Social Security Disability Attorneys in Delaware. Help with SSDI and SSI Claims » Medicare

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) Eligibility Criteria by Age

Steven Butler — Sun, 21 Feb 2010 21:18:51 +0000

When you apply for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) payments from the Social Security Administration, it is important to realize that different standards are used to determine your disability based on your age. As an adult, it is hardest to qualify for benefits if you are between the ages of 18-49. The closer you are to full retirement age, the easier it is to qualify for benefits.

Below is a brief overview of what you must establish in order to prove that you meet the medical requirements of disability. These are just general guidelines, so it is always important that you speak to an attorney about your eligibility even if it appears that you will not qualify based on the information below.

Disability Benefits for Individuals Ages 18-49

Generally to be found disabled:*
- You must have a solid work history (have worked in 5 of the last 10 years before becoming disabled and earned sufficient lifetime work credits); and
- You must have less than $1000/month (in 2010) of earned income; and
- You must have a medical condition (or a combination of medical conditions) that prevents you from performing any of the work you have done in the last 15 years; and
- You must be unable to perform any full-time work (regardless of pay or experience).

Disability Benefits for Individuals Ages 50-54

Generally to be found disabled:*
- You must have a solid work history (generally have worked in 5 of the last 10 years before becoming disabled and at least 7-8 years during your lifetime); and
- You must have less than $1000/month (in 2010) of earned income; and
- You must have a medical condition (or a combination of medical conditions) that prevents you from performing any of the work you have done in the last 15 years; and
- You must be limited to lifting no more than 10 pounds of weight; and
- You must be unable to stand for more than 15 minutes every hour in an 8 hour workday; and
- There must be no sit-down jobs that exist in the economy that use skills that you have acquired from jobs performed in the last 15 years that you still have the ability to perform today.

Disability Benefits for Individuals Age 55-64

Generally to be found disabled:^*
- You must have a solid work history (generally have worked in 5 of the last 10 years before becoming disabled and at least 8.5-10 years during your lifetime); and
- You must have less than $1000/month (in 2010) of earned income; and
- You must have a medical condition (or a combination of medical conditions) that prevents you from performing any of the work you have done in the last 15 years; and
- You must be limited to lifting no more than 20 pounds of weight; and
- There must be no jobs that exist in the economy that use skills that you have acquired from jobs performed in the last 15 years that you still have the ability to perform today.

Documentation Required to Proof Disability

You must have a documented medical impairment; and
You must be receiving ongoing care for your medical condition; and
You must comply with your doctor’s orders (take medication, attend scheduled appointments); and
Your doctor should support your application for disability.

Advantages of Being Found Disabled as Opposed to Early Social Security Retirement

Your Social Security Retirement benefits are not reduced (if you begin retirement early your benefits are reduced for the rest or your life); and
You are eligible to begin Medicare coverage after 24 months of Social Security disability payments; and
You protect your earnings record so that your retirement rate does not decrease.

When to Consider Social Security Disability

You are injured in any way that prevents you from performing work;
You are diagnosed with a medical condition that prevents you from performing work or is terminal;
You retire from work early because you are unable to continue to perform your work

What Happens if You do Not have Sufficient Work Credits to Qualify?

If you have limited income and resources, you may qualify for Supplemental Security Income Payments (SSI);
SSI has the same medical requirements as SSDI, but you also have to establish financial need for eligibility;
Social Security also considers income of spouse when determining eligibility.

This is just general information to help individuals that are considering applying for Social Security disability benefits. Please contact our office, the Social Security Administration, or another attorney if your situation matches the criteria discussed above.

^* The rules are slightly different for individuals that are illiterate or unable to communicate in English.

This article was written by Steven Butler. Steven is a partner at Linarducci & Butler, PA and his practice is limited to Social Security Disability/SSI claims. Steven offers free initial consultations for Social Security Disability/SSI claims to residents of Delaware, Maryland, New Jersey and Pennsylvania. To schedule a consultation with Steven, please use the Linarducci & Butler Contact Form or call 302-613-0707 to schedule an appointment.

