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Medicaid Information

Attached below are Frequently Asked Questions(FAQ) regarding medicaid and some helpful resources:

FAQ:

Supplemental Security Income (SSI) and Medicaid

Supplemental Security Income (SSI) is a needs-based monthly benefit program that is paid by the Social
Security Administration (SSA) to people who are elderly (age 65 or older) or disabled (ages 0 to 64) who
have limited income and resources. People may qualify for SSI even if they have not worked.

People who are approved for SSI also get Medicaid, which covers their medical expenses and may cover
additional Long-Term Services and Supports (LTSS), including institutional care in a nursing home or
rehabilitation center, or through a Medicaid Waiver that provides personal care services in the
community (i.e., at the person’s home or other setting) to assist them with activities of daily living.

RSDI, SSDI, and Medicare

Retirement, Survivors, and Disability Insurance (RSDI) is a monthly retirement benefit program that
retired workers can draw, based on their work history, starting at age 62.

Social Security Disability Insurance (SSDI) is a monthly disability benefit program paid by SSA to disabled
workers that is based on the work history of the disabled worker. This program does not require the
disabled worker to have limited income or resources.

The dependents (i.e., spouses or children) of workers who draw RSDI or SSDI can also qualify to draw
monthly benefits if they are eligible. RSDI benefits are available to spouses who are age 62 or older and
to widows or widowers of any age.

If the worker is retired, disabled, or deceased, their dependent children under age 18 and their
dependent adult children over age 18 who are disabled may qualify for monthly benefits.
Workers who are approved for RSDI or SSDI and their eligible dependents will also get Medicare when
they turn 65 or, if they are under 65 and disabled, after a 24 month waiting period. The 24-month
waiting period starts with the first month that the person becomes eligible for SSDI.

Can You Get Both SSI and RSDI or SSDI?

Yes, some people can qualify for both SSI and RSDI or SSDI. SSI is a needs-based program for people
with limited income and resources. People who get RSDI or SSDI can also qualify for SSI if they meet the
income and resource limits for SSI.

NOTE: Everyone who applies for SSI also automatically applies for SSDI, whether you know it or not.
The reason is that the SSI program is needs-based, so the SSI applicant must apply for any other benefits that they might qualify for, including SSDI, worker’s compensation, unemployment benefits, retirement or pension benefits, child support, etc.

DON’T PANIC: Many people who apply for SSI and SSDI, including people who have never worked, will
get a denial notice from SSA saying that they don’t qualify for SSDI because they haven’t worked long
enough. When you get this letter, don’t panic. Your SSI application is still pending, but you will have to
wait another 5 to 6 months for SSI to process the application.

Can You Get Both Medicaid and Medicare (dual Medicaid and Medicare)?

Yes, some people can qualify for both Medicaid and Medicare. If you get Medicare through RSDI or SSDI
and you also qualify for SSI, then you will get both Medicaid and Medicare. People who get Medicaid
benefits through other state programs may also qualify for dual Medicaid and Medicare if they also get
Medicare through RSDI or SSDI.

How Do You Meet the Disability and Functional Impairment Qualifications for SSI or SSDI?

Thankfully, the disability qualifications for SSI and SSDI are the same.

To qualify for SSI or SSDI disability, you must have a medically disabling condition that has lasted or is
expected to last for at least 12 months, or a condition that is expected to result in your death.

In addition, you will need to show evidence of functional impairment: that your condition restricts or
limits your ability to work at ANY substantial gainful employment (SGA). This includes not only your
traditional type of work but also any other type of work that you could reasonably be expected to do as
an alternative to your traditional type of work. This also applies to people who have never worked.

A simple definition of functional impairment for disabilities is:
How does your condition affect your ability to WALK, SIT, STAND, LIFT, CARRY, PUSH, or PULL?

A simple definition of mental impairment (cognitive and non-cognitive) is:
How does your condition affect the four areas of your life:

- - Your daily living
  - Your social interaction,
  - Your ability to focus and complete tasks, and
  - Your reaction to stress and pressure?

For example, someone who worked as a truck driver may be able to work as a receptionist in an office or
as a sales clerk for an online sales company. The alternative types of work don’t need to be related to
the traditional type of work. People who have never worked must also show that they are not able to
work at any type of substantial gainful employment (SGA).

In 2022, SGA is defined as any employment that pays gross wages of $1,350 per month.

EXAMPLE 1: A person who works full time for $10 per hour will earn $400 per week and at least
$1,600 per month, which exceeds the SGA limit. This also applies to people who work
part time.

EXAMPLE 2: A person who works part-time for $15 per hour for 20 hours per week will earn $300
per week. If the month has 4 pay periods, the person will earn $1,200, but if the
month has 5 pay periods, the person will earn $1,500, which exceeds the SGA limit.

