. In developing subsidies, employers are requested by the SSA to submit statements documenting the actual value of workers' services. Subsidies may be either specific or non-specific. In specific subsidies, employers designate a specific dollar amount after calculating the reasonable value of workers' services. In non-specific subsidies, employers are unable to designate a specific dollar amount as the subsidy. The amount of subsidies is determined by comparing the work of individuals in terms of time, skills, and responsibilities with that of nondisabled individuals in similar work. The proportional value of the work must then be estimated according to the prevailing pay scale of this work. SSA makes this determination. Special Conditions Special conditions are items provided by someone other than an employer (e.g. a VR agency, job coach, etc.). The following information regarding the relationship between supported employment and subsidies is taken from Regional SSA Program Circular, Disability Insurance: "Job Coach Services in Supported Employment," (Philadelphia Region, 8/2/89): "Job coach services provided to employees is a strong indication that the work is subsidized. If employers cannot furnish a satisfactory explanation identifying specific amounts as subsidies, further contact should be made with the State agency counselor and/or job coach to: * Compare the time, energies, skills and responsibilities of workers with disabilities with that of unimpaired individuals performing the same or similar work; * Estimate the proportionate value of services according to the pay scale for this work (not according to the job coach's salary); and * Determine how frequently the job coaches monitor the individuals and how intensively involved the coaches remain. There may be continuing support being given that is not immediately apparent. Extraordinary development, including precisely tailored questions, may be needed in order to fully document the actual level of subsidy. The monitoring agency usually keeps extensive records of all support activities. Almost uniformly, though, the job coaches will maintain records of time spent, type of support provided, and progress in achieving job independence. These records will be vital when determining subsidies whether it is a monetary one or non-specific (i.e., additional services, special considerations, etc.)." Unincurred Business Expense "Unincurred Business Expense" is SSA's term for self-employment business support that someone else gives to the beneficiary without cost. Examples include: * Unpaid help; * VR buys a computer for your business; * Unincurred business expenses (e.g., business loss); and/or * Soil Bank Payments (farmers). Because someone else is contributing this support, the IRS does not allow the individual to deduct his or her cost for income tax purposes. However, SSA deducts the value of these "expenses" when determining SGA for self-employed individuals. For an item or service to qualify as an unincurred business expense, it must be an item or service that the IRS would allow as a legitimate business expense if the individual paid for it, and someone else, other than the individual, did pay for it. Indicators of Possible Subsidy The following list of possible indicators of subsidies is not exhaustive and questions regarding a specific example should be directed to the local SSA office. * Sheltered employment; * Childhood disability involved; * Mental impairment involved; * Marked discrepancy between amount of pay and value of services; * Claimants or someone else alleges that claimants do not earn their pay; * Nature and severity of impairment indicates that employees receive help from others in doing the work; and/or * Government-sponsored job training or employment programs. The following example illustrates how subsidies affect Social Security benefits. Example: Subsidy Impact on Social Security Jim currently receives Social Security benefits, is labeled with mental retardation, and has used his nine-month trial work period during a previous period of employment. Therefore, the potential exists for Jim's Social Security benefit to stop immediately if he begins to earn gross monthly wages over the SGA level. Jim finds work in private industry through a supported employment agency, which provides job evaluation, training, and support. Jim earns $6 per hour. During the first month of employment, the job coach works with Jim eight hours a day and provides special transportation funded by the agency worth $55 a month. The extra training and supervision needed to maintain Jim's job is a subsidy. An unimpaired employee doing the same job receives only one hour of supervision each day. The subsidy is computed by multiplying the number of extra hours provided by the job coach (seven hours/day) by Jim's hourly wage of $6 for a daily subsidy of $42. During the first month Jim's gross wage of $960 would be reduced by the subsidy of $840 for countable earnings of $120. Since the countable earnings are below SGA, Jim is not considered to be engaging in SGA, and will therefore be eligible for Social Security in this month. His Social Security will continue for each month that the dollar amount of the subsidy reduces his gross monthly earnings below the SGA level. By the fourth month on the job, Jim receives assistance from the job coach for five hours per week. He has received a raise to $6.25 per hour based on performance and now pays for the $40 special transportation expense. The gross monthly earnings of $1000 are reduced by the subsidy ($6.25 x 20 hours of job coach intervention) of $125 and the IRWE of $40 for special transportation. Jim's countable earnings are now $835 per month. As his countable earnings exceed the SGA level he would not receive his Social Security benefit for this month (unless he had not used his grace period up). This example illustrates that the amount of subsidy decreases, as the employee becomes more productive and independent, changing the evaluation of the work from non-SGA to SGA. The following exercise demonstrates how to compute the effect of specific subsidy on SGA determination: (Example below) Worksheet: Calculating Effect of Specific Subsidy Bill has finished his TWP and is being reviewed for SGA. He receives 10 hours a month of supported employment services/support and earns $7.50 per hour ($850 per month) in his current job. Calculate the specific subsidy value of this support. What is the effect, if any, on the SGA determination? STEP ONE Hours of job coach intervention (on-site) per month or number of hours of additional supervision given Multiply by hourly wage of worker Equals monthly subsidy STEP TWO Monthly Gross Earnings Minus Monthly Subsidy Equals Monthly Gross Wages Counted Toward SGA Determining Subsidy To aid the SSA in making subsidy determinations, the following information should be provided. Relationship of Pay to Services · How are the total earnings computed? · What is the typical hourly rate for this position? · Is the pay reduced proportionately when the individual is absent from work? · Does individual receive any unusual assistance or supervision? If yes, describe. · If the pay is not set according to normal business practices, what consideration is given to the following: o Size of the individual's families; o Number of years of position service with the employer; o Previous earnings; o Friendship or relationship to employer; o Other factors unrelated to the performance of the worker; o Does the employer consider the work to be worth substantially less than the amount paid? If so, what are the reasons for this view?; o If the individual is still on the payroll despite unsatisfactory work, what is the employer's reasons for retaining them?; or o If the individual is no longer employed, what led to the termination of employment? Employer-Provided Job Subsidies (check those that apply and provide cost to employer whenever possible) ____ Extra supervision ____ hours at ____ per hour for month(s) of ____ Allows extra time to perform duties (describe): ____ Allows lower productivity (describe): ____ Special accommodations (describe): ____ Provides special transportation ___ miles per day or ____ hours per month at ____ per hour. ____ Adjusts work schedule (explain): ____ Adjusts duties (explain): ____ Wages paid above productivity (explain): ____ Other (describe): Documented cost of employer provided subsidies ________________________ Special Arrangements/Accommodations Are these workers subject to the same duties, expectations, responsibilities, and potential for promotion as other workers doing similar jobs for this employer? ____ yes ____ no Are there any special arrangements in place to maintain the client's worker in this job? ____ yes ____ no (If yes, explain) Were these jobs "created" specifically for this employment situation or client? ____ yes ____ no Would the employers hire workers outside the context of the supported employment situation? ____ yes ____ no If workers are terminated from this job, what will be the outcome for them? Briefly describe workers' past employment experiences and dates: Other comments that may help the Social Security Administration in assessing potential impact on benefits: Social Security Administration Work Activity Questionnaire Beneficiary___________________________________ SS#_________________________________________ Period______________________________________ Please answer the following questions. We have provided additional space at the end of this form for your answers or comments. Subsidy · Do/did you consider his/her work to be fully worth the amount paid? _____Yes _____No If "yes, go to section titled "Unsuccessful Work Attempt." If "no," please answer all of the following questions. · If you consider(ed) his/her work to be worth substantially less than the amount paid, please estimate the actual value of his/her services, if possible, and explain how you reached that figure. Express this either by a percentage or in dollars. If you gave us an estimate, go to the section titled "Unsuccessful Work Attempt." If you cannot give us an estimate, please answer the following questions. · Did you grant any of the following special considerations to allow this individual to work? (Check all that apply.) _____Fewer or easier duties _____Lower quality supervision _____More rest period's _____Special equipment _____Special transportation _____Extra help/ _____Lower production _____Less hours _____Irregular hours _____Frequent absences Please explain any items you checked above. · How did/do you compute this person's actual pay? What factors did you consider in setting this pay rate? Unsuccessful Work Attempt · Was/is the person frequently absent from work? _____Yes _____No · Did the person do the work under special conditions such as with extra help/supervision, fewer/easier duties, frequent rest periods, or lower production? _____Yes _____No · Was the person's work satisfactory? _____Yes _____No · If the person no longer works for you, when did his/her employment end and why? Space for any additional remarks you wish to provide Signature ___________________________________ Title ___________________________________ Date ___________________________________ Telephone Number ___________________________________ CHAPTER 8: IMPAIRMENT RELATED WORK EXPENSE AND TITLE II Effects of IRWE on Benefits The cost of certain impairment-related items and services required by individuals in order to work are deducted from gross earnings in calculating SGA, even if these items and services are also needed for non-work activities. The purpose of the IRWE is to allow Title II beneficiaries to reduce income below SGA levels until they can work at a level of self-sufficiency, which decreases reliance on benefits. For Social Security beneficiaries, deducting an IRWE may keep monthly gross earnings below SGA, thus enabling them to maintain Social Security eligibility. The cost of IRWE expenses can also be deducted from gross earnings during initial application processes, enabling individuals to meet the SGA requirement. Allowable IRWE Deductions For an IRWE deduction to be allowable, the following criteria must be met: * Expenses must be directly related to the person's impairment(s) listed in their SSA disability file or other impairment for which they receive medical treatment. * Individuals, because of a severe physical or mental impairments, must need the items or services to work; * Costs must be paid by the individuals and not be reimbursable from other sources; * Expenses must be paid in a month in which the individuals are, or were, working; and * Expenses must be reasonable (represents the typical cost for item or services in the persons community). The SSA list of allowable expenditures under IRWE is extensive and includes costs of adaptive equipment or specialized devices, attendant care, special transportation costs, as well as the cost of job coach services. Documentation of costs is submitted to the SSA claims representatives who are responsible for making the IRWE determination. Under some circumstances, IRWE payment for durable goods made during the 11-month period preceding the month work started can be deducted. Expenses incurred in a month of work but paid for after work stopped also can be considered. Sample Deductible and Non-Deductible IRWE Expenses Supported Employment Services Payments made by Social Security beneficiaries to purchase supported employment services necessary for individuals to obtain and / or maintain competitive employment may be allowable deductible expenses. Individuals with disabilities who are considering using the IRWE option may want to consider the following factors: 1. The expenses incurred during the initial support phases of supported employment are usually higher than can be comfortably accommodated within the monthly income amount individuals receive in earnings or benefit payments. Therefore, it may be advisable to use the IRWE option as a funding source for the follow-up phases (it may be more beneficial to use a PASS in the initial support phases); and/or 2. Use of other funding sources (i.e., VR services, MH / MR, DD services, etc.) with funds appropriated for the purpose of employment support services. This will avoid relaxation of demands on these sources, thus averting a miscalculated assessment of funding needs. Many individuals using the work incentives may later require supplemental resources to support their employment. Attendant Care Services Deductible: * Services performed in the work setting; * Services performed in the process of helping the beneficiaries prepare for work (dressing, etc.), the trip to / from work, and after work (cooking, bathing, etc.); * Services which may benefit other members of beneficiaries' families (i.e., cooking meals for the individuals which are also eaten by other family members); and/or * Paid services performed by family members who can prove individuals suffer economically due to performing the services (i.e., family members must stop working or work reduced hours in order to perform the attendant care services). Not Deductible: * Services performed on non-work days or involving non-work activities; * Services performed for other family members; * Paid services performed by family members who do not suffer economic loss by performing the services; and/or * Services performed "in-kind," whether or not family members suffer an economic loss. Transportation Costs Modified Vehicles: * Costs of structural or operating modifications (installing, maintaining, or repairing these items), which are directly related to the impairment. * Mileage allowance for one's own vehicle based on Federal Highway Administration standards. Unmodified Vehicles: * Where the impairment prevents the person from taking public transportation, not because of unavailability of public transportation. * The deduction is based on federal mileage allowance. Example: Person with cerebral palsy who is unable to walk to and from a bus stop. Driver assistance, taxicabs or other hired vehicles: * Deduct amount paid to driver. * If the person's own vehicle is used, deduct mileage allowance. NOTE: One can more easily qualify for this deduction when a person's impairment requires the vehicle to be modified. SSA Approved Mileage Allowances (based on vehicle weight)1 Car: "Subcompact" (Less than 2,500 lbs) - 28.9¢ per mile "Compact" (Less than 3,000 lbs) - 29.5¢ per mile "Intermediate" (Less than 3,500 lbs) - 33.4¢ per mile "Full-Sized" (3,500 lbs or more) - 37.9¢ per mile Pickup: "Compact" - 30.6¢ per mile "Full-sized" - 35.1¢ per mile Van: "Minivan" - 35.3¢ per mile "Full-sized" - 44.8¢ per mile Unknown Vehicle Type - 31.5¢ per mile The rates listed above take into account operating costs to include: Depreciation Parts and tires Tolls and parking Registration fees Finance charges Maintenance and repairs License fees Local, state, and federal tax Gas and oil Insurance Title fees Inspection fee Footnote 1: SSA will be phasing out the use of vehicle class mileage rates and replacing them with the standard mileage rate permitted by IRS for non-governmental business use. Use the IRS standard mileage rate in determining the mileage expense for IRWE purposes unless the vehicle class mileage is more advantageous to the individual. Medical Devices Deductible: · Wheelchairs; · Dialysis Equipment; · Pacemakers; and/or · Respirators. Not Deductible: · Any devices not serving a medical purpose. Prosthesis Deductible: · Artificial replacements for any body part (i.e., arms, legs, hips). Not Deductible: · Any prosthesis device considered to be primarily cosmetic. Work-Related Equipment & Assistants Deductible: · Typing aids (i.e., one-handed typewriters); · Training in the use of work-related equipment; · Special work tools; · Telecommunication devices; · Interpreter services for individuals with hearing impairments; · Visual aids for individuals with visual impairments (i.e., Braille devices, reader services, electronic enhancers); and/or · Job coaching fees. Not Deductible: · Work-related devices not paid for by beneficiaries or previously deducted as business expenses in cases of self-employed individuals. · General education. Residential Modifications Deductible: · Individuals employed outside the home - exterior modifications which permit access to street / transportation (i.e., ramps, railings, sidewalks); and/or · Individuals employed in home - modifications made to create a working space to accommodate individuals (i.e., widening doorway into office, installing wheelchair lift). Not Deductible: · Individuals employed outside the home - modifications to interior of home (i.e., lowering kitchen / bathroom cabinets, widening doorways); and/or · Individuals employed in home - expenses previously deducted as business expenses in determining SGA. Routine Drugs / Medical Services Deductible: · Costs of visits to doctor's office to obtain regularly prescribed medical treatment / therapy to attempt to control the disabling condition; and/or · Costs of regularly prescribed medical treatment / therapy which is necessary to control the disabling condition (i.e., anticonvulsant drugs, blood level monitoring, anti-depressant drugs, chemotherapy). Diagnostic Procedures Deductible: · Costs of procedures related to evaluation, control, or treatment of disabling condition (i.e., brain scan). Not Deductible: · Costs of procedures not paid for by beneficiaries. Nonmedical Appliances and Devices Deductible: · Appliances/devices prescribed by physicians as essential for controlling the disabling conditions at home or work (i.e., electronic air cleaner for individuals with severe respiratory conditions). Not Deductible: · Appliances/devices used at home or at the office which the beneficiaries do not have a verified work-related need (i.e., air conditioner, humidifier). Similar Items and Services Deductible: · Cost of expendable medical supplies (i.e., elastic stockings, incontinence pads, catheters); and/or · Costs of guide dogs, dog food, dog licenses, veterinarian services. Not Deductible: · Costs of appliances/devices used primarily for physical fitness, which are not prescribed by a physician (i.e., exercise bike). IRWE Computation Marcus is labeled with mental retardation and is receiving $650 per month CDB benefits. He starts working with gross monthly earnings of $850. Without an IRWE, Marcus' gross wages of $850, because they are greater than the SGA, will ultimately result in loss of his Social Security benefits following completion of his TWP. By deducting an IRWE from his gross monthly wages, his countable income would be below SGA and allow him to sustain his Social Security benefits. The following example illustrates this: Example: IRWE Calculations - Impact on Social Security Benefits STEP ONE Gross Monthly Earnings $850.00 Minus $150.00 IRWE Equals $700.00 Adjusted Gross Earnings (Non-SGA) STEP TW0 Gross Earnings $850.00 Plus $650.00 CDB Equals $1500.00 Monthly Income Minus $150.00 IRWE Equals $1350.00 Total Usable Income IRWE Summary There are no time limits on how long individuals can use the IRWE to pay for particular services or items. This is very beneficial for individuals who have on-going impairment-related work expenses such as transportation assistance or supported employment follow-along services. It is not necessary that an IRWE be a monthly recurring expense. In some instances, individuals may have a one-time expense, such as a piece of medical equipment. In this case, they may choose to have the expense deducted as an IRWE all in one month or to have the expense pro-rated over a period of 12 months. Pro-rating the expense is particularly helpful if the services or items are costly. This approach can enable individuals to recover a greater amount of the expense over time. The process of establishing an IRWE is easy. If an expense appears to meet all of the necessary criteria, individuals should document the cost of the expense and submit it to the local SSA office in letter format. Listing each of the criteria with an accompanying explanation of how the expense meets the criteria. The SSA claims representative will review it and make a determination. SECTION THREE: IMPACT OF EMPLOYMENT ON SOCIAL SUPPLEMENTAL SECURITY INCOME Objectives 1. Understand the impact of employment on SSI benefits. 2. Identify and calculate Student-Earned Income Exclusion. 3. Knowledge of 1619 provisions. 4. Understand continuing disability review process and TWWIIA protections. 5. Able to identify and calculate Impairment-Related Work Expense. 6. Understand and compute Blind-Work Expense. 7. Identify, utilize and calculate the Plan for Achieving Self-Support. CHAPTER 9: SUPPLEMENTAL SECURITY INCOME Impact of Income on SSI Not all income received is considered in determining the amount of the SSI benefit. SSA allows individuals a $20 general income exclusion, which is subtracted from their income. The general income exclusion is first applied to unearned income received. Any portion of the general income exclusion remaining is then applied to earned income. In addition to the general income exclusion, a $65 earned income exclusion is subtracted from earned income. For SSI recipients, earned income is the gross amount received in the calendar month, regardless of when it was earned. After the earned income exclusion is applied, SSA counts one-half of the remaining earned income. Then, the remaining amount of earned and unearned income after exclusions is combined to give the total countable income. This is the dollar amount that SSA uses to determine the SSI payment. All of the following examples and worksheets use the 2005 Federal Benefit Rate (FBR). Remember that these computations will vary depending on the level of state supplements. Before computing the impact of income on the individual's or couple's payments, determine their living arrangements and insert the correct FBR/state supplement figures for the state in which the person resides. EXAMPLE: Unearned Income and General Income Exclusion Individual with gross unearned income of $225 (such as Social Security or Veterans benefit) and no earned income. $225 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $205 Countable Unearned Income $0 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $0 Remainder Subtract $0 GIE if not used above Equals $0 Remainder Subtract $0 Earned Income Exclusion Equals $0 Remainder Subtract $0 Impair. Related Work Exp. Equals $0 Remainder $0 Divided by 2 Equals $0 Equals $0 Remainder Subtract $0 Work Expenses if Blind Equals $0 Total Countable Earned Income $205 Total Countable Unearned Income Plus $0 Total Countable Earned Income Equals $205 Countable Income Subtract $0 PASS Deduction Equals $205 Total Countable Income $579 Base SSI Rate Subtract $205 Total Countable Income Equals $374 SSI Payment WORKSHEET: Calculating Unearned Income and General Income Exclusion Mary receives $330 gross a month in Social Security benefits and has no other source of income. She is single and lives alone. Calculate the amount (if any) of SSI for which she is eligible. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment Examples and calculations of individuals with only earned income and both earned and unearned income follow: EXAMPLE: Earned Income and Exclusions Individual with earned income only. Example based on a person with $350 gross monthly earnings. $0 Unearned Income Subtract $0 General Income Exclusion (GIE) Equals Countable Unearned Income $350 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $350 Remainder Subtract $20 GIE if not used above Equals $330 Remainder Subtract $65 Earned Income Exclusion Equals $265 Remainder Subtract $0 Impair. Related Work Exp. Equals $265 Remainder Divided by 2 Equals $132.50 Remainder Subtract $0 Work Expenses if Blind Equals $132.50 Total Countable Earned Income $0 Total Countable Unearned Income Plus $132.50 Total Countable Earned Income Equals $132.50 Countable Income Subtract $0 PASS Deduction Equals $132.50 Total Countable Income $579 Base SSI Rate Subtract $132.50 Total Countable Income Equals $446.50 SSI Payment WORKSHEET: Calculating Earned Income Only John has no unearned income. He receives $700 gross income a month from his job. He is single and lives alone. Calculate the amount (if any) of his SSI payment. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract $65 Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment EXAMPLE: Earned and Unearned Income Individual with earned income and unearned income. Example based on a person with $263 gross monthly earnings and receiving $225 in Social Security benefits. $225 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $205 Countable Unearned Income $263 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $263 Remainder Subtract $0 GIE if not used above Equals $263 Remainder Subtract $65 Earned Income Exclusion Equals $198 Remainder Subtract $0 Impair. Related Work Exp. Equals $198 Remainder Divided by 2 Equals $99 Equals $99 Remainder Subtract $0 Work Expenses if Blind Equals $99 Total Countable Earned Income $205 Total Countable Unearned Income Plus $99 Total Countable Earned Income Equals $304 Countable Income Subtract $0 PASS Deduction Equals $304 Total Countable Income $579 Base SSI Rate Subtract $304 Total Countable Income Equals $275 SSI Payment WORKSHEET: Calculating Earned and Unearned Income Bill receives $200 in gross Social Security benefits and $500 gross earned income. Calculate the amount (if any) of his SSI payment, given that he is single, and lives alone. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract $65 Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment EXAMPLE: Eligible Couple -- Earned and Unearned Income In this example, the couple has $225 in gross unearned income as well as $463 in gross monthly earnings. The SSI payment is the total amount paid to the couple. Each couple receives one half of the SSI payment. $225 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $205 Countable Unearned Income $463 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $463 Remainder Subtract $0 GIE if not used above Equals $463 Remainder Subtract $65 Earned Income Exclusion Equals $398 Remainder Subtract $0 Impair. Related Work Exp. Equals $398 Remainder Divided by 2 Equals Remainder of $199 Subtract $0 Work Expenses if Blind Equals $199 Total Countable Earned Income $205 Total Countable Unearned Income Plus $199 Total Countable Earned Income Equals $404 Countable Income Subtract $0 PASS Deduction Equals $404 Total Countable Income $869 Base SSI Rate Subtract $404 Total Countable Income Equals $465 SSI Payment EXAMPLE: In-Kind Support and Maintenance (VTR) An individual receiving in-kind support and maintenance valued at the Value of One-Third Reduction (VTR) and is earning $250 in wages and $200 in Social Security (unearned). $200 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $180 Countable Unearned Income $250 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $250 Remainder Subtract $0 GIE if not used above Equals $250 Remainder Subtract $65 Earned Income Exclusion Equals $185 Remainder Subtract $0 Impair. Related Work Exp. Equals $185 Remainder Divided by 2 Equals $92.50 Remainder Subtract $0 Work Expenses if Blind Equals $92.50 Total Countable Earned Income $180 Total Countable Unearned Income Plus $92.50 Total Countable Earned Income Equals $272.50 Countable Income Subtract $0 PASS Deduction Equals $272.50 Total Countable Income $386 Base SSI Rate1 Subtract $272.50 Total Countable Income Equals $113.50 SSI Payment 1 One-third reduction WORKSHEET: Calculating In-Kind Support and Maintenance (VTR) Brett is receiving in-kind support valued at the Value of the One-Third Reduction (VTR) and is receiving $275 in wages and $150 in Veterans Benefits. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract $65 Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment EXAMPLE: In-kind Support and Maintenance (PMV) This is an individual with in-kind support valued at the Presumed Maximum Value (PMV) and earnings of $250 a month. $204 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $184 Countable Unearned Income $250 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $250 Remainder Subtract $0 GIE if not used above Equals $250 Remainder Subtract $65 Earned Income Exclusion Equals $185 Remainder Subtract $0 Impair. Related Work Exp. Equals $185 Remainder Divided by 2 Equals 92.50 Remainder Subtract $0 Work Expenses if Blind Equals $92.50 Total Countable Earned Income $184 Total Countable Unearned Income Plus $92.50 Total Countable Earned Income Equals $276.50 Countable Income Subtract $0 PASS Deduction Equals $276 Total Countable Income $579 Base SSI Rate Subtract $276.50 Total Countable Income Equals $302.50 SSI Payment Student-Earned Income Exclusion (SEIE) Responding to increases in costs associated with going to school since the original inception of this work incentive, SSA revised exclusion levels as part of their effort to promote students who receive SSI in financing their attendance in school and encourage employment outcomes effective January 2001. SEIE is a SSI work incentive program which allows individuals under age 22 who regularly attend school to exclude (as of January 2005) up to $1,410 of earned income per month (up to a maximum of $5,670 per year). This exclusion is applied before any other exclusion. Earnings received prior to the month of eligibility do not count toward the $5,670 annual limit. These amounts will be automatically adjusted on an annual basis to higher or the previous year's amounts or increased amounts based on the cost of living. Apply the exclusion only to the earned income and consecutively to months in which there is earned income until either the exclusion is exhausted or the individuals are no longer a student child. Prior to the most recent changes the levels were $1,370/$5,520 in 2004, $1,340/$5,410 in 2003, $1,320/$5,340 in 2002 and $400/$1,620 prior to that with no provisions for annual increases. SEIE Reporting "Regularly attending school" means the student takes one or more courses of study and attend classes: · In a college or university for eight hours a week; OR · In grades 7-12 for 12 hours a week; OR · In a training course to prepare for employment for 12 hours a week (15 hours per week if the course involves shop practice); OR · For less time than indicated above for reasons beyond the student's control, such as illness. For students who have to stay at home because of disability "regularly attending school" is when they are: · Studying a course or courses given by a school (grades 7-12), college, university, or government agency, AND · Having a home visitor or tutor who directs the study. The following information must be reported to the claims representative(s) or ESR: · Whether the student was regularly attending school in at least one month of the current calendar quarter or expected to attend school for at least one month in the next calendar quarter; AND · The amount of the student's earned income. NOTE: Verify the wages of the student even if they allege to have earned $65 or less per month. EXAMPLE: Computing SEIE Marcus is 20, and regularly attending school. He works full-time earning $1,480 a month, receives SSI and also gets $200 a month in Social Security benefit on his father's record. His benefits would be impacted as follows. $200 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $180 Countable Unearned Income $1,480 Gross Earned Income Subtract $1,410 Student-Earned Income Exclusion Equals $70 Remainder Subtract $0 GIE if not used above Equals $70 Remainder Subtract $65 Earned Income Exclusion Equals $5 Remainder Subtract $0 Impair. Related Work Exp. Equals $5 Remainder Divided by 2 Equals $2.50 Remainder Subtract $0 Work Expenses if Blind Equals $2.50 Total Countable Earned Income $180 Total Countable Unearned Income $2.50 Total Countable Earned Income $182.50 Countable Income $0 PASS Deduction $182.50 Total Countable Income $579 Base SSI Rate $182.50 Total Countable Income Equals $396.50 SSI Payment WORKSHEET: Computing SEIE Mary is 18, and regularly attending school. She works earning $1,200 a month, receives $200 in unearned income and has used $4,700 of her SEIE to date this year. Please compute impact of her earnings in her benefit payment. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract $65 Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment SSI Eligibility for Students Temporarily Abroad (00501.411) In 1999 and 2001, the Social Security Administration initiated contracts with Mobility International USA to ensure that professionals working with people with disabilities understand the importance of study abroad experiences and options for including it as part of employment preparation (Social Security Act, Sec 1611(f)(2); Section 204 of Public Law 103-296; 20 CFR 416.215 and 416.1327) The Social Security Handbook states (Chapter 21): "A student of any age may be eligible for Supplemental Security Income (SSI) benefits while temporarily outside the U.S. for the purpose of conducting studies that are not available in the U.S., are sponsored by an educational institution in the U.S., and are designed to enhance the student's ability to engage in gainful employment. Such a student must have been eligible to receive an SSI benefit for the month preceding the first full month outside the U.S." This provision is an exception to what is known as the "SSI presence rule." The "presence rule" does not allow for the payment or continuation of SSI benefits to an individual who is outside the United States for a full calendar month or 30 consecutive days or more. This rule was amended to allow for study abroad through legislation introduced by Congressman Pete Stark of California in 1994 as part of the Social Security Independence and Program Improvements Act and became effective January 1, 1995. The SSI Provision states: To continue to receive SSI for up to one year while studying abroad: * The required course of study must not be available in the U.S. * It must be sponsored by an educational institution in the U.S. * It must be designed to substantially enhance the SSI recipient's ability to work * The individual must be eligible for SSI for the one month immediately prior to leaving the U.S. * The individual must earn academic credits towards a degree while abroad If a SSI recipient is planning to study abroad and meets these criteria, arrange to continue his/her SSI payments while he/she is abroad. An example of a qualifying educational program under this provision would be intensive study programs that lead to fluency in a foreign language through immersion in the cultural and social milieu of a country where the language is spoken. Less intensive programs, which are generally available in the United States, would not qualify. The Agency implemented the provision in accordance with the rationale provided by Congress. The Benefits of Studying Abroad... * A more open and accepting attitude towards cultural and diversity issues * Increased skill level and/or investment in developing second language skills * Increased interest in local and global community involvement * Leadership skills * Self-confidence * Independent-thinking skills * Increased self-awareness and sense of direction * Improved general job skills (interpersonal skills, flexibility, adaptability) * The opportunity to learn other cultural and world view perspectives * A sense of accomplishment by achieving a goal ...Also increase employability It is critical that SSI recipients with disabilities get the experience needed to be employable, that SSA Benefits Specialists recognize the importance of studying abroad and, when possible, work with recipients to include it as part of employment preparation. The National Clearinghouse on Disability and Exchange offers free information and resources related to the numerous study and intern abroad options available to students with disabilities. NCDE is managed by Mobility International USA and sponsored by the Bureau of Educational and Cultural Affairs of the United States Department of State. For more information contact: Mobility International USA and The National Clearinghouse on Disability and Exchange PO Box 10767 Eugene, OR 97440 Tel: (541) 343-1284 (voice/TTY) Fax: (541) 343-6812 E-mail: clearinghouse@miusa.org www.miusa.org Overview of 1619 Special Provision Statuses While SGA is a consideration in establishing initial eligibility for SSI, once eligible, the amount of SSI payment individuals receive monthly depends solely on their total countable income and resources. Therefore, individuals will not lose their SSI payment eligibility due to work activity when earnings exceed the SGA level. 1619 (a) Public Law 99-643 has established two special provision status positions known as 1619(a) and 1619(b). Section 1619(a) enables individuals who continue to be disabled to receive special SSI cash benefits in place of their regular SSI payments, when earnings exceed the SGA level. To be eligible for 1619(a) benefits, individuals must continue to have the original disabling impairment under which eligibility for SSI was initially determined, and must currently meet all other eligibility rules, including the income and resource test. If all eligibility requirements continue to be met, when earnings increase too greater than the SGA level but remain lower than the break-even point, SSI recipients will automatically move into 1619(a) status. There are no observable differences in the SSI payments indicating the change from regular SSI payment to a 1619(a) special payment. Eligibility for 1619(a) cash payment will continue until: * earnings fall below SGA, at which point individuals will automatically move back into regular status and receive regular payments; and/or * earnings exceed the break-even point (BEP), at which time their cash payments will cease. Break-Even Point (BEP) While a reduction in the SSI cash payments will occur as earnings increase, SSI recipients will continue receiving cash payments until their total countable income increases to the point where their SSI payment is reduced to zero. This is referred to as the break-even point. The break-even point is the exact amount of monthly gross earnings that will reduce cash payment to zero. Keep in mind that there are other factors that will affect the break-even point calculation, such as: income of a SSI eligible spouse; deemed income from an SSI ineligible spouse; deemed income from a parent; in-kind income, and the Value of the Reduction (VTR). The break-even is calculated in the following manner for persons receiving SSI only: EXAMPLE: Break-Even Point Without State Supplement STEP ONE $ 579.00 Federal Benefit Rate x 2 Multiply by Two = $ 1,158.00 Subtotal STEP TWO $ 1,158.00 Subtotal + $ 85.00 Earned and Unearned Income Exclusion = $ 1,243.00 Break Even Point If there is unearned income received in addition to SSI, such as SSDI or Railroad Retirement Benefits, contact the SSI Claims Representative for assistance in computing the break-even point. There is no one formula for determining the break-even point because of the various combinations of earned and unearned income. 1619(b) Section 1619(b) of the 1987 legislation provides for continued Medicaid eligibility for individuals whose incomes are too high to qualify for an SSI cash payments, but are not high enough to offset the loss of Medicaid or publicly funded attendant care. Individuals will be eligible only for the 1619(b) protected Medicaid status if the sole cause for SSI payments cessation is increased earnings over the break-even point. If cash excess cessation is a result of anything other than earnings (e.g. determination of medical recovery or excess resources and/or excess unearned income.) individuals will not be eligible for 1619(b). A second criterion for 1619(b) status requires that individuals' gross earnings fall below certain limits called threshold amount (see Appendix D for 2002 listing). The thresholds are used as an administrative convenience to determine if "sufficiency of earnings" is met rather than performance case-by-case computations. The law does not mention thresholds. Earnings at or above the threshold amounts are considered to be sufficient to replace the cost of Medicaid coverage. Threshold amounts vary from state to state as a result of variations in the cost of medical services. Individualized thresholds can be computed if individuals have unusually high medical costs, work expenses or a PASS. Individuals are ineligible for 1619(b) if their earnings exceed the threshold amount. They may qualify for this provision at a later date if their earnings fall below the threshold amount within 12 months and all other eligibility requirements continue to be met. Individualized thresholds can be computed when individuals have unusually high medical costs, an approved PASS, or incur IRWEs or BWEs. These work incentives may be applied to reduce countable earned income below state threshold amounts. Medicaid Covered Services Medicaid can cover a wide range of services, including: physician care, pharmacy services, family planning services, podiatry care, home health care, certain medical supplies, x-ray services, eye examinations, psychiatric services, outpatient care, and dental care. Since some of these services are optional and not required as part of a State Medicaid Plan, you will need to check to see what services are covered by your State's Medicaid program. The Early Prevention, Screening, Diagnosis and Treatment Program (EPSDT) is a mandatory Medicaid service and will be available to children under 21 in your state. Under EPSDT, all optional services must be available to children whether or not they are available to adults as part of a State's Medicaid Plan. Medicaid "Needs" Tests A final criterion for 1619(b) is that individuals must need Medicaid in order to work. Compliance with this criteria is established through statements by the individuals to SSA regarding the use of Medicaid in the last 12 months, expected use within the next 12 months, or need for Medicaid if individuals become injured or ill within the next 12 months. To qualify for 1619(b) Medicaid status, individuals must: * Have a disabling condition or continue to be blind; * Need Medicaid in order to work; * Unable to afford benefits equivalent to those received if not working; and/or * Meet all other requirements for SSI payments other than earnings. At the time that SSI cash benefits cease due to increased earnings over the break-even point, SSA computer will automatically determine eligibility for 1619(b). The field office will confirm 1619(b) eligibility at the next determination. Advocates and family members should monitor earnings monthly and contact SSA as soon as SSI cash payments cease to insure that the 1619(b) determination is made. Medicaid Administration Medicaid eligibility can be decided by SSA for SSI beneficiaries or by another State Agency, but this varies from state to state. In 33 states, SSI benefits convey Medicaid entitlement. They include: Alabama Arizona Arkansas California Colorado Delaware Florida Georgia Iowa Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Montana New Jersey New Mexico New York North Carolina Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Vermont Washington Washington, DC West Virginia Wisconsin Wyoming Additionally, there are eight states that hold that SSI recipients are eligible for Medicaid but must apply separately within the state. These states include: Alaska Idaho Kansas Nebraska N. Mariana Islands Nevada Oregon Utah Finally, 11 states require Medicaid applications and determine eligibility using at least one criterion more restrictive than SSI. These states include: Connecticut Hawaii Illinois Indiana Missouri Minnesota New Hampshire North Dakota Ohio Oklahoma Virginia If individuals in 209(b) States fail to meet their state's Medicaid criteria, they will be eligible for Medicaid based on 1619(b) provided that they were eligible for Medicaid in the month prior to becoming eligible for 1619 special status provisions. The 1619 legislation stipulates that if individuals are eligible for Medicaid in one month and are determined by SSA to be eligible for 1619(b) in the following month, their Medicaid eligibility for 1619(b) will be protected. This happens even if they do not meet their state's requirements for Medicaid eligibility. Medicaid Buy-In Medicaid Protection for Working People with Disabilities States can extend Medicaid coverage to certain individuals with disabilities who work under a provision known as the Medicaid Buy-in. The Medicaid Buy-in first appeared as an option for States under Section 4733 of the Balanced Budget Act of 1997. The Buy-in is designed to provide Medicaid to working people with disabilities, who, because of relatively high earnings, cannot qualify for Medicaid under one of the other statutory provisions. Section 4733 allows States to provide Medicaid to these individuals by creating a new optional categorically needy eligibility group. Currently, under section 1619(a) of the Social Security Act, a working individual on SSI may continue to receive SSI payments and Medicaid as long as he or she continues to be disabled and meets SSI income and resource requirements. Under section 1619(b), Medicaid coverage may continue even when SSI payments stop due to earnings over the individual's break-even point. In order to qualify for continued Medicaid under 1619(b), the individual must: (1) continue to be disabled; (2) need Medicaid to continue working; and (3) not have sufficient income to replace the value of Medicaid benefits. In other words, the person's earnings must fall below certain income levels known as thresholds. This threshold amount varies greatly from state to state. At the point when an individual is no longer eligible for Medicaid under 1619b or other eligibility groups in their state's Medicaid Plan due to excess earnings, the Medicaid Buy-in may provide continued access. The Medicaid Buy-in program allows working individuals with disabilities to "buy into" their state's Medicaid program by paying a premium and/or cost share amount similar to the manner in which they would purchase health coverage on the private market. Any working individual with a disability who meets their state's specific eligibility requirements for the Buy-in may enroll in the program. A person is not required to be a current or previous recipient/beneficiary of Social Security Disabilities benefits or Medicaid in order to be eligible under the Medicaid Buy-in provision. However, if not receiving disability benefits from Social Security, the state must make a determination as to whether the person meets the definition of disability as defined in the Social Security Act. The fact that the individual is working will not be considered when making the disability decision for this law. As indicated above, eligibility for the Medicaid Buy-in will vary significantly from state to state, given that states have a great deal of flexibility in designing their programs. States are provided with the option of using the standard income (both earned and unearned) and resource limits for the SSI program, or they may choose to establish their own income and asset limits for the Buy-in. Many of the states currently operating Buy-in programs have opted to establish more liberal income and resource criteria for the program. Examples of these income provisions include the exclusion of unearned income and/or income from a spouse, and the application of earned income "disregards" for employment and other disability-related expenses necessary for work. In addition to increasing the asset limit from the current $2000 figure for an individual, a number of states have also established an opportunity for resources to be accumulated in approved accounts for retirement, medical savings and independence. A concern related to the accumulation of resources in such accounts relates to the ability of individuals to access health care under the regular Medicaid program in the event that employment and, therefore, access to the Buy-in is lost. Some states have addressed this issue by including a provision for individuals to continue receiving Medicaid for a specific period of time following termination of employment to allow for a "spend-down" of assets below the limits for the state's regular Medicaid program. In addition to establishing their own income and resource standards for the program, states also have the option to establish and require a payment of premiums or other cost-shares on a sliding fee scale for access to the program. The premium rate is required by law to be structured according to income. A provision under the Ticket to Work and Work Incentives Improvement Act of 1990 provides that States may require payment of 100 percent of the premium for individuals with incomes over 250 percent but below 450 percent of the federal poverty level, except that the premium cannot exceed 7.5 percent of the individual's income. The Ticket to Work and Work Incentives Improvement Act provided additional options to states in designing their programs. Specifically, states can choose to provide Medicaid to employed individuals who participate in the Medicaid Buy-in program but who later lose their eligibility due to medical improvement, but continue to have severe medically determinable impairments. Additionally, States may apply for grants to run a time-limited demonstration project to extend Medicaid to working individuals with potentially severe disabilities who, without health care, would likely progress to disability status. While the BBA of 1997 and TWWIIA of 1999 established and liberalized options for states in the development of Medicaid Buy-in programs, it is important to keep in mind that these provisions are optional, not mandatory. In other words, it is up to the individual states to develop and submit information to the Centers for Medicare and Medicaid Services (CMS) for approval of a Medicaid Buy-in. Medicaid Buy-in programs involve an amendment to the State's Medicaid Plan. Requirements for approval of the amendment and Buy-in Program are that Medicaid Buy-in plans must be statewide and they must provide the same comprehensive health care package as the state's regular Medicaid plan. A listing of states with the buy-in follows: Medicaid Buy-in States as of October 6, 2003 Alaska Arizona Arkansas California Connecticut Florida Illinois Indiana Iowa Kansas Maine Minnesota Mississippi Missouri Nebraska New Hampshire New Jersey New Mexico New York Oregon Pennsylvania South Carolina Utah Vermont Washington Wisconsin Wyoming States with Infrastructure Grants Alabama Alaska California Connecticut Idaho Iowa Illinois Kansas Kentucky Louisiana Maine Massachusetts Minnesota Missouri Nebraska New Hampshire New Jersey New Mexico New York Nevada North Dakota Oklahoma Oregon Pennsylvania South Dakota Virginia New Hampshire Utah Vermont Washington West Virginia Wisconsin Wyoming States with Demonstration and Infrastructure Grants Mississippi Washington, DC Rhode Island Texas *Information was provided by CMS **Other Information furnished by third parties (i.e., State agencies, other agencies and/or advocates). Submit updates or changes to Mary.Hoover@ssa.gov Importance of the 1619(b) Provision Section 1619(b) is an extremely important provision of the Social Security Act as it protects not only individuals' Medicaid coverage, but also maintains their eligibility to receive SSI cash benefits in future months where countable income falls below the allowable limits. This is provided that individuals continue to meet all other eligibility requirements for SSI. As 1619(b) status maintains an active SSI case standing for an indefinite period of time, individuals may work for several years above the allowable levels for SSI cash benefits. They will be reinstated automatically if loss of employment or reductions of earnings fall below the allowable levels. The key is to establish Medicaid eligibility prior to entering 1619 status to ensure entry to 1619(b) when earnings exceed the break-even point. Individuals will only be eligible to move into 1619(b) status if the reason for SSI benefit suspension is due to excessive earned income. If individuals no longer meet SSI eligibility due to any other non-disability requirement (e.g., resources exceed the statutory limit), their eligibility will be suspended until the next month in which all eligibility requirements are met. Individuals enter a 12-month suspension period, which begins with the first month the benefits should have been suspended regardless of when SSA actually takes the suspension action. If all eligibility requirements are again met within 12 months following the first month of ineligibility, individuals may be reinstated without filing new applications for SSI. After 12 consecutive months of ineligibility, new applications for SSI must be filed. This involves a new disability determination, including an SGA determination, although the expedited reinstatement of benefits will impact this. Continuing Disability Review (CDR) SSA is required by law to periodically determine whether recipients continue to be disabled and therefore eligible to continue receiving benefits. Under SSA's medical improvement standard, generally, once individuals are receiving benefits, substantial evidence must show that medical improvement related to their ability to work has occurred and that they are able to work. This must occur before SSA can determine whether individuals are no longer eligible to receive benefits. Most CDRs involve an interview at the local SSA office. Information is gathered about the current conditions and sources of medical treatment, and permission is requested to contact these sources. The information is forwarded to the DDS for a determination. The frequency of the medical reviews varies, depending on the likelihood of medical recovery. Cases identified at the point of initial eligibility as being likely to improve (Medical Improvement Expected) are usually scheduled to be reviewed within six to 18 months of the initial decision. Cases in which disabilities are not permanent (Medical Improvement Possible) are scheduled to be reviewed at least once every three years. Cases in which the disabilities are expected to be permanent (Medical Improvement Not Expected) are scheduled to be reviewed every five to seven years. For those individuals actively participating in vocational rehabilitation programs, reviews can be expected, pending completion of the training and/or rehabilitation/training programs. In addition, when individuals enter 1619(a) status, a review of their medical file, will be conducted within 12 months by the ODO in Baltimore, Maryland. If the determinations are not clear-cut whether individuals are continuing to meet medical criteria, their files will be returned to the local SSA office and a full CDR will be conducted. A special medical review, in addition to the regularly scheduled reviews, may be triggered by increases in earned income. CDR Protection Under TWWIIA Effective January 1, 2001, SSA will not be able to initiate a continuing disability medical review while an SSI recipient or SSDI beneficiary is using a "Ticket" under the Ticket to Work and Self Sufficiency program. This protection is discussed in greater detail in Chapter 21. Expedited Reinstatement of Benefits (EXR) (excerpted from The Benefits Planner, Cornell University, Fall 2001) Do The EXR Rules Apply to SSI? They sure do. However, most SSI recipients who lose benefits due to higher wages will retain an SSI connection through the 1619(b) Medicaid provisions (see box below). When they once again become eligible for SSI through reduced wages, they can go back to cash benefit status without the need to use the EXR rules. The most likely user of these provisions would be the SSI recipient who loses cash benefits because of wages or a combination of wages and unearned income, then either loses or fails to establish 1619(b) Medicaid eligibility. When that individual remains ineligible for either cash or 1619(b) Medicaid benefits for 12 consecutive months, he or she will lose his or her connection to SSI. This means a new application would be required, under pre-2001 rules, to re-establish eligibility for cash benefits if wages were sufficiently reduced and he or she met other SSI requirements. Effective January 2001, that individual can most likely use the EXR provisions to re-establish eligibility for SSI. All EXR requirements, as discussed above, apply to the individual seeking reinstatement of SSI. In addition, the individual must meet all SSI eligibility requirements related to income and resources. Flowchart 3: SSI Benefits SSI Disability Award 1611: $830/month (1619a) or $830/month (1611) If Earnings exceed BEP, then 1619 (b) or 12-month suspension Then 12 months earnings fall below allowed levels OR Benefits terminated, medical cessation and/or 12 months earnings over allowed levels Then reapplication process/appeal Expedited reinstatement of benefits if within 60 months of termination 6 months of provisional benefits New SSA disability determination If Yes, then SSI disability award 1611 If No, then reapplication process/appeal CHAPTER 10: IMPAIRMENT-RELATED WORK EXPENSES AND SSI The cost of certain impairment-related items and services that individuals require to work are deducted from gross earnings, even if these items and services are also needed for non-work activities. The purpose of the IRWE work inventive is to enable recipients of SSI benefits to recover some of the costs of expenses incurred as a result of their disability to support their work. Effects of IRWE on SSI Benefits For SSI recipients, deducting the cost of the IRWE from monthly gross wages increases the SSI cash payments they can receive. The cost of IRWE expenses can also be deducted from gross earnings during initial SSI application processes, enabling individuals to meet the SGA requirement. IRWE may also help individuals meet the income test for SSI eligibility. Allowable IRWE Deductions For an IRWE deduction to be allowable, the following criteria must be met: * Expenses must be directly related to the person’s impairment(s) listed in their SSA disability file or other impairment for which they receive medical treatment; * Individuals, because of a severe physical or mental impairments, must need the items or services to work; * Costs must be paid by the individuals and not be reimbursable from other sources; * Expenses must have been paid in a month in which an individual is, or was, working; and * Expenses must be reasonable (represents the typical cost for item or services in the person's community). The SSA list of allowable expenditures under IRWE is extensive, and includes costs of adaptive equipment or specialized devices, attendant care, special transportation costs, as well as the cost of job coach services. Documentation of costs is submitted to the SSA claims representatives or ESR who are responsible for making the IRWE determination. Under some circumstances, IRWE payment for durable goods made during the 11-month period preceding the month work started can be deducted and expenses incurred in a month of work, but paid for after work stopped, can be considered. Sample Deductible and Non-Deductible IRWE Expenses Exercises and Examples Employment Services Payments made by SSI recipients to purchase employment services necessary for individuals to obtain and / or maintain competitive employment may be allowable deductible expenses. Individuals with disabilities who are considering using the IRWE option may want to consider the following factors: 1. The expenses incurred during the initial phases of employment are usually higher than can be comfortably accommodated within the monthly income amount individuals receive in earnings or benefit payments. Therefore, it may be advisable to use the IRWE option as a funding source for the follow-up phases (it may be more beneficial to use a PASS in the initial support phases); and/or 2. Use of other funding sources (i.e., VR services, MH / MR, DD services, etc.) with funds appropriated for the purpose of employment services. This will avoid relaxation of demands on these sources, thus averting a miscalculated assessment of funding needs. Many individuals using the work incentives may later require supplemental resources to support their employment. Attendant Care Services Deductible: * Services performed in the work setting; * Services performed in the process of helping the beneficiaries prepare for work (dressing, etc.), the trip to / from work, and after work (cooking, bathing, etc.); * Services which may benefit other members of beneficiaries' families (i.e., cooking meals for the individuals which are also eaten by other family members); and/or * Paid services performed by family members who can prove individuals suffer economically due to performing the services (i.e., family members must stop working or work reduced hours in order to perform the attendant care services). Not Deductible: * Services performed on non-work days or involving non-work activities; * Services performed for other family members; * Paid services performed by family members who do not suffer economic loss by performing the services; and/or * Services performed "in-kind," whether or not family members suffer an economic loss. Transportation Costs Modified Vehicles: * Costs of structural or operating modifications (installing, maintaining, or repairing these items), which are directly related to the impairment. * Mileage allowance for one's own vehicle based on Federal Highway Administration standards. Unmodified Vehicles: * Where the impairment prevents the person from taking public transportation, not because of unavailability of public transportation. * The deduction is based on federal mileage allowance. Example: Person with cerebral palsy who is unable to walk to and from a bus stop. Driver assistance, taxicabs or other hired vehicles: * Deduct amount paid to driver. * If the person's own vehicle is used, deduct mileage allowance. NOTE: One can more easily qualify for this deduction when a person's impairment requires the vehicle to be modified. SSA Approved Mileage Allowances (based on vehicle weight) Footnote Reference 1 Footnote 1: SSA will be phasing out the use of vehicle class mileage rates and replacing them with the standard mileage rate permitted by IRS for non-governmental business use. Use the IRS standard mileage rate in determining the mileage expense for IRWE purposes unless the vehicle class mileage rate is more advantageous to the individual. Car: "Subcompact" (Less than 2,500 lbs) - 28.9¢ per mile "Compact" (Less than 3,000 lbs) - 29.5¢ per mile "Intermediate" (Less than 3,500 lbs) - 33.4¢ per mile "Full-Sized" (3,500 lbs or more) - 37.9¢ per mile Pickup: "Compact" - 30.6¢ per mile "Full-sized" - 35.1¢ per mile Van: "Minivan" - 35.3¢ per mile "Full-sized" - 44.8¢ per mile Unknown Vehicle Type - 31.5¢ per mile The rates listed above take into account operating costs to include: Depreciation Parts and tires Tolls and parking Registration fees Finance charges Maintenance and repairs License fees Local, state, and federal tax Gas and oil Insurance Title fees Inspection fee Medical Devices Deductible: * Wheelchairs; * Dialysis Equipment; * Pacemakers; and/or * Respirators. Not Deductible: * Any devices not serving a medical purpose. Prosthesis Deductible: * Artificial replacements for any body part (i.e., arms, legs, hips). Not Deductible: * Any prosthesis device considered to be primarily cosmetic. Work-Related Equipment & Assistants Deductible: * Typing aids (i.e., one-handed typewriters); * Training in the use of work-related equipment; * Special work tools; * Telecommunication devices; * Interpreter services for individuals with hearing impairments; * Visual aids for individuals with visual impairments (i.e., Braille devices, reader services, electronic enhancers); and/or * Job coaching fees. Not Deductible: * Work-related devices not paid for by beneficiaries or previously deducted as business expenses in cases of self-employed individuals. * General education. Residential Modifications Deductible: * Individuals employed outside the home - exterior modifications which permit access to street / transportation (i.e., ramps, railings, sidewalks); and/or * Individuals employed in home - modifications made to create a working space to accommodate individuals (i.e., widening doorway into office, installing wheelchair lift). Not Deductible: * Individuals employed outside the home - modifications to interior of home (i.e., lowering kitchen / bathroom cabinets, widening doorways); and/or * Individuals employed in home - expenses previously deducted as business expenses in determining SGA. Routine Drugs / Medical Services Deductible: * Costs of visits to doctor's office to obtain regularly prescribed medical treatment / therapy to attempt to control the disabling condition; and/or * Costs of regularly prescribed medical treatment / therapy which is necessary to control the disabling condition (i.e., anticonvulsant drugs, blood level monitoring, anti-depressant drugs, chemotherapy). Diagnostic Procedures Deductible: * Costs of procedures related to evaluation, control, or treatment of disabling condition (i.e., brain scan). Not Deductible: * Costs of procedures not paid for by beneficiaries. Nonmedical Appliances and Devices Deductible: * Appliances/devices prescribed by physicians as essential for controlling the disabling conditions at home or work (i.e., electronic air cleaner for individuals with severe respiratory conditions). Not Deductible: * Appliances/devices used at home or at the office which the beneficiaries do not have a verified work-related need (i.e., air conditioner, humidifier). Similar Items and Services Deductible: * Cost of expendable medical supplies (i.e., elastic stockings, incontinence pads, catheters); and/or * Costs of guide dogs, dog food, dog licenses, veterinarian services. Not Deductible: * Costs of appliances/devices used primarily for physical fitness, which are not prescribed by a physician (i.e., exercise bike). Exercises and Examples Marcus begins working with gross monthly earnings of $750 and has been receiving the full FBR. He is single and lives independently. He has an IRWE of $100. The following example illustrates the impact of IRWE on his SSI benefits. EXAMPLE: IRWE Calculations -- Impact on SSI $0 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $0 Countable Unearned Income $750 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $750 Remainder Subtract $20 GIE if not used above Equals $730 Remainder Subtract $65 Earned Income Exclusion Equals $665 Remainder Subtract $100 Impair. Related Work Exp. Equals $565 Remainder Divided by 2 Equals $282.50 Remainder Subtract $0 Work Expenses if Blind Equals $282.50 Total Countable Earned Income $0 Total Countable Unearned Income Plus $282.50 Total Countable Earned Income Equals $282.50 Countable Income Subtract $0 PASS Deduction Equals $282.50 Total Countable Income $579 Base SSI Rate Subtract $282.50 Total Countable Income Equals $296.50 SSI Payment To tabulate Marcus' usable income, $750.00 Gross Monthly Earnings Plus $296.50 SSI Payment Equals $ 1,046.50 Equals Total Income Subtract $100.00 IRWE Equals $946.50 Usable Income Mary receives $850 in gross monthly earnings. She is single and lives on her own. She has an approved IRWE of $175. Compute the impact on her SSI payment below. WORKSHEET: IRWE Calculations -- Impact on SSI Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment Let's use the same scenario we did earlier with Marcus, but this time he has an IRWE of $200 and receives $250 as a childhood disability beneficiary. The following example illustrates the impact of IRWE on both SSI and Social Security payments. For Social Security, subtract the $200 IRWE from his gross monthly earnings of $850. This brings his earnings to $650 a month, well below SGA. EXAMPLE: IRWE Calculations -- Impact on SSI and Social Security Benefits $250 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $230 Countable Unearned Income $850 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $850 Remainder Subtract $0 GIE if not used above Equals $850 Remainder Subtract $65 Earned Income Exclusion Equals $785 Remainder Subtract $200 Impair. Related Work Exp. Equals $585 Remainder Divided by 2 Equals $292.50 Remainder Subtract $0 Work Expenses if Blind Equals $292.50 Total Countable Earned Income $230 Total Countable Unearned Income Plus $292.50 Total Countable Earned Income Equals $522.50 Countable Income Subtract $0 PASS Deduction Equals $522.50 Total Countable Income $579 Base SSI Rate Subtract $522.50 Total Countable Income Equals $56.50 SSI Payment Now let's use the same scenario we did earlier with Mary except this time let's increase her earnings to $890 a month, leave her IRWE at $175 and give her a Social Security payment of $200 a month. Compute below the impact of this scenario on her benefits. WORKSHEET: IRWE Calculations -- Impact on SSI and Social Security Benefits Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment IRWE Summary There are no time limits on how long individuals can use the IRWE to pay for particular services or items. This is very beneficial for individuals who have on-going impairment-related work expenses such as transportation assistance or supported employment follow-along services. It is not necessary that an IRWE be a monthly recurring expense. In some instances, individuals may have a one-time expense, such as a piece of medical equipment. In this case, they may choose to have the expense deducted as an IRWE all in one month or to have the expense pro-rated over a period of 12 months. Pro-rating the expense is particularly helpful if the services or items are costly. This approach may enable individuals to recover a greater amount of the expense over time by increasing the SSI payment up to the FBR (plus any applicable state supplement). The process of establishing an IRWE is easy. If an expense appears to meet all of the necessary criteria, individuals should document the cost of the expense and submit it to the local SSA office in letter format. Listing each of the criteria and explain how the expense meets the criteria. The SSA claims representative or ESR will review it and make a determination. If an individual receives both SSI and Title II benefits, the IRWE is calculated in each program according to that program's rules, simultaneously. CHAPTER 11: BLIND WORK EXPENSE AND SSI Definition Under the BWE incentive program, any SSI recipient whose primary diagnosis is blindness, and who receives earned income is entitled to exclude from that income any ordinary and necessary expenses attributable to the earning of income. This is not counted in determining SSI eligibility and monthly cash payments, if individuals are: * 65 or under; or * 65 or older and receiving SSI cash payments due to blindness for the month before they turned 65. Allowable Expenses A BWE need not relate directly to individuals' blindness; it need only be reasonable work-related expenses incurred by the individual, and may not exceed total countable income. Examples of deductible expenses follows: Guide Dogs Amount Deductible: The cost of purchasing the dog and all associated expenses (e.g.: dog food, breast straps, licenses, veterinary services) Fees Amount Deductible: The amount paid (e.g.: licenses, professional association dues, union dues) Transportation To and From Work Amount Deductible: In own vehicle: Per mile rate based on the annually allowed limit Other than own vehicle: The cost of buses, carpools, or cab fares Vehicle Modification Amount Deductible: The actual amount paid Training to Use an Impairment-Related Item or an Item which is Reasonably Attributed to Work Amount Deductible: The cost of the training, plus travel expenses to and from the training facility (e.g.: cane travel, use of special equipment, Braille, grammar, use of vision and sensory aids for the blind, use of one-handed typewriter, computer program course). Taxes Amount Deductible: The amount of federal, state, and local income taxes withheld. Social Security Taxes: Deduct the actual amount paid on wages and self-employment income (NOTE: Do not deduct SSA taxes withheld on sick pay). Prosthesis Amount Deductible: The costs of the items, plus maintenance and repair of such items Other Work-Related Equipment/Services Amount Deductible: The costs of the items, plus maintenance and repair of items whether the individuals work at home or at the employer's place of business (e.g.: one-handed typewriters, typing aids, vision and sensory aids, special tools designed to accommodate apartments, translation of materials into Braille). Nonmedical Equipment/Services Amount Deductible: The costs of the items, plus maintenance and repair of items whether the individuals work at home or at the employer's place of business (e.g.: safety shoes, tools used on the job, uniforms, child care costs, air conditioners, humidifiers, posture chairs, portable room heaters). Drugs and Medical Services, which are Essential to Enable Individuals to Work Amount Deductible: The amount paid (e.g.: medication to control epileptic seizures). Physical Therapy Amount Deductible: The amount paid. Expendable Medical Supplies Amount Deductible: The amount paid (e.g. bandages, face masks, catheters, incontinence pads). Mandatory Pension Contributions Amount Deductible: The amount of contributions. (NOTE: Mandatory pension contributions are considered reasonably attributable to earning income and, therefore, are deductible. Voluntary pension contributions are considered saving plans and, as such, are life maintenance expenses and are not deductible). Meals Consumed During Work Hours Amount Deductible: The actual value of the meals. Attendant Care Services Amount Deductible: The same amount deductible as an IRWE (must be rendered in the work setting or the process of assisting individuals in making the trips to/from work and home, with certain limitations). Note that some BWE may also meet the criteria for an IRWE. When expenses meet both criteria, the expense can be counted as a BWE against SSI and an IRWE under Title II. Exercises and Examples EXAMPLE: Calculating Effect of BWE John is blind. John's federal, state and local taxes, together with FICA, total 33% ($200) of his gross monthly earnings ($600). In addition, it costs him $20 in transportation expenses and $20 a month for lunches at work. His revised SSI payment is calculated below. $0 Unearned Income Subtract $0 General Income Exclusion (GIE) Equals $0 Countable Unearned Income $600 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $600 Remainder Subtract $20 GIE if not used above Equals $580 Remainder Subtract $65 Earned Income Exclusion Equals $515 Remainder Subtract $0 Impair. Related Work Exp. Equals $515 Remainder Divided by 2 Equals $257.50 Remainder Subtract $240 Work Expenses if Blind Equals $17.50 Total Countable Earned Income $0 Total Countable Unearned Income Plus $17.50 Total Countable Earned Income Equals $17.50 Countable Income Subtract $0 PASS Deduction Equals $17.50 Total Countable Income $579 Base SSI Rate Subtract $17.50 Total Countable Income Equals $561.50 SSI Payment Earned income set aside in a BWE is subtracted from the individual's total earned income and may not exceed that amount. WORKSHEET: Calculating Effect of BWE Mary is blind, and earns $750 a month. Her federal, state and local taxes, together with FICA, total $250. In addition, she pays $60 a month for transportation and $30 for meals during the week. Compute the impact of her BWE below. Unearned Income Subtract General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract $65 Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment CHAPTER 12: PLAN FOR ACHIEVING SELF-SUPPORT (PASS) Purpose for a PASS PASS is an SSI work incentive under which persons with disabilities can set aside income and/or resources to be used to achieve specific work goals. A PASS can be established to cover the costs of obtaining an education, receiving vocational training, starting a business, or purchasing support services which enable individuals to work and result in reduction/cessation of benefits (SSI/SSDI). These support services may include: * The purchase of coaching/job advocacy supports needed to obtain / maintain employment; * Vocational evaluation; * The payment of transportation-related expenses; * The purchase of job-related equipment, uniforms, etc.; * The mechanism for allowing individuals or groups of individuals to purchase a business; and * Any other services/equipment needed to support individuals in a work-related manner. In April 1996, SSA revised its guidelines for administration of the PASS Program and created a new process for handling PASS applications and reviews. From the onset of the initial changes to PASS, SSA informed Congress and consumers that it would assess the impact of these new guidelines. The primary purpose for these changes was to ensure proper stewardship of the provision, in light of recent findings by the General Accounting Office that the program was being misused and mismanaged. While this assessment began in March of 1997, it was greatly accelerated by expressions of concerns by PASS applicants and participants regarding adverse impact of the enhancements and lack of consistent application of PASS guidelines across the United States. This assessment of the enhancements to the PASS Program was followed on December 1, 1997 with a statement made by Carolyn W. Colvin, Deputy Commissioner for Programs and Policy, Social Security Administration, which further amended the procedures for applying PASS policies, and the overall process for handling the work associated with PASS applications and reviews. The information outlined in this chapter includes these recent changes and SSA has recently issued complete instructions to its field offices via POMS, which incorporates all of these changes. Individuals having difficulty accessing the PASS Program, desiring addition information, or interested in providing customer feedback should contact SSA. Effects of PASS on Benefits PASS is simply the means to acquire the services and items needed for starting work, not the means to make income or resources available for ongoing costs. The purpose of a PASS is to increase or maintain income-producing capabilities, thus reducing individuals' reliance on government benefit support. For a PASS to be approved by SSA, there must be a reasonable chance that individuals can achieve their vocational goal. There must also be a clear connection between the vocational goals and the increased or maintained earning capacities. PASS is meant to assist a person in competing in the job market. PASS makes it financially feasible for individuals to set aside or save income and/or resources. These can be used to achieve vocational goals by enabling individuals to receive higher SSI payments as they work toward self-sufficiency. The PASS program provides persons with disabilities the opportunity to self-direct the vocational rehabilitation process. PASS Summary A PASS is meant to be a flexible tool to allow individuals with disabilities to either raise their SSI amount or become eligible for SSI, in order to obtain items or services that would help them return to work or increase their ability to support themselves by earning more than they currently are. A PASS gives additional SSI income to help individuals become less dependent on SSI at the end of the PASS. The income and/or resources set aside in a PASS are not counted in determining eligibility for SSI or in calculating the amount of the SSI benefit that individuals will receive. In determining SSI eligibility, individuals must meet an income and resources test. If their income (including earnings and unearned income such as Social Security) and/or resources are too high, they will not be eligible for SSI. However, by excluding this income and/or resources in a PASS, individuals could then meet the income and resources test, thus potentially qualifying for SSI. This is how it works: The SSI amount is increased (or individuals are made eligible for SSI when they would not be under the regular SSI rules), by excluding certain income or assets (also called resources), which would have to be counted under the regular SSI rules. Income and resources, which normally would reduce SSI or prevent eligibility, can be ignored if they are listed in the PASS and used towards occupational objectives. The extra SSI helps pay for their other living expenses (i.e. food, clothing, and shelter). In some cases, the extra SSI generated by a PASS will match the amount being spent in a PASS, so that the cost of the PASS is completely covered by the SSI increase. However, each PASS situation must be computed separately to find out. Even when the PASS does not replace the money spent dollar for dollar, there may be other factors that make a PASS advantageous, such as allowing Medicaid eligibility. The long-term benefits of a successful PASS, both financial and personal, may be worth an investment now. Earned and Unearned Income Individuals who have both earned and unearned income can set aside either, or both, of these incomes as well as deemed income from a spouse or parent or in-kind income to establish, or increase, SSI cash benefits. Earned Income: If individuals who receive SSI were to go to work, their new earnings would result in the SSI check being reduced. Recipients' SSI checks would normally be reduced by the earnings, minus allowable exclusions (known as the countable earned income). By setting aside new earnings that would normally reduce the SSI check, individuals are provided with an opportunity to purchase the goods and services needed to work. Unearned Income: Individuals who have only unearned income in the form of Social Security or another type of pension may also benefit from the PASS work incentive. Depending on the amount of their countable unearned income, individuals may not be eligible for SSI, or if eligible, be receiving a reduced SSI check (i.e., they would not be receiving the maximum FBR.) By setting aside a portion, or all of this countable unearned income in the PASS, individuals may be able to increase the amount of the SSI check they are currently receiving. Resources If individuals have resources that exceed the resource limit for SSI, these resources may be set aside in the PASS as well. Resources can be anything that is owned, including bank accounts, real estate, or personal property. In summary, a PASS can be established by setting aside one or more of the following to achieve a vocational goal: * Earned income (wages, self-employment, certain sick pay, royalties and or honoraria); * Unearned income (Social Security or other types of benefits, or other types of monetary support); and/or * Resources. The PASS enables individuals to recoup some or all of the expenses paid for under the PASS. PASS Approval Requirements For approval, each PASS must meet the following requirements: 1. Feasible Occupational Goal: The PASS must be specifically designed for each individual and have a designated and feasible occupational objective. Non-occupational objectives, such as basic living skills or homemaking skills, do not meet PASS requirements. The proposed vocational goals must be clearly stated, indicating job titles or, if self-employed, the type of business. It is important to note the individuals' age, prior work history, education and training, disability, and if there is a reasonable chance for them to attain the objective. The PASS must also indicate current earnings, estimated earnings pending PASS completion, and/or level of independent job performance, which the individual expects to reach. As part of SSA's assessment of the April 1996 enhancements to the PASS Program, they found that evaluations and notices did not make a clear distinction between the feasibility of the goal (based on a person's reasonable expectation to perform the work), and the viability of the plan for achieving it (based on the steps necessary to achieve the goal). Based on policy changes made on 12/1/97, operating instructions were modified to make a clear distinction between feasibility and viability, making sure the same distinction is made in all evaluations and notices sent to PASS applicants. As outlined in Carolyn Colvin's statement of 12/1/97, "unless there is evidence to the contrary, SSA's PASS Specialists will presume an occupational goal to be feasible, and the plan for achieving it to be viable, if any certain State or private professionals in the field of vocational rehabilitation and employment develops the PASS. If the PASS specialist cannot approve a PASS, he or she will discuss the matter with the individual as well as with the plan's preparer. If the PASS Specialist continues to believe that the goal is not feasible or the plan is not viable, he or she will document the file regarding the discussion and the reason for his or her position." If the PASS Specialists feel it is warranted, they may request the PASS applicant undergo a vocational assessment. If a vocational assessment is recommended, usually the cost of the assessment will be included as a PASS expense. 2. Limits on Occupational Goals The December 1997 changes to PASS clearly stipulate that existing POMS instructions describing the limit on occupational goals was found to have an exception in the case when an "entry-level" position did not produce sufficient income to cover the individual's living expenses, uncovered medical expenses, and work-related expenses. The operating guidelines have been revised so that "within the business, trade, or profession the individual chooses, his or her occupational goal must be the earliest point on the career path at which earnings can reasonably be expected to cover his or her living expenses (as they exist during the PASS), uncovered medical expenses, and work-related expenses." 3. Interval Steps/Milestones: The PASS must incorporate milestones and corresponding timeframes leading to attainment of the occupational objective. These demonstrate the person's progress toward achieving the goal and should be described sufficiently so that completion of steps is readily discernible. Milestones are best documented using criterion-based statements. This also includes the interval steps related to actually securing a job as stated in the occupational objective. 4. Definable Timeframe: Specific time frames must be established for the PASS. Schedules must be provided for meeting the vocational goals, which indicate the month and year that it is expected to begin and end. The time allotted must be reasonable for achieving the goal and reflect the person's estimated time for completing the goal. 5. Sources to be Set Aside: Plans must state the sources and the amount of income or resources to be set aside, such as earnings, SSDI, benefit supports (other than SSI), savings accounts, extra family support, stock dividends, and loans. The sources, amounts and rates of accumulation of income and resources must be adequate, but not excessive, to achieve the goal. Plans must also show how income/resources set aside will be kept clearly and easily identifiable. Separate bank accounts for PASS savings are a good way to provide for verification of PASS savings and expenditures. 6. Expenditures: The PASS must state how the money set aside will be spent to achieve the occupational objective. A list must be included of monthly planned expenditures by grouping or category with an explanation of their connection to the occupational objective. Expenses necessary for achieving the goal must be reasonable in price to be approved. Cost estimates for goods and services indicating how the costs were calculated should be included. Providers should be indicated when known. Goods and services under the PASS may be bought outright, rented or leased. In the case where an item of unusual value is to be purchased, the PASS must include a satisfactory justification as to why less expensive alternatives will not suffice. Some examples of items that may qualify as PASS expenditures include: * Educational and training costs, tuition, books, additional costs for room and board while away from home, associated fees and costs; * Equipment, tools, supplies, operating capital inventory, taxes, costs of fees and licenses; * Medical and social services, attendant and child care, operational or access modifications to buildings or vehicles; * Transportation costs and related finance, service and maintenance costs; and/or * Attendant care and/or job coaches. If there are questions about whether items or services are appropriate for inclusion under a PASS, please inquire! Take note that individuals who are denied a proposed PASS are entitled to the reason(s) in writing from the local SSA office. Remember, PASS is just the means to acquire the services and items needed for starting work, not the means to make income or resources available for ongoing costs. Start-up costs reflect the costs required to obtain the needed goods or services to enable the person to start the job or business. 7. Major Purchases: Per Carolyn Colvin's statement on 12/1/97 "allowable expenses for major purchases will not be limited to downpayments. Funds set aside for installment payments will be excluded to the extent that the expense remains related to, and supportive of, an approved occupational goal, and earnings do not negate the need to continue the exclusion." (This policy is in current instructions for field offices -- new POMS SI 00870.) 8. Organization: The PASS must be in writing and SSA has established form SSA-545 to assist in completing a Comprehensive Plan. Individuals should use form SSA 545 when initiating a PASS. Any Social Security office can assist in writing the plan. Also there are PASS preparers, advocates for the disabled, agencies, organizations, etc. that can help with the form. Form SSA-545 is included on pages 159-172 and is also available on-line at SSA's website. If another format is used, the applicant will still be responsible for providing SSA with the essential information requested in SSA-545. 