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1619(a)

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Rules that allow Supplemental Security Income (SSI) recipients to keep their SSI benefit at a lower level when they return to work.

1619(b)

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A rule that lets people who stop getting Supplemental Security Income (SSI) benefits due to work income keep their Medicaid health coverage while earning up to $35,688 per year. 1619(b) also makes it easier to get SSI benefits started up again if your countable income goes below SSI's income limit. For 1619(b), you must continue to meet other SSI eligibility rules, such as the resource limit.

Note: If your earnings are over this limit and you have high medical expenses, you might still qualify for 1619(b). Ask your local Social Security office about the 1619(b) Individualized Earnings Threshold.

ABLE Accounts

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A type of financial account for people who have disabilities that began before they turned 26. ABLE (Achieving a Better Life Experience) accounts have tax advantages and the money in these accounts does not affect eligibility for many benefits, including Supplemental Security Income (SSI), Medicaid, and Food Assistance Program (formerly Food Stamps). Money in ABLE accounts must be used for specific things, like education, housing, transportation, health care, work-related expenses, assistive technology, or other approved living expenses. Note: If you have more than $100,000 in your ABLE account, the money will be counted by the SSI program.

ABLE accounts can only be opened through specific programs or financial institutions and a person can only open one account. Each state regulates which financial institution offers ABLE accounts in that state. You do not have to open your account in your own state: if another state offers a program, it may let you open an account there. That lets you compare which financial institution offers the right options for you and means you can open an account even if no financial institution in your state offers accounts.

Michigan's ABLE account program is MiABLE. You can choose to open an account in another state’s ABLE program.

Active Work Requirement

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The minimum number of hours per week that an employee is required to work to qualify for and maintain eligibility for benefits.

Administrative Law Judge

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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.

Annual Election Period

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The period from October 15 – December 7 when you can enroll in and switch Medicare Part D plans.

Appeal

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A 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.

Asset Limit

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The maximum amount of assets you're allowed to own while maintaining eligibility for a particular disability benefits program. Most benefits programs do not count everything you own, including the home you live in and one car you own. For Supplemental Security Income (SSI), the first $100,000 in an ABLE account is not counted as assets. For Medicaid, Food Assistance Program (formerly Food Stamps), and some other programs, none of the money in an ABLE account is counted.

Also called a "resource limit."

Assets

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Things that you own, like a car or a house. You can only own a certain amount in assets and still qualify for many 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. For Supplemental Security Income (SSI), the first $100,000 in an ABLE account is not counted as assets. For Medicaid, Food Assistance Program (formerly Food Stamps), and some other programs, none of the money in an ABLE account is counted.
Also called "resources."

Assets for Independence Act (AFIA)

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Legislation that established Individual Development Account (IDA) programs for applicants who are not on FIP. The three goals of AFIA include: providing individuals and families with incentives to save earned income, increasing self-sufficiency, and improving the community.

Association-Sponsored Group Health Coverage

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Group coverage offered through an association like a union, guild, or trade organization.

At-Home Recovery Services

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Help with activities like bathing or dressing.

Basic Plan

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A Medicare Part D plan that meets just the minimum requirements laid out by the Centers for Medicare and Medicaid Services (CMS).

Benchmark Plan

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A Medicare Part D plan that has its monthly premium fully covered by the Low Income Subsidy.

Beneficiary

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The person who is getting a benefit.

Benefit Period

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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.

Benefits Planner

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A trained expert who can help Social Security beneficiaries understand disability benefit programs. Their goal is to help you avoid complications while developing a sustainable financial plan for your future. Use the list below to find a Benefits Planner serving your area.

United Cerebral Palsy of Michigan

1-800-828-2714

Counties Served: Alcona, Alger, Alpena, Antrim, Arenac, Baraga, Benzie, Charlevoix, Cheboygan, Chippewa, Clare, Crawford, Delta, Dickinson, Emmet, Gladwin, Gogebic, Grand Traverse, Gratiot, Houghton, Ionia, Iosco, Iron, Isabella, Kalkaska, Kent, Keweenaw, Lake, Leelanau, Luce, Mackinac, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missau, Montcalm, Montmorency, Muskegan, Oceana, Ogemaw, Ontonagon, Oscoda, Osceola, Otsego, Ottawa, Presque Isle, Roscommon, Schoolcraft, Wexford

United Cerebral Palsy Association of Metropolitan Detroit

1-800-827-4843

Counties Served: Livingston, Oakland, Wayne

The Arc Michigan

1-800-292-7851

Counties Served: Allegan, Barry, Bay, Berrien, Branch, Calhoun, Cass, Cass, Clinton, Eaton, Genesee, Hillsdale, Huron, Ingham, Jackson, Kalamazoo, Lapeer, Lenawee, Macomb, Monroe, Saginaw, Sanilac, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw

Benefits Planning Query (BPQY)

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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.

Tip: The BPQY is form number SSA-2459. If a Social Security Claims Representative does not know what a BPQY is, mention the form number.

Blind Work Expenses (BWE)

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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.

For more information, refer to the Social Security Red Book, Special Rules for Persons who are Blind.

Blindness

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Eyesight that is very limited. To be considered legally blind, you must:
  • 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
  • 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% or less visual field efficiency.

Social Security and other agencies use this definition of blindness to decide if you qualify for benefits programs, such as Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). Some people with vision impairments that do not meet these standards may still qualify for benefits.

Blue Book (Listing of Impairments)

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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.

Break-Even Point (BEP)

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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.

Budget Month (Benefits Eligibility)

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The month a benefits program looks at when it decides if you qualify and what you get in benefits. Programs look at your income and resources from the budget month.

The budget month may be the same as the current month, one month before the current month, or two months before the current month. Which month a program looks at depends on the program rules and your situation.

Note: DB101 Calculators use the correct budget month for each month and program.

