February 16, 2019

Questions to Government Benefits

There are many different government benefit programs for victims of TBI.  This section answers some questions about the services the government provides for those affected by Traumatic brain injury.

What is Social Security?
Social Security is a federal law that was enacted to protect
workers and their dependents from the loss of income because of
retirement, death or disability.  All employees fund the Social Security
system through payroll deductions.  This is the Social Security (FICA)
tax deduction that you see on the pay stub.  To qualify for Social
Security benefits, an employee must earn credits based on the income
they have paid into the system covered by the Social Security tax.

The number of credits needed to receive Social Security depends on your birthday, age, date of retirement or disability, or for survivor’s
benefits, the age of the worker who died.  The amount of income you need to accumulate for Social Security credits changes each year.

Full retirement benefits begin at age 65.  The standard retirement age will gradually increase until it reaches age 67 in the year 2027.  You can order a free report from the government which will list the income
reported under a worker’s name and estimate the future Social Security
benefits based on the age of expected retirement.  To order such a
report, call Social Security at 800-772-1213.

What type of basic federal government benefits programs are available to provide financial assistance to disabled persons?
There are two basic federal government programs that provide financial
benefits: Social Security Disability Insurance Benefits, which are
called “SSD” and Social Security Income, which is called “SSI”.

SSD benefits will be paid to a disabled worker and his or her
family if the worker has earned credit for a certain number of pay
credits under Social Security standards and if the workers earnings are
lost or reduced due to the worker’s disability.  Persons are considered
disabled if they have a physical or mental impairment which prevents
them from working, and that disability is expected to last for at least twelve months or, to result in death.

Under SSD government benefits, a worker is allowed to earn up to the “substantial, gainful activity level”.  The dollar value of the subsidies and disability work expenses are subtracted from the gross earnings in determining whether work is “substantial, gainful activity”.

Social Security will not automatically terminate SSD benefits if your
earnings exceed the maximum allowance, but the amount of the excess
earnings will reduce your monthly Social Security Disability check.  The
Social Security Disability Program also offers a “trial work” program to
test the ability of disabled persons to return to work without losing
benefits.  In most cases, the trial work period is limited to nine months, and is accumulated over your lifetime.

Can you receive both Workers’ Compensation and Social Security?
If you are on workers’ compensation, Social Security Disability
payments will be reduced.  It does not matter if you live with your parents, a spouse, children or by yourself, you can still collect the full
amount of Social Security Disability.  If the brain injury is so
significant that a disabled person is unable to manage money, the
Social Security Administration can designate a “representative payee”
who is appointed by Social Security to assist.

What should you expect when you apply for Social Security benefits?
The Social Security Administration needs to obtain sufficient medical
records to document a person’s injury and work history and work credits to award benefits.  It is not unusual for the Social Security
Administration to reject a person’s initial application for benefits.
If there is a catastrophic injury, you should always appeal a denial of
Social Security benefits.  It is critical to obtain all of the medical
records so that they can be presented to Social Security Administration
at the time of an appeal from a denial of benefits.

There is also a procedure to file for reconsideration on an application.  There are also procedures that should be given priority when there is a catastrophic brain injury, and the ability to request an immediate hearing.

The process for applying for Social Security benefits is
adversarial.  Although the Social Security Administration may send you
to an “independent medical exam”, a so-called IME, this is not truly
independent.  Social Security selects the doctor, pays the doctor and
receives a copy of the report.  If you are involved in an adversary
situation such as this, you should consider having an attorney or
representative attend the medical exam as an advocate for the disabled person.  You should also request in writing a copy of the report that is sent to Social Security.

Another avenue that you may want to consider is to contact your
Congressman.  Congressmen do have aides that can make calls to Social Security to inquire on the status of an application and to try and help obtain an expedited hearing.  Congressmen are your representatives and it is not an imposition for you to make such a call.