9. Deferred Expenses: Not all expenses may be allowed at the beginning of the PASS. In some cases, approval of certain goods and services may be contingent on the successful completion of milestones on which the need of the expenses is predicated. Subsequently, no expense will be approved unless the milestone is completed. Examples of Possible PASS Expenditures * Supported employment services such as job development and job coach services; * Equipment, supplies, operating capital, and inventory required to establish a business; * Tuition, books, supplies and all fees and costs imposed, by or in connection with, an educational or occupational training facility including tutoring, counseling, etc.; * Attendant care; * Child care; * Additional costs incurred for room and board away from principal residence which is required to attend educational, training, employment, trade or business activities; * Equipment or tools either specific to individuals' conditions or designed for general use (i.e., for individuals without disabilities); * Dues and publications for academic or professional purposes; * Uniforms, specialized clothing, safety equipment (everyday clothing is not allowable); * Basic life skills training if currently pursuing an occupational objective and the training is necessary for attaining the objective; * Medical and social services; * Operational or access modifications to buildings or vehicles to accommodate disabilities; * Least costly alternatives for transportation, including: - Public transportation and common carriers, - Hiring private or commercial carriers, - Assistance with purchase of a private vehicle; * Preparation fees for developing a PASS; * Licenses, certifications and permits required for employment (government-imposed penalties, fines, or income taxes are not allowable.) Non-Approvable Expenditures No expenditures will be approved that: * Will not be paid by the income and resources set aside; * Were in existence prior to initiation of the PASS goal, which can predate the submittal to SSA of the request for a PASS. (However, these could be incorporated as an IRWE/BWE if approvable); * Were purchased under a prior PASS unless a satisfactory justification is provided; * Is used to reduce countable income after the start-up period for a business. The use of an item as a business expense in determining taxes for business does not preclude using a PASS expense during the calendar years that encompass the start-up period; * Not paid for by the individual or if the individual expects to be reimbursed for the expense. Supported Employment as an Excludable Expense Individuals in a supported employment situation also may use a PASS to increase potential for self-support. This will generally occur through decreasing their costs for, and their reliance upon ongoing supports needed to work. An individual's objective is to work at a job with a certain level of independent performance as described in the plan. The goal may be to achieve stabilization or to reach an even higher level of performance. The individual plan should specify the anticipated level of performance in terms of supports required. The plan should be amended if it appears the person can perform at a higher level. Only the cost of actual job coaching services may be allowable as job coach expenses. A knowledgeable service, such as VR or employer, may be contacted to verify the need for coaching and the chance for increased independence. The reasonable allowable charge for these services will reflect the amount the local state VR pays for similar services. While extended or follow-along services generally would not be allowable under a PASS, they may qualify if the individual is seeking to increase his/her potential for self-support. PASS Candidates To qualify for a PASS, an individual must meet the following criteria: * Be under age 65 (unless receiving SSI disability payments in the month before age 65); * Be disabled or blind; * Meet all eligibility requirements for SSI with the exception of the income and resources test; * Have earnings, unearned income deemed income, in-kind income, or resources to set aside in the PASS. (Examples of unearned income include Social Security, private pension, monetary support or gifts from family or friends); and * Have expenses related to achieving the work goal. Likely Candidates: * Resources in Excess of Allowable Limits: Individuals who do not have earned or unearned income and have not qualified for SSI in the past due to resources in excess of the resource limit. By establishing a PASS to set aside these resources to achieve a vocational goal, individuals can qualify for SSI. * Unearned Income Only: Individuals who have unearned income only can establish a PASS to exclude the unearned income, thus establishing SSI. * Earned Income Only: Individuals who have earned income only can set aside earnings in the PASS and begin receiving SSI checks, although PASS does not affect the SGA determination that is required for initial eligibility. * Both Earned and Unearned Income: Individuals who have earned income and unearned income can set aside their wages, Social Security or both to establish SSI cash benefits. Again, PASS doesn't affect the SGA determination required during initial eligibility. * Earned Income and Receiving SSI: Individuals who have earned income and are receiving SSI can set the earnings aside in a PASS to increase the amount of their SSI check. This same situation is true for persons who have unearned income and receive SSI prior to PASS. * Earned Income (in near future) and Receiving SSI: Individuals who have SSI only but will begin working in the near future can establish a PASS to set aside the new wages starting with the first month of employment. The SSI check will only be reduced by the amount of countable earnings not set in the PASS. * Potential PASS candidates having income/resources include those individuals in school or training programs, currently receiving services from rehabilitation agencies, or interested in rehabilitation and becoming self-supporting. Not Likely Candidates: * Individuals ineligible for SSI for reasons other than excess income and/or resources. * Individuals who are unable to pursue occupational goals due to their mental/physical condition. * Individuals who are currently self-supporting. * Individuals who have already completed a PASS and have not tried to seek employment in the work goal for a prior approved PASS. * Individuals who do not have resources or income to set aside and do not expect any. * Individuals who do not need items or services to work. * Individuals who are NOT willing to set aside funds for PASS. Developing a PASS The development of a PASS may begin at any time. If individuals establishing the PASS are already receiving SSI, meeting initial SSI eligibility criteria is not required. If individuals are currently not receiving SSI, they must go through the regular SSI application procedure before a PASS can result in an SSI check being issued. Remember that all eligibility requirements for SSI must be met, with the exception of the Income and Resources Test, for a PASS to be used in establishing SSI cash payments. One of the criteria to be met is the SSA's definition of disability that says that individuals must not be working or if working, they must be earning under the SGA amount. Wages that are excluded under a PASS cannot be deducted from gross wages to meet the SGA criteria. However, if individuals establish a PASS to meet the Income and Resources Test, the PASS expense can simultaneously be computed as an IRWE (assuming it meets IRWE criteria) to reduce wages for the SGA/medical disability determination. Only during the determination of SSI eligibility may the same expense be counted as an IRWE and PASS simultaneously. Once individuals meet both the SGA and Income and Resources Test, the actual amount of their cash benefit is computed. In the computation, expenses must be considered either as a PASS or an IRWE. The PASS Specialist and ESR will play a vital role in the PASS application and review process. Each PASS Specialist and ESR are accessible via a 1-800 phone line and the customer can communicate directly with the PASS Specialist or ESR throughout the entire process. Specifically, "before denying a PASS on the basis that it is not a viable means of achieving the goal, SSA will contact the PASS Applicant, explain why the plan is not viable, and discuss with the applicant modifications that would make the plan viable." Starting a Business Under a PASS If a person is considering submitting a PASS with a work goal of self-employment, it must include a detailed business plan. The plan may require securing concurrence by more knowledgeable third parties as to the feasibility of the business in terms of the person's ability to conduct the business and ability of the business to be successful. For someone beginning a business, the start-up costs include the expenses for the first 18 months or longer, if necessary for business operation. Some possible third party reviewers may include: * the individual's physician; * vocational counselors; * small business administration; * local departments of employment and training; * local chambers of commerce; * local banks; * appropriate staff at local colleges. Components of a Business Plan The business plan must include the following components (not an exhaustive list): * Business name, address, owner * Business form * Description of the principal activity of the business, including a description of the product and/or service to be provided * Explanation of specific objectives of the business along with timetables for establishing the business and attaining the stated objectives * Explanation as to why business should succeed and unique features * A description of target market and audience demographics, and competition * A description of the mechanism for pricing the product/services as well as a description of production and quality control * A description of the financial plan, including any loans * Advertising plan * A list of personnel and their roles/qualifications Calculating a PASS Income set aside in a PASS affects the amount of SSI cash benefits received by reducing the amount of total countable income. Total countable income includes earned income and unearned income. In determining individuals' monthly SSI checks, claims representatives compute the amount of the total countable income and subtract this amount from the FBR. EXAMPLE: Effect of PASS on Unearned and Earned Income John receives $220 in Child Disability Benefits and $462 in gross monthly earnings. As an individual with earned and unearned income, his total countable income would be calculated as follows. $220 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $200 Countable Unearned Income $462 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $462 Remainder Subtract $0 GIE if not used above Equals $462 Remainder Subtract $65 Earned Income Exclusion Equals $397 Remainder Subtract $0 Impair. Related Work Exp. Equals $397 Remainder Divided by 2 Equals $198.50 Remainder Subtract $0 Work Expenses if Blind Equals $198.50 Total Countable Earned Income $200 Total Countable Unearned Income Plus $198.50 Total Countable Earned Income Equals $398.50 Countable Income Subtract $0 PASS Deduction Equals $398.50 Total Countable Income $579 Base SSI Rate Subtract $398.50 Total Countable Income Equals $180.50 SSI Payment Earned and unearned income set aside in a PASS is subtracted from the individual's total countable income, thus increasing the amount of the SSI payment received. In the previous example, for instance, without a PASS John would receive an SSI payment of $180.50. If a PASS were established to purchase job coach support services at $150 a month, for a work goal increase independence in the job site, the effect on the SSI payment is as follows: EXAMPLE: Effect of PASS on Unearned and Earned Income $220 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $200 Countable Unearned Income $462 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $462 Remainder Subtract $0 GIE if not used above Equals $462 Remainder Subtract $65 Earned Income Exclusion Equals $397 Remainder Subtract $0 Impair. Related Work Exp. Equals $397 Remainder Divided by 2 Equals $198.50 Remainder Subtract $0 Work Expenses if Blind Equals $198.50 Total Countable Earned Income $200 Total Countable Unearned Income Plus $198.50 Total Countable Earned Income Equals $398.50 Countable Income Subtract $150 PASS Deduction Equals $248.50 Total Countable Income $579 Base SSI Rate Subtract $248.50 Total Countable Income Equals $330.50 SSI Payment WORKSHEET: Effect of PASS on Unearned and Earned Income Mary receives $200 in CDB and $600 in gross monthly earnings. As an individual with a $175 PASS deduction, supporting her work goal, calculate how her payment is affected. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment Two Factors Affecting PASS and SSI Check Amount It is important to note that PASS will not always result in individuals recouping 100 percent of the dollar amount they are expending in a PASS. To be insured that the increase in the SSI check is equal to the amount spent in the PASS, the following two conditions must exist: * The total countable income is equal to, or less than, the FBR of $564; (more if State supplement involved); and, * The amount set aside in the PASS does not exceed the total countable income. Example: Expense Exceeds FBR The following is an example of a PASS calculated for an individual whose total countable income is greater that the FBR. Michael earns $450 in wages a month and receives a Social Security check of $450 (still in his TWP). If Michael were to set aside the full amount of his total countable income in a PASS to cover job coaching follow-along services, to increase his work productivity, his monthly SSI payment would be adjusted as follows: $450 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $430 Countable Unearned Income $450 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $450 Remainder Subtract $0 GIE if not used above Equals $450 Remainder Subtract $65 Earned Income Exclusion Equals $385 Remainder Subtract $0 Impair. Related Work Exp. Equals $385 Remainder Divided by 2 Equals $192.50 Remainder Subtract $0 Work Expenses if Blind Equals $192.50 Total Countable Earned Income $430 Total Countable Unearned Income Plus $192.50 Total Countable Earned Income Equals $622.50 Countable Income Subtract $622.50 PASS Deduction Equals $0 Total Countable Income $579 Base SSI Rate Subtract $0 Total Countable Income Equals $579 SSI Payment Worksheet: PASS Comparison While Michael will begin to receive an SSI check of $579 his monthly PASS expense will be $622.50. A comparison chart of his monthly finances with and without a PASS follows. Use the scenario in Example 13 and calculate Michael's possible benefits if he is not working, or working without a PASS. Not Working Income SSI Social Security Earnings Total Income Expenses Job Coaching Total Expenses Income Minus Expenses Total Income Working Without PASS SSI Social Security Earnings Total Income Expenses Job Coaching Total Expenses Income Minus Expenses Total Income Working with PASS SSI $579 Social Security $450 Earnings $450 Total Income $1,479 Expenses Job Coaching $622.50 Total Expenses $622.50 Income $1,479 Minus Expenses $622.50 Total Income $858.50 Michael will pay for his PASS expenses with the Social Security payments or his earnings. In this example, Michael recoups $579 of his $622.50 PASS expenditures. Because his monthly net income is being decreased by this amount, Michael must pay for the remaining $43.50 of his PASS expense. (The maximum dollar amount of federal SSI cash payment that can be received on a monthly basis is $579. This figure represents the maximum dollar amount (less state supplement) that individuals can recoup through SSI for goods and services paid for under a PASS. As a result, all persons with Total Countable Income over the combined amount will pay the difference out of their pocket, unless eligible for State supplement.) Example: Expense Exceeds Total Countable Income The following is an example of an individual who is setting aside more than her total countable income in a PASS. Mary earns $500 in wages a month and has no unearned income. Her total countable income is $207.50 prior to setting aside $350 a month in wages for a PASS expense associated with her work goal. $0 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $0 Countable Unearned Income $500 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $500 Remainder Subtract $20 GIE if not used above Equals $480 Remainder Subtract $65 Earned Income Exclusion Equals $415 Remainder Subtract $0 Impair. Related Work Exp. Equals $415 Remainder Divided by 2 Equals $207.50 Remainder Subtract $0 Work Expenses if Blind Equals $207.50 Total Countable Earned Income $0 Total Countable Unearned Income Plus $207.50 Total Countable Earned Income Equals $207.50 Countable Income Subtract $350 PASS Deduction Equals $0 Total Countable Income $579 Base SSI Rate Subtract $0 Total Countable Income Equals $579 SSI Payment As Mary has no countable income she begins to receive an SSI check of $579. However, while Mary's SSI check has increased by $207.50, her new PASS expense is $350. Her monthly finances with and without a PASS are as follows: Not Working Income SSI $579 Social Security $0 Earnings $0 Total Income $579 Expenses Job Coaching $0 Total Expenses $0 Income $579 Minus Expenses $0 Total Income $579 Working Without PASS SSI $371.50 Social Security $0 Earnings $500 Total Income $871.50 Expenses Job Coaching $350 Total Expenses $350 Income $871.50 Minus Expenses $350 Total Income $521.50 Working with PASS SSI $579 Social Security $0 Earnings $500 Total Income $1,079 Expenses Job Coaching $350 Total Expenses $350 Income $1,079 Minus Expenses $350 Total Income $729 Prior to establishing a PASS, Mary was receiving SSI payments in the amount of $371.50. Mary is therefore capable of increasing her payment by $207.50 ($579.00 -$371.50). Mary will pay for her PASS expenses using her earnings. She needs the SSI to pay for living expenses. WORKSHEET: PASS Exceeds FBR and Total Countable Income The following is an example of a PASS calculated for an individual whose total countable income is greater than the FBR. Brett earns $495 in wages a month and receives a Social Security check of $400 (still in his TWP). Set aside $695 of Michael's countable income in a PASS to cover job-coaching services. Unearned Income Subtract $20 General Income Exclusion (GIE) Equals Countable Unearned Income Gross Earned Income Subtract Student-Earned Income Exclusion Equals Remainder Subtract GIE if not used above Equals Remainder Subtract Earned Income Exclusion Equals Remainder Subtract Impair. Related Work Exp. Equals Remainder Divided by 2 Equals Remainder Subtract Work Expenses if Blind Equals Total Countable Earned Income Total Countable Unearned Income Plus Total Countable Earned Income Equals Countable Income Subtract PASS Deduction Equals Total Countable Income Base SSI Rate Subtract Total Countable Income Equals SSI Payment Effect of the One-Third Reduction Rule (Full In-Kind Support) In-kind support and maintenance is unearned income in the form of food, clothing, or shelter that is given to an eligible individual or is received because someone else pays for it. Whether someone else pays a living expense in full or just in part has a bearing on the amount of SSI cash benefits individuals receive. Individuals who live in someone else's household and receive both food and shelter and do not pay their pro rata share of the household expenses are subject to the full one-third reduction of their SSI benefits. This is referred to as the Value of the One-Third Reduction (VTR). Individuals falling into this category will have their SSI cash benefit reduced by one-third of the amount of the FBR. This reduction comes right off the top of their monthly benefit checks. The maximum amount of SSI that can be received by an individual who has a full in-kind support reduction is $386 ($579 - $193). A PASS will not help these individuals to increase their benefit to $579 (the SSI maximum benefit). The one-third reduction will be taken off the top of their SSI cash benefit, regardless of whether or not a PASS is used. An example follows: Jack receives SSI and will soon begin a new job earning $595 a month. Because Jack has a full in-kind support reduction, he currently receives $386 in SSI each month. Jack will need job coach support for his new job and intends to pay $405.66 a month for these services under a PASS. The following calculation shows how his SSI check will be affected given (1) his new earnings, (2) PASS expense, and (3) in-kind support reduction. Jack is eligible to receive $386 in SSI and $595 in wages for the job coaching services he needs under his work goal, and he recovers $255 of this in his SSI check (the amount he would not receive of SSI without a PASS). EXAMPLE: Calculating PASS with In-kind Support (VTR) (Earned Income Only) $0 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $0 Countable Unearned Income $595 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $595 Remainder Subtract $20 GIE if not used above Equals $575 Remainder Subtract $65 Earned Income Exclusion Equals $510 Remainder Subtract $0 Impair. Related Work Exp. Equals $510 Remainder Divided by 2 Equals $255 Remainder Subtract $0 Work Expenses if Blind Equals $255 Total Countable Earned Income $0 Total Countable Unearned Income Plus $255 Total Countable Earned Income Equals $255 Countable Income Subtract $405 PASS Deduction Equals $0 Total Countable Income $386 Base SSI Rate Subtract $0 Total Countable Income Equals $386 SSI Payment The Presumed Maximum Value Rule (Partial In-Kind Support) When the VTR rule does not apply ISM is determined using the Presumed Maximum Value Rule (PMV). For example, the PMV is used if the eligible individual has ownership interest or rental liability, separately purchases, or consumes food, gets only ISM, etc. SSA presumes that the maximum value of the support and maintenance an individual gets is no more than $213. They arrive at this figure by adding $20 to the one-third-reduction amount of $193. After subtracting a $20 general exclusion from the PMV, the reduction in the SSI check is $193. But, if the actual value of the ISM is less than the PMV, only the actual value is counted as ISM. For example, if a third party pays the household's electric bill which was $100, only $100 is counted as ISM and the $100 is divided equally among all the household members. If the household has four members, only $25 of ISM is counted for the SSI eligible individual. Individuals who have a partial in-kind support reduction and initiate a PASS are able to subtract the PASS expense from the PMV, making it possible to increase their SSI cash benefit amount to $579 (the maximum SSI payment amount). For individuals with a full in-kind support reduction (VTR) who are initiating a PASS, it may be in their best interest to begin contributing to the food and/or shelter expenses. Doing this may help them to recoup a greater amount of their PASS expenses through an increase in their SSI. The following example illustrates the benefits of taking this action. If Jack chooses to begin paying for his monthly food expenses, he will have a PMV in-kind support reduction. EXAMPLE: Calculating PASS with In-kind Support (PMV) (Earned Income Only) $213 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $193 Countable Unearned Income $595 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $595 Remainder Subtract $0 GIE if not used above Equals $595 Remainder Subtract $65 Earned Income Exclusion Equals $530 Remainder Subtract $0 Impair. Related Work Exp. Equals $530 Remainder Divided by 2 Equals $265 Remainder Subtract $0 Work Expenses if Blind Equals $265 Total Countable Earned Income $193 Total Countable Unearned Income Plus $265 Total Countable Earned Income Equals $458 Countable Income Subtract $405.66 PASS Deduction Equals $52.34 Total Countable Income $579 Base SSI Rate Subtract $52.34 Total Countable Income Equals $526.66 SSI Payment Deciding Between PASS and IRWE Many items or services, which are allowable under a PASS, may also meet criteria for exclusion as an IRWE. However, items or services may be excluded only under one of these two work incentive provisions at a time, when computing the amount of the SSI cash benefit to be received! It is not possible to set aside earnings under a PASS to purchase job coach services and at the same time subtract the expense of these services from monthly gross wages as an IRWE. At any given time, the expense of job coach services may be either a PASS or an IRWE for SSI cash benefit computation purposes. However, if the PASS goal has already been attained, it must be computed as an IRWE. When items or services meet criteria for both PASS and IRWE, it is better to establish a PASS because of the order in which these two exclusions are applied in the SSI benefit computation. An example of a vocational goal-related service calculated as an IRWE first and then as a PASS may best demonstrate the differences between the two work incentives. Two examples follow: Example: Calculating PASS and IRWE John must purchase job-coaching services to assist in his initial job training. The expense is $100 per month. This expense meets criteria for exclusion under both IRWE and PASS. John receives $414.50 a month in SSI and earns $300 in gross wages. His current monthly income is $714.50 from these sources. Once the expense is paid for, over and above his SSI check, John's spendable income is $644.50 without a PASS or IRWE. Below shows the impact of both PASS and IRWE on his usable income. IRWE $300 Gross wages Subtract $85 Exclusions Equals $215 Subtract $100 Cost of IRWE Equals $115 Countable earned income Divided /2 Equals $57.50 Total countable income $579 Base SSI Rate Subtract $57.50 Equals $521.50 SSI check $300 Wages Plus $521.50 SSI payment Equals $821.50 Monthly income Subtract $100 Cost of IRWE Equals $721.50 Monthly spendable income PASS $300 Gross wages Subtract $85 Exclusions Equals $215 Divided /2 Equals $107.50 Total countable income Subtract $100 PASS expense Equals $7.50 Revised countable income $579 Base SSI Rate Subtract $7.50 Total countable income Equals $571.50 SSI check $300 Wages Plus $571.50 SSI payment Equals $871.50 Monthly income Subtract $100 PASS expense Equals $771.50 Monthly spendable income The difference in the methods of calculating IRWE and PASS results in a 100 percent reimbursement of job coaching expense under PASS, and only a 50 percent reimbursement of the same expense under IRWE. As illustrated, it would be better for John to establish a PASS to pay for this expense. Some items established as a PASS may be switched to IRWE when the PASS exclusion is no longer available. Remember that it is usually better to use the PASS work incentive instead of the IRWE. Both options should be investigated with the assistance of the local SSA office to determine the best option for each situation. Concurrent PASS and IRWE It is permissible to have a PASS for one or more expenses and at the same time have an IRWE for other work-related expenses not covered by the PASS. The following case study and example illustrate the benefit of having a concurrent PASS and IRWE. EXAMPLE: Barbara is an SSI recipient with a disability. She is participating in a job-training program for which she is paid $400 monthly. She is currently excluding $50 per month (her contribution toward the cost of her physical therapy) as an IRWE. She decides to purchase a specifically modified van to allow her to continue the program pursue her work goal and secure employment. The van payment is determined to be excludable under a PASS at $350 per month. Barbara also receives $225 monthly in Social Security benefits. Without an IRWE or a PASS Barbara would qualify for an SSI payment of $206.50. $225 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $205 Countable Unearned Income $400 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $400 Remainder Subtract $0 GIE if not used above Equals $400 Remainder Subtract $65 Earned Income Exclusion Equals $335 Remainder Subtract $0 Impair. Related Work Exp. Equals $335 Remainder Divided by 2 Equals $167.50 Remainder Subtract $0 Work Expenses if Blind Equals $167.50 Total Countable Earned Income $205 Total Countable Unearned Income Plus $167.50 Total Countable Earned Income Equals $372.50 Countable Income Subtract $0 PASS Deduction Equals $372.50 Total Countable Income $579 Base SSI Rate Subtract $372.50 Total Countable Income Equals $206.50 SSI Payment EXAMPLE: Calculating Concurrent PASS and IRWE Using both the $350 PASS expense and IRWE enables Barbara to begin receiving an SSI payment of $579. $225 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $205 Countable Unearned Income $400 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $400 Remainder Subtract $0 GIE if not used above Equals $400 Remainder Subtract $65 Earned Income Exclusion Equals $335 Remainder Subtract $50 Impair. Related Work Exp. Equals $285 Remainder Divided by 2 Equals Equals $142.50 Remainder Subtract $0 Work Expenses if Blind Equals $142.50 Total Countable Earned Income $205 Total Countable Unearned Income Plus $142.50 Total Countable Earned Income Equals $347.50 Countable Income Subtract $350 PASS Deduction Equals $0 Total Countable Income $579 Base SSI Rate Subtract $0 Total Countable Income Equals $579 SSI Payment PASS and Social Security Remember that the PASS work incentive applies the SSI program and has no effect on the Social Security benefits received. However, some expenses paid for under a PASS also meet the criteria for exclusion as an IRWE. (When expenses meet the criteria for PASS and IRWE, the expense can be counted as a PASS for SSI payment calculation and also computed as an IRWE for on-going SGA determinations for Social Security.) The following example illustrates how this can be financially beneficial to individuals receiving both SSI and Social Security. Mark currently receives both SSI and $300 in Social Security. During previous employment he completed his TWP for Social Security. He is in his EPE for Social Security at the present time. Mark recently started a new job and is earning $850 monthly. He is in need of job coach support services that will cost $300 monthly which will assist him in preparing for a better paying job inadvertently offsetting the loss of all his benefits. If Mark does not use a work incentive to pay for this service he will lose his Social Security check immediately. His Social Security will stop with this new job because his earnings are over the SGA level. This is illustrated in the following calculation: EXAMPLE: Example Without PASS Applied $0 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $0 Countable Unearned Income $850 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $850 Remainder Subtract $20 GIE if not used above Equals $830 Remainder Subtract $65 Earned Income Exclusion Equals $765 Remainder Subtract $0 Impair. Related Work Exp. Equals $765 Remainder Divided by 2 Equals Equals $382.50 Remainder Subtract $0 Work Expenses if Blind Equals $382.50 Total Countable Earned Income $0 Total Countable Unearned Income Plus $382.50 Total Countable Earned Income Equals $382.50 Countable Income Subtract $0 PASS Deduction Equals $382.50 Total Countable Income $579 Base SSI Rate Subtract $382.50 Total Countable Income Equals $196.50 SSI Payment Because Mark will lose his Social Security, his spendable income will consist only of his $850 earnings and $196.50 SSI check. In addition, he is still faced with the $300 job coach expense. If Mark decides to establish a PASS to pay for the job coaching expense as part of a work goal, he will be able to retain $206.50 in SSI. (See the following calculation). Because job coaching also meets criteria for the IRWE exclusion, this expense will be deducted from his gross earnings before the SGA determination is made for Social Security. His countable earnings are now $550 ($850 - $300). Since his countable income is below the SGA level, he will maintain his $300 Social Security payment as well. EXAMPLE: SSI Example With PASS Applied $300 Unearned Income Subtract $20 General Income Exclusion (GIE) Equals $280 Countable Unearned Income $850 Gross Earned Income Subtract $0 Student-Earned Income Exclusion Equals $850 Remainder Subtract $0 GIE if not used above Equals $850 Remainder Subtract $65 Earned Income Exclusion Equals $785 Remainder Subtract $0 Impair. Related Work Exp. Equals $785 Remainder Divided by 2 Equals Equals $392.50 Remainder Subtract $0 Work Expenses if Blind Equals $392.50 Total Countable Earned Income $280 Total Countable Unearned Income Plus $392.50 Total Countable Earned Income Equals $672.50 Countable Income Subtract $300 PASS Deduction Equals $372.50 Total Countable Income $579 Base SSI Rate Subtract $372.50 Total Countable Income Equals $206.50 SSI Payment Mark's spendable income using the work incentives is $1,356.50. $850 Wages Plus $300 Social Security Plus $206.50 SSI Equals $1,356.50 TOTAL INCOME After Mark pays for his $300 PASS expense he will have $1,056.50 remaining. Final Comments on PASS Following are some additional highlights to the PASS Program outlined in Carolyn Colvin's statement on December 1, 1997: * Anyone whose PASS was terminated or denied after March 1996 will be contacted, informed of the 12/1/97 changes to the Program, and invited to submit a new PASS. * PASS reviews will continue to include current stewardship requirements, but will be more proactive and supportive. The PASS Specialists will augment these reviews with periodic telephone calls. These calls will help the PASS Specialist and the individual identify and remedy actual or potential problems before they affect the integrity of the PASS, and should improve chances for successful completion. * SSA will place emphasis on flexibility in amending a PASS retroactively when changes have occurred that do not compromise the integrity of the plan. PASS Case Study Sharon is 19, a student in school, due to graduate this spring. She is excited about the possibility of going to college and eventually being on her own. Sharon has cerebral palsy, uses a motorized wheelchair, and has use of her arms and hands but has very little strength in them, so needs assistance to transfer, to finish dressing, etc. She is a good student and is very motivated to keep learning. Sharon's goal is to become an elementary school teacher, and she wants to attend Peabody Teachers' College, a private school about 30 miles from her home. She has an open VR file, and they have agreed to pay about half of the cost of tuition and books ($2,700/semester; equivalent to a state university), but she must apply for grants first. Sharon would like to live on campus, and she would like to get a van and adapt it for her own use. She took a driver's evaluation, and they report that she is a good candidate for driver's education class. She has priced a van and it would cost nearly $20,000. VR is open to considering paying for modifications, if she has the van. Sharon currently lives with her retired parents, and she receives $66 (VTR) SSI and $345 Title II. She has saved no money, and her parents are not in a position to help her very much with costs of college. Directions: Divide into groups of 4-5. Select a group facilitator and reporter. Read through the case study and answer the following questions together. Report out as requested. 1. List three factors that might make Sharon a likely candidate for a PASS. 2. Given Sharon's vocational goal, list some possible milestones to accomplish it. 3. Brainstorm a possible list of monetary resources for each expense associated with reaching the goal (as best you can anticipate them). 4. What might be some decisions that Sharon would need to make if she pursues using a PASS as a major funding source for accomplishing her goal? PASS Format Following is a PASS format and directions prescribed by SSA. Page 1 of Form SSA-545-BK (2/99) PLAN FOR ACHIEVING SELF-SUPPORT Date Received________________________ In order to minimize recontacts or processing delays, please complete all questions and provide thorough explanations where requested. If you need additional space to answer any questions use the Remarks section or a separate sheet of paper. Name_____________________________________SSN_______________________________ PART I - YOUR WORK GOAL A. What is your goal? (Show the specific job you expect to have at the end of the plan. If you do not yet have a specific work goal and will be working with a vocational professional to find a suitable job match, show "VR Evaluation," be sure to complete Part II, question F on page 4. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working __________ per week/month (circle one). Show the number of hours of job coaching you expect to receive after the plan is completed. __________ per week/month (circle one). B. Describe the duties you expect to perform in this job. Be as specific as possible (standing, walking, sitting, lifting stooping, bending, contact with the public, writing reports/documents, etc.) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ C. How did you decide on this work goal and what makes this job attractive to you? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ D. If your work goal does not involve self-employment, how much do you expect to earn each month (gross) after your plan is completed? $__________/month End of Page 1 Form SSA-545-BK (2/99) E. If your work goal involves self-employment, explain why working for yourself will make you more self-supporting than working for someone else. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ NOTE: If you plan to start your own business, attach a detailed business plan. At a minimum the business plan must include the type of business; products or services to be offered by your business; a description of the market for the business; the advertising plan; technical assistance needed; tools, supplies, and equipment needed; and a profit-loss projection for the duration of the PASS and at least one year beyond its completion. Also include a description of how you intend to make this business succeed. F. Did someone help you prepare this plan? ___ YES ___ NO If "NO," skip to G. If "YES," show the name, address and telephone number of that individual or organization. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ May we contact them if we need additional information about your plan? ___ YES ___ NO Do you want us to send them a copy of our decision on your plan? ___ YES ___ NO Are they charging you a fee for this service? ___ YES ___ NO If "YES," how much are they charging? ____________________________ G. Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? ___ YES ___ NO If "NO," skip to Part II. If "YES," complete the following: Was a PASS ever approved for you? ___ YES ___ NO If "NO," skip to Part II. If "YES," complete the following: When was your most recent plan approved (month/year)?__________________________ What was your work goal in that plan?__________________________________________ Did you complete that PASS? ___ YES ___ NO If "NO," why weren't you able to complete it? __________________________________ ________________________________________________________________________________ ________________________________________________________________________________ If "YES," why weren't you able to become self-supporting?_______________________ ________________________________________________________________________________ Why do you believe that this new plan you are requesting will help you go to work? __________________________________________________________________________ End Page 2 Form SSA-545-BK (2/99) PART II - MEDICAL/VOCATIONAL BACKGROUND A. What are your disabling illnesses, injuries, or conditions?_______________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ B. Describe any limitations you have because of your disability (e.g., limited amount of standing or lifting, stooping, bending, or walking; difficulty concentrating; unable to work with other people, difficulty handling stress, etc.) Be specific. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ In light of the limitations you described, how will you carry out the duties of your work goal? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ C. List the jobs you have had most often in the past few years. Also list any jobs, including volunteer work, which are similar to your work goal or which provided you with skills that may help you perform the work goal. List the dates you worked in these jobs. Identify periods of self-employment.If you were in the Army, list your Military Occupational Specialty (MOS) code; for the Air Force, listyour Air Force Specialty (AFSC) code; and for the Navy, Marine Corps, and Coast Guard, list your RATE. Job Title Type of Business Dates Worked End of Page 3 Form SSA-545-BK (2/99) D. Circle the highest grade of school completed. 0 1 2 3 4 5 6 7 8 9 10 11 12 GED or High School Equivalency College: 1 2 3 4 or more 1. Were you awarded a college or postgraduate degree? ___ YES ___ NO When did you graduate?_________________________ What type of degree did you receive? (B.A., B.S., M.B.A., etc.) _________ In what field of study?__________________________________________________ 2. Did you attend special education classes? ___ YES ___ NO If "NO," skip to E. If "YES," complete the following: Name of school __________________________________________________________ Address___________________________________________________________________ Dates attended: From _____________________ To ______________________ Type of program__________________________________________________________ E. Have you completed any type of special job training, trade or vocational school? ___ YES ___ NO If "NO," skip to F. If "YES," complete the following: Type of training _________________________________________________________ Date completed ___________________________________________________________ Did you receive a certificate or license? ___ YES ___ NO If "NO," skip to F. If "YES," what kind of certificate or license? __________________________________________________________________________ __________________________________________________________________________ F. Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? ___ YES ___ NO If "YES," attach a copy of the evaluation and skip to Part III (page 5). If you cannot attached a copy, complete the following: When were you evaluated or when do you expect to be evaluated or when was the IWRP or IEP done or when do you expect it to be done? ________________ Show the name, address, and phone number of the person or organization who evaluated you or will evaluate you or who prepared the IRWP or IEP or will prepare the IWRP or IEP. __________________________________________________________________________ End of Page 4 Form SSA-545-BK (2/99) Part III - Your Plan I want my Plan to begin ___________________________________________(month/year) and my Plan to end_________________________________________________(month/year) List the steps, in sequence that you will take to reach this goal. Be as specific as possible. If you will be attending school, show the courses you will study each quarter/semester. Include the final steps to find a job one you have obtained the tools, education, services, etc., that you need. Step: Beginning Date: Completion Date: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ End Page 5 Form SSA-545-BK (2/99) PART IV - EXPENSES A. If you propose to purchase, lease, or rent a vehicle, please provide the following additional information: 1. Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2. Do you currently have a valid driver's license? ___ YES ___ NO If "YES," skip to 3. If "NO," complete the following: Who will drive the vehicle?______________________________________________ How will it be used to help you with your work goal?_____________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 3. If you are proposing the purchase a vehicle, explain why renting or leasing are not sufficient. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 4. Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ End of Page 6 Form SSA-545-BK (2/99) B. If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative (e.g., rental or a computer or purchase of a less expensive model) will not allow you to reach your goal. Explain why you need the capabilities of the particular computer/equipment you identified. Also, if you attend (or will attend) a school with a computer lab for student use, explain why use of that facility is not sufficient to meet your needs. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ C. Other than the items identified in A or B above, list the items or services you are buying or renting or will need to buy or rent in order to reach your work goal. Be as specific as possible. If schooling is an item, list tuition, fees, books, etc. as separate items. List the cost for the entire length of time you will be in school. Where applicable, include brand and model number or the item. (Do not include expenses you were paying prior to the beginning of your plan; only additional expenses incurred because of your plan can be approved.) NOTE: Be sure that Part III shows when you will purchase these items or services or training. 1. Item/service training _________________________Cost $ _____________ Vendor provider ___________________________________________________ How will this help you reach your work goal? ______________________ ___________________________________________________________________ How did you determine the cost? ___________________________________ ___________________________________________________________________ Why wouldn't something less expensive meet your needs? ____________ ___________________________________________________________________ ___________________________________________________________________ 2. Item/service training ________________________Cost $ ______________ Vendor provider ___________________________________________________ How will this help you reach your work goal? _______________________ ____________________________________________________________________ How did you determine the cost? ____________________________________ ____________________________________________________________________ Why wouldn't something less expensive meet your needs? _____________ ____________________________________________________________________ ____________________________________________________________________ End of Page 7 Form SSA-545-BK (2/99) 3. Item/service training _________________________Cost $ ______________ Vendor provider ___________________________________________________ How will this help you reach your work goal? ______________________ ___________________________________________________________________ How did you determine the cost? ___________________________________ ___________________________________________________________________ Why wouldn't something less expensive meet your needs? ____________ ___________________________________________________________________ ___________________________________________________________________ 4. Item/service training _________________________Cost $ _____________ Vendor provider ___________________________________________________ How will this help you reach your work goal? ______________________ ___________________________________________________________________ How did you determine the cost? ___________________________________ ___________________________________________________________________ Why wouldn't something less expensive meet your needs? ____________ ___________________________________________________________________ ___________________________________________________________________ 5. Item/service training _________________________Cost $ _____________ Vendor provider ___________________________________________________ How will this help you reach your work goal? ______________________ ___________________________________________________________________ How did you determine the cost? ___________________________________ ___________________________________________________________________ Why wouldn't something less expensive meet your needs? ____________ ___________________________________________________________________ ___________________________________________________________________ End Page 8 Form SSA-545-BK (2/99) D. If you indicated in Part II (page 4) that you have a college degree or specialized training, and your plan includes additional education or training, explain why the education/training you already received is not sufficient to allow you to be self-supporting. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ E. What are your current expenses each month (rent, food, utilities, phone, property taxes, homeowner's insurance automobile repair and maintenance, public transportation costs, clothes, laundry/dry cleaning, charity contributions, etc.)? $__________/month If the amount of income you will have available for living expenses after making payments or saving money for your plan expenses is less than your current living expenses, explain how you will pay for your living expenses. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ End Page 9 Form SSA-545-BK (2/99) PART V - FUNDING FOR WORK GOAL A. Do you plan to use any items you already own (e.g., equipment or property) to reach our work goal? ___ YES ___ NO If "NO," skip to B. If "YES," complete the following: Item______________________________________________________________________ Value_____________________________________________________________________ How will this help you reach your work goal?______________________________ __________________________________________________________________________ Item______________________________________________________________________ Value_____________________________________________________________________ How will this help you reach your work goal?______________________________ __________________________________________________________________________ B. Have you saved any money to pay for the expenses listed on pages 6-8 in Part IV? (Include cash on hand or money in a bank account.) ___ YES ___ NO If "NO," skip to C. C. Do you receive or expect to receive income other than SSI payments? ___ YES ___ NO If "NO," skip to F. If "YES," provide details as follows: Type of Income Amount Frequency (Weekly, Monthly, Yearly) D. How much of this income will you use each month to pay for the expenses listed in Part IV? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ End of Page 10 Form SSA-545-BK (2/99) E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? ___ YES ___ NO If "NO," skip to F. If "YES," how will you keep the money separate from other money you have? (If you will keep the savings in a separate bank account, give the name and address of the bank and the account number.) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ F. Will any other person or organization (e.g., Vocational Rehabilitation, school grants, Job Partnership Training Assistance (JTPA) pay for or reimburse you for any part of the expenses listed in Part IV or provide any other items or services you will need? ___ YES ___ NO If "NO," skip to Part VI. Who will pay Item/Service Amount When will the item/service be purchased PART VI - REMARKS __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ PART VII -- AGREEMENT If my plan is approved, I agree to: ___ Comply with all of the terms and conditions of the plan as approved by the Social Security Administration (SSA); ___ Report any changes in my plan to SSA immediately End of Page 11 Form SSA-545-BK (2/99) ___Keep records and receipts of all expenditures I make under the plan until asked to provide them to SSA. ___Use the income or resources set aside under the plan only to buy the items or services shown in the plan as approved by SSA. I realize that if I do not comply with the terms of the plan or if I use the income or resources set aside under my plan for any other purpose, SSA will count the income or resources that were excluded and I may have to repay the additional SSI I received. I also realize that SSA may not approve any expenditures for which I do not submit receipts or other proof of payment. I know that anyone who makes or causes to be made a false statement or representation of material fact in an application for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal Law and/or State Law. I affirm that all the information I have given on this form is true. Signature ______________________________________Date___________________________ Address________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Telephone: Home___________________________________ Work___________________________________ End Page 12 Form SSA-545-BK (2/99) PRIVACY ACT STATEMENT The Social Security Administration is allowed to collect the information on this form under section 1631 (e) of the Social Security Act. We need this information to determine if we can approve your plan for achieving self-support. Giving us this information is voluntary. However, without it, we may not be able to approve your plan. Social Security will not use the information for any other purpose. We would give out the facts on this form without your consent only in certain situations. For example, we give out this information if a Federal law requires us to or if your Congressional Representative or Senator needs the information to answer questions you ask them. PAPERWORK REDUCTION ACT NOTICE AND TIME IT TAKES STATEMENT The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. We estimate that it will take you about 120 minutes to complete this form. This includes the time it will take to read the instruction, gather the necessary facts and fill out the form. End of Page 13 Form SSA-545-BK (2/99) OUR RESPONSIBILITIES TO YOU We received the plan for achieving self-support (PASS) on _____________________. Your plan will be processed by Social Security employees who are trained to work with PASS. The PASS expert handling your case will work directly with you. He or she will look over the plan as soon as possible to see if there is a good chance that you can meet your work goal. The PASS expert will also make sure that the things you want to pay for are needed to achieve your work goal and are reasonably priced. If changes are needed, the PASS expert will discuss them with you. Your may contact the PASS expert toll-free at 1-______________________________. YOUR REPORTING AND RECORDKEEPING RESPONSIBILITIES If we approve your plan, you must tell Social Security about any changes to your plan. You must tell us if: Your medical condition improves. You are unable to follow your plan. You decide not to pursue your goal or decide to pursue a different goal. You decide that your do not need to pay for any of the expenses you listed in your plan. Someone else pays for any of your plan expenses. You use the income or resources we exclude for a purpose other than the expense specified in your plan. There are any other changes to your plan. You must tell us about any of these things within 10 days following the month in which it happens. If you do not report any of these things, we may stop your plan. You should also tell us if you decide that you need to pay for other expenses not listed in your plan in order to reach your goal. We may be able to change your plan or change the amount of income we exclude so you can pay for the additional expenses. YOU MUST KEEP RECEIPTS OR CANCELLED CHECKS TO SHOW THAT EXPENSES YOU PAID FOR AS PART OF THE PLAN. You need to keep these receipts or cancelled checks until we contact you to find out if you are still following your plan. When we contact you, we will ask to see the receipts or cancelled checks. If you are not following the plan, you may have to pay back the some or all of the SSI you received. End of Page 14 End of Form SSA-545-BK (2/99) PASS Review Process Initial PASS applications will be reviewed for compliance with POMS (SI E00870.000). Once an initial PASS application has been received by the field office, it will then be forwarded to a PASS specialist within a day for approval, modification, or denial. A PASS specialist will review the application using the "Initial PASS Checklist" below and will work directly with the PASS applicant to complete development of the PASS. Exhibit 1 -- Initial PASS Checklist Initial PASS Checklist I. Goal A. Is the goal a specific occupation or "VR Evaluation?" ___Yes ___No B. Does the individual have a reasonable chance of achieving the goal? ___Yes ___No C. If successful, will the goal result in sufficient earned income to significantly reduce/eliminate SSI or eliminate Social Security? ___Yes ___No NOTE: If A, B, or C are answered "No," the PASS must be modified (or denied if modification not appropriate). D. Was a personal contact made with the individual to ensure an understanding of PASS purpose and rules? ___Yes ___No E. Does the plan specify the total time necessary to reach the goal? ___Yes ___No II. PASS Expenses A. Are all expenses directly related to achieving the goal? ___Yes ___No B. Have less expenses alternatives been considered? ___Yes ___No C. Are all expenses reasonable? ___Yes ___No D. Does the individual have sufficient income to pay PASS expenses and normal living expenses? ___Yes ___No E. Are PASS funds being kept separate from other funds? ___Yes ___No III. Third Party Involvement A. If a PASS development fee was charged, does the plan provide details on: 1. the specific services provided ___Yes ___No 2. the number of hours spent by the third party on each service ___Yes ___No 3. the hourly rate charged by the third party ___Yes ___No Is the hourly rate reasonable for the local area? ___Yes ___No B. Is there a completed and signed SSA-3288 in file? ___Yes ___No IV. Decision A. Is the PASS signed? ___Yes ___No B. If appropriate, was the individual given the opportunity to modify the PASS? ___Yes ___No C. Have the proper notices been sent (including copies to a representative payee, an authorized representative or any other person/organization authorized by the individual to receive the notice)? ___Yes ___No D. Has the income/resources exclusion been posted to the SSR? ___Yes ___No E. Has the CG field been annotated for a resource exclusion? ___Yes ___No F. Has a copy of all PASS material (i.e., plan, addenda, documentation and notice(s)) been placed in FO PASS file? ___Yes ___No Once the review is completed, the PASS specialist will either request additional documentation from the applicant or release the approval or denial notice. Should a PASS application be denied, the applicant can request a redetermination by another PASS specialist. Progress reviews will be conducted at intervals determined by the PASS specialist and at least every 12 months. Reviews will be done using the following "PASS Progress Review" along with periodic phone calls from cadre members to identify and remedy actual or potential problems before they affect the integrity of the PASS. Exhibit 2 -- PASS Progress Review PASS Progress Review I. Goal A. Is the individual working in the job or business as specified in the plan? ___Yes ___No If "Yes," skip to Part II. B. Is the individual still following the plan as approved (i.e., has the person completed the milestones on time)? ___Yes ___No C. Has the timeframe for completing the plan changed? ___Yes ___No II. PASS Expenses A. Are all approved expenses paid? ___Yes ___No B. Have the PASS funds been used only for approved expenses? ___Yes ___No C. Have any of the expenditures been paid by another person or organization (other than a deemer)? ___Yes ___No D. Has the person been reimbursed from any source for any of the expenditures? ___Yes ___No E. Total amount excluded to date: $ __________ F. Total allowable expenditures to date: $ __________ G. If exclusion exceeds expenditures, are excess funds being kept separate from other funds? ___Yes ___No H. Has there been any change in the individual's income or resources that requires a change in the PASS? ___Yes ___No I. Is resumption of PASS after suspension an issue? ___Yes ___No III. Decision A. What is the status of the PASS? 1. Individual has reached work goal ___Yes ___No If "Yes," skip to B.2. 2. Individual has abandoned plan ___Yes ___No If "Yes," skip to B.1. 3. Individual is in compliance with plan or amendment ___Yes ___No If "Yes," go to B.1. If "No," go to B.2. B. What is the result of the review? 1. Extend PASS ___Yes ___No Continue with current plan ___Yes ___No Continue only with amendment ___Yes ___No PASS extended until _______________ 2. Stop PASS ___Yes ___No Suspension of plan ___Yes ___No Termination of plan ___Yes ___No PASS being stopped as of _______________ C. Have the proper notices been sent (including copies to a representative payee, an authorized representative, or any other person/organization authorized by the individual to receive the notice)? ___Yes ____No D. Has the income exclusion been adjusted on the SSR? ___Yes ___No E. If the PASS is being suspended or terminated, has a final accounting been done? ___Yes ___No SSI / Social Security Comparison Chart SSI - Below Age 18 No Trial Work Period (TWP), Extended Period of Eligibility (EPE), or unsuccessful work attempt provisions) SSI - Above Age 18 No Trial Work Period (TWP), Extended Period of Eligibility (EPE), or unsuccessful work attempt provisions) Social Security - Above Age 18 TWP, EPE, and unsuccessful work attempt provisions provided to individuals who are blind or non-blind SSI - Below Age 18 Credit for subsidy at initial eligibility determination SSI - Below Age 18 Credit for subsidy at initial eligibility determination Social Security - Above Age 18 Credit for subsidy SSI - Below Age 18 Credit for Impairment-Related Work Expense (IRWE) SSI - Above Age 18 Credit for Impairment-Related Work Expense (IRWE) Social Security - Above Age 18 Credit for IRWE SSI - Below Age 18 Credit for Blind-Work Expenses (BWE) SSI - Above Age 18 Credit for Blind Work Expense (BWE) Social Security - Above Age 18 Not applicable SSI - Below Age 18 Credit for Student-Earned Income Exclusion (SEIE) SSI - Above Age 18 Credit for Student-Earned Income Exclusion (SEIE) (up to age 22) Social Security - Above Age 18 Not applicable SSI - Below Age 18 Credit for Plan for Achieving Self-Support (PASS) (beginning at age 15) SSI - Above Age 18 Credit for Plan for Achieving Self-Support (PASS) Social Security - Above Age 18 Not applicable SSI - Below Age 18 Credit for Property Essential to Self Support (PESS) SSI - Above Age 18 Credit for Property Essential to Self Support (PESS) Social Security - Above Age 18 Not applicable Concurrent Exercise SSDI/SSI Work Incentives Review Exercise Zoey is a 20 year-old concurrent CDB beneficiary/SSI recipient who also has both Medicaid and Medicare coverage. She receives childhood disability benefits on her deceased father's work record in the amount of $300 per month and an SSI check of $299. She currently has no other forms of unearned income, is not receiving any in-kind support and maintenance, and is single and lives alone. She has not worked in the past, but recently received her "ticket" from the SSA and considering seeking services from the local employment network. 1. Before you offer advice, what are some indicators related to Zoey's potential use of work incentives that you should explore? 2. Assuming no potential exists for special work incentives, what would be the immediate effect of part-time employment generating $600 per month on Zoey's cash benefits and medical insurance? 3. What would be the effect on her cash benefits and medical insurance if she continues to work at this level of earnings for 13 continuous months? 4. What would happen to her cash benefits and medical insurance if Zoey increased her work hours in the 24th month of employment resulting in gross earnings of $900 per month? 5. If Zoey quit her job after 40 months of employment what would happen to her benefits? 6. What would happen if Zoey had to quit after 50 months of employment? SECTION FOUR: IMPACT OF EARNINGS ON OTHER SUPPORT PROGRAMS Objectives 1. Understand the Temporary Assistance for Needy Families and Food Stamp Programs and their impact on Supplemental Security Income and Social Security Disability Insurance. 2. Identify need for access and maneuver federal subsidy programs in light of Supplemental Security Income and Social Security Disability Insurance. 3. Knowledge of Unemployment Insurance and its impact on Supplemental Security Income and Social Security Disability Insurance. 4. Under Workers' Compensation and its impact on Supplemental Security Income and Social Security Disability Insurance. 5. Understand Earned Income Tax Credit and its impact on Supplemental Security Income and Social Security Disability Insurance. 6. Knowledge of Medicaid and State Child Health Insurance Program rules. CHAPTER 13: TEMPORARY ASSISTANCE FOR NEEDY FAMILIES AND FOOD STAMPS Temporary Assistance for Needy Families (TANF) Excerpted in part from TANF Report to Congress; www.acf.dhhs.gov and from State Policy Documentation Project, TANF data notes; www.spdp.org The Temporary Assistance for Needy Families (TANF) program was created August 22, 1996 by the Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104-193). It replaces the Aid to Families with Dependent Children (AFDC) program, the Job Opportunities and Basic Skills Training (JOBS) program, and the Emergency Assistance (EA) program. The overall objective is to promote work, responsibility, and self-sufficiency. TANF has a two-fold mission: * To assist families with dependent children to meet transitional financial need; and * To help these families become self-sufficient. To carry out the first mission, TANF funds may be used to provide needy families time-limited transitional cash assistance. Most commonly, these are single parent families. In most cases, individuals with disabilities will be referred and assisted with applying for SSA benefits by the state agency who implements the state's TANF program, as the SSA requirements are more lenient regarding requirement of work and the benefits may be more long-term. However, if an individual does not qualify for SSA benefits, or receives a very small amount, the person may receive TANF instead of or as a supplement of the benefit. This would be determined by whether the individual meets the requirements of his state for TANF recipiency. Unlike AFDC, which was a federal entitlement program, with money and specific guidelines going to each state, TANF funds are provided as a block grant to states and certain tribes under broad Federal guidelines. Under the new law, states were required to submit a state plan to the Secretary that outlined how the state intended to conduct a program in all political subdivisions that provide cash aid to needy families with (or expecting) children and that provide parents with job preparation, work and support services. States and tribes have great flexibility to determine the range of benefits and services that they will provide; therefore, it is impossible to give general parameters regarding financial eligibility, work requirements, etc., as these differ greatly from state to state. TANF gives each block grant recipient the opportunity to design programs that meet the specific needs of recipients within their jurisdiction and allows them to develop their own strategies for achieving program goals, including how to help recipients move into the work force. TANF funds may not be used to provide assistance to any family for a period longer than 60 months in a lifetime, although a state may choose to provide assistance for a shorter period of time. In addition, families receiving assistance under the TANF program are automatically eligible for services under the Child Support Enforcement program, created by the same law as TANF. Any current child support collected by this program reimburses the state and federal governments for TANF payments to the family. (These child support services are also available to non-TANF families who apply for such services, with collections of child support payments being sent directly to the family.) Characteristics of Each State Program Funded Under TANF Work First Strategies The central goal of TANF is to move welfare recipients into work. The law reflects this goal in several ways. With few exceptions, it requires all adults receiving assistance to work or participate in work activities. Under the TANF, parents or caretakers receiving assistance are required to engage in work when determined ready or within 24 months. States may impose work requirements sooner, as over 35 states currently do. Recipients who lose eligibility because of employment are entitled to a transitional period of Medicaid benefits. Almost all of the states have moved to "Work First" models in their welfare programs, requiring recipients to move quickly into available jobs. Nearly, every state requires TANF recipients and applicants to complete an Individual Responsibility Plan (IRP) in which recipients agree to specific steps toward self-sufficiency. States are enforcing these agreements, sanctioning people who fail to sign or live up to their agreements. States include sanctions that can remove the entire family from assistance where a parent refuses to cooperate with work requirements. However, states have the option to exempt single parents to work requirements who have children up to one year of age. At the beginning of 2000, 42 states had enacted policies to make-work pay, generally by increasing the amount of earnings disregarded in calculating welfare benefits. For example, Connecticut now disregards all earnings up to the poverty level. Most states have also simplified the treatment of earnings compared to the AFDC treatment. In conjunction with this process, by 2000, 43 states raised the level of resources and/or maximum value of a vehicle allowed to welfare recipients. This will make it easier for recipients to get to work and to accumulate savings that might lead to self-sufficiency. States may also establish exemption of resources kept in an Individual Development Account (IDA) established by a TANF applicant or recipient. IDAs are restricted accounts for post-secondary education, first home purchase, or business capitalization. Over thirty states exempt IDAs, with the excluded amount ranging from $1,000 to unlimited. Time Limits Families who have received assistance for five cumulative years (or less at state option) will be ineligible for cash aid under the new law. States are permitted to exempt up to 20 percent of their caseload from the time limit, and they have the flexibility to determine the criteria by which are excluded from being subject to the time limit. However, the law does require states to exempt the following: families not containing an adult receiving assistance; months of assistance received by an adult as a minor; not the head of household or married to the head of household; and any month in which the family lived on an Indian reservation with unemployment rates above 50 percent. Almost all states exempt persons with significant disabilities as part of the 20 percent allowance. States have the option to provide cash and non-cash assistance and vouchers to families who reach the time limit using a Social Services Block Grant or state funds. The most striking features of state policies regarding time limits are their variety and complexity. Many states have chosen intermittent time limits that limit the consecutive month of recipiency allowed within a longer time period. (For example, Virginia limits TANF receipt to 24 months in any 60-month period.) Nine states have chosen time limits of less than five years, but often with exceptions or exemptions. Twenty-seven states have chosen the federal limit of 60 months. Four states have chosen other options involving supplements from state welfare programs for those reaching federal limits. Emergency Cash Assistance Many states have provisions for making temporary payments for non-TANF recipients in emergency situations as part of their TANF programs. This may be a very helpful resource to SSI/SSDI recipients who lose benefits unexpectedly or who are waiting for an eligibility determination to be made when unemployed. Devolution Several states, including New York and California, are devolving key policy and program decisions to counties, which is allowed under the TANF laws. Several other states are in the process of devolving decisions about work activities and sanctions, and some are passing on decisions about factors such as eligibility to the counties. Benefit levels will still be determined at the state level, although in some cases the state will mandate a basic package, which counties can choose to exceed. TANF and SSI States have a great deal of flexibility in how they treat SSI benefits received by one or more TANF family members; however, universally, in some circumstances, a child may receive SSI while the family receives TANF. Therefore, if the TANF family parent becomes employed, earnings may affect the child's payment. This is very state-specific and one must understand a particular state's rules to accurately predict concurrent SSI and TANF. TANF and SSDI In most circumstances, the amount of SSDI that a beneficiary and his dependents receive will cause them to be financially ineligible for TANF. However, if the SSDI amount is low, but the person doesn't receive a concurrent SSI check due to excess resources, then the person could possibly receive TANF if the resources are not in excess of the state-specific resource limit. Furthermore, as with SSI, states have tremendous flexibility as to how they treat SSDI benefits in the test for TANF. State TANF Excerpted from http://www.spdp.org/ tanf/tanfdatnote.htm Abbreviations and Acronyms EA Emergency Assistance FPL Federal Poverty Level GA General Assistance HHS U.S. Department of Health and Human Services State - Alabama Name of TANF Cash Assistance Program - Family Assistance State - Alaska Name of TANF Cash Assistance Program - Alaska Temporary Assistance Program (ATAP) State - Arizona Name of TANF Cash Assistance Program - Employing and Moving People Off Welfare and Encouraging Responsibility (EMPOWER) State - Arkansas Name of TANF Cash Assistance Program - The Transitional Employment Assistance (TEA) State - California Name of TANF Cash Assistance Program - California Work Opportunity and Responsibility to Kids Program (CalWORKs) State - Colorado Name of TANF Cash Assistance Program - Colorado Works State - Connecticut Name of TANF Cash Assistance Program - Jobs First/Temporary Family Assistance State - Delaware Name of TANF Cash Assistance Program - A Better Chance (ABC) State - DC Name of TANF Cash Assistance Program - Temporary Assistance to Needy Families State - Florida Name of TANF Cash Assistance Program - Work and Gain Economic Self Sufficiency (WAGES) State - Georgia Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families Act (TANF) State - Hawaii Name of TANF Cash Assistance Program - Pursuit of New Opportunities (PONO) State - Idaho Name of TANF Cash Assistance Program - Temporary Assistance for Families in Idaho (TAFI) State - Illinois Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - Indiana Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - Iowa Name of TANF Cash Assistance Program - Family Investment Program (FIP) State - Kansas Name of TANF Cash Assistance Program - Temporary Assistance for Families (TAF) State - Kentucky Name of TANF Cash Assistance Program - Kentucky Transitional Assistance Program (K-TAP) State - Louisiana Name of TANF Cash Assistance Program - Family Independence Temporary Assistance Program (FITAP) State - Maine Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - Maryland Name of TANF Cash Assistance Program - Family Investment Program (FIP) Cash assistance component is Temporary Cash Assistance (TCA) State - Massachusetts Name of TANF Cash Assistance Program - Transitional Aid to Families with Dependent Children (TAFDC) State - Michigan Name of TANF Cash Assistance Program - Family Independence Program State - Minnesota Name of TANF Cash Assistance Program - Minnesota Family Investment Program (MFIP) State - Mississippi Name of TANF Cash Assistance Program - Temporary Assistance to Needy Families (TANF) State - Missouri Name of TANF Cash Assistance Program - Temporary Assistance State - Montana Name of TANF Cash Assistance Program - Families Achieving Independence in Montana (FAIM) State - Nebraska Name of TANF Cash Assistance Program - Aid to Dependent Children (ADC) State - Nevada Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - New Hampshire Name of TANF Cash Assistance Program - New Hampshire Employment Program (NHEP) and Family Assistance Program (FAP) State - New Jersey Name of TANF Cash Assistance Program - Work First New Jersey State - New Mexico Name of TANF Cash Assistance Program - New Mexico Works State - New York Name of TANF Cash Assistance Program - Family Assistance Program (FA) Child Assistance Program (CAP)--a voluntary alternative to FA currently available in 17 counties State - North Carolina Name of TANF Cash Assistance Program - Work First Program State - North Dakota Name of TANF Cash Assistance Program - Training, Education, Employment and Management Program (TEEM) State - Ohio Name of TANF Cash Assistance Program - Ohio Works First (OWF) State - Oklahoma Name of TANF Cash Assistance Program - Statewide Temporary Assistance Responsibility System (STARS) State - Oregon Name of TANF Cash Assistance Program - Aid to Dependent Children (ADC) State - Pennsylvania Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - Rhode Island Name of TANF Cash Assistance Program - Family Independence Program (FIP) State - South Carolina Name of TANF Cash Assistance Program - Family Independence Program (FIP) State - South Dakota Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) State - Tennessee Name of TANF Cash Assistance Program - Families First State - Texas Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) Achieving Change for Texas (ACT) State - Utah Name of TANF Cash Assistance Program - Family Employment Program State - Vermont Name of TANF Cash Assistance Program - Aid to Needy Families with Children (ANFC) State - Virginia Name of TANF Cash Assistance Program - Temporary Assistance for Needy Families (TANF) Virginia Initiative for Employment not Welfare (VIEW) is the work program State - Washington Name of TANF Cash Assistance Program - WorkFirst State - West Virginia Name of TANF Cash Assistance Program - WV Works State - Wisconsin Name of TANF Cash Assistance Program - Wisconsin Works (W-2) State - Wyoming Name of TANF Cash Assistance Program - Personal Opportunities with Employment Responsibilities (POWER) Monthly Cash Assistance and Food Stamp Benefits For a Single-Parent Family of Three with No Earnings -- 2001 Excerpted from http://www.spdp.org/tanf/financial/MAXBEN2000.PDF State - Alabama Cash Assistance - $164 Food Stamps** - $341 State - Alaska Cash Assistance - $923 Food Stamps** - $288 State - Arizona Cash Assistance - $347 Food Stamps** - $331 State - Arkansas Cash Assistance - $204 Food Stamps** - $341 State - California* Cash Assistance - $645 Food Stamps** - $245 Date of Recent Change in Cash Grant - October 2000 State - Colorado Cash Assistance - $356 Food Stamps** - $341 State - Connecticut* Cash Assistance - $543 Food Stamps** - $308 State - Delaware Cash Assistance - $338 Food Stamps** - $341 State - District of Columbia Cash Assistance - $379 Food Stamps** - $314 State - Florida Cash Assistance - $303 Food Stamps** - $341 State - Georgia Cash Assistance - $280 Food Stamps** - $341 State - Hawaii Cash Assistance - $570 Food Stamps** - $459 State - Idaho Cash Assistance - $293 Food Stamps** - $341 Date of Recent Change in Cash Grant - December 1999 State - Illinois Cash Assistance - $377 Food Stamps** - $318 State - Indiana Cash Assistance - $288 Food Stamps** - $341 State - Iowa Cash Assistance - $426 Food Stamps** - $337 State - Kansas* Cash Assistance - $403 Food Stamps** - $340 State - Kentucky Cash Assistance - $262 Food Stamps** - $341 State - Louisiana Cash Assistance - $190 Food Stamps** - $341 State - Maine Cash Assistance - $461 Food Stamps** - $332 Date of Recent Change in Cash Grant - July 1999 State - Maryland Cash Assistance - $439 Food Stamps** - $283 Date of Recent Change in Cash Grant - October 2000 State - Massachusetts* Cash Assistance - $633 Food Stamps** - $293 Date of Recent Change in Cash Grant - July 2000 State - Michigan* Cash Assistance - $459 Food Stamps** - $333 State - Minnesota*** Cash Assistance - $801 Food Stamps** - NA Date of Recent Change in Cash Grant - October 2000 State - Mississippi Cash Assistance - $170 Food Stamps** - $341 Date of Recent Change in Cash Grant - July 1999 State - Missouri Cash Assistance - $292 Food Stamps** - $341 State - Montana Cash Assistance - $493 Food Stamps** - $316 Date of Recent Change in Cash Grant - July 2001 State - Nebraska Cash Assistance - $364 Food Stamps** - $339 State - Nevada Cash Assistance - $348 Food Stamps** - $341 State - New Hampshire Cash Assistance - $600 Food Stamps** - $254 Date of Recent Change in Cash Grant - April 2000 State - New Jersey Cash Assistance - $424 Food Stamps** - $333 State - New Mexico Cash Assistance - $439 Food Stamps** - $276 Date of Recent Change in Cash Grant - July 1999 State - New York* Cash Assistance - $577 Food Stamps** - $298 State - North Carolina Cash Assistance - $272 Food Stamps** - $341 State - North Dakota Cash Assistance - $457 Food Stamps** - $322 State - Ohio Cash Assistance - $373 Food Stamps** - $339 Date of Recent Change in Cash Grant - January 2000 State - Oklahoma Cash Assistance - $292 Food Stamps** - $341 Date of Recent Change in Cash Grant - November 1997 State - Oregon Cash Assistance - $460 Food Stamps** - $325 State - Pennsylvania* Cash Assistance - $403 Food Stamps - $341 State - Rhode Island Cash Assistance - $554 Food Stamps** - $302 State - South Carolina Cash Assistance - $203 Food Stamps** - $341 State - South Dakota Cash Assistance - $430 Food Stamps** - $326 State - Tennessee Cash Assistance - $185 Food Stamps** - $341 State - Texas Cash Assistance - $201 Food Stamps** - $341 Date of Recent Change in Cash Grant - October 2000 State - Utah Cash Assistance - $451 Food Stamps** - $293 Date of Recent Change in Cash Grant - July 1998 State - Vermont* Cash Assistance - $631 Food Stamps** - $281 Date of Recent Change in Cash Grant - October 2000 State - Virginia* Cash Assistance - $320 Food Stamps** - $341 Date of Recent Change in Cash Grant - July 2000 State - Washington Cash Assistance - $546 Food Stamps** - $307 State - West Virginia Cash Assistance - $453 Food Stamps** - $290 Date of Recent Change in Cash Grant - October 2000 State - Wisconsin* Cash Assistance - $673 Food Stamps** - $250 State - Wyoming Cash Assistance - $340 Food Stamps** - $341 *Benefits vary by region or category. The figures cited here reflect maximum benefits for largest group of recipients in the state. **This reflects the FY 2001 food stamp benefit for a family of three that is receiving the welfare benefit listed for each state. The food stamp benefit formula includes a deduction that provides somewhat higher benefits for families with high shelter costs. This table calculates the food stamp benefit using the typical shelter costs in each state for food stamp households not receiving housing assistance. ***Minnesota provides a cash grant that combines welfare and food stamp benefits. Treatment of Earnings as of January 2000 State - Alabama Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for 3 months 20% in subsequent months State - Alaska Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $150 and 1/3 of the remainder for 12 months $150 and 25% of the remainder for the next 12 months $150 and 20% of the remainder for the next 12 months $150 and 15% of the remainder for the next 12 months State - Arizona Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 and 30% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $90 and 30% of the remainder State - Arkansas Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 20% and 60% of the remainder State - California Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $225 and 50% of the remainder State - Colorado Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 1/3 of the remainder for 4 months $120 for the next months $90 in subsequent months State - Connecticut Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% until earnings exceed federal poverty level State - Delaware Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 1/3 of the remainder for 4 months $120 for the next 8 months $90 in subsequent months State - DC Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $100 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $100 and 50% of the remainder State - Florida Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $200 and 50% of remainder State - Georgia Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 1/3 of the remainder for 4 months $120 for next 8 months $90 in subsequent months State - Hawaii Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $20 then $200, then 36% of the remainder State - Idaho Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 40% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 40% State - Illinois Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 67% State - Indiana* Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 1/3 of the remainder for 4 months $120 for the next 8 months $90 in subsequent months State - Iowa Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $20 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 20% and 50% of the remainder State - Kansas Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 20% and 50% of the remainder State - Kentucky Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for 2 months $120 and 1/3 of the remainder for the next 4 months $120 for the next 8 months $90 in subsequent months State - Louisiana Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $120 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $1,020 for 6 months $120 in subsequent months State - Maine Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $108 and 50% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $108 and 50% of the remainder State - Maryland Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 35% State - Massachusetts Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 50% of the remainder State - Michigan Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $200 and 20% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $200 and 20% of the remainder State - Minnesota Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 18% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 38% State - Mississippi Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for 6 months for some families** $90 in other months State - Missouri Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 67% and $90 of the remainder for 12 months $90 in subsequent months State - Montana Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $200 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $200 and 25% of the remainder for 24 months $100 in subsequent months State - Nebraska Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 20% State - Nevada Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 or 20%, whichever is greater Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for 3 months 50% for the next 9 months Greater of $90 or 20% in subsequent months State - New Hampshire Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 20% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 50% State - New Jersey Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - None Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for month 50% in subsequent months State - New Mexico Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $150 and 50% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $150 and 50% of the remainder State - New York Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $90 and 46% of the remainder State - North Carolina Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 27.5% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 100% for 3 months 27.5% in subsequent months State - North Dakota Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - Greater of $90 or 27%, and 50% of the "employment incentive limit"** Portion of Recipient's Earnings that is Disregarded in Benefit Determination - Greater of $90 or 27%, and 50% of the "employment incentive limit" for 8 months** Greater of $90 or 27%, and 30% of the "employment incentive limit" for 2 months Greater of $90 or 27%, and 10% of the "employment incentive limit" for 2 months Greater of $90 or 27%, in subsequent months State - Ohio Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $250 and 50% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $250 and 50% of the remainder State - Oklahoma Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $120 and 50% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 50% of the remainder State - Oregon Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 50% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 50% State - Pennsylvania Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 50% State - Rhode Island Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $170 and 50% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $170 and 50% of the remainder State - South Carolina Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 50% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 50% for 4 months $100 in subsequent months State - South Dakota Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 and 20% of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $90 and 20% of the remainder State - Tennessee Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $150 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $150 State - Texas Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $120 and 1/3 of the remainder Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 90% of the remainder for 4 months $120 in subsequent months State - Utah Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $100 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $100 and 50% of the remainder State - Vermont Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $150 and 25% of the remainder State - Virginia Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $90 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $120 and 1/3 of the remainder for 4 months** $120 for the next 8 months $90 in subsequent months State - Washington Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 50% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 50% State - West Virginia Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - 40% Portion of Recipient's Earnings that is Disregarded in Benefit Determination - 40% State - Wisconsin Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - None Portion of Recipient's Earnings that is Disregarded in Benefit Determination - None State - Wyoming Portion of Applicant's Earnings that is Disregarded in Eligibility Determination - $200 Portion of Recipient's Earnings that is Disregarded in Benefit Determination - $200 NOTES In a small number of states, the treatment of earnings is different for various groups of families. The information in this table reflects the treatment of earnings for the largest group of families in the state. *Indiana is expected to implement a new earned income disregard on July 1, 2000. Under the new policy 100% of earnings will be disregarded until earnings reach the Federal Poverty Level. Mississippi -- The 100% disregard is available only if families obtain full-time employment within 30 days of initial receipt of TANF or within 30 days following start of participation in work activities. North Dakota -- The maximum "employment incentive limit" is $184. Virginia -- The benefit rules for participants in Virginia's welfare reform program (i.e., those subject to the state time limit) allow families to continue receiving benefits until countable earned income (after the work expense deduction and earned income disregard) reached the federal poverty line. This is done through "fill-the-gap" budgeting and not through an earned income disregard. TANF Financial Eligibility Excerpted from http://www.acf.dhhs.gov/news/welfare/congress/ tanfp9.htm State - Alabama Resource Level - $2000 Individual Development Accounts (Amount) - No State - Alaska Resource Level - $1,000 Individual Development Accounts (Amount) - $10,000 State - Arizona Resource Level - $1,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Arkansas Resource Level - $3,000 Individual Development Accounts (Amount) - $5,000 State - California Resource Level - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Colorado Resource Level - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Connecticut Resource Level - $3,000 Individual Development Accounts (Amount) - No State - Delaware Resource Level - $1,000 Individual Development Accounts (Amount) - $5,000 State - DC Resource Level - $1,000 Individual Development Accounts (Amount) - No State - Florida Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Georgia Resource Level - $1,000 Individual Development Accounts (Amount) - $5,000 State - Hawaii Resource Level - $5,000 Individual Development Accounts (Amount) - No State - Idaho Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Illinois Resource Level - $3,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Indiana Resource Level - Recipients - $1,500 - Applicants - $1,000 Individual Development Accounts (Amount) - No State - Iowa Resource Level - Recipients - $5,000 - Applicants - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Kansas Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Kentucky Resource Level - $2,000 Individual Development Accounts (Amount) - $5,000 State - Louisiana Resource Level - $2000 Individual Development Accounts (Amount) - $6,000 State - Maine Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Maryland Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Massachusetts Resource Level - $2,500 Individual Development Accounts (Amount) - No State - Michigan Resource Level - $3,000 Individual Development Accounts (Amount) - No State - Minnesota Resource Level - Recipients - $5,000 - Applicants - $2,000 Individual Development Accounts (Amount) - No State - Mississippi Resource Level - $1,000 Individual Development Accounts (Amount) - No State - Missouri Resource Level - $1,000 - $5,000 for signees of social contracts - Under the 21st Century Communities waiver: limit increased by an additional $10,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Montana Resource Level - $3,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Nebraska Resource Level - Regular program $1,000 - Employment First 5,000 Individual Development Accounts (Amount) - No State - Nevada Resource Level - $2,000 Individual Development Accounts (Amount) - No State - New Hampshire Resource Level - Recipients $2,000 - Applicants $1,000 Individual Development Accounts (Amount) - No State - New Jersey Resource Level - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - New Mexico Resource Level - $1,500 Individual Development Accounts (Amount) - Yes Amount not specified State - New York Resource Level - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - North Carolina Resource Level - $3,000 Individual Development Accounts (Amount) - No State - North Dakota Resource Level - $1,000 Individual Development Accounts (Amount) - No State - Ohio Resource Level - No limit Individual Development Accounts (Amount) - $10,000 State - Oklahoma Resource Level - $1,000 Individual Development Accounts (Amount) - $2,000 State - Oregon Resource Level - Processing in IRP $10,000 - All others $2,500 Individual Development Accounts (Amount) - Yes Individual Education Account; $1/hour after 30 initial days of employment State - Pennsylvania Resource Level - $1,000 Individual Development Accounts (Amount) - Yes Education only State - Rhode Island Resource Level - $1,000 Individual Development Accounts (Amount) - Yes Amount not specified State - South Carolina Resource Level - $2,500 Individual Development Accounts (Amount) - $10,000 State - South Dakota Resource Level - $2,000 Individual Development Accounts (Amount) - $1,000 (For children attending school.) State - Tennessee Resource Level - $2,000 Individual Development Accounts (Amount) - $5,000 State - Texas Resource Level - $2,000 Individual Development Accounts (Amount) - $10,000 State - Utah Resource Level - $2,000 Individual Development Accounts (Amount) - Yes Amount not specified State - Vermont Resource Level - $1,000 Individual Development Accounts (Amount) - No State - Virginia Resource Level - $1,000 Individual Development Accounts (Amount) - $5,000 State - Washington Resource Level - $1,000 Individual Development Accounts (Amount) - $3,000 State - West Virginia Resource Level - $2,000 Individual Development Accounts (Amount) - No State - Wisconsin Resource Level - $2,500 Individual Development Accounts (Amount) - No State - Wyoming Resource Level - $2,500 Individual Development Accounts (Amount) - No *Available only to subsidized work component participants. Vehicle Asset Level State - Alabama Vehicle Asset Level - $0 Exclude Primary Car State - Alaska Vehicle Asset Level - $0 Exclude Primary Car State - Arizona Vehicle Asset Level - $0 Exclude Primary Car State - Arkansas Vehicle Asset Level - $0 Exclude Primary Car State - California Vehicle Asset Level - $4,650 State - Colorado Vehicle Asset Level - $0 Exclude Primary Car State - Connecticut Vehicle Asset Level - $0 Exclude Primary Car State - Delaware Vehicle Asset Level - $4,650 State - DC Vehicle Asset Level - $1,500 State - Florida Vehicle Asset Level - $0 Exclude Primary Car State - Georgia Vehicle Asset Level - $4,650 State - Hawaii Vehicle Asset Level - $0 Exclude Primary Car State - Idaho Vehicle Asset Level - $4,650 State - Illinois Vehicle Asset Level - $0 Exclude Primary Car State - Indiana Vehicle Asset Level - $1,000 State - Iowa Vehicle Asset Level - $3,889 State - Kansas Vehicle Asset Level - $0 Exclude Primary Car State - Kentucky Vehicle Asset Level - $0 Exclude Primary Car State - Louisiana Vehicle Asset Level - $10,000 State - Maine Vehicle Asset Level - $0 Exclude Primary Car State - Maryland Vehicle Asset Level - $0 Exclude Primary Car State - Massachusetts Vehicle Asset Level - $5,000 State - Michigan Vehicle Asset Level - $0 Exclude Primary Car State - Minnesota Vehicle Asset Level - $7,500 State - Mississippi Vehicle Asset Level - $1,500 State - Missouri Vehicle Asset Level - $0 Exclude Primary Car State - Montana Vehicle Asset Level - $0 Exclude Primary Car State - Nebraska Vehicle Asset Level - $0 Exclude Primary Car State - Nevada Vehicle Asset Level - $0 Exclude Primary Car State - New Hampshire Vehicle Asset Level - $0 Exclude Primary Car State - New Jersey Vehicle Asset Level - $9,500 State - New Mexico Vehicle Asset Level - $0 Exclude Primary Car State - New York Vehicle Asset Level - $4,650 State - North Carolina Vehicle Asset Level - $5,000 State - North Dakota Vehicle Asset Level - $1,500 State - Ohio Vehicle Asset Level - $0 Exclude Primary Car State - Oklahoma Vehicle Asset Level - $5,000 State - Oregon Vehicle Asset Level - $10,000 State - Pennsylvania Vehicle Asset Level - $0 Exclude Primary Car State - Rhode Island Vehicle Asset Level - $4,650** State - South Carolina Vehicle Asset Level - $10,000 State - South Dakota Vehicle Asset Level - $4,650 State - Tennessee Vehicle Asset Level - $4,600 State - Texas Vehicle Asset Level - $5,000 State - Utah Vehicle Asset Level - $8,000 State - Vermont Vehicle Asset Level - $0 Exclude Primary Car State - Virginia Vehicle Asset Level - $0 Exclude Primary Car State - Washington Vehicle Asset Level - $5,000 State - West Virginia Vehicle Asset Level - $4,500 State - Wisconsin Vehicle Asset Level - $10,000 State - Wyoming Vehicle Asset Level - $0 Exclude Primary Car *Represents the value of at least one car. Some States exclude cars for each licensed driver. **There is no limit when the car is to transport disabled family member. Maximum Sanctions for Not Complying with Work Requirements State - Alabama Loss of Cash Length of Sanction - 6 months State - Alaska Cash Reduced Length of Sanction - 12 months State - Arizona Loss of Cash Length of Sanction - 1 month State - Arkansas Loss of Cash Length of Sanction - 3 months State - California Loss of Cash Length of Sanction - up to 6 months State - Colorado Loss of Cash Length of Sanction - 3-6 months (county option) State - Connecticut Loss of Cash Length of Sanction - 3 months State - Delaware Loss of Cash Length of Sanction - lifetime State - DC Loss of Cash Length of Sanction - lifetime State - Florida Loss of Cash - Protective payee for children under 12 years of age. Length of Sanction - 3 months State - Georgia Loss of Cash Length of Sanction - until compliance State - Hawaii Cash Reduced Length of Sanction - 6 months State - Idaho Loss of Cash Length of Sanction - lifetime State - Illinois Loss of Cash Length of Sanction - 3 months State - Indiana Cash Reduced State - Iowa Loss of Cash Length of Sanction - 6 months State - Kansas Loss of Cash Length of Sanction - 2 months State - Kentucky Cash Reduced - Protective payee for remaining grant. State - Louisiana Loss of Cash State - Maine Cash Reduced - Third party payment for remaining grant. State - Maryland Loss of Cash Length of Sanction - 30 days of compliance State - Massachusetts Loss of Cash - May be allowed to participate in community service. State - Michigan Loss of Cash Length of Sanction - 1 month or until compliance State - Minnesota Cash Reduced - Vendor paid for remaining grant. State - Mississippi Loss of Cash Length of Sanction - lifetime State - Missouri Cash Reduced State - Montana Cash Reduced Length of Sanction - 12 months State - Nebraska Loss of Cash Length of Sanction - until end of time limit State - Nevada Cash Reduced Length of Sanction - 1 month State - New Hampshire Cash Reduced Length of Sanction - until compliance State - New Jersey Loss of Cash Length of Sanction - 3 months State - New Mexico Loss of Cash Length of Sanction - until compliance State - New York Cash Reduced State - North Carolina Loss of Cash State - North Dakota Loss of Cash Length of Sanction - until compliance State - Ohio Loss of Cash Length of Sanction - 6 months State - Oklahoma Loss of Cash Length of Sanction - until compliance State - Oregon Loss of Cash Length of Sanction - until compliance Pennsylvania Loss of Cash Length of Sanction - lifetime State - Rhode Island Cash Reduced - Payment to third party for children. State - South Carolina Loss of Cash Length of Sanction - 30 days of compliance State - South Dakota Loss of Cash State - Tennessee Loss of Cash Length of Sanction - 3 months State - Texas Cash Reduced Length of Sanction - 6 months State - Utah Loss of Cash Length of Sanction - until compliance State - Vermont Loss of Cash Length of Sanction - until compliance State - Virginia Loss of Cash Length of Sanction - 6 months State - Washington Loss of Cash Length of Sanction - until compliance State - West Virginia Loss of Cash Length of Sanction - 6 months State - Wisconsin Loss of Cash Length of Sanction - lifetime State - Wyoming Loss of Cash Length of Sanction - 1 month Emergency Assistance for Families Not Eligible for TANF Cash Assistance Provided in 25 States: 20 States - To prevent eviction 10 States - Short-term rental assistance 17 States - To prevent utility shut-off 18 States - Emergency housing assistance 17 States - Temporary shelter for the homeless 20 States - Other emergency assistance State provides emergency assistance to families not eligible for TANF cash assistance as follows: State - Arizona To prevent eviction To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Colorado Other Emergency Services State - Connecticut To prevent eviction Short-term rental assistance Emergency housing assistance Other Emergency Services State - Delaware To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Florida To prevent eviction Emergency housing assistance State - Idaho To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless State - Iowa To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Kansas To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Maine To prevent eviction To prevent utility shut-off Emergency housing assistance Other Emergency Services State - Massachusetts To prevent eviction Temporary shelter for homeless State - Michigan To prevent eviction To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Minnesota To prevent eviction To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Montana To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - New York To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Ohio To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Oregon To prevent eviction To prevent utility shut-off Temporary shelter for homeless Other Emergency Services State - Pennsylvania To prevent eviction Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Rhode Island Other Emergency Services State - Tennessee To prevent eviction To prevent utility shut-off State - Utah Other Emergency Services State - Vermont To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Virginia To prevent eviction Short-term rental assistance To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Washington Other Emergency Services State - West Virginia To prevent eviction To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services State - Wisconsin To prevent utility shut-off Emergency housing assistance Temporary shelter for homeless Other Emergency Services (All information in the TANF section of this manual were derived from State Policy Documentation Project, TANF data notes; www.spdp.org.) Food Stamp Program Excerpted in part from "Food Stamp Regulations" and "Facts About the Food Stamp Program," US Dept. of Agriculture The food stamp program helps low-income people buy food by using "stamps" provided in a booklet at grocery stores rather than cash. This is being shifted to a system of issuance through Electronic Benefit Transfer (EBT), which is a "credit card" held by the household that is used to pay for purchases. State public assistance agencies run the program through their local offices. Some basic rules apply in most states, but a few states have different rules. Therefore, it is important to learn about a particular state's rules in order to fully understand the food stamp program. The amount of food stamps a person can get is based on the U.S. Department of Agriculture's Thrifty Food Plan, which is an estimate of how much it costs to buy food to prepare meals for the size of household applying. This amount changes each year. The following table gives an example of amounts for various household sizes; however, the actual amounts vary slightly from state to state. People in Household Maximum Allotment 1 person $141 2 people $259 3 people $371 4 people $471 5 people $560 6 people $672 7 people $743 8 people $849 Each Additional Person + $106 There are state-by-state amounts for a household of three for the year 2000 listed on the TANF/Food Stamp amounts. If the applicant and everyone in the household receives SSI, they can apply for food stamps in the SSA office. Other households must apply for food stamps through their local food stamp or welfare office. Within a 30-day period, a decision must be made on the application. Emergency procedure is available for people requiring faster service. Eligibility Rules 1. The applicant must have a Social Security number for every household member, including children 2. With certain exceptions, adults between 16 and 60 must register for work, accept an offer of suitable work, and take part in an employment and training program to which they are referred by the food stamp office. Generally, those between 18 and 50 without children can only get food stamps for 3 months in a three-year period unless they are working or participating in a work program. 