Budget month examples from the Supplemental Security Income (SSI) program
  • If you have been getting SSI benefits for more than two months, the amount you get is usually based on your income from two months ago.
  • If you don't get SSI benefits, but your countable income drops below SSI's income limit, you might not have to wait two months to start qualifying for SSI. Instead, your first month of SSI benefits may be based on your income from the current month.
  • Usually, the second month of SSI benefits are based on income from one month ago.
  • If you have been getting SSI benefits for a while, but then your income goes over SSI's income limit, you don't still qualify for SSI benefits. Your benefits eligibility is based on your income from the current month.

Catastrophic Plan

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A health coverage plan that generally has a lower premium and provides most benefits only after a large deductible has been paid. This sort of plan is most useful for people who do not have regular medical expenses, but wish to be covered in case of an accident or other sudden and significant medical needs. These plans may allow you to see your primary care provider up to 3 times per year and get preventive care without paying the deductible.

If you are under 30, you can sign up for a catastrophic plan on Healthcare.gov. If you are over 30, a catastrophic plan will not exempt you from having to pay the $695 tax penalty that people without health insurance have to pay because of the individual mandate.

Citizenship Status

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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.

Co-Insurance

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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."

Consolidated Omnibus Budget Reconciliation Act (COBRA)

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If you lose your employer-sponsored health coverage, COBRA laws allow you to continue that coverage for up to 18 months in most situations.

Continuation Coverage

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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. You will usually have to pay the full costs of your continuation coverage, including any portion of the premium your employer may have paid for in the past. The federal continuation coverage law is called COBRA. Many states also have their own continuation coverage laws.

Continuing Disability Review (CDR)

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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.

Conversion Policy

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A conversion insurance policy is something you can buy when your employer-sponsored group health insurance policy ends. It lets you keep buying insurance through the same insurance company. You may have to use up all your COBRA coverage first, before you can get a conversion policy, depending on the regulations in your state.

Copayment

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A set amount you have to pay when you receive medical services. For example, you may have to pay $30 every time you visit the doctor or $20 to get a prescription refilled. This is also known as a "copay."

Countable Earned Income

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Countable earned income is the portion of your earned income that is counted by a benefits program. Earned income includes salaries, wages, tips, and any other money that you receive as pay for work that you do.

For example, the SSI program uses a special calculation to determine your countable earned income, your total countable income, and ultimately, your SSI benefit.

Countable Income

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The amount of income that Social Security or the state counts when figuring out if you qualify for benefits and, if so, the level of benefits you should get. Not all of your income counts.

Example: Supplemental Security Income (SSI) counts most unearned income, but a bit less than half of earned income. So, if you have $500 in unearned income and $500 in earned income, your countable income for SSI would be just $697.50, even though your total income would be $1,000. Other programs, such as disability-based Medicaid and Medicare Savings Programs often use calculations similar to SSI's.

Countable Income Calculation (SSI)

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The calculation used to determine how much of your unearned and earned income is counted when determining your SSI benefit and eligibility.

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.

Step 3: Add your countable unearned income to your countable earned income to find your total countable income.

Example: If you have $500 in unearned income and $500 in earned income ($1,000 total), your countable income for SSI would be: $480 in countable unearned income + $217.50 in countable earned income = $697.50.

Countable Resources (SSI)

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Resources are things you own, like a home or car. To be eligible for SSI, you can only have up to $2,000 in resources ($3,000 for a couple).

When determining whether or not you qualify for SSI, Social Security excludes certain resources from your countable resource total. Your home and one car do not count as resources, for example. Income received from Earned Income Tax Credits (EITC), Child Tax Credits (CTC), Food Assistance Program (formerly Food Stamps), grants, scholarships, fellowships, gifts, property essential to self-support, Individual Development Accounts (IDAs), and many other items may be excluded as well. Additionally, for SSI, the first $100,000 in an ABLE account are not countable resources.

Countable Unearned Income

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Countable unearned income is the portion of your unearned income that is counted by a benefits program. 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).

For example, the SSI program uses a special calculation to determine your countable earned and unearned income, your total countable income, and ultimately, your SSI benefit.

Coverage Effective Date

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The date an individual is enrolled in coverage. The effective date is usually not the same as the date of hire.

Creditable Coverage (Medicare)

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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.

Deductible

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The amount an individual is responsible for paying for health care services before the insurer begins to pay.

Deductible (Medicare)

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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.

Deemed Income (SSI)

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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.

Deeming Rules

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Rules used by Social Security and Medicaid 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.

Dependent

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A person, usually a child, who is economically dependent on another person. Different programs have different definitions of when someone is a dependent.

Disability (Definition used by private insurers)

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A level of impairment that causes private insurers to provide benefits to people who have paid a monthly premium for coverage.

There are two common levels of disability according to private insurers:

  1. Own-Occupation Disability (or “Own Occ” ) means your disability prevents you from performing your own occupation, which means you cannot do the work or job you have been trained to do and have experience in
  2. Any-Occupation Disability (or “Any Occ”) means your disability prevents you from performing any occupation:
    • Sometimes Any Occ means that your disability prevents you from performing any occupation that pays at least a specified percentage of what you earned before your disability

Own-occupation insurance policies pay you if you are unable to perform your own occupation, even if you are able to get a different type of job. They have higher premiums than policies that require you to be unable to perform any occupation. Check with your insurer to see which definition of disability your plan has.

Disability (Definition used by Social Security for Adults)

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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 Determination Process (SSA)

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The evaluation process the Social Security Administration (SSA) uses to decide whether a person's disability meets SSA’s disability criteria for disability-based benefits.

Disabled Adult Child (DAC)

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Social Security benefits for adults who:
  • Became disabled before turning 22, and
  • Have a parent who died or who gets retirement or SSDI benefits.

Also called "Childhood Disability Benefits" (CDB).

Donut Hole

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The gap in Medicare Part D coverage when you have between $3,700 and $7,425.00 in total drug costs in a year.

People on Medicare who fall within the “donut hole” get a 60% discount on brand name prescription drugs and a 49% 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.

Earned Income (EI)

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Salaries, wages, tips, professional fees, and other amounts you receive as pay for physical or mental work you perform. This can include things you get in exchange for work instead of wages, such as food, shelter, or other items. Funds received from any other source are not included. (Contrast: unearned income.)

