1. Entitlements Training:
The Basics
Adrian Wicker
301-493-4200 ext 411
240-429-9298
wickera@stlukeshouse.com

2. Social Security Administration (SSA)
1,300 local field offices (New Hampshire Ave
or Rockville)
10 regional offices
Over 60,000 employees
State contracted Disability Determination
Service (DDS) makes disability decision
Local field offices make ALL OTHER decisions
(including work incentives)

3. Benefits Under the Social Security Act
Title II: Retirement, Disability, Survivors and
Dependents Insurance (SSDI, CDB, DWB)
Title XVI: Supplemental Security Income (SSI)
Title XVIII: Medicare
Title XIX: Medicaid

4. Overview of SSA Benefits Programs
Based on Disability
Title II Title XVI
 Funded by the SSA trust  Funded by federal tax
fund dollars
 Entitlement program based  Welfare program based on
on work history financial eligibility
 Assumes 3 forms: SSDI,  Assumes 1 form: SSI
CDB, & DWB  Comes with Medicaid
 Comes with Medicare health coverage (no waiting
health coverage (after 24 period)
months)

5. SSA Disability Definition
There are 3 parts to the definition:
1. Must have an impairment
2. Must be unable to perform Substantial
Gainful Activity (SGA)
3. Impairment must meet duration requirement
(result in death or lasted/will last at least 12
months)

6. Substantial Gainful Activity (SGA)
Definition:
“the performance of significant physical and/or
mental activities in work performed for pay or
profit, regardless of the legality of the work.”
Benchmark:
SSA assigns a dollar figure to help them decide
whether SGA is being performed.
*Benchmark for 2012: $1,010 (non blind), $1,690 (blind)*

7. SGA is a Decision Not a Number
 SGA is based on a pattern of work
behavior
 SGA is a decision made by a Social Security
employee
 Social Security has various tools that they
use to make the SGA decision
 SGA uses countable income instead of
actual income

8. Eligibility for Title II Disability
Must have a disability
Must be unable to perform SGA
Must have worked recently enough and long enough
to qualify
 Measure this by counting amount of work credits earned (by paying
Social Security taxes on wages)
 Most people need at least 20 work credits in the 10 years prior to the
onset of their disability (this can vary based on the age you became
disabled
 Can earn a maximum of 4 credits per year (1 work credit = $1,130
gross wages in 2012)

9. Important Things to Remember About
Title II Disability…
 Title II is a form of insurance – not welfare
 Title II benefits are NOT means tested and therefore
there are no limits on resources or assets (any income
that is not earned)
 The Title II check amount is determined by work history
(amount of work credits earned)
 SGA decision applies at initial application and forever
onwards
 There is a 5 month waiting period before benefits may
begin

10. Title II Disability Work
Incentives: Safety Nets
 Trial Work Period (TWP)  Extended Period Medicare
 9 months in 60 month period
Coverage (EPMC)
 Months can be consecutive, but do
not have to  At least 93 months after TWP
 $720/mo is benchmark  Receive health care whether
receiving check or not
 Extended Period of
Eligibility (EPE)  Expedited Reinstatement
 36 month period (EXR)
 Easy back on benefits  5 years after date of termination
 Up to 6 months of provisional
 Grace period benefits
 1st time at SGA after TWP  Can lose Medicare coverage if found
 3 months of checks while at or above no longer disabled
SGA
 4th month at SGA check suspended if
in EPE or terminated if not in EPE

11. Title II Disability Work Incentives:
Deductions
Impairment Related Subsidy and Special
Work Expenses Conditions
(IRWE)  Extra help on the job
 Related to an impairment  Subsidy = out of employers
pocket
 Necessary for work
 Special Condition = out of a
 Out of pocket, not 3rd party pocket (e.g. SLH)
reimbursed
 EXAMPLE: job coaching, extra
 EXAMPLE: co-payments for supervision, subsidized
medications or doctor’s visits productivity

12. Eligibility for SSI
Individuals:
with a disability OR who are 65+
AND
have income/resources below specified limits
 Income limit = below SGA when applying
 Resource limit = below $2,000 for individuals and $3,000 for couples

13. Federal Benefit Rate (FBR)
FBR = the maximum SSI check amount that
someone can receive
Rate is set each year (January 1st)
Receive full FBR when responsible for food
and shelter
2012 Rates
Individual: $698.00/mo
Couple: $1,048.00/mo

14. Types of Income
Earned Income Unearned Income
Wages Title II benefits
Self employment
Veteran’s benefits
Commissions/fees
Worker’s comp
Tips
Sheltered workshop Unemployment
earnings Interest income
Royalties (e.g. from book Alimony/child support
sales)
Pensions
Americorps living
stipends

