Rules that allow people on Supplemental Security Income (SSI) to keep Medi-Cal coverage when their combined income is too high to get any SSI cash benefit. Under 1619(b), you can keep your Medi-Cal while earning up to $36,423/year.
A type of retirement plan in which people who are employed can automatically have money taken out of their paychecks and put aside into an account that is taxed less than a standard savings or investment account. This helps the account grow more quickly than other accounts. The person who puts the money aside can only use this money after reaching the age of 59 and a half. If money is withdrawn before that age, the person taking the money out has to pay a penalty.
A program that pays for some or all of the costs associated with HIV/AIDS medications. ADAP only covers Federal Drug Administration (FDA) approved medications on its formulary (list of covered prescriptions).
An official who oversees administrative hearings held to resolve a dispute between a government agency and a person affected by a decision of that agency. They oversee any initial appeal you may make with a government institution.
Money the government sends you to pay for your personal care before you actually receive those services. Then you pay your care provider directly once they provide those services.
A contract signed by the sponsor that shows that the immigrant applying for a green card is not likely to become dependent on the government for cash welfare or long-term care (nursing homes). There are two types of Affidavits of Support: Old (Traditional) and New (Enforceable).
This federal law, signed by President Obama in 2010, leads to significant changes in our nation’s health care system, including extending health care coverage to many more Americans. Many of the changes in the new law do not happen right away, but will take effect over the course of many years, through 2020. For more information on the ACA, visit HealthCare.Gov.
DB101 will continue to keep track of health care changes and update this website as more information on the reforms becomes available.
The process of determining whether a child who is an SSI beneficiary will meet the adult definition of disability. The redetermination happens within a year of the 18th birthday.
A Medi-Cal eligibility category that gives free Medi-Cal to people who are disabled or at least 65 years old and who meet income, asset, and medical requirements.
A federal law that protects the rights of people with disabilities at work and in public places. The ADA makes it illegal for employers, the government, or other public agencies to discriminate against (to treat unfairly or unequally) disabled people at work and in most public places, places, such as restaurants, hotels, and theaters. The law also requires employers to make reasonable accommodations to allow employees with disabilities to do their jobs.
An appeal is any request to have a third party review an agency’s decision. Requests may be verbal or written. Typically, appeals are requested when benefits, services, or treatments are denied, stopped, or reduced.
Things that you own, like a car or a house. You can only own a certain amount in assets and still qualify for most health care and disability benefit programs. The home you live in and the car you drive to work are exempt under most Social Security and state disability benefit programs. Also called "resources."
Legislation that established Individual Development Account (IDA) programs for applicants who are not on CalWORKs. The three goals of AFIA include: providing individuals and families with incentives to save earned income, increasing self-sufficiency, and improving the community.
The yearlong period that SDI uses to determine your regular wages. It starts around 17 months before your disability and ends around 5 months before then. Your base period is divided into 4 quarters, and the quarter with the highest wage is used to determine your benefit amount.
Weekly income replacement that generally lasts a maximum of 52 weeks. Benefits based on self-employment elective coverage are generally paid for a maximum of 39 weeks.
Payments are based on an individual’s income during the SDI program’s base period, which is prior to the onset of disability.
The time period that Medicare uses to measure an individual’s use of hospital and skilled nursing facility care. A benefit period begins the day an individual enters a hospital or skilled nursing facility (SNF). The benefit period ends after the individual is released and hasn't received any further hospital care (or skilled care in a SNF) for 60 consecutive days. If an individual goes into the hospital after one benefit period has ended, a new benefit period begins. The inpatient hospital deductible may be charged for each benefit period. There is no limit to the number of benefit periods an individual may have.
A trained expert who can help you understand or apply for benefit programs. Their goal is to help you avoid financial complications while developing a sustainable plan for the future. To find a benefits planner in California, use the DB101 Benefits Planner Directory.
A report that summarizes your current Social Security disability benefits and available work incentives. To order one, visit your local Social Security office or call 1-800-772-1213 (voice); 1-800-325-0778 (TTY). Be sure to review your BPQY carefully. If you have questions about it, contact a benefits planner or Social Security.
Documented expenses for services or items that you need in order to work. Service animal expenses, transportation to and from work, and visual and sensory aids are examples of BWEs. You must be eligible for Supplemental Security Income (SSI) based on blindness to use BWEs.
Blindness in Social Security disability programs is "statutory blindness," which means:
You have a central visual acuity of 20/200 or less in your better eye, even while you are wearing a correcting contact lens or glasses in that eye; or
You have a limitation in the field of vision of your better eye, so that:
You have a contraction of peripheral visual fields to 10 degrees from the point of fixation, or
The widest diameter of your visual field subtends an angle no greater than 20 degrees, or
You have a contraction of peripheral visual fields to 20 percent or less visual field efficiency.
If you have a visual impairment that is not "blindness" as defined above, but your reduced vision (alone or in combination with other disabilities) prevents you from working, you may still be eligible for Social Security disability benefits.
The Social Security publication that provides detailed information about disability programs to physicians and other health care professionals. The Blue Book includes the complete Listing of Impairments, which lists and defines those conditions considered severe enough to prevent a person from doing any gainful activity. The Blue Book can now be accessed online.
This is the income amount which reduces your Supplemental Security Income payment to zero when Social Security uses the countable income calculation. Your break even point can be determined by your earned and unearned income, living arrangements, and applicable income exclusions.
Formerly called Food Stamps, CalFresh is a county-run, federal program that helps people with low incomes buy food. Nationally the program is called the Supplemental Nutrition Assistance Program (SNAP). In California, the benefits are issued monthly on an electronic debit card (EBT) that can be used to buy most foods at many markets and food stores. To apply for CalFresh, go to the Department of Social Services website.
California Work Opportunity and Responsibility to Kids. The state welfare-to-work program that provides income support and access to health coverage on a temporary basis. CalWORKs was formerly Aid to Families with Dependent Children (AFDC).
The Cash Assistance Program for Immigrants. (CAPI) pays a cash benefit to some people with low incomes who cannot qualify for SSI because of their immigration status.
Living and intending to stay in California. Individuals living in a jail, prison, VA hospital, or other public institution are ineligible for benefits.
CARE/HIPP (Comprehensive AIDS Resources Emergency/Health Insurance Premium Payment Program)
A program that pays for private health insurance premiums for individuals who are disabled due to HIV or AIDS and who do not qualify for Medi-Cal/HIPP. Enrollment is administered through AIDS organizations authorized by CARE/HIPP.
Benefits for disabled adult children of recipients of Social Security disability or retirement benefits. Formerly known as Disabled Adult Child (DAC) benefits.
A Social Security cash benefit for children with a parent who gets Social Security retirement benefits or SSDI. Children with a deceased parent may also qualify.
Assuming they meet all other eligibility criteria, U.S. citizens and Qualified Aliens (inlcuding those who meet I-551 or I-94 status) are eligible for both Social Security and state public benefits programs.
Legal residents who don't have I-551 or I-94 status may be eligible for some state programs, but not for Social Security programs. This could include Legal Permanent Residents (LPRs), refugees, asylees, conditional entrants, people certified as victims of trafficking, certain people whose immigration status is pending, people under Temporary Protected or Family Unity Beneficiary Status, Lawful Temporary Residents, applicants for asylum, people who have been granted or are applying for withholding of removal, and all other people with a lawfully residing immigrant status.
People who are undocumented or non-immigrants are not eligible for any of these programs.