Earned Income Exclusion (SSI)

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$65 of earned income that is not considered when Social Security uses the SSI Countable Income Calculation to determine the benefit amount for a Supplemental Security Income (SSI) beneficiary. This $65 is in addition to the $20 general income exclusion, which may be earned or unearned income.

Earned Income Tax Credit (EITC)

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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.

Eligible Couple (SSI)

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A married couple where the partners live together and both qualify for Supplemental Security Income (SSI). The maximum SSI benefits amount for an eligible couple is $1,103, which is only about 150% of the individual maximum of $735.

Note: If you live in the same household as somebody else and the two of you act as though you are married and present yourselves to the community as being married, Social Security will consider you a married couple for SSI purposes. This is often referred to as "holding out."

Note: For SSI, Social Security only recognizes same-sex couples as married if they are legally married under Michigan law. (The rules are different for SSDI.)

Employer Mandate

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A part of the Affordable Care Act (ACA) that requires most employers with 100 or more employees to offer affordable insurance to their employees, or pay a fine.

Employer-Sponsored Health Coverage

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Health coverage offered through an employer as a benefit for employees and their families. Employers usually pay a portion of the monthly premium and the employee pays the rest.

Essential Health Benefits

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Benefits that federal law requires all health coverage plans provide. These benefits include:
  • Ambulatory patient services (care you get without being admitted to the hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Preventive and wellness services and chronic disease management, including:
  • Prescription drugs
  • Laboratory services
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Pediatric services for children, including oral and vision care

Exception (Medicare)

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A request to an insurance plan to pay for a medication that is not on the plan formulary or to otherwise bypass the plan's utilization controls (the rules that help the plan lower costs).

Exclusion

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A service that a health coverage plan won't pay for. Cosmetic surgery, for example, is not covered under most plans.

Expedited Reinstatement of Benefits

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A quicker way to get benefits restarted for individuals whose Supplemental Security Income (SSI) and/or Social Security Disability Insurance (SSDI) ends due to employment. You get up to six months of benefits while SSA decides if you have medically improved or not. This provision is available for up to five years after your benefits end.

Extended Period of Eligibility (EPE)

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A three-year period (36 months) after your SSDI Trial Work Period ends, during which you can keep getting SSDI benefits in any month when you earn less than the Substantial Gainful Activity level ($1,170 in 2017; $1,950 if you're blind).

If you earn more than SGA, your SSDI benefits will be suspended. However, during the EPE, you are eligible to have your SSDI benefits restarted if your earnings drop below SGA.

Fail First Rules

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An insurance requirement that you use a cheaper medication before trying more expensive options. This helps the insurance plan reduce costs.

Fair Share (SSI)

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The amount that each individual in a household is responsible for spending each month on food and shelter. If you live alone, it is the full cost of food and shelter. If you live with others, it is an equal portion of the total food and shelter expenses. For example, if you and three other people live together and spend a total of $4,000 per month on rent, utilities, and food, a fair share for each of you would be $1,000.

For the Supplemental Security Income (SSI) program and some other programs, whether an adult pays the fair share of expenses may affect benefits eligibility or benefits amounts.

Family Independence Program (FIP)

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This is Michigan's Welfare-to-Work program. FIP provides both cash and food assistance to low-income families with children. If you're on SSI and have children, you may be eligible for FIP.

FIP used to be called "Aid to Families with Dependent Children (AFDC)."

Federal Benefit Rate (FBR)

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The national benefit amount, established by the Social Security Administration (SSA), for Supplemental Security Income (SSI) recipients. For 2017, the FBR is $735 for an individual and $1,103 for a couple. Some states supplement this amount with additional payments for SSI beneficiaries.

FICA Taxes

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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.

Five-Year Window

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The 60 consecutive months (five years) during which you can work nine Trial Work Months.

The window begins on the first TWP month, but rolls forward until you have worked nine Trial Work Months within 60 consecutive months.

Food Assistance Program (formerly "Food Stamps")

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A county-run, federal program that helps people with low incomes buy food. To learn more, click here or call the Food and Nutrition Program Helpline at 1-800-481-4989.

Formulary

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A list of drugs that a health plan covers.

Freedom to Work

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A program that provides health coverage to working people with disabilities in Michigan who are not otherwise eligible for Medicaid. People in the Freedom to Work program get full Medicaid coverage in exchange for a monthly premium.

Fully-Insured Plan

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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.

General Enrollment Period

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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 (SSI)

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The $20 of earned or unearned income that is not considered when determining the amount for the Supplemental Security Income (SSI) benefit.

Grace Period

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When a person has a pattern of work in which countable earnings exceed Substantial Gainful Activity (SGA), the first 3-months of that pattern are the Grace Period. A person gets full Social Security Disability Insurance (SSDI) payments regardless of wages during this period.

Gross Benefit Amount

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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.

Gross Income

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Your earned income (before taxes and other deductions are made) plus your unearned income.

Gross Misconduct

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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.

Gross Monthly Earnings

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Your total earned income for the month before taxes and other deductions are made.

Gross Pre-disability Salary

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The total pre-tax income paid to an individual by an employer before a disability began and while the individual was covered by disability insurance.

Group Coverage

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Coverage offered to an individual through a group, such as employer-sponsored, association-affiliated or professional group coverage.

Guardian

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A person who has the legal authority and duty to care for another person.

Habilitative Services

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Services or devices which help a person with a health condition to develop skills useful for everyday living, which they have never developed before.

This is different than rehabilitative services, which help a person with a health condition relearn skills that they knew how to do before an illness, accident, or injury.

Health Insurance Portability and Accountability Act (HIPAA)

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A law that protects the privacy and confidentiality of your health information, such as medical records and test results. It regulates how health care providers are allowed to handle and share your protected health information.

HIPAA also prevents group health plans from denying you coverage based on your health condition and provides protections for those buying individual health coverage. However, these parts of HIPAA are protections that are no longer needed, since the Affordable Care Act provides all the same protections, plus more.

Health Maintenance Organization (HMO)

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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.

Health Screening

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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.