3. Countable resources must be $2000 or less. 4. Net monthly income of all household members must be under income limits. Listed below: People in Household 1 Gross Monthly Income Limit $973 Net Monthly Income Limit $749 People in Household 2 Gross Monthly Income Limit $1,313 Net Monthly Income Limit $1,010 People in Household 3 Gross Monthly Income Limit $1,654 Net Monthly Income Limit $1,272 People in Household 4 Gross Monthly Income Limit $1,994 Net Monthly Income Limit $1,534 People in Household 5 Gross Monthly Income Limit $2,334 Net Monthly Income Limit $1,795 People in Household 6 Gross Monthly Income Limit $2,674 Net Monthly Income Limit $2,057 People in Household 7 Gross Monthly Income Limit $3,014 Net Monthly Income Limit $2,319 People in Household 8 Gross Monthly Income Limit $3,354 Net Monthly Income Limit $2,580 Each Additional Person Gross + $341 Each Additional Person Net + $262 Examples of deductions from income include: Standard deduction of 20% of income Costs of dependent care Legally owed child support Shelter expenses that are more than half your income An example of how net income is calculated follows: Gross Income Computation: Determine household size Example: 4 people with no elderly or disabled members. Gross Income Computation: Add gross monthly income Example: $800 earned income + $214 social security = $1,014 gross income Gross Income Computation: If gross monthly income is less than the limit for household size, determine net income. Example: $1,014 is less than the $1,848 allowed for a 4-person household, so determine net income. Subtract Deductions to Determine Net Income and Apply the Net Income Test Example - $1,014 gross income Subtract 20% earned income deduction Example - $800 earned income x 20% = $160 Subtract standard deduction Example - $1,014 - $160 = $854 Subtract dependent care deduction, but not more than limit Example - $854 - $134 = $720 Subtract child support deduction Example - $720 - $116 = $604 Subtract shelter costs over 1/2 income Example - $0 Special Rules for People who Are Elderly or Disabled 1. Normally, people are not eligible for food stamps if an institution gives them their meals. However, if persons with disabilities live in certain nonprofit group living arrangements with no more than 16 residents, they may be eligible for food stamps, even though the residential provider prepares meals for them. 2. The resources of people who get SSI or TANF are not counted at all. 3. Households in which all members are receiving SSI and TANF are considered eligible based on income. 4. People receiving disability benefits are not subject to the work requirements of the basic food stamp rules. 5. Medical costs paid by the household in excess of $35 /month are deducted when calculating net income. For further information, contact your local or state food stamp office. There is a list of contact numbers on pages 204-206, or you can also find the nearest local office by calling your state's food stamp hot line. State Food Stamp Information/Hotline Numbers Excerpted from: http://www.fns.usda.gov/fsp/MENU/contacts/hotlines.htm Use the following numbers to get information on food stamp questions in the states and areas of states listed. Most are toll-free numbers. State - Alabama Phone number - 334-242-1700 State - Alaska Phone number - 907-465-3360 State - Arizona Phone number - 1-800-352-8401 State - Arkansas Phone number - 1-800-482-8988 State - California Phone number - 1-800-952-5253 State - Colorado Phone number - 303-866-5087 State - Connecticut Phone number - 1-800-842-1508 State - Delaware Phone number - 1-800-464-4357 State - DC Phone number - 202-724-5506 State - Florida Phone number - 1-800-342-9274 State - Georgia Phone number - 1-800-869-1150 outside metro area 404-657-9358 inside metro area State - Guam Phone number - 671-447-KEHA State - Hawaii Phone number - 808-586-5230 State - Idaho Phone number - 208-334-5818 State - Illinois Phone number - 1-800-252-8635 State - Indiana Phone number - 1-800-622-4932* State - Iowa Phone number - 1-800-972-2017 State - Kansas Phone number - None State - Kentucky Phone number - 1-800-372-2973 State - Louisiana Phone number - 1-800-256-1548 State - Maine Phone number - 1-800-452-4643 State - Maryland Phone number - 1-800-492-5515 State - Massachusetts Phone number - 1-800-645-8333 State - Michigan Phone number - 517-373-0707 State - Minnesota Phone number - 1-800-657-3698* State - Mississippi Phone number - 1-800-948-3050 State - Missouri Phone number - 1-800-392-1261 State - Montana Phone number - 1-800-332-2272 State - Nebraska Phone number - 1-800-430-3244 State - Nevada Phone number - 1-800-992-0900 (ext. 5765)* State - New Hampshire Phone number - 1-800-852-3345 (ext. 4238) State - New Jersey Phone number - 1-800-792-9773 State - New Mexico Phone number - 1-800-432-6217 State - New York (upstate) Phone numbers - 1-800-342-3009 and/or 1-800-343-8859 New York City Area Only Phone number - 718-291-1900 State - North Carolina Phone number - 1-800-662-7030 State - North Dakota Phone number - 1-800-251-8684 State - Ohio Phone numbers - Canton - 1-800-686-1569* Cincinnati - 1-800-686-1571* Cleveland - 1-800-686-1551* Columbus - 1-800-686-1568* Toledo - 1-800-686-1572* State - Oklahoma Phone number - None State - Oregon Phone numbers - 503-945-6092 and/or 503-945-6105 State - Pennsylvania Phone number - 1-800-692-7462 State - Rhode Island Phone number - 1-800-662-5018 State - South Carolina Phone number - 1-800-768-5700 State - South Dakota Phone number - 1-877-999-5612 State - Tennessee Phone number - 1-800-342-1784 State - Texas Phone number - 1-800-252-9330 State - Utah Phone number - 1-877-817-1800 State - Vermont Phone number - 1-800-287-0589 State - Virgin Islands Phone number - 340-774-2399 State - Virginia Phone number - 1-800-552-3431 State - Washington Phone number - 1-800-795-2518* and 1-800-865-7801 State - West Virginia Phone number - 1-800-642-8589 State - Wisconsin Phone number - None State - Wyoming Phone number - 1-800-457-3657 *These numbers are for in-state and out-of-state calls. All other 800 numbers are for in-state calls only. CHAPTER 14: FEDERAL HOUSING SUBSIDIES The lack of suitable, affordable housing is often a major barrier to successful employment of persons with disabilities. Still, various public and subsidized housing programs available to persons with disabilities can sometimes help to overcome this barrier. In addition, a number of rent-based work incentives allow families and individuals entering the workforce to retain more of their income. This chapter will provide a brief summary of the major federally sponsored programs that should be available in all states, with an emphasis on those policies most applicable to persons with disabilities. The reader should keep in mind: a) this is only an overview of the federal programs and their regulations; and b) this overview is based on federal regulations published as of December 8, 2004. State-subsidized housing programs also exist and may offer additional benefits, although they are not covered in this chapter. Introduction The three main types of federal housing assistance programs sponsored by the Department of Housing and Urban Development (HUD) are public housing, tenant-based Section 8 and the project-based housing subsidy programs. Public housing is owned and operated by local public housing authorities according to state legislation. Housing units take many forms from high-rise apartment buildings to detached single-family dwellings, and may be located at one site or scattered over several sites. The Section 8 program was established in 1974 as the government's primary rental housing assistance program. It is generally administered by a state or local public housing agency (PHA). HUD pays rental subsidies so that eligible families can afford safe, decent and sanitary housing. These Section 8 subsidies take the form of tenant-based or project-based assistance. Tenant-based subsidies allow recipients to rent housing in the private market and move with the tenant. The tenant-based subsidies have been merged into the new Housing Choice Voucher Program. Project-based subsidies are attached to specific units in privately owned and operated buildings. Because the subsidy is attached to the unit, rental assistance generally ends for the tenant when the tenant moves. HUD's programs are continually affected by the passage of federal legislation. The Quality Housing and Work Responsibility Act of 1998 created rent-based work incentives for public housing tenants with new or increased employment income. In April 2000, new regulations expanded these benefits to people with disabilities receiving housing benefits through the HOME Investment Partnerships Program, the Housing Opportunities for People with AIDS program (HOPWA), the Supportive Housing program (24 CFR part 583) and the Housing Choice Voucher program. Proposed regulations amending Part 583 omit any reference to the disallowance of earned income provided in 24 CFR 5.6.17. See 69 FR 43488 at 43496. Effective advocacy may require that you closely examine rent increases linked to increased earned income to confirm that the earned income disregards are being properly implemented in your area. In this chapter we will provide an overview of the provisions of the federal regulations as they apply to public housing, the Housing Choice Voucher Program, Section 8 project-based assistance, the HOPWA program, the Supportive Housing program and the Homeownership program. We will also provide comprehensive guidelines for assisting individuals with disabilities to determine how increased earned income impacts on housing costs. Eligibility for Federally Subsidized Housing Eligibility for public and subsidized housing is based upon citizenship, income and a family's prior tenant and criminal history if any. Non-citizens with eligible immigration status may qualify for a housing subsidy, if they are otherwise eligible. HUD uses three terms to describe income eligibility: "extremely low-income," "very low-income" and "low-income." * An extremely low-income family is a family whose income does not exceed 30 percent of the median income of an area as determined by HUD. * A very low-income family is a family whose income does not exceed 50 percent of the area's median. * Low-income families have an income that is no greater than 80 percent of the area's median income. Public housing applicants must be low-income families. However, 40 percent of public housing units newly rented each year must be occupied by extremely low-income households. Housing Choice Voucher applicants must be very low-income families. In addition, 75 percent of new admissions in the Housing Choice Voucher program must be extremely low-income families. Section 8 project-based programs must target 40 percent of all annual project admissions to extremely low-income families. Median income and the various corresponding income limits vary significantly from area to area. The following are examples for FY2004 for a one person family in the public housing or Section 8 housing programs: Location - Buffalo-Niagara Falls, NY Extremely Low-Income (30% of Median) $11,250 Very Low-Income (50% of Median) $18,750 Low-Income (80% of Median) $30,000 Location - Chicago, IL Extremely Low-Income (30% of Median) $15,850 Very Low-Income (50% of Median) $26,400 Low Income (80% of Median) $40,250 Location - Nassau-Suffolk, NY Extremely Low-Income (30% of Median) $17,900 Very Low-Income (50% of Median) $29,850 Low Income (80% of Median) $43,250 There is no asset limit for participation in HUD assisted housing programs. However, annual income does include net income from family assets. Income, such as interest, may be imputed if the asset is not in an income bearing account. Your local PHA can provide information about median income and income limits for your area. This information is also available from the HUD website at www.huduser.org. Calculating Rent Payments in Federally Subsidized Housing Total Tenant Payment Federal housing subsidy program rents are income-based. Eligibility and assistance levels are calculated according to a family's income. In general, families who receive federal housing assistance pay the higher of the following amounts as rent: * Thirty percent of the family's monthly adjusted income, or * Ten percent of the family's monthly income, or * If the family is receiving welfare assistance payments, the amount of that assistance that is specifically designated for housing. The amount that the tenant family is required to pay, based upon the above criteria, is called the total tenant payment. If the cost of utilities (except telephone) is not included in the family rent, a utility allowance equal to a PHA or HUD estimate of the monthly cost of a reasonable consumption of such utilities is established. For Section 8 programs other than the Section 8 Voucher Program, tenant rent is the total tenant payment minus any utility allowance. Participants in the Section 8 Voucher Program may pay up to 40% of their gross adjusted income for rent. Minimum Rent PHAs and housing authorities are required to establish minimum rents for tenants with little or no income. Public housing, Section 8 moderate rehabilitation programs and Section 8 tenant-based programs may set the minimum rent at an amount between zero and $50. Other Section 8 programs must set a minimum rent of $25. Housing providers are required to adopt hardship exemptions if a family is unable to pay the minimum rent because of financial hardship. The financial hardship exemption includes situations where: * A family has lost eligibility or is waiting for an eligibility determination for a Federal, State, or local assistance program * A family would be evicted because it is unable to pay the minimum rent (this exemption does not apply to any other form of rent) * Family income has decreased due to changed circumstances (e.g., serious medical problem, family member with income leaving the household) * A death has occurred in the family If a family requests a financial hardship exemption, the minimum rent requirement must be suspended beginning the month after family's request. Housing providers may not evict the family during the 90 day period beginning the month following the family's request for a hardship exemption. The PHA or housing authority must determine whether there is a qualifying financial hardship and whether the hardship is temporary or long term. * If there is no qualifying hardship, the minimum rent will be reinstated and the tenant must pay the minimum rent due for the suspended period. * In public housing, if the qualifying hardship is determined to be temporary, the housing authority must reinstate the minimum rent from the beginning of the suspension period and enter into a reasonable repayment agreement with the family for the amount of back minimum rent owed. * In all Section 8 programs, if the qualifying hardship is determined to be temporary, the PHA may not impose the minimum rent for the 90 day period following the date of the family's request for the exemption. At the end of 90 days, the minimum rent will be reinstated form the beginning of the suspension period and the PHA will enter into reasonable repayment agreement with the family for the amount of back minimum rent owed. * If the qualifying hardship is determined to be long term, the family will be exempted from minimum rent requirements for as long as the hardship continues. Definition of Family in Federally-Subsidized Housing Each applicant for assistance must meet the housing authority's or the PHA's definition of family. Within guidelines provided by HUD, PHAs and housing authorities have discretion in defining what constitutes a family. Programs serving a specific population may have additional requirements. Generally speaking, a family is either a single person or a group of persons and includes: * A household with or without children. A child who is temporarily away from home due to placement in foster care should be considered a member of the family. * A disabled family, which means a family whose head, co-head, spouse, or sole member is a person with a disability; or two or more persons with disabilities; or one or more persons with disabilities with one or more live-in aides. A person with a disability is a person who: - has a disability as defined in Section 223 of the Social Security Act, or - is determined by HUD regulations to have a physical, mental or emotional impairment that: a) is expected to be of long, continued, and indefinite duration; b) substantially impedes his or her ability to live independently; and c) is of such a nature that such ability could be improved by more suitable housing conditions, or - has a developmental disability as defined in Section 102 of the Developmental Disabilities Assistance and Bill of Rights Act. - the definition of a person with disabilities does not exclude persons who have the disease arising from the etiologic agent for acquired immunodeficiency syndrome (HIV). - for the purpose of qualifying for low income housing, the definition does not include a person whose disability is based solely on any drug or alcohol dependence. - for purposes of reasonable accommodations and program accessibility for a person with disabilities, the definition of "individual with handicaps" found in Title 24 of Code of Federal Regulations Section 8.3 is used. * An elderly family, which is defined as a family whose head, co-head, spouse, or sole member is at least 62 years of age; or two or more persons, each of whom are at least 62, living together; or one or more persons who are at least 62 living with one or more live-in aides. * A displaced family, which is a family in which each member or the sole member is a person displaced by governmental action, or whose dwelling has been extensively damaged or destroyed as a result of a disaster declared or otherwise formally recognized by federal disaster relief laws. * A remaining member of a tenant family is a family member of an assisted tenant family who remains in the unit when other members of the family have left the unit. * A single person who is not an elderly or displaced person, a person with disabilities, or the remaining member of a tenant family. Section 504 Requirements Section 504 of the Rehabilitation Act of 1973 (as amended) prohibits discrimination solely on the basis of disability in any program or activity receiving financial assistance. The rule requires that recipients of federal funds ensure that individuals with a disability receive equal opportunity to participate in programs and services. Public housing authorities and PHAs are considered recipients under the act (private owners are not, but must comply with other fair housing requirements). To ensure that individuals with disabilities have an opportunity to participate in subsidized programs, housing authorities and PHAs must make their admission process accessible. TDD, TTY or other equally effective communication systems must be provided. The cost of an interpreter for a hearing-impaired person, copies of legal documents, and informational materials in Braille or on tape must be available upon request. Federal Preference Rules The Quality Housing and Work Responsibility Act permanently repealed federal preference requirements. Under the prior rule, preferences were granted to those applicants who were involuntarily displaced, paid more than 50 percent of household income for rent or were residing in substandard housing. These preferences allowed qualified applicants to move up on the waiting list, thereby reducing their wait for financially assisted housing. Under the new law, public housing authorities and PHAs are required to give a certain percentage of available units to extremely low-income families. In addition, PHAs and housing authorities are required to give families with a member who has a disability a preference for any available accessible units. PHAs also have substantial discretion to adopt local preferences. This would allow subsidized housing providers to give individuals with disabilities broader access to affordable housing through a disability-related preference. It also gives housing providers the opportunity to reward tenants who are currently working or who are transitioning into the workforce. Public Housing Programs The United States Housing Act of 1937 established the federal Public Housing program, which is owned and operated by local public housing authorities according to state legislation. Housing units take many forms from high-rise apartment buildings to detached single-family dwellings, and may be located at one site or scattered over several sites. Federal law requires that public housing be accessible to individuals with disabilities making it an attractive option for low-income families that include a member with a disability. Local public housing authorities may make policies that provide single individuals with a disability preference over other single individuals, or that provide families that include a member with a disability with an admission preference. Housing authorities may not base such a preference on a specific type of disability. Public housing may also be attractive to families who have a poor rent payment history due to financial circumstance and who plan to return to work. While such a rental history might otherwise preclude admission to public housing, a family member's willingness to increase family income by entering the workforce, or by enrolling in a training or employment program may be considered by the housing authority. 1. Eligibility Requirements Public housing developments are specifically designated for low-income individuals and families. An applicant's family income may not exceed 80 percent of the median income of the county or metropolitan area where the housing development is located. Your local housing authority can provide income limits for your community. Income limits are also available at www.huduser.org. 2. Computing Income for Public Housing Tenants Rent in public housing is income-based. Traditionally, an increase in a public housing family's income caused by the transition from disability benefits to work was offset in part by an increase in the family's monthly rental obligation. The Quality Housing and Work Responsibility Act changed this in 1998 by mandating income disregards for new or increased income. Local housing authorities have some latitude in drafting income computation and income reporting requirements that can significantly affect the amount of rent owed by individuals as they move into the work force. Because public housing authorities can exercise discretion in setting local requirements, it is important to check with your housing authority to verify its policies. You may also ask for the Public Housing Authority's Plan, which must be made available to the public. a. Annual Income and Income Exclusions Because rent is based upon income, the way in which income is calculated and defined greatly impacts upon a family's monthly rental payment. Under federal regulations governing housing authorities, annual income is broadly defined as all amounts, monetary or not, which go to any family member (including temporarily absent family heads or spouse), unless an amount is excluded by law. HUD has clarified that "welfare assistance," for purposes of income calculation, includes TANF payments but only to the extent that such payments qualify as "assistance" under 45 CFR 260.31 and are not excluded under 24 CFR 5.609(c). Annual income also includes amounts derived during the year from assets belonging to any family member. Many mandatory income exclusions are specifically designed to encourage individuals to seek further education and job training by eliminating increased rents associated with a move into the labor market. The mandatory income exclusions include: * Income from employment of children (including foster children) under the age of 18 years * Payments received for the care of foster children or foster adults (usually persons with disabilities, unrelated to the tenant family, who are unable to live alone) * Lump-sum additions to family assets, such as inheritances, insurance payments (including payments under health and accident insurance and worker's compensation), capital gains and settlement for personal or property losses * Amounts received specifically for or in reimbursement of the cost of medical expenses for any family member * Income of a live-in aide * The full amount of student financial assistance paid directly to the student or to the educational institution * Special payments to a family member serving in the Armed Forces who is exposed to hostile fire * Amounts received under training programs funded by HUD * Amounts received by a person with a disability that are disregarded for a limited time for purposes of Supplemental Security Income (SSI) eligibility and benefits because they are set aside for use under a Plan for Achieving Self-Support (PASS) * Amounts received by a participant in other publicly assisted programs which are specifically for or in reimbursement of out-of-pocket expenses incurred (i.e., special equipment, clothing, transportation, child care, etc.) and which are made solely to allow participation in a specific program * Amounts received under a resident service stipend (not to exceed $200 per month) * Incremental earnings and benefits received by any family member from participation in qualifying State or local employment training programs * Earnings in excess of $480 for each full-time student 18 years old or older (excluding the head of household and spouse) * Deferred periodic amounts from SSI and Social Security benefits that are received in a lump-sum amount or in prospective monthly amounts Example: Joan is a single individual who was recently awarded retroactive SSI benefits totaling $20,000. Joan's total monthly benefit will be $579 and her first retroactive check is for $6,948 (monthly benefit rate of $579 x 12 months). Six months after receiving her first retroactive check, Joan receives a second check for $6,948. Joan continues to receive retroactive lump sums until the $20,000 is paid in full. Joan's monthly $579 payment is counted as income. The retroactive payments she receives are not. * Amounts paid by a State agency to a family with a developmentally disabled member living in the home to offset the cost of services and equipment needed to keep the disabled family member at home * Amounts received by participants in publicly assisted training programs for job-related expenses (such as special equipment, clothing, transportation, child care, etc.) * Temporary, non-recurring or sporadic income (including gifts) * Adoption assistance payments in excess of $480 per adopted child * Refunds or rebates for property taxes on the dwelling unit In addition, public housing programs (but not Section 8 programs) may exercise broad discretion in adopting additional exclusions for earned income. These income exclusions may include amounts necessary to replace benefits lost due to employment (e.g., medical insurance or other medical costs), amounts paid to individuals outside the family (e.g., child support or alimony), or costs incurred in order to go to work (e.g., the cost of special tools, equipment or clothing). b. Annual Income Adjustments The annual income of public housing tenant families is further adjusted by the following mandatory income deductions: * $480 for each dependent * $400 for elderly families * $400 for disabled families [defined as families whose head, spouse or sole member is a person with disabilities, or a family with two or more people with disabilities living together, or one or more persons with disabilities living with a live-in aide(s)] * Unreimbursed medical expenses of elderly or disabled families, and * Unreimbursed reasonable attendant care and auxiliary apparatus expenses for a family member with a disability to the extent necessary to enable any family member to be employed; however, this deduction may not exceed the earned income received by family members 18 years of age and older, who are able to work because of such attendant care or auxiliary apparatus. (Auxiliary apparatus include wheelchairs, ramps, adaptations to vehicles or special equipment to allow a blind person to read or type, but only if these items are directly related to enabling the individual with a disability or other family member to work.) Example: Gary uses a specially equipped van to get to work each day. The annual payments on the van (in excess of what the payments on a car without special equipment would be) total $500. Gary and his family also have $1,000 in medical expenses. The family's annual income is $20,000. Gary earns $4,000 at his job. Three percent of the family's annual income is $600. The family's combined disability and medical expenses exceed three percent of income and may be deducted. Gary's family is entitled to a $900 deduction for their combined medical expenses that represents the amount by which the sum of both the disability and medical expenses ($500 + $1,000 = $1,500) exceeds three percent of annual income ($1,500 (expenses) - $600 (three percent of income) = $900 deduction). Public housing authorities may authorize additional deductions from annual income. Other HUD programs must calculate additional deductions only as permitted by applicable program regulations. c. Self-Sufficiency Incentives: Earned Income Disallowance (Disregards) Under the Quality Housing and Work Responsibility Act, specific families are entitled to a disregard or disallowance of incremental earnings as an incentive to economic self-sufficiency. The purpose of this disregard is to limit a family's rental liability when household income increases due to a return to the workforce or an increase in work hours. Public housing authorities are required to disregard 100 percent of any increased employment income for a period of 12 months from the date that a member of an eligible family is first employed or from the date that the family's income increases. In addition, for the second period of 12 months following employment or increased income, the PHA is required to exclude 50 percent of any increase in employment-related income. The disallowance of increased income is limited to a lifetime 48-month period. Example: Roberta receives SSI payments totaling $579 per month. Pursuant to her lease agreement, Roberta is not obligated to report increased income until her annual recertification in December. In July 2005 Roberta begins to work earning $1,085 per month and her SSI check is reduced to $79 per month. Without the earned income disregard, Roberta's rent would have increased in January 2006. However, because in January Roberta benefited from not having to report her increased income for six months, she is entitled only to six more months of the 100 percent disregard. Beginning in July 2006 and for 12 months thereafter, Roberta's rent will be calculated based upon a 50 percent disregard. The following tenant families are eligible for the earned income disregard: * Families whose income increases as a result of employment of a family member who was previously unemployed (defined as earning no more than would be received for working 10 hours per week for 50 weeks at the established minimum wage in the 12 months previous to employment) for one or more years. For example, this provision may apply to the income of minors who turn 18. Example: Jose lives with his wife Rosa and their 17-year-old son Michael who is no longer in school. Jose works 20 hours each week as a janitor, Rosa receives SSI, and Michael works bussing tables. When Michael turns 18, his earnings will no longer qualify for an income exclusion. His family will, however, be entitled to an earned income disregard for the increase in household income attributable to Michael's earnings. * Families whose annual income increases due to increased earnings by a family member during participation in a self-sufficiency or other job training program Substance abuse or mental health treatment programs may be considered self-sufficiency or job training programs. Similarly, enrollment in a community college (despite the fact that the tenant is not enrolled in a special vocational program) may be considered job training as long as the studies pursued are designed to ready the tenant for work. Example: Robert receives $579 each month in SSI. He transfers from a day treatment program to a supported employment program sponsored by a mental health rehabilitation program, where he begins to earn $685 each month. Robert's SSI benefits are reduced to $279. However, his total monthly income increases to $964 ($279 + $685). Because Robert's monthly income housing authorities increased by $385 ($964 current income minus $579 prior SSI income), he is entitled to an earned income disregard for the additional $385 he receives each month. * Families with an annual income increase due to new employment or increased earnings during, or within six months after the receipt of TANF-funded assistance (including one-time payments, wage subsidies and transportation assistance totaling at least $500 over a six-month period) Example: Joan works 15 hours per week and earns $450 each month. She also receives $397 each month in SSI benefits. When Joan's car breaks down TANF pays a $600 repair bill on her behalf so she can continue to travel to work. Three months later, when Joan's hours double, Joan is entitled to an earned income disregard for the increase in her monthly income. d. Individual Savings Accounts As an alternative to earned income disregards, housing authorities may also offer Individual Savings Accounts for those tenant families who pay an income-based rent. At the option of the tenant family, the housing authority will deposit the total amount that would have been calculated as increased tenant rent resulting from the increased employment income into an interest-bearing savings account. The tenant family may only withdraw the monies deposited in the account for: * Purchasing a home * Paying the education costs of a family member * Moving from public or assisted housing * Paying other expenses approved by the housing authority that promote economic self-sufficiency If the family moves from public housing, the housing authority must pay the family any balance in the account, minus any amounts owed to the housing authority. e. Income Examination Requirements Federally subsidized housing programs generally use one of two models of income reporting. The first requires the tenant family to report mid-year increases in income as they occur. This reporting model may act as a disincentive to employment for tenants who are faced with immediate rental increases upon entry into the job market. The second model eliminates the family's obligation to report mid-year income increases, giving newly employed individuals the opportunity to become more financially stable before facing a rent increase. Since public housing authorities have the option of not requiring tenants to report increases in income between regular annual income re-certifications, tenants should check with their local public housing authority to determine whether an interim reporting requirement exists. f. Rent Computation Options Once a year, the public housing authority must offer tenant families a choice of paying either a flat rent or an income-based rent. Families have an opportunity to choose the rent option they consider to be most financially beneficial. The flat rent for a rental unit is based on its actual market value in the private market. The purpose of the flat rent option is to eliminate the disincentive of constantly increasing income-based rent for those families experiencing success in the job market. For families who choose the flat rent option, housing authorities may require income re-certification as infrequently as every three years (rather than annually). Annual re-certification of family composition remains mandatory. To assist the family in making an informed choice regarding its rent calculation options, the housing authority must tell the family the actual amount of income-based rent and the amount of the flat rent associated with the family's rental unit each year when the opportunity to elect arises. The housing authority must also advise the family of its policy for changing from flat rent to income-based rent due to hardship. A family that is paying a flat rent may request a change to payment of income-based rent if the family is unable to pay the flat rent because of financial hardship. The request may be made at any time; the family is not required to wait until such time as the annual option is represented. If the housing authority determines that the tenant family is unable to pay the flat rent, it must immediately allow the requested change to the income-based rent. This requirement is designed to assist families who experience either a reduction in income associated with loss of employment or earnings, or an increase in expenses for reasons including greater medical, child care or transportation costs. g. Restriction on Eviction of Families Based on Income As of November 26, 2004, HUD issued a final rule giving public housing agencies the authority to evict over-income tenants in order to make their units available for income-eligible applicants. This authority is discretionary. Formerly, PHAs were prohibited from evicting tenants based on income unless the PHA determined that there was decent, safe and sanitary housing of a suitable size available at a rent less than or equal to the tenant's current rent. See 24 CFR 960.261. The Family Self-Sufficiency Program The Family Self-Sufficiency (FSS) program is a special work incentive program designed to promote employment and to increase savings for families receiving Section 8 tenant-based assistance or living in public housing. PHAs and housing authorities that received HUD funds for additional units between 1993 and 1998 are required to maintain FSS programs. FSS program participants enter into a service plan and a contract that measure the family's progress in achieving self-sufficiency. Self-sufficiency is defined as independence from public housing subsidies and welfare cash assistance. The head of the family is required to agree to seek and maintain suitable employment through the term of the FSS contract. Successful completion of the FSS program occurs when all the family's agreed upon self-sufficiency objectives are met or when 30 percent of the family's adjusted monthly income equals or exceeds the fair market rent for the family's unit. The two main components of an FSS program are case management and the FSS escrow account. Each family in the FSS program is provided with a case manager. Participating families are provided with opportunities for education, job training, and counseling, together with services such as childcare and transportation assistance. As an additional incentive to FSS program participation, housing authorities and PHAs deposit funds into an FSS escrow account for each participating family. This provides a participating family with reimbursement for some or all of the rental increases associated with increased income as long as the family complies with program rules. The amount of the contribution depends on the family's original income level. FSS account contributions must be made at least annually. * Very low-income families receive the lesser of: (1) 30 percent of monthly adjusted income minus the family rent at the time of the effective date of the contract of FSS participation, or (2) the current family rent minus the family rent at the time of the effective date of the contract of FSS participation. Example: The Smith family's monthly-adjusted income at the time of the effective date of their FSS contract was $750 and their rent was $225. Through participation in the FSS program, the family's monthly-adjusted income increases to $850. The housing authority deposits $30 (30 percent of $850 = $255 - $225 rent) into the family's FSS account each month. * Low-income families receive the contribution as calculated for very low-income families (see above), but may not exceed the amount computed for 50 percent of median income. * Families who are not low-income are not entitled to an FSS account contribution. When a family successfully completes the FSS program, it will be given the full amount in its escrow account. The family will receive no funds if the program is not successfully completed. There is no limit to the amount that a family may accumulate in its FSS account. The housing authority stops contributing to the account once the FSS contract of participation is completed or terminated. A housing authority or PHA may elect to disburse funds from the FSS account if a participating family has fulfilled its interim goals and needs a portion of the FSS account funds to pay for education, work-related expenses, or for other purposes related to the goals of the family's FSS contract. Further information on the FSS may be found on the Center on Budget and Policy Priorities website at www.cbpp.org. Section 8 Housing Choice Voucher Program Tenant-based Section 8 rental assistance has been merged into one program called the Housing Choice Voucher Program. The Housing Choice Voucher Program helps very low-income, elderly and disabled families afford safe and sanitary housing in the private market. Housing Choice Vouchers are administered by public housing agencies generally referred to as PHAs. Sometimes the PHA is also the local Public Housing Authority. The PHA pays a housing subsidy directly to the private landlord on the participating family's behalf. The family is responsible for paying the difference between the actual rent charged by the landlord and the housing subsidy paid by the PHA. The PHA inspects the unit initially and at least once a year thereafter to ensure that it meets housing quality standards. Some PHAs allow voucher payments to be applied to a mortgage rather than rent payments, giving participating families the opportunity to become homeowners. 1. Eligibility Requirements As in public housing, eligibility for the Housing Choice Voucher Program is based upon total annual gross income and family size. In general, a family's income may not exceed 50 percent of the median income of the county or metropolitan area where the family lives. However, because PHAs are required to use at least 75 percent of their newly available vouchers for extremely low-income households with income at or below 30 percent of the median income, as a practical matter many higher income applicants are not assisted. Your local PHA can provide you with income limits for your area. Because demand for Section 8 assistance exceeds available resources, PHAs often maintain waiting lists. PHAs may establish local preferences to determine how applicants are selected from its list. These may include preferences for working families and for families with a member who has a disability. After the PHA has selected an applicant family from the waiting list and has determined its eligibility, the family will receive a Housing Choice Voucher. This voucher authorizes the family to search for suitable housing; it also requires the family to find a rental unit and submit a request for tenancy approval within a specified period of time. The voucher must provide the family with an initial period of at least 60 days to find housing. The PHA may grant extensions of search time and may determine the length of an extension as well as the circumstances under which it may be granted. The PHA has no limit on the number of extensions that it can approve. PHAs must approve an additional search term if needed as a reasonable accommodation to make the program accessible to and usable by a person with disabilities. The extension period must be reasonable for the purpose requested. 2. Computing Income in the Housing Choice Voucher Program a. Annual Income and Income Exclusions The federal regulations that establish the criteria for calculating annual income and income exclusions in public housing apply to Section 8 housing as well. See "Annual Income and Income Exclusions" in the Public Housing section above. b. Income Adjustments The federal regulations regarding mandatory income adjustments in public housing apply to Section 8 tenant-based subsidies as well. See "Income Adjustments" in the Public Housing section above. c. Earned Income Disallowance (Disregard) The Self-Sufficiency Incentives or Earned Income Disregard mandate was expanded from public housing tenants to individuals with disabilities in the Housing Choice Voucher Program in April 2001. The HUD regulations provide for a specific earned income disallowance for individuals with disabilities. These incentives mirror the provisions for the mandatory earned income disallowance in public housing. HUD's current regulations make the income disregard available to any household member with a disability instead of only to the head of household as previously provided. Also, the disregard is available only to program participants, not to applicants. The self-sufficiency incentives, i.e., the income disallowance for individuals with disabilities in the Housing Choice Voucher Program include: * an initial 12 month exclusion of all increased income * a second cumulative 12 month exclusion of 50 percent of increased income * a lifetime limit of 48 months for such exclusions See "Self-Sufficiency Incentives or "Earned Income Disallowance" in the Public Housing section above for further explanation of these disregards. d. Individual Savings Accounts Individual Savings Accounts, as an alternative to earned income disregards, are not available to Section 8 tenants. e. The Family Self-Sufficiency Program See "The Family Self-Sufficiency Program" in the Public Housing section above. f. Income Examination Requirements As in public housing, PHAs have the option not to require that increases in family income be reported between annual income re-examinations (see "Income Examination Requirements" in the Public Housing section above for further discussion). Your local PHA can provide more information on its income reporting requirements. A family may, at any time, request a redetermination of their rental obligation based on changes in income. PHAs must conduct income re-examinations on at least an annual basis. In the event that a tenant family's income increases to the point where the tenant's share of the rent equals the amount of rent due to the owner, the PHA will cease payments to the owner. This does not affect the tenant family's right to continued occupancy. The owner and tenant may decide to negotiate a new lease agreement when Section 8 subsidies terminate. If not, the existing lease remains in effect. To recommence Section 8 subsidy payments, the tenant family must advise the PHA of any decrease in income or increase in rent. The PHA will reinstate subsidy payments on the tenant family's behalf as long as less than 180 days have elapsed since the date of the last subsidy payment. If more than 180 days have elapsed, the family must reapply to receive further assistance, and may even be placed on a waiting list if the PHA's administrative plan so provides. g. Rent Computation The amount of housing assistance a family will receive in the Housing Choice Voucher Program is based both upon the family's size and income and also upon a PHA determined payment standard. The payment standard is the amount generally needed to rent a moderately priced dwelling unit in the local housing market. The payment standard is the maximum monthly subsidy payment a PHA may make on a tenant's behalf. PHAs have some leeway in setting the payment standard. Once set, the standard generally applies to all program participants with one exception. The PHA must provide a higher payment standard to a family with a member with a disability to enable that family to find housing suitable to its needs. Program recipients may select housing with a rent above the payment standard. The PHA will pay a monthly housing assistance payment to the landlord that is the lower of either: * the payment standard for the family minus the total tenant payment; or * the gross rent minus the total tenant payment (See the section on "Calculating Rent Payments in Federally Subsidized Housing" for an explanation of "total tenant payment.") If the unit rent is greater than the payment standard, the family is required to pay the excess amount in addition to their calculated share of the rent. However, when a family initially moves into a unit where the rent exceeds the payment standard, the family may not pay more than 40 percent of its adjusted monthly income for rent. In addition, Housing Choice Voucher recipients may not pay an amount for rent that exceeds the payment standard, except as described above. Advocates for individuals with disabilities should be sure that because a family is able to afford to pay more than 30 percent of income for rent, they are not required to do so by the PHA. The increased payment standard should be provided to the family who needs such a payment as a reasonable accommodation in order to rent suitable housing. Example: In Jonesville, the payment standard for a three-bedroom unit is $500. When the Maxwell family initially rents their apartment the rent is $400. The Maxwells' adjusted monthly income is $900. Their share of the rent is $300 (30 percent of $900). The PHA pays $100. After 2 years, a new owner takes over the property, makes substantial improvements and increases the rent to $550. The PHA pays $200 and the Maxwells pay $350 (representing 30 percent of their adjusted income plus the additional amount in excess of the payment standard). Two years later, the rent is again increased this time to $650. The Maxwells' adjusted monthly income has also increased and is now $2,000. However, because their share of the rent would exceed the payment standard (30 percent of $2,000 is $600), the Maxwells' are advised by their PHA that they must relocate to continue to take advantage of their Section 8 subsidy. Payment standards vary significantly from area to area. The following are examples of Fair Market Rents for one-bedroom units as proposed by HUD for 2005, and the lower and upper limits of the payment standard that can be set by the local PHA. Market rents for other areas are available at www.huduser.org. Location - Buffalo-Niagara, NY Fair Market Rent (1 bedroom) $542 Payment Standard Range $488 to $596 Location - Chicago, IL Fair Market Rent (1 bedroom) $820 Payment Standard Range $738 to $902 Location - Nassau-Suffolk, NY Fair Market Rent (1 bedroom) $1,037 Payment Standard Range $933 to $1,044 A PHA may be required to establish a higher payment standard when necessary to rent an accessible unit for a family that includes an individual with a disability. Section 8 Project-Based Assistance Section 8 project-based subsidies provide housing assistance to low-income families while they are residing in subsidized units. Because the housing subsidy is connected to the unit, Section 8 assistance generally ends when the family moves. 1. Eligibility Requirements Just as in the Housing Choice Voucher (Section 8) tenant-based program, very low-income or low-income families are eligible for Section 8 project-based subsidies, provided that they are citizens or non-citizens with eligible immigration status. In any fiscal year, 40 percent of all new project admissions must go to very low-income families. Project Owners' Preferences Subject to income-eligibility criteria, owners participating in Section 8 project-based assistance (other than moderate rehabilitation and the project-based certificate or voucher programs) may adopt particular preferences for selecting applicants for admission. However, these owners must adopt a written tenant selection plan, must inform all applicants about available preferences, and must give applicants an opportunity to show that they qualify for an available preference. Such preferences may include: * residency preference (admission of persons residing in a specific geographic region) which must be in accordance with non-discrimination and equal opportunity requirements; * preference for working families where the head, spouse, or sole member is employed; however, an applicant shall be given the benefit of this preference if the head and spouse, or sole member, is age 62 or older, or is a person with disabilities; no preference may be based on the amount of earned income; * preference for families that include a person with disabilities but no preference may be given to persons with a specific disability; * preference for families that include victims of domestic violence; * preference for singles persons who are elderly, displaced, homeless or persons with disabilities over other single persons 2. Computing Income for Section 8 Project-Based Tenants a. Annual Income and Income Exclusions The federal regulations that establish the criteria for calculating annual income and income exclusions in public housing apply to Section 8 project-based subsidies as well. See "Annual Income and Income Exclusions" in the Public Housing section above. b. Income Adjustments The federal regulations that establish the criteria for mandatory income adjustments apply to Section 8 project-based subsidies as well. See the section on Income Adjustments in the Public Housing section above. Note that Public Housing Authorities may adopt deductions in addition to the mandatory deductions listed but housing providers in the Section 8 program may not do so. c. Earned Income Disregards With one exception, the earned income disregards extended to the Section 8 Housing Choice Voucher program do not apply to Section 8 project-based housing. The earned income disregards do apply to the new project-based voucher program and also to project-based certificates converted to vouchers. Both of these subsidies are rare. It is therefore safe to assume that a tenant in Section 8 project-based housing will not be entitled to a disregard. On March 18, 2004, HUD issued a proposed rule for the project-based voucher program, which will replace the project-based certificate program. d. Individual Savings Accounts Individual Savings Accounts as described in the Public Housing section are not available to project-based Section 8 tenants. e. Income Examination Requirements The Section 8 project-based housing providers must conduct an annual re-examination of family income and composition. Additionally, the housing provider may adopt policies prescribing when and where a family should report changes in income or family composition. At any time, the housing provider may conduct an interim re-examination, or a family may request an interim determination of income. If the tenant's income increases to such an extent that the tenant's share of the rent is equal to, or exceeds, the total rent owed to the owner, the tenant may remain in the unit but will be required to pay fair market rent for the unit. Section 811 Supportive Housing for the Elderly and Persons with Disabilities Section 202 and Section 811 Supportive Housing for the Elderly and for Persons with Disabilities offers rental assistance for housing projects serving these specific populations. Projects designed for elderly households often provide a range of services tailored to the needs of their residents, whereas projects for persons with disabilities ensure that residents are provided with necessary supportive services appropriate to their individual needs. 1. Eligibility Requirements The Section 811 Supportive Housing program assists very low-income disabled households. Disabled households are defined as those composed of: * One or more persons, at least one of whom is 18 years or older and has a disability (See detailed definition of person with a disability in the HUD Occupancy Handbook 4350.3 p. 3-41 at www.HUDCLIPS.gov). * Two or more persons with disabilities living together * One or more persons with a disability living with a professionally certified aide * The surviving member(s) of an eligible household Section 811 Capital Advances help non-profit owners finance the development of rental housing with supportive services for people with disabilities. Services may vary, depending upon the target population, but could include items such as 24-hour staffing, in-unit call buttons or planned activities. Tenant acceptance of supportive services is not a condition of program eligibility. 2. Computing Income for Section 811 Tenants a. Annual Income and Income Exclusions The federal regulations that establish the criteria for annual income and income exclusions in public housing apply to Section 811 housing as well. See the "Annual Income and Income Exclusions" in the Public Housing section. b. Income Adjustments The federal regulations regarding mandatory income adjustments in public housing apply to Section 811 housing as well. See "Income Adjustments" in the Public Housing section above. Note that public housing authorities may adopt deductions in addition to mandatory deductions listed while PHAs administering Section 811 housing may not do so. c. Earned Income Disallowance The Earned Income Disallowance or Self-Sufficiency Incentives are not available in the Section 811 Supportive Housing for the Elderly and Persons with Disabilities. d. Individual Savings Accounts Individual Savings Accounts as an alternate to Earned Income Disregards are not available in the Supportive Housing Program. e. Income Examination Requirements The owners of housing funded under this program must re-examine the income and composition of tenant households at least every 12 months. Appropriate adjustments in rent must be made in accordance with federal regulation. In addition, tenant households must comply with lease requirements regarding interim reporting of changes in income. In the event the owner receives information regarding a change in household income, the owner must consult with the household and make appropriate adjustments. If a tenant's household income increases, the household remains eligible for project rental subsidy assistance until such time as the household's share of the rent equals or exceeds the total rent. At that time, the rental subsidy will be terminated. The termination of subsidy eligibility does not affect the tenant household's other rights under the lease agreement. Project rental assistance payments may be resumed if, as a result of further changes in income, rent or other circumstances, the household again meets the income eligibility requirements for rental assistance, provided that the project rent assistance contract between the owner and HUD remains in effect. Housing Opportunities for People with AIDS (HOPWA) Since 1992, the HOPWA program housing authorities funded a broad range of housing assistance and supportive services for low-income persons with AIDS/HIV and their families. Housing assistance includes emergency shelter, and project or tenant-based rental assistance. Supportive services include housing information, education and short-term rent, mortgage, and utility payment assistance to prevent homelessness. Except for short-term supported housing, each HOPWA recipient must pay rent based on his or her family's adjusted or monthly gross income. All housing assisted with HOPWA funds must meet regulatory housing quality standards. 1. Eligibility Requirements Any low-income individual with acquired immunodeficiency syndrome (AIDS) or related diseases, including infection with the human immunodeficiency virus (HIV), and the individual's family are eligible for housing assistance under this federal law. "Family" pursuant to the HOPWA regulations is defined as a household composed of two or more related persons and includes one or more eligible persons living with another person or persons who are determined to be important to their care or well being. Regardless of income, a person with AIDS or related diseases or the person's family members are eligible for other programs funded under HOPWA including housing information services. Any person living near a community residence is eligible to participate in that residence's outreach and educational programs regarding AIDS or related diseases. 2. Computing Income for HOPWA Tenants a. Annual Income and Income Exclusions The federal regulations that establish the criteria for annual income and income exclusions in public housing apply to HOPWA housing as well. See "Annual Income and Income Exclusions" in the Public Housing section above. b. Income Adjustments The federal regulations regarding mandatory income adjustments in public housing apply to HOPWA housing as well. See "Income Adjustments" in the Public Housing section above. c. Mandatory Earned Income Disallowance (Disregards) The Earned Income Disregard mandate was expanded from public housing tenants to persons in the HOPWA program in 2001. The HUD regulations provide for specific self-sufficiency incentives for individuals with disabilities. These incentives mirror the provisions for the mandatory earned income disregard in public housing. The self-sufficiency incentives for individuals in the HOPWA program include: * an initial 12 month exclusion of increased income * a second 12 month cumulative exclusion of 50 percent of increased income * a lifetime limit of 48 months for such exclusions See "Earned Income Disregards" in the Public Housing section above for further explanation of these disregards. d. Individual Savings Accounts Individual Savings Accounts as an alternate to Earned Income Disregards are not available in the Supportive Housing Program. e. Income Examination Requirements Although HOPWA assistance takes many different forms, the general rule at this time requires reporting of increased income only at the annual re-certification. f. Rent Computation Rent for all programs except short-term assistance is calculated as the amount which is the higher of: * 30 percent of the family's monthly adjusted income; or * 10 percent of the family's monthly gross income; or * a shelter allowance paid by a public agency as welfare assistance. If grants are used to provide rental assistance, additional requirements must be met regarding fair market value and reasonable rent. g. Notice and Effective Date of Rent Increases In the event that a HOPWA tenant's income exceeds 80 percent of the area's median income, the tenant's options under the current regulations are limited and depend on the form of subsidy received. Persons having a project-based subsidy may continue to live in their apartment and pay the fair market rent. They may re-apply for the subsidy if their income decreases in the future. However, persons having a tenant-based voucher will lose the voucher and, should they have a future need for housing, they will be placed on a waiting list for an available voucher. It is anticipated that new regulations not yet published will allow HOPWA tenants an exclusion for increased income for a limited period of time. Pilot Program for Homeownership Assistance for Disabled Families Under Section 302 of the American Homeownership and Economic Opportunity Act of 2000, a pilot project has been established whereby a PHA may provide homeownership assistance to a disabled family residing in a home purchased and owned by one or more members of the family. The PHA must determine that the following initial eligibility requirements are met: * the family is a disabled family * the family income does not exceed 99 percent of the median income for the area * the family is not a current homeowner * the family must close on the purchase of the home during the period from July 23, 2001 to July 23, 2004 * the family is qualified to receive homeownership assistance, has satisfactorily completed the PHA program of required pre-assistance counseling, and the unit is eligible. Note that in the pilot program the prohibition against assistance to any family, who was previously assisted under the homeownership program and defaulted on the mortgage, will not apply if the PHA determines that the default is due to catastrophic medical reasons or to the impact of a federally declared major disaster or emergency. Additional eligibility requirements under the HUD homeownership program do apply to the pilot project. For more information contact your local PHA. Other Project-Based Subsidy Programs A number of federal housing programs provide an indirect subsidy to tenants by reducing rental costs for all who reside in a particular housing development. Many tenants benefit from the indirect project subsidy and from a direct subsidy, such as Section 8. Tenants who receive only the project subsidy pay rent according to a rent schedule approved by HUD or a state supervising authority. Three such programs are described below: Section 236 projects vary as to their income eligibility requirements but most projects have an additional subsidy (e.g., Section 8, Rent Supplement, Rental Assistance Payment) for some or all tenants to offset operating expenses and to assist lower income families. HUD establishes a basic rent (minimum or contract) rent for each unit as well as a market rent (maximum) rent. The tenant rent is the greater of the basic rent or 30 percent of the tenant's adjusted monthly income but not more than the market rent. Re-certification is done annually, but regular excess income of $40 or more per month must be reported immediately. If the tenant's income increases to such an extent that the tenant rent exceeds the market rent, the tenant may remain in the unit but will be required to pay a surcharge or fair market rent for the unit, depending on the amount of increased income. The Rent Supplement Program provides an additional subsidy for some Section 236 project residents. The number of these subsidies for each project is limited to a certain percentage of the residents. An individual or family is eligible for this assistance if the applicant's annual income does not exceed 80 percent of the median income for the area as determined by HUD, unless HUD establishes a higher or lower percentage due to unusually high or low-incomes or other local factors. Annual re-certification is required and regular increased income of $40 or more must be reported in order to adjust the total tenant payment. If the total tenant payment exceeds the gross rent, the rent supplement subsidy terminates. The tenant may remain in the unit under the current lease provided that the tenant pays the market rent approved by HUD. Should the tenant's income decrease, the prior termination does not preclude resumption of the subsidy. The Rental Assistance Program (RAP) offers subsidies to low-income families. The tenant's share of the rent is income-dependent as in other Section 8 programs, and the minimum rent for project-based assistance is $25. More information about project-based subsidy programs can be found by reviewing the recently revised HUD Handbook 4350.3 Occupancy Requirements of Subsidized Multifamily Housing Programs available at www.hudclips.org. Helping People with Disabilities Determine the Impact of Employment on Housing Costs Questions to Ask and Information to Gather * Is the individual receiving housing assistance under a HUD administered program? * If so, under which program are they receiving assistance? * Which local housing authority, local PHA or other entity administers the program? * What is the family composition and income? * What is the current rent payment? * Is the rent payment income based? * If the individual is residing in public housing, are they paying a flat rent? (If so, then increased earnings will not impact rent payment.) * Is the individual receiving assistance from an employment-training program? * What is the PHA's (or other administering entity's) policy on frequency of income redeterminations, and tenant responsibility for reporting of increases in income? * If the individual is receiving assistance under a section 8 voucher, what is the payment standard? * Does the PHA allow any additional income adjustments beyond the standard ones? * Consider obtaining a copy of the PHA's annual plan (which is a public document). What Work Incentives can be Used to Defer Counting of Income? * Is the individual receiving assistance from any of the following programs: Public Housing; Housing Choice Voucher; Housing Opportunities for People with AIDS; HOME Investment Partnerships; Supportive Housing (for homeless persons)? * If so, were members of the household previously unemployed, or have they been participating in an employment training program, self-sufficiency program, or receiving TANF? * If so, the earned income disallowance applies and the Public Housing Authority or PHA cannot count 100 percent of increased earnings for the next 12 months, and 50 percent for the subsequent 12 months. Making the Calculations for New Income Based Rent If counting of income cannot be deferred: * What is the family's new projected annual gross income? (Be sure to account for changes in SSI and SSDI payments, and other benefits). * Review the Annual Income Exclusions and deduct all that apply. * Review the Annual Income Deductions, and deduct all that apply. * Calculate the new rent payment based upon the higher of: - the family's monthly adjusted income; or - the family's monthly income; or - if the family is receiving payments for welfare assistance from a public agency, the amount of assistance designated for housing. * Income based rent payments cannot exceed the actual rent for the unit. * Determine the impact of employment on the individual's or family's disposable income - new income minus new housing costs vs. old income minus old housing costs. - If the individual is in public housing, should that individual switch to flat rent at the next election period? Setting Aside Increased Rent * Does the PHA or housing authority participate in the Family Self-Sufficiency (FSS) Program? Can the family enroll in the FSS program and have the increased rent payment be deposited in a FSS escrow account? * If the individual is living in public housing, does the housing authority have the Individual Savings Account program? Could the increased rental payment be placed in an Individual Savings Account to benefit the individual or family? Make Sure Individuals Are Aware of: * All available income exclusions. * All available income adjustments. * All available income disregards. * All available rent increase set-asides. * The right to request re-examination of income at any time, and the importance of immediately reporting any decreases in income. * The right to switch from flat rent to income-based rent at any time. * The need to notify the PHA or other administering entity when the period of income disallowance (the 100 percent disallowance for 12 months, and the 50 percent disallowance for an additional 12 months) has been interrupted. Income Exclusions and Disallowances The following are methods available to people with disabilities to exclude or disallow earnings so that they will not impact rent payments. Income Excluded/Disallowed A. Total earnings from HUD training program Type of Housing Assistance Applies To All Income Excluded/Disallowed B. Increased earnings while in non-HUD training program Type of Housing Assistance Applies To All Income Excluded/Disallowed C. 100% of increased earnings for 12 months 50% of increased earnings for subsequent 12 months (months 13 - 24) Criteria to qualify * Previously unemployed for one or more years; or * Increased income due to participation in self-sufficiency program or other job training program; or * Increased earnings during or within six months of receiving TANF NOTE: 48 month life time limit on period of exclusion from the first month of increased earnings Type of Housing Assistance Applies To: A. Families in public housing B. Individuals with disabilities whose earnings increased, receiving assistance from: * Housing Choice Voucher Program * Housing Opportunities for People with AIDS * Supportive Housing (for homeless persons) * HOME Investment Partnerships Setting Aside Rent Increase for Family Use The following are methods of setting aside rent increases due to increased income, for future use by the family. These methods, Individual Savings Accounts or the Family Self-Sufficiency Program, are not offered by every Public Housing Authority (PHA). Individuals should check with their PHA to see if either option is available. Program Individual Savings Account (ISA) Applicable to Individuals Assisted Through Public Housing Amount Set Aside At the option of the tenant family, the PHA will deposit the total amount that would have been calculated as increased tenant rent resulting from increased income into an interest-bearing savings account. Program Details The tenant family may only withdraw with moneys deposited in the account for: * Purchasing a home * Paying the education costs of a family member * Moving from public or assisted housing * Paying other expenses approved by the PHA that promote self-sufficiency If the family moves from public or assisted housing, the PHA must pay the family any balance in the account, minus any amounts owed to the PHA. Program Family Self-Sufficiency Program Applicable to Individuals Assisted Through * Public Housing *Section 8 Housing Choice Voucher (Section 8 tenant based assistance) Amount Set Aside * The PHA will deposit the lesser of 30% of monthly adjusted income minus the family rent at the time of initial program participation or the current family rent minus the family rent at the time of the initial program participation, into an interest-bearing escrow account. * For low-income families, the contribution cannot exceed amount calculated for 50% of median income. Program Details The tenant family must comply with a plan to increase their self-sufficiency. Upon successful completion of the plan, the family receives the entire amount in their escrow account, which they can use for any purpose. Federally-Subsidized Housing Resources AIDS Housing of Washington 2014 East Madison, Suite 200 Seattle, WA 98122 206-488-5242 www.aidshousing.org US Department of Housing and Urban Development Project Contacts * For the HOME Investment Partnerships Program, contact Mary Kolesar, Office of Community Planning and Development, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-2470. * For the Housing Choice Voucher Program, contact Jerry Benuit, Office of Public and Indian Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-0477, ext. 4064. * For the Housing Opportunities for Persons with AIDS Program, contact David Vos, Office of Community Planning and Development, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-1934, ext. 4620. * For the Rent Supplement Program, contact Willie Spearmon, Office of Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410; telephone (202) 708-3000. * For the Rental Assistance Payment (RAP) Program, contact Willie Spearmon, Office of Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410; telephone (202) 708-3000. * For the Section 202 Supportive Housing Program for the Elderly (including Section 202 Direct Loans for Housing for the Elderly and Persons with Disabilities), contact Aretha Williams, Office of Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-2866, ext. 2480. * For Section 8 Project-Based, contact Willie Spearmon, Office of Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410; telephone (202) 708-3000. * For the Section 811 Supportive Housing Program for Persons with Disabilities, contact Gail Williamson, Office of Housing, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-2866, ext. 2473. * For the Shelter Plus Care Program, contact Allison Manning, State Assistance Division, Office of Community Planning and Development, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-1234, ext. 4497. * For the Supportive Housing Program (McKinney-Vento Act Homeless Assistance), contact Marion Jones, Office of Community Planning and Development, Department of Housing and Urban Development, 451 Seventh Street, SW., Washington, DC 20410, telephone (202) 708-1234, ext. 4502. * For all of the above telephone numbers, persons with hearing or speech-impairments may call 1-800-877-8339 (Federal Information Relay Service TTY). (Other than the "800" number, the telephone numbers are not toll-free numbers.) Center on Budget and Policy Priorities 820 First St. NE, Suite 510 Washington, DC 20002 202-408-1080 Contact Will Ficher www.cbpp.org National Housing Law Project 1012 14th Street NW, Suite 610 Washington, DC 20006 202-347-8775 www.nhlp.org National American Indian Housing Council/Coalition for Indian Housing and Development 900 Second Street NE, Suite 305 Washington, DC 20002 202-789-1754 or 800-284-9165 www.naihc.indian.com Office of HIV/AIDS Housing David Vas, Director US Dept of Housing and Urban Development 451 7th Street, SW Washington, DC 20410 202-708-1934, ext. 4620; TTY 202-708-1455; 1-800-877-8339 www.hud.gov/offices/cpd/aidshousing/programs/index.cmf US Department of Housing and Urban Development www.hud.gov www.hud.gov/group/disabilities.cfm www.hudclips.org CHAPTER 15: UNEMPLOYMENT INSURANCE PROGRAM Introduction A national unemployment insurance program established under the Social Security Act of 1935 provides for temporary and partial replacement of income to individuals who have lost their jobs due to no fault of their own. The Unemployment Insurance Program is a dual program of federal and state statutes. Within federal guidelines and standards, state unemployment laws establish a fund from which weekly unemployment benefits are paid to individuals who qualify. The States' Unemployment Insurance Funds are financed through a combination of federal and state taxes that are levied upon employers. The goals of this federal-state cooperative program are to: * Prevent unemployed individuals from experiencing severe financial hardships; and * To provide time for individuals to find work again in a new, equivalent job. Unemployment insurance benefits are funded by payroll tax contributions collected from businesses. The amount of contributions required of an employer is based on the amount of wages paid, the amount of contributions to the Trust Fund, and, finally, the employer's "experience rating." A business' experience rating is related to the amount of unemployment benefits received in the past by former employees. If a state has an unemployment insurance law that meets the basic provisions of the federal law, employers can credit their state taxes against the federal tax. For employers to continue to obtain the tax offset allowed in the federal law, the state unemployment insurance system must continue to conform to the general requirements in the federal law. The federal contributions to the program are used by the state for costs associated with administration of the program, while state contributions fund the cost of the actual unemployment benefits paid to individuals. Taxes paid by businesses under state laws are deposited in the Unemployment Trust Fund of the United States Treasury Department. Separate accounts are maintained for each state and the states may make withdrawals at any time from their account. However, funds withdrawn may be used solely for the purpose of unemployment benefit payment. Covered Employment Over the years, several federal laws have added significantly to the number and types of workers protected under the State Unemployment Insurance programs. The list of covered employment below is mandated under federal law. Many states have expended coverage beyond that provided by federal legislation. Private employers in industry and commerce: Private employers in industry and commerce are subject to the law if they have one or more individuals employed on one day in each of 20 weeks during the current or preceding year, or if they paid wages of $1500 or more during any calendar quarter in the current or preceding year. Agricultural employment: Agricultural workers are covered on farms with a quarterly payroll of at least $20,000 or employing 10 or more employees in 20 weeks of the year. Domestic employment: Domestic employees in private households are subject to the Federal Unemployment Tax Act (FUTA) if their employer pays wages of $1000 or more in a calendar quarter. State and Local Government and Non-Profit employment: Most employment in state and local government and in non-profit organizations is covered by state law as a condition for securing federal approval of the state law. Under this form of coverage, local government and non-profit employers have the option of making payroll tax contributions as under FUTA or of reimbursing the state for unemployment benefit expenditures actually made. Federal Civilian Employees and Ex-Service Members of the Armed Forces: Unemployment benefits for federal civilian employees and ex-service members of the armed forces are paid for through federal funds, but are administered by the states. Benefit amounts are paid according to the provisions of the state law. Employment Not Covered: * Self-employed individuals * Workers employed by their families * Elected officials * Legislators * Members of the judiciary * State National Guard * Non-profit organizations that employ fewer than four workers in 20 weeks in the current or preceding calendar year. Again, the above list represents parameters established by federal law. Many states have extended coverage beyond these federal parameters. It is critical that benefits specialists become familiar with their state's law and provisions regarding covered employment for the unemployment insurance program. Eligibility for Unemployment Insurance Benefits Within broad federal standards, states are responsible for developing and administering their Unemployment Insurance Law and program. The state Unemployment Insurance (UI) agency is responsible for handling the claims or application for benefits of unemployed workers, deciding in each case whether the individual is entitled to unemployment benefits, and for paying the benefits. Specifically, states decide on the content of their Unemployment Insurance program in the following areas: * Payroll tax contribution rates within the specific federal limitations; * Eligibility requirements that individuals must meet in order to receive the benefit; * Factors that disqualify a person from receiving unemployment insurance benefits; * The amount of weekly unemployment benefits to be paid; and * Benefit duration, or the period of time that an individual may receive the benefit. Eligibility for Unemployment Insurance Benefits Unlike other programs discussed previously, the Unemployment Insurance program is not a means-tested program. Regardless of an individual's income and resources, unemployment insurance benefits are paid as a matter of right to unemployed workers who have worked a sufficient amount of time and/or who have a sufficient amount of earnings in covered employment. The general requirements for receiving unemployment benefits are as follows: * The worker must file a claim for unemployment benefits with the state Unemployment Insurance agency. * The worker must have worked previously on a job covered by the state law. * The worker must have earned a given amount of wages in covered employment during a specified "base period". In most States the base period is the first four quarters of the last five completed calendar quarters prior to the time that the individual submits the claim for unemployment benefits. Less than one half individuals who are unemployed receive benefits, primarily due to the fact that many workers do not meet the specific work/earnings requirement. * The worker must be able to work. In general, unemployment insurance benefits are not payable to workers who are sick or unable to work for any other reason. However, a few states continue to pay the benefits within the legal limits to workers who became ill after they had established their eligibility for the unemployment benefit. Additionally, in five States and Puerto Rico, workers contribute to special disability funds from which disability benefits are paid for non-work connected sickness or accident. * The individual claiming benefits must register for work at a state employment services office must actively be seeking employment, and must also be available for work and ready and willing to accept a suitable job if one is offered. * In addition to the above requirements, the individual must also meet the eligibility and qualifying requirements of the state law, and be free from disqualifications. Disqualifications are conditions or factors that will render individuals ineligible for unemployment benefits. An individual will be disqualified if it is determined that they have: * Quit their job voluntarily without good cause. In some states, the law reads, "without good cause attributable to the employer" or "connected with the work." * Been discharged for misconduct in connection with their work. * Refused or failed, without good cause, to apply for, or accept, an offer of suitable work. What is "suitable" work is generally decided by the state; however, under federal law no worker may be denied benefits for refusing to accept a new job under substandard labor conditions, or where a labor dispute is involved, or where he or she would be required to join a company union or to resign from or refrain from joining any bona fide labor organization. * Become unemployed because of a work stoppage as the result of a labor dispute, in which he or she is interested or participating, that occurred at the establishment where last employed. In addition to the disqualifications listed above, many states have identified additional disqualifications. Depending on the state, a disqualification for unemployment benefits may result in a postponement of benefits, a reduction in the amount of benefits, or both. Except in limited situations, however, individuals who are determined disqualified for benefits at a specific point in time will not have their work credits canceled or their benefit rights eliminated entirely. Unemployment Benefit Amount Unemployment benefits generally replace about one-half of an individual's after-tax wages lost each week, within minimum and maximum limits. The actual dollar amount of the benefit received is computed according to the unemployment benefit formula established in the state's law, and takes into consideration the amount of wages received by the person in the past. In most states, the benefit formula computes a weekly benefit as a fraction of the wages a person received in one or more quarters of the base period. All states have established a maximum benefit amount, and no worker, regardless of their earnings level during the base period, receives more than this maximum. The states vary in terms of whether this maximum benefit amount is a fixed dollar amount or a flexible amount that is adjusted according to the weekly wages of covered employees. Twelve states and the District of Colombia provide allowances for certain dependants in addition to the weekly benefit check. Across these twelve States, allowances vary considerably in terms of dependants covered and dollar amount paid. All 12 states include an allowance for children under the ages of 16, 18, or 19. Additionally, nine states include a non-working spouse, and three states include other dependent relatives. Generally, the amount of the allowance per dependant is $20 a week, or less. Duration of Unemployment Insurance Benefits The number of weeks that an individual may receive Unemployment Insurance benefits ranges from 1 to 26 weeks in a benefit year, depending on the state's law. The average number of weeks that benefits are received is 15. Until the individual finds another job, or the benefit period ends, they will receive a weekly payment by reporting at regularly scheduled times to the Unemployment Insurance agency in their state. A program of federal/state Extended Benefits provides for the payment of additional unemployment benefits for workers who have exhausted their entitlement to regular state benefits during periods of high unemployment. State law determines most eligibility conditions for Extended Benefits. There is, however, a federal requirement that individuals applying for Extended Benefits must have had 20 weeks in full-time employment (or the equivalent in insured wages) and must meet special work requirements. A worker who has exhausted their regular unemployment benefits and who meets the federal/state requirements may receive Extended Benefits for a maximum of 13 weeks. Overall, individuals are subject to a maximum total of 39 months of regular and Extended Benefits. Extended Benefits are payable at the same rate as the weekly amount under the regular State Program. Please note - Due to variations in formulas used to trigger the Extended Benefit provision, in some states, individuals have access to an additional seven months of Extended Benefits, for an overall period of 20 months. Application Process Individuals must file a claim for Unemployment Insurance Benefits in their state. Claims may be filed in any state, regardless of where the worker was previously employed. A worker who has been employed in several states, or who moves into a new state and is out of a job, must follow the same application process that other individuals in the state follow. The worker must file a claim and register for a job. He or she should explain about his or her work in other states. The Unemployment Agency will gather the information and forward the claim to the other state(s) in which the individual may be qualified for benefits, or may instead provide the individual applying with contact information needed to file the claim directly with the other state(s). Any benefits to which the worker may be entitled will be paid by check sent directly for the state that owes them. Wages, which have been earned in two or more states, will be combined. In most states, a waiting period of one week of total unemployment is required before benefits can begin. Three states pay benefits retroactively for the waiting period if unemployment lasts a certain period or if the individual returns to work within a specified period. The Office of Workforce Security map with links to individual state unemployment offices and information is provided at http://workforcesecurity.doleta.gov/map.asp. Right to Appeal The worker and their employer may appeal any determination on unemployment benefit claims. If a worker believes that the determination on his or her claim is wrong, an appeal may be filed in the office where the claim was filed within 5 to 30 days after the worker is notified of the decision. An employer may appeal if he or she does not agree with a determination on an employee's claim. Affect of Unemployment Benefits on SSI and SSDI Individuals receiving SSDI will experience no impact on their cash benefit eligibility as a result of receiving an unemployment insurance benefit. Of course, it will be critical that the loss of earnings be reported to the Social Security field office. This is particularly important for individuals in their extended period of eligibility to ensure that cash benefits are paid as a result of earnings falling below the SGA level. Individuals receiving SSI will experience an impact on their cash benefit payment status as a result of receiving unemployment insurance benefits in any given month. Unemployment benefits for purposes of the SSI program are considered to be unearned income. As a result, while the individual will receive a partial replacement of wages through their unemployment benefit, they will simultaneously experience a reduction in their monthly SSI cash benefit. The SSI cash benefit will be reduced in the amount of the monthly unemployment insurance benefits received, minus the $20 dollar general exclusion, assuming that the general exclusion has not been applied in the month to any other type of unearned income. It is also important to keep in mind that the potential exists for receipt of the unemployment benefit to result in a loss of Medicaid coverage for the SSI recipient. This will only occur in situations where the amount of the unemployment benefit (unearned income) in a specific month is sufficient to place the individual over their break-even point. The break even point is the point at which an individual is no longer eligible for an SSI cash benefit, but is considered for eligibility for continued Medicaid under 1619b. A person will not meet the criteria for 1619b if the reason their SSI cash benefit ceased is due to unearned income placing them above their break-even point. The likelihood that Medicaid eligibility will be affected will be greater for individuals who are already receiving other types of unearned income, such as SSDI. Another situation where receipt of unemployment benefits will impact a person's SSI cash benefits is in situations where deeming is taking place. If an SSI recipient is subject to deeming and the ineligible parent or spouse whose income is deemed becomes eligible for unemployment benefits, a portion of the unemployment benefits received will be deemed as available to the SSI recipient. North American Free Trade Agreement (NAFTA) and Trade Adjustment Assistance (TAA) NAFTA, the North American Free Agreement, provides assistance to workers who have lost their job because of trade with Mexico and Canada. The benefits of this program are similar to TAA, Trade Adjustment Assistance, which provides assistance to workers who have been totally or partially separated from their jobs because of increased foreign imports. The two programs (NAFTA and TAA) are discussed together because the benefits are similar. Both programs provide weekly cash benefits called Trade Readjustment Allowances (TRA) to eligible applicants as well as training, job search and relocation allowances, and other reemployment services such as employment registration, employment counseling, vocational testing, job placement, or other supportive services. NAFTA and TAA Benefits include: 1. Help finding a job through the state employment office. 