An outside company that processes COBRA and/or OBRA premiums. As this company may be located in another state, it may not be familiar with health insurance laws in your state.
The portion of the payment for medical services that an individual is responsible for. For example, your health coverage may pay for 80% of the costs of a service, while you will have to pay the remaining 20%. That 20% is known as "co-insurance."
Temporary or transitional work that is performed in the public or private nonprofit sector that provides the Welfare-to-Work participant with job skills that can lead to employment.
The federal government pays benefits planners in communities around the country to help people think ahead about work incentives and benefits issues. CWIC's are benefits planners who are trained by the Social Security Administration to assist beneficiaries with programs including Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) in addition to other related programs.
If you lose access to group health insurance that you got through your employer for certain reasons, including a job change, divorce, or job loss, there are laws that allow you to continue your group coverage temporarily. This is known as continuation coverage. Often you will have to pay for your continuation coverage. The federal continuation coverage law is called COBRA. Many states also have their own continuation coverage laws.
A periodic review to determine if there has been any medical improvement in your condition and/or to determine whether you continue to be eligible for Social Security benefits for other reasons. The two types of reviews are called a medical CDR and a work CDR.
Having cooking facilities means that you have a refrigerator and at least 2 burners. Hotplates count as burners if they have temperature controls. You can substitute a microwave oven for one of the burners or hotplates.
A set amount you have to pay when you receive medical services. For example, you may have to pay $10 or $20 every time you visit the doctor or get a prescription refilled. This is also known as a "copay."
A health insurance plan that provides services at a lower premium than what it would cost the state to pay for those same services. The health insurance could be Medicare, private insurance, or employer-sponsored coverage.
Salaries, wages, tips, and any other money that you receive as pay for work that you do is considered "earned income."
Your countable earned income is the portion of that earned income that the Supplemental Security Income (SSI) program considers when deciding how much your SSI benefit should be. The SSI program uses a special calculation to determine your countable earned income, your total countable income, and ultimately, your SSI benefit.
The formula used to determine income and to consider eligibility for SSI-Linked, Medically Needy, and Aged and Disabled Medi-Cal programs.
Step 1: If you have unearned income (for example, an SSDI benefit), subtract a $20 "General Income Exclusion" from it to calculate your countable unearned income. If you do not have unearned income, this exclusion is applied to any earned income.
Step 2: If you have earned income (for example, wages), subtract a $65 "Earned Income Exclusion" from it (along with the remainder of the $20 "General Income Exclusion" that you have not applied to Unearned Income), along with any Impairment Related Work Expenses, and divide the resulting figure by two to find your countable earned income. If you have Blind Work Expenses, subtract them after you divide by two.
Step 3: Add your countable unearned income to your countable earned income to find your total countable income.
Different Medi-Cal programs may include more deductions or exclude certain types of income. See the program descriptions for details.
Funds received from sources for which no paid work activity is performed are considered "unearned income" (for example, disability benefits such as SSDI, SSI, short- and long-term disability insurance; VA benefits; Workers' Compensation; income from a trust or investment; spousal support).
Your "countable unearned income" is the portion of that unearned income that the Supplemental Security Income (SSI) program considers when deciding how much your SSI benefit should be. The SSI program uses a special calculation to determine your countable earned and unearned income, your total countable income, and ultimately, your SSI benefit.
Health-insuring organizations that are organized and operated by a governing board appointed by the county’s Board of Supervisors. All Medi-Cal beneficiaries residing within the county are required to enroll unless they have a voluntary aid code, which allows them to enroll in fee-for-service Medi-Cal. The first plan was implemented in Santa Barbara County in 1983. Five County Organized Health Systems plans operate in eight counties: Monterey, Napa, Orange, San Mateo, Santa Barbara, Santa Cruz, Solano, and Yolo.
Under HIPAA, creditable coverage is prior health coverage that allows you to reduce pre-existing condition exclusionary periods when applying for new coverage. Most forms of health coverage can count as creditable.
Coverage that is at least as good as that offered through Medicare Part D. Your health coverage plan can tell you whether or not your coverage is creditable.
A hospital facility that provides outpatient and certain inpatient services to people in rural areas. Critical Access Hospitals are given a special status by Medicare.
A process that allows a job seeker and potential employer to individualize a job description so that the job seeker's strengths would be utilized while the employer's needs would be met.
The amount an individual is responsible for paying before Medicare begins to pay. For Part A, the deductible must be paid each benefit period. For Parts B and D, the deductible must be paid each year.
The amount of another person’s income – spouse, sponsor, sponsor’s spouse, parent – that is considered to belong to the individual regardless of whether the person receives this money.
The amount of another person’s income (a spouse or parent, for example) that is considered to belong to the individual regardless of whether the person receives this money.
Rules used by Social Security and Medi-Cal that determine an individual’s eligibility when living with a non-disabled spouse. If the individual is a minor, deeming rules apply to the parents.
A person, usually a child, who is economically dependent on another person. Different programs have different specific definition of when someone is a dependent.
Disability (Definition used by California State Disability Insurance - SDI)
Any illness or injury which prevents an individual from doing their regular or customary work. SDI includes disabilities resulting from elective surgery, pregnancy, childbirth, or a related medical condition. The disability must be verifiable by a medical provider. The SDI program may require some applicants to undergo an Independent Medical Examination to determine disability status.
A condition that is expected to last at least 30 days and that significantly impairs the individual’s ability to be regularly employed or participate in Welfare-to-Work activities.
To qualify for an exemption from Welfare-to-Work activities due to a disability, a CalWORKs recipient must provide verification from a physician that states the disability, its expected duration, and the extent to which it impairs employment and/or Welfare-to-Work activities. The individual must also actively seek medical treatment to qualify for an exemption.
Definition of disability may be two-tiered: an inability to participate in the employee's own occupation (regular work) on the first tier, and an inability to participate in any occupation (any work) on the second tier. Refer to policy for definitions of disability.
Disability (Definition used by Social Security for Adults)
The inability to engage in any Substantial Gainful Activity (SGA) due to any medically determinable physical or mental impairment which can be expected to result in death or last for a continuous period of at least 12 months.
A person must not only be unable to do his/her previous work but cannot, considering age, education, and work experience, engage in any other kind of SGA which exists in the national economy. It doesn't matter whether such work exists in the immediate area, or whether a specific job vacancy exists, or whether the worker would be hired if he/she applied for work. The worker’s impairment(s) must be the primary reason for his/her inability to engage in SGA.
Disability (Definition used by Social Security for Children)
A child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
Generally, the only time it is required to disclose a disabling condition at the workplace is when requesting a reasonable accommodation. Even then, the requirement is only to present the employer with information demonstrating that a reasonable accommodation is needed for the person to perform the essential functions of the job.
• We have a common residence;
• Neither of us is married to someone else, or is a member of another domestic partnership with someone else that has not been terminated, dissolved, or adjudged a nullity;
• We are not related by blood in a way that would prevent us from being married to each other in this state;
• We are both at least 18 years of age;
• We are both members of the same sex or one/or both of us is/are over the age of 62 and meet the eligibility criteria under Title II of the Social Security Act as defined in 42 U.S.C. Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as defined in 42 U.S.C Section 1381 for aged individuals;
• We are both capable of consenting to the domestic partnership;
• We consent to the jurisdiction of the Superior Courts of California for the purpose of a proceeding to obtain a judgment of dissolution or nullity of the domestic partnership or for legal separation of partners in the domestic partnership, or for any other proceeding related to the partners’ rights and obligations, even if one or both partners ceases to be a resident of, or to maintain a domicile in, this state.