If a person enrolls in a Medicare supplement during the Medigap open enrollment period, an insurance company cannot use health screening. But, if a person tries to enroll in a Medicare supplement outside of the open enrollment period, then a private insurance company can still use health screening.

High-Deductible Plan

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A health coverage plan with a relatively low premium 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.

HIV/AIDS Disability Form 4814 for Social Security

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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.

Home Health Care (Medicare)

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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.

Hospice Care (Medicare)

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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).

Hospital Stays (Medicare)

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Services covered by Medicare Part A that include a semiprivate room, meals, general nursing, and other hospital services and supplies.

Impairment Related Work Expenses (IRWE)

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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.

In Arrears

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Payment received for the prior month.

Income

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Money from salaries, wages, tips, disability benefits, investments, dividends, and funds received from any other source. Includes both earned and unearned income.

Indemnity Plan

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A type of health insurance plan. You pay monthly premiums and usually have co-insurance and a yearly deductible as well. Also known as fee-for-service.

Independent Review Entity

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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.

Individual Development Account (IDA)

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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.

Individual Disability Policy

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Wage-replacement coverage you buy directly from an insurance company, usually through an agent, that provides benefits if you become disabled. You are responsible for paying for the entire premium, and most individual policies require medical underwriting.

Individual Health Coverage

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Private health insurance an individual or family purchases. The individual or family pays a monthly premium and the plan agrees to pay a portion of the cost of approved medical services when needed, like for preventive care, lab tests, surgery, or prescription drugs. The easiest way to purchase an individual plan is through Healthcare.gov.

The government may help individuals and families with low to middle income who get their coverage through Healthcare.gov pay for their monthly premiums and a portion of the cost of approved medical services.

Individual Mandate

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A part of the Affordable Care Act (ACA) that requires most Americans to have health insurance that meets a minimum standard, or pay a fine. This fine is sometimes called the ACA “tax penalty.” Public insurance programs like Medicare or Medicaid, insurance offered through your employer, and insurance you buy through Healthcare.gov all count as meeting the individual mandate.

You do not have to pay a fine, even if you do not have health insurance, if:

  • You cannot afford the lowest cost plan option (because either the lowest cost plan is more than 8% of your income or your income is low enough that you don’t legally have to file taxes)
  • You have a religious objection
  • You are an American Indian
  • You are only without coverage for less than three months
  • You are an undocumented immigrant, or
  • You are incarcerated.

If you do not have health coverage, and you do not meet any of the exceptions, you will have to pay a fine each year you do not have coverage.

Individual Plan for Employment (IPE)

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A plan that lists the employment services and outcomes needed to achieve your PASS goal.

Initial Enrollment Period (Medicare)

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The period when a beneficiary can first sign up for Medicare Part B or Part D. For Social Security Disability Insurance (SSDI) and Disabled Adult Child (DAC) beneficiaries, the initial enrollment period begins during the 24th month of a beneficiary’s SSDI or DAC payments. The initial enrollment period typically lasts about 10 months.

Initial Enrollment Period (Private Coverage)

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The first time an individual is eligible to enroll in a group’s benefits programs.

In-Kind Support and Maintenance (ISM)

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A Supplemental Security Income (SSI) term that describes food and/or shelter which is supplied or paid for by someone other than the SSI beneficiary. Shelter expenses can include rent, mortgage payments, property taxes, heating fuel, gas, electricity, water, sewer service, and garbage collection.

If you do not pay your fair share of food and/or shelter, your maximum possible SSI benefits amount may be reduced. Depending on your situation, your ISM may be calculated using SSI's Value of One-Third Reduction (VTR) rule or the Presumed Maximum Value (PMV) rule.

Note: ISM rules usually only apply to adults, not to children under 18 years old. For children, parent-to-child deeming rules usually apply instead.

Inpatient

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An individual who has been admitted to the hospital.

Inpatient Care

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Health services received after an individual is admitted to the hospital.

Integration

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The adjustment of payments when an individual is eligible for more than one benefit program.

Interval Steps

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Measurable milestones that show progress towards achieving a vocational goal in a Plan to Achieve Self-Support. For example, if the goal is to obtain a job, the job search would be considered an interval step.

Lifetime Reserve Days

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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 $658 in 2017.

Liquid Assets

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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.

Long-Term Care

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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.

Long-Term Disability Insurance

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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.

Low Income Subsidy (LIS) (Extra Help)

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Help paying for Medicare Part D for people with low to moderate income and resources. Also known as "Extra Help".

There are two levels of the Low Income Subsidy:

  • The full subsidy is for people who also get Medicaid coverage or who are in a Medicare Savings Program (MSP). You may also qualify if your countable income is less than $16,281 per year and your resources are less than $7,390, if you are single (the limits are higher for larger households).
  • The partial subsidy is for people who can’t get the full subsidy, but have less than $18,090 in countable income and less than $12,320 in resources, if you are single (the limits are higher for larger households).
    • With the partial subsidy, you will pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and will only have to pay a $82 deductible before you get help paying for drugs. You will have to pay coinsurance and copayments for your medications, but they will be lower than they would be without the partial LIS.

Note: Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply for the LIS even if you are not sure that you will qualify.

Low- or No-Cost Medicaid

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Medicaid coverage that has no monthly premium or a low monthly premium. Most people have no premium. For people who do have a premium, it's generally $26 per month or less.

To apply for Medicaid, contact your county human services agency.

Managed Care

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Health coverage that requires you to get most services within a network.

With managed care, you have a primary care provider who oversees your care and refers you to specialists within the network when needed.

Medicaid

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A state-run health care program that pays medical expenses for people who are disabled, young, elderly, or poor. If you meet program requirements, Medicaid will help pay for a variety of medical services including visits to the doctor, hospital stays, medical equipment, home care services, and prescription drugs.

To apply for Medicaid, visit your county human services agency.

Medicaid with a Spend-Down (Deductible)

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A way of getting Medicaid when your countable income is greater than the income limit for some ways of qualifying for Medicaid.