2. Payment for costs of approved training. Sometimes this may include transportation and basic living expenses. 3. Help paying the costs of finding a job outside of the area (up to $800). 4. Help paying the costs associated with relocating for another job (up to 90% of allowable moving expenses and a lump sum of $800). 5. Cash payments for up to 26 additional weeks after regular Unemployment Insurance payments have been exhausted for eligible applicants. Filing a NAFTA/TAA Application: Three or more workers or their representatives may file a petition for NAFTA or TAA. NAFTA petitions are filed with the Governor of the state in which the workers' firm or its' subdivision are located. TAA petitions are sent to the Office of Trade Adjustment Assistance in the US Department of Labor. To file either a NAFTA or TAA petition, applicants must first go to the state employment office and ask for the NAFTA/TAA counselor. When the petition is certified, an "impact date" will be established and a group of affected workers will be identified. To be eligible for benefits, affected workers must have been laid off or put on a reduced schedule on or after the "impact date." If the petition is terminated or denied the affected workers may ask for an administrative reconsideration by the US Department of Labor, Office of Trade Adjustment Assistance within 30 days after the publication of the denial or termination in the Federal Register. The state employment office will provide additional information about the reconsideration process. To qualify for all phases of the NAFTA/TAA program, applicants must file for benefits as soon as a petition affecting workers in the company is certified. There are different time limits for each of the program components. Eligibility for weekly cash payment (TRA) is very specific and may involve work search and/or training participation requirements. CHAPTER 16: WORKERS' COMPENSATION The lack of suitable, affordable housing is often a major barrier to successful employment of persons with disabilities. Still, various public and subsidized housing programs available to persons with disabilities can sometimes help to overcome this barrier. In addition, a number of rent-based work incentives allow families and individuals entering the workforce to retain more of their income. This chapter will provide a brief summary of the major federally sponsored programs that should be available in all states, with an emphasis on those policies most applicable to persons with disabilities. The reader should keep in mind: a) this is only an overview of the federal programs and their regulations; and b) this overview is based on federal regulations published as of November 2001. State-subsidized housing programs also exist and may offer additional benefits, although they are not covered in this chapter. General Provisions Every state has enacted workers' compensation laws to protect employees against loss of income and for medical payments due to work related injury, accident, illness, or disease. The workers' compensation program is administered by a state agency and most employers are required by law to participate. The exceptions to this are Texas and New Jersey, which have voluntary systems in operation. The basic elements of the workers' compensation system common across states include the following: * Benefits are provided for accidental job-related injury. An employee is entitled to statutory benefits from the business when they suffer a "personal injury by accident arising out of and in the course of employment." * Benefits include partial replacement of lost wages, medical and rehabilitation benefits, and death benefits. * Covered businesses and types of jobs are defined by state law. * Fault is generally not an issue. Neither the employee's own negligence in causing the accident nor the business' complete lack of fault are factors in deciding whether the worker gets benefits. * Employees give up the right to sue the business for the work-related injury or illness in exchange for the assured benefits under the Workers' Compensation program. * Employees retain the right to sue negligent third parties if a third party's negligence helped cause the accident. Proceeds from the lawsuit are used first to reimburse the employer for benefits paid to the employee. For businesses, the Workers' Compensation program limits their liability for on-the-job injuries to the remedies/benefits available under the workers' compensation statute in their respective State. The following are the types of benefits typically available to injured workers under the Workers' Compensation program: * Income replacement for partial or total disability of a temporary or permanent nature. Wage loss benefits usually cover about one-half to two-thirds of the employee's average weekly wage. Practically all-state laws place lower and upper limits on the weekly amounts payable. * Medical costs * Rehabilitation costs * Coverage for certain occupational diseases that are established in State laws. * Survivor's benefits in the case of a fatal illness or injury. The above benefits under Workers' Compensation apply only to work-related injuries. Benefits are not available for self-inflicted injuries or those caused by intoxication or substance abuse. Coverage As indicated above, specific standards and guidelines for the Workers' Compensation program are established in state law. State laws dictate how much Workers' Compensation insurance must be purchased by businesses, the types of employment covered, and the percentage of wage replacement to the injured worker. As a result, while variations exist in coverage and benefits between states, within a state little difference will exist between the Workers' Compensation packages provided by different employers. In most states, the state law covers employers who have at least one employee. Some states exempt small businesses. How a "small business" is defined varies, but generally is defined as businesses with fewer than three, four or five employees. In addition to working for a business covered by their state's law, an individual's type of work or position must also be covered. The following are frequently excluded, or not covered, by the Workers' Compensation program: * Business owners * Independent contractors * Domestic employees in private homes * Farm workers * Maritime workers * Railroad employees * Unpaid volunteers Workers' Compensation for Federal Government Employees The following information is excerpted in part from the US DOL publication CA-550, "Questions and Answers about the Federal Employees' Compensation Act (FECA)" The federal Employees' Compensation Act (FECA) provides for worker's compensation benefits for federal civilian employees who are injured on the job. FECA is administered by the Office of Workers' Compensation Programs (OWCP), U.S. Department of Labor, through 12 district offices located across the United States. The costs for the workers' compensation payments are paid from the Employees' Compensation Fund, which OWCP administers. Each year, each employer reimburses the Fund for the amounts paid to its employees in workers' compensation benefits during the previous year. Coverage All civilian employees of the United States, except those paid from non-appropriated funds, are covered. Special legislation provides coverage to Peace Corps and VISTA volunteers; Federal petit or grand jurors; volunteer members of the Civil Air Patrol; Reserve Officer Training Corps Cadets; Job Corps, Neighborhood Youth Corps, and Youth Conservation Corps enrollees; and non-federal law enforcement officers under certain circumstances involving crimes against the United States. FECA coverage is extended to federal employees regardless of the length of time on the job or the type of position held. Part-time, seasonal, and intermittent employees are covered. All kinds of injuries, including diseases caused by employment, are covered if they occur in the performance of duty. However, benefits cannot be paid if injury or death is caused by willful misconduct of the injured employee, by intent to bring about the injury or death of oneself or another, or by intoxication of the injured employee. Diseases and illnesses aggravated, accelerated or precipitated by the employment are covered. The employee must submit medical and factual evidence showing that the employment aggravated, accelerated, or precipitated the medical condition. Eligibility The employee must provide medical and factual evidence to establish five basic elements: * The claim was filed within the time limits set by the FECA; * The injured or deceased person was an employee within the meaning of the FECA; * The employee actually developed a medical condition (or damaged a prosthesis) in a particular way; * The employee was in the performance of duty when the event(s) leading to the claim occurred; and * The medical condition found resulted from the event(s) leading to the claim. A notice or claim must be filed within three years of the date of injury. However, if a claim is not filed within three years, compensation may still be paid if written notice of injury was given within 30 days, or the employer had actual knowledge of the injury within 30 days after it occurred. Benefits Under FECA, injured workers are provided partial wage replacement, vocational rehabilitation, and medical benefits. This is similar to the common types of benefits provided injured workers under state Workers' Compensation laws. Wage-loss compensation is paid at two-thirds of the employee's pay rate if he or she has no dependents, or three-fourths of the pay rate if he or she is married or has one or more dependents. The maximum payment per month cannot exceed three-fourths of the highest rate of basic pay provided for Grade GS-15. Basic pay excludes locality pay. Conditions that result in a reduction of the wage replacement benefit include the following: a. The employee returns to work and has actual earnings from employment, either with the original employer, or with a new employer, or from self-employment, and those earnings do not equal the wages of the job held at the time of injury, as adjusted for inflation. b. The employee can earn wages in a particular job which is both medically and vocationally suitable, and which is reasonably available in the employee's commuting area. Compensation can be reduced even if the employee does not actually work in the job identified. When compensation is reduced on this basis, OWCP issues a formal decision describing the job, its physical requirements, and the vocational preparation needed for it. Benefit Payment Period Compensation payments can be made after wage loss begins and the medical evidence shows that the employee cannot perform the duties of his or her regular job. No waiting period is required when permanent disability exists, or when the disability causing wage loss exceeds 14 days. Short-term compensation payments are issued each week. The period covered may include compensation for several days to several weeks. Long-term compensation payments are issued every four weeks. An employee may receive compensation payments for as long as the medical evidence shows that total or partial disability exists and is related to the accepted injury or condition. OWCP requires most employees receiving compensation for disability to undergo medical examinations at least once a year. This evaluation is usually obtained from the employee's treating physician. OWCP may, however, require the employee to be examined by another physician. Compensation ends when: * The employee returns to full duty in the job held when injured, or is otherwise re-employed in a job, which results in no loss of wages; * The employee refuses an offer of a suitable job, and the cause for refusal is not reasonable. OWCP will decide whether the job offer was suitable and whether the refusal was reasonable. Acceptable reasons for refusal include, but are not limited to: withdrawal of the offered position by the employer; acceptance of other work by the employee which fairly and reasonably represents his or her earning capacity; and a worsening of the employee's medical condition, as documented by the medical evidence, to the point that the employee is disabled for the job in question. Unacceptable reasons for refusal include, but are not limited to: the employee's preference for the area in which he or she currently resides; personal dislike of the position offered or the work hours scheduled; lack of potential for promotion; lack of job security; retirement; and previously-issued rating for loss of wage-earning capacity based on a constructed position where the employee is not already working at a job which fairly and reasonably represents his or her wage-earning capacity. * The employee abandons a suitable job. OWCP will decide whether the job was suitable and whether the reason for abandonment was reasonable and apply its finding retroactively. * OWCP receives medical evidence showing that the employee no longer has limitations from the work-related injury which affected the performance of his or her duties when the injury occurred, or that the employee's disability is not usually related to the work-related injury; * A beneficiary is convicted of defrauding the federal government with respect to a claim for benefits. Effect of Workers' Compensation Benefits on SSDI and SSI Title II or SSDI Dependent on the dollar amount of an individual's workers' compensation or public disability benefit, receipt of these types of benefits may result in a reduction of their or their family's SSDI cash benefit. Generally, speaking about ten percent of SSDI beneficiaries are impacted by receipt of workers' compensation or public disability benefit. The following provides information on the formula used to determine how the SSDI cash benefit is affected. Step One: Establish the exact amount of the following figures: * the dollar amount of the monthly SSDI cash benefit that is received by the individual. In cases where there are spouses' and/or children's insurance benefits paid on the wage-earners record, it will be necessary to determine the SSDI total family benefit paid. * the dollar amount of the workers' compensation or public disability insurance benefit received. * the dollar amount that represents 80% of the beneficiaries average current earnings SSA defines the average current earning as the highest of the following: 1. the average earnings used by the Social Security Administration to figure the SSDI benefit, 2. the person's average monthly earnings from any work that they performed that was covered by Social Security during the five highest years in a row after 1950, or 3. the person's average monthly earnings for work during the five-year period immediately prior to becoming disabled. Again, the average current earnings are the highest of these three amounts. Once the average current earnings are determined, 80% of this figure is used as the benchmark in determining the impact on the SSDI cash benefit. In summary, for step one we have established the amount of SSDI benefit received, the amount of the workers' compensation or public disability benefit received, and finally the 80% of the average current earnings benchmark. Step Two: * Determine which is higher, the SSDI benefit or the 80% of the average current earnings figure. Using whichever of the two figures is higher, subtract from this figure the dollar amount of the workers' compensation or public disability benefit. The remaining amount represents the new adjusted SSDI monthly benefit. Step Three: * Add the adjusted SSDI benefit to the workers' compensation or public disability benefit to arrive at the total monthly income received by the individual from these two sources. Example I Harold is receiving a monthly SSDI benefit. He becomes eligible for a workers' compensation benefit in September of 2000. In step one, establish the following factors for Harold. His monthly SSDI benefit is $507.90. His workers' compensation benefit each month is $410. Eighty percent of his average current earnings are $800. Step One: SSDI Benefit $507.90 Workers' Compensation benefit $410.00 80% of average current earnings $800.00 In step two, take the greater of his SSDI cash benefit and 80 % of average current earnings figure. In Harold's case, his 80% of average current earnings is higher than $800. From the $800 amount, subtract the $410 workers' compensation benefit. This leaves Harold with the revised SSDI cash benefit of $390. Step Two: Greater of 80% of ACE/SSDI $800.00 Workers' Compensation Benefit minus $410.00 Adjusted SSDI Monthly Benefit equals $390.00 In the final step, add the adjusted SSDI benefit of $390 to the workers' compensation benefit of $410. This provides Harold of a total monthly income from these two sources of $800. Step Three: Add Adjusted SSDI to Workers' Compensation Benefit Adjusted SSDI $390.00 Workers' Compensation Benefit plus $410.00 Total Monthly Income equals $800.00 Example II Example of an SSDI beneficiary with family members receiving an SSDI benefit on his wage record. Tom is entitled to a monthly SSDI cash benefit of $559.30. His wife and two children are also entitled to monthly benefits of $93.20 each. The total family benefit under SSDI is $838.90. Tom also begins to receive workers' compensation benefit of $500. In step one established the following for Tom. The SSDI total family benefit is $838.90. The workers' compensation monthly benefit is $500, and Tom's 80% of average current earnings figure is $820.10. Step One: SSDI Benefit $838.90 Workers' Compensation Benefit $500.00 80% of Average Current Earnings $820.10 In step two, take the SSDI total family benefit, which is the higher of the two figures when compared to the 80% of the average current earnings figure. Again, the SSDI total family benefit figure is $838.90. From this figure subtract the $500 workers' compensation benefit. This results in an adjusted SSDI amount of $338.90. Tom's wife and two children will lose their benefits altogether as the reduction is always taken from the dependents' benefits first. The remaining amount of the reduction is then subtracted from Tom's benefit to arrive at the $338.90 figure. Step Two: SSDI Benefit $838.90 Workers' Compensation minus $500.00 Revised SSDI equals $338.90 In the final step, add Tom's revised SSDI of $338.90 to his $500 workers' compensation benefit. This gives him a total monthly benefit of $838.90. This is the exact amount of the SSDI total family benefit that was previously received by Tom and his family members. Step Three: SSDI $338.90 Workers' Compensation plus $500.00 Total Monthly Benefit equals $838.90 Important Points * While the beneficiary may experience a reduction in his or her SSDI cash benefit, the total amount of the combined SSDI and workers' compensation will never be less than the total amount of SSDI received by the individual and their family prior to reduction. * Changes in factors such as family composition and the amount of the workers' compensation or public disability benefit received will result in a recalculation of the reduction. This may potentially mean an adjustment in the SSDI cash benefit. All changes must be reported by the beneficiary to the Social Security Administration. * Some individuals may receive a lump sum workers' compensation payment to settle their claim. The adjustment to the person's SSDI cash benefit in these instances is made by prorating the lump sum payment over the number of months the workers' compensation benefit would normally be made if the person had not gotten the lump sum. * The reduction in SSDI due to a workers' compensation benefit will continue until the month that the individual reaches age 65 or the month that the workers' compensation payment stops, whichever comes first. * In addition to workers' compensation, other public disability payments may affect a person's SSDI cash benefit. This includes payments made under a federal, state or local government law or plan that pays for conditions that are not job related. Examples include civil service disability benefits, military disability benefits, state temporary disability benefits, and state or local government retirement benefits which are based on disability. The adjustment to a person's SSDI cash benefit for these types of payments is determined in the same manner as described above for the workers' compensation benefit. Title XVI or SSI Supplemental Security Income or SSI is a program that is based on economic need. The more that a person has in income both earned and unearned income the less they receive in SSI cash benefit. For purposes of the SSI program a workers' compensation benefit is considered to be one type of unearned income. Therefore, a person who receives a workers' compensation benefit or other public disability benefit will experience a reduction in their SSI. Specifically, the SSI cash benefit will be reduced by the amount of the monthly workers' compensation payment or public disability benefit less the $20 general exclusion. Assuming that this exclusion has not already been applied to some other form of form of unearned income that the person receives. It's important to keep in mind that workers' compensation benefits or other public disability benefits will also impact SSI when deeming is involved. This includes both situations of spouse to spouse deeming as parent to child deeming. If the spouse or parent begins to receive a workers' compensation benefit, a portion of this benefit will be deemed as being available to the SSI recipient, and will consequently result in a reduction in their SSI cash benefit. A potentially greater concern than the impact on the SSI cash benefit is the potential loss of Medicaid eligibility due to receipt of the workers' compensation or public disability benefit. The receipt of a workers' compensation or other public disability benefit will only result in a loss of Medicaid coverage in situations where the amount of the workers' comp or public disability benefit in a given month is sufficient to place the person over their break-even point. The break-even point is the point at which the individual is no longer eligible to receive a SSI cash benefit. When an individual reaches their break-even point, their eligibility for Section 1619b is determined. The 1619B provision enables individuals who qualify to continue their Medicaid coverage in spite of the fact that they are no longer eligible for an SSI cash benefit. To be eligible for 1619B, there are a number of requirements that must be met. One of these requirements is that the sole reason that the person lost their eligibility for SSI cash benefit must be due to the fact that they have earnings over the allowable limits. In other words, an individual will not meet the criteria for 1619B if the reason for loss of the SSI cash benefit is due to unearned income (such as a workers' compensation benefit) placing them over their break-even point. Also, keep in mind that the likelihood that a person's Medicaid eligibility will be affected is even greater for individuals who already receive some other type of unearned income such as SSDI. In summary, the receipt of a workers' compensation or public disability benefit will have a significant impact on a person's Social Security disability benefits. In some cases, their health care coverage will be affected as well. Consequently, Benefit specialists must commit the time and resources necessary to become familiar with their own states' workers' compensation statue as well as its implications for beneficiaries and recipients who receive these benefits. CHAPTER 17: EARNED-INCOME TAX CREDIT Introduction The following information is excerpted in part from the IRS publication 596, "Earned Income Credit" The Earned Income Tax Credit (EITC) was enacted initially as a provisional measure in the Tax Reduction Act of 1975 and subsequently made permanent in the Revenue act of 1978. The EITC is a federal income tax credit for individuals (regardless of disability) who work and have earned income under certain levels. A goal of the Credit is to reduce or offset the amount of payroll taxes while at the same time encouraging individuals who might otherwise receive other public benefits to seek and pursue employment. The Credit usually results in a reduction in the amount of taxes owed or a refund, meaning more useable income in the pocket of the qualifying individual. The intent of the EITC is to offset a portion of living expenses and Social Security contributions under the Federal Insurance Contributions Act (FICA)-providing much needed aid to individual who work but have income below the poverty level. To be eligible for the tax credit individual must meet four general sets of rules. Eligibility Publication 596 of the Internal Revenue Service provides helpful information for individuals trying to determine their eligibility for the EITC. Many common tax forms filled out on annual basis reference this publication as a tool for assisting in determining eligibility. The publication is available on-line at: http://www.irs.gov/pub/irs-pdf/p596.pdf There are 15 general rules that a person must meet if they are to qualify for EITC. The fall under four main categories: rules for everyone; rules if there are qualifying children; rules if there are no qualifying children; and rules for computing and claiming the EITC. A simple checklist at the end of this chapter is provided for screening an individual's eligibility for EITC. Rules for Everyone There are six initial rules that a person must meet if they are to take their first steps toward qualifying for the EITC. If all six rules are not met, the individual does not qualify and there is no reason to continue the qualifying process-proceeding through the other three levels of rules. Rule 2: The individual must have a valid Social Security Number (SSN) An individual who wants to qualify must have a valid SSN for themselves and a spouse (if filing a joint return) and any qualifying child. An individual can only claim the EITC if they have an SSN that allows them to work. If their social security card says "Not valid for employment," they cannot get the EITC. Further detail and information on missing or incorrect SSN, other taxpayer identification numbers, or applying for a SSN are available in IRS publication 596. Rule 3: The individual's tax filing status cannot be "Married, Filing Separately" If an individual is married, they usually must file a joint return to qualify for EITC. If the individual's spouse did not live with them anytime during the past six months, that individual may be able to claim the EITC and file as "Head of Household," instead of "Married, Filing Separately." Rule 4: The individual must be a citizen of the United States or Resident Alien all year An individual trying to qualify for EITC cannot claim the EITC if they are a non-resident alien for any part of the year, unless they are married to a U.S. citizen or a resident alien, and choose to be treated as a resident for all of that year by filing a joint return. Rule 5: The individual cannot file Form 2555 or Form 2555-EZ These IRS forms deal exclusively with foreign earned income. IRS publication 54 provides additional information on this type of income. Rule 6: The individual's investment income must be less than $2650 Investment income totaling more than $2650 will disqualify an individual from claiming the EITC. Additional information on totaling investment income and references to current tax forms are provided in IRS publication 596. Rule 7: The individual must have earnings from work To qualify for EITC, a individual must work and have earned income. If an individual is married and files a joint return, they can meet this rule if at least one spouse works and has earned income. Earned income includes all the income received from working -- unless it is not taxable. Rules to Determine if There are Qualifying Children If an individual has met rules 1-6, whether there are qualifying children must be determined. If an individual does have qualifying children, they must file tax Form 1040 or Form 1040A to claim the EITC. Tax Form 1040EZ is not allowed. The individual must complete Schedule EIC (which will be presented later) and attached to the tax form. To determine whether or not an individual has qualifying children, proceed to Rule 8. Rule 8: Children's Relationship, Age and Residency Test A child is considered a qualifying child if they meet the Relationship, Age, and Residency Tests. Relationship Test The child being considered must be the son, daughter, adopted child, grandchild, stepchild, or eligible foster child of the individual seeking to qualify for the EITC. An adopted child includes a child placed with the qualifying individual for adoption by an authorized placement agency, even if the adoption is not final. A grandchild is any descendant of the qualifying individual's son, daughter, or adopted child. This definition could include a great-grandchild, great-great-grandchild, etc. A child, not a dependent, doesn't have to be the qualifying individual's dependent to be a qualifying child, unless he or she is married. The following table excerpted from IRS Publication 596 outlines conditions for relationship. A married child, married at the end of the year, does not meet the relationship test unless the qualifying individual can claim the child's exemption, or the reason they cannot claim the child's exemption is that they gave that right to the child's other parent. A foster child will be considered eligible if the qualifying individual cared for that child as they would their own child, and the child lived with them for more than half the year, except for temporary absences or is a sibling or siblings dependant. Age Test A qualifying child must be under age 19 at the end of the year; a full-time student under age 24 at the end of the year; or permanently and totally disabled at any time during the year, regardless of age. The following definitions clarify the age test. A full-time student is a student who is enrolled for the number of hours or courses the school considers to be full-time attendance. To qualify as a student, the child must be, during some part of each of any five calendar months during the calendar year: a full-time student at a school that has a regular teaching staff, course of study, and regular student body, or a student taking a full-time, on-farm training course given by a school described in (1), or a state, county, or local government. The five calendar months need not be consecutive. A school can be an elementary school, junior or senior high school, a college, university, or a technical, trade, or mechanical school. However, on-the-job training courses, correspondence schools, and night schools do not count as schools for the EITC. Vocational high school students who work in co-op jobs in private industry as a part of a school's regular course of classroom and practical training are considered full-time students. A child is not a full-time student if he or she attends school only at night. However, full-time attendance at a school may include some attendance at night as part of a full-time course of study. A child is permanently and totally disabled if he or she cannot engage in any substantial gainful activity because of a physical or mental condition and a doctor determines the condition has lasted, or can be expected to last, continuously for at least a year or can lead to death. Residency Test A child must have lived with the qualifying individual in the United States for more than half of the year. The following definitions clarify the residency test. A home can be any location where the qualifying individual regularly lives within one of the 50 states or the District of Columbia. A qualifying individual does not need a traditional home. For example, if a child lived with the individual for more than half the year in one or more homeless shelters, that child meets the residency test. U.S. military personnel stationed outside the United States on extended active duty are considered to live in the United States during that duty period for purposes of the EITC. Extended active duty means the qualifying individual is called or ordered to duty for an indefinite period, or for a period of more than 90 days. Once the individual begins serving their extended active duty, they are still considered to have been on extended active duty even if they serve less than 90 days. If a child was born or died in the current year, he or she is considered to meet the residency test if the qualifying individual's home was the child's home for the entire time he or she was alive during the current year. Include the time that the qualifying individual and their child is away from home on a temporary absence (including a kidnapped child) due to a special circumstance, as time lived at home. Examples of a special circumstance include: illness, school attendance, business, vacation, and military service. Keep in mind, a qualifying child must have a valid SSN unless the child was born and died in the current year. If a child meets these three tests, they qualify and the individual can proceed to Rules 8 and 9. Otherwise, proceed directly to rules pertaining to individuals who do not have qualifying children. Rule 9: A Qualifying Child Cannot Be Used By More Than One Person to Claim the EIC Many times a child may meet the rules as a qualifying child for more than one person. However, only one person can claim the EITC using that particular child. If a qualifying individual and someone else have the same qualifying child they can choose which one takes the EITC using that particular child. Rule 10: The Qualifying Individual Cannot Be A Qualifying Child Of Another Person A qualifying individual is a qualifying child of another person (individual's parent, guardian, foster parent, etc.) if they are that person's son, daughter, adopted child, stepchild, grandchild, or eligible foster child; at the end of the year they were under age 19, or under age 24 and a full-time student, or any age if they were permanently and totally disabled at anytime during the year; and, they lived with that person in the United States for more than half of the year (all year if they were an eligible foster child). If the qualifying individual (or their spouse if filing a joint return) is a qualifying child of another person, they cannot claim the EITC. This is true even if the person for whom they are a qualifying child does not claim the EITC or meet all of the rules to claim the EITC. Rules if There are No Qualifying Children If a qualifying individual meets all the general rules and it is determined that there are no qualifying children, to continue in the eligibility process they must meet rules 11-14. Rule 11: The Qualifying Individual Must Be At Least Age 25 But Under Age 65 If a qualifying individual is married and filing a joint return, one of the two spouses must be at least age 25, but under age 65, at the end of the current year. It doesn't matter which spouse meets the age test, as long as one of the spouses does. Rule 12: The Qualifying Individual Cannot Be The Dependent Of Another Person If the qualifying individual is not sure whether someone else can claim them (or their spouse if filing a joint return) as a dependent, IRS Publication 501 will clarify the rules for claiming a dependent. If someone else can claim the qualifying individual (or their spouse if filing a joint return) as a dependent on his or her return, but does not, the individual still cannot claim the EITC. Rule 13: The Qualifying Individual Cannot Be A Qualifying Child Of Another Person A qualifying individual is a qualifying child of another person (individual's parent, guardian, foster parent, etc.) if they are that person's son, daughter, adopted child, stepchild, grandchild, or eligible foster child; at the end of the year they were under age 19, or under age 24 and a full-time student, or any age if they were permanently and totally disabled at anytime during the year; and, they lived with that person in the United States for more than half of the year (all year if they were an eligible foster child). If the qualifying individual (or their spouse if filing a joint return) is a qualifying child of another person, they cannot claim the EITC. This is true even if the person for whom they are a qualifying child does not claim the EITC or meet all of the rules to claim the EITC. Rule 14: The Qualifying Individual Must Have Lived In The United States For More Than Half Of The Year The qualifying individual's home (and their spouse's if filing a joint return) must have been in the United States for more than half the year. A home can be any location where the individual regularly lived within one of the 50 states or the District of Columbia. The qualifying individual does not need a traditional home. If they lived in one or more homeless shelters in the United States for more than half the year, they meet this rule. U.S. military personnel stationed outside the United States on extended active duty are considered to live in the United States during that duty period for the EIC. Extended active duty means the qualifying individual is called or ordered to duty for an indefinite period or for a period of more than 90 days. Once they begin serving their extended active duty, they are still considered to have been on extended active duty, even if they serve less than 90 days. Rules for Computing and Claiming the EITC If a qualifying individual has met all the general rules and was either determined to have qualifying children or not to have qualifying children but still eligible for the EITC, the following final rules outline how to calculate and claim the Credit. A qualifying individual must calculate two amounts to see if they meet the final two rules and to calculate the amount of their EITC, their total earned income and modified adjusted gross income (AGI). IRS Publication 596 provides worksheets to calculate these amounts. Rule 1: The Qualifying Individual's Income Must Meet Certain Criteria A qualifying individual's income cannot exceed $34,458 ($35,458 for married filing jointly) if they have more than one qualifying child, $30,338 ($31,338 for married filing jointly) if they have one qualifying child, or $11,490 ($12,490 married filing jointly) if they do not have a qualifying child. Earned income was explained under Rule 6 and some examples are shown below: Examples of Taxable and Nontaxable Income Taxable Earned Income Wages, salaries, and tips Nontaxable Earned Income Salary deferrals and reductions Taxable Earned Income Union strike benefits Nontaxable Earned Income Meals and lodging provided for the convenience of your employer Taxable Earned Income Taxable long-term disability benefits received before minimum retirement age Nontaxable Earned Income Excludable dependent care benefits and/or adoption benefits Taxable Earned Income Net earnings from self-employment Nontaxable Earned Income Excludable combat pay and military basic housing and subsistence allowances Taxable Earned Income Gross income received as a statutory employee Nontaxable Earned Income Excludable educational assistance benefits Certain Native Americans receiving earnings exempted from federal income tax and considered nontaxable earned income. Rule 15: Your Earned Income Must Be Less Than... * $34,458 ($35,458 for married filing jointly) if you have more than one qualifying child, * $30,338 ($31,338 for married filing jointly) if you have one qualifying child, or * $11,490 ($12,490 for married filing jointly) if you do not have a qualifying child. Earned income generally means wages, salaries, tips, and other taxable employee compensation, and net earnings from self-employment. Calculating EITC The IRS can support individuals in calculating their income tax (see IRS Publication 967). The IRS will figure an individual's EITC if certain instructions are followed, as detailed in IRS Publication 596. If an individual has a qualifying child, they must complete and attach Schedule EIC. Publication 596 is available on-line at: http://www.irs.gov/pub/irs-pdf/p596.pdf It is strongly recommended that professional tax preparation services be sought when supporting an individual in qualifying for an EITC. While the benefits specialist can assist an interested individual in informally exploring their qualifications for the Credit, there could be potential reciprocity should a benefits specialist make a definitive determination that the individual is eligible and develops the claim on their behalf. This is a potential area where it might be in the best interest of the BPA&O provider or benefits specialist to initiate a referral for tax preparation support. Advance Payment of EITC A qualifying individual can receive part of their EITC for the coming year in their paycheck by completing Form W-5 and giving it to their employer. If an individual expects to be eligible for the EITC in the next year and/or has a qualifying child, they may choose to get payments of the EITC in their paycheck now, instead of waiting to get the Credit all at once in the next year when they file their tax return. These payments are called advance EIC payments. Step 1 - Eligibility for Advance Payments An individual can answer the following four questions to see if they are eligible for advance payments of the Credit. Please note, that when a question says, "expect," the individual does not have to know that they will be able to answer "yes" when they file their tax return. The individual can only make a best guess that they will be able to answer "yes." As long as an individual can answer "yes" to each and every question, then advance payment may be an option. If at any point the answer is "no," the individual does not qualify for advance payment. * Does the qualifying individual expect to have a qualifying child? * Does the individual expect that their earned income and modified adjusted gross income will each be less than approximately $29,000? * Does the individual expect to be eligible for EITC in the next year, as explained under the proceeding four groups of rules? * Are the individual's wages subject to withholding of federal income tax, social security tax, or Medicare tax? Step 2 - Complete Form W-5 and Give to Employer If the individual is able to answer "Yes" to all the questions in Step 1, and they wish to get part of their EITC now, they must give their employer a Form W-5 for the next year. The law will only permit the individual's employer to pay them part of their EITC in advance payments during the year. The remainder of the Credit will be entitled available when they file their tax return at the end of year and claim the EITC. Individuals desiring advance payments must file Form 1040 or Form 1040A for that year (even if they would otherwise not be required to file a tax return). They cannot file Form 1040EZ. An individual must file a return to report the payments they got in their paycheck throughout the year and to take advantage of any additional EITC. Impact of EITC on Certain Welfare Benefits The EITC and advanced EITC payments a qualifying individual may be eligible for are not used to determine whether or not they are eligible for certain means-tested benefit programs. This includes: * Temporary Assistance for Needy Families (TANF) * Medicaid and Supplemental Security Income (SSI) * Food stamps * Subsidized housing for individuals with low income However, amounts an individual may receive not spent within certain periods of time may count as an asset (or resource) and affect the individual's eligibility for these programs. EITC Eligibility Checklist An individual may claim the EITC if they answer YES to all the following questions. 1. Is the individual's AGI less than: * $11,490 ($12,490 for married filing jointly) if you do not have a qualifying child. * $30,338 ($31,338 for married filing jointly) if you have one qualifying child, or * $34,458 ($35,458 for married filing jointly) if you have more than one qualifying child? Yes No 2. Does the individual, their spouse, and their qualifying child each have a valid SSN? Yes No 3. Is the individual's filing status married filing jointly, head of household, qualifying widow(er), or single? Caution: If the individual is a non-resident alien, answer YES only if their filing status is married filing jointly and they are married to a U.S. citizen or resident alien. Yes No 4. Answer YES if the individual is not filing Form 2555 or Form 2555-EZ. Otherwise, answer NO. Yes No 5. Is the individual's investment income $2,650 or less? Yes No 6. Is the individual's total earned income at least $1 but less than: Yes No * $11,490 ($12,490 for married filing jointly) if they do not have a qualifying child, * $30,338 ($31,338 for married filing jointly) if you have one qualifying child, or * $34,458 ($35,458 for married filing jointly) if they have more than one qualifying child? 7. Answer YES if the individual (and their spouse if filing a joint return) are not a qualifying child of another person. Otherwise, answer NO. STOP: If the individual has a qualifying child, answer questions 8 and 9 and skip 10-12. If the individual does not have a qualifying child, skip questions 8 and answer 10-12.* Yes No 8. Does the individual's child meet the age, residency, and relationship tests for a qualifying child? Yes No 9. Is the individual's child a qualifying child only for that person? Answer YES if the individual's qualifying child also meets the tests to be a qualifying child of another person, but either (a) the other person is claiming the EIC using that child, or (b) if the other person is claiming the EIC using that child, allows you and not the other person, to treat the child as a qualifying child. Yes No 10. Was the individual's main home (and their spouse's if filing a joint return) in the United States for more than half the year? Yes No 11. Was the individual (or their spouse if filing a joint return) at least age 25 but under age 65 at the end of 2004? Yes No 12. Answer YES if the individual (and their spouse if filing a joint return) cannot be claimed as a dependent on anyone else's return. Answer NO if the individual (or their spouse if filing a joint return) can be claimed as a dependent on someone else's return. Yes No *PERSONS WITH A QUALIFYING CHILD: If the individual answered YES to questions 1 through 9, they can claim the EIC. Remember you can claim the EIC. Remember to fill out Schedule EIC and attach it to their Form 1040 or Form 1040A. They cannot use Form 1040EZ. PERSONS WITHOUT A QUALIFYING CHILD: If the individual answered YES to questions 1 through 7, and 10 through 12, they can claim the EIC. IF THEY ANSWERED NO TO ANY QUESTIONS THAT APPLY TO THEIR CASE: They are not eligible for the EIC. CHAPTER 18: MEDICAID AND STATE CHILD HEALTH INSURANCE PROGRAMS This chapter was adapted, with permission, from materials previously published by Neighborhood Legal Services, Inc. of Buffalo, NY The lack of suitable, affordable housing is often a major barrier to successful employment of persons with disabilities. Still, various public and subsidized housing programs available to persons with disabilities can sometimes help to overcome this barrier. In addition, a number of rent-based work incentives allow families and individuals entering the workforce to retain more of their income. This chapter will provide a brief summary of the major federally sponsored programs that should be available in all states, with an emphasis on those policies most applicable to persons with disabilities. The reader should keep in mind: a) this is only an overview of the federal programs and their regulations; and b) this overview is based on federal regulations published as of November 2001. State-subsidized housing programs also exist and may offer additional benefits, although they are not covered in this chapter. Introduction Medicaid, also know as Medical Assistance, is a cooperative federal-state program authorized by Title 19 of the Social Security Act. Medicaid may be known by a name that is unique to your state, such as California's MediCal program or Tennessee's TennCare program. On a federal level, Medicaid is administered through the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, within the U.S. Department of Health and Human Services. On a state level, overall responsibility will rest with one state agency in each state. Actual administration of Medicaid is often delegated to any number of other entities, including: one or more other state agencies; local Medicaid units; or health maintenance organizations (if your state uses a managed care model for any part of its Medicaid delivery system). Persons with disabilities, who are recipients of Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), frequently cite the fear of losing health care coverage as a major barrier to successful employment. Medicaid is typically the most important health care program serving SSI or SSDI recipients who are working, or plan to work. Because Medicaid is so important to recipients, a Benefits Specialist must develop a general understanding of what Medicaid has to offer in your state and the various methods of establishing or retaining eligibility. In an effort to provide the Benefits Specialist with a solid grounding on Medicaid, this chapter will: explain what services are available, or potentially available, to Medicaid recipients; explain the various ways that individuals with disabilities become eligible for Medicaid; explain Medicaid's appeals system; and provide a number of Medicaid-related resources available to advocates on the Internet. Services Covered by Medicaid Required services must be a part of every state plan, and include: Inpatient Hospital Care Outpatient Hospital Care Physician's Services Laboratory and X-Ray Services Nurse Midwife Services Rural Health Clinic Services Prenatal Care Family Planning Services Skilled Nursing Facility Services For Persons Over Age 21 Home Health Care Services to Persons Over 21, Eligible For Skilled Nursing Services (Includes Medical Supplies and Equipment) Pediatric and Family Nurse Practitioner Services Early Periodic Screening, Diagnosis and Treatment for Persons Under Age 21 Vaccines for Children Federally Qualified Health Center Optional services that may be incorporated in a state plan include: Podiatrists Services Optometrist Services and Eyeglasses Chiropractor Services Private Duty Nursing Clinic Services Dental Services Physical Therapy Occupational Therapy Speech, Hearing and Language Therapy Prescribed Drugs Dentures Prosthetic Devices Diagnostic Services Screening Services Preventive Services Rehabilitative Services Transportation Services Services for Persons Age 65 or Older in Mental Institutions Intermediate Care Facility Services Intermediate Care Facility Services for Persons with Mental Retardation/ Developmental Disabilities and Related Conditions Inpatient Psychiatric Services for Persons under Age 22 Christian Science Schools Nursing Facility Services for Persons under Age 21 Emergency Hospital Services Personal Care Services Hospice Care Case Management Services Respiratory Care Services Home and Community Based Services for Individuals with Disabilities and Chronic Medical Conditions For those working with children and young persons with disabilities under age 21, it is important to note that the Early Prevention, Screening, Diagnosis and Treatment (EPSDT) program is a mandatory Medicaid service in every state. The importance of this is that EPSDT recipients are entitled to services through all the optional categories, including those, which a particular state has not opted to cover as part of its state Medicaid Plan for adults. A Benefits Specialist must become familiar with the Medicaid waiver provisions available in your state (discussed below). Some Medicaid waivers will provide, to selected categories of recipients, a number of services not included in the state plan. These waiver services may include optional services not available to the general Medicaid population and services not traditionally available as required or optional services. The experience of Benefits Specialists and other advocates is that certain categories of service, because of their expense and/or unavailability through many private insurance plans, tend to be the most important to SSI and SSDI recipients who work. These include inpatient hospital care, home health care (including personal care services and private duty nursing), medical equipment or assistive technology (typically covered under the required home health care category as durable medical equipment or under several optional categories, including prosthetic devices), psychiatric services, and prescription drugs. Since many states will not cover some of the expensive optional services, such as private duty nursing or prescriptions, it is important to determine whether those are available as part of your state plan or through a special waiver program. Eligibility for Medicaid: In General Medicaid is often the only health insurance plan for persons with disabilities who have limited income. For those dually entitled to Medicaid and Medicare, Medicaid is usually the better of the two programs. An increasing number of individuals with disabilities are looking to Medicaid as their primary health insurance plan, notwithstanding higher levels of income. Medicaid may be available to those individuals through state-specific waivers, through optional buy-in programs, or through the 1619(b) provisions, all discussed below. During the past 20 years, many new ways have been created to qualify for Medicaid. For example, the Medicaid provisions in Title 19 have been amended to create the optional waiver and buy-in programs. The SSI provisions in Title 16 of the Social Security Act have been amended to make four separate classes of former SSI recipients eligible for continued Medicaid. Since these provisions are not well publicized or well understood, many individuals who could be eligible never obtain Medicaid. Without that eligibility, any discussion about Medicaid funding for the variety of expensive health-related services becomes purely academic. Using SSI as the Conduit to Automatic Medicaid Eligibility In most states, Medicaid eligibility is automatic for SSI recipients. SSI recipients automatically qualify for Medicaid in 39 states and the District of Columbia. If the SSI check is as little as $1, Medicaid eligibility is automatic. In most of these states, the SSI recipient does not need to take any action as their eligibility is automatically certified. In some of these states, eligibility is automatic, but the individual SSI recipient must file a Medicaid application to establish that eligibility. The states in which a separate Medicaid application must be filed include: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah, and the Northern Mariana Islands. In 11 states, known as section 209(b) states, Medicaid eligibility is not automatic for SSI recipients. These states use their own Medicaid eligibility criteria, which differs from SSI criteria. The Medicaid eligibility employed by 209(b) states will vary greatly from state to state, and may be more restrictive or more liberal than SSI's criteria. The states which exercise the 209(b) option include: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. If you reside in one of these states, you will need to find out how SSI recipients qualify for Medicaid in your state. Working with SSI's income and resource rules will often ensure Medicaid eligibility. The SSI income and resource rules are discussed in Chapter XX. Individuals, spouses and parents can often organize their finances to ensure SSI and Medicaid eligibility. For example, in a state that pays the 2005 SSI federal benefit rate (FBR) of $579, with no state supplement, a single parent living with two children including one with a disability would be able to maintain SSI eligibility for the child with a disability until the parent's gross monthly income reaches $2,731 ($32,772 per year). If Medicaid is critical to the child, the parent may wish to work with his or her employer to keep their income below $2,731 per month. This could be done by accepting extra health benefits in lieu of cash; putting money into a cafeteria plan or flexible spending account (approved under section 125 of the Internal Revenue Code), if available; or by going to a part-time schedule. If Medicaid is important to the child, the parent must be careful to keep the parents' and child's resources within SSI limits. For example, retaining exempt resources, such as the residential home or a vehicle for travel to medical appointments, will not affect SSI eligibility. On the other hand, accumulating more than $2,000 in a child's savings account would result in a termination of SSI eligibility and, with it, the right to automatic Medicaid in most states. The considerations for adult SSI recipients will be the same or very similar. Four Provisions Allow Former SSI Recipients to Retain Medicaid The following provisions each allow a former SSI recipient to be treated as an SSI recipient for Medicaid purposes, allowing that person to continue eligibility for Medicaid. Recipients of Social Security Widow's/Widower's Benefits: If a person loses SSI when he or she becomes entitled to Social Security widows or widowers' benefits, the person remains automatically eligible for Medicaid if SSI eligibility would continue in the absence of the widow's or widowers' benefits. Eligibility continues only for so long as the person remains ineligible for Medicare, a period of 24 months following the first month of Social Security eligibility. Example: Mary was receiving SSI benefits of $579 per month and was automatically eligible for Medicaid in her state. Upon the death of her husband, she qualifies for Social Security Widows' Benefits of $600 per month, which makes her ineligible for continuing SSI benefits. She will continue to be eligible for Medicaid, as if she was still a SSI recipient, for the two-year waiting period for Medicare. Recipients of Social Security DAC Benefits: A recipient of Social Security Child's Insurance Benefits, often referred to as Disabled Adult Child's (DAC) benefits, can continue eligibility for automatic Medicaid if, after July 1, 1987, the person lost SSI due to entitlement to or an increase in DAC benefits. Example: Paul, age 33, was receiving SSI benefits in early 2005 at the FBR of $579. He was also automatically eligible for Medicaid in his state. During the spring of 2005, Paul's father dies and Paul becomes eligible for Social Security DAC benefits of $750 per month and loses his SSI benefits because of excess income. Since Paul lost his benefits due to receipt of DAC benefits he will remain eligible for Medicaid so long as his resources and income other than DAC benefits remain within SSI limits. The Pickle Amendment: This protects certain persons who, after April 1977, were eligible for both SSI and SSDI and later lost eligibility for SSI because the receipt of SSDI, along with any other income, made the person ineligible for SSI. Automatic eligibility for Medicaid continues if the person would be presently eligible for SSI if SSDI cost of living increases since the person last received SSI are disregarded. Example: In 2002, John was receiving $464 in monthly SSDI benefits and $101 in SSI benefits (the 2002 FBR was $545). That same year he started receiving a private pension of $125 per month, making his combined SSDI and private pension income more than allowed by SSI [i.e., his countable income of $569 (i.e., $589 - 20 general income exclusion) was now more than the SSI rate of $545]. Having lost SSI, John also lost his right to automatic Medicaid. Assume John's pension will remain a constant $125 per month. Because the Pickle Amendment allows John to disregard SSDI cost-of-living increases since 2002 (i.e., since he was last dually entitled to SSI and SSDI), his countable income for Pickle Amendment purposes will remain a constant $569 in future years. This was more than the FBR of $552 in 2003 and more than the FBR of $564 in 2004, meaning that he remained ineligible for Medicaid under Pickle. In 2005, with the FBR now up to $579, John's countable income of $569 (after ignoring SSDI cost-of-living increases) is now less than the SSI rate for his state. Since John would now be eligible for a small SSI check ($10) if the post-2002 SSDI increases are ignored, John is now eligible for Medicaid under Pickle. For a more detailed explanation, see Bonnyman, G., Medicaid Eligibility in a Time Warp, 22 Clearinghouse Rev. 120 (June 1988) and Bonnyman, G., A Quick and Easy Method of Screening for Medicaid Eligibility under the Pickle Amendment (updated and published annually in the Clearinghouse Review). Section 1619(b): Continued Medicaid for Persons Who Lose SSI Due to Wages: This special work incentive is fully discussed in Chapter XX. It provides Medicaid for individuals who lose SSI benefits when earnings are too high. Under 1619(b), automatic Medicaid continues if the person would continue to be eligible for SSI if the wages were ignored and if annual income is less than a specified income threshold. In section 209(b) states, Medicaid continues, pursuant to the 1619(b) criteria, if the individual was eligible for Medicaid in the month prior to losing SSI and other 1619(b) criteria is met. The income threshold changes every calendar year and will be different in each state, based on the state's unique SSI rate and Medicaid expenditures. These thresholds range from $20,000 to $45,000 per year. A higher, "individualized threshold" can be established if medical or other expenses are high enough. Obtaining Medicaid Through the Medically Needy or Spend Down Program The Medically Needy Program, as Available to Persons with Disabilities, is an Option Exercised by Two-Thirds of the States: Medically needy individuals are those who would qualify for Medicaid, including individuals who are disabled, but have income or resources above limits set by their state. Since Medicaid agencies often do not explain the spend down (or "share of cost") program to applicants or recipients, you should find out if your state offers this option and take steps to educate yourself and your clients/consumers on how it works. How the Spend Down Works: Each state sets its medically needy income levels based on family size. For example, New York set its 2004 level at $659 per month for a household of one. All individuals meeting the federal (i.e., SSI) definition of disability, who have income and resources below the medically needy level, automatically qualify for Medicaid. A state must establish a uniform set of income and resource rules for determining income for the medically needy. The state's methodology employed in determining income and resource eligibility "shall be no more restrictive than the methodology which would be employed under the [SSI] program in the case of ... blind, or disabled individuals ...." Individuals with income above the medically needy level do not automatically qualify for Medicaid. They must first meet a "spend down" or "share of cost" test. The spend down is the amount by which income exceeds the medically needy level after subtracting allowable deductions. For example, in New York, a single adult with a disability receives a monthly SSDI check of $779, which exceeds the state's 2004 medically needy level of $659. The Medicaid agency will disregard the first $20 as an unearned income exclusion and the individual will face a $100 spend down (i.e., countable income exceeds the medically needy level by $100). The spend down acts like a deductible or insurance premium that must be paid or incurred before coverage begins. Nearly any medical expense that is paid or incurred can be used to meet a spend down requirement, even if it is for goods or services not covered by your state plan. The following is a list of typical expenses that may be used: health insurance premiums and co-payments; doctor bills; mental health bills (including a psychiatrist's services and mental health counseling services); dental bills; home health care; prescriptions drugs; eyeglasses and optometry bills; and over-the-counter drugs or purchases related to health care. Home and Community-Based Waivers These provisions allow states, with approval of the federal Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration, to waive (or not follow) specific requirements of the Medicaid Act. These are often referred to as "section 1915(c) waivers." All states participate in these optional waivers to varying degrees. Waiver of "Statewidedness:" Ordinarily, the state's Medicaid plan must offer comparable coverage in all regions of a state. It would be illegal, under regular Medicaid rules, to offer a Medicaid-funded service to some individuals that is not offered to Medicaid recipients statewide. A waiver can be approved to offer a level of Medicaid coverage in one or more sections of the state, or to a limited number of recipients, that is not available to all recipients statewide. Waiver of Comparability: Ordinarily, the state's Medicaid plan must treat all similarly situated recipients equally. It would be illegal, under regular Medicaid rules, to offer a Medicaid-funded service to one individual with a disability and not offer it to others with a different disability. A waiver could select a targeted group of recipients (such as persons with traumatic brain injury or persons with AIDS) and offer them a scope of services not available to persons who have different disabilities but similar needs. Waiver of Certain Income and Resource Rules: A waiver can be implemented which exempts certain populations from the general income and resource requirements. For example, the Katie Becket waiver allows a Medicaid program to disregard parental income and resources for certain children. These waiver programs are structured to provide an alternative to institutional care and often provide greater access to a range of services and equipment (often referred to as durable medical equipment or assistive technology) than available under other covered services within the state plan. A number of other services may be available under your state's unique waiver program or programs, such as case management, job coaching, homemaker services, home health aide services, adult day health, habilitation, respite, home modifications, partial hospitalization and psycho-social rehabilitation for persons with psychiatric diagnoses. Some of these are optional services that a state may not cover in its regular state plan. Others are services that are not otherwise available as either required or optional services. The Medicaid Buy-in Program This optional program, created by the Balanced Budget Act amendments of 1997, is designed to provide health insurance to working people with disabilities who, because of relatively high earnings, cannot qualify for Medicaid under another provision. These provisions were specifically targeted to those SSDI recipients who, because they were not also eligible for SSI, could not qualify for Medicaid under the 1619(b) provisions. Subject to federal criteria, a state can structure the buy-in as it sees fit. The original 1997 buy-in included several key eligibility components: * Individuals are not required to have been on SSI. * Eligibility was set at net income of less than 250 percent of the federal poverty level, with all SSI exclusions applied. For a household of one, this meant a state could provide Medicaid to an individual who has $40,000 or more in annual wages. * Except for their earnings, the person with a disability would be eligible for SSI. * Substantial gainful activity (i.e., earnings in excess of $830 monthly in 2005, and adjusted in later years) is not an eligibility consideration. A person could be eligible for the buy-in despite earning in excess of the substantial gainful activity amount. * States could increase the Medicaid resource limits to as high as $14,000. * States could charge premiums or other cost-sharing charges. Section 201 of the Ticket to Work and Work Incentives Improvement Act of 1999 included several key provisions to make the Buy-in program more attractive: * It allows states to offer a buy-in to persons with earnings up to 450 percent of the poverty level. For a household of one, this means a state could provide Medicaid to an individual who has $70,000 or more in annual wages. * States are now allowed to set income limits and require cost sharing and premiums, based on income, on a sliding scale. A state could require some individuals to pay the full premium as long as the premiums do not exceed 7.5 percent of the individual's total income. * States must require a 100 percent premium payment for individuals with adjusted gross incomes greater than $75,000 unless states choose to subsidize the premium using their own funds. At the time this document was written, 30 states had adopted and were implementing buy-in programs, with many additional states at various stages of pre-implementation (including several that had been adopted and were awaiting federal approval, and several pending in state legislatures). You should check the status of the buy-in program in your state as it may offer the only means of accessing continuing Medicaid for those SSDI recipients who are unable to access continuing Medicaid through the 1619(b) program. Appealing Medicaid Decisions Under federal Medicaid law, a Medicaid applicant or recipient is entitled to an administrative hearing any time a decision is made which affects his or her right to Medicaid or to any service for which Medicaid funding is sought. This is known as a "fair hearing" and will be available in all states. A person whose Medicaid benefits or right to services funded by Medicaid are either denied or terminated is entitled to a written notice of that decision. The notice must explain: the action that is being taken, the reason for the action, the right to a hearing to appeal the decision, and the availability of free services from a Legal Services, Legal Aid or similar program (such as a Protection and Advocacy program). States are permitted to establish their own time limits for requesting hearings. Typically, the Medicaid recipient will be permitted a time limit (30 - 60 days) for requesting the hearing. However, if the notice indicates that an ongoing benefit, such as funding for home health care services, is to be terminated on a certain date, the recipient will need to request the hearing before the termination date if continued services are going to be requested pending the appeal. Federal Medicaid law provides that benefits are to be continued pending the appeal (a concept often referred to as "aid continuing") if the hearing is requested before the effective termination date and the recipient (or advocate working on his or her behalf) specifically requests the continuation of benefits. Medicaid Resources on the Internet A growing number of Medicaid-related resources are available on a wide variety of web sites. The web sites listed below include those of the federal Center for Medicare and Medicaid Services and several private agencies that are national in scope. Benefits Specialists will also want to identify government and not-for-profit agency web sites that are unique to their states. Federal Agency Web Sites Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration's Web Site - www.cms.gov Not-for-Profit Agency Web Sites National Health Law Project - www.healthlaw.org National Senior Citizens Law Center - www.nsclc.org National Assistive Technology Advocacy Project - www.nls.org/natmain.htm Introduction to State Child Health Insurance Program For many individuals with disabilities contemplating a return to work, the question of continued medical coverage is a pressing issue. While SSI recipients returning to work are able to continue receiving Medicaid coverage for themselves in most states, what about their children? What if they find a job, which pays too much for their children to continue on Medicaid, but which does not itself provide health insurance? For these individuals, the State Child Health Insurance Program (SCHIP) may provide health care coverage. The Balanced Budget Act of 1997 created SCHIP, by adding a new Title 21 to the Social Security Act. Initially, many had referred to it as the Child Health Insurance Program, or CHIP. However, pursuant to Section 704 of the Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999, the Federal government is prohibited from using the terms Child Health Insurance Program or CHIP. Therefore, we will use the term SCHIP. Final regulations implementing SCHIP became effective on June 23, 2000. The regulations add very little to the Title 21 requirements and are designed primarily to guide the States in obtaining reimbursement under the program. The Centers for Medicare and Medicaid services (CMS), formerly the Health Care Financing Administration (HCFA), which administers SCHIP, has a very helpful SCHIP web site. The site is located at www.hcfa.gov/init/children.htm. It contains a series of questions and answers developed by CMS which provide interpretive guidance about the program, copies of informational letters sent to the States about the program, information about State implementation of SCHIP, and links to other helpful web sites. Program Overview: The Basics of SCHIP The purpose of SCHIP is "to provide funds to States to enable them to initiate and expand the provision of child health assistance to uninsured low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children." The statute authorizes $40 billion over 10 years to be distributed to all 50 states and all U.S. territories. It commenced with the 1998 fiscal year, which began on October 1, 1997. Like Medicaid, the program is optional for each state, but as of the 2000 fiscal year (October 1, 1999), every state and territory is participating. Funds are allocated to each state based on a ratio, which includes the number of uninsured low-income children and the total number of low-income children in the state. To receive funding, a state must have an approved plan, describing how the state will implement the program. However, "to provide states with the flexibility and time needed to develop their programs and to submit their child health plans," HCFA (now CMS) published "reserved" rates for the 1998 and 1999 fiscal years, which became final once each state's plan was approved. The statute gives states an incredible amount of flexibility in implementing their program. States may simply extend Medicaid coverage to children who are eligible for SCHIP, create a separate program, or use a combination of both. Therefore, to fully understand how SCHIP is being implemented, it is critical to obtain your state's plan to determine the basic program structure, who is eligible and what services are covered. A link is provided to each state's SCHIP program from the federal governments SCHIP website at www.insurekidsnow.gov. Despite SCHIP's flexibility, the law provides some basic guidelines that will apply to all states. Each state's plan must include a description of the following: 1. The actual child health assistance to be provided under the plan; 2. Eligibility standards, including those relating to the geographic areas to be served, age, income and resources (including any standards relating to spend downs and disposition of resources), residency, disability status (so long as any standard relating to such status does not restrict eligibility), access to or coverage under other health coverage, and duration of eligibility. Such standards may not discriminate on the basis of diagnosis; 3. Eligibility screening to ensure that only eligible children receive services under the program, that children found to be eligible for Medicaid are referred to the Medicaid program, and that eligible American Indians are provided services; 4. Outreach to families of children likely to be eligible under the program or under other public or private insurance programs to inform them of available coverage and to assist them in enrolling their children in programs for which they are eligible; and 5. Procedures for coordinating SCHIP with other public and private health insurance programs. In an effort to improve outreach to children who may be eligible but who have not yet enrolled in the program, the Agricultural Risk Protection Act of 2000 "established a critical link between the National School Lunch Program, Medicaid and [SCHIP]." States may now share information with SCHIP and Medicaid "agencies about families who participate in the school lunch program in an effort to help identify eligible children." Almost every state has taken advantage of this opportunity to "enlist the support of schools in its outreach and enrollment strategies." Sign Them Up: A Quarterly Newlsetter about the Children's Health Insurance Program (CHIP), p. 5 (Fall 2001, Children's Defense Fund). SCHIP Eligibility Criteria As noted above, states are given a wide degree of latitude in establishing eligibility criteria, including ages, geographic areas, income and resource rules, and duration of eligibility. Again, however, there are certain mandatory guidelines. Generally, coverage must be limited to children who are under 19 years of age, who are not eligible for Medicaid or other health insurance, and whose family income is below 200 percent of the federal poverty level for their size of family (which is up to $34,100 per year for a family of four). See www.insurekidsnow.gov. However, children enrolled in a state-created insurance program, which was in place prior to July 1, 1997, and did not utilize any federal funds, will still be eligible for SCHIP. Effective November 1, 2002, the definition of child has been amended to include "the period from conception to birth." This will allow a state, if it chooses, to cover prenatal care and delivery. If a state has raised its Medicaid eligibility level above 150 percent of the poverty level before June 1, 1997, the state may raise the eligibility standards for SCHIP to 50 percent above the current Medicaid income level. However, the State cannot lower its Medicaid income and resource limits in an effort to make children ineligible for Medicaid and thereby eligible for SCHIP. Any financial eligibility criteria must not operate to cover children in families with higher incomes without covering children in families with lower incomes. Nor can the eligibility criteria deny coverage to children with pre-existing medical conditions. Finally, children who are inmates in a public institution or who are patients in an institution for "mental diseases" are not eligible for coverage. On July 1, 2000, HCFA (now CMS) announced criteria for special demonstration projects under SCHIP. States that have had at least one year of experience implementing SCHIP and have submitted all of their required reports are eligible. In addition, the state will have "to provide assurances that it has met the primary purpose of SCHIP by expanding eligibility to low-income children" and "demonstrate that it is successfully reaching and enrolling eligible children." In such cases, one of the possible demonstration projects can be to extend coverage "to low-income parents of the children they are enrolling in Medicaid and SCHIP." Available SCHIP Services As noted above, states may choose to deliver services in one of three basic ways. They may simply choose to extend basic Medicaid coverage to those children determined to be eligible for SCHIP. In those cases, the state must apply, to SCHIP-eligible children, the full range of Medicaid services available to all other Medicaid eligible children in the state. This would include all the services available under Medicaid's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The EPSDT program mandates that states provide all medically necessary mandatory and optional Medicaid services. See English, Abigail and Madlyn Morreale, The New Children's Health Insurance Program: Major Provisions and Early Lessons, ABA Center on Children and the Law, www.abanet.org/child/chipfinal.html. If a state chooses to create its own separate SCHIP program, it has a large degree of flexibility in choosing the scope of services to cover. There are four basic options available to states: benchmark coverage, benchmark-equivalent coverage, the preexisting state-based program in New York, Florida or Pennsylvania, or any other coverage package which is approved by CMS (formerly HCFA) as "appropriate." Benchmark coverage must be equivalent to the coverage available to federal employees, state employees, or members of the largest commercial, non-Medicaid health maintenance organization in the state. Benchmark-equivalent coverage must be the "actuarial equivalent" of one of the benchmark packages. They must include, at a minimum, the following categories of services: * Inpatient and outpatient hospital services * Physicians' surgical and medical services * Laboratory and x-ray services * Well-baby and well-child care, including age-appropriate immunizations The state must also include the following optional services, if the benchmark package used by the state to determine "actuarial equivalence" includes them: * Coverage of prescription drugs * Mental health services * Vision services * Hearing services States are free to provide coverage for benefits that are not listed in either of these categories. In fact, the scope of permissive services is extremely comprehensive. Covered services may include the following: * Inpatient hospital services * Outpatient hospital services * Physician services * Surgical services * Clinic services (including health center services) and other ambulatory health care services * Prescription drugs and biologicals and the administration of such drugs and biologicals, only if such drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person * Over-the-counter medications * Laboratory and radiological services * Prenatal care and pre-pregnancy family planning services and supplies * Inpatient mental health services, including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structured services * Outpatient mental health services, including services furnished in a state-operated mental hospital and including community-based services * Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) * Disposable medical supplies * Home and community-based health care services and related supportive services (such as home health nursing services, home health aide services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members, and minor modifications to the home) * Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing care, pediatric nurse services, and respiratory care services) in a home, school, or other setting * Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest * Dental services * Inpatient substance abuse treatment services and residential substance abuse treatment services * Outpatient substance abuse treatment services * Case management services * Care coordination services * Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders * Hospice care * Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by state law and only if the service is: a. prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by state law, b. performed under the general supervision or at the direction of a physician, or c. furnished by a health care facility that is operated by a state or local government or is licensed under state law and operating within the scope of the license. * Premiums for private health care insurance coverage * Medical transportation * Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals * Any other health care services or items specified by the Secretary and not otherwise excluded Cost Sharing States are permitted to impose cost sharing charges, including premiums, deductibles and coinsurance, but the schedule for any of these charges must be made public. Any cost-sharing income received by the state will reduce the state's appropriation under the program. Furthermore, any cost-sharing requirements must not favor children of higher income families over lower income families. No cost-sharing may be imposed for the preventive services of well-baby and well-child care, and age-appropriate immunizations. Finally, if the state is operating a Medicaid expansion program, the Medicaid rules for any cost sharing will apply. There are additional limitations on the use of cost sharing based on the income of the family. For families above 150 percent of the federal poverty level, cost- sharing requirements may be imposed on a sliding scale, based on income, but the total amount of cost sharing cannot exceed five percent of the family's income per year. For families below 150 percent of the federal poverty level, cost-sharing charges are limited to the Medicaid levels for non-categorically eligible individuals. Under applicable Medicaid requirements, the maximum permissible enrollment fees or premiums must be based on income and will vary from $1 to $19 per month. Additionally, the maximum permissible deductible is $2 per month. See English, Abigail and Madlyn Morreale, The New Children's Health Insurance Program: Major Provisions and Early Lessons, ABA Center on Children and the Law, www.abanet.org/child/chipfinal.html. Conclusion Although states are given a broad degree of discretion in implementing SCHIP, its basic purpose and scope of coverage make it an important program to extend health insurance coverage to low-income children who are not otherwise eligible for Medicaid. For those parents with disabilities contemplating a return to work, the SCHIP in your state may ensure that health insurance will be available to those children. SECTION FIVE: BENEFITS PLANNING Objectives 1. Develop and practice effective communication skills. 2. Understand successful interviewing skills. 3. Apply effective negotiation and mediation practices. 4. Under Workers' Compensation and its impact on Supplemental Security Income and Social Security Disability Insurance. 5. Understand and practice effective information gathering and report writing. CHAPTER 19: EFFECTIVE COMMUNICATION STRATEGIES Introduction As a benefits specialist, you will present a great deal of new information to beneficiaries and recipients and possibly their support person(s). There remains a responsibility to assess how well the person understands the options and recommendations presented, as this understanding is the basis of some very important decision-making that will follow, either with the support of the practitioner or without. Throughout this process and through the rest of your working relationship with the person, your communication skills, and how you use them, greatly affect your effectiveness as a benefits specialist and on the person's decisions. While communication is a combination of both expressive and receptive factors, about 70 percent of effective communication is receptive (listening). Only about 30 percent is expressive (what you "send"). Within the expressive portion of communication, over half of what people "hear" from you is what you send with your body language. The second largest piece is your voice tone/inflection, while only a small part of effective communication is actually the words you speak. Active Listening Skills Because of the importance of receptive skills we will explore these first. There are some common roadblocks to good listening that many people experience. They are discussed below, together with some suggestions about how they can be avoided/ Becoming distracted while listening. This can be due to any one of several factors: * Distracting environmental factors. Arrange a location as free as possible of distractions (close the door, unplug the phone, borrow a conference room, go to a neutral location, such as a church or library) * Thinking about what you are going to say when the person stops talking. Look the person directly in the eyes. Practice using active listening responses (discussed below) after the person finishes, to lower your feelings of urgency to have an answer ready. Ask the person if you may jot a note or two so you can lower your anxiety about forgetting what you need to say in response. * Finding what the person is saying boring. Imagine that the subject being discussed is of utmost importance to you (practice empathy; discussed below). Ask the person to summarize their thoughts or point out the most important points for you, rather than having them tell you the whole story, in order to help you problem-solve with them. Then, be sure to listen till they are finished. * Do not book appointments too close together. It's better to plan an ample amount of time and finish early, than the other way around, as you will then be left with some unplanned time to catch up on phone calls or to review your notes, or even prepare for your next appointment. If you still feel pushed for time when with the customer, be honest with the person about this as soon as you realize it, so the person has input on how to best use the limited time, and to help you decide what can be accomplished in another way or at a different time. You may disagree with what the customer is saying or the conclusions they are drawing. Practicing "value-free" counseling skills may help to overcome this roadblock to listening. These are described below. "Values-Free" Communication One of the cardinal values in the helping profession is that all human beings have worth, regardless of their past or present behavior, beliefs, lifestyles, or station in life. Before people will risk sharing personal problems and legitimate concerns they may hold regarding benefits and employment, they must first feel fully accepted and experience the good will and helpful intent of the benefits specialist. Your role is not to judge but to seek to understand customers and their issues and to assist them in their search for solutions related to their goals, not the goals you hold for them. In cases where you disagree with the goals of the customer, you should strive to concentrate on the person, rather than on the particular goal or behavior of concern, and to be very clear about what you can or cannot assist them with, within ethical boundaries. In working on the problem of value conflict between yourself and the customer, it is important to recognize his/her personal biases and values in order to see where you may have challenges. (For instance, you believe strongly that anyone who can work and earn their way, even if only partially, should do so, and their benefits should be reduced or discontinued if they do not do everything they can to achieve this.) Although your values are important in guiding your life goals, and they may even be part of why you are in this profession, they are still yours, and they are not necessarily better or worse than someone else's values, and you must set them aside while engaging and working with the customer. * Use clarifying questions to try to get a better understanding. Example: "Are you saying that you think that, for you, keeping your benefits as they are currently stand is more appealing than being employed, even if you would have more money by working?" Or "Will you please explain to me some more about why you've made this decision? I still feel a little unsure of your main reasons for deciding this." * Use validation to engage the individual in continued discussion of the issue. Example: "I can certainly see that it is scary for you to consider tampering with your benefits when there are so many things that are not certain yet, such as whether a job will work out, and whether the SSA will make the changes correctly. Maybe we can think about what would help make this option feel less scary." With this strategy, you are responding to the feeling, before dealing with the content of the customer's comments. To summarize, it is important to remember that when developing good listening skills, we can follow the advice of Lily Tomlin, as Edith Ann, when she advised that we "listen with the same intensity that we usually save for talking." Seek first and understand before pushing to be understood. Expressive Communication The second part of effective communication is expressive communication. This constitutes about 30 percent of good conversation. Of this 30 percent, about 50 percent is body language, 35 percent is voice tone/inflection, and only about 15 percent is the actual words that we speak. Body Language The following is a list of effective body language that facilitates open and honest conversation: 1. Sit with your body leaning slightly forward, not too relaxed and not "tight" in your posture. This implies "I'm interested in what you have to say." If you are slumped in your chair, it may be interpreted as lack of interest or respect for the speaker. A posture that is too intense may be threatening to the speaker or may signal that you are in a hurry. 