The gap in Medicare Part D coverage when you have between $2,930 and $6,657.50 in total drug costs in a year.
In the past, Medicare would not help pay for your drug costs during this period unless you qualify for the Low Income Subsidy. That changed in January 2011, however. Today people on Medicare who fall within the “donut hole” get a 50% discount on brand name prescription drugs and a 7% discount on generics. This discount will continue to grow until 2020, when the donut hole coverage gap is closed completely. These changes are happening as a result of the Affordable Care Act passed in 2010.
Salaries, wages, tips, professional fees, and other amounts you receive as pay for physical or mental work you perform. Funds received from any other source are not included. (Contrast: unearned income.)
Income received from work that is disregarded in the countable income calculation. This calculation evaluates an individual’s financial eligibility for Aged and Disabled Federal Poverty Level (ADFPL), Breast and Cervical Cancer Treatment Program (BCCTP), In Home Supportive Services (IHSS), Medically Needy (MN) and California Working Disabled Program (CWD) Medi-Cal.
A rule designed to encourage people on Section 8 to try working. It allows people with disabilities to take a new job and exclude 100% of their earnings during their first year of employment, and 50% of their earnings during the second year.
So if you're on Section 8 and you start working after being unemployed, the amount you pay in rent will stay the same for the first 12 months. And during the second 12 months, your housing authority will only count half of your total work earnings towards rent.
A federal income tax credit for low income working individuals and families. The credit reduces the amount of federal income tax you owe and can result in a refund check. Most people claim their Earned Income Tax Credit (EITC) when they file their federal income taxes.
Optional State Disability Insurance (SDI) for the self-employed. Individuals must pay premiums based on self-employment taxes. Unlike SDI for employees, elective coverage generally provides income replacement benefits for a maximum of 39 weeks.
One of several types of health coverage programs that Medi-Cal offers. Each eligibility category has specific requirements, and an individual may be eligible for more than one category.
An employment services agency that is approved by Social Security. Employment Networks may offer a variety of services such as job readiness services, placement services, vocational rehabilitation, training, job coaches, transportation or other supports.
Employment Network examples:
Employers
Employers offering or arranging for job training
Employers collaborating with community based organizations
Transportation providers
Staffing and placement agencies
Consumer groups
State Department of Rehabilitation
Private providers of rehabilitation services
Vocational rehabilitation Service Projects for American Indians with disabilities
Cottage industries such as benefits planning services combined with other services
Public or private schools providing transitional education or career development services
Organizations working with ethnic, disability, or religious faith groups
A geographic area, such as a neighborhood, that meets certain population, size, and poverty guidelines. An area must be nominated by the local government and the state to become an Empowerment Zone. The Zone is marked by poverty, unemployment, and general distress. Empowerment Zones receive federal funding for community development. A list of Empowerment Zones can be found on the HUD website.
Essential functions are the fundamental job duties that you must be able to perform on your own or with the help of a reasonable accommodation. An employer cannot refuse to hire you because your disability prevents you from performing duties that are not essential to the job. At the same time, you cannot ask for an essential function to be removed from your job description as a reasonable accommodation.
When your employer-sponsored health insurance begins, for a certain period of time the insurance company can refuse to pay for care or services related to a pre-existing condition that you had when the insurance started. There are legal limits on how long the exclusionary period can last.
Immediate reinstatement of benefits for individuals whose Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI) ended due to employment. This provision is available for up to 5 years after Social Security work incentives have been exhausted.
A statement from your health insurance company showing the health care services you have received and how much the insurance company has paid for those services.
A period of time (36 months) after your Trial Work Period ends, during which you can continue to get your SSDI benefit during months when you earn less than a certain amount.
A federal law that allows you to take up to 12 weeks off of work for the birth or adoption of a child, to care for a family member, or if you have a serious medical condition. You need to have worked for your employer for at least one year to qualify for FMLA coverage and your employer must employ at least 50 people.
Total taxable income. This includes money, goods, property, and services from all sources after any adjustments or deductions that are shown on a federal tax return.
The national benefit amount, established by the Social Security Administration (SSA), for Supplemental Security Income (SSI) recipients. The Federal Benefit Rate (FBR) is administered by SSA for all states and Commonwealths annually. For 2012, the FBR is $698 for an individual and $1,048 for a couple.
Monthly and annual income amounts used to determine financial eligibility for state and federal benefit programs.
Each year, the U.S. Department of Health and Human Services (HHS) issues the Federal Poverty Guidelines in the Federal Register. The current Federal Poverty Level for one person is $10,890 per year; for two people, it's $14,710. Add $3,820 for each additional person.
Taxes that are deducted from your paycheck when you work to help pay for Social Security and Medicare. FICA stands for Federal Insurance Contributions Act.
An insurance plan purchased for employees by an employer, through an insurance company. The employer pays premiums to that company, and the insurance company is responsible for providing the costs of health care, as agreed upon in the policy. Fully-insured plans are subject to federal and state regulation.
The period of time between January 1 and March 31 when a Medicare beneficiary can sign up for Part B coverage. Benefits will not begin until July 1 of that year, and a beneficiary may be subject to a late enrollment fee of 10% for each 12 month period they did not have Part B Medicare.
General Income Exclusion (Supplemental Security Income Program)
A county program that provides relief to those who are unable to support themselves by their own means, or by friends or relatives, other public funds, or other assistance programs.
The total benefit amount an insurance company pays before deductions. Deductions are made for an individual’s disability income and for earnings he/she is receiving.
A serious violation of company policy or the commission of a crime affecting the workplace that may result in the loss of COBRA benefits. Although "gross misconduct" is not defined in COBRA legislation, past examples include embezzlement, misrepresentation, theft, and non-work related violence.
The maximum amount of group coverage available to an individual during the initial enrollment period that does not require medical underwriting. For example, an individual may obtain guaranteed issue amount coverage of two times his or her annual salary, with higher benefit amounts requiring medical underwriting.
A period of time when an individual can enroll in a Medicare supplement plan without medical underwriting or waiting periods. Medicare supplement providers cannot deny coverage during these periods.
H
Health Insurance Portability and Accountability Act (HIPAA)
A law that allows you to use prior coverage to reduce preexisting condition exclusionary periods. HIPAA also prevents group health plans from denying you coverage based on your health condition and provides protections for those buying individual health coverage.
A common type of health care coverage plan. HMOs require that you only see certain doctors and that your primary care physician decides when you need to see a specialist.
A process that allows Medicare supplement carriers to refuse coverage based on an individual’s health history. This process is also known as medical underwriting.
HIPAA and similar California laws prevent employer-sponsored health coverage plans from denying coverage based on health status. This includes physical and mental health conditions, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
A low cost insurance program for children and teens in California. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for free Medi-Cal.
Medi-Cal has a list of certain conditions, like AIDS, that they automatically consider high cost. For other conditions, Medi-Cal estimates how much it would cost them to pay for your condition. They then estimate how much it would cost them to pay for your private insurance premiums. Conditions that are more expensive for Medi-Cal to cover are high cost conditions.
A cheap plan that usually doesn’t pay for the first few thousand dollars of health care expenses (this is your deductible) but will typically cover your expenses after you pay a certain set amount.