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Importance of Healthcare Debate for Social Security Disability Applicants

Steven Butler — Tue, 15 Dec 2009 20:45:03 +0000

There has been much discussion in the news recently as Congress has been debating reforms to healthcare. In just the last week, 50% of individuals I met with did not have healthcare coverage. These individuals had lost healthcare coverage because they were unable to continue to perform their jobs because of disability. They do not qualify for any State-Assisted Medical Coverage because of household income, and their spouse does not have a healthcare plan that they are eligible to enroll in. Due to limited income, severe pre-existing conditions, and lack of affordable healthcare coverage, these individuals are forced to go without medical coverage.

Why Change Anything, I Am Happy with My Health Insurance?

Most individuals I speak to regarding these issues are not worried about the healthcare debate because they are happy with the current coverage that they have. These individuals often ignore how easy it would be to lose this coverage. For the majority of Americans, healthcare coverage is linked to your job. If you lose your job, you also lose your medical coverage. Although this is not an issue for a healthy individual that is able to obtain a new job (and new coverage), if you have lost your job because of your medical condition, you may quickly find yourself without medical insurance coverage. Even if you are eligible for COBRA coverage, when the choice is paying your mortgage and buying groceries or paying for health insurance, most individuals choose the necessities. No one ever expects to be in a position that they will not have health insurance available to them.

Medical Coverage does not Begin Immediately with Social Security Disability

What is shocking to most people is that if they are found disabled by the Social Security Administration, they do not immediately qualify for healthcare coverage. Under the best-case scenario, an individual that is ultimately found disabled is not entitled to Medicare coverage until 29 months after they last worked. (This is assuming that the individual was found disabled on the first of the month that they stopped working, and that the Social Security Administration determined that the medical condition was severe enough that they were entitled to disability from the day that they stopped working.)

If you are found entitled to Supplemental Security Income payments, you are entitled to Medicaid coverage immediately. However in order to qualify for SSI, you must be able to establish that you have very little assets, and little or no income on a monthly basis. Your spouse’s income is considered when determining your eligibility for SSI. The majority of the time if you qualify for SSI, it is likely that you already had Medicaid coverage, because the Medicaid criteria are similar to SSI.

During the waiting period for Medicare, no assistance is provided for medical treatment. If you do not have health insurance, you are expected to pay for your treatment out-of-pocket. Due to the amount of your Social Security Disability Insurance, you normally do not qualify for any income-based assistance from your State. Although the government has determined that your condition is severe enough to prevent you from performing work, no help is provided to obtain the treatment you need. Once Medicare beings, these benefits are just extended to the disabled individual and are not available to a spouse or dependents.

The Importance of COBRA

The thing that surprises me about many of the uninsured people that I meet is that they had an opportunity to purchase COBRA. The individuals refused COBRA because of the cost of the coverage. These individuals were unaware of the wait time for Medicare coverage and did not realize that they would not qualify for Medicaid because of their household income. Their immediate concern was paying their existing bills. They rarely considered the impact that one hospitalization could have on them financially. Many of these individuals are later forced into bankruptcy because of the cost of required medical care.

Even though COBRA initially sounds like a expensive alternative, you must consider how much your treatment will cost without insurance coverage. I have several clients that have medications that would cost more than the monthly COBRA premium. They quickly find after they refuse COBRA coverage, that the cost of one hospitalization would have paid for 12 months of COBRA. These individuals also discover that when they are unable to pay for medical treatment, it becomes less likely that they can establish their eligibility for Social Security Disability. Since they are unable to work and they do not have medical coverage, their financial situation only becomes worse.

Alternatives for individuals without Healthcare Coverage

It is possible for individuals without healthcare coverage to purchase personal policies. However these policies are often expensive, and rates raise with age. Insurers are allowed to consider your pre-existing health conditions, and in certain situations even exclude coverage based on pre-existing conditions. Affordable personal healthcare policies for older individuals normally require high deductibles. A yearly deductible of $5000 or more may be enough to prevent an individual from obtaining treatment even though they have healthcare insurance.