A spend-down (also called a deductible) is the amount you agree to pay for health care expenses each month before Medicaid starts to pay the rest of your health care bills. Your spend-down amount equals the actual dollar amount of your countable income above the regular Medicaid income limit.

In other words, when your medical bills in a month, paid or unpaid, reach this spend-down amount for you, the rest of the medical services in that month will be paid by Medicaid. If you can plan all your non-urgent medical and dental appointments in the same month, you may pay less for them.

Medical Savings Account (Medicare)

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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.

Medical Treatment/Care

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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.

Medical Underwriting

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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.

The Affordable Care Act prohibits health insurance companies from doing medical underwriting and excluding pre-existing conditions from coverage. Other forms of insurance, like private disability insurance, can do medical underwriting and exclude pre-existing conditions.

Medically Necessary

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Services or supplies that are considered by Medicare to be appropriate and needed for treatment.

Medicare

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A federal program that provides health insurance for people 65 or older and many people under 65 who have disabilities. After a person gets Social Security Disability Insurance (SSDI) benefits for two years, he or she qualifies to get Medicare as well.

Medicare Advantage (Part C)

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A way of getting combined Medicare coverage through a health plan run by a private insurance company, instead of getting Original Medicare (Parts A, B, and D). Medicare Part C plans can be Managed Care (Medicare HMOs), Private Fee-for-Service, Preferred Provider Organization, and Special Needs Plans. If you get Medicare Parts A and B, you can choose whether you want to join a Part C plan or prefer staying enrolled in Original Medicare.

Medicare Advantage Prescription Drug (MA-PD) Plan

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Medicare Part D drug coverage that is offered through a Medicare Advantage plan.

Medicare Appeals Council

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A group of people within the Centers for Medicare and Medicaid Services (CMS) who hear Medicare appeals after they have gone to an Administrative Law Judge.

Medicare Carrier

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A private insurance company that contracts with Medicare.

Medicare Cost Plan

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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.

Medicare Health Maintenance Organization (HMO)

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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.

Also known as "Medicare Managed Care Plan."

Medicare Managed Care Plan

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Medicare Part A

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The part of Medicare that helps pay for medical care you get while you’re in a hospital.

Medicare Part B

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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.

Medicare Part D

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The part of Medicare that helps pay for prescription drugs.

Medicare Plans

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Health coverage options that include: Original Medicare, Medicare Advantage Plans, and Medicare supplement policies.

Medicare Preferred Provider Organization (PPO) Plan

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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.

Medicare Private Fee-for-Service Plan

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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 Program (MSP)

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A program that helps people with low income and low resources pay for their Medicare expenses, such as Medicare Part A and B premiums, coinsurance, and deductibles. There are four Medicare Savings Programs:
  • The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,005 per month or less if you live alone). QMB helps pay for your Part B premium and reduces copayments and deductibles. Note: If you have SSI-related Medicaid coverage, you automatically qualify for QMB.
  • The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,206 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
  • The Additional Low-Income Medicare Beneficiary (ALMB) program, also called Q1, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,357 per month or less if you live alone). ALMB helps pay for the Part B premium, but does not help with anything else.
  • The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,170 per month), but have countable income that’s 200% of FPG or less ($2,010 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.

For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.

The resource limit for QMB, SLMB, and ALMB is $7,280 if you live alone and $10,930 if you live with someone else. For QDWI, it’s $4,000 if you live alone and $6,000 if you live with another person.

Apply for an MSP by using form DHS-1426 and giving it to your county human services agency. For help with your application, visit or call your local county human services agency or call the Medicaid Beneficiary Help Line at 1-800-642-3195 or 1-866-501-5656 (TTY)

Medicare Supplement

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A supplemental insurance policy sold by private insurance companies to fill gaps in Original Medicare. In Michigan, there are 2 Medicare supplement plans: the Basic Plan and the Extended Basic Plan. These plans are standardized. One company’s Basic Plan must offer the same services as another company’s Basic Plan.

Medicare supplement policies are available only to individuals using Original Medicare 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 sometimes referred to as "Medigap."

Milestone

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A significant, visible step toward achieving a vocational goal.

Net Benefit Amount

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The benefit amount an insurance company pays after deducting income.

Net Income

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The amount of income you have after certain amounts are subtracted from it.

Network

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A group of doctors or medical service providers who have signed a contract with a health coverage plan. If you have health coverage through a Health Maintenance Organization (HMO), you generally have to see doctors within the network. Preferred Provider Organizations (PPOs) and Point of Service (POS) plans allow you to see doctors outside of your network, but you will have to pay more.

Nonpreventive Care Services

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Health care services that are medically necessary and are aimed at treating illnesses, as opposed to preventing them. (Contrast: preventive care services.)

OBRA

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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 Social Security Disability Insurance (SSDI).

Onset Date (Social Security)

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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.

Open Enrollment Period

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The annual time period when an individual may add or change private insurance plans offered by an employer, an association, or through Healthcare.gov. Certain situations, such as divorce, the birth of a child, or loss of another insurance plan may allow a person to sign up for an insurance plan outside of this time period.

Original Medicare

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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).

Individuals with Medicare choose to either stay in Original Medicare or enroll in a Medicare Advantage Plan. Medicare Advantage plans will have different costs and covered services than Original Medicare.

Out-Of-Pocket Costs

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The health care related costs you pay yourself without help from Medicare, Medicaid, or other health insurance.

Out-Of-Pocket Maximum

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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.

Outpatient Services

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Health services received outside of hospital care, including after an individual is released from the hospital.

Overpayment

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Payment that exceeds the approved benefit amount.

Parental Control

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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.

Parent-to-Child Deeming

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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.

PASS Cadre

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A group of experts who review, monitor, and approve users' Plans to Achieve Self-Support (PASS). In the Detroit metro area, call the Pontiac PASS Cadre at 1-866-299-3777, ext. 28449. In the rest of Michigan, call the Grand Rapids PASS Cadre at 1-877-322-5883, ext. 18873.

PASS Review

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A regular review of your Plan to Achieve Self-Support (PASS) that takes place at least once every six months. A PASS specialist will check how your plan is progressing and collect receipts for your PASS expenses.