A form for individuals with HIV/AIDS who are applying for Social Security Disability Insurance (SSDI) benefits. The form requires physicians to identify whether an individual has one of the 41 opportunistic infections listed on the form, and to specify any "repeated manifestations" of other symptoms that restrict certain aspects of the individual's life.
Services covered by Medicare including part-time or periodic skilled nursing care; home health aide services; physical therapy; occupational therapy; speech-language therapy; medical social services; durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers); medical supplies; and other services.
Services covered by Medicare Part A for individuals with a terminal illness. Services may include prescriptions for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare. Hospice care is usually given in an individual’s home; however, Medicare may cover some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
Documented expenses for services or items that are related to a serious medical condition or impairment and needed in order to work. Wheelchairs, physician visits, copayments for prescriptions, and other medical expenses are some examples of IRWEs. The expenses must be verified by original receipts and canceled checks and approved by Social Security.
A program that provides domestic, paramedical, and personal assistance services for people with disabilities so that they can live independently or maintain employment safely. The IHSS program provides an alternative to living in an institution for many people.
Money from salaries, wages, tips, disability benefits, investments, dividends, and funds received from any other source. Includes both earned and unearned income.
Offices that help people with disabilities live independently by offering information, teaching skills, and helping plan benefits. Your local Independent Living Center (ILC) has information about all aspects of living with a disability, including housing, transportation, Personal Assistance Services (PAS), employment, education, and benefits.Independent Living Centers are run by people with disabilities.
A person outside of a Part D plan who reviews an appeal. This is the first person outside of the plan to review an appeal during the Part D appeals process.
A deeming exception for CAPI applicants whose sponsor signed an Old Affidavit of Support. An individual is considered to be indigent if he/she receives less than the federal Supplemental Security Income (SSI) benefit amount - $698 per month in 2012 for an individual ($1,048 for a couple).
Coverage that you buy directly from an insurance company, usually through an agent. You are responsible for paying for the entire premium, and most individual policies require medical underwriting.
A savings account in which your deposits are "matched" at a certain rate. If you have a 2-to-1 match, for example, an additional $2 will be deposited for every $1 that you deposit in your account. IDAs are usually used to save for school, purchasing a home, or starting a business.
A type of retirement plan in which people who are employed can put aside money every year into an account that is taxed less than a standard savings or investment account. This helps the account grow more quickly than other accounts. The person who puts the money aside can only use this money after reaching the age of 59 and a half. If money is withdrawn before that age, the person taking the money out has to pay a penalty.
A personal income limit that enables an individual to retain Supplemental Security Income-linked Medi-Cal coverage when their earnings go above the state's threshold amount. Social Security will determine an Individual Threshold Amount if the individual has Impairment Related or Blind Work Expenses, a Plan to Achieve Self-Support, a publicly funded personal attendant, or medical expenses above the state average amount.
A formal agreement between a ticket holder and an Employment Network that describes how services will help the person to achieve an employment goal. The Plan includes specific steps and a time schedule that may span several years.
An educational plan for a student receiving special education services. The IEP is created with input from parents, teachers, staff, and the student. It includes information on the student’s current performance, goals and evaluation, and on what specific services the student will need.
The period when a beneficiary can first sign up for Medicare Part B or Part D. For Social Security Disability Insurance (SSDI) and Childhood Disability Benefits (CDB) beneficiaries, the initial enrollment period begins during the 24th month of a beneficiary’s SSDI or CDB payments. The initial enrollment period typically lasts about 10 months.
Initial Enrollment Period (Private Health Coverage)
The first time an individual is eligible to enroll in a group’s benefits programs. During this period, the individual’s medical history is not subject to review. Once enrolled, however, pre-existing condition exclusionary periods may apply.
Food and/or rent only which is supplied or paid for by someone else, not the person who gets SSI cash benefits. Sometimes referred to as ISM. Clothing is not considered ISM.
Measurable milestones that show progress towards achieving a vocational goal in a Plan for Achieving Self-Support. For example, if the goal is to obtain a job, the job search would be considered an interval step.
Being able to sign contracts, vote, and enjoy other rights and responsibilities of adulthood. Generally, in the United States, people become legal adults when they turn 18. This is a separate concept from Representative Payee.
A limit of how much an insurer will spend on you. For example, a plan might cover medical costs until they've spent $100,000, at which point they will no longer help pay for your medical costs.
The days following a 90-day hospitalization. Medicare allows an individual 60 lifetime reserve days per benefit period that may only be used once during an individual’s lifetime. Medicare will pay for lifetime reserve days, whether used at once or over the individual's lifetime. However, the individual must pay for the daily coinsurance of $578.00 in 2012.
Cash or other property which can be converted to cash within 20 days, excluding non-work days. Liquid assets include: checking and savings accounts, stocks, bonds, mutual fund shares, promissory notes, mortgages, and life insurance policies.
Services that assist individuals with long-term medical and personal needs. Long-term care may include medical services, physical therapy, custodial care, and assistance with activities of daily living such as dressing, eating, and bathing. Long-term care may be provided at home, in the community, or in facilities, including nursing homes and assisted living facilities. Medicare will not pay exclusively for custodial care.
Private insurance that replaces some of your income when you can't work because of a disability. Long-Term Disability (LTD) generally covers disabilities that last more than a year. To apply for LTD, speak with your employer's human resources department, or contact a private insurance company.
A window of time prior to enrollment in a new health plan used to define pre-existing conditions. If, for example, your private health plan has a “6-month look-back,” any health condition that you received medical advice, diagnosis, care, or treatment for within the six months prior to enrollment would be considered a pre-existing condition.
Health insurance for Californians who are unable to obtain coverage in the individual health insurance market, usually due to pre-existing condition exclusionary periods.
Amount of cash aid a CalWORKs applicant is eligible for based on family size. Families who do not have any earned or unearned income are considered exempt and will receive a higher cash payment.
A private organization authorized by the Social Security Administration (SSA) to manage the Ticket to Work Program. As Program Manager, MAXIMUS provides outreach, recruitment, training, and payment processing to Employment Networks.
A joint Federal and state program that provides assistance with medical costs to some low income individuals with limited resources. Medicaid programs vary from state to state. The federal Medicaid program is called Medi-Cal in California.
A program that allows individuals working with a disability to retain Medi-Cal (Medicaid) coverage through premium payments. In California, this program is called the California Working Disabled Program.
A Medi-Cal program that requires most recipients to receive services within a network. Recipients are assigned a primary care provider who is responsible for managing their care. Also known as Medi-Cal Prepaid Health Plan.
The person who provides a medical certification of a disability. They can be a licensed physician, surgeon, U.S. government medical office, osteopathic physician, chiropractor, podiatrist, optometrist, dentist, designated psychologist, nurse-midwife, nurse practitioner, midwife, or accredited religious practitioner.
A Medicare Advantage (Part C) option where Medicare gives your plan money to deposit into a savings account. You can use this money to pay for Medicare costs. After you meet a high yearly deductible, the plan will help pay for Medicare services.
Any medical care that you receive for a medical condition. Some examples include being prescribed medication, visits to the doctor, and therapy for a mental health problem.
The review of an individual’s medical history and/or medical records to determine if the individual is eligible for coverage. Medical underwriting, which may include new medical testing, can be used to deny coverage or determine if a particular pre-existing condition will be covered.
A Medi-Cal eligibility category that allows you to have countable income up to 250% of the Federal Poverty Level. You pay a small premium for Medi-Cal that is based on your income.