Medicaid is available to individuals with financial need, but if you have any source of income or your spouse is employed, it unlikely that you will qualify for this program. If you do not qualify for Medicaid, Delaware Residents may qualify for the Community Healthcare Access Program (“CHAP”). CHAP is a network of physicians and healthcare centers in Delaware that agree to provide discounts for medical services. There are still financial eligibility guidelines, but CHAP extends medical coverage to an additional group of individuals that normally would not qualify for help.

If you do not qualify for Medicaid or CHAP, healthcare is also available through a sliding-scale healthcare center. These facilities determine your eligibility for their services based on financial criteria, and limit the number of patients that they can see. Households with higher incomes will still be required to pay out-of-pocket co-pays for healthcare treatment, but will receive a substantial discount off the normal cost.

Although all of these options are better than no treatment, you will still not receive the same level of care that you would with a traditional health insurance plan. It will be harder to obtain specialist treatment for your condition, and some tests and medications that are needed will be excluded. Since treatment will be limited, establishing disability will be harder.

Pay Attention to Healthcare Debate

The purpose of this post is not to advocate any specific plan for reform, but instead to raise awareness of unforeseen healthcare concerns. Most of the uninsured people that I meet never expected to find themselves uninsured. They are normally hard-workers that simply did not realize that if their job ended due to disability, they would also lose medical benefits. These are individuals that always had healthcare coverage, and now when the need it the most, no affordable option is available.

Because continuing treatment is important to the Social Security Disability determination, many of these people will be denied benefits that they deserve because they cannot obtain the medical treatment that they need. These people need to share their stories with elected officials, family, friends and the public. It is only through increased awareness of these problems that there will ever be support for meaningful reform.

Relevant Links:

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Applying for Social Security Disability Insurance while Receiving Long Term Disability Benefits

Steven Butler — Wed, 09 Dec 2009 05:37:44 +0000

When you are receiving Long Term Disability (“LTD”) benefits, you are normally required by your LTD insurer to apply for Social Security Disability Insurance (“SSDI”). Your LTD carrier will normally provide you with an option of using a legal representative that they hire. The representative is not always an attorney. Normally it is a national company, and you may never actually have an attorney work on your claim. It is rare that you meet anyone in person from the company that the LTD carrier hires unless you have to attend an Administrative Law Judge hearing. The LTD company will try to entice you to use the firm that they hire with a suggestion that this is a free benefit of your LTD policy.

Most people do not realize that there is a clause in their LTD policy that indicates that if you are approved for SSDI, your LTD benefits will be reduced. Your LTD benefits are normally reduced by almost the entire amount of your SSDI (there is a normally a clause in your LTD policy that states that you will receive a minimum monthly amount of $50-$100, even if your SSDI is greater than your LTD benefit). This is why you are required to apply for SSDI if you are approved for LTD benefits. If you are approved for SSDI, your LTD company will issue an overpayment and require you to repay any amount that you receive in SSDI for the same month that your received LTD benefits.

Most individuals that are approved for LTD benefits sign a form acknowledging that they are being paid at their full LTD rate, but informing them they will be responsible for repaying a SSDI offset if they are eventually approved for SSDI. Once you are approved for SSDI, the LTD company will request a copy of your SSDI Notice of Award, and will compute how much you should have received on a monthly basis in LTD payments if you had received your SSDI payments when they were actually due. You must repay the difference between what you should have been paid by the LTD company and what you were actually paid.

It is important to remember that you do not have to use the legal representative offered by your LTD company. You can hire your own attorney to help you with your SSDI application. I normally recommend that individuals contact their LTD carrier prior to hiring their own attorney. It is important that you receive a written statement from your LTD carrier indicating that if you are approved for SSDI, you will receive a credit for the attorney fee before the LTD overpayment is assessed. If you receive a credit for the SSDI attorney fee, you end up having the assistance of a private attorney for free.

Reasons why you should consider obtaining your own attorney.