2. Maintain good eye contact. This signals that you are interested, paying attention, and it enhances development of trust and rapport. Be sensitive to cultural or disability-related exceptions, however, as some people consider too much direct eye contact to be a "power-play" or an invasion of their personal boundaries. Just watch for indications for discomfort with your eye contact and adjust your style accordingly. 3. Facial expression that is natural, shows interest, and is free of shock, dismay, irritation, or disagreement encourages open communication. If you feel comfortable in your role with the individual, this will be relatively easy to accomplish. However, if you are new to this role and somewhat nervous, be aware of your facial expressions, as they may reflect your nervousness. You may appear very intense as you focus on doing a good job, and your expressions may be misinterpreted as meaning one of the above-mentioned reactions. 4. Distracting body movements can also detract from effective communication, such as fiddling excessively with some object such as a pen or piece of paper. Just remember to watch the customer for signs that your body movements are distracting or annoying them. Voice Tone and Inflection The sincerity reflected in your voice is even more powerful than the words spoken in letting the person know what you think. If your voice tone is too severe, too playful, or too authoritarian, the customer may interpret these as being scary, patronizing, or that you feel superior to them, which hampers open communication. Voice tone should match the intent of the words you are speaking and should be adjusted to the needs of the individual. Words Words are the final piece of expressive communication, and the cautions to observe regarding this part can be summed up easily. Eliminate jargon and hard-to-understand language from your discussions with the customer. SSA language is quite intimidating, as is the language related to other supports and agencies that may be part of your discussions with the person. Therefore, make sure the person understands any specific language you must use that is not commonly understood, and remind them often that it is okay to ask for clarification at any time. In addition, when explaining complicated concepts and when talking through examples, possibilities, and options, it may be helpful to use visual "props" to help the person follow the concepts being discussed. Play money, calculation forms, a computer spread-sheet, and so on, are good supplies to keep handy to make your words more meaningful for individuals who are having a difficult time understanding concepts you are presenting. Interviewing Skills Tips for Conducting Effective Interviews In addition to using good communications skills to improve general effectiveness, a benefits specialist must develop good interviewing techniques in order to engage with the customer and to collect complete and accurate information. Some tips for conducting effective interviews follow: * Have in mind exactly what you need to know. Take a few notes. It may help to have some standard questions written and in your visual field to remind you of questions that need to be answered. However, do not rely on this written list or form so heavily that it interferes with good communication strategies, such as good eye contact and active listening. * Be prepared to probe for different information and details that you think may be helpful in advising the customer, even if your question list doesn't address the content of the discussion. * Keep your interviewing short and to the point, and adhere to the timelines that you set with the customer. * If the customer doesn't appear to know the answer to important questions, skip those questions and plan to obtain the information in another way (i.e., ask the customer to send or bring you written documents, or ask him/her for permission to ask someone else who might know). Avoid wasting time having the customer guess the answers to your questions. Interviewing Strategies In addition to these general tips for conducting interviews, there are some specific strategies for gathering information from individuals who have some specific difficulties with being interviewed: * The person seems reluctant to give information, either in general or about specific topics, such as income and resources, or past work history: 1. Explain why you need the information and how you will use it. Reiterate your commitment to the person's privacy and not sharing the information with anyone without the person's permission. 2. Slow down the process and put extra attention into building rapport and trust with the customer. 3. Rephrase your questions to get only the information you must have, if your questions have been broader. 4. Ask the person what would be better for them (i.e. sending the questions home for them to complete, postponing the interview to a time that they feel more comfortable, or suggest bringing someone with them with whom they feel comfortable) * The person becomes unfocused and unable to concentrate before the interview is completed. 1. Take a short break and come back to the conversation. 2. Reschedule another time to finish, if the first tip doesn't work. 3. Suggest that the person bring someone with them for support. 4. Rephrase your questions into short questions that can be answered with yes or no answers (closed-ended questions). * The person goes off into long stories following each question, and/or becomes upset when questions are asked because of past events (such as a payback or a job loss). 1. Give a short opportunity for the person to digress, empathize if the person is upset, and then redirect the person back to the interview. 2. Do not begin to digress with the person! Approaches to Interviewing There are three general approaches to interviewing, and each has advantages for specific circumstances. They are discussed below. 1. Linear (e.g., "What happened first and then what happened?" "What was the next event that you remember?" or "When did you begin your first job?" "When did it end?" "What were the dates of the next employment?") This is an effective interviewing tool when you have a short period of time to gather a lot of information, or you are establishing a timeline of activities, or the customer tends to digress. 2. Branching (e.g., "When did you begin the first job?" "How many hours / week did you work, and what was your hourly wage?") This is a good strategy when you need more complete information than you are able to get with a linear approach to interviewing. 3. Meandering (e.g. "Tell me about jobs you have had since you began receiving SSDI?") This is a more conversational approach to interviewing and tends to put the interviewee more at ease, so is very effective with a customer with whom you haven't built rapport. The interviewer must keep the interview focused and synthesize the information obtained. This information is likely to be more complete than the first two approaches. Assessing Verbal Barriers in Communication Directions: Rate elimination of ineffective responses by placing marks in appropriate boxes through observation of a roleplay or videotape. 1. Moralizing, sermonizing ("shoulds, oughts") Not Observed Observed (Needs Improvement) Comments 2. Advising prematurely Not Observed Observed (Needs Improvement) Comments 3. Persuading, giving logical arguments, lecturing, instructing, arguing, intellectualizing Not Observed Observed (Needs Improvement) Comments 4. Judging, criticizing, blaming Not Observed Observed (Needs Improvement) Comments 5. Analyzing, diagnosing, making glib interpretations: labeling behavior Not Observed Observed (Needs Improvement) Comments 6. Reassuring, sympathizing, consoling, excusing Not Observed Observed (Needs Improvement) Comments 7. Using sarcasm or employing distractive humor Not Observed Observed (Needs Improvement) Comments 8. Threatening, warning, counterattacking Not Observed Observed (Needs Improvement) Comments 9. Using excessive closed-ended questions Not Observed Observed (Needs Improvement) Comments 10. Stacking questions Not Observed Observed (Needs Improvement) Comments 11. Asking leading questions Not Observed Observed (Needs Improvement) Comments 12. Using phrases repetitively (i.e., "ok," "you know," "that's neat"). List: Not Observed Observed (Needs Improvement) Comments 13. Other responses that impede communication. List: Not Observed Observed (Needs Improvement) Comments Assessing Physical Attending Behaviors Through observation, rater will check: Strength Need Comments 1. Direct eye contact Strength Need Comments 2. Warmth and concern reflected in facial expression Strength Need Comments 3. Eyes on same level as interviewee's Strength Need Comments 4. Appropriately varied and animated facial expressions Strength Need Comments 5. Arms and hands moderately expressive: appropriate gestures Strength Need Comments 6. Body leaning forward; attentive but relaxed Strength Need Comments 7. Voice clearly audible but not loud Strength Need Comments 8. Warmth in tone of voice Strength Need Comments 9. Voice modulated to reflect nuances of feelings and emotional tone of interviewee's messages Strength Need Comments 10. Absence of distractive behaviors (fidgeting, yawning, gazing out window, looking at watch Strength Need Comments Negotiation Skills There may be times when a practitioner needs to provide support to the a beneficiary for several reasons, namely to: negotiate access to services; obtain information; make informal decisions; or provide information and coaching to assist the person to negotiate for themselves effectively. In other cases, the support may be to negotiate with, or on behalf of, the beneficiary. In negotiating, there are several premises, which improve your effectiveness: * "There will always be differences of opinions about people and disabilities and their ability/need to work." * "All conflicts will eventually be resolved." * "People are okay; but their behavior may not be." * "To win does not mean to take ALL." When a concern arises, it is important to communicate it as soon as possible in order to keep things from getting out of hand. In communicating about an issue, keep in mind the following points: *Define the problems clearly. Spend time reasoning, defining and making sure you know what the problem is. * Contact the key person. The biggest mistake people make is contacting the wrong person. Contact should be made with the person holding the "key" to the issue. * Schedule a face-to-face meeting when talking about a concern. Without this, it is easier for one party to "ignore" the other (not really listen to what is being said). A face-to-face meeting is also a way to build the groundwork for a good relationship. * THINK POSITIVELY! Once a meeting to discuss the issue has been arranged, it's important to be prepared for the meeting. Following are some tips for establishing good communication and keeping frustration levels to a minimum during a problem-solving meeting. * Introduce yourself. * Clearly state your concern(s). Be specific. Cite examples. Don't minimize the issue. * Maintain eye contact and speak directly to those present. * Admit your own feelings. * Listen actively to what everyone has to say. * Provide deserved "strokes." * Admit mistakes. * Talk sparingly. Consider not talking at times, if appropriate. Stop when you're finished. * Speak positively. Use productive humor where appropriate. * Don't ask questions to which you already know the answers. Make statements. * Be venturesome-accept risk-compromise. * Take the initiative to "RESTART THE CONVERSATION." Six Rules of Successful Negotiation 1. Separate the person from the problem. 2. Avoid assuming or interpreting another's motives out of your own fears. 3. Listen until you "experience the other side." 4. Focus on interests, not positions. 5. Be hard on problems; easy on people. 6. Find options for mutual gain. Mediation There are times when it might be more helpful to provide or refer for mediation rather than in supporting the beneficiary's negotiation. Unlike supporting negotiation, when mediating, the practitioner offers themself as a neutral party to facilitate a positive communication process between two or more people who are negotiating. Following are some tips for effective mediation: Structure communication * Talk to each party separately * Encourage direct communication when hostility is low; discourage direct communication when hostility is high * Set ground rules; ask the parties to commit to following the rules for open communication Follow the four steps of problem solving * Help the parties identify and prioritize their interests and issues * Emphasize common interests; identify conflict as a situation best solved jointly * Suggest integrative solutions Increase the parties' motivation to settle * Have them set a time limit for conflict settlement * Emphasize team and organizational goals * Provide consequences for agreement/nonagreement * Instill optimism Who makes a good mediator? Someone... ... with expertise in processing communication; a good facilitator ... who can control the confrontation setting, climate and process ... good at problem solving ... familiar with the people in conflict, but who doesn't exercise direct control over them; someone who can be neutral Final Thoughts All of the communication skills and strategies discussed above will make the benefits specialist more effective in all aspects of his/her job, and in other relationships in their lives. The application of these skills will assist individuals in making decisions regarding employment and its impact on benefits. If these strategies are used, how do you ensure that the appropriate actions take place throughout the process to minimize the chances of problems occurring and to assure the inclusion of work incentives? In the report that we hope you will provide to the customer, several scenarios will be presented. It is particularly important for the benefits specialist to withhold comment as to which options presented to the customer they think are best. In some cases, the customer will ask your opinion, and it is certainly acceptable to offer this, as long as you qualify your comments as opinions and remind the individual that you will not think less of them, or that you are any less willing to offer your support, if they choose a different option than you have mentioned. Many times, the individual will need some time to consider the information presented. The benefits specialist should not rush the person in the decision-making process but should set a date to reconvene, even if this is by phone. If this is not done, some individuals will tend to procrastinate and decisions may never result. CHAPTER 20: INFORMATION GATHERING, ANALYSIS, ADVISING, AND REPORTING The lack of suitable, affordable housing is often a major barrier to successful employment of persons with disabilities. Still, various public and subsidized housing programs available to persons with disabilities can sometimes help to overcome this barrier. In addition, a number of rent-based work incentives allow families and individuals entering the workforce to retain more of their income. This chapter will provide a brief summary of the major federally sponsored programs that should be available in all states, with an emphasis on those policies most applicable to persons with disabilities. The reader should keep in mind: a) this is only an overview of the federal programs and their regulations; and b) this overview is based on federal regulations published as of November 2001. State-subsidized housing programs also exist and may offer additional benefits, although they are not covered in this chapter. BPA&O Decision Tree Query -- Action / Decisions: 1. Assess the Situation 2. Determine the level of support needed Short-term Information and Referral Short-term Problem response - requires research, contact with one or more agencies to find an answer to a specific problem or question. Query -- Action / Decisions: 1. Assess the Situation 2. Determine the level of support needed In-depth Intermediate Is it a crisis? Need to respond quickly e.g. urgent Intermediate Is it time-sensitive? e.g. agency deadline, job offer Pro-Active Planning *collect *verify *analyze *confirm desired response (written/verbal face to face phone/email Is there a need for long-term support? LONG TERM BENEFITS MANAGEMENT Data Collection and Profiling Data collection and profiling is typically seen as the initial point of entry into the benefits planning and assistance construct. Data collection is the process by which information and data is collected and a customized comprehensive benefits profile may be completed outlining several important facets of the beneficiary's or recipient's financial status and life. These include: * Personal demographics * Personal direction / future outlook * Description of disability * Outline of other agency involvement * Description of monthly income * Summary of existing resources * Description of Property Essential to Self Support * Employment information * Trial Work Period analysis * Extended Period of Eligibility analysis * Expedited Reinstatement of Benefits * Applying Expedited Reinstatement of Benefits * Health insurance needs * Analysis of Impairment-Related Work Expenses * Analysis of Blind Work Expenses * Analysis of Subsidies * Plan for Achieving Self Support history/potential * Ticket to Work Support * Ticket to Work Information gathering and data collection is a sensitive area. The needs of the customer being served will dictate the level and sophistication of information to be gathered. In the case of beneficiary or recipient simply calling for a quick piece of advice, it may not be necessary to compile a comprehensive profile of the individual's status. Rather, the benefits specialist will pick and choose specific areas where they need additional information upon which to base their counsel and advice. Attached in Appendix F is a model Data Collection Questionnaire. This questionnaire is intended to be used as a guide in conducting both telephone and in-person interviews of persons with disabilities and/or the persons who seek assistance on their behalf. In some cases, the practitioner will need to gather no more than a fraction of the information sought by the form. In other cases, the practitioner will want to cover all, or most of, the questions. If in doubt, it is recommended that the practitioner obtain all the suggested information during the interview and gather any documents (e.g., Social Security Administration notices) that might be relevant. In all cases of long-term benefits advisement and management, it is recommended that this form, or something like it, be used to ensure completeness, comprehensiveness, and consistency of information collected. The questionnaire is intended as an aid to analyze the effect of work on benefits. The user of the form may wish to customize it to meet the individual needs of the practitioner. For example, if your agency serves transition-aged students, you may want to develop an additional set of questions regarding the nature of special education services the child receives. If your agency serves only members of a particular disability group, you may wish to develop a set of questions based on the typical symptoms, limitations and interventions that may be expected. The remainder of this unit walks through the major headings of the questionnaire. For each heading, we explain the data that should be gathered, why that information is important, how to analyze the information collected, and finally, how to report your findings. The reader should keep in mind that some benefits specialists might not have the expertise to identify and analyze every issue suggested in this form. However, the form will be helpful in spotting issues that can be then referred to persons or agencies who will be in a position to provide the analysis and information needed. Gathering Personal Demographic Information It is important that the adviser gather basic contact information, including name, address, phone number and other contact information. Information about age, marital status and living arrangements is critical as a recipient's SSI check may be affected by the answers to those questions. The form seeks information about other family members in the household, as their existence may suggest the need to determine whether the benefits of other household members will be affected by the work activity of the individual being profiled. When collecting information, be sensitive to several areas: * Level of discomfort on the part of the person sharing information * Sensitivity of information and confidentiality * Individual's need for reassurance * Need to triangulate data collected to verify accuracy * Identification of other stakeholders in the person's life * Possible need to go through the questionnaire in a non-linear manner, as information is shared Name of Interviewer: Date of Interview(s): Was the Client/Consumer Interviewed? __ yes __ no Other Person(s) Interviewed (i.e., not the client/consumer): Initial Questions Presented: I. Personal Demographics Name: Social Security #: Address: County of residence: State of residence: Date of birth: Type of residence, check one: __ Home, apartment __ Group home __ Intermediate Care Facility (ICF) __ Hospital __ Other, please describe: __ Residential placement, funding (specify) Home phone: Work phone: Fax: E-mail: __ Married __ Single __ Divorced Name of spouse: Names, ages of children: Living arrangements Live alone? __ yes __ no Live with spouse? __ yes __ no Live with children? __ yes __ no Live with roommate? __ yes __ no Share expenses? __ yes __ no Gaining an Understanding of Personal Direction and Future Outlook Gathering information on the individual's personal direction and future outlook begins with making sure you have and understand some basic information: * interests and preferences; * long range goals and aspirations * employment, * post-secondary and continuing education, * community living; * what a person feels they need to achieve their desired outcomes. While it is important to weigh this information when providing advice and counsel, it is also important to understand what skills, interests and preferences the individual brings to the table. In some cases, this information may be provided as part of the referral or may be evident in existing data. The role of the benefits specialist is not to "diagnose" and become an "evaluator," but rather to use the information available as a benchmark to consider in the planning and assistance process. II. Personal Direction and Future Outlook Reason for referral: Expectations for services being requested: Preferred location to receive services: Individual's long-range dreams and aspirations (within 1-3 yrs.): Employment: Postsecondary and/or continuing education: Community living: What the person expresses they need to achieve their desired outcomes (frame as supports): This information is vital to projecting the future orientation of the individual being served and discovering specific considerations that may need to be made should the person be seeking benefits advisement or require long-term management supports. Completing a Summary of Personal Demographics and Future Outlook: Exercise The first two sections of the Benefits Screening Questionnaire (Personal demographics and Personal Direction and Future Outlook) are pieces of information that can easily be compiled into a forward for the comprehensive report. They would provide important information about why the individual was referred; what the individual's personal and home life experience is like; as well as the dreams, aspirations and potential outcomes they are interested in. Using Section I and II of the completed Profile in Appendix F, and pairing up with a colleague, draft a few paragraphs from the profile that could be used as a forward to the report. Use the Reporting Template provided in Appendix G to draft your document. Describing and Reporting Disability This section seeks information about the person's diagnosis, doctors/therapists, medications, and their side effects. It also seeks functional information about how the disability limits activities, including ability to work. The information gathered here could be important in determining if the person is eligible for impairment related work expenses (IRWEs) or blind work expenses (BWEs). It could also be important in evaluating whether certain expenses proposed for a Plan for Achieving Self Support (PASS) are needed to overcome a particular limitation. Gathering the names and addresses of health professionals at this point eliminates the need to seek that contact information later, when a letter is needed to support the application for an IRWE, BWE or PASS deduction. III. Disability Description Primary diagnosis: Secondary diagnosis: Tertiary diagnosis: Age at onset of disability: Specific date if available: Currently seeing a doctor or therapist? __ yes __ no Name, address of doctor or therapist: Medication, please list: Any side effects: __ yes __ no Describe side effects: How does disability limit activities? How does disability limit ability to work? Compiling a description of an individual's disability is an extremely sensitive portion of the comprehensive report and one that requires much thought and foresight. When defining the individual's disability, stick with the original disabling condition, which first established their eligibility for benefits. That does not preclude providing more functional information regarding residual capacities and functional limitations or other tertiary diagnosis. A comprehensive summary of the individual's disability might include: * Primary diagnosis or label, as determined by a qualified medical examiner * Secondary and tertiary diagnosis * Onset of disability * Medications received and functional side effects * Description of how the disability limits an individuals functioning, and possibly, work activity When drafting this portion of the report, use first-person language that is empowering to the person and recognizes their individuality first and not their label. For example, if John had a label of severe mental retardation, you wouldn't state any of the following: * Mentally retarded, John is unable to.... * (makes John's disability his identity rather than his name) * The retarded.... (classifies John with a group of people assuming they are homogeneous, ultimately losing his identity as a result) You could say: * John has been diagnosed with... * John experiences... * John is an individual with the following unique capacities, strengths and interests who is also classified with a label of ... Collecting Information On and From Other Service Providers the Person May be Involved With Many individuals with disabilities who are working or planning to work will be involved with another state or local agency such as state or private vocational rehabilitation (VR); the state MR/DD system; state MH system; or others. Some individuals will receive services from both state and private agencies. If an individual being served is not involved with, or aware of, other service delivery networks, you should take the opportunity to explore the employment and services and supports potentially available to them, to assist them in making a better informed choice as they consider. This section seeks information about specific agencies providing services, the name and contact information for key personnel assigned, and the nature of services being provided. In some cases, you may want to obtain the individual service plan or any other documents that describe the services provided. The information gathered here could be very relevant in determining whether any employment is subsidized. The information could also be helpful in determining whether there are any additional goods or services needed that could be funded out of a PASS. Benefits specialists and other professionals who regularly take part in planning activities with individuals with disabilities also need to be on guard against the somewhat inevitable tendency for this process to become predictable and routine. When this happens, professional participants lose sight of the significant impact this planning has for the quality of life and future for that individual. Regularly transpose yourself to the position of the individual and family, and ask if the planning process is really taking into consideration their interests, needs and concerns; and whether you are bringing the necessary compassion, creativity, and energy to work with you to create positive outcomes. When crafting a section of the comprehensive report on involvement of the beneficiary or recipient with other agency or support networks, there are several factors to keep in mind and to document. * If still in school, when will the person exit? * Is the person currently participating in any educational programs that might impact on benefit status? * If being provided services and supports from other agencies, what timeframes should we be aware of? * Do any of the programs or services provided hold implications for what we are trying to accomplish? * Are there teachers or counselors involved in the person's life that should be invested in the benefits planning and assistance process? * What strategies should be used to invest these potential stakeholders? * Does the individual currently have a formal plan for services that should be considered? * If need arises, do we have access to the individual(s) commissioned with developing those plans? IV. Involvement With Other Agencies / Support Systems Is the individual still enrolled in secondary school? __ yes __ no If yes, name of school: Name, phone number of teacher: Describe education program: Is the individual enrolled in continuing education or a postsecondary education institution? __ yes __ no If yes, name of school: Name, phone number of counselor: Describe education program: Is the individual involved with the state VR agency? __ yes __ no If yes, name of agency: Name, phone number of VR counselor: Describe program, services getting from agency: Is the individual involved with a private VR agency? __ yes __ no If yes, name of agency: Name, phone number of VR counselor: Describe program, services getting from agency: Is the individual involved with the State MR/DD system? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Is the individual involved with the State MH system? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Is the individual involved with any other agencies? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Briefly describe other informal or unpaid supports in the individual's life (family, friends, etc.). Summarizing Monthly Income This section seeks information regarding all income of the individual and other members of the household. The intent is to determine how the person's current or future work activity will affect SSDI, SSI, Medicare or Medicaid benefits. It also seeks to paint a picture of income needed to offset the loss of cash benefits. Information about the income of other household members is sought for two reasons. If that income is from SSI, welfare or some other form of public benefit, the adviser needs to identify whether those benefits will be affected by the individual's wages. If the other household member has wages or other income, the adviser needs to identify whether those wages or other income might affect the person's eligibility for, or amount of, SSI benefits. If the individual receives SSDI benefits, the questionnaire asks whether they are collected against the consumer's earnings record, or as a Disabled Adult Child (DAC), or as the widow/widower of another wage earner. The answer to these questions could determine continuing eligibility for health care coverage. For example, the person who loses SSI when he or she becomes eligible for SSDI/DAC benefits may be able to retain automatic Medicaid, indefinitely, under a special provision of the law. Similarly, the person who loses SSI when he or she becomes eligible for SSDI widows or widower's benefits may be able to retain automatic Medicaid during the 24-month waiting period for Medicare eligibility. Prior to providing advisement on future scenarios, the practitioner must do a comprehensive job of identifying other means-tested benefits, services or supports an individual may receive. This would include not only SSI, but also: * Pell grants or other financial aid received during postsecondary education * TANF * Food stamps * State subsidized housing * HUD support * Other public welfare programs V. Monthly Income Unearned Income: SSDI amount: Type of benefit (check appropriate benefit): __ Against own record __ Disabled Adult Child __ Widows/Widowers __ Other: __ Unknown Unemployment amount: Veteran's benefit amount: Railroad Retirement Pension amount: Alimony / Palimony amount: Child Support amount: Private disability insurance amount: Worker's Compensation amount: Other amount (specify types): Financial Needs-Based Assistance (means tested): SSI amount: Pell grant amount: TANF amount: Food stamps amount: State subsidized housing: __ yes __ no amount: HUD: __ yes __ no amount: Other amount (specify types): Anyone in household receive welfare benefits? __ yes __ no Describe form and amount: If individual receives SSDI or SSI: Name, address of Social Security office serving them: If known, name, address, phone, fax and email address of Claims Representative serving them: Earned Income / Wages: ___ employed by others ___ self- employed Monthly gross amount: Weekly gross amount: Bi-weekly gross amount: If wages vary, please explain: Other income in household: Spouse, describe form and amount: Children, describe form and amount: Reporting Monthly Income When compiling a summary of the individual's monthly income, make sure to be "values-free" when reporting types of income received. Whether earned or unearned income, the impact on both must be explored with equity. Unearned Income Given that unearned income is considered first in SSA's calculations for the SSI program, outline the specific types of unearned income and amounts received and how the individual is entitled. This should be coupled with either notation or footnote as to how these benefits may be affected by earnings or fluctuations in other benefits or entitlements. Unearned income might include, but not limited to: Veteran's benefits; Railroad Retirement Pension; alimony / palimony; child support; private disability insurance; and/or, Worker's Compensation. When available, it may also be important to provide contact information for subsequent caseworkers or claims representatives. Financial Needs-Based Income While also considered unearned income, it may be important in some cases to separate out needs-based income in the income summary specific financial needs-based income received (e.g. .SSI, HUD, TANF, etc.). These incomes will inevitably be affected, based on other income received. This type of income is usually associated with providing the individual and/or their family with a minimal means of existence and not only provide financial resources but possibly access to affordable housing and other essential daily support. Make sure to reference type of income, source, and amount with a footnote or notation as to how each specific type of income listed may be affected by other types of income. When available, it may also be important to provide contact information for subsequent caseworkers or claims representatives. Earned Income and Wages Begin this piece by summarizing current or potential employment status (for example, in the employ of another, self-owned business, considering employment option, etc.). Depending on the person's financial status, it may be desirable to translate all earnings into an average monthly amount or to provide specific analysis of weekly or bi-weekly income. It may also be useful to calculate annual earnings, should the figure be needed to measure against certain state thresholds. Particular attention and description should be given to any wage variations that may occur during specific periods of time (e.g. production slowdowns, busy seasons, etc.). It is also important to explain other income received by a spouse or child, including source and amount. Consider concluding this section by providing an individualized comprehensive budget, which shows the individual's monthly incomes versus monthly expenses. This could prove an important piece of information, especially when demonstrating how an existing job may not allow an individual to meet monthly expenses. Preparing a Monthly Budget Exercise Breaking into groups of three, prepare a monthly budget considering the information outlined above. Have one person play the role of the consumer contributing the financial information, another the role of recorder designing the budget, and the last the interviewer collecting the information. Be ready to volunteer to transcribe the budget prepared onto a transparency to share with the class. Identifying and Summarizing Resources This section seeks information about home ownership, bank accounts and other liquid assets. It also seeks information about ownership of a vehicle. These issues are primarily relevant to SSI and Medicaid eligibility because those programs require that an individual must have limited resources. Here is a place where you may wish to customize the questionnaire to add questions that are relevant to your state's Medicaid criteria. The questions in this section may also have relevance for the person who receives only SSDI, but who may wish to consider using a PASS to become eligible for SSI. In order to take advantage of the PASS, that person's resources must be within SSI's limits. VI. Resources (Relevant to SSI, Medicaid eligibility.) The Individual Own home __ yes __ no If jointly owned, please indicate other owner(s): Bank accounts Savings, list amount: Checking, list amount: Other, describe and list amount: Individual retirement account (IRA), tax deferred annuity or similar retirement account - describe and list amounts: Vehicle(s) owned by individual Model and year: Check one: __ car __ van __ truck __ Other, describe: Current fair market value: If market value is more than $4,500, is it: Modified for use by a person w/ disability? __ yes __ no Used as transportation to get to work? __ yes __ no Used for necessary medical appointments? __ yes __ no Responsible relative with whom the person resides Check one: __ spouse __ parent(s) __ Other, describe: Own home: __ yes __ no Bank accounts Savings, list amount: Checking, list amount: Other, describe and list amount: Individual retirement account (IRA), tax deferred annuity or similar retirement account - describe and list amounts: Extracting information directly from the screening questionnaire, highlight existing resources that an individual may have. Keep in mind, this section specifically pertains to the SSI program and meeting the resource portion of the income and resources test. This information may prove crucial in the case of someone who is considering application for SSI eligibility. When summarizing existing resources, consider classifying these resources under several broad categories: residential; savings account(s); checking account(s); retirement account(s); other account(s); vehicle(s); and resources of another individual with whom the person resides. In each case, it will be important to identify specific amounts, and to discuss fluctuations that might occur over specific periods of time. In the case of the individual residing with another, specify the nature of the relationship. It is also critical to assess and document any property that is essential to the person's self-support. Make sure to detail and describe the property owned, its inherent value, and how it is currently used or expected to be used. Conclude this section by providing notation as to resource considerations the individual may need to make, such as specific dollar amounts resources will need to be kept under, or resources that may count against the individual's eligibility for SSI. Identifying Property Essential to Self Support For SSI recipients, property is considered "exempt" and not counted by SSI as a resource if it is essential for self-support. This could include both property owned and used as an employee. Here you might list carpenter's tools or mechanic's tools. Potentially, this include a very wide range of property used for self-employment, i.e., in the person's own business, including the physical building(s), equipment and business-related vehicles. Keep in mind that any of the resource issues addressed in this part and the previous part of the questionnaire are also relevant to section 1619(b) Medicaid, which requires that a person have resources within SSI limits. VII. Property Essential for Self Support Describe any property owned (and its value) that is used in job as an employee (such as mechanic's tools, carpenter's tools): Describe any property owned (and its value) that is used in "self employment"(such as office equipment, company vehicle, stock, business bank account): Developing and Reporting Employment History This section seeks considerable information about the employer, the job, when it started and the nature of any special supervision or services provided at the job. This section should also be filled out if the person is about to start working or is considering a job. The information gathered here is relevant in a number of ways. The information about when the job started and the rate of pay will be relevant to SSDI recipients and the adviser who must analyze continued eligibility under the substantial gainful activity rule. This information will be used in tandem with the information gathered in sections VIII (trial work period) and IX (extended period of eligibility) to allow the adviser to perform a comprehensive benefits analysis for the consumer. The information about how the job was found, extra supervision and whether the job is a supported employment position will be relevant if the adviser will be expected to assist the consumer in showing that their work was subsidized in order to lower countable wages below SGA. Depending on the answers to these questions, there may or may not be a need to more fully develop the subsidy issue in section XII of the questionnaire. When benefits advisement is done in a timely manner, it will often occur at the point when a person is about to start work or is thinking about it. This will be a critical part of the questionnaire in those cases. VIII. Employment Information (If Employed, About to Start Working or Considering a Job) Name, address of employer or potential employer: Describe job (or potential job) Title: Duties: Hours: Salary/hourly wage: Benefits: Date you started working (as employee): How job was found? Found on own: __ yes __ no Agency helped find job, describe: If self employed (or potentially self employed) Describe business: Date started: Was job selected because of limits of disability? __ yes __ no If yes, please explain: Any extra or special supervision on job? __ yes __ no If yes, describe: Is this a "supported employment" position? __ yes __ no Agency sponsoring job: Is there a job coach? __ yes __ no Name: Hours per month: Services performed: How long will job coach remain in picture? Does government agency (i.e., other that employer) pay all or part of wage? __ yes __ no Please describe: Please record work history (last 10 years) or attach resume/vita. Place of Employment: Title Duties Wage/Hours Dates Briefly describe any past attempts at self-employment: Business Location Dates Income Reason for Cessation Consider summarizing employment information and the individual's work history, by beginning to detail the extent to which the person is currently working or the employment scenario being considered. This should include: * ocation; * address; * job title; * wage and benefit information; * duties; and, * other pertinent information that must be considered. If self-employed or considering this option, it may also include: * type of business; * location; * timeframe of business; * income information; * business plan; * business profile; and/or, * reason for business cessation. For an individual who is already employed, consider providing a profile of how the person secured the job. This information could prove extremely beneficial in helping to ascertain the extent to which an individual may be able to seek employment on their own, advance in their career, or connect to external support systems to assist in job placement, training and advancement. In the case of someone who has been provided external supports to obtain, maintain, or advance in employment, identifying and documenting specific supports provided and person(s) responsible may prove an important consideration for development of employment safety nets. Depending on the person the report is being prepared for and purpose of referral, consider profiling the individual's employment history, attaching a copy of the person's resume, or profiling their self-employment history. If networked closely with the individual's employment support system, also consider working closely to outline in the summary important support needs which may contribute to the individual's long-term work attachment, which, when coupled with a plan for benefits planning and assistance, provides a comprehensive safety net. Conducting a Trial Work Period Analysis The trial work period (TWP), like its companion work incentive, the extended period of eligibility, applies only to SSDI recipients. If a person receives only SSI benefits, you need not complete this section. The completion of this section could be easy or challenging, depending on whether the consumer has a long history of work activity. Except in those cases where there is no work history or the person just started working, we recommend that the person completing the form develop a comprehensive, month-by-month, history of work and wages since the consumer first started collecting SSDI benefits. This can be done on the attached "Notes" pages or on a separate document. Based on the comprehensive history of work and wages, you can answer the questions listed in this section. This will determine whether the consumer has exhausted the TWP by earning more than the monthly limit in nine months during a rolling 60-month period. If not, the TWP months can be listed, putting the adviser in a position to monitor the TWP as part of long-term benefits advisement. IX. Trial Work Period (TWP) Analysis This section applies to SSDI recipients only. To complete this section, it may be necessary to develop a comprehensive, month-by-month, history of work and wages since the consumer first started collecting SSDI benefits. This can be done on the attached "Notes" pages or on a separate document. Also, if the person is self-employed you may need to discuss what constitutes a trial work month. Date when first received SSDI? Has the person worked and earned more than TWP amount in any month(s) since first receipt of SSDI? __yes __no If no, full nine-month TWP available. If yes, continue through questions. Did person use up nine TWP months before 1/1/92? If yes, no TWP available unless SSDI terminated, eligibility re-established after new application five-month waiting period. If person did not exhaust TWP before 1/1/92 Work nine TWP months during 60-month period, which ended after 1/1/92? __yes __no If yes, TWP exhausted. If less than nine TWP months during 60-month period, list each TWP month during past 60 months. For each, list month, year and gross wages earned. [Note: In many cases, will have to obtain information from SSA.] Month Year Gross Wages Earned Based on information, how many TWP months left? Month Year Gross Wages Earned Based on information, how many TWP months left? Month Year Gross Wages Earned Based on information, how many TWP months left? Year Gross Wages Earned Based on information, how many TWP months left? If less than nine TWP months during 60-month period, list each TWP month during the past 60 months. For each, list month, year and gross wages earned. [Note: In many cases, will have to obtain information from SSA.] Use table on pg. 316 to chart 60 months from the current month/year. Begin reporting the trial work period analysis by stating the date when the individual first received Social Security. Going back in history, trace and identify a timeline, which presents months in which a person worked and earned more than monthly limit. Make sure to present this information in the context of the 60-month rolling window. For individuals who received Social Security prior to January 1, 1992, make sure to explain that the 60-month rolling window prior to this date did not apply, and any months in which earnings exceeded $200 per month will count against the trial work period. Further, make sure to reference that individuals are only entitled to one trial work period per eligibility / determination of disability. If all TWP months have been expended, make the transition into a discussion on the analysis of extended period of eligibility (EPE), as described below. If TWP months remain, highlight the number and close this section of the report by discussing the implications of completing the TWP, then move into the next section on EPE. Year January February March April May June July August September October November December Conducting an Extended Period of Eligibility Analysis Like the TWP, the extended period of eligibility (EPE) applies only to SSDI recipients. Once the TWP section above is completed, completion of this section should be easy. If the TWP is not yet completed, this section can be left blank or the words "trial work period not yet completed" can be inserted. If the TWP has been completed, the month and year that it was completed is filled in and the EPE begins the very next month. Accurate completion of the TWP and EPE sections is critical for the benefits specialist who is working with the SSDI recipient. To date, SSA has not asked its staff to monitor the TWP and EPE as they occur, in order to give recipients a running account of where they stand. The benefits specialist, then, must assume this role. For those consumers in the middle of a TWP or EPE, a six-month check-up may be critical in providing a running account of how many months are left in the TWP or EPE. X. Extended Period of Eligibility (EPE) Analysis (SSDI recipients only) Ninth TWP month (month/year): Beginning of EPE (month/year): Last month of 36-month EPE (month/year): Remember, during EPE: The first time that the individual is determined to be performing substantial gainful activity by earning more than the applicable SGA amount, they will get SSDI checks for that month and two more (i.e., during the "grace period") Following the grace period: * No SSDI check during months countable gross wages exceed the SGA amount. * Will get SSDI check when countable gross wages less than the SGA amount. Impairment related work expenses (IRWEs) and subsidies are deducted from gross wages. A table similar to the one on page 316 can be used to chart EPE months from the point the individuals TWP ended. Listing of EPE payment, nonpayment months: While TWP and EPE are distinct and separate, it is important to help individuals who will be reading the report to understand the correlation between the two. Make sure to clearly explain that if SSA makes a determination that an individual has medically recovered, s/he may not be entitled to a TWP and/or EPE. When compiling this section of the report, provide the reader with enough information to understand the EPE. In addition, identify and outline a timeframe which shows where the person currently stands in relation to using their EPE. At minimum, this should include dates associated with: * End of TWP; * Beginning of EPE, and * Projected end of EPE. The report should clearly explain that the first time the individual is determined to be performing substantial gainful activity by earning more than SGA, they will get SSDI checks for that month and two more (i.e., during the "grace period"). Following the grace period they will receive no Social Security check during months countable gross wages exceed SGA although they will get a Social Security check when countable gross wages are less than SGA. At this juncture in the report, reference the role that Impairment-Related Work Expenses (IRWE) and subsidies may play in reducing gross monthly wages below the SGA level. Applying Expedited Reinstatement of Benefits This series of questions seeks to assist the benefits practitioner in identifying a beneficiary's eligibility for expedited reinstatement of benefits. When reporting on this provision make sure to explain the protection and timeframe during which a beneficiary can access this safety net. XI. Expedited Reinstatement (EXR) A. Has individual received SSDI benefits in the past? __yes __no If no, stop and go on to B. If yes, continue. Did individual lose SSDI due to performance of SGA? __yes __no If no, stop and go to B. If yes, continue. Has individual completed their TWP and EPE? __yes __no If no, stop and go to B. If yes, continue. Has individual either stopped working or ceased performing SGA? __yes __no If no, stop and go to B If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSDI claim. B. Has the individual received SSI benefits in the past? __yes __no If no, stop If yes, continue. Did the individual lose SSI due to budgeting of wages or a combination of wages and other income? __yes __no If no, stop. If yes, continue. Is individual currently receiving Medicaid through the 1619(b) program? __yes __no If yes, stop. The EXR provisions are not needed to reinstate SSI cash benefits. If no, continue. Would individual be eligible for SSI based on current income because he/she either stopped working or is now earning less money? __yes __no If no, stop. If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSI claim. Formulating Health Insurance Needs The first set of questions in this section seeks to identify the current health insurance that is available to the consumer, including Medicaid, Medicare and private insurance coverage. The section specifically asks for out-of-pocket expenses incurred for Medicaid spenddowns, Medicare Part B premiums and private insurance premiums. These expense questions are asked for several reasons. First, the adviser should make sure that the consumer is taking advantage of any special health insurance benefits that are available. These include provisions like: the Qualified Medicare Beneficiaries (QMB) program under which a state or local Medicaid agency will pay for the optional Medicare Part B premiums; the section 1619(b) provision, allowing former SSI recipients who lose SSI because of wages to continue eligibility for Medicaid; and the special provisions allowing persons who lose SSI due to receipt of SSDI/DAC or SSDI for widows/widowers to continue receiving Medicaid in some circumstances. Collect information about out-of-pocket expenses for health insurance, as the payments for doctors, therapists, medication and other health-related care is important in determining just how much of this care is covered by health insurance and how much is paid by the consumer. This will be instructive for the benefits specialist in determining both the current income/expenses of the consumer and how much that individual stands to lose if one or more of their health benefits are lost. The information may also be instructive in nature as the specialist may be able to identify one or more expenses that the consumer is paying that could be picked up through one of their health insurance plans or through a different program. For the specialist who needs to consider the availability of impairment related work expenses (IRWEs)(see section XI.), this information will be invaluable in determining the potential amount of any IRWE deduction. XII. Health Insurance Needs Health insurance coverage, check each that is available: __ Medicaid Amount of spend down, if any: (Note: Not every state will have a Medicaid spend down program.) ___ Medicare ___ Part A (hospitalization) ___ Part B (outpatient) Does individual pay Part B premium? __ yes __ no Discuss availability of Medicaid payment of Part B premium ___ Private insurance Monthly/quarterly/yearly premium paid by individual: ___ Other, please describe: Total out-of-pocket expenses for spend downs, premiums: Monthly: Yearly: Special Medicaid categories If not eligible for Medicaid, but receives Medicaid with a spend down: Did you receive SSI in the past? __yes __ no Section 1619(b) eligibility: Did you lose SSI due to wages? __ yes __ no If yes, go through 1619(b) eligibility work up. Medicaid eligibility under SSDI/DAC, SSDI for widows/widowers, Pickle Amendment provisions: Did you lose SSI due to receipt of some form of Social Security benefits? __ yes __ no If yes, please describe: Go through work up for special eligibility categories. If your state has a Medicaid Buy-In and the individual is not otherwise eligible for Medicaid, screen for buy-in eligibility. Doctor visits Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Psychiatrist visits Estimate monthly or annual costs What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Mental health counseling Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Other therapies (occupational, physical, speech, etc.) Please describe: Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Home health care Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Medication Estimate monthly or annual costs: Describe each medication and purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Other health-related costs For each, list item(s), monthly or annual costs, purpose and how covered: Item Monthly/Annual Cost Purpose How Covered Reviewing, Projecting and Documenting Health Insurance Needs When reviewing, projecting future need for, and documenting existing use of health care coverage, begin by thoroughly identifying the person's existing coverage. This should include not only Medicare and Medicaid but also private insurance the individual may maintain or have. Medicaid Critical to the Medicaid recipient is identifying under what grounds the individual was made eligible for Medicaid. In the case of an SSI recipient who receives Medicaid, the importance of 1619(b) coverage should be explained early on in the report. This may include a description of the 1619(b) eligibility criteria which includes: * the individual continues to have the original disabling condition; * the reason for cash benefit cessation is due to increased earnings in excess of the break-even point; * the individual continues to meet the ongoing resource test; * the individual earnings haven't exceeded the state income threshold; and, * the individual needs Medicaid in order to work. For the individual who is a non-SSI recipient but still receives Medicaid, it is important to document the state's medical neediness level. In some cases this amount may be the same as the federal benefit rate. This figure is critical in considering what level of spend-down an individual might have to pay, should earnings increase over the medical neediness level. Note: Remember, Medicaid, through state-specific waiver programs, often funds other needed services beyond healthcare, such as case management, residential support, transition planning and employment support. Medicare When discussing Medicare in this section, first identify whether the individual is receiving traditional Medicare or managed care Medicare (officially known as Medicare Part C or Medicare+Choice). In addition, identify whether the individual receives Part A or Part B coverage or both, remembering that someone must receive Part A to be entitled to Part B. Some additional information to report is whether the individual pays the Part B premium or if Medicaid pays it through either the Qualified Medicare Beneficiaries (QMB) or Selected Low Income Beneficiaries (SLMB) programs. Both the QMB and SLMB programs apply a monthly income test. Complete discussing Medicare in this section by highlighting in the report the extended coverage which will be available for at least a 39-month period or 93-month period after the trial work period, as long as the individual does not medically recover. Make sure when projecting medicare cessation and termination to use a tracking form similar to the one provided in Chapter 6. Also note that generally individuals who have completed their EPE and had benefits terminated prior to 9/30/00 will not be eligible for a new period of extended Medicare coverage under the TWWIIA provisions. Note: If the individual lost SSI due to receipt of Social Security benefits, consider continued Medicaid eligibility under special provisions for recipients of SSDI/DAC or SSDI for widows/widowers. Also, consider eligibility under the Pickle Amendment. Private Insurance Important to note here is whether the individual is part of a group or individual policy and whether the individual, employer, or a combination, pays the premium. It may also be important to provide notation if the individual receives this insurance as a dependent under the policy of another. Note: Many insurance policies provide for continued coverage for adult dependent children with disabilities. However, some policies may provide that an individual who is working does not meet the definition of disabled. Given this, it will be important to incorporate into the report, if appropriate, the private insurer's definition of disability as it applies to adult dependent children. Summary It may be important to summarize at the conclusion of this section expenditures under the following categories, highlighting if costs are current or projected, their purpose, how covered, and monthly/annual "out of pocket" expenses. * Doctor visits * Psychiatrist visits * Mental health counseling * Other therapies * Home health care * Medication * Other health related costs It would be wise to educate the individual at some point, either verbally or in the context of the report, regarding guaranteed insurance coverage under the Health Insurance Portability Act. Identifying and Reporting Impairment-Related Work Expenses Impairment related work expenses (IRWEs) are important to SSDI recipients as they may allow them to reduce countable income below the substantial gainful activity level. They are important for SSI recipients as deductions from wages in determining countable earned income. This section provides a fill-in-the-blank format for the more common IRWEs, such as transportation or medication expenses. As with other parts of the questionnaire, in some cases you will want to take more detailed notes at the end of the form or attach additional pages. XIII. Analysis of Impairment Related Work Expenses Remember the three-part criteria for IRWE: Individual must pay expense in question; Item/expense must be related to disability; Individual could not work if he or she did not receive item or service Transportation IRWE Nature of item/service: How related to disability and work: Monthly cost: Medication IRWE Nature of item/service: How related to disability and work: Monthly cost: Health insurance IRWE (premiums, co-payments, deductibles). (Note: SSA has no written policy on the deductibility of health insurance premiums. They have been approved as IRWEs in individual cases.) Nature of item/service: How related to disability and work: Monthly cost: Other IRWEs (check each that applies and describe below): attendant care at home attendant care at work medical devices prosthetic devices work related equipment residential modification to work away from home residential modifications to work at home Other # 1 Nature of item/service: How related to disability and work: Monthly cost: Other # 2 Nature of item/service: How related to disability and work: Monthly cost: Before making recommendations as to potential IRWEs which might be available to an individual in the report, provide an explanation of how the use of an IRWE could potentially impact an individual's monthly income. Clearly explain how an IRWE might allow recovery of a portion of expenses paid for impairment-related work items. Following a brief summary, highlight findings from the screening, itemizing work expenses related to the individual's disability under the following categories: * Transportation * Medication * Health Insurance * Other expenses (see POMS for listing of additional expenses) Make sure to explain the nature and cost of the item or service and how it is related to the individual's disability and work. This documentation will prove useful should a decision be made to apply for an IRWE. This information can then be excerpted directly into a letter of request, along with copies of receipts for the expenses for which consideration is being sought. Another important consideration is providing counsel to the individual as to whether large ticket expenses should be taken at one time or pro-rated over a 12-month period. Remember, an IRWE may be taken under the SSI program affording a recipient the opportunity to recoup up to 50 percent of the cost of monthly disability work-related expenses. It may also be taken under the SSDI program to reduce countable wages used to determine if the individual is performing SGA during the EPE. This application would potentially reduce the person's gross monthly earnings below the SGA, allowing them to receive their cash benefit. Identifying and Recommending Use of Blind Work Expenses Blind work expenses (BWEs), an SSI work incentive, are available to individuals who are legally blind. They provide for a very extensive list of work-related deductions from earned income, some of which need not be disability-related. Any time the consumer is legally blind, the benefits specialist should explore the use of BWEs even if the individual is not currently working. It is expected that most benefits advisement agencies will serve only a small percentage of consumers who are legally blind. For this reason, the questionnaire does not contain a checklist of the most common BWEs for the interviewer. We recommend that you keep such a list or worksheet available for those occasions when the consumer is legally blind. If your agency serves only persons who are legally blind or a high percentage of them, you may wish to customize the questionnaire to include a BWE checklist. XIV. Blind Work Expenses (BWEs) Is the individual legally blind? __ yes __ no If legally blind and individual is working: Is the individual an SSI recipient? __ yes __ no If yes, do BWE work up. If the person is not an SSI recipient, do work up for potential SSI eligibility using BWEs. If legally blind and not currently working, explain potential for BWEs. Following a similar protocol as listed in the IRWE section begin this section of the report by briefly describing the intent of a blind work expense and the individual's eligibility based on SSA's definition of blindness. Before making recommendations in their report about potential BWEs that might be available to an individual, provide an explanation about how use of the expenses could potentially impact that individual's monthly income. Clearly explain how a BWE might allow them to recoup all, or some portion of the expenses associated with working. Following a brief summary, highlight findings from the screening, itemizing expenses associated with working that the individual expends. Explain the nature and cost of the item or service and how it is related to the individual working. This documentation will prove useful should a decision be made to apply for a BWE. This information can then be excerpted directly into a letter of request along with copies of receipts, for the expenses for which consideration is being sought. Analyzing, Projecting, and Documenting Subsidy Like IRWEs, subsidies are important to SSDI recipients as they may allow them to reduce countable income below the substantial gainful activity level. The primary use of this section is to provide a checklist for determining the probable existence of a subsidy. If a subsidy is likely to exist, the benefits specialist will need to document it in the "notes" section of the questionnaire or in a separately attached document. XV. Analysis of Subsidies Remember why we look for a subsidy: to ensure that only earnings which represent the true value of the work a person is performing is considered in making the determination of SGA. Subsidy checklist Is government agency paying part of wage? __ yes __ no Does individual get special assistance on the job? __ yes __ no Does individual perform fewer duties than others? __ yes __ no Does employer accept less in productivity than from others? __ yes __ no Does individual receive extra rest periods/breaks? __ yes __ no Is individual frequently absent or working irregular hours because of disability? __ yes __ no Does individual receive job coach assistance? __ yes __ no If you checked yes to any of the above, describe the special circumstances: Calculate value of monthly subsidy, indicating countable wages after subsidy: When documenting existing, and/or projecting future, subsidy begin by explaining how subsidy works and its potential impact on the individual's benefit. Document evidence of possible subsidy identified through the screening process. When possible, it is important to document the type of subsidy: agency-sponsored; employer-sponsored (specific or non-specific); and/or subsidy for the self-employed. Note: Not in all cases will the benefits specialist be able to project an actual dollar amount or worth of the subsidy. In the case of a non-specific employer-sponsored subsidy, the claims representative will need to assist in allocating an amount. That doesn't preclude the benefits specialist from providing additional information or clarification to assist the claims rep in making their decision. In any case, it is critical to be as specific and quantifiable as possible to explain the potential subsidy. When concrete quantifiable information is not available, qualifying statements will prove helpful to the claims representative. In closing, make sure to provide mathematical calculations explaining how subsidy amounts were calculated and describe how formulas were derived, providing back-up documentation if needed and/or requested. Exploring Plan for Achieving Self Support: History and Potential Use The Plan for Achieving Self Support (PASS) is an SSI work incentive that provides for special exclusions of income and/or resources. The PASS is important because it may provide a source of funding, for items that will help the consumer reach a work goal, where no other funding for the items is available. The primary use of this section is to provide a screening tool to determine whether the PASS might be available to an individual. To that end, the questionnaire seeks to identify two key elements: the existence of income (other than the SSI check) or resources that would be counted by the SSI program; and the existence of expenses related to the work goal, that will not be funded by any other source, and that could be funded through a PASS. If the answers to these questions identify the consumer as a likely candidate for a PASS, the benefits specialist should either: schedule a separate meeting with the consumer to fully explore the possibility of a PASS; refer the consumer to an agency that can assist them in that regard; or refer them to an SSA office to explore the possibility of a PASS. XVI. SSI Plan for Achieving Self Support (PASS) Does individual have an approved PASS? __ yes __ no If yes, describe briefly and obtain a copy for file. If no, explain PASS and then complete remaining questions. Does individual have income other than SSI? __ yes __ no If yes, please describe (see section V, above): Does individual have resources in the form of bank accounts or items that could quickly be converted to cash? If yes, please describe (see section VI, above): Are there goods and/or services that would help individual reach a vocational goal that he or she would purchase if extra money were available? __ yes __ no If yes, list items, their expected purpose and their approximate cost, if known: Item Purpose Approximate Cost Again, based on who the report is targeted to, it may be very important to provide a brief synopsis of what PASS is and why it might be useful to this individual. Never assume that the person reading the report is savvy about issues pertaining to all work incentive provisions. When completing this section of the report, keep in mind that a person's successful candidacy for the PASS program hinges on certain variables. If the person participated in the program in the past and did not achieve the occupational objective identified, documentation will need to be presented explaining the specific circumstances under which this occurred, if future candidacy is going to be established. Make sure to highlight what makes this individual a good PASS candidate, articulating findings from the screening. However, do not consider this section a PASS application. We simply want to present the possible option of a PASS. While the benefits specialists may be able to summarize a great deal of information that will go a long way in completing the actual application, it shouldn't be assumed that the benefits specialists will be the one who supports this person in completing the SSA-545. Present enough information to allow the person to understand the option and to make a case as to why this scenario may be one that should be considered. Given that most benefit specialists are not vocational rehabilitation experts, there may be a need to work closely with a vocational rehabilitation counselor, an employment agency, or someone else with expertise in the area of identifying a feasible occupational goal. It is critical to ensure others are available to assist in the development of a viable plan to support the person in achieving their occupational objective. Complete this section of the report by re-emphasizing the employment goal stated by the individual earlier in the screening, and outline specific items and/or services, their expected purpose, and associated costs that might support the person in obtaining this goal and becoming more self-sufficient. Ticket to Work The Ticket to Work Self Sufficiency Program is the SSA's primary return to work program for beneficiaries with disabilities. The following questions will assist the practitioner in identifying the beneficiary's current level of involvement. XVII. Ticket to Work Is individual receiving services under a Ticket? __yes __no If no, stop. If yes, continue. Name of Employment Network: Contact at EN: Describe services received from EN: NOTE: If individual is receiving services from the state's vocational rehabilitation agency, they may be receiving those services under the Ticket. Explain that individual will not be subject to a continuing disability review while using a Ticket and making timely progress. Keeping Comprehensive Notes There are two important types of notes that the effective benefits specialist should maintain. This includes field notes taken while compiling the screening profile, and actual case notes of activities, events, and other information conducted and collected which is pertinent to the actual case. Field Notes As a screening session or interview is being conducted, the practitioner should keep copious notes outlining information being shared by the beneficiary or recipient and/or other stakeholders in their life. These notes will serve as a reference when conducting an analysis of data collected and verifying data reported. Case Notes Maintaining a case record is a vital part of effective management. As part of the record, case notes should be maintained in their own section. At a minimum, case noting should include the following important elements: * Date; * Person(s) involved; * Brief description of event/activity; * Summary of outcomes; and a, * Prescription for next steps, as necessary and needed. Verifying the Profile To determine if information collected about an individual is accurate, reliable and true (trianulating), the benefits specialist should use at least three modes. These common modes include: observation, demonstration, and testing/surveying. When collecting information, it is important to gauge the extent to which you feel the beneficiary or recipient or other information contributors are reliable reporters. This can be done by cross-referencing information collected and verifying points of agreement. A variety of sources can be used to test data obtained, particularly in regard to information such as trial work months, employment history, or other types of information that are likely to "leave a trail." For example, information regarding trial work months could be obtained by contacting your SSA office. Employment history could be verified by looking at the individual's resume, looking at past income tax reports, etc. The key to reliable data is in multiple modes of verification. Data Collection Exercise Using scripts, form groups of three and complete the portion of the Data Collection Questionnaire as assigned. One person should serve as the interviewer, the other as a customer and the third as group recorder and observer. Be prepared to come back together to discuss particular tips your team has found for gleaning the most reliable and useful information. Forms provided earlier in Chapter Two can be used to assess effectiveness of communication. Profile Scripts Personal Demographics Script: Date: September 2002 Your name: Anne Perreault (that's French Canadian you know; you are distant cousin of Gilbert Perreault, a Hall-of-Fame hockey player) Age: 40, born 7/2/62 Social Security #: make one up Address: 123 Any Street, Buffalo, New York 14214 (Erie County)(you live alone) Phone: 888-8888 (you are reluctant to give your work phone, 999-9999, because your boss said "no personal calls" unless it is a dire emergency)(no email or fax) Marital status: Single Children: Your daughter, Jill Perreault, age 22, lives nearby in Buffalo Personal Direction and Future Outlook Script: The reason you came to see the benefits specialist is because you are worried about your right to keep collecting SSDI benefits. You have been working for nearly two years. You want to know if you were entitled to the checks you have already received and whether you have a right to keep collecting SSDI checks. You would like to maintain your current job. If all goes well, you would like to work in a supervisor's job in this business (a bulk mail service), or you would even consider starting your own business if your therapist thought you could do it. You also think that your private rehabilitation counselor plays an important part in your success and you would like to keep that support. Your big concern about making these moves is that you want to stay in a very small business; you don't want to work in a large office. You just want to work and go home to your apartment, without having to socialize with your co-workers. You tried going back to college a few years ago and it did not work out. You have no immediate plans to continue your education. You want to remain as independent as possible and will need to have enough money to keep living in your own apartment. You want to keep seeing your therapist and getting help from your case manager. ("I still have to do it on my own. They can help me find the best ways to live and work based on who I am.") You have a small, but important support network. That support network includes three key people: your 66-year-old mother, Madeline Perreault; your 22-year-old daughter, Jill Perreault; and your one close friend, Mary Jamison. You and your mom meet each other's needs for companionship. You go to church together, to the movies, and to dinner. Your daughter calls on the phone at least once during the week and visits most weekends. She has a car and often takes you shopping. Your friend Mary provides the support that only a peer can provide. She has problems that are similar to yours and is the one person, other than your therapist, that you can confide in about your disability. You talk to Mary, by phone, 3 to 4 times per week. Disability Description Script: You have a long history of emotional problems. It all started when you were 28 years old. You remember those days like they were yesterday. It was the summer of 1990, when your daughter, Jill, was 10 years old. For a while you just told everyone you were not feeling well. You missed a lot of work and your daughter stayed with her grandmother most of that summer. After many years of therapy, you have progressed to the point where you are back on your own, living in your own apartment. You are also working again, but not a lot. You worry that the anxiety attacks will return. You often get very nervous when there is a lot of commotion. This is why you prefer to work in a small business without lots of people. You are still getting counseling through the Southside Counseling Center on Elm Street in Buffalo. You see a psychiatrist, Dr. Renee Paul, once every two months. Dr. Paul monitors your medication and your mental health status. You also see a counselor, John Johnson, every two weeks. Mr. Johnson has been your counselor now for four years. You have an understanding with Mr. Johnson that it is O.K. to call him in between appointments if you are having a rough day. You probably do this about twice per month. Dr. Paul wants you to stay on Prozac for the indefinite future. You have been taking this medication for depression for about 12 months now and as far as you can tell it does not create any significant side effects. It is very important that people understand that you are not "cured." You still have good days and bad days. "On bad days, I have very limited energy. Generally, I do not want to interact with lots of different people. On a bad day, I prefer to keep to myself and go about my business, whether it is at work or home." Because of your disability, it is difficult to work a full-time schedule. You need a job where you can take off if you are having a bad day. Therefore, it is very important that you are employed by an understanding and tolerant employer. Other Agency Involvement Script: You have been involved with VESID for several years now. You are still working with the same counselor, Teddy Thomas, whom you like now that the two of you have a better understanding of what you would like to pursue as a goal. A few years ago, Mr. Thomas was really pushing social work on you and you started college to pursue that goal. Most recently, Mr. Thomas arranged for VESID to pay for job coaching supports when you started working in ABC Rehab's supported employment program. You worked in their bulk mail service. Now that you are working for the private business, Quality Mailers, they continue to pay for limited case management supports. Donna Romero is the case manager with ABC Rehab who continues to meet with you 2 to 4 times per month. When you meet with her, the two of you discuss problems you may be having on the job and strategies to deal with those problems. You are not involved with any other agencies. Employment Information Script: Your current job is with a business called Quality Mailers, Inc. They are located at 239 Swan Street, Buffalo, New York 14203. Your position is that of "bulk mail specialist." It is your job to make sure that a bulk mailing order is properly sorted, coded, and bagged for delivery to the Post Office. You work four days per week, Monday, Tuesday, Thursday, and Friday. Your workday runs from 9:30 a.m. to 3:30 p.m., with 30 minutes off for lunch. You really have no benefits other than one week's vacation. You have no health insurance and have no sick days. When you must take off a day because of your disability you do not get paid. Your rate of pay is $7.50 per hour. Keep in mind that it is now September 2002 and you have been working at this job since January 2002. ABC Rehab, following one year of successful employment in a similar job for their in-house bulk mailing service, placed you there. ABC has a longstanding relationship with Quality Mailers and they have hired other persons with disabilities. Your rehabilitation counselor at ABC assured you that Quality Mailers would be understanding and tolerant of your disability. During your first three months at Quality Mailers, January through March 2002, you received 3 hours per week of job coaching support. Your job coach was Jerry Greene. Mr. Greene "helped me to deal with the new job and deal with my disability." The two of you worked together to develop strategies to deal with your disability. Before the current job, you worked at ABC Rehab, Inc. between January 2001 and December 2001. Your job there was almost identical to your job at Quality Mailers. At ABC, you worked in a much more supported environment. You never had less than five hours of job coaching per week. During this period you worked 50 hours per month and made $6.00 per hour. You did not work between 1994 and 2001. Before you became disabled, you worked four years, 1986 to 1990, as a secretary. The company you worked for was General Accounting, Inc. and your rate of pay when you left was $14,000 per year. You left that job in the summer of 1990. Between 1991 and 1994, you worked for a temporary agency, Kelly Services. Your work for them was sporadic (four to six days per month) and you did general office work. Your rate of pay with Kelly Services ranged from $5.00 to $7.00 per hour depending on the job. During the fall of 1993, you worked at J.C. Penny in Cheektowaga as a sales clerk. This job paid $5.00 per hour. Your duties included waiting on customers and running a cash register. You left this job because you could not take the pressure. Developing a Comprehensive Report The first step in developing a comprehensive benefits advisement report is to review the profile that has been developed in its entirety. Often the novice practitioner will jump into exploring application of different work incentives creating an array of options and scenarios without first considering the person's complete life situation. For example, while at face value it may appear that someone has an IRWE that is not being taken full advantage of, that might not be as important as the fact that the person resides in a state where eligibility for Medicaid may not be met. This could potentially shift the priority of what a benefits specialist might choose to focus in on first. Documenting Scenario Analysis and Providing Computation of Useable Income Example This is the section of the report where the benefits specialist attempts to weave possible futures together, providing clear visual examples of how a person's employment outlook might be altered under certain scenarios. It is important at this juncture to not force decisions but rather simply present options from which the individual can make an informed choice. The last section of the report provides the opportunity to make closing comments and suggest a specific scenario or series of options that may be most advantageous to the individual. This is simply where the array of options that are available is explained and set side by side for comparison and contrast. One of the best ways to do this might be to simply create certain options and number them. For example: - Option I: Gross Monthly Income Not Working; - Option II: Gross Monthly Income Working with an IRWE; - Option III: Gross Monthly Income Working With A PASS. Under each option, provide a written commentary briefly explaining the option and its unique features. A side-by-side table showing how monthly income might vary by the option selected could then follow this. Michael receives SSI and SSDI and is not currently working. He is interested in knowing how his benefits and useable monthly income would be affected if he went to work. He is also very interested in the PASS and/or IRWE incentive as a tool to purchase the training he needs to be able to work. Option I Income Not Working SSI $149.00 Social Security $450.00 Earnings $0.00 Total Income $599.00 Expenses Job Coaching $0.00 Total Expenses $0.00 Income $599.00 Minus Expenses $0.00 Equals Total Useable Income $599.00 Option II Income Working with an IRWE SSI $149.00 Social Security $450.00 Earnings $450.00 Total Income $1,049.00 Expenses Job Coaching $622.50 Total Expenses $622.50 Income $1,049.00 Minus Expenses $622.50 Equals Total Useable Income $426.50 Option III Income Working with a PASS SSI $579.00 Social Security $450.00 Earnings $450.00 Total Income $1,479.00 Expenses Job Coaching $622.50 Total Expenses $622.50 Income $1,479.00 Minus Expenses $622.50 Equals Total Useable Income $856.50 It is important to note that Michael is not recouping all of the money he is spending on goods and services under his PASS. In this example Michael recoups $564.00 of his $622.50 PASS expenditures. Because his monthly net income is being decreased by this amount, Michael must pay for the remaining $58.50 of his PASS expense. Attempt at all costs to remain "values-free" at this point in the report. Again, deciding which option to select is up to the individual and other stakeholders in their life. Provide as much information as possible and consider providing some supplemental information, footnotes, or annotations where additional information pertaining to a specific option may be found. Scenario Computation Exercise Using the information provided in Appendix F (Anne's completed Screening Questionnaire completed in 2005) propose some options that Anne might want to consider. Make sure to define each option and then present a side-by-side comparison of impact on gross monthly income. Anne is particularly interested in what her useable income is going to be at the end of each month. Option I: Describe: Option II: Describe: Option III: Describe: Option I Option II Option III Making Closing Comments and Final Scenario Recommendations Making closing comments and providing a set of recommendations is extremely sensitive and requires much thought about how the individual being served is best supported in making an informed decision and providing the right information. Deciding to choose or select a certain option is more than just evaluating the mathematical calculations provided. It requires the person to holistically look at their life and make an informed choice as to the impact of their decision on the financial well-being, physical and mental health, and continued wellness of others in their family. Values-free writing is the key here. The benefits specialist should thoughtfully consider the breadth of the person's life and those who could be affected and make recommendations, beyond just which "option" should be selected. Recommendations might also include other considerations to which the person should be sensitive. Some recommendations may also include the thoughts of other stakeholders with expertise outside the benefits planning realm, such as long-term employment supports, which might be an important part of someone's safety net should they decide to move toward employment. While definitely outside the realm of the benefits specialist's expertise, external consultants might provide some useful and essential assistance in crafting recommendations for the individual to consider. Verifying Soundness of Advice to be Given As discussed earlier, it is critical to ensure the accuracy of information provided to beneficiaries and recipients. The same holds true for verifying and ensuring the accuracy of analysis and advice to be given. This can be done in several ways: * Double checking mathematical calculations * Verifying source data * Using commercially available calculation software to verify analysis * Having a colleague or mentor double check your work * Establish a relationship with someone within your local SSA office who might provide additional guidance re: policy interpretation Using the Profile for Counsel A comprehensive profile is the key to providing quality advisement to beneficiaries and recipients considering employment and other options to increase self-sufficiency. The profile developed can be used in several ways depending on the purpose for referral. A practitioner could simply print out the profile for future reference or for use by someone else. Or, as will be discussed in the next unit, a comprehensive report outlining different scenarios and how they impact the financial well-being of the person being advised could be generated. What the term "comprehensive" means, as it applies to benefits advisement, will vary, depending on the needs of the individual SSI or SSDI recipient or beneficiary. Depending on those needs, the intervention will be either short term or long term. An agency providing full-service benefits planning and assistance should be available for both short-term and long-term advisement. Other agencies, which provide more limited benefits assistance, will offer only short-term advisement. Depending on the scope of the long-term support needed and requested, an individual may be provided with this advisement in the context of a long-term benefits management plan. Short-term Advisement and Counsel Providing advice and counsel begins at the point when a benefits specialist is not just collecting data (profiling) but actually beginning to analyze the data collected, and providing advice and counsel regarding specific scenarios which should be taken into consideration by the beneficiary and recipient and/or their stakeholders. The premise of these resource materials is that benefits advisement is most effective when it is both individualized and comprehensive. The term "individualized" should be self-explanatory. Benefits advisement must be delivered on a case-by-case basis, to one individual at a time. Although resource materials must, by their nature, be directed at general principles and a large audience, the application of those principles must be based on knowledge of a person's individual circumstances and the employment-related goals he or she has set. SECTION SIX: BENEFITS ASSISTANCE Objectives 1. Apply and practice delivery of effective benefits assistance. 