Medicare is a federal program that provides health insurance for people over 65 and many people under 65 who have a disability. If you receive Social Security Disability Insurance benefits, you will be eligible to receive Medicare after a two year and five month waiting period.
A way to organize your Medicare benefits. When you use services within the plan’s network, it helps pay for costs. When you use services outside the plan’s network, Original Medicare helps pay.
A Medicare Advantage option that can have lower copayments than the Original Medicare Plan, but generally limits individuals to visiting doctors, specialists, or hospitals within the plan's network. Plans must cover all Medicare Part A and Part B services, and some plans cover extras, like prescription drugs. Medicare Managed Care Plans are only available in some areas of the country.
Medicare Part B is the part of Medicare that helps pay for medical care you get when you are not staying in a hospital, such as when you go to see a doctor.
Also known as "Medicare Advantage", Medicare Part C is a Medicare program that offers benefits from private insurance companies. These plans can provide more choice and extra benefits. Medicare Part C plans include: Managed Care (Medicare HMOs), Private Fee-for-Service, Preferred Provider Organization, and Special Needs Plans. Everyone who has Medicare Parts A and B is eligible to join a Part C plan, except most people with End-Stage Renal Disease (ESRD).
Medicare Part C used to be called "Medicare + Choice."
A Medicare Advantage option that gives an individual the choice of visiting providers within the network or seeing a provider outside of the network for an additional cost. An individual does not need a referral from their primary care physician to see a specialist.
A Medicare Advantage option that allows an individual to go to any Medicare-approved doctor or hospital. The insurance plan, rather than the Medicare program, decides what services it will cover and how much it will pay. Although an individual may pay more under this plan, he/she may have extra benefits that the Original Medicare Plan doesn't offer.
Medicare Savings Programs help people on Medicare pay for some of their out-of pocket Medicare costs. The costs paid depend upon your income but can include Medicare Part A and B premiums, coinsurance, and deductibles. You need to be earning less than 135% of the Federal Poverty Guidelines (FPG) + $20 ($1,246/month for an individual, $1,675/month for couples through 6/30/2012) to qualify for a Medicare Savings Program.
There are three different Medicare Savings Programs you may qualify for:
Qualified Medicare Beneficiary (QMB), if your income is less than 100% of FPG + $20 ($928/month for an individual, $1,246/month for couples)
Service Limited Medicare Beneficiary (SLMB), if your income is less than 120% of FPG + $20 ($1,109/month for an individual, $1,491/month for couples)
Qualified Individual (QI), if your income is less than 135% of FPG + $20 ($1,246/month for an individual, $1,675/month)
If you qualify for a Medicare Savings program, the state will pay some of your Medicare expenses for you. The expenses that the state pays for depend upon your income and may include Medicare Part A and B premiums, coinsurance, and deductibles.
You need to be earning less than 135% of the Federal Poverty Guidelines + $20 to qualify for a Medicare Savings program ($1,246 per month for an individual, $1,675 per month for couples through 6/30/2012).
A supplemental insurance policy sold by private insurance companies to fill gaps in the Original Medicare Plan. In California, there are 12 Medicare supplement plans labeled Plan A through Plan L.
Medicare supplement plans are available only to individuals using the Original Medicare Plan, and it is illegal for an insurance carrier to sell a Medicare supplement to an individual who does not have Original Medicare.
Medicare supplements are also referred to as "Medigap."
The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law that says health plans are not allowed to limit benefits for mental health or substance use disorder more than they limit benefits for other medical coverage.
An evaluation that measures an individual's ability to complete activities of daily living (dressing, toileting, bathing, eating, respiration, getting around in the house) and instrumental activities of daily living (housekeeping, shopping, taking medication, meal preparation, managing finances, and getting around out of the house). The needs assessment determines an individual’s level of need for the In Home Supportive Services Program.
Health care services that are medically necessary and are aimed at treating illnesses, as opposed to preventing them. (Contrast: preventive care services.)
If you are on COBRA for 18 months, you may be able to extend your health care coverage for an additional 11 months via OBRA protections. Important: You must apply for OBRA within 30 to 60 days of the date that you're approved for SSDI.
Offices with free tools, resources, and services that can help you find employment or training and get help with other work-related needs. They can help you with various things, including:
Giving you advice about local employers who are hiring
Teaching you the basics of how to do a job search
Helping you with your resume
Practicing job interviews
Showing you how to use online jobs websites like CalJOBS
The date, after reviewing an individual's medical records, that Social Security determines that a disability began. The date Social Security receives an application does not necessarily establish the onset date.
An employment activity under the Welfare-to-Work Program that provides skills to CalWORKs participants. An employer in the public or private sector can receive compensation for On-the-Job Training of a CalWORKs recipient.
The annual time period when an individual may add or change coverage in an employer-provided or association-affiliated insurance plan. Changes during most of these annual periods will require medical underwriting to add benefits not elected during the initial enrollment period. The federal government calls this period "open season", and other insurers may use different terms.
A pay-per-visit health coverage plan that allows individuals to go to any doctor, hospital, or other health care supplier who accepts Medicare and who is accepting new Medicare patients. The individual is responsible for paying a deductible and copayment. Under Original Medicare, Medicare pays a portion of the Medicare-approved amount, while the individual pays for his/her share (coinsurance). Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
The maximum amount of money that you have to spend on health costs in a year. After you reach the out-of-pocket maximum, your policy will pay the entire cost of covered services. The out-of-pocket maximum does not count the premiums you pay, and certain other costs may or may not be counted.
Services that are prescribed by a doctor and often administered by in-home care providers. They typically require some level of training or judgment and are essential to the health of the recipient. Common examples include injections, administration of medication, catheter insertion and care, tube feeding, ventilator and oxygen care, treatment of wounds, and other services requiring sterile procedures.
Social Security uses this as one measure of whether or not a beneficiary should receive an independent living benefit rate. A child is considered to be under "parental control" if their parent has the authority to make decisions on their behalf.
A monthly fee that parents must pay for their child's Medical Assistance (MA) coverage if their income exceeds 100 percent of Federal Poverty Guidelines (FPG).
Social Security’s process of figuring out how much of parents’ income is used to pay for a child’s basic needs. Some of the parents' income may be considered the child's when determining whether or not the child is eligible for disability benefit programs.The amount of deemed income is subtracted from the benefit amount.
Once you start a PASS, your PASS Cadre will review it on a regular basis (at least once every 6 months) to see how your plan is progressing and to collect receipts for your expenses. This is known as your "PASS review."
A program administered by a pharmaceutical company that provides financial assistance with prescription drug costs. PAPs offer free and discounted prescription drugs to those who qualify.
Unable to engage in any Substantial Gainful Activity (SGA) due to any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of at least 12 months.
Permanently Residing in the U.S. Under Color of Law (PRUCOL)
Noncitizens who are residing in the United States with the knowledge and permission of the Department of Homeland Security (DHS). This category includes noncitizens:
Subject to an Order of Supervision
On whose behalf an immediate relative petition has been approved and who are entitled to voluntary departure
Who have properly filed an application for an adjustment to lawful permanent resident status
Granted a stay of deportation
Granted voluntary departure and who are awaiting issuance of a visa
In deferred action status
Who entered and have continually resided in the United States since before January 1, 1972
A group of local pharmacies you can buy prescription drugs from. If you purchase drugs from within your pharmacy network, your prescription drug plan should cover it.