15. Examples of Income and Resource
Exclusions
Income not counted: Resources not counted:
 Value of food stamps  Home in which beneficiary
 Income tax refunds lives in
 Earned income tax credits  1 car per household
 Home energy assistance  Retroactive SSI/Title II
 Assistance based on need payments (for up to 9
funded by state/local months)
government
 Small amounts of income  PASS protected income and
received irregularly or resources
infrequently  Whole life insurance (face
 Food, clothing, shelter based value less than $1,500)
on need provided by private  Some trusts
non-profit agencies
 Cash that is loaned and must  Some student financial
be repaid assistance

16. Important Things to Remember About
SSI…
Same SGA definition applies to both SSI and
Title II
SGA does not apply to SSI after initial
application
SSI recipients can make more than SGA and
still receive SSI (1619a)
SSI is a poverty program and therefore income
and resources can cause checks to fluctuate,
be suspended, or be terminated

17. SSI Work Incentives:
Safety Nets
1619a Expedited
allows earnings to go Reinstatement (EXR)
above SGA without  5 years after date of termination
 Up to 6 months of provisional
checks being stopped benefits
1619b 12 month Suspension
keep MA when SSI check Period
= $0, until earnings are  SSI suspended if resources go
above state threshold over limit
($38,660/year)  12 months to go back below,
then terminated

18. SSI Work Incentives:
Deductions
Impairment Related  Student Earned
Work Expense (IRWE) Income Exclusion
 Related to an impairment (SEIE)
 Necessary for work
 under age 22
 Out of pocket (not reimbursed)
 “regularly attend school”
Blind Work Expense  working
(BWE)  Plan for Achieving Self
 Necessary for work
 Out of pocket (not reimbursed)
Support (PASS)
 Does not have to be related to  way to set aside income
blindness and/or resources for
achieving work goal

19. Title II Disability vs. SSI
Title II Disability SSI
 Disability Insurance  Poverty program
 Family Benefit  SSI recipient only
 Medicare  Medicaid
 IRWE  IRWE
 SGA  SGA (only when applying)
 No resource limit  Resource limit (2k/3k)
 EXR  EXR
 Monthly check depends on  FBR of $698/$1,048
the workers earnings  Amount of check varies
 All or nothing check  BWE (SSI only)
 TWP, EPE, Subsidy/Special
condition (SSDI only)

