PABSS prerequisite

February 2016

Social Security Title II Basics

Who Can be Served by PABSS?

People who receive disability benefits from

Social Security

- Supplemental Security Income (SSI)

based on disability.

- Social Security Disability Insurance

(SSDI).

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Who Else Can be Served by PABSS?

- Recipients of Title II dependent or

survivor benefit that is based on disability

- some individuals who receive Medicare

as a former SSDI recipient or those

receiving 1619b Medicaid.

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Cash Benefits Administered by SSA

The Social Security Administration (SSA) is a federal agency that administers two federal cash benefit programs:– Social Security (Title II)

– Supplemental Security Income (Title XVI)

Both pay benefits to those who meet the agency’s disability standard.

Each includes a different set of detailed work incentives and rules about work.

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Disability Definition

The inability to engage in any substantial gainful activity (SGA) by reason of medically determinable physical and/or mental impairment(s) which can be expected to last for a continuous period of not less than 12 months or result in death. 20 CFR 404.1505, 416.905

Statutory Blindness. 20 CFR 404.1581 et seq., 416.981 et seq.

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Establishing Disability

The 5 Steps of Sequential Evaluation– Engaging in SGA?

– Severe impairment or combination of impairments?

– Does impairment(s) meet or equal a Listing?

– Does impairment(s) prevent PRW?

– Does impairment(s) prevent other work?

20 CFR 404.1505, 416.905

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Eligibility Requirements: Disability Benefits from Social Security

SSDI – Meet disability or blindness criteria

and have worked long enough in jobs

covered by Social Security taxes.

SSI – Meet disability or blindness criteria

and have limited income and resources

(needs based) (more on this in the second

webinar).

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How and when do you get a Title II benefit (SSDI)?

File an application and provide evidence of

diagnoses and functional limitations.

SSA determines disability and the onset date

– 5 month waiting period

– 12 month duration rule

SSA calculates the benefit rate based on the

applicant’s work history in FICA covered

work.

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Distinctive Features SSDI - Social Security Disability Insurance

SSDI - Funded by FICA taxes and is not

needs based or based on living arrangement.

Benefit amount is based upon level of

earnings over working years

Paid on 3rd of month or on a Wednesday –

based on the day of birth.

Medicare coverage starts after 24 months of

entitlement

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More distinctive features

The Social Security program is compulsory

for most workers, and based on insurance

principles. It is designed to partially replace

earnings lost due to the retirement, disability

or death of an insured person.

To qualify, the disabled person must have a

recent work history.

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The amount of work one needs to qualify depends on their age

Before age 24 - 1-1/2 years of work in a three-year

period before becoming disabled

Age 24-31 - work during half the time between age 21

and the time the disability began

Age 31 or older - work during five out of the 10 years

before the disability began

20 CFR 404.130

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When you pay Social Security taxes you earn work credits

You can earn up to a maximum of 4 work

credits each year.

The work credits are based on the total

amount of your wages or self-employment

income during the year.

In 2016, for each $1,220 in gross earnings

you get one credit, max. of 4 credits per year

Earn $4,880 to earn 4 credits in 2016

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Amount of SSDI Benefit

Benefits are calculated based on work history

Monthly benefit payment amounts depend upon the

worker’s work/wage history and are unique to each

worker.

Maximum benefit payable is $2639 per month in

2016.

If the Social Security benefit amount is lower than

the full SSI payment, one may be eligible to receive

both Social Security and SSI. More on this later.

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Disability Onset Date

SSA will determine the disability onset date

for SSDI benefits. It is the first day the

applicant meets the definition of disability

The 5 month waiting period counts from the

month of disability onset.

The 12 month duration of disability

requirement counts from the month of

disability onset.

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Disability Onset Date

Substantial Gainful Activity during either of

these periods may result in a denial of the

application for SSDI.

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Retroactive Payments

SSDI benefits may be paid retroactively for up to 12

months prior to the date of application. The actual

amount of retroactivity depends on the disability

onset date and where that falls in relationship to the

date of application.

For Example: Disability onset was 09/10/2012. Five

month waiting period makes the first month of

eligibility 03/2013. However, beneficiary doesn’t file

until 01/22/2015. If approved, benefits are only paid

back one year to 01/2014, not back to 03/2013.

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Five Month Waiting Period

Payment begins the sixth full month after the date

SSA determines the disability began. In other words

the first 5 months after disability onset are non-

payment months.

For example, if the disability began on June 15,

2014, the earliest a benefit could be paid would be

for the month of 12/2014.

Benefits are paid a month behind. So, the December

benefit would be paid in January 2015.

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What is Substantial Gainful Activity (SGA)?

Work is “substantial” if it involves doing

significant physical or mental activities or a

combination of both.