A Supplemental Security Income (SSI) program that allows you to set aside income and assets for expenses related to a specific work goal. Income that you use for these expenses will not cause your SSI benefit to go down. Assets that you spend on PASS expenses won't count towards the SSI limit.
A type of health coverage that allows you to choose between HMO, PPO, and Indemnity coverage. You can choose to pay less and have your care managed by a physician, or pay more to have more choices in the doctors you can see.
A condition that does not yet interfere with your abilities or keep you from working, but may one day develop into a disability that keeps you from working.
You are HIV positive (you do not have an AIDS diagnosis, do not have Opportunistic Infection (OI), and do not have any symptoms), you are working, and you are likely to become disabled if you don’t get medical treatment.
Any condition for which “medical care” was received within six months prior to the effective date of insurance coverage. Medical care includes the use of prescription drugs and physician consultations and services. During a pre-existing condition exclusionary period, coverage for that condition is either not provided or can be limited.
The period of time from the coverage effective date that the insurer does not cover a pre-existing medical condition. The individual will normally be covered for the condition once the specified time has elapsed.
A government-run insurance plan for people who can’t get insurance because of pre-existing medical conditions, including mental health conditions. People have to pay premiums to participate, but the law limits the amount people have to pay.
The PCIPs are meant to be temporary; they will end on January 1, 2014, when government-regulated insurance exchanges start operating. By this date, the law also says that insurance companies won’t be allowed to deny people coverage because of pre-existing conditions.
A type of health insurance plan. You pay a monthly premium and, when you use medical services, copayments and deductibles. PPOs have networks of physicians. You can see any doctor in the network without getting prior authorization from a primary care physician. Seeing a doctor outside of the network is more expensive.
A rule that sets a maximum value on the amount of certain types of in-kind support and maintenance that SSI counts. The PMV rule generally applies when someone is getting free food or shelter, but not both. The PMV at any given time is 1/3 of the Federal Benefit Rate + $20. For 2012, the PMV is $252.67 for an individual and $369.33 for a couple.
A status granted to Supplemental Security Income (SSI) applicants who have a high chance of being found disabled according to Social Security Administration (SSA) standards. If the SSA finds you presumptively disabled, they will begin benefit payments while your application is still being reviewed.
The SSA may find you presumptively disabled if you meet the medical criteria of the Blue Book Listing of Impairments or if you have HIV/AIDS and meet the criteria of SSA Form 4814. In either case, you must also meet SSI financial requirements to be eligible for presumptive disability benefits.
Repayments of presumptive disability benefits are not required even if SSI benefits are ultimately denied.
Health care services aimed at keeping you healthy by preventing illness; for example, Pap tests, pelvic exams, yearly mammograms, and flu shots. (Contrast: non-preventive care services.)
A doctor that provides basic care and acts as an individual’s first point of contact when seeking health services. In many Medicare Managed Care Plans (Medicare HMOs), an individual must see their primary care doctor before going to a specialist.
The doctor, nurse practitioner, or other medical service provider who is in charge of your medical care in a Health Maintenance Organizations (HMO). In HMOs, you have to see a PCP in order to get a referral to see a specialist. Other types of health coverage might not have PCPs, or might charge you more if you see a specialist without getting a referral from a PCP.
In some cases, your doctor or medical service provider must get permission from your health care plan before providing you with certain services. This is known as "prior authorization."
The review of an individual’s medical records, or the performance of medical testing, to determine eligibility for coverage. Individuals who elect coverage through a group during the initial enrollment period for the guarantee issue amount are not normally required to furnish proof of good health.
The date an individual first contacts the Social Security Administration (SSA) to file for Supplemental Security Income (SSI) benefits. The protective filing date establishes the earliest possible date an individual can receive SSI benefits.
According to Social Security, you are considered a qualified alien if the Department of Homeland Security (DHS) says you are in one of these categories:
Lawfully Admitted for Permanent Residence (LAPR) in the United States, including "Amerasian immigrant" as defined in Section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988, as amended;
granted conditional entry under Section 203(a)(7) of the Immigration and Nationality Act (INA) as in effect before April 1, 1980;
paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year;
refugee admitted to the United States under Section 207 of the INA;
granted asylum under Section 208 of the INA;
deportation is being withheld under Section 243(h) of the INA as in effect before April 1, 1997, or removal is withheld under Section 241(b)(3) of the INA; or
“Cuban or Haitian entrant” under Section 501(e) of the Refugee Education Assistance Act of 1980 or in a status that is to be treated as a “Cuban or Haitian entrant” for SSI purposes.
A Medicare Savings Program that pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their free Medicare Part A due to earnings. To qualify, an individual must:
Be less than 65 years old,
Be eligible for Medicare Part A,
Have income at or below 200% of the Federal Poverty Level (until 3/31/2012, $1,815.00 per month for individuals, $2,452.00 for couples),
Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
Expenses for certain items or services that are approved by your Flexible Spending Arrangement (FSA). You should get a list of what things count as qualified medical expenses, so you know ahead of time which things will be covered by your FSA, and which things will not
An IRS classification that may allow a taxpayer to claim the EITC and certain other tax credits. In general, to be a taxpayer’s qualifying child, a person must satisfy four tests:
Relationship — the taxpayer’s child or stepchild (whether by blood or adoption), foster child, sibling or stepsibling, or a descendant of one of these.
Residence — has the same principal residence as the taxpayer for more than half the tax year. Exceptions apply, in certain cases, for children of divorced or separated parents, kidnapped children, temporary absences, and for children who were born or died during the year.
Age — must be under the age of 19 at the end of the tax year, or under the age of 24 if a full-time student for at least five months of the year, or be permanently and totally disabled at any time during the year.
Support — did not provide more than one-half of his/her own support for the year.
A spouse, domestic partner, or parent whose employer-sponsored health plan premiums are paid for by Medi-Cal/HIPP. Medi-Cal/HIPP pays premiums for qualifying family members when it is cost effective to enroll the family member in the employer-sponsored plan.
A feature of the SSI program that makes it easy to restart your SSI benefit if you lost it because of work alone. If you are 1619(b) eligible and you stop working, you will be able to get your SSI benefit restarted quickly without having to file a new application or wait for medical review.
An adjustment or modification to a job or workplace that enables an employee to successfully perform the essential duties of the job.
In education, a reasonable accommodation is a modification that allows a student with a disability to successfully participate in an activity, class, test, or other aspect of school.
A request to an employer to make a modification to a job or workplace that allows an employee to successfully perform the essential duties of a job. The request can come from the employee, or an employee's friend, family member, or medical provider. Reasonable accommodation rules are case-by-case situations, and employers and employees can negotiate the terms under the law.
A written authorization to visit a specialist from an individual’s primary care doctor. In many Medicare Managed Care Plans (Medicare HMO), an individual must get a referral before receiving care from anyone except the primary care doctor. If an individual fails to get a referral, the plan may refuse to pay for care.
A noncitizens who, while outside the U.S. and their home country, was granted permission to enter and live in the U.S. because they had a well-founded fear of persecution in their home country.
Attend a college or university for at least 8 hours a week under a semester or quarter system
Be in grades 7 - 12 for at least 12 hours a week
Be in a course of training (with shop practice) for at least 15 hours a week to prepare for a paying job
Be in a course of training (without shop practice) for 12 hours a week
In some circumstances, like illness or unavailability of transportation, students may be allowed to spend less time than indicated above and still be considered “regularly attending” for the purposes of the SEIE.