20. Medicaid (Medical Assistance)
• What Is It?
– A program that pays medical expenses for
some people who meet income and
resource (asset) limits. A partnership
between the federal government and state
governments, each party pays a
percentage of program costs. In Maryland,
the split is usually 50%-50%.
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21. Medicaid (Medical Assistance)
• How Can I Get It?
– You are automatically (categorically)
eligible if you receive:
• Supplemental Security Income (SSI)
• Temporary Cash Assistance (TCA)
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22. Medicaid (Medical Assistance)
• How Can I Get It?
– You may also be eligible through:
• The Employed Individuals with Disabilities
(EID) Program
• Continuing Medicaid for people who lose SSI
payments due to earnings (1619(b))
• Continuing Medicaid for people who lose SSI,
but would be eligible if not for cost of living
increases in some other cash benefits from
Social Security (Pickle Amendment)
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23. Medicaid (Medical Assistance)
• How Can I Get It?
– You may also be eligible through:
• Continuing Medicaid for people who lose SSI
due to Childhood Disability Beneficiary (CDB)
benefits
• Medicaid Waiver programs
• Public Assistance to Adults (PAA)
• Medically Needy (“Spend down”) Program
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24. Medicaid (Medical Assistance)
• How Can I Get It?
– You may also be eligible through:
• Maryland Children’s Health Program (MCHP)
• MCHP Premium
• Medicaid for Families Program
• Various other categories
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25. Medicaid (Medical Assistance)
• Do I Need to Apply for Other Benefits
to Get It?
– Yes. Medicaid is a benefit of last resort,
and you must apply for any other benefits
to which you may be entitled.
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26. Medicaid (Medical Assistance)
• What It Pays For:
Medicaid pays the recipient’s full cost for most
medical expenses, including:
– Ambulance and wheelchair van services and emergency
medical transportation
– Ambulatory surgical care services
– Clinic services
– Dental services (including orthodontic care) for
individuals under age 21
– Diabetic care services (covered by managed care
program)
– Family planning services & supplies
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27. Medicaid (Medical Assistance)
• What It Pays For:
– Health maintenance organization (HMO) services
– Healthy Kids Program services
– Home and community based services for people with
disabilities in Medicaid Waiver programs
– Home health care
– Hospice care
– Hospital services
– Kidney dialysis services
– Lab and X-ray services
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28. Medicaid (Medical Assistance)
• What It Pays For:
– Medical day care services
– Medical equipment
– Medical supplies
– Medicare premiums, deductibles and co-payments
– Mental health treatment, case management and rehab.
services
– Nurse anesthetist, nurse midwife and nurse
practitioner services
– Nursing home services
– Oxygen services and related respiratory equipment
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29. Medicaid (Medical Assistance)
• What It Pays For:
– Personal care services
– Pharmacy services (small co-payment; for those
who receive Medicare Part D, Medicaid eliminates
almost all out-of-pocket costs)
– Physical therapy
– Physician services
– Podiatry
– Psychiatric rehabilitation services
– Residential treatment facility services
– Substance abuse treatment
– Targeted case management for targeted groups
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30. Medicaid (Medical Assistance)
• What It Pays For:
– Transportation to covered services (through local
health departments)
– Vision care services (eye exams every two years;
eyeglasses for individuals under age 21)
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31. Medicaid (Medical Assistance)
• How You Get Medical Care:
– Most recipients must join managed care
organizations (MCO’s). They will receive
information about their choices and must sign up.
If they don’t sign up, a MCO will be chosen for
them.
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32. Medicaid (Medical Assistance)
• How You Get Medical Care:
– Some recipients do not have to join a MCO, and
can receive “fee for service” care. These include
those who:
• Also get Medicare
• “Spend down” to qualify
• Have “rare and expensive” illnesses or
disabilities
• Enroll in EID
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33. Medicare
– Medicare provides medical coverage to people who
are elderly or disabled. It’s a federal program.
– Most recipients become eligible by:
• Receiving Social Security Disability benefits after a
two-year waiting period, or
• Being age 65 and having worked (or having a
spouse who worked) at least 10 years in Medicare-
covered employment (may qualify at age 65
without sufficient work history, but must pay Part A
premium), or
• Having end stage renal disease
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34. Medicare
– Medicare Part A pays for hospitalization, some skilled
nursing home care, some skilled home health care and
hospice care.
– Most recipients receive Part A without paying
premiums or co-payments. Some pay premiums of
$248/month or $451/month in 2012.
– Most pay a deductible of $1,156 for the first 60 days of
hospitalization, $289/day for days 61 - 90 and
$578/day for days 91 – 150 in 2012.
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35. Medicare
– Medicare Part B pays for medical services.
– Most recipients pay:
• A premium of $99.90/mo. (more for those with
very high incomes) in 2012
• 20% coinsurance for most services; 50% for some
psychiatric services
• Annual deductible - $140 in 2012
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36. Medicare
– Medicare Part D provides prescription coverage.
– Most recipients pay:
• Monthly premium (varies according to chosen plan)
• $320 deductible per year in 2012
• 25% of costs between $321 and $2,930 per year in 2012
– plan covers 75%
• All drug costs from $2,931 to $6,657.50 per year in 2012
(“donut hole”)
• In 2012, people in the donut hole receive discounts of
50% on brand name drugs and 14% on generics
• 5% co-payments – or co-pays of $6.50 for brand name
drugs and $2.60 for generics – for costs over $6,657.50
in 2012 – plan covers the rest
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37. Medicaid Rocks!
– Medicaid pays for almost all Medicare costs that the
individual would otherwise have to pay:
• $99.90/mo.) Part B (medical insurance) premium
• 20% co-payments for medical expenses (50% for
some psychiatric services)
• Deductibles for Parts A and B
• Premiums (up to $34.57/month in 2012) and
deductibles for Part D (prescription coverage)
• Fills “donut hole” for Part D
• Individual pays only $1.10 or $3.30 co-payment per
prescription in 2012
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38. Employed Individuals with Disabilities (EID)
Also known as the Medicaid Buy-In, EID is a work
incentive that provides Medicaid, for a limited
premium, to people who:
– Meet Social Security’s disability criteria after reaching
age 18
– Are U.S. citizens or qualified aliens aged 18 – 64
– Are working for pay
– Meet income limits
– Meet resource limits
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39. Employed Individuals with Disabilities (EID)
Disability
– You may be eligible for EID if you:
• Currently receive SSDI
• Formerly received SSDI or SSI as an adult and lost
the benefit for reasons other than medical
improvement (i.e., earnings, other income or
resources)
• Meet Social Security’s medical disability standard,
but are not eligible for SSDI or SSI due to non-
disability criteria.
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40. Employed Individuals with Disabilities (EID)
Disability
If you have not received SSDI or SSI before
• You may need to apply for SSDI when you apply for
EID. If you are denied SSDI for non-disability
reasons (such as earnings), you will get a disability
determination for EID.
• If you earn over $1,900/month from work (or, if you
are blind, over $2,600/month), you will not need to
apply for SSDI, and will get a disability
determination for EID.
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41. Employed Individuals with Disabilities (EID)
Disability
If you have not received SSDI or SSI before
• If your EID disability determination shows you meet
Social Security’s medical standards, you will be
approved for EID.
• If your SSDI application is approved (and you meet
the other EID eligibility conditions), you will be
approved for EID.
• If a disability determination shows you don’t qualify
for EID (or SSDI), you can appeal.
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42. Employed Individuals with Disabilities (EID)
Paid Work
– No minimum level of earnings – may be very small, but
need to be verified
– Must result in income during enrollment period
– Must be subject to state and federal reporting and
withholding or estimated tax payments
– May be employed or self-employed
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43. Employed Individuals with Disabilities (EID)
Countable Income
– “Countable” income must be below 300% of federal
poverty level (FPL)
• $33,510/yr. ($2,793/mo.) for an
individual (in 2012)
• $45,390/yr. ($3,783/mo.) for a
married couple (in 2012)
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44. Employed Individuals with Disabilities (EID)
– Countable resources for individual or couple must be
below:
• $10,000
– Use Aged, Blind and Disabled rules for resources, plus:
• 401(k), 403(b), Keogh and pension plans are
excluded
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45. Employed Individuals with Disabilities (EID)
Premiums
– Monthly premiums on a sliding scale
• Countable income up to 100% federal poverty level
(FPL) – premium = $0/mo.
• Countable income = 101% - 200% FPL – premium =
$25/mo.
• Countable income = 201% - 250% FPL - premium =
$40/mo.
• Countable income = 251% - 300% FPL – premium =
$55/mo.
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46. Employed Individuals with Disabilities (EID)
Once You’re Enrolled
– If found eligible, Medicaid is retroactive to the 1st day
of the month the application is received
– EID provides “fee for service” Medicaid – don’t join a
managed care organization
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47. Medicare vs. Medicaid
Medicare Medicaid
 Eligible after 24 month  In Maryland automatically
waiting period when eligible if receiving any
receiving Title II Disability amount of SSI
 Pays 80% of many medical  Pays 100% of most medical
expenses expenses
 Medicare while working: if  Medicaid while working: if
you loose Title II Disability you lose SSI due to
you can keep MC up to 93 earnings you can keep MA
months after end of TWP until earnings exceed state
threshold