Period of Entitlement

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The continuous period from the award start date of a benefit to the date when eligibility for the benefit or program stops.

Pharmacy Network

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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.

Plan to Achieve Self-Support (PASS)

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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 benefits to go down. Assets that you spend on PASS expenses won't count towards the SSI limit.

A PASS specialist can help you set up a Plan to Achieve Self-Support.

Point-Of-Service (POS) (Medicare)

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An option offered by some Medicare Managed Care Plans that allows an individual to use doctors and hospitals outside the plan at an additional cost.

Point-Of-Service (POS) Plan (Private Health Coverage)

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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.

Potentially Disabling Condition

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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.

Pre-Disability Income

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Pre-Existing Condition

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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 Affordable Care Act prohibits health insurance companies from doing medical underwriting and excluding pre-existing conditions from coverage. Other forms of insurance, like private disability insurance, can do medical underwriting and exclude pre-existing conditions.

Pre-Existing Condition Exclusionary Period

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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.

The Affordable Care Act prohibits health insurance companies from doing medical underwriting and excluding pre-existing conditions from coverage. Other forms of insurance, like private disability insurance, can do medical underwriting and exclude pre-existing conditions.

Pre-Existing Condition Insurance Plan (PCIP)

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Government-run insurance plans for people who couldn’t get insurance because of pre-existing medical conditions, PCIPs ended on January 1, 2014. Now, insurance companies cannot deny people health coverage because of pre-existing conditions. People who don’t have health insurance can get coverage through Healthcare.gov.

Preferred Provider Organization (PPO)

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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.

Premium (General)

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A regularly scheduled payment to an insurer or health care plan.

Premium (Medicare)

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A regularly scheduled payment to an insurer or health care plan.

If you're on SSDI or DAC and Medicare, you likely won't have to pay a premium for Medicare Part A coverage. You may have to pay a Part B premium, however. For most people, the premium for Part B coverage is $109.00 per month. If you qualify, a Medicare Savings Program or other programs can help pay for your Part B premium.

If you sign up for Part D prescription drug coverage or have a Medicare Advantage (Part C) plan instead of Original Medicare, you will also usually have to pay a premium. The exact amount of your premium will depend on the plan you choose.

Prescription Drug Plan (PDP)

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A Medicare Part D plan that only offers drug coverage. Also known as a "stand-alone" plan.

Presumptive Disability

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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.

Preventive Care Services

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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.)

Primary Care Physician (Medicare)

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A doctor who 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 may need to see their primary care doctor before going to a specialist.

Primary Care Provider (PCP)

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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.

Prior Authorization (Medicare)

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A requirement to get an insurance plan's permission to use a certain medication. This helps the insurance plan reduce costs.

Prior Authorization (Private Health Coverage)

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A health plan process of reviewing medical services or medications before they give you permission to go ahead with the service or use the medication. This is done to ensure that the service or medication is appropriate and necessary before the plan pays for it.

Private Duty Nursing

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The care of clients by nurses. Most nurses who provide private duty care are working one-on-one with individual clients. Sometimes such care is provided in the client's home, or an institution, such as a hospital, nursing home or other such facility.

Private Health Coverage

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Health coverage through a private company that pays for medical expenses. A monthly premium must be paid for this coverage by the individual or family covered, by an employer, or by an association. The individuals covered by private health plans must also make payments such as copayments or coinsurance each time they use certain medical services.

In some cases, the federal government may help low to middle-income families pay for private health coverage through tax subsidies if they are in very specific situations and do not have other affordable health coverage alternatives.

Probate

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A legal process after a person dies during which a court decides whether that person’s will is valid or not. If the person didn’t leave a will, the court will decide who gets the person’s money and property. The process can be complicated, and take anywhere from a few months to several years.

Property Essential to Self-Support (PESS)

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Anything that you own and need to support yourself. If the Social Security Administration (SSA) approves the property that you claim is Property Essential to Self-Support (PESS), Social Security will not count these things as resources when figuring out if you are eligible for Supplemental Security Income (SSI) benefits. Three types of property can be excluded as PESS:
  • Property that you use in a trade or business (for example, your inventory) or personal property you use for work as an employee (for example, tools or equipment)
  • Up to $6,000 of the value of nonbusiness property that you use to produce something that helps with your daily living (for example, land that you use to produce vegetables that you eat)
  • Up to $6,000 of the value of property if the property gives you a return of at least a 6% per year (for example, property you own and rent to someone else)

You must be using the property to support yourself or expect to start using it again within a reasonable period of time, usually 12 months.

Qualified Alien

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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.

Qualified Medical Expense

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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

Qualifying Events

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Events that may end individuals' employer-sponsored group health coverage but qualify them for COBRA or other continuation coverage.

For employees, qualifying events can include:

  • Quitting
  • Being fired for a reason besides gross misconduct
  • Being laid off
  • Having your work hours reduced

If you are covered under your spouse’s employer-sponsored health coverage, you can get continuation coverage if your spouse loses coverage for any of the above reasons or because:

  • The employee dies
  • There’s a divorce or legal separation
  • The employee becomes eligible for Medicare

Quick Benefit Restart

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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.

Referral

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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.

Regular Attendance (SEIE)

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To be considered “regularly attending” school for the Student Earned Income Exclusion (SEIE), a student has to meet one of the following requirements:
  • 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.

Rehabilitative Services

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Services or devices which help a person with a health condition to relearn skills that they knew how to do before an illness, accident, or injury.

Reporting Agencies

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Agencies to which you need to report any changes in your income or living situation, if you get public benefits.

If you're on Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), call Social Security at 1-800-772-1213 or 1-800-325-0778 (TTY), or visit your local Social Security office, and ask what's the best way for you to report. Note: Reporting rules for SSI and SSDI are different and if you get both benefits, you must report income for them separately.

If you're on Medicaid, State SSI Payment (SSP), or any other state health care or cash assistance programs, report any changes in earnings to your county human services agency.