An individual who receives benefits on someone else's behalf. Social Security conducts a careful investigation before appointing a relative, friend, or other interested party as the representative payee of individuals who need help managing their benefits. For children under 18, a parent or guardian is usually the representative payee.
Household goods and personal effects that have a total value of $2,000 or less
One car if it is: necessary for employment, or necessary for medical treatment, or modified for use by a disabled person, or it provides necessary transportation to perform essential daily activities, or has a current market value less than $4500
Property of a trade or business that is essential for self-support
Non-business property which is essential to self-support
Resources of a blind or disabled individual necessary to fulfill an approved PASS
Certain stocks held by Alaskan natives
Life insurance, if the total face value of all policies on one person do not exceed $1500. Otherwise, the cash surrender values of life insurance policies will count as a resource
Restricted allotted Native American lands
Payments or benefits paid under other Federal statutes
Disaster relief assistance
Burial space of any value, and burial funds up to $1500
Title XVI (SSI) or Title II (SSDI) retroactive payments for 6 months
In addition to the home you live in and one car, there are several other resources that may be excluded when determining your Supplemental Security Income (SSI) countable resource total. Earned Income Tax Credits (EITC), Child Tax Credits (CTC), CalFresh (formerly Food Stamps), grants, scholarships, fellowships, gifts, property essential to self-support, Individual Development Accounts (IDAs), and many other items may be excluded. For more information, you can read the SSI Spotlight on Resources.
Accessible cash resources that include: individual/joint checking and savings accounts, retirement accounts, stocks, bonds, mining rights and cash value in a life insurance policy.
Cash or property that you own, can convert to cash, or can use to support yourself. Stocks, bonds, and savings accounts are a few examples of resources.
Retirement, Survivors, and Disability Insurance (RSDI)
Social Security program that provides monthly income to people with disabilities, survivors or dependents of people with disabilities, and retired people. Social Security Disability Insurance (SSDI) is one part of RSDI.
The total amount of money that a business earns before expenses are deducted. Example: Julia's consulting business earns $5,000 per month, but spends $2,000 per month on expenses. Her company's total monthly revenue is $5,000; her company's monthly net income ($5,000 minus $2,000) is $3,000.
Regular attendance and satisfactory progress in the Welfare-to-Work and Cal-Learn programs. In the Cal-Learn program, satisfactory progress is considered a grade point average of 2.0
A health insurance plan that supplements a primary insurance plan. Health care costs not covered by the primary plan can be submitted to the secondary payer, which often covers some or all of the deductibles, copayments, and other services not covered by the primary insurance provider.
A rule that allows certain people to keep their Social Security benefits after being found to no longer be medically disabled. For Section 301 to apply, a person who gets benefits has to be participating in a Social Security approved employment support program, and participation in that program has to increase the likelihood that he or she will not need Social Security benefits after completing the program. Vocational rehabilitation and PASS are two examples of “Social Security approved employment support programs."
An analysis of how you're suited for different types of work settings and jobs. The analysis might look at your strengths and weaknesses as well as your likes and dislikes.
Full-time vocational training or education that also fulfills the work activity requirements under the Welfare-to-Work Program. The training or program must be expected to be completed within 24 months and take place at an approved school.
A plan that covers an individual’s medical expenses with company funds set aside to pay health claims. In general, self-insured plans are subject to federal, but not state, health coverage laws. Ask your employer or plan to find out if you are in a self-insured plan.
The period of time an individual is required to be employed by a company or be a member of an association before becoming eligible to enroll for the group’s health coverage. Also known as the minimum service requirement.
Private insurance that replaces some of your income when you can't work because of a disability. Short-Term Disability (STD) generally covers disabilities that last a year or less. To apply for STD, speak with your employer's human resources department, or contact a private insurance company.
Services that include a semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies. Medicare covers skilled nursing facility care after the individual has been in the hospital for 3 days.
The Social Security Administration (SSA) oversees the SSI and SSDI programs. You contact SSA by calling 1-800-772-1213 (ph) or 1-800-325-0778 (TTY), or you can use the Social Security office locator to find the office nearest you.
Benefits received because a parent is (or was) eligible for Social Security Disability or Social Security retirement insurance. These benefits end at 18, unless the child is in high school or another secondary school, in which case they end at 19.
Wage replacement income for individuals who have worked and paid FICA taxes and who now have a disability meeting Social Security disability rules. SSDI provides a variety of benefits to family members when a primary wage earner in the family becomes disabled or dies. SSDI is financed with Social Security taxes paid by workers, employers, and self-employed persons. SSDI benefits are payable to disabled workers, widows, widowers, and children or adults disabled since childhood who are otherwise eligible.
A certification that an individual is medically eligible for Social Security disability programs. Individuals can use this medical award document to qualify for OBRA even if they are not eligible for Social Security disability programs for non-medical reasons.
The period when an individual can apply for Medicare coverage without a late enrollment penalty and can sign up for Medicare supplement without a pre-existing condition waiting period. The special enrollment period typically spans the first eight months following the loss of group health coverage.
Special Enrollment Period (Private Health Coverage)
When you get private group health coverage through your employer, you can only sign up for, or make changes to, an insurance plan during the open enrollment period. However, under certain circumstances, such as marriage, birth of a child, or loss of other insurance, a group health plan offers a special enrollment period. This special enrollment period lets you sign up for group health insurance, or make changes to your plan, without having to wait for an open enrollment period.
Rights that allow an individual to qualify for health coverage without having to undergo medical underwriting. Special Enrollment Rights can be requested from an employer within 30 days after previous health coverage is exhausted or terminated. They apply to individuals who do not enroll during the initial enrollment period or have lost their health coverage.
A Medicare Advantage option that provides health care focused on certain health conditions. These plans provide comprehensive Medicare coverage to manage a particular disease or condition, such as congestive heart failure, diabetes, or End-Stage Renal Disease (ESRD). Medicare Special Needs Plans are only available in some areas of the country.
A person who, by signing an affidavit of support, agrees to support an immigrant as a condition of the immigrant’s admission for permanent residence in the U.S.
An exclusion that allows most students to work without their SSI benefit decreasing. The SEIE lets you keep the first $1,700 in earnings each month without affecting the countable earned income calculation. But there is an annual cap of $6,840, so if you earn more than this in any given year, the income starts counting again.
Work that disqualifies an individual from Social Security disability benefits. Social Security uses monthly countable earned income limits to determine whether or not an individual is performing SGA. Impairment-Related Work Expenses (IRWEs) and other items can be subtracted when determining countable income.
For 2012, SGA is $1,010 ($1,690 for people who are blind).
An income benefit program for disabled individuals who are unable to engage in any Substantial Gainful Activity (SGA). Eligibility for the program is based on financial need established by income and assets requirements. The maximum monthly SSI benefit for most individuals in 2012 is $854.40, $1,444.20 for most couples.
Services to help people with disabilities find a job or remain employed. Services include things like job skills training, job coaching, or help requesting workplace accommodations.
The penalty assessed when funds are borrowed against the cash value of a whole life policy. The surrender charge decreases the longer the individual is insured.
If you were to cancel a life insurance policy prior to death or maturity, you would likely receive some portion of the full value of that policy. The amount you would receive is known as the “surrender value.” The surrender value of your policy should be written into it. If you do not know the surrender value, contact your policy administrator to find out. Not all policies have a surrender value (i.e. - burial insurance and many term insurance policies).
A Ticket that has been temporarily inactivated because a beneficiary could not make progress on his/her Individual Work Plan due to illness or disability. The clock stops on the timely progress review schedule, and there is no penalty for the delay.