2. Understand and be able to support a beneficiary considering using or already participating in the Ticket to Work and Self-Sufficiency Program. 3. Understand myriad of service delivery planning documents that exist across systems and how to integrate benefits planning and assistance. 4. Understand touchpoints applying to both SSI and SSDI. 5. Practice effective crisis management and problem solving. 6. Understand case management strategies. CHAPTER 21: SUPPORT PLANNING Introduction Once an individual has decided to pursue an employment goal, a possible next step for the benefits specialist is to support the person by designing a strategic plan for achieving their goals while also achieving the benefits effects that have been anticipated. Here is where the differences between planning and assistance become evident. The entire process of decision-making that we are discussing requires the individual to consider more than one option, to weigh these options in relation to themselves and their circumstances and goals, and then to choose one course over the others. This process asks questions such as whether or not to become employed, whether or not (possibly) to ask others to help with benefits management, and whether to continue to use services long-term. If the person is unaccustomed to making these types of decisions or if the person has a representative payee, it is important for the benefits specialist to encourage the individual to enlist the support of someone whose input they trust (many times this is the person who is their rep payee) to be part of these discussions and the decision-making. The benefits advisor should stay in an information-giving capacity, rather than being seduced into over-influencing the decisions or making the decisions for the person. This portion of the BPA&O process (decision making), is concluded when the individual has and understands the steps that need to occur depending on the decisions they have made. At this point, the individual has decided to manage the process, has secured the assistance of a natural support, has secured the support of an agency (via inclusion of steps into their strategic plan), or has secured your assistance in managing the strategic plan. Support Plans Developing an effective model for providing benefits assistance begins with identifying a need for long-term support and services. If goals and objectives are needed to guide delivery of services and supports, they may be integrated into pre-existing service delivery plans. However, if this is not possible or desired, then develop a separate support plan. A sample plan format is outlined later in this chapter, followed by a completed support plan.\ There are several additional items to keep in mind when developing support plans for individuals with disabilities: * This is the individual's support plan, not yours. The plan must be understood, and agreed to, by the consumer who chooses when, how and who will deliver the supports identified. * As a supporter, it is essential to assess the extent to which the individual can self-manage their own benefit/employment situation. While the individual may not initially demonstrate the ability to self-manage their situation, this could be developed over time. So, make sure plans being developed always push the individual to develop ownership in the process, with a focus on future orientation and capacity building. * Any good plan requires an array of resources to successfully fulfill the mission of the plan. There is a tendency to stop successful implementation once the funds have been identified. However, we know that there are typically many human resources that are taken for granted and thus not adequately invested in the plan. * When gauging the timeframe of the plan itself, take into consideration the frequency at which the consumer may need to be reinforced or encouraged. Once crafted, many plans are written to fulfill some reporting requirement and are never revisited, to customize to the individual's needs, desires, or preferences. * Never assume that someone else is going to do something just because you talked about it and agreed to it. Safety nets are the essential cornerstone of a good plan. Always identify the safety nets that will ensure the overall success of the plan. Finally, while there is a natural proclivity to boilerplate plans, each plan crafted should be customized to meet the unique situation of the person being served. Nothing raises questions regarding the quality or comprehensiveness of services and supports delivered by an agency or professional like a "carbon copy" or "cookie cutter" plan. Comprehensive Benefits Support Plan Consumer Name: SSN: Address: Phone: Fax: E-mail: Explanation of Need for Support: Activities Time Frames Person/Agency Responsible Role Desired Outcomes Resources Needed Quality Indicators of Success: Completed Comprehensive Benefits Support Plan Consumer Name: John B. Recipient SSN: 000-00-0000 Address: 000 Security Boulevard, Baltimore, Maryland 00000 Phone: (000)-000-0000 Fax: (000)-000-0000 E-mail: B/R000@outlook.com Explanation of Support Need: John has expressed a need for support in reporting monthly work expenses and earnings on a regular basis. He has received termination notices in the past based on assumptions made on the part of SSA when he did not report his expenses and earnings information in a consistent manner. Activities/Goals: Benefits counseling Time Frames: Monthly Person/Agency Responsible: Peer Advocates R-Us / Joe Kewl Role: Provide benefits consultation and initially conduct monthly reporting to SSA . Activities/Goals: John will compile and bring expense receipts and pay stubs to monthly counseling sessions. Time Frames: Weekly/Monthly Person/Agency Responsible: John B. Recipient Role: Assemble Handi-Transport receipts at end of each day in file by door. Put pay stubs in file weekly. Take monthly to counseling session. Desired Outcomes: Joe will support John in gradually implementing a self-management strategy for reporting monthly impairment-related work expenses and gross monthly earnings to SSA in a consistent manner John will consistently report expenses and earnings to SSA with only a verbal monthly prompt. Joe will get to a point where he is only initiating follow-up calls to the SSA Claims Rep every other month to check reporting. Resources Needed: - Monthly postage provided by John. - Reimbursement for counseling sessions provided by State VR Program. - Buy-in from Claims Rep - Copy of Support Plan provided along with monthly check-ins. Quality Indicators of Success: - John will utilize a personal filing system at home - SSA Claims Rep will support self-management plan - Peer Advocates R-Us will gradually reduce support while still maintaining oversight of management plan - John will gradually assume responsibility for consistently reporting weekly expenses and monthly earnings to SSA minimizing the occurrence of potential crisis benefit situations. Additional Thoughts on Support Planning Encourage the customer to tell you what they understand about the required action at each action point and how best to carry out that action (i.e., mail, drop-in). You are assessing the person's need for support in carrying out the plan and the level of detail that needs to be in the plan to assist the person to use it effectively, should he decide to complete the needed activities himself or with the help of family or friends. It is a good idea to suggest organization strategies to the individual, such as writing all the action dates on a calendar once an employment date is known, keeping all papers in a central location, and asking for reminder calls at certain points from a friend, if the person tends to forget dates and obligations frequently. Introduction to Other Support Systems Excerpted in part from Wittenburg, D., Fishman, M., Golden, T.P., & Allen, V. (2000). School-to-Work Transitions by Youth with Disabilities: Background and Policy Research Issues. Ithaca, NY: Cornell University, Rehabilitation Research and Training Center on Economic Impact of Employment Policy for Persons with Disabilities. Vocational Rehabilitation VR is a nationwide federal-state program that provides medical, therapeutic, counseling, education, training, work-related placement assistance, and other services, such as programs to enhance services for special populations. VR was established to provide the services and supports that a person might need to overcome a barrier to employment. Specifically, it covers the following services: "The assessment to determine eligibility and needs, including, if appropriate, by 1) someone skilled in rehabilitation technology (i.e., AT); 2) Counseling, guidance and job placement services and, if appropriate, referrals to the services provided by WIA providers; 3) Vocational and other training, including higher education and the purchase of tools, materials and books; 4) Diagnosis and treatment of physical or mental impairments to reduce or eliminate impediments to employment, to the extent financial support is not available from other sources, including health insurance or other comparable benefits; 5) Maintenance for additional costs incurred during rehabilitation; 6) "Transportation, including adequate training in the use of public transportation vehicles and systems, that is provided in connection with the provision of any other service described in this section and needed by the individual to achieve an employment outcome (emphasis added)." Transportation may include vehicle purchase. Under the regulations, transportation is defined as "travel and related expenses that are necessary to enable an applicant or eligible individual to participate in a [VR] service."; 7) Personal assistance services while receiving VR services; 8) Interpreter services for individual's, who are deaf, and readers, rehabilitation teaching and orientation and mobility services for individuals who are blind; 9) Occupational licenses, tools, equipment, initial stocks and supplies; 10) Technical assistance for those who are pursuing telecommuting, self-employment or small business operation; 11) Rehabilitation technology (i.e., AT), including vehicular modification, telecommunications, sensory, and other technological aids and devices; 12) Transition services for students with disabilities to facilitate the achievement of the employment outcome identified in the IPE; 13) Supported employment; 14) Services to the family to assist an individual with a disability to achieve an employment outcome; and 15) Post-employment services necessary to assist an individual to retain regain or advance in employment" (Hagar, 1999, pg. 1). Certain services, however, require that the person satisfy a means test. People enter the VR system in a variety of ways. Some enter the system while they are in school because of their IEP. Others enter because of their participation in other programs (e.g., SSA VR Reimbursement Program). Finally, some enter the program on their own or because of a referral from a stakeholder. VR offices are generally located in close proximity to, or with, other state program offices, such as TANF, and in many states are coordinated with one-stop delivery systems. To be eligible for state VR services, a participant must meet certain criteria. First, they must have a physical or mental impairment that results in a substantial barrier to employment. The disability does not need to be so severe that it qualifies the person for DI or SSI benefits, however. SSI and DI recipients can receive VR services, assuming they intend to achieve an employment outcome. Second, they must be able to benefit from VR services. Finally, they must eventually be able to achieve an employment outcome. State VR agencies can deny benefits if they can show that a person cannot benefit from the services. To make determinations, state VR agencies use existing data, such as medical reports, SSA records, and education records and, to the extent that existing data is insufficient to determine eligibility, an assessment by the VR agency (Hagar, 1999). A VR counselor is assigned to those who become eligible for services. The counselor will develop and coordinate the types of assistance a person with a disability needs for employment, including the development of an Individual Plan for Employment (IPE). The IPE is a written agreement between VR and the client to achieve the individual's employment goal, and must be consistent with his/her interests, unique strengths, priorities, abilities, and capabilities. The state VR counselor provides some services directly to the eligible individual and arranges for, and/or purchases, other services from providers in the community. Before providing certain services, the VR counselor must consider the availability of comparable services and benefits for which the individual is eligible through other sources, such as Medicaid. For non-SSA (SSI and Disability Insurance recipients) VR participants, the payment method for VR services varies by state. Based on the individual's available financial resources, the state VR agency may require an eligible individual to help pay for services. All eligible VR participants who are accepted, however, have access to the following services at no cost: assessments to determine eligibility and VR needs, vocational counseling, guidance, referral services, and job placement services (American Foundation for the Blind, 1999). SSA makes special payment provisions to provide VR assistance to participants. SSA provides funds to reimburse VR agencies for costs incurred in successfully rehabilitating SSI recipients. SSA defines a successful rehabilitation as one in which participation in services results in performance of substantial gainful activity, for a continuous period of at least nine months. The TWWIIA will affect this existing vocational rehabilitation reimbursement program as detailed later in this manual. In addition to the state-federal VR system, private (non-profit and proprietary) rehabilitation services provide services to people with disabilities. The private services are usually reimbursed through private funding sources-typically, insurance carriers or self-insured employers. It is important to note that while youth with disabilities do access the non-profit human service delivery system often as part of their transition planning process, they generally do not encounter the proprietary VR system because the programs target individuals with disabilities originating in adulthood, through an accident or illness covered by some form of insurance (Stapleton, et al, 1999). Mental Retardation/Developmental Disabilities (MR/DD) Individuals with MR or DD generally enter the state MR/DD system at an early age and stay in this system during their post-school transition. According to Assistant Secretary for Planning and Evaluation (1999), Medicaid funds account for nearly three-quarters of the operating costs of these systems. State MR/DD agencies work cooperatively with local governments, voluntary organizations, service providers, and families to provide necessary services for persons with MR/DD. In most states, MR/DD agencies provide several services, including after-school programs; services for the aged; housing and residential options; counseling; day treatment services; developmental programs; family support services; financial assistance; health care; respite care; transportation; waiver programs; research, prevention and intervention programs; and supported and sheltered employment. While Medicaid historically financed long-term institutional care, there have been recent movements to place persons with MR/DD in community settings. For example, Medicaid Home and Community Based Waiver programs have been effective at reducing institutionalization, but pressure from the federal and state governments to reduce Medicaid spending has led to an interest in managed care alternatives.1 1 For example, some individuals in the MR/DD system, who meet Medicaid financial eligibility requirements, might also be eligible for Supported Living Services (SLS). SLS is a Medicaid waiver program, which offers supports in the households of individuals with disabilities and also provides opportunities for adults with disabilities to move into their own homes. Unlike traditional twenty-four hour supervision models, SLS offers an array of supports to choose from to help individuals with disabilities achieve independent living status. DD definitions vary by state, but, in general, youth under age 22 can qualify for services if they have had mental retardation or a related condition (e.g., cerebral palsy, epilepsy, autism or other neurological conditions). Footnote Reference 2 IEPs will likely guide youth with MR/DD to the appropriate state agency for services. In many cases, youth may enter the MR/DD system through early childhood direction agencies or medical practitioner referral. Footnote 2: Another commonly referenced definition for a developmental disability is a severe, ongoing, mental and/or physical disability that was present before twenty-two years of age. It is important to note that some states vary age of onset of disability requirements. For example, Arizona requires onset of disability before age 18. The MR/DD system is guided by a service delivery-planning construct similar to the IEP. The Individual Service Plan (ISP) requires specific services, supports, roles, responsibilities, and timeframes for assisting individuals in meeting their objectives. In most cases, MR/DD practitioners develop ISP with assistance from counselors, case managers, or others with administrative oversight. Regular and intermittent progress reporting and evaluation is required and conducted under specific state law and regulation. Mental Health People with mental health support needs may access a relatively independent, and loosely coordinated public and private service system-collectively referred to as the "de facto mental health service system" (Surgeon General, 1999). The system is comprised of four major components that include: * Specialty mental health sector: consists of mental health professionals such as psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers trained to treat people with mental disorders. Services provided in this sector are performed mostly in outpatient settings such as private office-based practices or in public or private clinics. * General medical/primary care sector: consists of health care professionals such as general internist, pediatricians, and nurse practitioners. The general medical sector is typically associated with being the first point of contact for adults with mental disorders. * Human Services Sector: social services, school-based counseling services, residential rehabilitation services, VR, criminal justice-based services, and religious professional counselors are part of this sector. For children, school mental health services are a major source of care, as are services in the child welfare and juvenile justice systems. * Voluntary Support Network Sector: consists of self-help groups such as 12-step programs and peer counselors. The network has become an established component within the mental and addictive disorder treatment system as adult usage of services has increased since the early 1980s. The Substance Abuse and Mental Health Services Administration (SAMHSA) is the federal agency in charge of the state mental health systems. The Center for Mental Health Services (CMHS), one of the three centers under SAMHSA, awards state grants for providing mental health services to people with mental illnesses. These grants are designed to improve access to community-based health care delivery systems for people with serious mental illnesses who do not have private health insurance (SAMHSA, 2000). CMHS works closely with each state to design a customized service delivery plan that addresses the unique needs of the state's populations. Each state administers its public mental health budget and authorizes services in several broad areas, including: system leadership for state and local county mental health units; systems oversight, evaluation and monitoring; administration of federal funds; and operation of state mental health programs, hospitals and/or institutions. Medical professionals, human service agencies, and/or schools refer people into the mental health system. Individuals with mental impairments gain access to these services by meeting specific state medical criteria.3 Because the largest provider of mental health services to children and adolescents is the school system, most youth with mental illnesses will contact the mental health system before their exit from school. Individuals with mental impairments may enter this system during their schooling years through the Comprehensive Community Mental Health Services for Children program in several states or local collaborative programs administered jointly by schools and county mental health services. Upon leaving school, some youth may continue to use services. 3 In general, these criteria are specified in the Diagnostics Statistical Manual-4R Workforce/Development System People with disabilities who do access the VR, SSI, or TANF systems might still access work and other support services through the state Workforce Development system. The Workforce Investment Act of 1998 (WIA) organized federal statutes governing the job training, adult education and literacy, and VR programs into a one-stop delivery system.4 Under this system, states are required to develop workforce development plans that describe how the state will meet the needs of major customer groups, including individuals with disabilities, and show how the plans will ensure nondiscrimination and equal opportunity. WIA mandates that one-stop systems be readily accessible to all Americans. Some of the partners in this system include employment services, adult education, post-secondary vocational education, VR, Welfare-to-Work, and Community Services Block Grant. All adults are eligible for core services, and youth enrolled in school are eligible for certain services if they meet certain state criteria for employment, income, and/or disability. Each state VR is also required to conduct an assessment of how its state's workforce investment system is meeting the needs of individuals with disabilities. 4 WIA replaced the Job Training Partnership Act (JTPA). Other There are a number of other systems and private organizations that provide school and employment supports to youth during the post-school transition. These programs generally differ in size and scope. In general, these programs provide a wide range of services that support school or employment-related activities. One of the other large support programs is the network of School-to-Work programs, created by the School to Work Opportunities Act of 1994. The Departments of Education and Labor provide grants for these programs to colleges and universities, state and local education agencies, and other public and private non-profit organizations, to develop innovative strategies to assist youth, including those with disabilities. The majority of school-to-work transition services are funded and administered at the state and school district level. In some cases, these programs provide funding to support services to aid in the youth's IEP. There are also several other demonstration projects funded through the Department of Education, Department of Labor, and SSA, which provide employment support. The services provided under these programs can vary significantly across states and target groups. An example of a recent policy change that provides employment supports is the Assistive Technology Act of 1998. Specifically, this act provides grants to continue state assistive technology projects. For a detailed list and summary of these other employment supports, see (Stapleton, et al., 1999). Finally, several non-profit and community-based organizations provide employment, school, and "other" (e.g., psychological) support services. Many of these organizations receive funding from several sources, including charitable donations, public agency grants (e.g., School-to-Work grants) and contracts, foundation grants, and fund-raising activities. In general, these agencies provide a wide range of employment services, from prevocational assessment, to job coaching and post-employment follow-along services (Stapleton, et al, 1999). Some of these organizations, such as The National Multiple Sclerosis Society, provide services to people with specific limitations. Other organizations, such as Goodwill Industries, The Arc, and Easter Seals, provide services to broader populations. History of SSA and Vocational Rehabilitation As discussed earlier, Congress has made provisions for the SSA to provide incentives to working for beneficiaries and recipients with disabilities. In addition to the disability programs and work incentive provisions that the SSA oversees, they also administer a vocational rehabilitation (VR) program for providers of VR services to beneficiaries and recipients enrolled within their disability programs. Prior to 1981, when Congress established the existing program, SSA awarded State VR agencies block grants to work with beneficiaries and recipients. Unfortunately, the State VR agencies did not report use of these funds on a "per case" basis and SSA was unable to document the success of the VR program utilizing the original block grant formula. Inadvertently, this resulted in SSA not knowing if beneficiaries and recipients were in fact going to work and decreasing reliance on monthly cash benefits. To remedy this situation, Congress modified the program to a reimbursement-based, outcome-oriented formula. The VR Reimbursement Program was intended to help beneficiaries and recipients go to work. Under this program, SSA pays State VR agencies and alternate participants for the costs of VR services and supports provided to beneficiaries and recipients that result in the beneficiary becoming employed under specific criteria. Legislative authority for SSA's VR Program and reimbursement of costs for the provision of VR services and supports is outlined in Section 222(d) of the Social Security Act for beneficiaries under the Social Security Disability Insurance Program and Section 1615 of the Social Security Act for recipients of the Supplemental Security Income Program. Initial regulations to implement the VR Reimbursement Program and allow payments to State VR agencies were published in 1983. These regulations were amended on March 15, 1994, to allow SSA to pay alternative participants for the costs of their services under the same criteria governing payments to State VR agencies and to improve the administration and costs effectiveness of the program. State VR agencies (or alternative participants) offering VR services and supports contributing to beneficiaries and recipient’s working for a period of not less than nine months at the Substantial Gainful Activity (SGA) level are reimbursed the costs for those services and supports if they meet the conditions for reimbursement. Keep in mind that for a case to be considered a successful rehabilitation under the VR Reimbursement Program, a beneficiary or recipient must be employed for a continuous period at the SGA level. This is defined as at least nine months within a consecutive 12-month window. This included: nine consecutive months; nine of ten consecutive months regardless of the reason for the one-month break; or, at least nine months within 12 consecutive months, if the break in SGA was due to circumstances beyond the beneficiary's or recipient's control and unrelated to the person's impairment. Prior to the implementation of the Ticket to Work and Work Incentives Improvement act of 1999 (Public Law 106-170), SSA referred beneficiaries and recipients for VR services through either State VR agencies established under the Rehabilitation Act of 1973 or through alternative participants who had signed contracts with SSA to provide VR services to beneficiaries and recipients. The regulations in 1994 expanded the reimbursement program by allowing SSA to refer beneficiaries and recipients to alternative public or non-public VR providers (called alternate participants) for VR services on a case-by-case basis if the State VR agency did not serve a referred individual. Prior to these changes, SSA could only refer beneficiaries and recipients to alternative participants if a State VR agency opted to not participate in the VR Reimbursement Program (all State VR units chose to participate) or if they stopped, or limited, their participation to select groups. While these amendments to the VR program provided SSA with much more flexibility in selecting service providers, it still reserved right of first selection to State VR agencies, making alternative participants a secondary service delivery option. SSA enhanced the availability of VR services and supports to the beneficiaries and recipients through the infrastructure of the VR Reimbursement Program. Savings to the Social Security trust funds and general revenues for SSI are realized by beneficiaries and recipients going back to work and decreasing their reliance on monthly cash benefits. Over the next few years as the SSA rolls out and implements the Ticket to Work program in States selected by the Commissioner of the SSA under Public Law 106-107, the provisions of the Social Security Act for referring beneficiaries to State VR agencies will cease to be in effect in those states. Additionally, the use of alternative participants under the VR reimbursement programs will be phased out in the States as the Ticket to Work program is implemented. Further, sections 222(b) and 1615(c) of the Social Security Act were also repealed in section 101(b) of the Ticket to Work Act under which the Commissioner of the SSA was authorized to impose sanctions (i.e. make deductions from SSDI benefits or suspend SSI benefits) with respect to any beneficiary who refused, without good cause, to accept and participate in VR services made available under the reimbursement program. The Ticket to Work Program was implemented in three phases. The table below outlines the three phases and States and territories that were impacted. Phase I - January 2002 Arizona, Colorado, Delaware, Florida, Illinois, Iowa, Massachusetts, New York, Oklahoma, Oregon, South Carolina, Vermont and Wisconsin Phase II - Calendar Year 2002 Alaska, Arkansas, Connecticut, Georgia, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, North Dakota, South Dakota, Tennessee, Virginia and the District of Columbia Phase III - Calendar Year 2003 Alabama, California, Hawaii, Idaho, Maine, Maryland, Minnesota, Nebraska, North Carolina, Ohio, Pennsylvania, Rhode Island, Texas, Utah, Washington, West Virginia, Wyoming, American Samoa, Guam, North Mariana Islands, Puerto Rico and the Virgin Islands Overview of the Ticket to Work and Self-Sufficiency Program The Ticket to Work and Work Incentives Improvement Act (Public Law 106-170) was signed in to law on December 17, 1999. The purpose of Public Law 106-170 is four fold: - provide health care and employment preparation and placement services to individuals with disabilities that will enable those individuals to reduce their dependence on cash benefit programs; - encourage States to adopt the option of allowing individuals with disabilities to purchase Medicaid coverage that is necessary to enable such individuals to maintain employment; - provide individuals with disabilities the option of maintaining Medicare coverage while working; and, - establish a "Ticket to Work and Self-Sufficiency Program" that allows SSDI and SSI beneficiaries to seek employment services, VR services and other support needed to obtain, retain, or maintain employment and reduce their dependence on cash benefit programs. Public Law 106-170 directed the Commissioner of Social Security to establish a Ticket to Work and Self-Sufficiency program (section 1148), which would expand the universe of service providers available to SSDI and SSI disability beneficiaries and provide them with a ticket they may use to obtain VR services, employment services, and other support services from an employment network of their choice. Under the Ticket to Work program a beneficiary will have the options of deciding when and whether to use his or her Ticket to obtain services from a provider known as an Employment Network (EN), or from the State VR agency. A beneficiary with a Ticket may assign his or her Ticket to the EN of their choosing, or State VR agency, as long as that EN or State VR agency is willing to accept their Ticket. A beneficiary may discuss their employment and rehabilitation plan with as many ENs in their areas as they wish, or the State VR agency, and a list of available providers can be obtained from the Program Manager MAXIMUS, Inc. However, a beneficiary cannot assign their Ticket to more than one EN or the State VR agency at a time. The EN or State VR agency will provide employment services, VR services and other support services to assist the beneficiary in obtaining, regaining and maintaining self-supporting employment as specified in the beneficiary's Individualized Work Plan (IWP), developed with an EN, or Individualized Plan for Employment (IPE), if developed with the State VR agency. At any time a beneficiary can retract their Ticket from an EN or State VR agency and reassign it to another if they continue to meet the Ticket eligibility requirements. Ticket Eligibility To be eligible to receive a Ticket a SSDI and/or SSI beneficiary must meet several criteria: * be 18 through 64 years of age; * if an SSI recipient, be eligible for disability payment under the adult disability standard * be receiving a Federal Social Security and/or SSI cash benefit based on disability; * have a disabling impairment which is not expected to medically improve or a disabling impairment for which medical improvement is possible but cannot be predicted; or * have an impairment that is expected to improve but have undergone at least one Continuing Disability Review (CDR). PLUS not receiving: "301" payments, benefits while appealing a medical cessation; provisional cash benefits while SSA is considering an expedited reinstatement; and, presumptive disability payments. Individuals must also reside in a "Ticket State." The Ticket A Ticket is a document that provides evidence of SSA's agreement to pay an EN or State VR agency to which a beneficiary's Ticket is assigned for providing services and supports to the beneficiary under the Ticket to Work program if certain conditions are met. The Ticket is a red, white and blue document approximately 6" by 9" in size. The left side of the document includes the beneficiary's name, ticket number, claim account number and the date SSA issued the Ticket. The Ticket number is 12 characters and comprises the beneficiary's own social security number, the letters "TW" and a number 1, 2, etc. A number 1 in the last position would signify that this is the first ticket the beneficiary has received. The right side of the Ticket includes the signature of the Commissioner of SSA and the language below: This ticket is issued to you by the Social Security Administration under the Ticket to Work and Self-Sufficiency Program. If you want help in returning to work or going to work for the first time, you may offer this ticket to an Employment Network of your choosing or take it to your State vocational rehabilitation agency for services. If you choose an Employment Network and it agrees to take your ticket, or if you choose your State agency and you qualify for services, these providers can offer you services you may need to go to work. An Employment Network provides the services at no cost to you. The Social Security Administration will pay the Employment Network if you assign your ticket to it, and the Employment Network helps you to go to work and complies with other requirements of the Program. An Employment Network serving under the Program has agreed to abide by the rules and regulations of the Program under the terms of its agreement with the Social Security Administration for providing services under the Program. Your State agency can tell you about its rules for getting services. Assigning and Re-assigning A Ticket and Extension Periods A beneficiary can assign a ticket if the Ticket is valid and if the beneficiary is receiving a cash payment. To assign a Ticket a beneficiary must first find an EN or State VR agency that is willing to take their Ticket. Once both parties have agreed, the beneficiary and a representative of the EN must develop and sign an IWP. If the beneficiary elects to work with his/her State VR agency, the beneficiary and representative of the State VR agency must agree to and sign an Individualized Plan for Employment (IPE) and an additional form. The EN will then submit a copy of the signed IWP/IPE along with appropriate forms to the Program Manager. The effective date of the Ticket assignment will be the first day on which these requirements for ticket eligibility are met and the IWP or IPE has been signed. A beneficiary may take a Ticket out of assignment for any reason. The beneficiary must notify the Program Manager in writing. The Ticket will no longer be assigned to that EN or State VR agency effective with the first day of the month following the month in which the beneficiary notifies the Program Manger. If an EN goes out of business or is no longer approved to participate as an EN in the Ticket to Work program, the Program Manager will take the beneficiary's Ticket out of assignment. In addition, if the beneficiary's EN is no longer able to provide services, or if the State VR agency stops providing services because the beneficiary is determined to be ineligible for services, the EN or State VR agency may ask the Program Manger to take the beneficiary's Ticket out of assignment. In both of these latter situations, a notice will be sent to the beneficiary informing them of this decision. A beneficiary may re-assign their Ticket as they deem appropriate and as long as they continue to meet eligibility for participation in the Ticket to Work program. To re-assign a Ticket all of the following requirements must be met: a. A beneficiary may reassign his/her ticket if he/she meets the criteria for assigning a ticket described above. b. If the beneficiary does not meet the criteria, he/she may reassign his/her ticket only if he/she: * Continues to meet the ticket eligibility requirements, * Has an unassigned ticket, * Has an EN/State VR agency who is willing to work with him/her and sign a new IWP/IPE. * If the ticket is not in use, the IWP/IPE must be completed and signed within 30 days of unassignment. If the ticket is in use, the employment plan must be completed and signed before the end of the extension period. The reassignment is effective on the first day these requirements are met. If the beneficiary reassigns the ticket to the same EN/State VR Agency that he/she was previously working with, SSA resumes counting the months in the initial 24-month period or the 12-month progress review period. If the beneficiary reassigns the ticket to a new EN/State VR Agency, the 24-month period starts over. However, if the reassignment occurs in a 12-month progress review period, SSA resumes counting the months rather than starting over. Extension Period As stated above, the beneficiary or EN/State VR Agency may unassign the ticket. The "extension period" is the 3-month time frame after unassignment that the beneficiary who is using a ticket has to select an EN/State VR Agency. If the beneficiary does not reassign the ticket during the extension period, it is considered not in use at the end of the extension period. The extension period does not count in determining whether the beneficiary is making timely progress toward his/her work goals. Inactive Status During the initial 24-month period after ticket assignment, the beneficiary can make a written request to the PM to place his/her ticket in inactive status due to possible relapses in health condition or emergency situations. Months in inactive status do not count in deciding whether the beneficiary is making timely progress toward his/her work goals, as discussed later. The ticket is not in use when inactive. The beneficiary can make another written request to the PM to reinstate ticket use. While the ticket is in inactive status, SSA may initiate a medical CDR. Medical Continuing Disability Review (CDR) Protection and Use of a Ticket A medical CDR is the review conducted by SSA to determine whether or not a beneficiary continues to meet SSA's disability standard. SSA will not conduct a medical CDR when the beneficiary is using the ticket. However this protection does not apply to work reviews that SSA may conduct to determine whether or not a beneficiary is engaging in substantial gainful work. "Using A Ticket" To be considered "using a ticket" a beneficiary must assign his/her Ticket to an EN. SSA defines "using a ticket" as a specified period of time during which the beneficiary is actively following his/her approved plan to become self-supporting. The EN monitors the beneficiary's progress with the plan, but the PM actually decides if the beneficiary is "using" the ticket. SSA cannot initiate a medical CDR while the beneficiary is using the Ticket. If a Ticket has been assigned after a medical CDR has been initiated, SSA will complete that CDR. If, during that CDR, SSA decides that the beneficiary has medically recovered, usually benefits will be terminated. However, in some circumstances, SSA may continue benefits if the ticket assignment was made prior to the medical CDR decision. Active Participation The initial 24-month period begins the month following the month in which a beneficiary's Ticket is considered to be assigned. During the initial 24-month period a beneficiary must be actively participating in his/her employment plan. This means that the beneficiary is engaging in activities outlined in the employment plan on a regular basis and within the approximate timeframes. During the initial 24-month period, SSA does not count any month in which the Ticket is in an extended period or in inactive status in deciding whether the beneficiary is making timely progress toward self supporting employment. The EN will notify the PM if the beneficiary is not following the plan. Also, the PM will conduct a progress review at specified intervals. If the beneficiary fails to successfully complete the review, he/she has the choice of either having SSA review the PM's decision or re-entering in use status. Even if it has been determined by the program manager that a beneficiary is not making timely progress toward self-supporting employment he/she may continue to participate in the Ticket to Work Program. However, he/she will no longer be provided medical CDR protection. Once the beneficiary successfully completes the initial 24-month period progress review, he/she will then be required to perform work activity for a prescribed amount of time within the next 12-month period and have earnings at a specified level. The chart below shows the guidelines that the PM uses when conducting a progress review. NOTE: The non-blind SGA amount is the annual SGA amount for disability beneficiaries who are not blind. The gross non-blind SGA amount represents the SGA earnings amount before any work incentive exclusions are applies. Review Period - Initial 24-months Participation Criteria - Beneficiary following signed employment plan Review Period - First 12-months (25 - 36 ticket months) Work at least 3 months at gross non-blind SGA level with ticket in use (may include work months in initial 24-month period) Review Period - Second 12-months (37 - 48 ticket months) Work at least 6 months at gross non-blind SGA level with ticket in use Review Period - Third and subsequent 12-months (49 and + ticket months) Worked 6 of 12 months and SSDI and/or Federal SSI benefits not payable because earnings or NESE too high (after work incentives applied) Progress Reviews As stated above, progress reviews will be conducted at 24-months and subsequently every 12 months following the initial 24-month progress review. These reviews will be conducted by the Program Manager, Maximus. 24-Month Progress Review At the completion of the first 24 months during which a beneficiary used their Ticket, the Program Manager will conduct a Progress Review. During this review the Program Manager will answer three questions as per the final Ticket regulations: 1. Is the beneficiary actively participating in their employment plan? Simply, is the Beneficiary engaging in activities outlined in their employment plan on a regular basis and in the approximate time frames specified in the plan. These activities may include employment, if agreed to in the employment plan. 2. Does the beneficiary's employment plan have a goal of at least three months of work by the time of the beneficiary's first 12-month progress review? 3. Given the beneficiary's current progress in their employment plan, can the individual be expected to reach this goal of at least three months of work at the time of their first 12-month progress review? It is important to note that if a beneficiary engages in one or more months of employment during their initial 24-month period, these months can count toward the three months of employment required as part of the criteria for the first 12-month progress review that follows the 24-month progress review. If during the 24-month progress review the program manager is able to answer yes to all three questions than then beneficiary will be found to be making timely progress toward self-supporting employment until the first 12-month progress review. If the answer to any of these questions is no that the program manager will find that the beneficiary is not making timely progress and send a written notice of the decision to the beneficiary at their last known address. The notice will explain the program managers reasoning and inform the beneficiary of the right to ask for a review of the decision. The decision will be effective 30 days after the date on which the program manager sends the notice of the decision to the beneficiary unless a request for review is made. 12-Month Progress Reviews The 12-Month Progress Review is a two-step process that involves a retrospective review and anticipated work level. During step one the program manager will check to see if the beneficiary completed the work requirements in the just completed 12-month progress review period. If they have completed the work requirements the program manager will go to step two. If not, the program manager will make a determination that the beneficiary is not making timely progress toward self-supporting employment. During the first 12-Month Progress Review the beneficiary must work for at least three of the 12 months at the SGA level for non-blind beneficiaries prior to income exclusions. These three months do not need to be consecutive. During the second 12-Month Progress Review period, and in later 12-Month Progress Review periods, the beneficiary must work at least six of 12 months at the SGA level for non-blind beneficiaries prior to income exclusions. For subsequent 12-Month Progress Review periods the beneficiary must work for six of 12 months with earnings substantial enough to eliminate SSI and SSDI cash payment for those six months worked. Appealing Timely Progress Review Decisions If a beneficiary disagrees with a decision made at the conclusion of a Timely Progress Review, that beneficiary can request a review of the decision made before the 30th day after the date on which the Program Manager sends the notice of decision. SSA will consider the beneficiary to be making timely progress until they make a decision. SSA will send a written notice of their final decision to the beneficiary at their last known address. If they decide that the beneficiary is no longer making timely progress, their decision will be effective on the date on which they send the notice of decision to the beneficiary. When "Using A Ticket" Ends The period of using a Ticket ends with the earliest of the following: - The 60th month for which an outcome payment is made to an EN/State VR agency; - For State VR agencies that chose the cost reimbursement method, the 60th month for which an outcome payment would have ended; - The beneficiary is no longer meeting timely progress requirements; - The beneficiary fails to reassign the ticket my the end of the 3-month extension period; or - Entitlement to Social Security disability benefits or eligibility for Supplemental Security Income cash benefits based on disability ends. Ticket Termination A beneficiary's Ticket will terminate if and when they are no longer eligible to participate in the Ticket to Work program. If a Ticket is terminated a beneficiary will no longer be able to assign it and an EN or State VR agency will not receive milestone or outcome payments achieved in or after the month in which the Ticket was terminated. A beneficiary's eligibility to participate in the Ticket to Work program will end, and Ticket will terminate, in the earliest of the following months: 1. The month in which entitlement to SSDI benefits based on disability ends for reasons other than work activity or earnings, or the months in which eligibility for SSI benefits based on disability or blindness terminates for reasons other than work activity or earnings, whichever is later; 2. If the beneficiary is entitled to widow's or widower's insurance benefits based on disability, the month in which the beneficiary turns age 65; or, 3. If the beneficiary is eligible for SSI benefits based on disability or blindness, the month following the month in which they turn age 65. Program Manager On September 29, 2001 SSA competitively awarded a 5-year contract to MAXIMUS, Inc. of McLean, Virginia to provide program manager services to assist SSA in the administration of the Ticket to Work and Self Sufficiency Program. The responsibilities of the contractor include: - Recruiting, recommending, and monitoring of ENs - facilitating access by beneficiaries to ENs - facilitating payments to ENs - performing administrative duties such as reviewing IWPs; reviewing amendments to IWPs; ensuring that ENs only refer to a State VR agency for services pursuant to an agreement regarding the conditions under which such services will be provided; and resolving disputes between ENs and State VR agencies with respect to agreements; resolving disputes between a beneficiary and an EN which cannot be resolved by the EN's internal grievance procedures; and referring disputes between beneficiaries and ENs to SSA for a final decision if this is requested by either of the parties. SSA will periodically evaluate the Program Manager. This evaluation will include, but not be limited to, an assessment examining the following areas: * Quality of services; * Cost control; * Timeliness of performance; * Business relations; and * Customer satisfaction. MAXIMUS, Inc. can be reached at: Ticket to Work Program Toll-free line: 1-866-968-7842 Toll-free TDD line for Hearing and Speech Impaired: 1-866-833-2967 Employment Network(s) (ENs) EN Qualifications An EN is any qualified entity that has entered into an agreement with the SSA to function as an EN under the Ticket to Work Program. To serve as an EN an entity must meet and maintain compliance with both general and specific selection criteria. General criteria include: having systems in place to protect the confidentiality of personal information about beneficiaries seeking or receiving services; being both physically and programmatically accessible; not discriminating in the provision of services based on a beneficiary's age, gender, race, color, creed, or national origin; having adequate resources to perform the activities required under the agreement with SSA or the ability to obtain them; and, implementing accounting procedures and control operations necessary to carry out the Ticket to Work Program. The specific criteria that an entity must meet to qualify as an EN include: using staff who are qualified under applicable certification, licensing or registration standards that apply to their profession including certification or accreditation by national accrediting or certifying organizations; using staff that are otherwise qualified based on education or experience, such as by using staff with experience or a college degree in a field related to the services the EN wants to provide such as vocational counseling, human relations, teaching, or psychology; and taking reasonable steps to assure that if any medical and related health services are provided, such medical and health-related services are provided under the formal supervision of persons licensed to prescribe or supervise the provision of these services in the State in which the services are performed. Any entity must have applicable certificates, licenses, or other credentials if such documentation is required by State law to provide VR services, employment services or other support services. EN Responsibilities The EN assumes responsibility for the coordination and delivery of employment services, vocational rehabilitation services or other support services to beneficiaries who have assigned their Ticket to that EN. An EN may consist of a one-stop delivery system established under the Work Investment Act of 1998 or either a single provider of such services or a group of providers organized to combine their resources into a single entity. An EN provides services either directly or by entering into agreements with other providers, which can furnish appropriate services and serves prescribed service areas and takes measures to ensure that services provided under the Program meet the requirements of individual work plans. An EN must develop and implement individual work plans in partnership with each beneficiary they have agreed to provide services to in a manner that affords the beneficiary the opportunity to exercise informed choice in selecting an employment goal and specific services needed to achieve that employment goal. Each IWP must meet the requirements detailed in the section below. Finally, the EN must report to the Program Manager each time it accepts a Ticket for assignment; submit a copy of each signed IWP to the Program Manager; submit to the Program Manager copies of amendments to a beneficiary's IWP; submit to the Program Manager a copy of any agreement the EN has established with a State VR agency; submit information to assist the Program Manager conducting the reviews necessary to assess a beneficiary's timely progress; report to the Program Manager the specific outcomes achieved with respect to specific services the EN provided or secured on behalf of the beneficiary; provide a copy of its most recent annual report on outcomes to each beneficiary considering assigning a ticket to it; meet all financial reporting requirements; collect and record such data as SSA requires; and, adhere to all requirements specified in the agreement with SSA. SSA will periodically evaluate an EN's performance to ensure effective quality assurance in the provision of services by ENs. SSA will solicit and consider the views of the individuals the EN serves and the Program Manager monitoring the EN. ENs must make the results of these periodic reviews available to beneficiaries to assist them in choosing among available ENs. State Vocational Rehabilitation Agencies Every State agency administering or supervising the administration of the State plan approved under Title I of the Rehabilitation Act of 1973, as amended, must participate in the Ticket to Work program if it wishes to receive payments from SSA for serving beneficiaries who are issued a Ticket. The Ticket to Work program does provide different payment options that are available to a State vocational rehabilitation agency for provided services. A State vocational rehabilitation agency participates in the program in one of two ways when providing services to a particular beneficiary under the program. On a case-by-case basis the State agency may participate either as an EN or under the cost reimbursement payment system. When the State agency serves a beneficiary with a Ticket as an EN, the agency will use the EN payment system it has elected for this purpose, either the outcome or outcome-milestone payment system. The State vocational rehabilitation agency will have periodic opportunities to change the payment system it uses when serving as an EN. When serving a beneficiary who does not have a Ticket, the State vocational rehabilitation agency may seek payment only under the cost reimbursement payment system. A State vocational rehabilitation agency can choose to function as an EN or to receive payment under the cost reimbursement payment system each time that a Ticket is assigned or reassigned to it if payment has not previously been made with respect to that Ticket. If payment has previously been made with respect to that Ticket, the State agency can receive payment only under the payment system under which the earlier payment was made. An EN may refer a beneficiary it is serving to a State vocational rehabilitation agency for services if the State vocational rehabilitation agency and EN have an agreement that specified the conditions under which services will be provided by the State agency. This agreement must be in writing and signed by both parties prior to the EN referring any beneficiary to the State agency for services. The Individualized Work Plan An IWP is a required written document signed by an EN and a beneficiary, or a representative of a beneficiary, with a Ticket. It is developed and implemented in partnership when a beneficiary and EN have come to a mutual understanding to work together to pursue the beneficiary's employment goal. The purpose of the IWP is to outline the specific employment services, vocational services and other support services that the EN and beneficiary have determined are necessary to achieve the beneficiary's stated employment goal. The beneficiary and EN share the responsibility for determining the employment goal and the specific services needed to achieve that goal. At a minimum the IWP must include: - a statement of the vocational goal including, as appropriate, goals for earnings and job advancement; - a statement of the services and supports necessary for the beneficiary to accomplish that goal; - a statement of any terms and conditions related to the provision of these services and supports; - a statement that the EN may not request or receive any compensation for the costs of services and supports from the beneficiary; - a statement of the conditions under which an EN may amend the IWP or terminate the relationship; - a statement of the beneficiary's rights under the Program, including the right to retrieve a Ticket at any time if the beneficiary is dissatisfied with the services being provided by the EN; - a statement of the remedies available to the beneficiary, including information on the availability of advocacy services and assistance in resolving disputes through the State P&A System; - a statement of the beneficiary's right to privacy and confidentiality regarding personal information, including information about the beneficiary's disability; - a statement of the beneficiary's right to seek to amend the IWP; and, - a statement of the beneficiary's right to have a copy of the IWP made available to the beneficiary, including in an accessible format chosen by the beneficiary. The EN is responsible for ensuring that each IWP contains this information. Employment Network Payment Systems The underlying premise of the Ticket to Work program is to pay ENs based on the satisfactory employment (or self-employment) outcomes of the SSDI or SSI beneficiary. With the exception of four milestone payments available under the Outcome-Milestone Payment System, and the separate option for State VR Agencies to be paid under the longstanding cost reimbursement payment system, all payments to an EN occur based on work activity that results in the beneficiary's loss of SSDI benefits and disability-based Federal cash SSI benefits. Election of an EN Payment System ENs may elect to be paid under one of two EN payment systems - the Outcome Payment System or the Outcome-Milestone Payment System. Payments under the new EN payment systems differ depending on the option chosen and the types of benefits received by the beneficiary. The pace of payments to an EN will also depend on how quickly the beneficiary achieves the required work outcomes. An EN elects one of the two payment systems when it enters into an agreement with SSA to serve as an EN. After first electing a payment system, the EN can then make one change in its chosen payment system at any time during the first 12 months after the month it becomes an EN, or within 12 months after the month the Ticket program starts in its state, whichever occurs later. Additionally, at least every 18 months SSA will offer each EN the opportunity to change its elected payment system. Payments Under the Two EN Payment Systems Each calendar year SSA bases the payments for both EN payment systems, described below, on something called the Payment Calculation Base. One of two Payment Calculation Bases is used, depending on whether the individual served is an SSDI or SSI beneficiary. For SSDI beneficiaries (including concurrent SSDI/SSI beneficiaries), the Payment Calculation Base will be the average monthly disability insurance benefit payable for the months during the preceding calendar year to all disabled worker beneficiaries who are in current pay status for the month in which the benefit is payable. For SSI beneficiaries (who are not concurrently SSDI beneficiaries), the Payment Calculation Base will be the average monthly Federal SSI payment based on disability payable for the months during the preceding calendar year to all beneficiaries who: i) are have attained age 18 but not age 65; ii) are not concurrent SSDI/SSI beneficiaries; and iii) are in current pay status for the month in which the payment is made. Under the Outcome Payment System, SSA can pay the EN for up to 60 outcome payment months that a beneficiary attains during his/her outcome payment period. A beneficiary attains an outcome payment month when no SSDI or disability-based Federal cash SSI payments are payable because of work or earnings. An EN can be paid for an outcome month only if it is attained after a beneficiary has assigned his or her ticket to the EN and before the individual's ticket terminates. An outcome payment under this payment system will be equal to 40 percent of the Payment Calculation Base for the calendar year in which the outcome payment month occurs, rounded to the nearest whole dollar. Under the Outcome Milestone Payment System, SSA can pay the EN for up to four milestones achieved by beneficiary after the ticket is first assigned and the beneficiary begins to work. In addition, SSA can pay the EN for up to 60 outcome payment months that the beneficiary attains for each month that no SSDI or disability-based Federal cash SSI payments are payable because of work or earnings. The Four Milestones are based on the earnings levels that SSA uses when it considers whether a beneficiary's work activity is SGA. The requirements for meeting the four milestones are as follows: * The first milestone is met when the beneficiary has worked for one calendar month and has gross earnings from employment (or net earnings from self employment) for that month that are more than the SGA threshold amount. * The second milestone is met when the beneficiary has worked for three calendar months within a 12-month period and has gross earnings from employment (or net earnings from self employment) for each of the three months that are more than the SGA threshold amount. The month used to meet the first milestone can be included in the three months used to meet the second milestone. * The third milestone is met when the beneficiary has worked for seven calendar months within a 12-month period and has gross earnings from employment (or net earnings from self employment) for each of the seven months that are more than the SGA threshold amount. Any months used to meet the first two milestones can be included in the seven months used to meet the third milestone. * The fourth milestone is met when the beneficiary has worked for 12 calendar months within a 15-month period and has gross earnings from employment (or net earnings from self employment) for each of the 12 months that are more than the SGA threshold. Any months used to meet the first three milestones can be included in the 12 months used to meet the fourth milestone. An EN can be paid for a milestone only if the milestone is attained: * after a beneficiary has assigned his or her ticket to the EN, * before the individual attains the first outcome payment month, and * before the individual's ticket terminates. The payment amounts for the four milestones are each tied to a percentage of the Payment Calculation Base for the calendar year in which the month of attainment of the milestone occurs, rounded to the nearest dollar. Each of the 60 Outcome Payments under the Outcome-Milestone Payment System is equal to 34 percent of the Payment Calculation Base for the calendar year in which the outcome payment month occurs, rounded to the nearest whole dollar. If the EN received one or more milestone payments with respect to an individual, each outcome payment made to the EN with respect to the same individual will be reduced by an amount equal to 1/60th of the milestone payments made. For example, if an EN received a total of $900 in milestone payments, each of the 60 outcome payments would be reduced by $15. Keep in mind that an EN may not receive all four milestones under the outcome-milestone payment system. Once a beneficiary's earnings meet the criteria for receiving an outcome payment, the EN will begin receiving outcome payments and no further milestone payments will be made. In such a case, the EN does not actually "lose" the milestone amounts. They are part of the outcome payment base and will be paid out over the 60-month outcome payment period. Rates for Calendar Years 2002 - 2005 During calendar years 2002 through 2005, the following payment calculation bases (PCB) apply: SSDI PCB: $791.68 (2002) $819.19 (2003) $840.61 (2004) $868.20 (2005) SSI PCB: $476.80 (2002) 491.05 (2003) $498.34 (2004) $510.23 (2005) The following chart summarizes the payment rates under the two EN payment systems for calendar year 2004, based on the type of benefit received. It also provides the percentage of the PCB each payment rate equals. Payment System Type of Payment Payment Rate (% of PCB) SSDI Rate (SSDI and Concurrent) SSI Rate (SSI Only) Payment System: Outcome Payment System Type of Payment: Outcome Payment Payment Rate (% of PCB): 40% SSDI Rate (SSDI and Concurrent): $347.00 SSI Rate (SSI Only): $204.00 Payment System: Outcome-Milestone Payment System Type of Payment: Milestone #1 Payment Rate (% of PCB): 40% SSDI Rate (SSDI and Concurrent): $295.00 SSI Rate (SSI Only): $173.00 Type of Payment: Milestone #2 Payment Rate (% of PCB): 68% SSDI Rate (SSDI and Concurrent): $590.00 SSI Rate (SSI Only): $347.00 Type of Payment: Milestone #3 Payment Rate (% of PCB): 136% SSDI Rate (SSDI and Concurrent): $1,181.00 SSI Rate (SSI Only): $694.00 Type of Payment: Milestone #4 Payment Rate (% of PCB): 170% SSDI Rate (SSDI and Concurrent): $1,476.00 SSI Rate (SSI Only): $867.00 Type of Payment: Outcome-Milestone Payment Footnote Reference 5 Payment Rate (% of PCB): 34% SSDI Rate (SSDI and Concurrent): $295.00 SSI Rate (SSI Only): $173.00 Footnote 5: Under the outcome-milestone payment system, each outcome payment will be reduced by an amount equal to 1/60th of the milestone payments received by an EN with respect to an individual. Payments to State VR Agencies A State VR Agency participates in the Ticket program in one of two ways: as an EN, or under the longstanding cost reimbursement payment system that is spelled out in the SSDI and SSI regulations. The State VR Agency, on a beneficiary-by-beneficiary basis, may choose whether it will serve a beneficiary as an EN or under the cost reimbursement program. The choice of payment systems is generally made when the State VR Agency first notifies the Program Manager of its decision to serve the beneficiary. If the beneficiary was already a consumer of the State VR Agency prior to receiving a ticket, the agency notifies the PM of its payment system election at the time the beneficiary decides to assign the ticket to the State VR Agency. For those beneficiaries it serves under the EN payment system, the State VR Agency has the same option as other ENs to elect either the Outcome Payment System or the Outcome-Milestone Payment System. When the VR agency elects to serve an individual beneficiary as an EN, it will be bound by the EN payment system it elected. Like other ENs, the State VR Agency will periodically have opportunities to change the payment system it uses when serving as an EN. The cost reimbursement option for payment is described earlier in this chapter. When it is used, the State VR Agency is paid by SSA for all of its qualified rehabilitation expenses with respect to a particular beneficiary. The total payment to the agency under this traditional reimbursement system may, on a case-by-case basis, be more or less than what it would receive for the same beneficiary using one of the EN payment systems. Limitations on Payments to ENs SSA will pay an EN only for milestones or outcomes achieved after the beneficiary's ticket was assigned to the EN and before the ticket terminates. In no event, can the EN charge the beneficiary for any services provided by the EN. Beneficiaries may meet some, but not all of the goals needed to for 60 outcome payment months. Can the EN keep the milestone and outcome payments in such a case? The answer is yes, provided SSA does not subsequently determine that one or more of the payments was made in error. Each milestone or outcome payment to an EN will be paid based on whether the criteria for that payment is met. So, for example, an SSDI only beneficiary who exhausts his or her trial work period, works for 27 months at the SGA level immediately following the trial work period, and then has to quit working, will not achieve all 60 outcome months. In the example, the person would have probably achieved 24 outcome months following the nine-month trial work period and a three-month grace period with continued benefits. In that case, even though the beneficiary can return to SSDI payment status since he/she stopped performing SGA and is within the 36-month extended period of eligibility, the EN can keep the 24 outcome payments due as the result of the 24 months in which the beneficiary was not eligible for an SSDI payment. There will be some cases in which two or more ENs qualify for payment on the same ticket. This may occur because the beneficiary assigned the ticket to more than one EN at different times and now more than one EN is claiming that their services contributed to the achievement of a milestone or outcome. When that happens, payment will still be limited based on the payment formulas discussed above (i.e., the total payments are not increased because more than one EN is involved) and the milestone or outcome payments will have to be split up. The Program Manager must make an "allocation" recommendation with regard to what percentage of a particular payment will go to each EN. If the beneficiary is served by two ENs that have each selected a different payment option, the Program Manager must recommend a payment allocation and each EN's payment will be based on the payment option in effect for each EN when the ticket was assigned to each. This splitting of payments could involve an EN and a State VR agency that serves the beneficiary as an EN. In that case the allocation of payments would be made as described above. However, if the State VR Agency is paid by SSA under the cost reimbursement system with respect to a ticket, such a payment precludes any later payment to an EN, or State VR Agency serving the beneficiary as an EN, under either the Outcome Payment or Outcome-Milestone Payment Systems. Similarly, if either an EN, or a State VR Agency, is paid under one of the EN payment systems, that payment would preclude any subsequent payment to a State VR Agency under the cost reimbursement system, with respect to a ticket. What if SSA receives a request for payment, with respect to the same ticket, from an EN or State VR Agency that elected payment under an EN payment system, and also receives a request for payment from a State VR Agency that elected payment under the cost reimbursement system? The final regulations provide that: SSA will pay the provider that first meets the requirements for payment under its elected payment system; or, if both providers first meet those requirements in the same month, SSA will pay the claim of the provider to which the beneficiary's ticket is currently assigned. If the ticket is not currently assigned to either, SSA will pay the claim of the provider to which the ticket was most recently assigned. Dispute Resolution The Ticket program offers a dispute resolution system for three types of disputes: those between beneficiaries and State VR Agencies acting as ENs; those between beneficiaries and ENs that are not State VR Agencies; and those between ENs that are not State VR Agencies and Program Managers. Disputes Between Beneficiaries and State VR Agencies When a State VR Agency serves a beneficiary, the agency is required to comply with all of the provisions under Title I of the Rehabilitation Act of 1973 (29 U.S.C. 720 et seq) and its implementing regulations found in 34 C.F.R. Part 361. One of those requirements is the opportunity to resolve disputes through formal mediation services or an impartial hearing process. Any individual who is seeking or receiving VR Agency services, who is dissatisfied with a determination made by personnel of the agency, has the right to a timely review of that determination. Each State VR Agency must develop and implement procedures to ensure that an individual may request a timely review, which must include the right to mediation and an administrative hearing before an impartial hearing officer. The VR Agency must notify individuals, in writing, of their right to mediation, an impartial hearing, and the availability of the Client Assistance Program (CAP) to assist them with disputes. This notice must be provided at the following times: at the time of the individual applies for VR services; at the time the individual is assigned to a category in the State's order of selection, if the State VR agency has established an order of selection under section 361.36; at the time the Individual Plan for Employment (IPE) is developed; and upon the reduction, suspension, or cessation of VR services. At an impartial hearing, the individual has the right to be represented by an attorney or other advocate. Both the individual and the agency can present evidence and cross examine witnesses. The hearing decision is final and must be implemented, unless appealed. The 1998 amendments to the Rehabilitation Act provide that a State VR Agency may establish a procedure for a second level of administrative review. The review officer must be the chief official of the designated State VR Agency or an official from the office of the Governor. If the state does establish a second level of administrative review, either party may appeal within 20 days of the hearing officer's decision. The review officer cannot overturn a hearing decision unless, based on clear and convincing evidence, the decision is "clearly erroneous" based on an approved State VR Plan, Federal law, Federal Vocational Rehabilitation regulations, or State regulations or policies that are consistent with Federal regulations. The 1998 amendments also add the right for either party (i.e., the consumer or the VR agency) to appeal a final administrative decision to federal court (or to state court if your state provides for court review of administrative decisions). The administrative hearing required to be offered by State VR Agencies is very similar to the hearing available to SSI and SSDI beneficiaries who are dissatisfied with decisions by SSA affecting their benefits. Unlike the very informal dispute resolution procedures governing ENs that are not State VR Agencies, described below, the VR Agency hearing provides an extensive opportunity to present live testimony and cross examine adverse witnesses. The hearing officer is then required to render a written decision, which must determine if the services in dispute are mandated under the very intricate provisions of Title I and its implementing regulations. Disputes Between Beneficiaries and ENs For disputes between beneficiaries and ENs that are not State VR Agencies, the Ticket program offers a three-step dispute resolution process: 1. The beneficiary can file a complaint through the EN's internal grievance procedures. 2. If the EN's internal grievance procedures do not result in an agreeable resolution, either the beneficiary or the EN may seek a resolution from the PM. 3. If either the beneficiary or the EN is dissatisfied with the resolution proposed by the PM, either party may request a decision by SSA. All ENs that are not State VR Agencies must establish written grievance procedures that a beneficiary can use to seek a resolution to a dispute under the Ticket program. The EN must give each beneficiary seeking services a copy of its internal grievance procedures and inform him or her of the right to refer a dispute first to the PM for review, and then to SSA for a decision. The EN is also required to inform each beneficiary of the availability of assistance from the State Protection and Advocacy system. At a minimum, the EN is required to inform each beneficiary seeking services under the Ticket program of the procedures for resolving disputes when: * the EN and the beneficiary complete and sign the IWP; * services in the beneficiary's IWP are reduced, suspended or terminated; and * a dispute arises related to the services spelled out in the beneficiary's IWP or to the beneficiary's participation in the program. When the EN's grievance procedures do not result in a satisfactory resolution, either the beneficiary or the EN may ask the PM to review a disputed issue. The final regulations do not spell out any time limit for requesting this review, but do require the PM to contact the EN to submit all relevant information within 10 working days. The information to be submitted should include: * a description of the disputed issue(s); * a summary of the beneficiary's position, prepared by the beneficiary or a representative of the beneficiary, related to each disputed issue; * a summary of the EN's position related to each disputed issue; and * a description of any solutions proposed by the EN when the beneficiary sought resolution through the EN's grievance procedures, including the reasons the beneficiary rejected each proposed solution. The PM has 20 working days to develop a "written recommendation," that should explain the reasoning for the "proposed resolution." Upon receiving the PM's recommendation, either the beneficiary or the EN may request, in writing, a review by SSA. That request for review must be received by the PM within 15 working days of the receipt of the PM's recommendation. The PM has 10 more working days to refer this request to SSA. The request for SSA review must include: a copy of the beneficiary's IWP; information and evidence related to the disputed issue(s); and the PM's conclusion(s) and recommendation(s). SSA's decision in response to this request is final. No further appeal within SSA is available and the regulations do not provide for any court appeal. Representation of Beneficiaries in Ticket Disputes If a beneficiary is using either the appeals system for resolving disputes with State VR Agencies, pursuant to Title I of the Rehabilitation Act, or using the more informal procedures for resolving disputes with ENs, pursuant to the final Ticket regulations, the beneficiary can be represented by an attorney, advocate, or any other person. The two advocacy programs, available in every state and territory to assist beneficiaries with these disputes, are the Client Assistance Program (CAP) and the Protection and Advocacy for Beneficiaries of Social Security (PABSS) program. The CAP was created in the mid 1980s, largely to assist individuals with disabilities in connection with State VR Agency disputes, and may also be available to assist with EN disputes. The PABSS was created as part of TTWWIA and is available to assist beneficiaries with EN disputes, including disputes with State VR Agencies serving as ENs. Some state Protection and Advocacy agencies will provide services under both the CAP and PABSS programs. Dispute Between ENs and Program Managers For disputes between ENs that are not State VR Agencies and the PM, that do not involve an EN's payment request, there is a two-step dispute resolution process: 1. The EN can seek a resolution through the PM's internal grievance procedures; and 2. If the PM's internal grievance procedures do not result in a mutually agreeable solution, the PM must refer the dispute to SSA for a decision. Whenever there is no mutually agreeable solution to the EN's dispute, the PM has 20 working days to refer the dispute to SSA with all the relevant information. The information should include: * A description of the disputed issue(s); * A summary of the EN's and the PM's position related to each disputed issue; and * A description of any solutions proposed by the EN and PM when the EN sought resolution through the PM's grievance procedures, including the reasons each party rejected each proposed solution. SSA's decision in response to this dispute is final. No further appeal within SSA is available and the regulations do not provide for any court appeal. Questions and Answers on the Ticket to Work For more information on frequently asked questions pertaining to the Ticket to Work and Work Incentives Improvement Act of 1999, visit SSA's Office of Employment Support Program's web site at: http://www.ssa.gov/work Link to "Legislation" for up-to-date information on legislation and regulations pertaining to the employment supports of individuals with disabilities. Additional information is available on MAXIMUS' website at: http://www.yourtickettowork.com. Integrating Benefits Planning and Assistance Supports Into Existing Service Delivery Constructs If the individual has another strategic plan in operation, related to his or her life and employment possibilities, it is often best to support the person integrating the action points associated with benefits management into that plan, rather than to create a separate plan (one person, one plan!). Many times, the person may already be enrolled with the state office of Vocational Rehabilitation and may have an IPE either written or in process. By writing down the actions needed to ensure smooth transitions in benefits, the customer can take this to his or her counselor and ask to have it included, as well as ask for assistance in securing the supports needed to carry through, if needed. Other individuals will have a transition plan associated with their school program, if they have not graduated, and this is another place to think about integrating these strategies. Many people with developmental disabilities or mental illnesses have case specialists (or service coordinators) who maintain a plan of support with the person. This is an ideal place to encourage the person to integrate the benefits management steps. Keep in mind that there are many situations where the person may not have a plan because they are not connected to other support agencies, and may not want to be. In other cases, integrating the action points into another plan may not be good assurance that they will be attended to, as there are some support agencies and personnel that are more thorough than others, and there is certainly a widespread lack of information and skill related to benefits management among the above-mentioned providers of supports. Therefore, the benefits specialist must be sensitive to this, relying on past experiences and the input of the customer to assist them in deciding whether including the action steps into one of the plans will provide enough support to them to ensure a smooth transition with benefits as they begin to pursue an employment goal. The Individual Education Plan and Transition Planning Transition and Work Incentives Planning. (1999). Ithaca, NY: Program on Employment and Disability, Cornell University. Retrieved January 10, 1999 from the World Wide Web: http://www.ilr.cornell.edu/ped/ssa/transition.html As federally defined, transition planning should begin at age 14, or earlier if deemed appropriate. As mandated in the Individuals with Disabilities Education Act, several transition benchmarks exist: development of a statement of needed transition instruction, development of the IEP, identification of long-term adult outcomes, identification of needed transition services, and finally, development of the coordinated set of activities. While these benchmarks are for the most part static, personnel responsible for each benchmark may not be. This poses a large barrier to coordinating benefits advisement and management support for a student in the transition process. Given actual team members and personnel may vary, we are going to explore the benchmarks by looking at what they specifically entail and the potential advisement roles which should be explored and played. Statement of Needed Transition Instruction Early on in a student's transition planning process, a "statement of needed transition instruction" must be incorporated into the student's IEP. This is the first benchmark, or step, on the road of transition planning. Depending on the state and district of the student, this statement may be obtained using one or more different approaches. For example, in New York State, districts must complete what is called a Level One Vocational Assessment by age 12. This assessment is comprised of several pieces of information aimed at identifying a student's vocational interests and preferences, basic skills, past successes, and long-term adult outcomes. Other states and districts use instruments like Transition Planning Inventories and other tools to baseline where a student is, and to project where they want to go. Whatever the tool, it assists the user in formulating long-term adult outcome statements in the student's own words which leads them to formulate a statement of needed instruction that will either move the student toward, or refine, their projected adult outcomes. This is an important benchmark for beginning to consider how disability benefits planning and assistance and use of work incentives might be incorporated into the transition planning process and IEP. At this juncture, several questions should be answered as part of the base line assessment process or annual planning: * Does the student currently receive SSI? * If so, to what extent? * If not, is there economic need evident that might lead you to advise the family to apply for benefits? If the student has benefits, is there a benefits management / advisement plan in place? * If working are they currently reporting their earnings? * If yes, are they using work incentives? * Have they used work incentives in the past? * If the student does not get benefits but is possibly eligible, does the student or family need support in making application and pulling information together? * Does the student and/or family know of community agencies that can provide support and assistance as they seek to maneuver the SSA system? * Does the student have a prior work history? These questions begin to frame very clearly the specific transition-support needs a student might have that should be incorporated into a student's statement of needed transition instruction. For example, if a student is receiving benefits, working, not reporting earnings, and doesn't understand the impact of work on their check, then this student's needed transition instruction could include: benefits advisement and counsel; training and/or coursework concerning consumer economics or specifically, SSA disability and work incentive programs; or functional activities of daily living instruction focused on money management and consumer awareness. As questions are answered, statements of needed transition instruction can be formulated and roles needing to be played become increasingly evident. Developing the IEP Following formulation of needed transition instruction is the development of the student's IEP. Each year as part of the student's education program, the long-term adult outcomes are revisited and modified annually, to assist the student in moving toward or refining their long-term adult outcomes with the goal to assist the student in achieving higher academic standards. At this point, similar questions continue to be asked. However, questions are also asked that move the student toward adult living, learning and earning outcomes. Leading questions dictating level of benefits advisement and support needed should focus first on whether or not the student desires to work or to go on to postsecondary education. For students thinking about employment, clarification is needed and additional information must be collected, such as: * What are quality indicators of employment for this student? * Are the student's preferred outcomes viable, and do they have a feasible plan for attainment? * If not, how will we support them in identifying more viable and feasible outcomes? * What supports might this student need to work toward this outcome? * What are the current resources and supports we can build a plan upon? * Where can additional resources and supports be secured? * Is the student planning on working this year? * If so, is a benefits advisement / management plan in place? * Will the student use work incentives other than the Student-Earned Income Exclusion? * Are personnel responsible for student progress documentation aware of performance/capacity reporting implications? * What level of earnings/income will the student need, to generate support for their learning and living adult outcomes? For students considering postsecondary education, it is also important to clarify whether or not they will be working at the same time. These individuals in particular might benefit a great deal from active benefits advisement and full use of the work incentive provisions. When thinking of supporting students in moving toward full community living, it is important to break this large area down into smaller components, specifically: recreation/leisure; residential; financial; medical/health; transportation; and legal/advocacy. As community living is broken down into these smaller areas, the implications each holds for a transition-aged student who receives SSI are recognized. Inevitably, where and with whom the student lives, and how old they are, is going to affect the amount of the Federal Benefit Rate used, or income of a parent or guardian that may be deemed toward a student under 18. When examining the medical/health arena, the issue of ongoing health insurance must be faced. While 1619(b) provides for ongoing Medicaid coverage for those who maintain eligibility for this status, if a student turns 18 and is moved into the SSDI program (either as a DAC or through their own insured coverage) Medicare does not have a 1619(b) provision. To receive Medicare insurance, an individual must complete a 24-month waiting period following eligibility determination for Title II benefits. This could potentially pose a particular dilemma for transition-aged youth moved from the SSI to the SSDI program, who will have a two-year period without healthcare coverage. However, youth who received SSI and had Medicaid coverage prior to their age 18 re-determination are ensured ongoing Medicaid coverage under the Pickle Amendment. The effective transition planner or benefits advisor will assist a student in understanding the complexity of legal/advocacy-related need areas. These areas specifically relate to knowledge, skills, capacities or supports that must be in place if the student is to make a successful transition to adulthood. Some areas for consideration include: knowledge of civil rights legislation; understanding of complexity of individual support and advocacy needs; ability of the student to self-advocate, monitor, and manage their own benefits situation; and long-term legal planning supports, should a student ever need to file an appeal with SSA. Responses to the questions identified earlier begin to highlight specific activities and possible goals and objectives that will need to be formulated to support the student's educational program. Some possible activities might include: * Ongoing investigation of current benefit status * Exploration of possible effect of future/current earnings on benefit * Exchange of benefit and work-related information with the student, family, educators and involved community agencies * Appropriate and relevant documentation of work-related activities, progress, and ongoing support needs * Accurate and timely reporting of earnings and other pertinent information to SSA * Application of work incentive provisions * Continued career exploration * Development of a benefit advisement plan * Development of a work incentive management plan (e.g. how a * PASS will be managed, etc.) Coordinated Set of Activities The final benchmark of transition to consider when supporting a transition-aged youth is the Coordinated Set of Activities. The coordinated set of activities has been interpreted in several different ways. The coordinated set of activities should be seen as an opportunity for us to ensure that a quality IEP has been crafted that incorporates all of the elements discussed. It provides a chance to assess and document the extent of employment / post-school activities incorporated into a student's IEP that move them toward, or refine, their long- term adult outcomes based on their identified support needs. It also provides a chance to identify and evaluate the quality and quantity of community experiences, instruction, and related services that move the student toward the same. In addition, need for activities of daily living instruction or functional vocational assessment should be assessed, documented and provided, as deemed appropriate. Do not forget the impact that turning 18 holds for transition-aged beneficiaries and recipients. It is important to provide supports and proactively plan for this pivotal point in a child's educational program and benefit status. Some important activities might include: * Gathering records and data to make a case for continued benefits as an adult; * Assessing the impact of re-determination on current use of work incentives; * Keeping abreast of pending re-determination dates; * Advising students and families as to the impact of being switched from SSI to SSDI/DAC; * Proactively seeking advocacy and support should an appeal be required. Continued Payment of Benefits for Children and Those Turning Age 18 Who Are Participating in an Approved Vocational Rehabilitation Program On August 10, 1999, the Office of Employment Support Programs of the Social Security Administration provided further guidance in field memorandum file number EM-99079, clarifying that the procedure for determining continued payment of benefits under "section 301" of the Social Security Disability Amendments of 1980 applies to