In 2016 SGA is presumed at earnings

averaging over $1,130 gross a month for

those eligible on the basis of disability.

For those eligible on the basis of statutory

blindness it’s $1,820. [substantial]

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Other benefits payable under Title II

Benefits authorized under Title II of the

Social Security Act can also be paid for

Retirement, Dependent benefits for certain

family members of retired or disabled

workers, and Survivors benefits for certain

family members of deceased workers (20

CFR 404.310 – 404.374)

These individuals ARE NOT PABSS eligible

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Retirement Insurance Benefits

Generally need 40 quarters of coverage to qualify.

Receive full retirement (based on earning history at

Full Retirement Age.

Can elect retirement benefits as early as age 62 but

this result in a permanently reduced benefit.

Medicare eligibility starts at age 65.

These beneficiaries are Not PABSS eligible

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Child Disability Benefits (CDB), POMS DI 10115.001, 20 CFR 404.350 - .352.

The child must:

Be the child of a worker entitled to retirement or

disability, or who died fully or currently insured

Be a dependent of the worker and

Be unmarried. (some exceptions)

Be 18 or older and be under a disability which began

before age 22.

These beneficiaries are PABSS eligible.

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Disabled Widow(er)s DWB, POMS DI 10110.001, 20 CFR 404.335 - .337

Applicant must be:

Surviving spouse or surviving divorced spouse of

worker who died with enough credits to be insured

for benefits, Age 50 – 60,

Disabled within specific time periods (called

prescribed period)

Unmarried

These beneficiaries are PABSS eligible.

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Other Dependent and Survivor Benefits

There are other categories of dependent and

survivor benefits payable on the wage record

of a disability/retirement beneficiary or

deceased wage earner.

E.g., minor child benefits and spousal or

widow/or benefits based on age.

These beneficiaries are not PABSS eligible.

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Medicare for SSDI eligible individuals

Medicare coverage automatically begins

after being entitled to disability benefits for 24

months. Exception: no wait for those with

End Stage Renal Disease and ALS.

Example: Month of eligibility is 01/2014 –

Medicare A&B effective 01/2016 [Title II]

SSA will send information about Medicare

several months before coverage starts.

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Medicare

Medicare has 4 parts.– Part A - hospital insurance

– Part B - medical insurance

– Part C - Medicare Advantage (managed care)

– Part D Prescription drug coverage must be purchased from private insurer

Recipients of early retirement benefits are not eligible for Medicare until age 65 and then they are automatically enrolled.

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Sources of Law and Policy

United States Code (U.S.C.). Contains the

federal statutes that created the Title XVI (SSI)

(42 U.S.C. §1381 et. seq.) and Title II (42 U.S.C.

§402 et. seq.) programs.

Code of Federal Regulations (C.F.R.). Contains

the federal regulations implementing for the Title

XVI (20 C.F.R. § 416 et seq.) and Title II (20

C.F.R. § 404 et.seq.) Programs.

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Sources of Law and Policy

Case law. Decisions of the Federal District Courts,

U.S. Circuit Courts of Appeals, and the U.S.

Supreme Court.

Social Security Rulings (SSR). Statements of policy

and interpretations adopted by SSA based on

federal court and administrative decisions, policy

statements, and opinions of SSA’s Office of General

Counsel. Published in the Federal Register, they are

binding on all components of SSA, but do not have

the force and effect of law.

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Sources of Law and Policy

Acquiescence Rulings explain how SSA will apply

decisions of the U.S. Circuit Courts of Appeals that

are at odds with SSA’s national policies.

Program Operations Manual System (POMS). The

POMS provides guidelines for day-to-day operations

in SSA’s district offices and at Disability

Determination Services (DDS). The POMS does not

have the force and effect of law and cannot be used

where it conflicts with the statute or regulations.

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Sources of Law and Policy

Hearings, Appeals and Litigation Law Manual

(HALLEX). Published by the SSA Office of

Hearings and Appeals (OHA), the HALLEX

conveys guiding principles to OHA staff,

defines procedures for carrying out policy,

and provides guidance for processing and

adjudicating claims at the ALJ hearing,

Appeals Council, and federal court levels.

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Sources of Law and Policy

www.socialsecurity.gov

On the home page

Go to - Our Agency

Then, in the drop down box, choose - Program

Rules

You can then choose to view statute provisions,

regulations, Social Security Rulings, POMS,

HALLEX, Emergency Messages, or Chief ALJ

Bulletins.

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Upon completion

Send the spoken verification words to

PABSS@ndrn.org

Subject line - pre-requisite training

(If these are not received you will be denied entry to the

onsite training)

Please email any questions/comments to

Cheryl.Bates-Harris@ndrn.org

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