The attorney will work directly for you. They will not represent the interest of your LTD company in any direct way. They will not share information with your LTD company without your authorization.
You get to choose someone that you are comfortable with. Most of the legal representatives used by LTD carriers are national companies. You normally work with a non-attorney during the SSDI process, and you cannot visit a local office of the person representing you. If you choose your legal representative, you can make sure that you are actually working with an attorney.
If your LTD benefits are terminated, you may also lose the legal representative that your LTD company hired. The legal representative provided by the LTD company may have a primary responsibility to your LTD company and not to you. If you are no longer eligible for LTD benefits, your LTD company may not have an interest in continuing to pay for your legal representation for your SSDI application.
National legal representatives do not have local knowledge. The companies used by LTD carriers may not be familiar with the nuances of the local Social Security offices and the Administrative Law Judges in your area. Since they do not represent a large number of individuals in your area, they do not approach your claim with the same unique knowledge that a local attorney has.
You support your local community. A local attorney normally lives in the same community as you. The local attorney pays local taxes, and uses the money that they earn to help other local businesses prosper. By obtaining a local attorney, you help your own community, and you help the local attorney stay in business so that they can also be available to assist friends and family members with similar issues.

Why it is important to pursue SSDI while obtaining LTD benefits.

Although you are required to apply for SSDI based on your LTD policy that is not the only reason that you should pursue SSDI. There are several other advantages for you if you are approved for SSDI.

You may be eligible for SSDI longer. Most LTD policies define you disabled for up to 24 months if you are unable to perform the duties of your past work, or if you are unable to work because of a mental illness. After 24 months, you are normally only entitled to continue to receive LTD payments if you have a physical condition that prevents you from performing any full-time work. If you are under the age of 50, you will only be approved for SSDI if you are able to establish that you are unable to perform all full-time work. However, you are entitled to continue to receive SSDI with no time limit even if you are found disabled and remain unable to work solely because of mental illness.
Medicare Coverage. If you are approved for Social Security Disability, you also become eligible for Medicare after you receive SSDI for 24 months. The only way that you can receive Medicare before the age of 65, is if you are found disabled by the Social Security Administration and receive SSDI.
SSDI is not reviewed as often. Once you are approved for SSDI, normally the Social Security Administration only reviews your SSDI eligibility every 3-5 years (sometimes longer). Depending on your condition, it is common for LTD companies to review your eligibility as frequently as every few months. I have represented many individuals that have lost their eligibility for LTD benefits while a SSDI claim was still being decided. Since the Social Security Administration reviews claims so infrequently, it is likely that you will remain eligible for SSDI longer than LTD.
To remain eligible for SSDI coverage. SSDI has a recent work requirement in order to qualify for benefits. You have to have worked in 5 out of the last 10 years prior to becoming disabled in order to qualify for SSDI. If you wait to apply for SSDI for an extended period after you stop working, not only are you potentially losing past-due benefits from SSDI ( you can only receive past-due SSDI payments for a maximum of 12 months prior to your application date), but you also risk losing your SSDI insured status. That means that you may not ever be able to submit a new application for SSDI if you are denied on the first claim you file.
You protect your Social Security earnings record. If you fail to apply for SSDI and you are unable to work for several years, each of those years will show up with no earnings in your Social Security Statement. This can cause your retirement benefits to be reduced. However if you are approved for SSDI, any year that you are disabled, a “disability freeze” is placed on your Social Security record. In other words, the Social Security Administration will remove any years that you disabled from your earnings statement, and your Social Security Retirement benefit amount will not continue to be reduced for every year that you are not working.

Keep your SSDI attorney advised of any changes in your LTD Benefits

If you are pursuing both LTD and SSDI, it is important to notify your attorney if you are also applying for LTD and if you approved for LTD. It is important to remember that even if you are awarded SSDI, the majority of money that you are awarded in past-due benefits will have to be paid back your LTD company. Your should provide copies of any forms that your doctors complete for your LTD company, to your SSDI attorney. A knowledgeable SSDI Attorney can help advise you of any other issues that you may encounter as you pursue both SSDI and LTD payments, and can provide you with instructions on what to do if you are approved for SSDI and you also received LTD payments.