all age 18 redetermination and continuing disability review cases. Section 5113 of the Omnibus Budget Reconciliation Act of 1990 extended eligibility for "section 301" payments to individuals whose disability ceased because of medical recovery while participating in an approved non-state "alternative participant" VR program. The field memorandum clearly articulates that "section 301" does apply to an individual age 18 and older whose impairment is determined to be no longer disabling, as a result of re-determination as an adult, as long as they are participating in an approved VR program. This further clarification strongly supports the movement and connection of students, prior to school exit, into approved VR programs. Inadvertently, connecting students to VR programs could potentially have two positive outcomes: reducing the numbers of SSI recipients at age 18 not being determined eligible for SSI as an adult, and more transition-aged youth becoming attached to employment. The Individualized Plan for Employment and State Vocational Rehabilitation Pursuant to Title I of the federal Rehabilitation Act, each state will have a state vocational rehabilitation (VR) agency to provide services to individuals with disabilities to assist them in entering the work force. Some states will do this through a single state agency, but the state may designate a second agency to serve individuals who are blind. For example, New York's two-state VR agencies are the Office of Vocational and Educational Services to Individuals with Disabilities (VESID) and the Commission for the Blind and Visually Handicapped (CBVH). State VR agencies can fund a wide range of goods and services which are connected to a person's vocational goal. Congress has stated that VR services are to empower individuals to maximize employability, economic self-sufficiency, independence, and integration into the work place and the community through "comprehensive and coordinated state-of-the-art programs." Consistent with these principles, and subject to state-specific financial need guidelines that may be in place, a state VR agency is available to fund items such as vocational training, college tuition, transportation, vehicle modification, assistive technology, and supported employment services. Each individual who is served by a state VR agency will receive services pursuant to an individualized plan of employment (IPE). This plan had been called the individualized written rehabilitation plan (IWRP). The name was changed to the IPE, pursuant to the Rehabilitation Act amendments of 1998. Like its counterpart, the IEP for students receiving special education services, the IPE is the blueprint that will identify all services provided by the state VR agency. Any service provided to meet the employment goal must be specified on the IPE. The IPE should enable the individual to achieve the agreed-upon employment objectives, and must include the following: * The specific employment outcome, chosen by the individual, consistent with the unique strengths, concerns, abilities and interests of the individual; * The specific VR services to be provided, in the most integrated setting appropriate to achieve the employment outcome, including appropriate assistive technology and personal assistance services; * The timeline for initiating services and for achieving the employment outcome; * The specific entity, chosen by the individual, to provide the VR services, and the method chosen to procure those services; * The criteria for evaluating progress toward achieving the employment outcome; * The responsibilities of the VR agency, the individual (to obtain comparable benefits) and any other agencies (to provide comparable benefits); * In states which have a financial needs test, any costs for which the individual will be responsible; * For individuals with the most significant disabilities and who are expected to need supported employment, the extended services to be provided; and * The projected need for post-employment services, if necessary. The IPE must be reviewed at least annually and, if necessary, amended if there are substantive changes in the employment outcome, the VR services to be provided, or the service providers. Any changes will not take effect until agreed upon by the individual and the VR counselor. If the person who is served by the state VR agency is a recipient of SSDI or SSI (or is expected to be a recipient upon application), the consumer's need for benefits planning and assistance should be identified in the IPE. The IPE should identify the entity, which will provide the benefits planning and assistance, and spell out how that service will be funded. (At least two states that we know of, New York and Ohio, are selectively funding the provision of these services. In New York, the VR agency contracts with independent living centers and will soon contract with other agencies as part of a demonstration project; in Ohio the VR agency has a contract with a legal aid office to provide the service.) Benefits screening, advisement, and management, as described elsewhere in this manual, will often be critical to the successful employment of an individual with a disability. With the new emphasis in the 1998 Rehabilitation Act amendments on consumer involvement in writing the IPE, many consumers, or their advocates, will want to insist that these services be written into the IPE and, if necessary, funded by the state VR agency. (Currently, both the law and regulations governing state VR agencies are silent on whether benefits planning and assistance are required services. It is noteworthy, however, that under the new Ticket to Work and Self Sufficiency provisions, this is one of the specifically enumerated services that Employment Networks can provide to "ticket" holders.) The Individual Service Plan and Other State Programs In addition to the IEP and IPE, there are other service delivery and support planning constructs. Under the Mental Retardation and Developmental Disabilities system, an Individual Service Plan maintains a similar structure to that of the IEP and IPE. (These additional constructs may go by various names, including Individual Habilitation Plan (IHP) and/or an Individual Support Plan (ISP).) Whatever the name, the service delivery and support planning constructs outline specific areas that parallel the IPE and IEP. These include: * Introduction to the individual planning is being done with; * Goals; * Objectives; and, * Action Strategies; Introduction This information typically describes the person for whom the planning is being done. This usually entails the person's present situation cutting across all aspects of their life, which might include present levels of performance, capacities, interests, preferences, support needs, and existing support systems. A general introduction will also provide an outline of the individual's overall dreams and aspirations, and projecting long-term desired outcomes. This may be framed in the context of "future statements" or "desired states." Goals Goals are typically framed within a 1-3 year period, although can as much as 3-5 years. Goals will typically address most life domains including living, loving, learning and earning. While broad in context, they provide the framework upon which objectives are crafted to serve as a stepladder to achieving the overall goal. Objectives Objectives are typically written to be achieved within one month to one year. They outline very specific outcomes that must occur, that serve as milestones to reaching the goal established. A given goal may have several objectives that lead to its attainment. Keep in mind, there are primarily two types of objectives, which can be written: learning and service objectives. Learning objectives, as the title suggests, assist the individual being supported in developing or acquiring a specific skill or competency. Service objectives focus on providing help, or supporting an individual in an area where capacities negate independence. Action Strategies Action strategies clearly identify several important pieces of information related to the goals and objectives, specifically: * What needs to be done; * Who will do it; * What the timeframes will be; * How success will be measured; and, * The frequency at which progress will be measured. These strategies could be related to who will offer support; who will access other resources; or what the customer will do to achieve learning or service objectives. If possible, the benefits specialist should consider and attempt to achieve actions that would be in a separate benefits support plan (included in the objectives) and most importantly, in the action strategies of the ISP or related plan. As referenced earlier in the IPE section, there are several touchpoints / support needs which should be considered for inclusion in the ISP, based on an individual's unique set of needs. These include, but are not limited to: * Ongoing investigation of current benefit status * Exploration of possible effect of future/current earnings on benefit * Exchange of benefit and work-related information with the student, family, educators and involved community agencies * Appropriate and relevant documentation of work-related activities, progress, and ongoing support needs * Accurate and timely reporting of earnings and other pertinent information to SSA * Application of work incentive provisions * Continued career exploration * Development of a comprehensive benefit advisement plan * Development of a work incentive management plan (e.g how a PASS will be managed, etc.) Support Plan Case Study Breaking into small groups of 3-5, review the following case study and propose possible support needs and plan accordingly. John B. Recipient is considering taking a part-time job as a greeter with the local historical society in their museum. The job pays minimum wage to start, although provides incentive raises to promote job longevity, gradually increasing his hourly wage to $10 at the end of two years of employment. John is excited about beginning this job in a month. John recently moved into a supported apartment program and will be living independently. His parents are concerned that he has never taken care of his own finances, although the residential program assures them that a staff person will work with him each week to manage his finances and do his shopping and banking. The residential program has called you because they just lost their benefits specialist and are concerned because John receives both SSI and Social Security and his placement is contingent upon maintaining his health care coverage. Potential Needs for Support: Activity/Goal Timeframes Person(s) Responsible Role Desired Outcome Resources Needed Quality Indicators of Success: CHAPTER 22: LONG TERM BENEFITS ASSISTANCE Introduction An individual's success in realizing their employment, financial and life goals will ultimately depend on effective management of their benefit programs. As addressed earlier, changes at any time, with any number of variables (including an individual's employment, financial resources, living arrangements and work incentive utilization) may result in a significant impact on their benefit eligibility and payment status, and their heath care coverage. Given these potential impacts, ensuring an overall positive change in a person's financial and life situation necessitates continuous and effective monitoring and management of their benefit status. Benefits assistance is about designing, implementing, monitoring, and evaluating the outcome of a long-term benefits support plan. Benefits assistance services usually build on the earlier efforts of the benefits specialist to establish a complete and accurate benefits profile, to analyze and provide advice on potential benefit paths, and, finally, to assist the individual in establishing a long-term benefits management plan based on their informed choice of action. The goals and objectives of this plan serve as a critical guide to the delivery and evaluation of benefit assistance services. It is important for the benefits specialist to clarify for both the funder of benefits planning and assistance, and the consumer, the point at which benefits planning is shifting into benefits assistance. Planning is focused on analysis and counsel, while assistance deals more with providing long-term supports to oversee and proactively monitor an individual's benefit status and financial well-being. Benefits Assistance Characteristics Effective benefits assistance services are characterized by the delivery of supports that are individualized, comprehensive, proactive, and available on a continuous basis. Individualized supports: The benefit assistance supports required vary significantly from person to person depending on a number of factors. The factors include: * The array of benefits received; * The nature and degree of interplay between benefit programs; * The existence of benefit complications or problems; * The level of anticipated change in the person's benefits, employment and life situation; * The individual's knowledge regarding their benefit programs and ability to advocate for themselves; * The existence of other programs or naturally occurring supports in the person's life that can address support needs. As these factors will vary widely in each case, benefits assistance plans must be developed on a person-by-person basis. The initial benefits assistance planning process provides a critical opportunity for assessing what type of support needs exist, the intensity of the supports needed, and the benefit specialist's role in delivering or arranging for them. Comprehensive services: When discussing benefits assistance, the term "comprehensive" will be defined based on the support needs of each beneficiary or recipient. At one end of the spectrum, comprehensive services for one individual may consist of monthly or bi-monthly meetings to update employment and benefit information, help with reporting income to SSA, provide regular assistance with managing work incentives, and advocating on behalf of the person with other agencies. At the other end, an individual's benefits assistance services may simply consist of periodic reassessment of benefit status and education concerning benefit issues as they arise. In a broader sense, the term comprehensive addresses the needed for an agency to ensure that an array of benefit assistance support services and access to information on all possible federal, state, and local benefits are made available to individuals. A comprehensive program of benefit assistance services includes the following key service components: * Data collection, profiling and analysis * Advisement and counsel * Information and referral * Counseling * Support planning * Long-term intervention * Problem solving and advocacy For benefits assistance programs limited in the array of services offered and/or scope of information provided, a strong information and referral component will be critical to the overall success of the individual. Efforts must be made to establish and maintain a network of community resources to ensure that all support needs are met, from benefits profiling and advisement to benefits management. Proactive services: To ensure that smooth benefit transitions are experienced that result in an overall positive impact; it is critical that benefits assistance services be provided on a scheduled, continuous basis. Proactive benefits assistance is characterized by planning for, and providing, supports at regular checkpoints, as well as at critical transition points in an individual's benefit, employment and overall situation. These regular, intermittent checkpoints, or wellness visits, reduce the likelihood and negative impacts of benefit complications by providing for: * consistent communication with the individual; * the opportunity to reassess the benefit situation as it currently exists; and, * an opportunity to identify needs for benefit decisions and actions, as well as additional services, such as information and referral, problem solving and advocacy, and crisis management. Long-Term Services: Effective benefits assistance services involve the provision of supports to beneficiaries and recipients over time. Generally, long-term benefits assistance will involve the need for communication between adviser and consumer over a period of one to three years. In some cases, however, the adviser will retain an open case file and provide services for longer than three years, as individual circumstances dictate. It could extend for more than 36 months, for example, if the benefits specialist will be monitoring a consumer's activity during the entire trial work period and extended period of eligibility. Similarly, benefits assistance may extend beyond 36 months if a benefits specialist is monitoring an approved PASS through the full period of the consumer's undergraduate program. As with the types and intensity of services needed, the duration of follow-along benefits assistance services will not only vary from person to person, but may also vary for a particular individual over time. For example, an individual whose case file was closed after several months of assistance regarding a work/benefit transition may identify the need for support in developing a PASS, or responding to a CDR notice, at a later point in time. Flexibility of the program that allows beneficiaries and recipients to move in and out of active case service status, as well as the overall accessibility and responsiveness of the benefits specialist, are key to effective support. The following are just a few examples of situations where long-term benefits management is appropriate: * The consumer is an SSI recipient who is expected to have significant variations in earned income (i.e., wages) from month to month. * The consumer is an SSI recipient who is expected to have significant variations in the amount of exclusions from income from month to month. These exclusions could include, for example, IRWE, BWE, or the student-earned income exclusion. * The consumer is an SSDI beneficiary who will need to monitor progress through a trial work period and/or extended period of eligibility. * The consumer is eligible for both SSI and SSDI. Since the effect of work on benefits will vary greatly for the two programs, it is not likely that a person could provide adequate advisement in just one or two sessions with the consumer. Proactive Benefits Monitoring and Assistance Strategies The dynamic interplay between employment, financial status and benefits requires that benefits specialists continually draw on an array of tools throughout the process of supporting benefits management. Analysis of the factors affecting a person's situation conducted during the initial profiling process will need to be updated regularly as new conditions or factors surface. As a result of each updated analysis, new scenarios or opportunity paths will need to be developed and explored. Education and advisement about new possibilities and choices will likewise be necessary, as well as additional planning for the continued delivery of benefits assistance. The following outlines a number of strategies for the organization and delivery of benefits assistance services. Benefits Assistance Meetings A primary component of benefits assistance services involves periodic or proactive meetings to ensure that the necessary communication occurs between all parties to move ahead with accomplishing the goals and objectives of the benefits assistance plan. These visits need to be scheduled and held with the beneficiary or recipient on an on-going basis, every three to six months, depending on the individual's need for support, or when critical transition points are experienced in employment and benefits. Based on benefit management goals and activities laid out in the plan, a timeline or schedule of services may be established to serve as a tickler for contact points. The long-term benefits plan can simultaneously serve as an agreement between the service provider and the individual, as well as a focal point for the on-going meetings and communication regarding the delivery of service. For individuals with relatively straightforward and consistent benefit and employment situations, the initial plan may serve to guide the delivery of benefits management services over an extended period of time. In most cases, however, the plan will serve as an evolving tool for the benefits counselor and the individual, and will be reviewed and built upon over time as the individual's situation changes or unanticipated issues arise. While the periodic, on-going meetings with beneficiaries and recipients will need to be tailored to address the specific needs of the person, the following areas of discussion are suggested as a guide: * Update of extensive personal, financial, and work-related information originally gathered in the benefits profile; * Review of benefits management goals and objectives, including an update on progress made, issues or problems raised, and an evaluation of outcomes; * Identification, analysis and advisement regarding new variables affecting the benefits monitoring and management process. This may require revising existing goals and objectives and/or adding new ones. * Review and update of benefits assistance service and support needs based on new information/changes in situation; * Informal education and resource information related to specific benefit and work incentive provisions; * Direct problem-solving and advocacy for the issues identified; * Information and referral to community resources to address needs. The benefits specialist will need to work with the consumer to identify other relevant individuals involved in the person's benefit management process. To the extent possible, these individuals should be included in the periodic update meetings, as specific needs for their expertise, services, and supports are identified. This may include individuals from other agencies providing services or benefits to the individual, as well as family, friends and others involved in providing supports. Such an inclusive approach will provide greater assurance that the benefits management plan is built on complete and accurate information and that the needs/supports identified will leverage and build upon natural supports and resources currently available. While the benefits management update meetings serve as the backbone of the follow-along services, they will in most instances need to be supplemented by periodic telephone or written communication with the beneficiary or recipient and other significant individuals involved. As mentioned earlier, all information gathered during the course of the benefits management meetings or other communications, and any record of the information and advice given, should be documented in the individual's case file. Critical Transition or Touchpoints To minimize the incidence of benefit complications, the benefits specialist should make every effort to anticipate fluctuations or changes in an individual's employment and financial situation, as well as other factors that will potentially affect benefits and overall well-being. The events or incidents being explored below are common touchpoints where the benefits specialist will need to plan for and intervene to ensure adequacy of safety nets and smooth benefits transitions. SSI Touchpoints Event - Increase or decrease in earnings from employment An increase or decrease in a person's earnings from employment will result in a change in their monthly SSI cash benefit. Changes in earnings may be caused by the fluctuations in the individuals work hours, pay rate, a change in pay dates, or termination of employment. Overview - The SSI program is funded by the general revenues of the Federal Treasury and is intended to provide a minimum level of monthly income to persons who are aged, disabled, or blind and demonstrate economic need (i.e., have little or no income or resources). Individuals who are eligible for SSI receive a monthly cash benefit and will usually qualify for health care coverage under Medicaid as well. The SSI monthly benefit is intended to serve as a financial safety net for recipients during periods of time when they are not able to work at a substantial level, as well as during the process of working towards an employment goal. As SSI is an economic need-based program, it is intended to supplement any income or resources an individual already has to ensure that they have a minimum level of income each month to meet their basic food and shelter needs. Therefore, the dollar amount of SSI benefit received by an individual in a given month depends on the dollar amount of other income they have for that particular month, as well as their resources, living arrangement, and use of work incentives. In January of each year, Congress establishes the Federal Benefit Rate (FBR), which is the maximum dollar amount that an individual or couple can receive in SSI cash benefit on a monthly basis. The recipient's monthly earnings from employment affects how much of the FBR is actually received. Generally, the more an individual has in earnings, the less they receive in SSI. Not all of the person's earnings, however, are counted in determining the amount of their monthly SSI benefit. There are several income exclusions that are available to all SSI recipients. First, a $20 general exclusion is subtracted from a person's income from any source. The general exclusion is applied first to any unearned income the person has. If the individual has no unearned income, then the general exclusion is subtracted from their earnings. Secondly, a $65 earned income exclusion is subtracted from the person's earnings. Finally, the SSA excludes one-half of the amounts of earnings after the $20 and $65 exclusions are applied. So, in other words, the SSI check is reduced $1 for every $2 earned after the other exclusions. Event: Increase or decrease in unearned income Examples of unearned income include SSDI, veterans' benefit, civil service annuity, or monetary support received from another person. Deemed income is another type of unearned income that is counted for individuals who are married or under the age of 18. Deemed income refers to the amount of the parent or spouse's income that is considered to be available to the recipient. A formula is used by the SSA to determine the amount of the parent's income and resources that are deemed to be available to the child, taking into consideration the amount of income and number of parents and children in the house. Background: As with earnings, the more unearned income a person has, the less they will receive in their monthly SSI cash benefit. The $20 general exclusion referenced above is subtracted from the recipient's unearned income. The remaining unearned income, or countable unearned income, will reduce the person's SSI cash benefit dollar for dollar. In particular, benefit specialists should watch for changes in unearned income as a result of the following situations: * An SSI recipient becomes eligible for an SSDI benefit, because of working and earning enough quarters for coverage on his or her own record. * An SSI recipient with parental deemed income experiences a change in the number of parents/children living in the household. * An SSI recipient reaches 18 years of age, at which point parental income is no longer deemed. * An SSI recipient who is 18 years or age or older is determined eligible for SSDAC as a result of being a dependent of an insured worker who retires, becomes disabled, or dies. Event: Change in resources To meet initial as well as continuing eligibility for SSI, an individual must meet a resource test. Resource limitations are established under the Social Security Act and include countable real or personal property that cannot exceed $2,000 for an individual or $3,000 for a couple. If a person has resources in excess of the allowable limits at the beginning of a month, it renders them ineligible for an SSI cash benefit in that month and in future months, until their resources are again below the established limits. A listing of resources counted can be obtained from your local SSA Office. Event: Changes in living arrangement Background: In-kind support and maintenance is considered to be unearned income in the form of food, clothing, or shelter that is given to an individual by someone else. If a person is 18 years of age or older, and receives food, clothing or shelter from a third party, they will be determined to be receiving in-kind support and this will result in their SSI check being reduced by 1/3 of the amount of the federal benefit rate. If an individual is able to pay within $5 of their fair share of the household expenses they'll be determined not to be receiving in-kind support and will avoid this reduction in their benefit. Event: Change in Marital Status Background: Two SSI recipients who are married are subject to the couples Federal Benefit Rate. This will result in a decrease in the amount of SSI received by each recipient. Additionally, when an SSI recipient marries an individual who does not receive SSI, a portion of the spouse's income may be counted as deemed income, resulting in a decrease in SSI cash benefit. SSI recipients who end a marriage relationship will conversely experience an increase in SSI. Event: Attainment of Age 18 Background: Upon reaching age 18, SSI recipients will be subject to a re-determination process to determine their continued eligibility for SSI under the adult disability criteria. If determined eligible, SSI cash benefits will continue. There will, however, be a difference in the calculation of the monthly cash benefit they are eligible to receive because parental deemed income will no longer apply and living arrangement and in-kind support rules will apply. Event: Movement into 1619(a) status Background: Section 1619(a) basically provides a safety net that enables individuals who continue to be disabled to receive special SSI cash benefits in place of their regular SSI benefits, when earnings exceed the SGA level. To be eligible for 1619(a) benefits, individuals must continue to have the original disabling impairment under which eligibility for SSI was initially determined, and currently meet all other eligibility rules, including the income and resource test. If all eligibility requirements continue to be met, when earnings increase to greater than the SGA level but remain lower than the break- even point, SSI recipients will automatically move into 1619(a) status. There are no observable differences in the SSI checks indicating the change from regular SSI benefits to a 1619(a) special benefit. Individuals will only receive notice regarding the reduction in their checks when their increased earnings place them over the SGA level. Eligibility for a 1619(a) cash benefits will continue until earnings fall below SGA, at which point individuals will automatically move back into regular status and receive regular checks; or earnings exceed the break-even point (BEP), at which time their cash benefits will cease. Event: Movement into 1619(b) status Background: Section 1619(b) of the 1987 legislation provides for continued Medicaid eligibility for individuals whose incomes are too high to qualify for an SSI cash benefits, but are not high enough to offset the loss of Medicaid or publicly funded attendant care. Individuals will be eligible only for the 1619(b) protected Medicaid status if the sole causes for SSI benefits cessation are increased earnings over the break-even point. If cash benefits cessation is a result of a determination of medical recovery or are due to resources and/or unearned income in excess of the statutory limits, individuals will not be eligible for 1619(b). A second criterion for 1619(b) status requires that individuals' gross earnings fall below certain limits, called threshold amounts. The thresholds are used as an administrative convenience to determine if "sufficiency of earnings" is met rather than performance case-by-case computations. The law does not mention thresholds. Earnings at or above the threshold amounts are considered to be sufficient to replace the cost of Medicaid coverage. Threshold amounts vary from state to state as a result of variations in the cost of medical services. Individualized thresholds can be computed if individuals have unusually high medical costs, work expenses, or a Plan for Achieving Self-Support (PASS). Individuals are ineligible for 1619(b) if their earnings exceed the threshold amount. They may qualify for this provision at a later date if their earnings fall below the threshold amount within 12 months and all other eligibility requirements continue to be met. A final criterion for 1619(b) is that individuals must need Medicaid in order to work. Compliance with this criteria is established through statements by the individuals to the SSA regarding the use of Medicaid in the last 12 months, expected use within the next 12 months, or need for Medicaid if individuals become injured or ill within the next 12 months. To qualify for 1619(b) Medicaid status, individuals must: * Have a disabling condition or continue to be blind; * Need Medicaid in order to work; * Be unable to afford benefits equivalent to those received if not working; and/or * Meet all other requirements for SSI payments other than earnings. At the time that SSI cash benefits cease as a result of the formula explained above, the SSA computer would automatically determine eligibility for 1619(b). The field office will confirm 1619(b) eligibility at the next determination. Advocates and family members should monitor earnings monthly and contact the SSA as soon as SSI cash benefits cease, to ensure that the 1619(b) determination is made. Medicaid can be administered by the SSA or by another state agency, but this varies from state to state. In 32 states, eligibility for SSI brings automatic entitlement to Medicaid. SSDI Touchpoints Individuals who begin working under the SSDI program are provided with several opportunities under the Act to try their hand at work. However, if an SSDI beneficiary medically recovers from their originating disability under which eligibility was established, these provisions of the law do not apply. It is critically important to stay abreast of the individual's work status as is noted below. Event: Participation in/ Completion of Trial Work Period Background: SSDI beneficiaries not recovering from their medically determined disability are entitled to a nine-month trial work period (TWP). The TWP will begin the first month an individual is entitled to Title II benefits or files application for disability benefits. The TWP ends only if individuals perform nine months (not necessarily consecutively) of trial work within a rolling period of 60 consecutive months. TWP months must be carefully tracked, because a 36-month extended period of eligibility (EPE) begins immediately following the nine-month TWP. Event: Participation in/Completion of Extended Period of Eligibility Background: If a beneficiary has not medically recovered at the conclusion of the nine-month TWP, the individual will immediately enter into a 36-month Extended Period of Eligibility (EPE). This period begins the month following the ninth TWP month and is a minimum of 36 consecutive months. At the conclusion of the TWP and during the EPE if it is determined that a beneficiary is working at an SGA level, they will receive their full benefit check for the month in which SGA was determined, plus the following two months. This is known as a "grace period" to allow the beneficiary a period of time to adjust to the fact that they will not receive a SSDI check in the months following the conclusion of the grace period in months, which their earnings exceed SGA. During the EPE, it is not necessary to file a new application for benefits to resume. Following the grace period, Title II cash benefits are received only during the remaining EPE months in which gross earnings are below the SGA level. It is important to note that for individuals who are self-employed, individual determinations of what quantifies SGA during EPE will be established. The claims representatives will make this individualized determination by looking at: how many hours of work were performed; who performed the services; net and gross earnings; subsidies; and other particulars. Consistency and accuracy in reporting monthly fluctuations in earnings between SGA and non-SGA levels is critical in avoiding overpayment or underpayment of Title II benefits during this period. The EPE ends the first month following the 36th month that individuals engage in SGA. For example: Individuals could earn below SGA in the 37th, 38th, and 39th months and continue to be in the EPE. If they earn SGA in the 40th month, the EPE ends. After the EPE has ended, if they decrease earned income due to medical impairment, a new application for Title II must be filed. Currently, within 12 months they can reinstated. Event: Extended Medicare Coverage Background: Title II beneficiaries who lose benefit entitlement due to performance of SGA, but continue to be disabled, are eligible for extended Medicare coverage. The extended coverage is for a minimum of at least 93 months. In addition, it is possible for individuals with disabilities to buy into the Medicare program once the extended Medicare coverage is exhausted and Medicaid may possibly assist in paying the premium, which is over $300 a month. Touchpoints Applying to Both the SSI and SSDI Programs Event: Use of Work Incentives. Background: The use of work incentive provisions can help beneficiaries and recipients in two significant ways. They can help individuals to pay for services or items that they need in order to work, and to maintain or even increase their cash benefits until they are stable in employment. In addition to the 1619(a) and 1619(b) work incentives, the PASS, IRWE, and BWE are incentives that enable people with disabilities to recover expenses they incur while working towards greater economic self-sufficiency. The goals of the work incentive programs are to assist individuals to achieve gainful employment, increase independence, facilitate empowerment, and acquire self-support. In some cases, the work incentives can be used during the initial SGA test to assist individuals who may be working and earning at or above SGA level to establish eligibility. The dollar amount of impairment related work expenses (IRWE) and subsidies are subtracted from the gross monthly wages before the SGA determination is made. Individuals may be earning over the SGA level and still meet the disability criteria if the dollar amount of their IRWEs and/or subsidies is significant enough to reduce their gross monthly earnings below the SGA level. Earnings set aside under a Plan for Achieving Self-Support (PASS) cannot be deducted from gross monthly wages to meet the SGA criteria. However, if individuals are using wages under a PASS to pay for impairment-related work expenses, the PASS expense can simultaneously be computed as an IRWE to reduce wages for the SGA disability determination. Regardless of whether the work incentive is used during the initial eligibility process or once benefits are established, a decision by a beneficiary or recipient to work and use the work incentives available to them should involve thorough up-front evaluation and planning to ensure an overall positive impact. First, projections should be made on the immediate effect of the earnings and the work incentive plan on cash benefits and the overall financial situation. Second, the long-term impact of changes in both earnings and work incentive utilization must be investigated. Some of the very basic questions that the benefits specialist will want to assist the individual in addressing include the following: * What happens if earnings increase or decrease? * If the vocational goal is reached, will benefits cease all together? * What will be the impact on medical coverage? * If a work incentive will be used to pay for a work expense that the individual has as a result of their disability, will the IRWE or PASS be more financially advantageous? * Will the work incentive allow for funding of a needed service on a long-term basis, or will it be necessary to explore other funding options? * If money or resources are accumulated under a PASS and the plan is interrupted, how will continuing eligibility for SSI be affected? * How will resources, money accumulated under a PASS affect the individual's eligibility for other benefits they may be receiving, such as housing? Successful utilization of the work incentives and smooth benefit transitions ultimately depend on a cooperative effort between beneficiaries and recipients, families, advocates and the SSA. Proactive communication with the SSA will help to ensure that decisions made regarding employment and work incentive use are based on sound, accurate information and projections. Event: SSI Age-18 Redeterminations Background: As previously discussed, a redetermination review will be conducted for all individuals when they reach their 18th birthday. The purpose of the age-18 redetermination is to ensure that the individual meets the disability eligibility criteria for adults receiving SSI. The local SSA office wil contact the recipient to initiate the process. The potential loss of SSI as a result of the age-18 redetermination process holds significant implications for young adults and their efforts to become successfully employed. Consequently, strong justification is provided for benefits specialists, school, and rehabilitation professionals to take an early and active role in working with youth, their families, and the Disability Determination Service towards an accurate determination of SSI eligibility for the adult program. The following are suggested guidelines for the involvement of benefits specialists and other school and rehabilitation professionals in this process: * Provide information on the age 18 redetermination requirement to individuals on the childhood SSI roles and their families. Discussions regarding SSI and the requirement that all youth must be redetermined for the adult SSI program should happen early in the transition process. Information shared should include both a discussion of the redetermination process as well as information regarding how input will be gathered and used in the work evaluation component of the process. The role of the individual, family, school professionals, and others in the process should likewise be addressed. * Gather and provide documentation to the Disability Determination Service necessary to support an accurate determination of eligibility. It is critical to keep in mind that the documentation provided by teachers and rehabilitation professionals is used in the redetermination process to evaluate a young adult's residual functional capacity and related ability to perform substantial work. In light of this, it is extremely important that the information provided give an accurate and comprehensive representation of the individual's performance, including functional work limitations and information on the supports that are necessary to enable the work activity. In some instances, the forms used by DDS to gather input contain only questions related to the student's performance in the classroom and other school settings. If a student has engaged in community-based work experience, documentation of performance and necessary supports should be included as supplemental information. Requests for information on age-18 redeterminations will include questions related to assessing the potential for fraud and abuse. In responding to these questions, it is critical that teachers and others consider carefully both the purpose of the questions as well as the observations and information on which their responses are based. * Plan early for the possible implications of benefit cessation with the individual and their family. Young adults who are utilizing and relying on their SSI for access to critical work supports will need to consider possible alternatives to maintain these supports should benefit eligibility cease. If not already established, efforts should be made to assist the individual in establishing eligibility and access to services under the State Vocational Rehabilitation Agency prior to the age-18 redetermination process. Other community agencies and resources should be investigated as well. Involving vocational rehabilitation and other agencies early in the transition planning process will reduce the likelihood that gaps in services will occur and enhance the overall supports available to the student. * Encourage and support students and their families to appeal benefit cessations that result from age-18 redeterminations. A multi-step appeals process is available to all individuals who do not agree with a determination by DDS that they are not disabled. The first step of the appeals process involves a reconsideration of the initial determination at the state DDS level. If a favorable decision is not reached at the reconsideration level, the determination can be appealed through an Administrative Law Judge Hearing. The final steps may include an Appeals Council Review, followed by civil action in a U.S. District Court. Notice of Action from SSA In a perfect world, the benefits specialist would be able to operate proactively at all times, planning for all benefit events and transitions before they occur and taking action to ensure smooth benefit progress. Unfortunately, not all benefit events or decisions can be anticipated! In some instances, the beneficiary/recipient will receive notice of actions that will need to be handled on a reactive basis. Change in Benefit Status SSA will provide written notice to beneficiaries/recipients of all decisions it makes and actions it plans to take. The notice will include an outline of information or factors on which they are basing their decision/action. Individuals receiving benefits have the right to appeal any decision made if they disagree with it or think that it is a mistake. The documents that SSA sends regarding the decision are critical to keep on hand as they will assist in responding to or appealing the decision. There are timelines that must be adhered to for a beneficiary/recipient to exercise their right to appeal. All decisions must be appealed within 60 days. In the case of some disability decisions, if the appeal is initiated within 10 days, the individual may be able to continue receiving their cash benefit while they appeal. Keep in mind that if they are once again determined not disabled as a result of the appeal, they may have to pay the money back. Overpayment/Underpayment Overpayments and underpayments in SSI and SSDI benefits are commonly experienced, and can have significant impact on an individual's financial well-being. An overpayment exists when the individual receives more in their cash benefit than they were eligible to receive during a specified period of time. Overpayments may occur for a number of reasons, including, but not limited to: * An SSI recipient had resources exceeding the allowable limits for a cash benefit during the period of time; * An SSI recipient had additional earned or unearned income that was not reported/counted by SSA in determining the cash benefit during a specific period of time; * An SSDI beneficiary received cash benefits after the trial work period and a SGA determination was made; * SSI or SSDI cash benefits were paid during a period of time that the individual was not eligible due to medical recovery; * An SSI or SSDI cash benefit was paid during a period of time when any number of other eligibility requirements were not met. The notice of overpayment sent to the beneficiary or recipient will include information on the time period of the overpayment, reason for it, and amount of overpayment. A request for reconsideration of the overpayment can be filed within 60 days of receiving the notice. This 60-day period may be extended if there is "good cause." The beneficiary/recipient may also file for a waiver of SSA's right to recover the overpayment if an argument can be made that the individual was not at fault. This would include situations where the individual was unaware of overpayment or told by SSA that it was not an overpayment, among other things. A waiver may be requested at any time. If it is determined that SSA will move forward with recovery of an overpayment, the beneficiary or recipient will experience a decrease in their monthly cash benefit. Benefit Cessation For both the SSI and SSDI programs, benefits can be stopped at any point in time that an individual fails to meet any of the disability and/or non-disability requirements for the program. Again, appeals of the decision must be filed within the established timeframes. It is critical for the benefit specialist to consider the opportunities for the individual to continue benefits while appealing. Additionally, individuals who are determined medically recovered as a result of any of the CDR processes outlined previously, may be eligible for continued cash benefits under Section 301. This provision allows for the continued payment of monthly cash benefits to individuals determined to be medically recovered if they are under an approved vocational rehabilitation plan. The plan must be in place before the CDR process was initiated, and there must be a good likelihood that providing benefits while the person completes the plan will result in self-sufficiency and their ultimate removal from the benefit roles. Information and Referral Information and referral services will be a key component of the services that a benefits specialist provides in assisting a person with managing their benefits over time. The benefits specialist will frequently find himself or herself in the position of identifying needs for services that are beyond the purview of their program to provide, such as support in the area of employment development and supports and assistive technology. This is where the development and maintenance of a network of community providers discussed in Unit II becomes critical. As with all other services provided, the level of support in information and referral must be customized to individual needs. Problem Solving and Crisis Management While the onus may be on the benefits specialist to be as proactive in monitoring an individual's benefit status and as knowledgeable regarding SSA's policy and regulations as they can be, inevitably, situations will arise that require problem solving and crisis management. It is important in these situations to understand that the benefits planning and assistance arena is comprised of an array of human interactions during which, at any point, error or assumptions can be made that inadvertently result in problems/crisis. There are some important elements to consider: * Is this really a problem or crisis situation? * Is the nature of the situation base on financial, social, medical, or vocational factors? * Are others affected by this situation? * Is this a safety net issue? * Does this situation involve other individuals? * Is expertise needed outside of benefits planning and assistance? * Who is available to network with on this issue? Problem Solving Strategies Keep in mind that some individuals may need extensive support in resolving a problem while others may be capable of solving problems on their own. While the tendency may be to resolve the situation on their behalf, it is important to use the opportunity as a "teachable moment." Keep in mind the multiple steps associated with problem solving and gauge where the individual you are working with may need some skill building support. Step One: Recognize that there is a problem Step Two: Understand the breadth and depth of the problem Step Three: Generate potential solutions to the problem Step Four: Evaluate and analyze solutions generate projected outcomes and consequences of each Step Five: Select a solution Step Six: Implement the solution Step Seven: Evaluate outcomes and consequences If desired outcome not achieved: Step Eight: Identify factors contributing to lack of desired outcomes Step Nine: Evaluate and analyze other solutions generated to project potential for success Step Ten: Return to Step Five Do's and Don'ts of Crisis Management Do 1. Try to buy time in order to investigate the situation. Don't 1. Abandon the person requesting your support if they request your immediate attention. Do 2. Be sensitive to the individual's problem and "legitimize" the complaint. Don't 2. Accept the individual's perceptions of the situation at face value without investigation. Do 3. Assure the individual that you will take steps to work with them to solve the problem. You are the "expert" - inspire confidence in your ability. Don't 3. Evade the situation, come across "wishy-washy," sound unsure of your ability, or make excuses. Do 4. Investigate the situation thoroughly, utilizing all available information services. Don't 4. Assume you know how to handle the situation without investigation or commit yourself to a specific plan of action without gathering information. Do 5. Develop and implement an intervention plan that treats root causes of the crisis. Don't 5. Attempt to solve major problems by treating symptoms of a more pervasive underlying cause. Do 6. Use the least intrusive method of intervention, then move up the hierarchy. Don't 6. Jump in with the most intrusive intervention strategy. Do 7. Utilize existing supporters and stakeholders in intervention plan to maximize involvement. Don't 7. Try to solve the crisis all by yourself without investing others in the solution. Do 8. Be creative and have back-up plans prepared. Don't 8. Assume that your first plan will always be successful. Crisis Intervention Plan Individual: Date: Issue (problem): The problem could have been avoided if: Others to invest in plan: NAME AFFILIATION RESPONSIBILITY/ROLE Goal Strategies Person(s) Responsible Timeframe Follow-Up Future safety nets to be considered: Crisis Management Case Studies Case Study 1: Chris is an SSDI beneficiary who tells you that he has been working part-time for the past four years. He has been getting help with his taxes from a volunteer tax preparer who is collecting Social Security retirement benefits. As he describes his work activity during the past four years, it becomes clear to you that he has been receiving benefits for some time that were not due him, under the SGA rule. [The tax preparer incorrectly advised him that his earnings, which were over $8,000 in 1997 and 1998, and over $9,000 in 1999 and 2000, would not affect his SSDI benefits. You know differently, and warn him that he has probably been overpaid.] He has never talked directly to an SSDI Claims Representative. Instead, he reported his earnings by calling the toll-free number. You contact the SSA at his request, and are told that the beneficiary is overpaid by almost $22,000. He is also considered to have completed his TWP and EPE. His benefits terminate immediately. This news throws Chris into a deep depression. Each time you talk to him, he suggests that suicide is a solution to his problem. His emotional status deteriorates so quickly that he has to quit his job. What do you do? Case Study 2 In another scenario, you are meeting for the first time with a young man named Jake. Jake recently graduated from high school and his mother comes to the appointment with him. He proudly tells you he has been working for two months, earning $450 a month. You have to ask if he has reported this work activity to the SSA. His mother says they were not aware that they were required to report. You explain how earned income reduces the SSI payment, and that he has been overpaid. Both the young man and his mother become very agitated when you explain that his SSI payment will be reduced not only by the "countable" portion of his wages but by the amount that is withheld monthly to recover the overpayment. The mother says her son should quit working rather than lose part of his SSI payment. This would leave him with no activity at all during the day since he is no longer in school and he lives with his mother, who works full-time. What is the best way to approach this situation? Case Study 3 Mary is a woman who is receiving SSDI due to a severe medical condition that is now under control with treatment. Her benefit picture is complicated by the fact that she has three minor children, and each of them gets a monthly benefit because she has a disability. The family's total income (her benefits combined with the children's) is over $1100 per month. This individual was very successfully employed prior to her disability, and, having a strong work ethic, she wants to return to work. However, she can't return to her previous occupation, and she has been advised by her physician not to work full-time. Through your analysis, she learns that if her earnings are above the SGA level, not only may her cash benefits be terminated eventually; her children's benefits may stop as well. Her projected earnings do not replace the $1,100 she loses, particularly when you consider the net income after taxes. In addition, as a part-time employee, she is not likely to qualify for employer-sponsored health insurance. Currently, her children are eligible for a special health care benefit for families with income below the poverty level. This coverage will be lost if her SSDI benefit terminates. When you pause during your report to ask if she has any questions, she suddenly bursts into tears. She admits that she is embarrassed at having to live off the government. She wants to be able to give her children the things they need, and she wants to be a good role model by demonstrating the importance of work. She says that she does not understand all of this work incentive information, and she just wants to forget the whole thing. What do you do? Case Study 4 You are explaining a benefit analysis to a man named Bill when, suddenly, he becomes angry and begins to escalate talking about how the government is trying to steal his money. He does not overtly threaten you, but his anger continues to grow and he is not making any motions to leave your office. What would you do in this situation? Case-Load Management Strategies Benefits specialists supporting a caseload of individuals in managing their benefits will need to be effective organizers and time managers. It will be difficult, if not impossible, to remain proactive if you are always finding yourself "behind the eight ball!" The following are some tools and suggestions to consider. The benefits assistance process involves long-term service to the consumer over a period that will usually be 12 months or longer. It immediately follows the completion of the screening and profiling process, and the presentation of a detailed report to the consumer. The period for benefits assistance will usually vary between 12 and 36 months, depending on individual circumstances. It could extend for more than 36 months; for example, if the benefits specialist will be monitoring a consumer's activity during the entire trial work period and extended period of eligibility. Similarly, benefits assistance may extend beyond 36 months if a benefits specialist is monitoring an approved PASS through the full period of the consumers undergraduate program. An individualized timeline should be prepared for each individual, which incorporates not only the planned timeframe for wellness visits and telephone/contact letters, but the specific touchpoints that will apply to their situation as well. Examples of other items to be incorporated into the schedule are contacts concerning the trial work period, extended period of eligibility, transition to 1619(b), work incentive milestone dates, and CDRs. Additionally, the benefits specialist may chose to establish a tickler file that lists by month all contacts and benefits assistance activities to be carried out for all consumers they are supporting in their caseload. Establishing and Maintaining a Case Record Main Case Record Elements Maintaining comprehensive records of all data gathered, reports developed, and interactions with the beneficiary/recipient and other parties is critical to good planning and management of benefits over time. The following is suggested as a format for organizing information specific to an individual's case in a case file: * Section 1 - Data collection instruments such as an Interview Questionnaire (screening/profiling) and/or Benefits Management Checklist. This is basically the benefits management timeline in a check-off format. * Section 2 - Correspondence with, and on behalf of, beneficiary/ recipient. This section includes the initial report to the consumer developed during the process of providing benefits advisement, reports from intermittent visits, and correspondence with other agencies and members of the individual's support network. * Section 3 - Case logs or a record of contacts with the individual whether they are in person, by telephone, or letter, etc. The case log should include documentation of issues discussed and actions taken, as well as provide dates. * Section 4 - Financial records and other reports or notices regarding benefits received. This section may also include SSI budget worksheets, a month-by-month listing of income, pay stubs, and so forth. * Section 5 - Information on work incentive programs, including PASS documentation, letters and documentation submitted on IRWEs, BWEs and so on. Any correspondence with SSA regarding work incentives would be maintained in this section. * Section 6 - Agency referral and intake forms and documents, release forms, SSA Appointment of Representative Form (SSA 1696). Importance of Consistent and Accurate Reporting to SSA Effective benefits management will ultimately depend on good communication with the Social Security Administration. A key component of this communication is reporting information to the SSA that will impact continued eligibility and benefit amounts. The benefits specialist should take the time to meet with local SSA staff to discuss reporting procedures, timelines and content. The following are some additional strategies to ensure information is reported appropriately to the SSA: * Encourage beneficiaries/recipients to develop their own personal Social Security notebook, complete with names and contact information, dates that contacts were made and any information obtained. Again, all written notices and letters from SSA should be saved in this notebook, as well as copies of documents submitted to SSA. * Keep a log of phone calls, office visits, and names of SSA staff members who assisted in any way. * Know which benefit is received (i.e., SSI and/or SSDI) * Know who is responsible for reporting information. The beneficiary or recipient is responsible unless they have a representative payee. * For both SSI and SSDI, report changes in earnings from employment. If the individual receives both benefits, ensure that the correspondence is directed to both the SSI and SSDI divisions. Failure to do so may result in one benefit being adjusted accordingly, while the other is not. * For SSI, keep SSA informed of any changes in resources, living arrangements, living expenses, student status, and marital status. * Provide documentation of subsidies the person may be receiving, as well as any work-related expenses they may have as a result of their employment. * Inform SSA of any change in work incentive utilization. SECTION SEVEN: OUTREACH Objectives 1. Understand importance and utility of a network. 2. Identify critical stakeholders. 3. Practice network-building strategies. CHAPTER 23: OUTREACH AND NETWORK BUILDING Introduction Essential to any customer-service based industry is the network upon which services and supports are built upon and targeted. Some of the fastest growing and most successful companies in the United States are those which are based on personal network marketing approaches-companies that utilize personal marketing agents to tap into their network of friends, colleagues and associates. What is a Network According to the American Heritage Dictionary of the English Language (Morris, 1969), a network can be defined several ways: * An openwork fabric or other structure in which rope, thread, wires, or other materials cross at regular intervals; * Anything resembling a net in concept or form, as by being dispersed in intersecting lines of communication; * A chain of interconnected radio or television broadcasting stations; and/or * A group or system of electric components and connecting circuitry designed to function in a specific manner. For the purpose of benefits planning and assistance, we take important elements from each to define a network as... "a dispersed tapestry of stakeholders crossing at regular intervals to share information and resources weaving a chain of interconnected activities, services and supports." Networking is an important skill and feature of benefits planning and assistance as it provides the context within which the practitioner will work. Many new benefits specialists may be entering the field with a small to nonexistent network. The remainder of this unit will focus on strategies and activities to enhance network building and outreach. Important Stakeholders Critical to the benefits specialist's network are several important stakeholders, including: individuals with disabilities, their families, their service providers, their advocates, their planners, their supporters, and SSA. Beneficiaries and Recipients with Disabilities The core of a benefits specialist's network is the beneficiaries and recipients who require benefits planning and assistance services and supports. Rapport and trust are the important elements of relationship building with this group. Past successes will further expand this network. Negative or unsuccessful experiences may pose an obstacle as to how others will perceive the services and supports provided. Family Members As with beneficiaries and recipients, family members are another prime stakeholder to invest in as part of the benefits specialist's network. As important as the trust and rapport built, is the extent to which the practitioner "listens" to needs, concerns and fears expressed by family members. In some cases, benefits received by the individual may in part support the financial well being of the person's immediate family. Investment and information sharing with this group is essential and may play another large role in expanding the practitioner's network. Advocates Advocates are broadly defined to include: peer counselors, independent living personnel, legal representation, due process representatives, and others charged with defending, supporting or advocating on behalf of the beneficiary or recipient. The savvy benefits specialist will understand the significance this group has as part of an effective network. While most would agree the beneficiary or recipient is the benefits specialist's primary customer, they do have secondary customers, which may include funders of their services. Here we begin to outline a struggle that may potentially exist as benefits specialists define their role in providing advocacy-related support. It is important to be aware of the impact advocacy may have on secondary customers, especially when providing counsel to individuals on actions they may need to take. An effective network would include linkages and relationships with and advocates within the geographic area being targeted, affording the benefits specialist a greater opportunity to refer the beneficiary and/or recipient in cases where potential conflict of interest may exist. Service Providers This is an important stakeholder group for benefits specialists, providing the services and supports that their customers may need but that they are not able, or equipped, to provide. This would include: employment networks, residential programs, providers of community rehabilitation services, state agencies, workforce investment councils, and other groups with specific areas of expertise. It is not expected that the benefits specialist be an expert in all areas, but that when the case arises, they have the ability to network their customers with those that do (e.g. rehabilitation counseling, vocational assessment, supported employment, community living, etc.). This group is also an important consumer of information and training that the practitioner may make available, as well as an important referral source. Planners/Case Managers Planners and case managers are another important stakeholder group to invest in the benefits planning and assistance process. Often, beneficiaries and recipients are already attached to another service delivery system. Whether it is state vocational rehabilitation, the mental retardation and developmental disability system, schools, or the mental health system, these individuals probably already actively participate in some sort of formal service delivery planning process, which is outlined in a planning document. Planners and case managers, besides being another potential referral source, may also play a key role in establishing long-term benefits planning and assistance supports. As the designers of individualized service delivery plans, they have the ability to integrate goals and objectives concerning benefits management that may result in the individual's long-term success. Support Personnel Support personnel are those individuals in the beneficiary/recipient's lives who have specific roles and responsibilities in supporting the person on a regular basis. These people are important members of the practitioner's network, as they are providers of reliable qualitative information about what is going on in the individual's life, where support needs exist, and potential safety net strategies. This group would also benefit from information and resource sharing and serve as a potential referral source. SSA Last but not least, SSA is a vital partner. The effective benefits specialist will maintain close relations and connections to both their local, state, and regional SSA office. Locally, they can establish important relationships and reporting protocols with claims representatives and employment support representatives (ESR). At the state level, they can keep abreast of proposed changes coming down the road and maintain relationships with PASS Specialists and ESRs. At the regional level they can learn about of other effective practices and regional roll-out of special demonstrations and events. Benefits planning and assistance is about establishing partnerships that enhance the self-sufficiency and economic wellness of beneficiaries and recipients while at the same time supporting their employment interests. Stakeholder Analysis - Exercise Working with a small group from your agency or by yourself, take fifteen minutes to begin conducting a Stakeholder Analysis. This is another important step in developing a broad marketing plan for benefits planning and assistance services and supports. This will help you identify your network and other stakeholders, who need to be brought into the fold. The Stakeholder Analysis is provided in Appendix H. If you are part of a larger agency or school providing benefits planning and assistance, you may wish to use the tool to conduct Stakeholder Analysis. Strategies for Network Building There are several ways to expand personal and professional networks within your community and geographic area being served. 1. Research agencies and schools through advertising, trade journals and newspapers 2. Become familiar with the array of services, supports and products available within your community targeted to individuals with disabilities 3. Research local needs and trends 4. Find out who the decision-makers are in the specific stakeholder groups you are targeting 5. Participate in the broad array of functions and activities offered around the human services community 6. Join/participate in human services coalitions/consortia 7. Tap into existing networks you maintain to secure advice and recommendations for broadening the network 8. Talk to other divisions or agencies and schools you or your agency is familiar with 9. Seek referrals from everyone - let your community know what you are attempting to do and how you can help 10. Offer secondary services and products to members of your network 11. Develop and disseminate information including fact sheets, brochures and cover letters, using both direct mail and Internet applications, such as listservs, to get your message out into the community 12. Enhance education and human interest through face-to-face contact; participate in events such as college fairs and job fairs and provide community education programs/presentations 13. Secure references from existing members of your network and past satisfied customers 14. Provide media releases of successes and stories of human interest Important Steps in Developing a Network Creating Mutual Gains As network members are beginning to be recruited, it is important to answer some preliminary questions to begin establishing mutual gains. This is an approach that employs the identification of mutual interests to resolve differences and establish common ground and includes: * Identifying what the end-result benefit is to both parties * What potential problems our collaboration may be able to resolve * Why someone would want this * How this might help both parties or individuals being served gain recognition, self-esteem, or a better quality product * How the other party or individuals being served might enjoy greater profit; and/or, * How future crisis may be avoided. Establishing Trust Establishing trust and rapport with an individual or stakeholder group is a human variable that must be addressed. The effective practitioner can accomplish this in several ways. First, being available is an important and often underrated trait. In this age of e-mail, voice mail, and automated phone answering systems it can often be difficult to connect with another human being. Positioning yourself as accessible and available to your network will ultimately result in your being relied upon as a consistent mechanism for information and other services. In our age of quality management initiatives, it can't be emphasized enough the role that "What I can do for you" versus "What can you do for me" can play in building trust and establishing rapport. When attempting to establish trust, the practitioner should never err on the side of over-promising what they can deliver. Establishing success stories up front and securing references and recommendation will go a long way in others building trust and confidence in your services and supports. Building Collaboration Building collaboration and making community connections is critical to expanding benefits planning and assistance networks. For the most part, connections with others will increase opportunities to: build on a community's strengths; provide for the whole person; increase potential for survival and growth; and potentially improve cost-effectiveness. Factors that impede connections: * Fear of putting the people we serve at risk, possibly because we may need to give up some responsibility; we feel we know the person best; it won't get done unless we do it ourselves * Easier to just do it yourself * No history or bad history of coordination * Needs are immediate * Little knowledge of available services, goals, operations * Able to operate independently * Turf issues and pride * Always done it this way * Don't have the time Factors that foster connections: * Recognition and sensitivity to differences * Understanding each person's and agency's goals, operations and services * Complementary goals with similar values and philosophy * Voluntarily entered relationships * Support from management * Scarce resources and fostered interdependency * Mutual gains established * Mutual planning * Frequent opportunity for information exchange * Capacity for data management and sharing of outcomes * Well organized and intended connections * Gradual implementation * Ongoing evaluation of outcomes of connections Maintaining an Effective Network Like a garden, a network is only as effective as the amount of time put into nurturing it. To simply have a list of agencies and individuals on a piece of paper is not enough. The practitioner needs to intentionally foster planned intersections with their network, regular points in time when either information and resources are shared, updates are provided, or other activities are planned that are essential to the livelihood and wellness of the network. A log for recording stakeholder contacts is an important tool. It not only provides a record of who the benefits specialists have been in contact with but also the topic and potential outcomes. This information can be easily established in a database program and easily summarized, analyzed and/or reported. A sample log that has been databases is provided in Appendix I. This contact log will prove useful in several areas: * Tracking outreach activities * Tracking short-term advisement, technical assistance, or problem solving * Tracking marketing activities * Logging community training * Documenting networking activities SECTION EIGHT: ETHICS Objectives 1. Understand ethical considerations a practitioner must make. 2. Negotiate ethical dilemmas. 3. Practice effective professional conduct. CHAPTER 24: ETHICAL CONSIDERATIONS Applying the Information in This Handbook There is an incredible amount of information contained in this handbook pertaining to SSA disability benefit programs, their associated work incentives, and the delivery of benefits planning, assistance and outreach services. The question now becomes, how should this information be applied in day-to-day practice? Benefits specialists face numerous situations in their work requiring a high degree of discretion, judgment, maturity, and the ability to balance competing demands. Solutions to benefits problems are not always cut-and-dried and there are times when benefits specialists must rely on their own internal moral compasses to achieve resolution. It is not enough just to know the material, although a firm grasp of the content is essential. A benefits specialist must be able to use the material in a consistently responsible manner. Ethical Considerations As in all professional counseling fields, benefits planning and assistance involves helping people resolve problems with highly critical and sensitive life issues. Benefits assistance provided to persons with disabilities is further complicated by the heightened vulnerability of persons with disabilities and the complexity of the information applied. Because of these facts, benefits specialists must commit to upholding stringent ethical standards and principles in the performance of their work. These principles can be grouped into 5 main categories: 1. Maintaining professional competence 2. Protecting consumer confidentiality 3. Serving consumer interests and respecting consumer choices 4. Avoiding conflicts of interest 5. Maintaining personal integrity Principle 1 - Maintaining professional competence Benefits specialists deal with critical issues relating to personal finances and health care coverage that can have a profound impact on a consumer's economic and physical well being. A serious error can have a disastrous effect on an individuals' ability to pay for food, housing, utilities, or essential medical services. It is important that benefits specialists recognize the power they wield through the information and advice they give. In order to provide sound advice, benefits specialists must attain and maintain a high level of knowledge and skill and apply this knowledge and skill effectively. Professional competence also includes the wisdom to recognize the limitations of one's knowledge and when consultation or referral is appropriate. It is important to understand that a benefits specialist could never achieve 100% competency in all areas and on all topics. The material is far too complex and changes too frequently to ever master it completely. In order to identify those areas in which external consultation, referral, or additional training may be necessary, benefits specialists must conduct a thorough assessment of skills and competencies. A self-assessment tool for benefits specialists is contained in Appendix L, which can assist with this task. The results of the self-assessment should direct the benefits specialist in his/her professional development. Finally, professional competence includes diligence in providing professional services in a courteous, prompt, planful and thorough manner. Every transaction with a consumer is a reflection of the benefits specialists' professional competence. Principle 2 - Protecting consumer confidentiality In order to provide effective services, benefits specialists often are required to gather a wide range of financial and personal information about the consumer. In some cases, information about the individual's disability may also be collected including medical and/or psychiatric records. All of this information must be kept strictly confidential and may not be disclosed to any external party without express written permission from the consumer. To accomplish this, the benefits specialist will need to use a standardized release of information form that has been carefully reviewed and signed by the consumer. These releases should be obtained at the initial meeting at which time the consumer should be informed that information would only be shared with external parties if approved by one of the signed releases. Remember that it is never permissible to release confidential information obtained from another source (such as the SSA) to anyone else, even with a signed release. Benefits specialists must also be aware of other ways that confidential information can be inadvertently exposed including email fax transmission and conversations with others. Principle 3 - Serving consumer interests and respecting consumer choices Benefits specialists must remain focused on serving the best interests of the consumers at all times. In most cases this equates to maximizing financial benefit from working while minimizing the negative impact of earnings on benefits. To accomplish this, the benefits specialist must use his/her knowledge and expertise to inform the consumer of all positive and negative effects of any chosen path and offer advice about the best course of action to pursue. While the benefits specialist may offer advice about strategies for maximizing positive employment effects, he/she ultimately must respect the choices made by the consumer. There will be times that consumers make choices contrary to the advice of the benefits specialist. Sometimes these choices are not in the best interests of the consumer in the opinion of the benefits specialist. The benefits specialist will have fulfilled his/her responsibility as long as all information has been provided to help the consumer understand the issues and make a fully informed choice. The specialist's job is to work toward the goals sought by the consumer, not what the specialist deems to be appropriate. Similarly, the specialist must remain clear about who the primary consumer is. The benefit specialists' job is to advocate for what the consumer desires, not what the parent, payee, job coach, residential services provider, vocational rehabilitation counselor, or SSA claims representative thinks is best. There will be times when it is very difficult to balance the competing desires of all involved parties. Principle 4 - Avoiding conflicts of interest A potential conflict of interest arises any time the benefits specialist, or his/her employer, has a real or apparent conflict with the best interest of the consumer. The clearest example of a conflict of interest would be where the SSA or another agency that is responsible for determining the consumers' right to a particular benefit employs the specialist. Another example would be where the specialist is related to or has a business relationship with the person at the SSA or another agency that is responsible for deciding issues related to the consumers' case. A third example is where the specialist, or his/her employer, is in a position to benefit monetarily from the consumer's work activity and benefit status. The best approach is to avoid any real or perceived conflicts of interest when providing BPA&O services. In cases where a potential conflict of interest exists, the specialist should disclose the potential conflict and continue to work with the consumer only if he/she agrees to do so despite the conflict. The disclosure and subsequent approval to continue services should be confirmed in writing to avoid future misunderstandings. Principle 5 - Maintaining personal integrity Consumers and their family members often place benefits specialists in a position of tremendous trust and confidence. The ultimate source of such trust is the benefits specialists' personal integrity. In deciding the proper course of action in any counseling situation, a benefits specialist must always rely on his/her own internal moral compass. While the benefits specialist is obligated to zealously pursue the interests of the consumer, this goal must be met within the bounds what is otherwise legal and ethical. The benefits specialist is not expected to pursue the consumers' interests if SSA's (or other government entity) laws, regulations, and policies clearly preclude what the consumer is seeking. Whenever is appears that what the consumer wants and what the benefits specialist knows is proper are in conflict, the specialist should make it clear that he/she is not willing to pursue the desired course of action. While benefits specialists are ethically obligated to inform the consumers of actions that are potentially illegal or improper as well as the consequences of pursuing such courses, they may not ethically report confidential information to the SSA or any other agency. If a consumer insists on pursuing an improper course of action, the best for the benefits specialist to inform the consumer that he/she must discontinue services. Planning for such issues in advance and entering into written agreements with consumers at the outset of the counseling relationship may avoid many ethical dilemmas. This agreement should spell out the consumer's rights under the benefits specialists' code of ethics as well as responsibilities for complying with all applicable SSA laws, regulations and policies. Examples of Ethical Dilemmas Faced by Benefits Specialists From the previous discussion it is clear that a great many ethical issues come into play when providing BPA&O services. The following scenarios further illustrate the difficult nature of some of these ethical issues. Read each scenario and work in small groups to strategize on how they should best be handled to uphold the standards previously described. Scenario 1: An SSDI recipient who been your client for several months and is now working full time and earning more than the current SGA amount. You have been working closely with his parents and have provided lots of information and training on various work incentives. The parents realize that the consumers' TWP is nearing an end. They ask you to assist them with claiming that the consumer is significantly subsidized in employment, even though your assessment is that the consumer works at a competitive level and is not supported by an agency. The parents explain that they really need to keep the consumer on disability benefits as he recently moved into an apartment that he would not be able to afford without the SSDI check. Scenario 2: A dual SSDI/SSI recipient accepts a volunteer opportunity working in a church day care. After some months, the church offers to give the consumer a periodic contribution from the congregations' collection funds to thank the consumer for all she has done to help the children and as a charitable contribution toward her living expenses. The consumer informs you of this arrangement and tells you that she has asked that the contributions be made in cash and that she does not intend to report it to the SSA, as it is not really earned income. Scenario 3: the employer offers an SSI recipient who has been working part time for some months a full time position. The consumer is capable of maintaining full time employment but tells you that she does not want to accept a full time position because she does not want her SSI check to reduce any further. Scenario 4: An SSI recipient who also receives HUD rent subsidy, food stamps and TANF payments with Medicaid for her two children tells you that she earns extra money by giving manicures to friends, relatives and neighbors. She has never reported this as income even though she sometimes earns as much as $300 in a month. She is fearful of reporting this income because of the combined effect on all of the cash and in-kind transfer benefits she receives. Code of Professional Conduct The benefits specialist is expected to maintain professional relationships with an array of stakeholders including consumers, family members, and employees of the SSA or other agencies. It is important that the benefits specialist approach all of these relationships with the highest degree of professionalism. It is good practice to treat all beneficiaries/recipients as any successful business would treat its customers. When meeting for scheduled appointments, make sure timeliness is observed and allow sufficient time for the meeting. If an appointment must be cancelled or changed, let the consumer know about it at as early as possible. Remember that the consumer's time is just as valuable as your own. These practices should apply to all those you meet with, including agency personnel or SSA representatives. Much of the benefit specialists' work may be conducted over the telephone. A good rule of thumb is to return phone calls within one business day. It is a good practice to use your voice mail messaging system or agency receptionist to let callers know that you are out and when you will return. This information will help callers gauge when they can expect a return call. For benefits specialists with very challenging schedules, telephone appointments can be an efficient way to conduct business. It is also a good method for limiting the number of conversations with consumers who call frequently. Despite the active use of the telephone and the increased use of e-mail, letter writing is still the primary method of conveying or confirming important information. Correspondence should be dated, appropriately formatted, signed by the sender with title indicated, and printed on agency letterhead. Always proofread correspondence before sending it to make certain that it contains no typographical or content errors. Always retain a copy of correspondence for the case record. When using fax machines, be sure to keep a copy of the cover sheets as proof that documents were transmitted. When using e-mail, follow the same rules as for agency correspondence. E-mail culture seems to allow formality in communication, but remember: this is a method of professional communication and should be treated as such. Most e-mail messages sent and received should be printed out with a copy retained in the case record. Finally, remember that you must work in close partnership with SSA representatives and other agency personnel to serve the best interests of beneficiaries/recipients. You will not be successful in this endeavor if you do not achieve and maintain positive professional relationships with these persons. It is essential that benefits specialists are polite when communicating with other professionals. The benefits specialist is only one player in the equation and must not try to work in isolation of all the other stakeholders. It is only by pulling together all relevant players and working together as a team that quality BPA&O services can be provided. Next Steps The first thing to do after completing this training is nothing. By that we mean that you need to go back to your state project and let the information you have just been bombarded with sink in a little bit. The next step is to start gathering the information you need on all of the relevant state benefits programs and begin to learn it. Finally, you will need to devise a professional development plan based upon the results of your self-assessment to gain mastery of the content or techniques you identified as needing improvement (see Appendix L). To remain effective, benefits specialists must engage in an ongoing process of skill upgrade. Get used to the fact that you will never "graduate." APPENDIX A: SAMPLE JOB DESCRIPTIONS Job Description: Benefits Specialist Purpose Footnote Reference 1: This position will provide benefits planning, assistance and outreach and management support too SSA beneficiaries and recipients with disabilities who are exploring career development, and/or pursuit, maintenance or advancement of employment. The benefits specialist collects data on individual's current benefit status, provides critical analysis of impact of work and earnings on these benefits, and makes recommendations to the individual and other stakeholders in their life as to safety nets and benefit management plans that should be put into place as the individual develops a plan for employment. This specialist integrates benefit support plans into existing service delivery constructs to ensure continuity of the employment planning and benefits advisement and management process. Footnote 1: Note: An individual may not perform these duties on a full-time basis. In fact, often the supports and services outlined within this description are frequently provided as part of the responsibilities of another job classification. For example, job coaches often report between 5-20% of their time being devoted to delivery of services and supports outlined within this description. The same for individuals classified within school districts as transition planners. Supervision: Individual benefits specialists are supervised in accordance with the human resources policy and procedures maintained by the agency/organization they are employed with. Outputs of work should be supervised and evaluated by an individual with an understanding of the complexity of the position. In addition, to ensure the continuous quality improvement of services and supports provided, the specialist regularly seeks customer feedback. Major Responsibilities: Network Building/Outreach: * Conducts outreach to key stakeholders including: individuals with disabilities; their families, advocates and providers; and employment networks * Shares information regarding SSA disability/return to work programs and work incentive provisions across stakeholder groups * Identifies individuals and cultivates SSA-related expertise to expand network of advisement and management supports available in a specific geographic location * Establish collaborative relationships with relevant agencies and organizations to gain knowledge and access to ongoing information and support * Maintains strategic plan for outreach and marketing Benefits Planning: * Identifies and documents personal demographics * Profiles individual's benefit status including: - type and amounts of benefits (SSI or SSDI); - types and amounts of unearned income (e.g. unemployment, Veteran's Benefits, civil service, railroad retirement pension, alimony, child support, private disability insurance, worker's compensation, etc.); - types and amounts of financial needs-based assistance (e.g. Pell Grants, TANF, food stamps, state subsidized housing, HUD, and other subsidies); - earned income and/or wages from self-employment; - health insurance status; and, - for SSDI, number of trial work period and extended period of eligibility months used. * Assesses and identifies current work status including: - supports and subsidy provided; - past/present service providers; - work history and references; and, - history of impact of work on benefits in the past. * Conducts analysis of forementioned * Applies different benefit scenarios to study impact and effect of future earnings on benefit status * Develops report highlighting and outlining options and recommendations for consideration as part of the career development and employment process * Supports the individual, their key stakeholders, and supporters in understanding the report and defining next steps for both the individual being served and the benefits advisor If deemed appropriate and needed: * Assists the individual, their key stakeholders, and their support teams in making informed choices and establishing both employment-related goals as well as needed benefits management supports Benefits Assistance: * Evaluates and understands the array of service delivery plans that may be intersecting and dissecting the individual's life and assists the individual, the key stakeholders and the employment coordination team in incorporating benefits management goals and objectives into existing service delivery planning constructs (e.g. Individualized Education Program, Individual Plan for Employment, Individual Service Plan, etc.) * Informs the individual, their key stakeholders and their support teams as to touch points they will need to be sensitive to in regard to reporting, reviews, redeterminations, documentation and other areas * Ensures that a comprehensive plan has been developed that identifies: - supports/activities needed; - time frames - responsibilities and roles - desired outcomes - resources needed - quality indicators * Provides or identifies providers of proactive benefits management and monitoring including, but not limited to: - intermittent wellness visits (every 3-6 months as prescribed by team); - regular ongoing communication via phone, letter, e-mail, etc...; - updating knowledge and information sharing of impact of new policies on benefit and employment status; - provision of crisis management supports; - information and referral; and, - problem solving and advocacy. * Assesses, evaluates and informs on touch point issues regarding SSI including, but not limited to: - age 18 redetermination and possible shifts to either SSI as an adult, SSDI/DAC, denial of continued benefits or continuation of benefits if enrolled in an approved vocational rehabilitation program; - 1619(b); - increase in earned and unearned income; - increase in resources; - marital status; - living arrangements; - in-kind supports; - over and underpayment; - continuing disability review; and, - use of work incentives. * Assesses, evaluates and informs on touch point issues regarding SSDI including, but not limited to: - trial work period; - extended period of eligibility and grace period; - continuing disability review; - extended Medicare coverage; and, - loss of job. Qualifications: Must possess excellent written and oral communication, interpersonal, problem solving, organizational skills, mathematical calculation proficiency, and like working with people. Knowledge of vocational rehabilitation, employment and training is preferred; Bilingual/bicultural helpful. Individuals who have experience as consumers of disability-related services and in providing peer counseling, advocacy and support are encouraged to apply. Job Description: Protection and Advocacy for Beneficiaries of Social Security (PABSS) Purpose: Advocate - Protection and Advocacy for Beneficiaries of Social Security (PABSS) Supervision: PABSS Unit Director Scope: This is a professional position responsible for the provision of services to Social Security Disability Insurance and Supplemental Security Income beneficiaries with disabilities who want to secure or retain employment and need services and assistance to allow them to work. This position will: * Provide information and referral to beneficiaries with disabilities about work incentives and employment, including information on the types of services and assistance that may be available to assist them in securing or regaining gainful employment; * Investigate and review any complaint of improper or inadequate services provided to a beneficiary with a disability by a service provider, employer or other entity involved in the beneficiary's return to work effort; * Provide consultation to and legal representation on behalf of beneficiaries and disabilities when such services become necessary to protect the rights of such beneficiaries; * And advocate to identify and correct deficiencies in entities providing vocational rehabilitation services, employment services and other support services to beneficiaries with disabilities. Major Responsibilities: * Provide information, referral, and advocacy services to obtain services and supports which are commonly recognized as impacting on Social Security beneficiaries' ability to obtain, maintain, or retain employment including ancillary supports, which may include, but is not limited to, assistance to coordinate transportation services, personal care assistants, childcare, assistive technology, and healthcare. * Conduct timely intakes to ascertain the facts and issues of client problems, provide accurate information and counsel about individual rights and assume responsibility for the proper handling of individual casework. * Investigate, research and prepare appropriate responses to requests for information and/or assistance in accordance with Agency program procedures. * Assist beneficiaries in resolving disputes and differences with providers, employers, attorneys, benefits planning, assistance, and outreach (BPAO) programs, employment networks, advocacy organizations, and other service providers/entities involved in the Social Security beneficiary's return to work effort through alternative means of dispute resolution, including fact-finding, facilitation, good-faith negotiation, conciliation, mediation, arbitration, and any combination of procedures, that may be used to address disputes or issues that arise in their return to work efforts. * Assist beneficiaries secure access to meaningful opportunities to prepare for employment that is consistent with their interest, preferences and capabilities. * Endeavor to improve programs that provide services to and promote the employment of social security beneficiaries, by working with said agency and reporting/discussing problems with the Program Manager. * Address any issues related to obtaining, maintaining, or advancing in employment, including those issues, which may interfere with the Social Security beneficiary's ability to maintain employment. * Address any issues of discrimination related to a Social Security beneficiary's employment, be it in the application process or a later failure to provide reasonable accommodation, promotion, etc. * Represent beneficiaries of Social Security in connection with their return to work efforts. * Conduct outreach and provide education and training to social security beneficiaries to inform them of the availability of work incentives and VR service providers in both the public and private sectors who can provide them the employment and rehabilitation services they need to enter or return to the workforce. * Maintain and disseminate resource materials. * Monitor state/federal regulations and policies pertaining to program area and participates in regulatory advocacy. * Maintain public contact with organizations, consumer groups, community agencies, and others for the purpose of education and training about beneficiaries of Social Security related issues and benefits and rights and laws. * Coordinate with civil rights and human service programs that provide services to and promote employment for beneficiaries of Social Security to obtain, maintain, or retain employment, as well as work to educate employers as to Social Security beneficiaries' opportunities to obtain real jobs that pay real wages. * Participate cooperatively in advocacy unit as part of an interdisciplinary team and participates in regular case unit staffings to review and discuss casework. * Perform related tasks consistent with skills and abilities and general responsibilities as may be assigned. Qualifications: The employee in this position must possess the following knowledge, skills and abilities in order to perform the required duties: * Knowledge of state/federal laws, programs and issues relating to civil rights and human service programs, specifically as they correlate with the provision of PABSS services to assist beneficiaries of Social Security to obtain, maintain, or retain employment. Specialized knowledge in a disability-related field may be required. * Sound professional judgment. * Sound reasoning skills, which will allow the employee to effectively analyze complex cases, make decisions about the proper course of action to take in cases and to advocate effectively and persuasively on behalf of beneficiaries of Social Security. * Oral and written communications skills which will allow the employee to effectively and professionally communicate with beneficiaries of Social Security and other individuals over the telephone, in writing and in person, including but not limited to, employers, governmental agencies, benefits planning, assistance, and outreach (BPAO) programs, employment networks, advocacy organizations, and other service providers/entities involved in the Social Security beneficiary's return to work effort. * Interpersonal skills, which will allow the employee to maintain productive working relationships with all staff members and to work in an interdisciplinary team with other professionals. * Organizational skills, which will allow the employee to manage multiple priorities and tasks and allow the employee to meet self imposed and externally set deadlines. * Ability to take direction, supervision, and comply with the office policies and procedures of the Center. Education: * Four-year college degree in rehabilitation, social work, mental health counseling, or a related social service or education degree. * Five years experience in advocacy or a related field. Education beyond a four-year degree can substitute for experience on a year-for-year basis, not to exceed three years. APPENDIX B: WORK INCENTIVE RESOURCES, PUBLICATIONS, AND REFERENCES Ball, J., Gerhardt, P.F., Holmes, D.L., & Alessandri, M. (1994). A Parents Guide to the SSA and Social Security Work Incentive Programs.