Representative Payee

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A person who gets and manages benefits on someone else's behalf. Social Security does an investigation before making a relative, friend, or other person the representative payee of a beneficiary who needs help managing their benefits. For children under 18, a parent or guardian is usually the representative payee.

Resource Exclusions (SSI)

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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), Food Assistance Program (formerly Food Stamps), grants, scholarships, fellowships, gifts, property essential to self-support, Individual Development Accounts (IDAs), and many other items may be excluded. Additionally, for SSI, the first $100,000 in an ABLE account are not countable resources.

For more information, you can read the SSI Spotlight on Resources.

Resource Limit

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The maximum amount of resources you're allowed to own while maintaining eligibility for a particular disability benefits program. Most benefits programs do not count everything you own, including the home you live in and one car you own. For Supplemental Security Income (SSI), the first $100,000 in an ABLE account is not counted as resources. For Medicaid, Food Assistance Program (formerly Food Stamps), and some other programs, none of the money in an ABLE account is counted.

Also called an "asset limit."

Resources

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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. The home you live in and the car you drive to work are exempt under most Social Security and state disability benefit programs. For Supplemental Security Income (SSI), the first $100,000 in an ABLE account is not counted as resources. For Medicaid, Food Assistance Program, and some other programs, none of the money in an ABLE account is counted.

Also called "assets."

Retirement, Survivors, and Disability Insurance (RSDI)

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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.

Retroactive Payments

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Payments made for the period between disability onset and application approval.

Revenue

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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.

Section 301

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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."

Self-Insured Plan

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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.

Service Wait

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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.

Short-Term Disability Insurance

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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.

Skilled Nursing Facility Care

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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 three days.

Social Security Administration (SSA)

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A federal government agency that runs important programs like:

Social Security offices also handle some aspects of Medicare.

To contact SSA, call 1-800-772-1213 or 1-800-325-0778 (TTY) or visit your local Social Security office.

Visit the SSA.gov website.

Social Security Child's Benefits

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A Social Security cash benefit for children with a parent who gets Social Security retirement benefits or Social Security Disability Insurance (SSDI). Children with a deceased parent may also qualify.

Social Security Disability Insurance (SSDI)

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A Social Security Administration program that gives money each month to people who have a disability that meets Social Security disability rules and who, in the past, worked and paid FICA taxes for enough time to qualify. SSDI has no income limits and no resource limits. The amount you get in SSDI benefits depends on your Social Security earnings record. After getting SSDI benefits for two years, you automatically qualify for Medicare health coverage.

SSDI also offers benefits to family members, including children and widows, when a primary wage earner in the family becomes disabled or dies. Additionally, adults whose disabilities began before they turned 22 may be able to get Disabled Adult Child (DAC).

Special Enrollment Period (Medicare)

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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)

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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.

Special Needs Plan (SNP)

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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.

Learn more about Special Needs Plans on Medicare.gov.

Special Needs Trust

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A legal arrangement that lets someone else (a person or an organization, called the trustee) manage resources or assets for a person with disabilities (called the beneficiary). If a Special Needs Trust is set up correctly, the money in the trust won’t count toward the resource or asset limits for benefits programs like Supplemental Security Income (SSI) or Medicaid (Medicaid), and it can be used to pay for the beneficiary’s expenses that aren’t covered by their public benefits. If you are the beneficiary of a Special Needs Trust, your trust can have more assets in it than the resource limits for benefits programs usually allow, and the money can pay for things like recreation, telephone bills, education, and vacations.

The Special Needs Alliance can help you find an attorney who specializes in Special Needs Trusts.

SSA-approved Vocational Rehabilitation Plan

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An employment support program that meets Social Security's criteria for Section 301.

SSI Resource Exclusions

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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), Food Stamps, grants, scholarships, fellowships, gifts, property essential to self-support, Individual Development Accounts (IDAs), and many other items may be excluded.

Review your resources and resource exclusions with a Benefits Planner or a PASS specialist.

SSI Unearned Income Exclusions

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Types of unearned income that do not affect Supplemental Security Income (SSI) program eligibility or benefits amount.The main unearned income exclusions are:
  • The first $20 per month
  • Income set aside or being used for a Plan to Achieve Self-Support (PASS)
  • State or locally funded assistance based on need
  • Rent subsidies under HUD programs
  • Food Assistance Program (formerly Food Stamps) and other food or meal programs, and
  • The first $60 of infrequent or irregularly received income in a quarter.

Social Security has a complete list of the types of unearned income that are not counted by the SSI program. Some of the SSI exclusions on the list are:

  • AmeriCorps programs
  • Burial Funds (Interest on Excluded)
  • Child Care Assistance Under the Child Care and Development Block Grant Act
  • Department of Education (DE) and Bureau of Indian Affairs (BIA) Student Assistance
  • Disaster Assistance
  • Educational Assistance
  • Energy Assistance
  • Federal Perkins Loan
  • Federal Supplemental Education Opportunity Grants (FSEOG)
  • General Assistance
  • Gifts Occasioned by Death
  • Gifts of Domestic Travel Tickets
  • Grants, Scholarship, Fellowships, and Gifts
  • Home Energy Assistance
  • Home Produce
  • Housing Assistance
  • Individual Development Accounts (IDAs) (Demonstration Project)
  • Individual Development Accounts (IDAs) (TANF Funded)
  • Leveraging Educational Assistance Program (LEAP)
  • Low Income Energy Assistance
  • Pell Grants
  • Private Nonprofit Assistance
  • Refunds of Taxes Paid on Real Property or Food
  • Relocation Assistance
  • School Breakfasts
  • School Lunches
  • State Assistance Based on Need
  • Women, Infants, and Children Program (WIC)

State SSI Payment (SSP)

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SSP is a state program that provides an extra cash payment to people receiving Supplemental Security Income (SSI).

SSP is paid once every three months in March, June, September, and December. If you live alone, the SSP benefit is $42 once every three months; if you live with others, it's $28 once every three months. When you apply for SSI at your local Social Security office, you're automatically applying for SSP as well.