A federal welfare program, formerly known as Aid to Families with Dependent Children (AFDC), that provides income support and access to Medi-Cal for low-income adults with children. In California, TANF is known as CalWORKs.
A program of the federal Social Security Administration (SSA) designed to expand access to employment for Social Security beneficiaries with disabilities.
Active participation in the Individual Work Plan (IWP) during the first two years of the Ticket program. Thereafter, timely progress is referred to as "increased work activity and earnings" (Year 3, 4, and 5).
As long as an individual is making timely progress on the IWP, Social Security will not initiate a medical continuing disability review.
Benefits received because a parent is (or was) eligible for Social Security Disability Insurance (SSDI) or Social Security retirement insurance. Title II child’s benefits end at 18, unless the child is in high school or another secondary school, in which case they end at 19.
Trial Work month income levels are indexed annually for increases or decreases in the cost of living. Previous Trial Work month gross income levels were:
The Trial Work Period is the nine Trial Work months occurring within a five-year window when you can work and continue to get your full SSDI benefit. These work months can occur one right after the other or be spread out over time.
Funds received from sources for which no paid work activity is performed. Disability benefits such as SSDI, SSI, short-term disability insurance, and long-term disability insurance; VA benefits; Workers' Compensation; income from a trust or investment; spousal support; dividends, profits, or funds received from any source other than work are all usually considered unearned income.
CalWORKs generally defines unemployed as having worked less than 100 hours in the previous 4 weeks. In a two parent household, one of the parents can work more than 100 hours per month so long as the family income after deductions (countable income) is below the income limit for the program.
Uniformed Services Employment and Reemployment Rights Act (USERRA)
The Uniformed Services Employment and Reemployment Rights Act (USERRA) is a federal law that protects veterans’ and service members’ employment rights. It says that a person can miss up to five years of work because of military duty and have the right to be re-employed by the employer they had before going on duty. It also requires employers to make reasonable accommodations for disabled veterans.
Financial or other assistance from an agency or individual to help establish or sustain a self-employed person’s business. Examples include a government agency paying for some of your business expenses, or providing you with things of value (e.g. office space) free of charge.
Social Security rules do not penalize you for receiving unincurred business expenses. Instead, Social Security deducts the value of any unincurred business expenses from your net income when deciding if you have reached the Substantial Gainful Activity (SGA) level for any given month. SSA uses fair market value to assess the value of any unincurred business expenses.
The estimated value of any unpaid assistance from your spouse, children or others provided to your business. If someone provides your business with 10 hours/month of free web design work, and the prevailing wage for that kind of work in your community is $25/hour, the value of that unpaid help is $250/month.
Social Security rules do not penalize you for receiving unpaid help. Instead, Social Security deducts the value of any unpaid help that your business receives from your net income when deciding if you have reached the Substantial Gainful Activity (SGA) level each month.
Income that is not subject to state or federal taxes. Income from State Disability Insurance (SDI), Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI) are all examples of untaxed income.
Rules that plans use to keep their prescription drug costs down. You may, for example, need prior authorization from the plan to use a particular drug.
A rule that decreases the amount of the SSI benefit that a person is eligible for by 1/3. The VTR rules apply when someone is receiving both food and shelter from another person.
An individual who is a victim of sex trafficking; or, a victim of the forced or fraudulent recruitment, harboring, transport, or provision of a person for labor or services that subject the person to involuntary servitude, peonage, debt bondage, or slavery.
Victim of Violence/Victim of Abuse/Domestic Violence Survivor
An individual who has endured assaultive or coercive behavior that includes: physical abuse, sexual abuse, psychological abuse, economic control, isolation, stalking, and threats.
A law that allows qualified immigrants in an abusive situation to apply for a lawful immagration status directly to the Department of Homeland Security, without the assistance of a sponsor.
A service to help a person examine their work skills, education level, employment background, and interests, in order to help them decide on a career path that will be well matched to their skills and interests.
Wage replacement is a monthly cash benefit that is either a percentage of your pre-disability income or a fixed dollar amount. Short-Term or Long-Term Disability Insurance offers wage replacement. Wage replacement is also known as pay replacement or income replacement.
For the purposes of calculating Substantial Gainful Activity (SGA), wage subsidy and special conditions are support you get on the job that may result in your getting more pay than the actual value of the services you perform. Wage subsidy refers to support you get from your employer; special conditions are generally given to you by someone other than your employer, for example a vocational rehabilitation agency.
Social Security looks at wage subsidy and special conditions when they make an SGA decision. They only use earnings that represent the real value of the work you perform to decide if your work is at the SGA level. If Social Security decides that wage subsidy or special conditions exist, you can earn more while continuing to get your benefits.
Wage subsidy or special conditions may exist if:
You get more supervision than other workers doing the same or a similar job for the same pay
You have fewer or simpler tasks to complete than other workers doing the same job for the same pay, or
You have a job coach or mentor who helps you perform some of your work
Note that Social Security uses wage subsidy and special conditions rules when they are deciding if you have earned Substantial Gainful Activity after your SSDI Trial Work Period is over. Social Security does not use these rules during your Trial Work Period or in any Trial Work month.
A delay in covering services for an individual with a pre-existing condition. Individuals are exempt from a waiting period if they have had 6 months of previous, continuous coverage.
The amount of time you have to wait between becoming disabled and receiving a benefit. For example, many private disability plans begin paying benefits 7 days after an illness forces you to leave work.
Activities that meet the Welfare-to-Work requirement. Most CalWORKs recipients must participate in 20 hours of core activities. Your county may include all or some of the following as acceptable core activities:
Subsidized or unsubsidized employment
Work experience
On-the-job training
Work-study
Self-employment
Community service
Vocational education and training
Job search and job readiness assistance
The rest of the Welfare-to-Work requirement can be fulfilled with non-core activities, which may include:
Adult basic education
Job skills training directly related to employment
Education directly related to employment
Secondary school
Mental health, substance abuse, and domestic violence services
One of the eligibility requirements for SSDI is to have worked and paid FICA taxes for specified periods of time. If you work and earn at least $1,130 for one quarter (three months), and pay FICA taxes, you earn one SSDI "work credit." You can earn up to four credits within a 12-month period.
The number of work credits needed to qualify for SSDI depends upon how old you were when Social Security determined that you are disabled.
If you were determined disabled before age 24, you need 6 credits within the past 3 years to be eligible for SSDI.
If you were determined disabled between the ages of 24 and 31, you need 12 credits within the past 6 years to be eligible for SSDI.
If you were determined disabled after you turned 31, you need the number of work credits shown in the table below. And unless you are blind, you need to have earned at least 20 of those credits in the 10 years prior to becoming disabled.
Work Credits Required for SSDI Eligibility for those Born After 1929
Social Security’s rules that are used to adjust Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits when an individual works.
A federal program that encourages employers to hire job seekers from one of nine targeted groups by offering employers a federal tax credit. The purpose of the WOTC is to help job seekers in the targeted groups overcome barriers to employment.
A program that you may qualify for if you apply for financial aid at your college or university. If you qualify, it will be easier for you to get a part-time job on campus or nearby, because the federal government will help some employers pay your salary.
A Social Security sponsored pilot project that attempts to help 14-25 year olds transition from school to work. For more information, see the Youth Transition Demonstration Project web page.
Find an Expert
Find a professional who can answer your questions or help with your benefits.