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Centers for Medicare and Medicaid Services (CMS) Releases 2010 Medicare Fact Sheet and Part B Premium Increase

Steven Butler — Mon, 19 Oct 2009 04:21:39 +0000

On October 16, 2009, the Center for Medicare and Medicaid Services (CMS) released the 2010 Medicare Fact Sheet. According to CMS, the Medicare Part B monthly premium will increase to $110.50 for 2010. This is an increase of $14.10 per month (or $169.20 per year). Since there was no Cost-Of-Living Adjustment (COLA) for Social Security beneficiaries for 2010, the majority of individuals currently on Medicare will not see an increase in their monthly premium. (Federal Law includes a “hold harmless” provision that indicates that premiums will not be increased for Medicare beneficiaries receiving Social Security Benefits, if the increase from COLA does not exceed the increase in the Medicare monthly premium.)

As a result of the hold harmless provision of the Social Security Act, CMS indicated in the 2010 fact sheet that 73% of beneficiaries are protected from an increase in 2010. The Part B premium provides beneficiaries with co-insurance for doctor visits. Individuals that first enroll in Medicare Part B after November 2009 will have to pay the increased monthly premium of $110.50. The majority of beneficiaries that will be required to pay a higher premium are those that currently do not have the Part B premiums withheld from monthly Social Security payments (including individuals with low incomes whose premiums are paid through state subsidies).

Beneficiaries that file an individual tax return and have a “modified adjusted gross income” greater than $85,000 in 2010, or individuals that file a joint return and have “modified adjusted gross income” of greater than $170,000, will also be responsible for higher Medicare Part B premiums for 2010. Medicare has published a Frequently Asked Question on its’ website to help individuals with “Higher Income Levels” determine their Medicare Part B premium for 2010.

Additionally, the Medicare Part B deductible for doctor visits will be increased from the current $135 per year to $155 per year for 2010. The Medicare Part A deductible (that is paid when an individual has an inpatient hospital, skilled nursing facility, hospice or other qualified home health care service of 1-60 days) will increase to $1100 for 2010. This is an increase of $32 from the 2009 deductible. (According to my reading of 42 U.S.C.S. S 1395l, there is no “hold harmless” provision for Medicare Part A and Part B deductibles). All beneficiaries enrolled in Medicare Part D prescription drug coverage will also experience increased monthly premiums in 2010.

As indicated above, the majority of individuals that are currently receiving Medicare benefits will not see an increase in monthly Medicare Part B premiums for 2010, but will experience a net increase in Medicare costs as deductibles and Part D premiums will increase. Individuals that are currently disabled, but will not qualify for Medicare coverage until after November 2009, will not only face the increased deductibles and Part D premiums, but will also be required to pay the increased Medicare Part B premium of at least $110.50 per month when their Medicare coverage begins. Medicare has updated its’ Frequently Asked Questions to help individuals determine if their Medicare Part B premium will increase.

Although the “hold harmless” provision has protected current Medicare beneficiaries from seeing a monthly Part B premium increase in 2010, the next time Social Security payments are increased for COLA, it is likely that Medicare beneficiaries will see a much more sizable jump in their monthly premium payment. Not only will the beneficiaries have to pay the increase that occurs in that current year, they will also be responsible for any increases that had previously occurred that had not impacted them because of the “hold harmless” provision. (For example, if there is an increase of Social Security Payments because of COLA in 2011 and Medicare premiums increase to $120 per month in 2011, the individual would have their monthly Medicare Part B premium increased from $96.40 per month to $120 per month).

President Barack Obama called for Congress to quickly pass an Economic Recovery Provision for 2010 that would extend a onetime payment of $250 to all individuals receiving Social Security Retirement, Disability and Supplemental Security Income Payments. If you are currently receiving Social Security benefits and eligible for Medicare Coverage, it is important that you contact your United States Senators and United States Representative(s) to encourage them to support President Obama’s Economic Recovery Payment for 2010 so that you can qualify for a onetime payment of $250 in 2010. Delaware Residents should contact Senator Thomas Carper, Senator Edward Kaufman, and Representative Michael Castle. Passage of this legislation would help offset the increased costs that will be incurred from the Medicare deductible increases and the increase in Medicare Part D premiums outlined above.

If you are currently a client of Linarducci & Butler and have additional questions about the Medicare premium increase, please contact our office.