(3rd Ed.). Princeton, NJ: Eden Press. Berkowitz, Monroe. (1994). Improving the Return to Work of Social Security Disability Beneficiaries. National Academy of Social Insurance Conference "Disability and Work": Santa Monica, CA. Brady, Kathleen. (1994). Using SSI and DI Work Incentives: What Assistance is Being Provided? By Whom? How is it Financed? National Academy of Social Insurance Conference "Disability and Work": Santa Monica, CA. Children's Disability Training Manual. (March 1997). Social Security Administration. Office of Disability: Baltimore, Maryland. Publication No. 64-075. Colvin, C.W. (December 1, 1997). Plan for Achieving Self Support. Social Security Administration: Baltimore, MD. Davey, J., Lopez-Soto, E., Nellist, R., Saran, Mr.R., Sheldon, J.R., Tarantino, L., & Udell, D. (1994). Benefits Management for Working People with Disabilities. Rochester, NY: Greater Upstate Law Project. Department of Health and Human Services. Program Operations Manual System, Part 05, Supplemental Security Income; Subchapter 70. Baltimore, MD: Social Security Administration. Families in Control of the System. (1992). Guide to Social Security Benefit Programs and Work Incentives. Richmond, VA: Virginia Commonwealth University, Employment Support Institute. Federal Register, April 6, 1989, Part II. Department of Health and Human Services, Social Security Administration. Hoynes, H.W., & Moffitt, R. (1994). The Effectiveness of Work Incentives in DI and SSI: Lessons from Other Transfer Programs. National Academy of Social Insurance Conference "Disability and Work": Santa Monica, CA. Hubbard, Therese, S. (1987). What Advocates and Service Providers Should Know About the Effects of Employment on Social Security Disability Insurance and Supplemental Security Income. Eugene, OR: University of Oregon, Rehabilitation Research and Training Center. Hunt, H.A., Habeck, R.V., Owens, P., & Vandergoot, D. (1994). Disability and Work: Lessons from the Private Sector. National Academy of Social Insurance Conference "Disability and Work": Santa Monica, CA. Lassiter, M., O'Mara, S., Axton, L. (1987). A Layman's Guide to Successful Advocacy with the Social Security Administration. Norfolk, VA. Martin, D.A. (1994). Some SSI/SSDI Work Incentive Proposals. National Academy of Social Insurance Conference "Disability and Work": Santa Monica, CA. Office of Supplemental Security Income, Division of Program Management and Analyses. (1990). Supplemental Security Income: Plans for Achieving Self-Support. SSA Program Circular, No. 05-90-0. O'Mara, Susan (1994). Understanding Social Security Benefits. Virginia Commonwealth University, Employment Support Institute: Richmond, VA. O'Mara, Susan (1994). Understanding and Using the PASS Work Incentive. Virginia Commonwealth University, Employment Support Institute: Richmond, VA. O'Mara, Susan & Ferrell, Connie. (1993). Social Security Regulations Impacting the Employment of Persons with Disabilities. Cornell University, Program on Employment and Disability: Ithaca, New York. Parent Educational Advocacy Training Center. (1986). Guidebook for People Receiving Disability Benefits. Alexandria, VA: Supported Employment Opportunities. Plans for Achieving Self Support, Inservice Training, SSA Office of Human Resources, Training and Management Analyses Office of Training, August, 1988. Program Operations Manual System, Part 05, Supplemental Security Income; Subchapter 70. U.S. Department of Health and Human Services, Social Security Administration. SSA Program Circular, Supplemental Security Income, No. 05-90-0 SSI, Plans for Achieving Self Support (PASS). Office of Supplemental Security Income, Division of Program Management and Analyses, September 28, 1990. SSA Program Circular, Philadelphia Region, Disability Insurance, No. 89-2 Job Coach Services in Supported Employment. "Supplemental Security Income Seminar Materials." (1990). Social Security Administration: Baltimore, MD. SSInsights: Gathering Medical and other Evidence. (1997). Institute for Child Health Policy: Gainsville, Florida. Selby, Paul. (1994). Project Door's Guide to Using Social Security Work Incentives. Indiana University, Institute for the Study of Developmental Disabilities: Bloomington, IN. Sheldon, J. (1994). Work Incentives for Persons with Disabilities Under the Social Security and SSI Programs. Clearinghouse Review, pp. 236-251. Sheldon, J. (1991). PASS: SSI's Plan for Achieving Self-Support. Clearing-house Review, pp. 962-978. Sheldon, J. (1989). Work Incentives for Disabled Persons Under the Social Security and SSI Programs. Clearing-house Review. 22, 1074-1087. Social Security Administration. Job Coach Services in Supported Employment. SSA Program Circular. Philadelphia Region, No. 89-2. Social Security Administration. (1994). A Desktop Guide to Social Security and SSI Work Incentives. Washington, DC: U.S. Government Printing Office, (Pub. No.05-11002). Social Security Administration. (1994). Disability. Washington, DC: U.S. Government Printing Office, (Pub. No. 05-10029). Social Security Administration. (1994). Disability Notes. Baltimore, MD: Office of Disability, (Pub. No.64-040), 12). Social Security Administration. (1994). Disability Notes. Baltimore, MD: Office of Disability, (Pub. No.64-040, 11). Social Security Administration. (1994). How Social Security Can Help with Vocational Rehabilitation. Washington, DC: U.S. Government Printing Office, (Pub. No.05-10050). Social Security Administration. (1994). If You Are Blind: How Social Security Can Help You. Washington, DC: U.S. Government Printing Office, (Pub. No. 05-10052). Social Security Administration. (1994). State Assistance Programs for SSI Recipients. Washington, DC: U.S. Government Printing Office. (Pub. No. 17-002). Social Security Administration. (1994). Working While Disabled: How Social Security Can Help. Washington, DC: U.S. Government Printing Office, (Pub. No.05-10095). Social Security Administration. (1993). Graduating to Independence. Washington, DC: U.S. Government Printing Office. Social Security Administration. (1993). Social Security Handbook 1993 (11th Ed.) Washington, DC: U.S. Government Printing Office, (Pub. No.65-008. Social Security Administration. (1992). Disability Evaluation Under Social Security. Washington, DC: U.S. Government Printing Office, (Pub. No.64-039). Social Security Administration. (1992). Red Book on Work Incentives. Washington, DC: U.S. Government Printing Office. (Pub. No.64-030). Social Security Administration. (1992). Understanding SSI. Washington, DC: U.S. Government Printing Office. (Pub. No.17-008). Social Security Administration. (1991). Working While Disabled: A Guide to PASS While Receiving SSI. Washington, DC: U.S. Government Printing Office, (Pub. No.05-11017). Walling, M. (1994). Preliminary Analysis of Final Regulation Changes to Title 20, Parts 404 and 416, Subpart V: Payments for Vocational Rehabilitation Services. Media, PA: Service Enhancement Associates. Whitehead, Claude & McCaffrey, Frances (1988). "A Guidebook for the Employment Initiatives of the 99th Congress: Opportunities for Persons with Disabilities." Columbus, OH. APPENDIX C: 2005 State SSI Payment Schedule To be obtained and inserted by the training participant APPENDIX D: 2005 1619(B) THRESHOLDS BY STATE 1619 (b) Thresholds DISABLED State - Alabama Threshold - $20,553 State - Alaska Threshold - $44,550 State - Arizona Threshold - $24,489 State - Arkansas Threshold - $23,075 State - California Threshold - $30,754 State - Colorado Threshold - $29,886 State - Connecticut Threshold - $45,095 State - Delaware Threshold - $31,185 State - District of Columbia Threshold - $28,016 State - Florida Threshold - $23,991 State - Georgia Threshold - $22,912 State - Hawaii Threshold - $23,450 State - Idaho Threshold - $34,527 State - Illinois Threshold - $28,686 State - Indiana Threshold - $29,194 State - Iowa Threshold - $24,214 State - Kansas Threshold - $28,809 State - Kentucky Threshold - $23,266 State - Louisiana Threshold - $23,580 State - Maine Threshold - $34,417 State - Maryland Threshold - $29,436 State - Massachusetts Threshold - $31,786 State - Michigan Threshold - $21,365 State - Minnesota Threshold - $39,531 State - Mississippi Threshold - $22,433 State - Missouri Threshold - $26,668 State - Montana Threshold - $24,689 State - Nebraska Threshold - $30,801 State - Nevada Threshold - $26,738 State - New Hampshire Threshold - $39,291 State - New Jersey Threshold - $28,041 State - New Mexico Threshold - $27,339 State - New York Threshold - $37,575 State - North Carolina Threshold - $26,403 State - North Dakota Threshold - $31,353 State - Ohio Threshold - $28,576 State - Oklahoma Threshold - $21,216 State - Oregon Threshold -$24,655 State - Pennsylvania Threshold - $24,795 State - Rhode Island Threshold - $31,667 State - South Carolina Threshold - $24,593 State - South Dakota Threshold - $28,186 State - Tennessee Threshold - $19,091 State - Texas Threshold - $26,014 State - Utah Threshold - $26,326 State - Vermont Threshold - $29,976 State - Virginia Threshold - $25,484 State - Washington Threshold - $22,630 State - West Virginia Threshold - $24,346 State - Wisconsin Threshold - $29,921 State - Wyoming Threshold - $22,988 State - North Mariana Island Threshold - $14,916 BLIND State - California Threshold - $32,290 State - Iowa Threshold - $24,742 State - Massachusetts Threshold - $32,635 State - Nevada Threshold - $29,361 State - Oregon Threshold - $25,255 APPENDIX E: ACCESSING SSA INFORMATION AND OTHER RESOURCES ONLINE Social Security Administration "Online": Assessing SSA Publication via the Internet/Fax More public information from the Social Security Administration is now part of the "information superhighway." The agency has established Social Security Online, an expanded Internet site at its Maryland headquarters for electronic distribution of agency publications. Internet is a public-domain network linking universities, foundations, libraries, corporations, government agencies and other host organizations. An estimated 20 million users at 22,000 networks worldwide can use Internet to exchange information at their desktop personal computers. Social Security Online is part of the recent surge of interest in the Internet that was generated by the National Performance Review (NPR). The NPR report urges Federal agencies to increase their efforts to deliver information and services to the public through electronic communications. Through Internet, users now can access wide range of Social Security information products. These products, which are also available in traditional printed form, include: * Public statements by Commissioner Aphel. * Publications describing the Social Security retirement survivors and disability insurance, and Supplemental Security Income programs. Some are in Spanish as well as English. * Statistical tables about these programs. * Newsletters and other periodicals. * Legislative updates and press releases. * Actuarial reports on the state of the Social Security trust funds. * Frequently asked questions and answers. Users are free to copy and print material from Social Security Online and redistribute it to others. Because these are U.S. government publications, there are no copyright restrictions. Internet users have several ways to access Social Security Online, depending on their preference and the computer hardware and software available to them: * Mosaic, a graphical interface that presents photos and text in magazine-style format. The Internet address is: WWW.SSA.GOV * Gopher, a text-only hierarchical menu system. The Internet address is: GOPHER.SSA.GOV If your protocol requires you to type "GOPHER" in order to begin, the address might be: GOPHER GOPHER.SSA.GOV * File Transfer Protocol (FTP), for direct transfer of text files to the user's local computer. The Internet address is: FTP.SSA.GOV * Electronic mail document server, which provides documents through an automated e-mail reply system. Send an e-mail message "send index:" (without the quotes, no other text) to: INFO@SSA.GOV You will then receive an index of documents by return mail. Internet users can post questions about Social Security information products and can leave messages suggesting improvements in Social Security Online. The agency's toll-free number, 1-800-772-1213, as they apply to individuals can handle questions about Social Security benefits. SSA's Fax Catalog In addition, interested individuals can also request more than 180 documents from SSA through fax catalog. Documents include fact sheets about various aspects of SSA. Call the toll free number 1-888-475-7000 from a touchtone phone and a voice menu will lead you through the simple steps to receive documents. Up to three documents each time a call is placed can be requested. Searchable National Resource Directory: This online resource provides quick access to a searchable database of the following resources by state: VR Agencies DD Agencies MH Agencies Community Rehab Providers P&A Programs BPA & O Projects SPI Projects Educational Departments PASS Specialists ESRs Work Incentive Liaisons and more Go to: http://www.passonline.org/resources On-line PASS Application and Tutorial: A website dedicated to providing an on-line PASS tutorial; interactive application which can be completed, printed and/or saved; and, a resource directory. Go to: http://www.passonline.org or http://www.ilr.cornell.edu/ped/pass Work Incentives Learning Portal: This interactive on-line learning tool is an internet-based version of this curriculum, complete with video streaming and exercises. Go to: http://www.ilr.cornell.edu/ped/ssa APPENDIX F: DATA COLLECTION: A MODEL QUESTIONNAIRE Benefits Screening Profile A Sample Questionnaire This Questionnaire is adapted from one developed by Neighborhood Legal Services, Inc. of Buffalo, New York and is intended as an aid to analyze the effect of work on benefits. It should be used as a guide in conducting both telephone and in-person interviews of persons with disabilities and/or the persons who seek assistance on their behalf. In some cases the interviewer will need to gather no more than a fraction of the information sought by the form. In other cases the interviewer will want to cover all or most of the questions. If in doubt, obtain all the suggested information during the interview and gather any documents (e.g., Social Security Administration notices) that might be relevant. Name of Interviewer: Date of Interview(s): Was the Client/Consumer Interviewed? __ yes __ no Other Person Interviewed (i.e., not the client/consumer): Initial Questions Presented: I. Personal Demographics Name: Social Security #: Address: County of residence: State of residence: Date of birth: Type of residence, check one: __ Home, apartment __ Group home __ Intermediate Care Facility (ICF) __ Hospital __ Other, please describe: Phone: Home phone: Work phone: Fax: E-mail: Residential placement funding (specify): Married / single / divorced (circle one) Name of spouse: Names, ages of children: Living arrangements Live alone? __ yes __ no Live with spouse? __ yes __ no Live with children? __ yes __ no Live with roommate? __ yes __ no Share expenses? __ yes __ no II. Personal Direction and Future Outlook Reason for referral: Expectations for services being requested: Preferred location to receive services: Individual's long-range dreams and aspirations: Employment: Postsecondary and/or continuing education: Community living: What the person expresses they need to achieve their desired outcomes (frame as supports): Individual's current family and social connections: III. Disability Description Primary diagnosis: Secondary diagnosis: Tertiary diagnosis: Age of onset of disability: Specific date if available: Currently seeing a doctor or therapist? __ yes __ no Name(s), address(es) of doctor(s) or therapist(s): Medication, please list: Any side effects: __ yes __ no Describe side effects: How does disability limit activities? How does disability limit ability to work? IV. Involvement With Other Agencies / Support Systems Is the individual still enrolled in secondary school? __ yes __ no If yes, name of school: Name, phone number of teacher: Describe education program: Is the individual enrolled in continuing education or a postsecondary education institution? __ yes __ no If yes, name of school: Name, phone number of counselor: Describe education program: Is the individual involved with the state VR agency? __ yes __ no If yes, name of agency: Name, phone number of VR counselor: Describe program, services getting from agency: Is the individual involved with a private VR agency? __ yes __ no If yes, name of agency: Name, phone number of VR counselor: Describe program, services getting from agency: Is the individual involved with the State MR/DD system? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Is the individual involved with the State MH system? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Is the individual involved with any other agencies? __ yes __ no If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: If yes, name of agency: Name, phone number of case manager/rep: Describe program, services getting from agency: Briefly describe other informal or unpaid supports in the individual's life (family, friends, etc.): V. Monthly Income Unearned Income: SSDI amount: Type of benefit (check appropriate benefit): __ Against own record __ Disabled Adult Child __ Widows/Widowers __ Other: __ Unknown Unemployment amount: Veteran's benefit amount: Railroad Retirement Pension amount: Alimony/Palimony amount: Child Support amount: Private disability insurance amount: Worker's Compensation amount: Other amount (specify types): Financial Needs-Based Assistance (means tested): SSI amount: Pell grant amount: TANF amount: Food stamps amount: State subsidized housing: __ yes __ no amount: HUD: __ yes __ no amount: Other amount (specify types): Anyone in household receive welfare benefits? __ yes __ no Describe form and amount: If individual receives SSDI or SSI: Name, address of Social Security office serving them: If known, name, address, phone, fax and email address of Claims Representative serving them: Earned Income/Wages: ___ employed by others ___ self-employed Monthly gross amount: Weekly gross amount: Bi-weekly gross amount: If wages vary, please explain: Other income in household: Spouse, describe form and amount: Children, describe form and amount: VI. Resources (Relevant to SSI, Medicaid eligibility.) The individual Own home __ yes __ no If jointly owned, please indicate other owner(s): Bank accounts Savings, list amount: Checking, list amount: Other, describe and list amount: Individual retirement account (IRA), tax deferred annuity or similar retirement account - describe and list amounts: Vehicle owned by individual Model and year: Check one: __ car __ van __ truck __ other, describe: Current fair market value: If market value is more than $4,500, is it: Modified for use by a person w/disability? __ yes __ no Used as transportation to get to work? __ yes __ no Used for necessary medical appointments? __ yes __ no Responsible relative with whom person resides Check one: ___ spouse ___ parent(s) ___ other, describe: Own home __ yes __ no Bank accounts Savings, list amount: Checking, list amount: Other, describe and list amount: Individual retirement account (IRA), tax deferred annuity or similar retirement account - describe and list amounts: VII. Property Essential for Self Support Describe any property owned (and its value) that is used in job as an employee (such as mechanic's tools, carpenter's tools): Describe any property owned (and its value) that is used in "self employment"(such as office equipment, company vehicle, stock, business bank account): VIII. Employment Information (If Employed, About to Start Working or Considering a Job) Name, address of employer or potential employer: Describe job (or potential job) Title: Duties: Hours: Salary/hourly wage: Benefits: Date you started working (as employee): How job was found? Found on own: __ yes __ no Agency helped find job, describe: If self employed (or potentially self employed) Describe business: Date started: Was job selected because of limits of disability? __ yes __ no If yes, please explain: Any extra or special supervision on job? __ yes __ no If yes, describe: Is this a "supported employment" position? __ yes __ no Agency sponsoring job: Is there a job coach? __ yes __ no Name: Hours per month: Services performed: How long will job coach remain in picture? Does government agency (i.e., other that employer) pay all or part of wage? __ yes __ no Please describe: Please record work history (past 10 years) or attach resume/vita. Place of Employment Title Duties Wage/Hours Dates Place of Employment Title Duties Wage/Hours Dates Place of Employment Title Duties Wage/Hours Dates Place of Employment Title Duties Wage/Hours Dates Briefly describe any past attempts at self-employment: Business Type Location Dates Income Reason for Cessation IX. Trial Work Period (TWP) Analysis This section applies to SSDI recipients only. To complete this section, it may be necessary to develop a comprehensive, month-by-month, history of work and wages since the consumer first started collecting SSDI benefits. This can be done on the attached "Notes" pages or on a separate document. Also, if the person is self-employed you may need to discuss what constitutes a trial work month. NOTE: The minimum gross wages for a TWP "services month" was $200 from 1/90 to 12/00; $530 during calendar year 2001; and will be $560 during calendar year 2002; $570 during calendar year 2003; $530 during calendar year 2004 and will be $590 during calendar year 2005. Date when first received SSDI? Has person worked and earned more than TWP amount in any month(s) since first receipt of SSDI? __ yes __ no If no, full nine-month TWP available. If yes, continue through questions. Did person use up nine TWP months before 1/1/92? If yes, no TWP available unless SSDI terminated, eligibility re-established after new application and new five-month waiting period. If person did not exhaust TWP before 1/1/92 Work nine TWP months during 60-month period which ended after 1/1/92? __ yes __ no If yes, TWP exhausted. If less than nine TWP months during 60-month period, list each TWP month during past 60 months. For each, list month, year and gross wages earned. [Note: In many cases, will have to obtain information from SSA. This information is now available through the Benefits Planning Query or BPQY, which can be requested from SSA.] Month Year Gross Wages Earned 1. 2. 3. 4. 5. 6. 7. 8. 9. Based on information, how many TWP months left? X. Extended Period of Eligibility (EPE) Analysis (SSDI recipients only) Ninth TWP month (month/year): Beginning of EPE (month/year): Last month of 36-month EPE (month/year): Remember, during EPE: The first time that the individual is determined to be performing substantial gainful activity by earning more than the applicable SGA amount, they will get SSDI checks for that month and two more (i.e., during the "grace period") Following the grace period: - No SSDI check during months countable gross wages exceed the SGA amount. - Will get SSDI check when countable gross wages less than the SGA amount. Impairment related work expenses (IRWEs) and subsidies are deducted from gross wages. Listing of EPE payment, nonpayment months: This should be done on a separate worksheet. XI. EXPEDITED REINSTATEMENT (EXR) A. Has individual received SSDI benefits in the past? __ yes __ no If no, stop and go on to B. If yes, continue. Did individual lose SSDI due to performance of SGA? __ yes __ no If no, stop and go to B. If yes, continue. Has individual completed their TWP and EPE? __ yes __ no If no, stop and go to B. If yes, continue. Has individual either stopped working or ceased performing SGA? If no, stop and go to B __ yes __ no If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSDI claim. B. Has the individual received SSI benefits in the past? __ yes __ no If no, stop. If yes, continue. Did the individual lose SSI due to budgeting of wages or a combination of wages and other income? __ yes __ no If no, stop. If yes, continue. Is individual currently receiving Medicaid through the 1619(b) program? __ yes __ no If yes, stop. The EXR provisions are not needed to reinstate SSI cash benefits. If no, continue. Has individual received either SSI cash benefits or 1619(b) Medicaid within the past 12 months? __ yes __ no If yes, stop. The EXR provisions are not needed to reinstate cash benefits. If no, continue. Would individual be eligible for SSI based on current income because he/she either stopped working or is now earning less money? __ yes __ no If no, stop. If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSI claim. XII. Health Insurance Needs Health insurance coverage, check each that is available: __ Medicaid Amount of spend down, if any: If enrolled in a Buy-In program, amount of premium, if any: (Note: Not every state will have a Medicaid spend down or Medicaid Buy-In program.) __ Medicare __ Part A (hospitalization) __ Part B (outpatient) Does individual pay Part B premium? __ yes __ no Discuss availability of Medicaid payment of Part B premium __ Private insurance Monthly/quarterly/yearly premium paid by individual: __ Other, please describe: Total out-of-pocket expenses for spend downs, premiums: Monthly: Yearly: Special Medicaid categories If not eligible for Medicaid, or receive Medicaid with a spend down: Did you receive SSI in the past? __ yes __ no Section 1619(b) eligibility: Did you lose SSI due to wages? __ yes __ no If yes, go through 1619(b) eligibility work up. Medicaid eligibility under SSDI/DAC, SSDI for widows/widowers, Pickle Amendment provisions: Did you lose SSI due to receipt of some form of Social Security benefits? __ yes __ no If yes, please describe: Go through work up for special eligibility categories. If your state has a Medicaid Buy-In and individual is not otherwise eligible for Medicaid or eligible for Medicaid with a spend down, screen for buy-in eligibility. Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Psychiatrist visits Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Mental health counseling Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Other therapies (occupational, physical, speech, etc.) Please describe Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Home health care Estimate monthly or annual costs: What purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Medication Estimate monthly or annual costs: Describe each medication and purpose? How covered? Total out-of-pocket expenses Monthly: Yearly: Other health-related costs For each, list item(s), monthly or annual costs, purpose and how covered: Item Monthly/Annual Cost Purpose How Covered XIII. Analysis of Impairment Related Work Expenses Remember three-part criteria for IRWE: Individual must pay expense in question; Item/expense must be related to disability; and, Individual could not work if he or she did not receive item or service. Transportation IRWE Nature of item/service: How related to disability and work: Monthly cost: Medication IRWE Nature of item/service: How related to disability and work: Monthly cost: Health insurance IRWE (premiums, co-payments, deductibles) (Note: Current SSA policy allows IRWE deductions for co-payments and deductibles, but not for premiums.) Nature of item/service: How related to disability and work: Monthly cost: Other IRWEs (check each that applies and describe below): attendant care at home attendant care at work medical devices prosthetic devices(work related equipment residential modification to work away from home residential modifications to work at home Other # 1 Nature of item/service: How related to disability and work: Monthly cost: Other # 2 Nature of item/service: How related to disability and work: Monthly cost: XIV. Blind Work Expenses (BWEs) Is the individual legally blind? __ yes __ no If legally blind and individual is working: Is the individual an SSI recipient? __ yes __ no If yes, do BWE work up. If the person is not an SSI recipient, do work up for potential SSI eligibility using BWEs. If legally blind and not currently working, explain potential for BWEs. XV. Analysis of Subsidies Remember why we look for a subsidy: to ensure that only earnings that represent the true value of the work a person is performing are considered in making the determination of SGA. Subsidy checklist Is government agency paying part of wage? __ yes __ no Does individual get special assistance on the job? __ yes __ no Does individual perform fewer duties than others? __ yes __ no Does employer accept less productivity than from others? __ yes __ no Does individual receive extra rest periods/breaks? __ yes __ no Is individual frequently absent or working irregular hours because of disability? __ yes __ no Does individual receive job coach assistance? __ yes __ no If you checked yes to any of the above, describe the special circumstances: Calculate value of monthly subsidy, indicating countable wages after subsidy: XVI. SSI Plan for Achieving Self Support (PASS) Does individual have an approved PASS? __ yes __ no If yes, describe briefly and obtain a copy for file. If no, explain PASS and then complete remaining questions. Does individual have income other than SSI? __ yes __ no If yes, please describe (see section V, above): Does individual have resources in the form of bank accounts or items that could quickly be converted to cash? If yes, please describe (see section VI, above): Are there goods and/or services, that would help individual reach a vocational goal, that he or she would purchase if extra money were available? __ yes __ no If yes, list items, their expected purpose and their approximate cost, if known: Items Expected Purpose Approximate Cost XVII. Ticket to Work Is individual receiving services under a Ticket? __ yes __ no If no, stop. If yes, continue. Name of Employment Network: Contact at EN: Describe services received from EN: NOTE: If individual is receiving services from the state's vocational rehabilitation agency, they may be receiving those services under the Ticket. Explain that individual will not be subject to a continuing disability review while using a Ticket and making timely progress. NOTES Benefits Screening Profile A Sample Completed Questionnaire Name of Interviewer: Connie Michaels Date of Interview(s): 9/24/07 Was the Client/Consumer Interviewed? X yes __ no Other Person(s) Interviewed: Mark Sanders, Rehabilitation Counselor, ABC Rehab, Inc. Initial Questions Presented: Has been working for nearly 2 years. Is she still entitled to SSDI? Was she entitled to checks she got during past 2 years? I. Personal Demographics Name: Anne Perreault Social Security #: 000-00-0000 Address: Anywhere County of residence: Local State of residence: USA Date of birth: 7/2/67 Type of residence, check one: X_ Home, apartment __ Group home __ Intermediate Care Facility (ICF) __ Hospital __ Other, please describe: Home phone: 888-8888 Work phone: 999-9999 (emergency calls only) Fax: N/A E-mail: N/A Residential placement funding (specify): Married/single/divorced: single Name of spouse: N/A Names, ages of children: Jill Perreault, age 20 (also lives in Buffalo) Living arrangements: Live alone? X yes __ no Live with spouse? __ yes __ no Live with children? __ yes __ no Live with roommate? __ yes __ no Share expenses? __ yes __ no II. Personal Direction and Future Outlook Reason for referral: Wants to know if still eligible for SSDI despite her working for nearly 2 years. Expectations for services being requested: Wants to know if she was entitled to the SSDI checks received to date. Is she entitled to any SSDI checks in the future? Preferred location to receive services: Individual's long-range dreams and aspirations: Employment: Maintain her current employment. In future, work in supervisory capacity, or run her own business doing this work. Postsecondary and/or continuing education: None at this time. Community living: Continue in her own apartment. What the person expresses they need to achieve their desired outcomes: Timely information regarding benefits - i.e., benefits advisement Rehabilitation counseling support. Individual's current family and social connections: 66 year old mother, Madeline Perrault; 20 year old daughter, Jill Perrault; one close friend, Mary Jamison, who also is in treatment for mental illness. Mother - Does things socially with Anne. They go to church, to dinner, to movies together. They support each other. Daughter - Calls on the phone; visits on weekends. Has car and often takes Anne shopping. Friend, Mary - A person with similar problems. She is the one person, other than Anne's therapist, that Anne can really confide in about her disability. Anne talks to her by phone 3 to 4 times per week. III. Disability Description Primary diagnosis: Longstanding depression Secondary diagnosis: Anxiety disorder Tertiary diagnosis: None Age of onset of disability: 28 Specific date if available: summer 1995 Currently seeing a doctor or therapist? X yes __ no Name(s), address(es) of doctor(s) or therapist(s): Dr. Renee Paul, Psychiatrist Southside Counseling Cente 22 Elm Street Buffalo, N.Y. 14203 John Johnson, MSW, Counselor Same address Medication, please list: Prozac, xx mg., xx times per day Any side effects: yes X no Describe side effects: None at this time How does disability limit activities? "On bad days, I have very limited energy. Generally, I do not want to interact with lots of different people. On a bad day, I prefer to keep to myself." How does disability limit ability to work? It is difficult to work a full-time schedule; and difficult to constantly interact with others on the job. Needs a job where she can take off if having a bad day. An understanding and tolerant employer is a key. IV. Involvement With Other Agencies / Support Systems Is the individual still enrolled in secondary school? __ yes X no If yes, name of school: Name, phone number of teacher: Describe education program: Is the individual enrolled in continuing education or a postsecondary education institution? __ yes X no If yes, name of school: Name, phone number of counselor: Describe education program: Is the individual involved with the state VR agency? X yes __ no If yes, name of agency: NYS Office of Vocational and Educational Services to Individuals with Disabilities (VESID) Name, phone number of VR counselor: Teddy Thomas, 847-0000 Describe program, services getting from agency: Paid for past job coaching supports. Still paying for limited case management supports from ABC Rehab. Is the individual involved with a private VR agency? X yes __ no If yes, name of agency: ABC Rehab Name, phone number of VR counselor: Donna Romero, Case Manager Describe program, services getting from agency: Meets with Anne 2 to 4 times per month to discuss problems on job, develop strategies to deal with them. Is the individual involved with the State MR/DD system? __ yes X no Is the individual involved with the State MH system? __ yes X no Is the individual involved with any other agencies? __ yes X no Briefly describe other informal or unpaid supports in the individual's life (family, friends, etc.): V. Monthly Income Unearned Income: SSDI amount: $486 Type of benefit (check appropriate benefit): X Against own record __ Disabled Adult Child __ Widows/Widowers __ Other: __ Unknown Unemployment amount: No other unearned income Veteran's benefit amount: Railroad Retirement Pension amount: Alimony/Palimony amount: Child Support amount: Private disability insurance amount: Worker's Compensation amount: Other amount (specify types): Financial Needs-Based Assistance (means tested): SSI amount: None currently, received in past Pell grant amount: None TANF amount: None Food stamps amount: None State subsidized housing: __ yes X no amount: HUD: __ yes X no amount: Other amount (specify types): None Anyone in household receive welfare benefits? __ yes X no Describe form and amount: If individual receives SSDI or SSI: Name, address of Social Security office serving them: Buffalo District Office, 111 West Huron Street, Buffalo, N.Y. 14202 If known, name, address, phone, fax and email address of Claims Representative serving them: Gary Janes, same address, 845-1234, 845-1238 (fax), gjanes@ssa.gov Earned Income/Wages: X employed by others __ self-employed Monthly gross amount: $850, expected to temporarily increase to $1,400 Weekly gross amount: Bi-weekly gross amount: If wages vary, please explain: October, November and December 2007 will be busy season. Other income in household: N/A Spouse, describe form and amount: Children, describe form and amount: VI. Resources (Relevant to SSI, Medicaid eligibility.) The individual Own home __ yes X no If jointly owned, please indicate other owner(s): Bank accounts Savings, list amount: $350 Checking, list amount: $229 Other, describe and list amount: none Individual retirement account (IRA), tax deferred annuity or similar retirement account - describe and list amounts: N/A Vehicle owned by individual Model and year: N/A Responsible relative with whom person resides Check one: ___ spouse __ parent(s) __ other, describe: N/A VII. Property Essential for Self Support Describe any property owned (and its value) that is used in job as an employee (such as mechanic's tools, carpenter's tools): N/A Describe any property owned (and its value) that is used in "self employment"(such as office equipment, company vehicle, stock, business bank account): N/A VIII. Employment Information Name, address of employer or potential employer: Quality Mailers, Inc., 239 Swan Street, Buffalo, New York 14203 Describe job (or potential job) Title: Bulk Mail Specialist Duties: Ensure that mail is properly sorted, coded, and bagged for delivery to Post Office. Hours: Monday, Tuesday, Thursday, Friday - 9:30 to 3:30 Salary/hourly wage: $8.50/hour Benefits: Only benefits required by law, plus one week's vacation. No health insurance, no sick days. Date you started working (as employee): January 2007 How job was found? Placed by ABC Rehab Found on own: __ yes X no Agency helped find job, describe: Placement following success at similar position within ABC Rehab. If self employed (or potentially self employed) Describe business: N/A Date started: Was job selected because of limits of disability? X yes __ no If yes, please explain: Employer has hired other persons with disabilities, was expected to make allowances for Anne's disability. Any extra or special supervision on job? __ yes X no If yes, describe: Is this a "supported employment" position? X yes __ no Agency sponsoring job: Is there a job coach? X yes __ no Name: Jerry Greene Hours per month: 13 hours per month, January - March 2007 Services performed: Acclimate to job; develop strategies to work around limitations associated with disability. How long will job coach remain in picture? Stopped after 3 months. Does government agency (i.e., other that employer) pay all or part of wage? __ yes X no Please describe: Place of Employment - Quality Mailers, Inc. [Current job] Title - Bulk Mail Specialist Duties - Ensure that mail is properly sorted, coded, and bagged for delivery to Post Office Wages/Hours - $8.50/hour 100 hours per month Date - 1/07-9/07 Place of Employment - ABC Rehab, Inc. Bulk Mail Service Title - Bulk Mail Specialist Duties - Nearly identical to above, in a More supported environment Wages/Hours - $6.60/hour 100 hours per month Date - 1/06-12/06 Place of Employment - J.C. Penny Cheektowaga, NY Title - Sales Clerk Duties - Wait on customers, run cash register Wages/Hours - $5/hour Date - Fall 1998 Place of Employment - Kelly Services Buffalo, NY Title - Temporary secretary jobs Duties - General office Wages/Hours - $5 to $7/hr. Date - Sporadic 1996-98 Place of Employment - General Accounting, Inc. Title - Secretary Duties - Typing, filing, Telephone, make appointments Wages/Hours - $14,000/yr. Date - 1991-95 Briefly describe any past attempts at self-employment: N/A Business Type Location Dates Income Reason for Cessation IX. Trial Work Period (TWP) Analysis Date when first received SSDI? January 1999 Has person worked and earned more than $200 in any month(s) since first receipt of SSDI? X yes __ no If no, full nine-month TWP available. If yes, continue through questions. Did person use up nine TWP months before 1/1/92? No If yes, no TWP available unless SSDI terminated, eligibility re-established after new application and new five-month waiting period. If person did not exhaust TWP before 1/1/92 Work nine TWP months during 60-month period which ended after 1/1/92? X yes __ no If yes, TWP exhausted. If less than nine TWP months during 60-month period, list each TWP month during past 60 months. For each, list month, year and gross wages earned. [Note: In many cases, will have to obtain information from SSA.] Month Year Gross Wages Earned 1. 2. 3. 4. 5. 6. 7. 8. 9. Based on information, how many TWP months left? X. Extended Period of Eligibility (EPE) Analysis (SSDI recipients only) Ninth TWP month (month/year): September 2006 Beginning of EPE (month/year): October 2006 Last month of 36-month EPE (month/year): September 2009 Remember, during EPE: The first time that the individual is determined to be performing substantial gainful activity by earning more than the applicable SGA amount, they will get SSDI checks for that month and two more (i.e., during the "grace period") Following the grace period: - No SSDI check during months countable gross wages exceed the SGA amount. - Will get SSDI check when countable gross wages less than the SGA amount. Impairment related work expenses (IRWEs) and subsidies are deducted from gross wages. Listing of EPE payment, nonpayment months: This should be done on a separate worksheet. See "Notes" section for analysis of SSDI payments due and not due during the EPE. XI. EXPEDITED REINSTATEMENT (EXR) A. Has individual received SSDI benefits in the past? X yes __ no If no, stop and go on to B. If yes, continue. Did individual lose SSDI due to performance of SGA? X yes __ n If no, stop and go to B. If yes, continue. Has individual completed their TWP and EPE? _ yes X no If no, stop and go to B. If yes, continue. Has individual either stopped working or ceased performing SGA? If no, stop and go to B __ yes X no If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSDI claim. B. Has the individual received SSI benefits in the past? X yes __ no If no, stop. If yes, continue. Did the individual lose SSI due to budgeting of wages or a combination of wages and other income? X yes __ no If no, stop. If yes, continue. Is individual currently receiving Medicaid through the 1619(b) program? X yes __ no If yes, stop. The EXR provisions are not needed to reinstate SSI cash benefits. If no, continue. Has individual received either SSI cash benefits or 1619(b) Medicaid within the past 12 months? __ yes __ no If yes, stop. The EXR provisions are not needed to reinstate cash benefits. If no, continue. Would individual be eligible for SSI based on current income because he/she either stopped working or is now earning less money? __ yes __ no If no, stop. If yes, continue. Interviewer should do a full screening for potential EXR eligibility on the SSI claim. XII. Health Insurance Needs Health insurance coverage, check each that is available: X Medicaid Amount of spend down, if any: none (appears to be 1619(b) recipient) If eligible through a Buy-In, the amount of premium if any: X Medicare X Part A (hospitalization) X Part B (outpatient) Does individual pay Part B premium? X yes __ no Discuss availability of Medicaid payment of Part B premium __ Private insurance Monthly/quarterly/yearly premium paid by individual: __ Other, please describe: Total out-of-pocket expenses for spend downs, premiums: Monthly: Yearly: Special Medicaid categories If not eligible for Medicaid, or receive Medicaid with a spend down: Did you receive SSI in the past? X yes __ no Section 1619(b) eligibility: Did you lose SSI due to wages? X yes __ no If yes, go through 1619(b) eligibility work up. (Interviewer's note: Appears to be getting Medicaid through 1619(b)) Medicaid eligibility under SSDI/DAC, SSDI for widows/widowers, Pickle Amendment provisions: Did you lose SSI due to receipt of some form of Social Security benefits? __ yes X no If yes, please describe: Go through work up for special eligibility categories. If your state has a Medicaid Buy-In and individual is not otherwise eligible for Medicaid, screen for buy-in eligibility. Doctor visits Estimate monthly or annual costs: $200/year What purpose? Periodic check ups, as needed when sick How covered? Medicaid and Medicare Total out-of-pocket expenses Monthly: $0 Yearly: $0 Psychiatrist visits Estimate monthly or annual costs: $600 What purpose? Monitor counseling progress and medication How covered? Medicaid and Medicare Total out-of-pocket expenses Monthly: $0 Yearly: $0 Mental health counseling Estimate monthly or annual costs: $1,200/year What purpose? Ongoing treatment How covered? Medicaid Total out-of-pocket expenses Monthly: $0 Yearly: $0 Other therapies (occupational, physical, speech, etc.): N/A Home health care: N/A Medication: Estimate monthly or annual costs: $120 mos/$1,440 yr Describe each medication and purpose? Prozac, to treat depression How covered? Medicaid Total out-of-pocket expenses Monthly: $0 Yearly: $0 Other health-related costs For each, list item(s), monthly or annual costs, purpose and how covered: Item - Bus fare - travel to appointments Monthly/Annual Cost - $7.50/month, $90/year Purpose - Psychiatrist, mental health counselor visits How Covered - out-of-pocket Item - Over-the-counter medications Monthly/Annual Cost - $5/month, $60/year Purpose - As needed How Covered - out-of-pocket XIII. Analysis of Impairment Related Work Expenses Transportation IRWE Nature of item/service: Bus fare to psychiatrist, mental health counselor How related to disability and work: Cannot work without ongoing treatment Monthly cost: $7.50 Medication IRWE Nature of item/service: None Health insurance IRWE (premiums, co-payments, deductibles) Nature of item/service: Medicare Part B premium How related to disability and work: Medicare pays 80% of cost for psychiatrist Monthly cost: $78.20 [Interviewer's note: Medicaid may pay for premium under either QMB or SLMB programs.] Other IRWEs (check each that applies and describe below): N/A XIV. Blind Work Expenses (BWEs) Is the individual legally blind? __ yes X no If the answer is yes, do work up for BWEs. XV. Analysis of Subsidies Subsidy checklist Is government agency paying part of wage? __ yes X no Does individual get special assistance on the job? __ yes X no yes, in past Does individual perform fewer duties than others? __ yes X no Does employer accept less productivity than from others? __ yes X no Does individual receive extra rest periods/breaks? __ yes X no Is individual frequently absent or working irregular hours because of disability? X yes __ no Does individual receive job coach assistance? __ yes X no yes, in past If you checked yes to any of the above, describe the special circumstances: Currently, off site support is from ABC Rehab case manager approximately 1 hour per month. Employer has set up work schedule based on disability- related limitations. Employer tolerates disability-related absences of one or two days per month. Between January and March 2007, ABC also provided job coach support of 3 hours per week. Calculate value of monthly subsidy, indicating countable wages after subsidy: Value of job-coaching subsidy, January - March 2007, using SSA-approved method: - 13 hours job coaching x $8.50 per hour (Anne's hourly wage) = $110.50 per month XVI. SSI Plan for Achieving Self Support (PASS) Does individual have an approved PASS? __ yes X no If yes, describe briefly and obtain a copy for file. If no, explain PASS and then complete remaining questions. Does individual have income other than SSI? X yes __ no If yes, please describe See section V, above Does individual have resources in the form of bank accounts or items that could quickly be converted to cash? If yes, please describe: See section VI, above. Only a small reserve, $350, in savings account. Are there goods and/or services, that would help individual reach a vocational goal that he or she would purchase if extra money were available? X yes __ no If yes, list items, their expected purpose and their approximate cost, if known: Item - Automobile Expected Purpose- Allow her to travel to places of employment in Suburbs, or allow her needed vehicle to establish her own bulk mail business Approximate Cost - $8,000 for good used car XVII. Ticket to Work Is individual receiving services under a Ticket? _X yes __no If no, stop. If yes, continue. Name of Employment Network: VESID (i.e., New York's VR agency) Contact at EN: Teddy Thomas Describe services received from EN: Paid for job coaching in part. Counseling provided as needed. NOTE: If individual is receiving services from the state's vocational rehabilitation agency, they may be receiving those services under the Ticket. Explain that individual will not be subject to a continuing disability review while using a Ticket and making timely progress. NOTES SSDI payment and nonpayment months during EPE: 10/06-12/06: Non-SGA months, only $660 in monthly earnings ... SSDI checks due 1/07-3/07: Non-SGA months, less than $830 in countable earnings ... SSDI checks due [After subsidy deductions for job coaching assistance (see section XIV.), job coaching subsidy is at least $110.50 per month for January, February, and March 2007, reducing wages below $830 SGA amount.] 4/07: Benefit cessation month (i.e., first month of SGA within EPE) 4/07-6/07: Grace period (cessation month and next two months)... SSDI checks due 7/07: SGA month... no SSDI check due [Gross wages $850 with no subsidy, meaning that countable earnings are $850 (i.e., more than SGA amount of $830).] 8/07, 9/07: Same analysis as July 10/07, 11/07, 12/07: SGA months ... no SSDI checks due [With expected wages of $1,400 per month, there are not enough projected IRWEs and subsidies, no matter how calculated, to reduce wages below $830.] Appendix G: Data Collection: A Series of Sample Reporting Formats/Templates Reporting Templates SAMPLE LETTER REPORT FORMAT October 31, 2007 Ms. Anne Perreault 123 Any Street Anywhere, USA 00000 Dear Ms. Perreault: On October 22, 2007, I met with you, your daughter Jill Perreault and your rehabilitation case manager, Donna Romero of ABC Rehab, Inc. We discussed my Benefits Advisement Report and the questions you had. This letter is to provide you with a written statement confirming that discussion. What You Told Me About Your Current Benefits, Work Activity, and Household Situation: You told me that you currently receive $486 in Social Security Disability Insurance (SSDI) benefits. In the past, you received Supplemental Security Income (SSI) benefits, but lost those in 2006 when you started working. Currently, you are earning $850 (gross) each month in wages from your employment. You said your wages would increase to $1,400 per month for the months of October, November and December 2007. You also stated that you currently live alone in an apartment. You said that you have regularly reported your wages to the Social Security Administration (SSA) and they have continued to send you SSDI checks through the present. Questions You Asked: Your stated you are concerned about SSDI eligibility. You wondered whether you were eligible for the SSDI benefits during 2006 and the first nine months of 2007. You also wondered whether you continue to be eligible, and whether you will be eligible in the future. Other Issues: You also had concerns about your continued eligibility for Medicaid. Analysis of Your Current Situation: Based on what you told me, it appears that you were eligible for SSDI throughout 2006 and for at least the first six months of 2007. After that, things are a little less certain. The following is an explanation, broken down by time periods: - January through September 2006: This was your nine-month trial work period. You are always entitled to keep your SSDI check for the full trial work period no matter how much you make. Ms. Anne Perreault October 31, 2007 Page 2 - October 2006 through March 2007: These are the first six months of what is known as your Extended Period of Eligibility (EPE), a 36-month period immediately following the trial work period. You always get SSDI benefits during the EPE if your wages are less than what SSA considers to be substantial gainful activity (currently defined as $830 per month).1 Even though your gross wages were $850 per month during January, February and March 2006, SSA will deduct at least $8.50 for each hour of job coaching you received during each of these months. This reduced your "countable wages" to less than $810 for each of these months. 1 NOTE: This sample Letter Report assumes the SGA amount stays at a constant $830 (i.e., the 2005 level). In reality the SGA level will probably increase each year after 2005. - April 2007 through June 2007: SSA will probably say that April 2007 is the first month you performed substantial gainful activity after your trial work period. If so, they will still give you a grace period of three months to keep your benefits. So, you were entitled to receive SSDI during these months. - July 2007 through September 2007: Assuming SSA continues to find that your countable wages were more than $830 during this period, you would not be eligible for SSDI during these months. Also, as I mentioned, SSA may later send you a notice saying that you were overpaid for these months. - October 2007 through December 2007: With $1,400 gross in wages expected, your countable wages will clearly be above $830 and you will not be eligible for SSDI benefits for these months. - January 2008 and later: Since you expect your wages to go down again, you will be eligible for SSDI benefits again for each month that your countable wages are below the substantial gainful activity amount. The substantial gainful activity amount could go up above the current limit based on annual indexed increases to this amount as of January 2008. You'll need to call me in early December so we can discuss this. The general rule is that you can keep your SSDI checks for any month within the 36-month EPE (your EPE runs from October 2006 to September 2009) that your countable wages are below the substantial gainful activity amount. Your Medicaid should continue because you get Medicaid through the section 1619(b) program. So long as you are still disabled and keep your resources within SSI's limits, you would not stand to lose Medicaid unless your annual wages went well above $37,000.2 Your Medicare eligibility should also continue for several years, even if you lose your right to collect SSDI checks. 2 This is based on New York's 2005 1619(b) eligibility threshold of $37,575 per year. Ms. Anne Perreault October 31, 2007 Page 3 The last thing we discussed was the possibility of using SSI's Plan for Achieving Self Support (PASS) to help you get a car to get to a better paying job, or to help you set aside money to start your own bulk mailing business. You agreed that you are not ready to use a PASS yet, but may want to talk about it again in the very near future. Your Current Plans: I understand that you plan to continue working at Quality Mailers and working with Donna Romero and your mental health counselor to get you through the difficult times. You will let me know if you change your job or hours of work per month; or if you get any notices from Social Security regarding the possible overpayment of benefits for some of the months during 2007. I will keep your file open and plan to contact you periodically if I do not hear from you. You should feel free to call me if you have any questions regarding this letter or if you have any questions in the future. Very truly yours, John B. Counselor Benefits Specialist SAMPLE ABBREVIATED REPORT FROM BENEFITS SPECIALIST TO THIRD PARTY PAYMENT SOURCE [This report is based on the hypothetical case of Anne Perreault (see completed "Benefits Screening Profile," in Appendix F]. The assumption is that your state's vocational rehabilitation (VR) agency, or some other agency, is paying for the benefits advisement services and requires that you provide this short-form report based on the completed profile and your analysis of the issues presented by Anne's case. This example assumes that the VR agency has the usual demographic information about Anne and wants only a general discussion of your analysis. Anne will be provided a copy of this report, but the targeted reader is the VR counselor. Since this was prepared for use in 2005, it continues to use the 2005 SGA amount of $830 as the SGA amount for 2006 and 2007. In reality, the 2005 and 2006 SGA amounts are likely to be adjusted upwards of $830 based on increases in the National Wage Index.] Name of Consumer: Anne Perreault Report Requested By: Teddy Thomas, Rehabilitation Counselor, Anywhere VR Report Prepared By: Connie Michaels, Benefits Specialist, BPA&O Project Date(s) of Interview: 9/24/07 Date of Report: 10/31/07 Attachments to Report: Completed "Benefits Screening Profile" Initial Questions Presented: Individual has been working for nearly two years. Is she still entitled to SSDI? Was she entitled to SSDI checks she received during the past two years? I. Personal Information Ms. Perreault wants to maintain her current employment. In the future, she would like to either work in this field in a supervisory capacity or by running her own business. She finds it difficult to work full-time, as it is difficult to interact with others on the job. She needs an understanding and tolerant employer, who will let her take off if she is having a bad day. II. Monthly Income and Resources Ms. Perreault receives $486 in SSDI benefits and $850 in gross wages, with wages expected to increase to $1,400 gross during October, November and December 2007. Wages are expected to return to $850 in January 2008. Her only resources: $350 in savings; $229 in a checking account. III. Employment Ms. Perreault works part-time for Quality Mailers, Inc. in Buffalo as a "Bulk Mail Specialist." She started this supported employment position in January 2007, and received job coaching services of 13 hours per month during the period January through March 2007. Job coaching was then terminated. She performed a similar job during 2006 in a more supported environment, earning gross wages of $660 per month (100 hours at $6.60 per hour). IV. Trial Work Period (TWP) and Extended Period of Eligibility (EPE) Ms. Perrault has exhausted her TWP in September 2006. Her 36-month EPE began October 2006 and will run through September 2009. During her TWP, she was entitled to her SSDI check each month. She was entitled to SSDI checks for at least the first nine months of her EPE (i.e., through June 2007) for the following reasons: - During the last three months of 2006 her gross income was less than the substantial gainful activity (SGA) amount; - During the first three months of 2007 her gross income, minus job coaching subsidies, continued to be less than the SGA amount; and - During the second three months of 2007, April through June, she was entitled to a "three-month grace period" because April was her first month of SGA during her EPE. - During the July through September 2007 period, Anne was not entitled to an SSDI check as her gross countable wages, $850 per month, were more than the SGA amount of $830. During October through December 2007, Ms. Perreault is expected to gross $1,400 per month. Her countable wages for this period will be well above the SGA level each month and she should not expect to be eligible for SSDI payments. When wages go back down to $850 per month in January 2008, I can only speculate on whether she will be eligible for SSDI. If her countable wages (after deducting subsidies) are less than the 2008 SGA amount, she will once again be eligible for SSDI. V. Health Insurance Ms. Perreault receives Medicaid under the 1619(b) program, since she lost SSI benefits in 2006 due to her wages. She does not have private health insurance. She is also eligible for Medicare and pays a $78.20 monthly Medicare Part B premium. I will check her eligibility for either the Qualified Medicare Beneficiaries (QMB) program or the Selected Low Income Medicare Beneficiaries (SLMB) program for payment of this premium by her local Medicaid agency. She can continue to receive Medicare for at least 93 months following the end of her TWP, even if she no longer receives an SSDI check. VI. Impairment Related Work Expenses Impairment related work expenses (IRWEs) are expenses paid by the individual, for disability-related items, that allow that individual to work. Like subsidies, IRWEs can be used as a deduction from gross income when measuring wages against the SGA rule. Ms. Perreault has two expenses that may qualify as IRWEs. Both are items for which Medicaid may be able to pay. She pays $7.50 per month for bus fare to her psychiatrist and counseling appointments. The other out-of-pocket expense is the $78.20 Medicare Part B premium, which allows her to obtain payment for doctor and psychiatry bills. (In past cases, some advocates have convinced SSA that this is an IRWE even though their policies are silent on this issue. Current SSA policy provides that insurance premiums cannot be IRWEs.) If these expenses are paid by Medicaid, rather than by Ms. Perreault, they cannot be counted as IRWEs. NOTE: The $7.50 for bus fare and the $78.20 for Part B premiums were not part of the field assignment facts. Therefore, there were no IRWEs in the field assignment. In those cases in which a beneficiary convinced SSA that a health insurance premium was an IRWE, the payment of the premium ensured coverage by the insurance program or Medicare of an expense that would have qualified as an IRWE if paid by the beneficiary. VII. SSI's Plan for Achieving Self Support (PASS) Ms. Perreault and I briefly discussed potential use of the PASS. One possibility would be to use the PASS to purchase a vehicle that would allow her to pursue upgraded employment in locations not reachable through public transportation. The other possibility involved use of the PASS to supplement any funding that may be available through [name of VR agency] to pursue her own bulk mailing business. Since Ms. Perreault agreed that both of these goals are two years or more away, she will not pursue the PASS at this time. VIII. Concluding Remarks I agreed that I would retain an open file for Ms. Perreault to monitor her case and advise her on an ongoing basis with respect to these issues. SAMPLE COMPREHENSIVE REPORT FROM BENEFITS SPECIALIST TO THIRD PARTY PAYMENT SOURCE [This report is based on the hypothetical case of Anne Perreault (see completed "Benefits Screening Profile," Appendix F]. The assumption is that your state's vocational rehabilitation (VR) agency, or some other agency, is paying for the benefits advisement services and requires that you provide this full-scale report based on the completed profile and your analysis of the issues presented by Anne's case. This example assumes that the VR agency has the usual demographic information about Anne, but would like a very extensive write up in other respects. Anne will be provided a copy of this report, but the targeted reader is the VR counselor. Since this was prepared for use in 2005, it continues to use the 2005 SGA amount of $830 as the SGA amount for 2006 and 2007. In reality, the 2005 and 2006 SGA amounts are likely to be adjusted upwards of $830 based on increases in the National Wage Index.] Name of Consumer: Anne Perreault Report Requested By: Teddy Thomas, Rehabilitation Counselor, Anywhere, VR Report Prepared By: Connie Michaels, Benefits Specialist, BPA&O Project Date(s) of Interview: 9/24/07 Date of Report: 10/31/07 Attachments to Report: Completed "Benefits Screening Profile" Initial Questions Presented: Individual has been working for nearly two years. Is she still entitled to SSDI? Was she entitled to SSDI checks she received during the past two years? I. Personal Demographics As relevant to this report, Ms. Perreault is a single adult who lives alone in her own apartment. She has no minor children. II. Personal Direction and Future Outlook Ms. Perreault wants to maintain her current employment. In the future, she would like to either work in this field in a supervisory capacity or run her own business doing this work. To accomplish these goals, she will need both benefits advisement and ongoing rehabilitation support. III. Disability Description See completed Profile for full description. Ms. Perreault finds it difficult, because of her disability, to work a full-time schedule. It is difficult to constantly interact with others on the job. She indicates that she needs a job where she can take off if she is having a bad day. She believes that an understanding and tolerant employer is very important to her continued success. IV. Involvement with Other Agencies/Support Systems Ms. Perreault is not involved with any educational institution or with any state agency other than [name of VR agency]. She does receive services from a private rehabilitation agency, ABC Rehab. Her case manager, Donna Romero, talks with Ms. Perreault on the phone about once every two months to discuss problems on the job. V. Monthly Income Unearned income: $486 SSDI benefits (against own earnings record) Earned income: $850 gross wages, expected to increase to $1,400 gross during busy months of October, November and December 2007. Wages are expected to return to the $850 level in January 2008. VI. Resources Savings Account: $350 Checking Account: $229 She does not own any other property, real or personal. She does not own a vehicle. VII. Property Essential for Self Support None. VIII. Employment Information Current employment: Ms. Perreault currently works for Quality Mailers, Inc., 239 Swan Street, Buffalo, New York 14203, as a "Bulk Mail Specialist." She works part-time, four days per week (100 hours per month at $8.50 per hour = $850 per month). She started this job January 2007. Noteworthy from a benefits standpoint: The employer was selected based on Ms. Perreault's disability, having hired other persons with disabilities. This is a supported employment position in which she received job coaching services of 13 hours per month during the period January through March 2007. The job coaching was then terminated. Past employment: Ms. Perreault performed a similar job during 2006 at ABC Rehab (1/06 to 12/06). This was in a much more supported environment. She earned gross wages of $660 per month, working 100 hours per month and earning $6.60 per hour. (See completed Profile for 1988-95 work history.) IX. Trial Work Period (TWP) Analysis Date first received SSDI: January 1997 When was TWP exhausted: January through September 2006 were the nine TWP months for SSDI purposes. This means that Ms. Perreault has exhausted her TWP and will not be entitled to a new TWP during this period of SSDI entitlement. During each of the nine TWP months, Ms. Perreault was entitled to keep her full SSDI check. She was entitled to all SSDI checks received during the January through September 2006 period. X. Extended Period of Eligibility (EPE) Analysis Ninth TWP month: September 2006 Beginning month of EPE: October 2006 Last month of 36-month EPE: September 2009 During the first three months of the EPE, October through December 2006, Ms. Perreault was clearly entitled to her SSDI checks because she was earning less than the substantial gainful activity or SGA amount. During the next three months of the EPE (months 4-6), January through March 2007, she should also have been entitled to her SSDI checks because her wages would be reduced by a job coaching subsidy. Under the most conservative analysis of the subsidy, Social Security must multiply the job coach hours by the individual's hourly wage to determine the monthly subsidy amount ($8.50 x 13 = $110.50). Subtracting the subsidy from the gross wage ($850 - $110.50), her countable wages were $739.50. Since this was less than the SGA amount of $830 per month, she continued be entitled to SSDI benefits during this period. During the July through September 2007 period, Ms. Perreault was not entitled to SSDI checks because her countable wages, $850, more than the SGA amount of $830 (she was no longer getting job coach support). During the months of October through December 2007 (months 13-16 of the EPE), Ms. Perreault is expected to earn $1,400 per month in gross wages. Since any subsidies for these months would be minimal, her countable wages will be well above the SGA level each month and she should not expect to be eligible for SSDI payments. Ms. Perreault has related to me that her wages will go back down to $850 per month in January 2008. Since I do not yet know what the SGA rate will be in 2008, I can only speculate on whether she will be eligible for SSDI. I can tell you that January 2007 will be the 17th month of her EPE. Effective January 2008, if Ms. Perreault's countable wages (after deducting any subsidies or impairment related work expenses) is less than the 2008 SGA amount, she will once again be eligible for SSDI. XI. Health Insurance Needs Current Health Insurance: Ms. Perreault receives Medicaid and Medicare. My interview revealed that she received a small SSI supplement to her SSDI through early 2006 when she started working at ABC Rehab. Having lost her SSI due to wages, Ms. Perreault became eligible for Medicaid under the 1619(b) program. Based on her current situation (i.e., she continues to have a disability; her unearned income and resources are within SSI limits), she continues to be eligible for Medicaid under 1619(b). She does not have private health insurance. Ms. Perreault is also eligible for Medicare and pays a $78.20 monthly premium (2005 rate) to enroll in the Medicare Part B program for outpatient care. I will be checking to determine whether she meets the eligibility guidelines under either the Qualified Medicare Beneficiaries (QMB) program or the Selected Low Income Medicare Beneficiaries (SLMB) program for payment of this premium by her local Medicaid agency. Since Ms. Perreault is still in her EPE, she will continue to qualify for extended Medicare benefits. The Part A Medicare will continue to be cost-free and the Part B Medicare will be subject to a premium payment. If she continues to have a disability, she can continue to receive Medicare benefits for 93 months following the end of her TWP. Even if she is no longer eligible for an SSDI check, she will remain eligible for Medicare under the same terms into the year 2014. Need to Retain Medicaid and Medicare: Until Ms. Perreault finds a job with a good health insurance plan, Medicaid will be very important to her. Medicaid pays for nearly $2,500 in counseling and medication expenses annually. Medicare will be of secondary importance. Of the $800 per year in doctor and psychiatrist expenses, Medicare generally pays for the first 80 percent with Medicaid picking up the rest. XII. Analysis of Impairment Related Work Expenses Impairment related work expenses (IRWEs) are expenses paid by the individual, for disability related items, that allow that individual to work. Like subsidies, IRWEs can be used as a deduction from gross income when measuring wages against the SGA rule. Currently, Ms. Perreault has two expenses that may qualify as IRWEs. However, both are items for which Medicaid may be able to pay. She pays $7.50 per month for bus fare to her psychiatrist and counseling appointments. With prior approval from Medicaid, I believe Medicaid can reimburse this expense. (NOTE: Transportation in an optional Medicaid service and will not be available in all states.) The other out-of-pocket expense is the $78.20 Medicare Part B premium, which allows her to obtain payment for doctor and psychiatry bills. (In past cases, some advocates have convinced SSA that this is an IRWE even though SSA's policies were silent on this issue. Current SSA policy provides that an insurance premium payment cannot be an IRWE.) As stated in section XI, above, this may also be an expense Medicaid can cover under the QMB or SLMB programs. If these are paid by Medicaid, rather than by Ms. Perreault, they cannot be counted as IRWEs. XIII. Blind Work Expenses These do not apply because Ms. Perreault is not legally blind. XIV. Analysis of Subsidies See discussion under section X, above, involving the Extended Period of Eligibility. XV. SSI's Plan for Achieving Self Support (PASS) I have attached a short article describing how the PASS can be used to set aside income or resources to help an individual meet an employment goal. The money set aside in the approved PASS will not be counted under SSI's income or resource rules. Ms. Perreault and I briefly discussed the potential use of the PASS in the future. One possibility would be to use the PASS to purchase a vehicle that would allow her to pursue upgraded employment opportunities in locations not reachable through public transportation. The other possibility involved use of the PASS to supplement any funding that may be available through [name of VR agency] to pursue her own bulk mailing business. Since Ms. Perreault agreed that both of these goals are two years or more away, she will not pursue the PASS at this time. XVI. Concluding Remarks I agreed that I would retain an open file for Ms. Perreault to monitor her case and advise her on an ongoing basis with respect to the following: * Her eligibility for continued SSDI during the remainder of her EPE based on any changes to the SGA amounts; any changes to her monthly income; and any need to analyze the availability of IRWEs and subsidies; * Her eligibility for ongoing Medicaid under 1619(b), and her eligibility for ongoing Medicare under the extended eligibility provisions; * Her potential use of a PASS to set aside money for a vehicle, for expenses related to setting up a business, or for other expenses that will help her meet a future employment goal. APPENDIX H: STAKEHOLDER ANALYSIS The following analysis is being completed for an: __ Individual __ Agency __ School STAKEHOLDER ANALYSIS: Beneficiaries and Recipients Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: STAKEHOLDER ANALYSIS: Family Members Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: STAKEHOLDER ANALYSIS: Service Providers Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: STAKEHOLDER ANALYSIS: Advocates Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: STAKEHOLDER ANALYSIS: Supports/Direct Line Workers Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: STAKEHOLDER ANALYSIS: SSA Existing Network Stakeholder Group: How Accessed: When Accessed: Satisfaction Level: Area for Improvement: Network Development Stakeholder Group: Outreach Plan: Timeframes: Mutual Gains: APPENDIX I: CONTACT LOG Date of Event: How request came in: __Phone __Email __Web __Other Who's working on it: Name: Title: Agency: Address: Phone: Problem/Issue/Request: Provided with the following: __Phone Call __Email __Information and material __On-site technical assistance __Training __Referral __Other Date of resolution: DD/MM/YY Follow up date: DD/MM/YY Area: __Information and Referral __Problem Solving __Employment & Disability Policy (RRTC) __Support Planning __Benefits Planning __Benefits Assistance __Crisis Intervention __Training __Technical Assistance __Organizational Development __Other: Outcome of Support Provided: TA Stakeholder __Advocate/Advocacy Organization/IL Personnel Number Impacted _____ TA Stakeholder __Arbitrator/Mediator Number Impacted _____ TA Stakeholder __Business/Employer Number Impacted _____ TA Stakeholder __Continuing/Postservice Education (e.g. RRCEP/CRP-RRCEP/UAP) Number Impacted _____ TA Stakeholder __ES Representative Number Impacted _____ TA Stakeholder __Federal/State Agency Rep Number Impacted _____ TA Stakeholder __Health Care Provider Number Impacted _____ TA Stakeholder __Individual/Student with a Disability Number Impacted TA Stakeholder __Legal Consultant Number Impacted TA Stakeholder __Local Disability Agency Rep Number Impacted _____ TA Stakeholder __Local Non-Disability Agency Number Impacted _____ TA Stakeholder __Media Number Impacted _____ TA Stakeholder __Parent/Family Member of a Person with a Disability Number Impacted _____ TA Stakeholder __PASS Specialist Number Impacted _____ TA Stakeholder __Postsecondary ED Rep (e.g., preservice/undergraduate/graduate) Number Impacted _____ TA Stakeholder __Professional Society Number Impacted _____ TA Stakeholder __Research Institution (e.g., RRTC, etc.) Number Impacted _____ TA Stakeholder __Secondary Education Personnel Number Impacted _____ TA Stakeholder __SSA Central Number Impacted _____ TA Stakeholder __SSA Local Number Impacted _____ TA Stakeholder __SSA Regional Number Impacted _____ TA Stakeholder __State/Local/Provincial Gov't Rep Number Impacted _____ TA Stakeholder __Other: Number Impacted _____ Time Spent -- Hours: Minutes: APPENDIX J: BPA&O SELF-ASSESSMENT CHECKLIST Refer to Chapter One for a guide to completing this assessment and further definition of specific activities, supports, or services. Benefits Planning and Assistance Self-Assessment Checklist __Individual __Agency __School OUTREACH Activity/Service/Support: Conduct outreach to key stakeholders Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Information sharing on SSA-related issues with stakeholder groups Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Identify individuals and cultivate SSA-related expertise to expand network Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Establish collaborative relationships with relevant agencies and organizations Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Market services and supports among external stakeholders and process owners Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Negotiate aspects / purpose of referral Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Contract and monitor services and supports with outside vendors Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support: Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration INFORMATION AND REFERRAL Activity/Service/Support Outline specific services and supports that can be provided Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Establish a referral network of practitioners Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Refer for additional needed services and supports as appropriate Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Refer for protection and advocacy Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Monitor case status Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Ensure confidentiality of information Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Provide short-term technical assistance and training Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Share information regarding SSA-related issues across stakeholder groups Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration COUNSELING Activity/Service/Support Utilize array of data collection and information gathering strategies Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Formulate effective questions and probing for information Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Verify/triangulate information collected Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Facilitate person-focused planning Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Define roles, responsibilities, and counseling functions/supports needed Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Create supportive environment and build rapport and trust Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Network customers for assistance with employment planning, career development, disability adjustment or other specialized counseling areas Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Use repertoire of general counseling skills as needed including Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration DATA COLLECTION Activity/Service/Support Conduct critical interviewing Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify and document personal demographics Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Collect and describe information pertaining to individual's disability Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Develop profile of individual's financial / benefit status Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Assess and identify current work status Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify current attachment to service delivery systems Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify other critical stakeholders Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Compile information into a comprehensive profile Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration BENEFITS ANALYSIS Activity/Service/Support Review stated employment goals and/or request for short-term technical assistance or education Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Conduct analysis of information contained in the benefits profile or information requested Provided Referral Available Expertise Evident Needs Developmentv Frequency Duration Activity/Service/Support Apply different benefit scenarios to study impact and effect of future earnings on benefit status Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify long-term benefit planning and assistance support an individual may need Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify existing service delivery systems and plans in which long-term benefits planning and assistance supports can be incorporated Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Explore individual's past success/failure in self-managing benefits Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Identify needed safety nets to minimize risk and fears Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Evaluate services and supports provided across each primary domain considering information obtained to continuously improve deliverables Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration SCENARIO ADVISEMENT Activity/Service/Support Provide short-term technical assistance pertaining to specific scenarios being explored Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Provide education and training as requested Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Disseminate print information as requested Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Develop a comprehensive report for consideration as part of the career development and employment process Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Recommend long-term benefit planning and assistance support an individual may need Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Show how benefits planning and assistance supports can be infused within existing service delivery systems and plans Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Develop and/or recommend self-management tools and strategies for managing benefits Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Recommend potential safety nets to minimize risk and fears Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Support the individual and their key stakeholders in understanding the report and defining next steps Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Provide counseling support to assist the individual in making an informed choice as to options and goals to pursue Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Inform the individual, their key stakeholders and their support teams as to touch points they will need to be sensitive to Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration BENEFITS ASSISTANCE AND PLANNING Activity/Service/Support Assist the individual, their key stakeholders, and their support teams in making informed choices and establishing goals Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Evaluate and understand the array of service delivery plans that may be intersecting and dissecting the individual's life and provide assistance in incorporating benefits management goals Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Ensure that a comprehensive support / employment plan has been developed Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Maintain case recording and documentation Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Negotiate conflict and establish mutual gains Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Assess, evaluate and inform on touch point issues regarding SSI Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Continue to inform the individual, their key stakeholders and their support teams as to touch points Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Manage case load responsibilities Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Monitor case progress Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Evaluate effectiveness of services and supports provided Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration Activity/Service/Support Other: Provided Referral Available Expertise Evident Needs Development Frequency Duration APPENDIX K: SAMPLE STANDARD RELEASE/REP FORMS Sample Standard Release of Information Forms Authorization for Source to Release Information to the Social Security Administration (Form SSA-827) The SSA-827 is the form SSA uses whenever we will need to contract medical sources for information. When the form is signed the beneficiary or recipients is authorizing their medical source to release information to SSA. SSA will need an original SSA-827 for EACH source listed on the individual's form(s) (SSA-454, SSA-3368, SSA-3341-F6, SSA-3820, SSA-3881,(HA-4486), PLUS at least 2 extra forms. (For example, if the person has 5 medical sources, SSA will need at least 7 SSA-827's). Sources include doctors, hospitals, clinics, nurses, social workers, family members, friends, governmental agencies, employers, etc. Make sure there is an original signature on each form. Do not copy signed forms. The beneficiary or recipient should sign their own form. If you are inquiring for another individual who has been declared legally incompetent, their legal guardian or legally recognized representative should