48. PRIMARY ADULT CARE (PAC)
• Provides primary care for adults age 19 or older with very low
incomes and resources who do not have Medicaid or
Medicare
• Basic medical coverage – including mental health, medications
and other services – but not hospitalization
• Household includes the individual and spouse (if they live
together)
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49. PRIMARY ADULT CARE (PAC)
• Countable income must be under 116% of FPL.
• Countable income must be under these limits in 2012:
– $1,080/mo. for 1-person household
– $1,463/mo. for 2-person
• Co-payments for medications - $2.50 - $7.50 per prescription
in 2012
• No resource limit
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50. SSI/SSDI Outreach, Access and
Recovery
 SOAR allows clients without benefits who meet certain
criteria to complete an expedited application process
for SSI/Title II Disability benefits.
 There are two main criteria:
1) They must have a mental illness
2) They must be homeless or “at risk” of homelessness
 Completing the SOAR process allows a client to have
their application go to a special group within DDS who
will return a decision much more quickly than the
traditional application process.

51. Ticket to Work
 Ticket to Work (TTW) is a program open to all clients that
allows them to assign their “Ticket” to an Employment
Network (or agency) in exchange for services
 While a Ticket is assigned a client is subject to Timely
Progress Reviews (TPRs) to determine if they are meeting
the outcomes schedule dictated by SSA.
 While a client is meeting their TPRs, they are exempt from
Continuing Disability Reviews (CDRs) which are periodic
reviews conducted by SSA to determine if a client remains
disabled.
 When a client completes 9 months of work over SGA, the
agency gets reimbursed for “reasonable costs” associated
with providing rehabilitation services to the client

52. Resources
 Social Security Administration
 www.ssa.gov
 1-800-772-1213 (*only use 800 number to schedule appointments,
call local office for specific information)
 EID
 Carla Bryant (443-514-5034, 1-800-637-4113, eid@mdod.state.md.us)
 Medicare
 http://www.medicare.gov/
 1-800-MEDICARE
 Medicaid
 http://www.dhmh.state.md.us/mma/mmahome.html
 SHIP (helpful for Medicare questions)
 http://www.medicarehelp.org/
 301-590-2819