Relevant Links:

Social Security Administration Officially Announces No COLA for 2010 and Publishes 2010 Fact Sheet On October 15, 2009, the Social Security Administration officially announced...
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Social Security Administration Officially Announces No COLA for 2010 and Publishes 2010 Fact Sheet

Steven Butler — Fri, 16 Oct 2009 05:23:28 +0000

On October 15, 2009, the Social Security Administration officially announced that there will be no Cost-of-Living Adjustment (COLA) for Social Security Disability and Supplemental Security Income recipients for 2010. This is the first time since the Cost-of-Living Adjustment was codified by Congress in 1975 that there will not be an increase in benefits for recipients. The maximum Supplemental Security Income Benefit will remain at $674 per month in 2010.

Although there will be no COLA for 2009, increases were announced for Substantial Gainful Activity and Quarters of Coverage. Substantial Gainful Activity (SGA) for 2010 will be defined as earned income of $1,000 per month or more. Individuals that earn less than $1,000 per month can still potentially qualify for Disability Benefits despite working. Individuals that are already receiving Social Security Disability Insurance are able to work on a part-time basis as long as earned income does not exceed SGA.

In 2010, individuals must earn at least $1,120 to earn one Quarter of Coverage for Social Security purposes. To earn the maximum of 4 Quarters of Coverage for the year, an individual would need to make at least $4,480 of earned income in 2010. (Individuals must establish that they have at least 20 Quarters of Coverage in the last 10 years before becoming disabled to potentially qualify for Social Security Disability Insurance).

The Center for Medicare and Medicaid Services announced on October 16, 2009 that Medicare Part B monthly premiums will also increase in 2010.

For individuals that are enrolled in Medicare in November 2009 and December 2009, Federal Law has a “hold harmless provision” that prevents an increase to Medicare Premiums if COLA is not large enough to cover increase of Part B Premium. This means that for most individuals currently receiving Social Security Disability Insurance benefits there will be no increase in Medicare premiums as long as Medicare eligibility and enrollment began no later than November 2009. Additional information about the “hold harmless provision” of the Social Security Act can be found at the Center for Medicare Advocacy Website. (For a detailed description of the 2010 Medicare Premium and Deductible increases, please see “CMS Announces 2010 Medicare Fact Sheet and Part B Premium Increase.”)

What you can do.

If you are currently receiving Social Security benefits, it is important that you contact your United States Senators and United States Representative to encourage them to support President Obama’s Economic Recovery Payment for 2010 so that you can qualify for a onetime payment of $250 in 2010. Delaware Residents should contact Senator Thomas Carper, Senator Edward Kaufman, and Representative Michael Castle and encourage each Congressman to support the Economic Recovery Payment for 2010.

If you are currently a client of Linarducci & Butler, PA, please contact our office with additional questions.

Relevant Links:

Centers for Medicare and Medicaid Services (CMS) Releases 2010 Medicare Fact Sheet and Part B Premium Increase On October 16, 2009, the Center for Medicare and Medicaid...
Social Security Disability Applicants’ Access to Professional Representation Act of 2010 Signed Into Law Today the National Organization of Social Security Claimants’ Representatives (NOSSCR)...
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Don’t lose Medicaid Because of the Receipt of Social Security Disability Insurance Benefits

Steven Butler — Fri, 18 Sep 2009 18:31:23 +0000

Because of financial struggles that occur when an individual is disabled and unable to perform work, it is common for an individual to qualify for Medicaid coverage (poverty based medical insurance program) in Delaware prior to applying for or being found disabled under the Social Security Disability Insurance (SSDI) program of the Social Security Administration. Prior to March 1, 2001, many individuals who were on Medicaid before they were approved for SSDI, lost their eligibility for Medicaid as a result of being approved for SSDI. Once an approval was issued, the Delaware Division of Social Services would send an individual a notice indicating that their Medicaid was terminated because of their income from SSDI.

Effective March 1, 2001, Delaware extended Medicaid eligibility to certain individuals that were approved for SSDI. The program was named “Medical Assistance During Transition to Medicare” or “MAT” and was codified as part of the Delaware Administrative Code. (See Title 16 Sec. 17800 of Delaware Administrative Regulations).