EXAMPLE 3: The SGA definition also applies to self-employment income after reasonable self-employment expenses are deducted.

You will need to provide medical evidence to confirm your diagnosis and document how your condition restricts or limits your ability to work at ANY substantial gainful employment that pays $1,350 per month or more.

Medical Guide for SSI and SSDI Disability

The SSA uses a medical guide called the Blue Book to determine if the applicant meets the medical
criteria to qualify for SSI or SSDI. There are different criteria for children (ages 0 to 17) versus adults
(ages 18 to 64). People who are 65 or older will qualify for SSI or RSDI benefits based on age and don’t
need to meet the disability criteria.

Listing of Impairments – Adult Listings (Part A) – For ages 18 or older
     https://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm
          1.0 Musculoskeletal Disorders
          2.0 Special Senses and Speech
          3.0 Respiratory Disorders
          4.0 Cardiovascular System
          5.0 Digestive System
          6.0 Genitourinary Disorders
          7.0 Hematological Disorders
          8.0 Skin Disorders
          9.0 Endocrine Disorders
          10.0 Congenital Disorders that Affect Multiple Body Systems
          11.0 Neurological Disorders
          12.0 Mental Disorders
          13.0 Cancer (Malignant Neoplastic Diseases)
          14.0 Immune System Disorders

Listing of Impairments – Childhood Listings (Part B) – For ages 0 thru 17
     https://www.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm
          100.00 Low Birth Weight and Failure to Thrive
          101.00 Musculoskeletal Disorders
          102.00 Special Senses and Speech
          103.00 Respiratory Disorders
          104.00 Cardiovascular System
          105.00 Digestive System

   106.00 Genitourinary Disorders
   107.00 Hematological Disorders
   108.00 Skin Disorders
   109.00 Endocrine Disorders
   110.00 Congenital Disorders that Affect Multiple Body Systems
   111.00 Neurological Disorders
   112.00 Mental Disorders
   113.00 Cancer (Malignant Neoplastic Diseases)
   114.00 Immune System Disorders

SSI and SSDI Compassionate Allowances List (CAL)

SSA has developed a Compassionate Allowances List (CAL) to quickly identify more than 200 diseases and other medical conditions that meet SSA standards for disability benefits. These conditions include certain cancers, adult brain disorders, and some rare disorders that affect children. It allows SSA to identify claims where the applicant’s disease or condition clearly meets the SSA statutory standard for disability, which reduces waiting time for SSI and SSDI claims for people with the most serious conditions.
https://www.ssa.gov/compassionateallowances/conditions.htm

When Should You Apply for SSI?

- If you are in a hospital or medical institution for more than a month, you can apply for SSI before you leave so that your benefits can begin quickly after you leave.

- For children who are turning 18: Do not apply until the month AFTER your child turns 18. Children who are under 18 are treated as minors, and SSI must count the income and resources of their parents to determine if they are eligible for SSI. Most children will not qualify for SSI if their parents’ income and resources are counted.

- A child who turns 18 is still considered to be a minor in the month that they turn 18 because they were 17 on the first day of the month. SSI will look at the parent’s income and resources for this month and deem it, if appropriate, to the child.

- See Deeming Parental Income & Resources: pages 23-26 and page 88.

https://www.ssa.gov/pubs/EN-17-008.pdf

How Can You Apply for SSI?

Online at https://www.ssa.gov/benefits/disability/ GOOD OPTION
Call SSA at 800-772-1213 to schedule an appointment to apply for SSI PROBLEMS
Call your local SSA office to schedule a phone appointment to apply for SSI PROBLEMS
Apply through a representative who handles disability applications, such as a disability attorney or a disability advocate. GOOD OPTION
It usually takes about 6 months to get a decision after you apply for SSI or SSDI. If your application was denied and you file an appeal, it may take about a year to get a decision.

What documents do I need to apply for SSI:

Social Security card or number
Proof of age: birth certificate or birth record or other document showing your date of birth
Citizenship or alien status record
Proof of income: Earned income, unearned income, and deductible work expenses. See Income, pages 17-19.

https://www.ssa.gov/pubs/EN-17-008.pdf

Proof of resources: Bank statements, property deed or tax appraisal statements, life or disability insurance policies, burial contracts, burial plots, statements for CDs, stocks, mutual funds, bonds, or retirement accounts. See Resources, pages 13-15:

https://www.ssa.gov/pubs/EN-17-008.pdf

Titles or registrations for vehicles, including cars, trucks, motorcycles, boats, campers, etc.
Medical sources or reports:
- Medical records, if you have them
- Contact information for all medical providers who have treated you (name, address, & phone)
- List of all prescription and non-prescription medications that you take, with dosage.
School records (for children with disabilities):
- School assessments and IEPs,
- Names of teachers, therapists, caregivers, and schools
Work history for the past 15 years, before you became disabled:
- Names of employers
- Dates worked
- Job titles
- Hours worked per day and per week
- Earnings
- Description of job duties and type of work you performed
Proof of living arrangements:
- Lease or rent payment OR monthly mortgage payment with monthly insurance and taxes
- Monthly utilities (electric, gas, water, sewer, septic system, garbage)
  - Don’t include phone, internet, or cable
- Monthly food cost
  - Don’t include any non-food items like soap or paper products, in the monthly food cost