What is Supplemental Security Income?
SSI payments are made monthly to disabled persons who have
limited income and assets.

SSI benefits are generally available to families with incomes up
to $24,000, and sometimes even a larger amount, depending on the number of people residing in the household and certain other factors.

For eligible children, SSI can mean up to $422 a month, perhaps more,
depending on the family income.  In most states, children who qualify
for as little as $1.00 of SSI are also eligible for free health care
through Medicaid.

Families should contact an attorney to apply for SSI, whether or
not they have previously applied.

What is Medicare?
Medicare is a federal government program which provides benefits
to elderly patients.  Most people over 65 are entitled to Medicare, Part
A (hospital benefits) because they are eligible for Social Security
retirement benefits.

When you enroll for Medicare Part A, you automatically are signed up for Medicare Part B (medical insurance) for which you have to pay a monthly premium.  If you choose, you can refuse to pay for the Medicare Part B coverage.

You are also entitled to receive Medicare Part A benefits if you are
under 65 and have been eligible for Social Security Disability benefits
for at least 24 months.  This is critically important coverage for
individuals who have suffered a traumatic brain injury.  If you are
already receiving Social Security Disability benefits, you will
automatically be enrolled in Medicare Part A and Part B beginning in the
25th month.  You will not be charged a monthly premium for Part A if you are on Social Security Disability.  If you refuse Medicare Part B
medical insurance, then a Part B premium will be deducted from your
monthly disability check.  Medicare coverage will continue until you are
no longer disabled.

The only long term care services Medicare will pay for is a
Medicare certified skilled nursing facility, part time or intermittent
home health care services or hospice care.

You cannot rely on Medicare to meet either nursing home or home health expenses on a long term basis for the catastrophically brain injured.

What is Medicaid?
Medicaid, also known as Medical Assistance, is a program that is
administered by both the federal government and the individual state governments.  Federal and state governments share the cost of Medicaid programs.

If a disabled person meets the eligibility requirements, Medicaid can provide medical care from any doctor, hospital or health care provider that participates in the Medicaid program.  You need to contact the state agency that administers the Medicaid program to obtain an application.

Eligibility for Medicaid is based on income and the financial resources of the person and family applying.  There are two levels of eligibility for Medicaid: (1) categorically needed and (2) medically needed.

To be categorically needed, individuals or families must receive some type of supplement benefit such as Supplemental Security Income (SSI), Aid for Families with Dependent Children (AFDC), or general medical assistance.

If you qualify for Medicaid, the program will pay for skilled nursing
home care and home health care if you need skilled nursing services.

Are there vocational rehabilitation services available in your state?
Many states have a Department or Office of Vocational
Rehabilitation to provide services for disabled children and disabled adults, age 17 and older.  You need to contact your local state Brain Injury Association or other resources in your state. Click on State Resources to find out how to reach out to the Office of Vocational Rehabilitation in your state.

There is an application process involved.  Typically, a person
must have a physical or mental disability which creates an employment
barrier.  The disabled person must also be reasonably expected to become more employable as a result of some rehabilitation services.  The purpose of these programs is to attempt to rehabilitate and to gain

Vocational rehabilitation services include medical and therapeutic services and physical and can include necessary surgeries, hospitalizations, prosthetic and assisted devices, eyeglasses, special
services, such as transportation or dialysis, diagnosis and treatment
for mental and emotional disorders, physical therapy, occupational
therapy and speech or hearing therapy.

The Office of Vocational Rehabilitation can also provide communication services, vocational training, financial support and transportation for those enrolled in the program.

View answers to these TBI legal questions:

Funding Resources Homepage
Legal Questions: Who Pays For Long Term Care?
Legal Questions: Health and Accident Insurance
Legal Questions: Workers Compensation
Legal Questions: Auto Insurance
Legal Questions: Defective Products
Legal Questions: Slip and Falls
Legal Questions: Government
Legal Questions: Guardianship
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