Beginning March 1, 2001, individuals in Delaware who were already receiving Medicaid and were approved for at least one month of Supplemental Security Income payments (SSI is the Social Security Administration’s poverty based disability program) no longer lost their eligibility for Medicaid because of the receipt of SSDI. The only requirements were that 1) the individual lost Medicaid because of receipt of SSDI, and 2) they were not yet eligible for Medicare. This was an important change, because previously these same individuals would lose eligibility for Medicaid if their SSDI payments were above the State income limits. Since Medicare does not begin until 24 months after eligibility for the first SSDI payment, before MAT, it was common for individuals to lose Medicaid and have to go months or even as long as 2 years without government provided medical coverage, despite being found disabled by the Social Security Administration.

Unfortunately, MAT did not extend Medicaid coverage in every situation. Only individuals that were approved for SSDI and had at least one month of SSI eligibility qualified for this program. The result was that anyone in Delaware that was receiving Medicaid and approved for SSDI, but was not approved for SSI (or never applied for SSI), still lost their Medicaid eligibility and had no government provided medical insurance coverage until Medicare began.

Effective September 1, 2008, Delaware extended MAT to any individual that was 1) not yet eligible for Medicare and 2) lost eligibility for Medicaid on or after January 1, 2008 due to the receipt of SSDI. As a result, even if an individual never met the requirements for SSI, they became eligible to retain Medicaid as long as they were receiving Medicaid before their SSDI claim was approved. This change in the Administrative Regulations closed a loophole that was causing many individuals in Delaware to lose all government provided medical coverage once they were approved for SSDI until they were finally eligible for Medicare.

In effect, this now means that no Delaware resident who is receiving Medicaid should lose government provided medical insurance just because of being found disabled by the Social Security Administration. Unfortunately, the regulations are not being applied consistently by the Delaware Division of Social Services. Many of my clients have had Medicaid benefits terminated after being approved for SSDI benefits, even though they should still qualify under MAT. I have found that several employees of the Delaware Division of Social Services are still not aware of these changes, and need reminders on how to properly apply the MAT Regulations.

I recommend that individuals that receive a notice that their Medicaid coverage has been terminated because of receipt of SSDI (who are not yet eligible for Medicare), print out copies of the applicable regulations and provide them to their Social Worker. Additionally, the individual should provide the Social Worker with the Notice of Approval from the Social Security Administration to prove that the source of their new income is SSDI benefits.

In order to implement this Medicaid gap coverage, individuals that fall within these limited categories are made eligible for $5.00 in an optional Delaware SSI State Supplement program regardless of the amount of their earned or unearned income. A Medicaid redetermination may be necessary after qualifying for SSDI, but the Administrative Regulations provide that eligibility for Medicaid continue until Medicare eligibility begins.

Remember, both of these extensions of Medicaid only apply if you were already receiving Medicaid before you were approved for SSDI. If you did not qualify for Medicaid before being found disabled under the SSDI program, you will still need to wait 24 months from the date of your first SSDI payment until you are eligible for Medicare Coverage. If you have not yet been approved for SSDI, and do not have medical insurance, you can use the Delaware Division of Social Services online Application for Social Services and Internet Screening Tool to determine if you qualify for State Assistance while waiting for your disability determination.

If you were represented by an attorney for your Social Security disability claim, and your Medicaid is terminated before you are eligible for Medicare, I would recommend that you ask your attorney to write a letter to your Social Worker describing the applicable regulations and explaining why you should retain your eligibility. If you live outside of Delaware, it is important that you determine if your State has a similar MAT program.

Relevant Links

Applicable Medical Assistance during Transition to Medicare Regulations

Delaware Administrative Code Title 16, Section 17800 Medical Assistance during Transition to Medicare
Delaware Administrative Code Title 16, Section 17801 Status Eligibility
Delaware Administrative Code Title 16, Section 17802 Financial Eligibility
Delaware Administrative Code Title 16, Section 17803 Eligibility Determination
Delaware Administrative Code Title 16, Section 13434 Recipients of Optional State Supplement Payments

Delaware Medicaid

Medicare

United State Medicare

Sample Letter

Sample Letter Requesting Redetermination of Medicaid Termination

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