Student Earned Income Exclusion (SEIE)

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An exclusion that allows most students to work without their SSI benefit decreasing. The SEIE lets you keep the first $1,790 in earnings each month without affecting the countable earned income calculation. But there is an annual cap of $7,200, so if you earn more than this in any given year, the income starts counting again.

Subsidy (Individual Health Coverage)

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A support provided by the federal government that helps people and families with low to middle income pay for their health coverage when they purchase it through Healthcare.gov. This support means that individuals and families may qualify to get health plans with lower premiums and other expenses.

Families with income at or below 400% of the Federal Poverty Guidelines (FPG), $47,520 for an individual in 2017 ($97,200 for a family of four), may get help paying for their health coverage premium.

Families with income at or below 250% of FPG, $29,700 for an individual ($60,750 for a family of four), may also get qualify to get health coverage with lower expenses, such as reduced copayments, coinsurance, or deductibles, as long as they choose to get a silver plan.

Substantial Gainful Activity (SGA)

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The amount of monthly earned income that shows a person is doing significant work according to Social Security. People who cannot earn more than SGA due to their disabilities may be considered disabled by Social Security and other agencies that use Social Security’s definition of disability.

In 2017, SGA is $1,170 per month ($1,950 for people who are blind).

SGA levels for previous years:

Year Disabled, Non-blind Blind
2016 $1,130 $1,820
2015 $1,090 $1,820
2014 $1,070 $1,800
2013 $1,040 $1,740
2012 $1,010 $1,690
2011 $1,000 $1,640
2010 $1,000 $1,640

Social Security lists the SGA levels for earlier years.

Supplemental Security Income (SSI)

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A Social Security Administration program that gives cash benefits to people with disabilities who have limited income and resources. The amount you get in SSI benefits is based on your financial need and your living situation. The maximum monthly SSI benefit is $735 for individuals and $1,103 for eligible couples.

Surrender Value

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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).

Tax Penalty (Individual Mandate)

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A fee that people without health coverage may need to pay. The fee in 2017 is $695 or 2.5% of your income, whichever is greater.

Uninsured people won’t have to pay the fee if they:

  • Are uninsured for less than 3 months of the year
  • Have very low income
  • Do not file a tax return because their income is too low
  • Earn 138% of the Federal Poverty Guidelines (FPG) or less ($16,643 or less for an individual; $33,948 for a family of four) and live in a state that hasn’t expanded Medicaid eligibility
  • Are a member of a federally recognized Indian tribe
  • Have religious objections to health insurance

Ticket

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A standard electronic form that indicates eligibility for the Ticket to Work Program.

Ticket to Work Program

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A Social Security Administration (SSA) program that helps adults with disabilities prepare for, find, and keep jobs. To qualify, you must be 18 – 64 years old and currently be getting Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits.

Ticket to Work offers free services, such as:

Learn more on the Ticket to Work website.

Tiered Drug Levels

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Different levels of coverage offered by Medicare Part D (prescription drug) plans. Drugs in lower levels usually have lower copayments and drugs in higher levels usually have higher copayments.

Trial Work Month (SSDI)

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Any month when gross monthly earnings are above $840 (for 2017). Impairment-Related Work Expenses (IRWEs) cannot be deducted when figuring out Trial Work month earnings.

Trial Work month income levels are indexed annually for increases or decreases in the average wage. Previous Trial Work month gross income levels were:

  • $810 in 2016
  • $780 in 2015
  • $770 in 2014
  • $750 in 2013
  • $720 in 2012
  • $720 in 2011
  • $720 in 2010
  • $700 in 2009
  • $670 in 2008
  • $640 in 2007
  • $620 in 2006
  • $590 in 2005
  • $580 in 2004
  • $570 in 2003
  • $560 in 2002
  • $530 in 2001
  • $200 from 1990 to 2000, and
  • $75 before 1990.

Trial Work Period (TWP)

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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.

U.S. Citizen

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A person who is:
  • Born in one of the 50 states, Washington D.C., Puerto Rico, Guam, Northern Mariana Islands, U.S. Virgin Islands, American Samoa, or Swain’s Island
  • Born outside of the U.S. to at least one parent who is a U.S. citizen
  • Granted citizenship status by U.S. Citizenship and Immigration Services (USCIS)

When applying for benefits, contact the agency you are applying to to find out what documents are acceptable for proving citizenship.

Unearned Income (UI)

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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.

Uniformed Services Employment and Reemployment Rights Act (USERRA)

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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.

Unincurred Business Expenses

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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.

Unpaid Help

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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.

Utilization Controls

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Rules that insurance plans use to keep their prescription drug costs down. You may, for example, need prior authorization from the plan to use a particular drug.

Vesting Requirement

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Vocational Counselor

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A counselor who works with people to help them identify potential job options.

Vocational Rehabilitation

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State agency that helps people with disabilities prepare for, find, and keep jobs that are consistent with their skills, strengths, and interests. Michigan's VR agency is called the Michigan Rehabilitation Services (MRS).

Wage Replacement

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A type of benefit that provides money each month to make up for wages you no longer receive due to disability. It can be either a percentage of your pre-disability income or a fixed dollar amount. Short-Term or Long-Term Disability Insurance are private wage replacement programs, while Social Security Disability Insurance (SSDI) is a public program. Wage replacement is also known as pay replacement or income replacement.

Wage Subsidy and Special Conditions

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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.

Waiting Period (Medicare Supplement)

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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.

Waiting Period (Short- and Long-Term Disability)

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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.

Work

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Physical or mental activity that is actually performed and results in earned income.

Work Credits (SSDI)

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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 $1,300 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
Became Disabled At Age:
Number of Credits Needed
31 through 42
20
44
22
46
24
48
26
50
28
52
30
54
32
56
34
58
36
60
38
62 or older
40

Work Goal

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The specific job an individual wishes to have after completing a Plan to Achieve Self-Support. Also known as a vocational or occupational goal.

Work Incentives

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Rules used to encourage people to work when they use public benefits. Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid all have work incentive rules.

Workers' Compensation

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A program that replaces income and provides for medical treatment when you can't work because of on-the-job injuries.