See Living Arrangements, pages 20-22:

https://www.ssa.gov/pubs/EN-17-008.pdf

List of documents that you may need when you apply for SSI: pages 31-33.

https://www.ssa.gov/pubs/EN-17-008.pdf

What is SSI “Fair Share” of Household Expenses?

SSA will reduce your SSI payment by one-third if you live in another person’s household throughout a month and you do not pay your “fair share” for the food and shelter you get from the household.

The one-third reduction doesn’t apply if you live in another person’s household but you pay your “fair share” of the expenses for food and shelter.

The one-third reduction doesn’t apply if you live in your own home or apartment and you pay for your own food and shelter expenses.

SSI calculates monthly household expenses and average monthly household expenses as follows:

A Monthly rent or mortgage (incl. real estate taxes and insurance)

B Monthly utilities (electric, gas, water, sewer, garbage)

C Monthly food (don’t include non-food items)

A + B + C TOTAL MONTHLY HOUSEHOLD EXPENSES

D Number of people living in the home.

(A + B + C) / D FAIR SHARE = AVERAGE HOUSEHOLD EXPENSES PER PERSON

NOTE: Do not include phone, internet, cable, clothing, car, transportation, or any non-food items in the total of household expenses.

If the SSI recipient contributes his/her “fair share”, then the SSI payment is not reduced. If the SSI recipient contributes less than his/her “fair share”, then the SSI payment may be reduced by 1/3 to represent the “deemed income” from other members of the household.

Use SSA Form SSA-8011-F3 to report changes to your household expenses and contributions.

https://secure.ssa.gov/apps10/poms/images/SSA8/G-SSA-8011-F3-1.pdf

Other resources about how to calculate Fair Share of household living expenses:

https://www.ssa.gov/ssi/text-living-ussi.htm

https://www.ssa.gov/ssi/spotlights/spot-one-third-reduction.htm

Who Should Use an Attorney to Apply for SSI or SSDI?

If you have a very clear case of disability, you may not need to hire a disability attorney or advocate. Examples of clear cases of disability include:

IQ below 70 with significant functional limitations
Severe autism with significant functional limitations
Blind, deaf, or nonverbal
Loss of 2 or more limbs
Cancer of esophagus, gall bladder, kidney, liver, pancreas, or thyroid,
Heart transplant wait list (1A/1B)

Hiring a disability attorney or advocate to apply for SSI or SSDI will increase your chances of approval and help you avoid the appeals process. An attorney or advocate will be familiar with the Social Security rules and regulations regarding eligibility and will help you compile the necessary documents, beyond a reasonable doubt, that you are disabled and eligible for disability benefits.

If you applied for SSI or SSDI without an attorney and were denied, it is very important to hire an attorney to help you with the appeal process.

How Much Does an SSI or SSDI Attorney Cost?

Your SSI or SSDI attorney’s fees are limited by federal law. The attorney will not get paid unless your SSI or SSDI application is approved. When this happens, they will be paid 25% of your back pay, up to a maximum of $6,000, and you will get 75% of the back pay. The attorney’s fees will be deducted from your back pay before you get your payment.

EXAMPLE 1: If your attorney files your SSI application in January and it is approved in July, then you will get 6 months of back pay for January to June. If you are awarded the maximum SSI of $841 per month, then your total back pay will be $5,046.

Your attorney will get 25%, or $1,261.50.
You will get the rest of the back pay, or $3,784.50.
You will get the full monthly SSI benefit of $841 starting in July.

EXAMPLE 2: If you filed your own SSI application and it was denied, you can hire an attorney to handle your appeal. If your appeal is approved, your attorney will get 25% of your back pay, starting with the month you signed the contract with the attorney until the month before your case was approved.

If you hired the attorney in March and your case was approved in December, the attorney will be paid 25% for the 9 months of back pay when he/she represented you ($1,892.25) and you will get 75% of the back pay for these months ($5,676.75).
You will also get 100% of the back pay from the month you filed the SSI application until the month you signed the contract with the attorney.
You will also get 100% of your monthly SSI benefit starting the month that your SSI was approved.

Are there any good SSI or SSDI attorneys in Austin?