A Guide to Your Rights

• An Overview and Introduction
• Health Insurance
• Patient Safety
• Private Benefits:
  Motor Vehicle Insurance
• Private Benefits: Disability Insurance
• Private Benefits: Workers Compensation
• Public Benefits:
  Commonwealth Of Pennsylvania
• Public Benefits:
  Crime Victims Compensation Fund
• Public Benefits:
  Federal Government
• Public Benefits: Attendant Care
• Disabled Children
• Rehabilitation Hospitals
  & Facilities
• Vocational Rehabilitation Services
• Civil Litigation: Claims For Damages
• Resources
• Support Groups
• Entitlements And Benefits
• Acknowledgements

 

Public Benefits: Federal Government

The primary source of federal funds that may be available for the catastrophically injured is through Social Security.

The Social Security system is a government retirement program that all workers pay into during their working years. The Social Security system can be complicated, particularly those programs that are available for disabled workers, but it might be helpful to bear in mind that the fundamental idea is really a very simple one: if a worker becomes disabled and unable to work, the Social Security system allows that person to access their benefits earlier than they would otherwise be able to.

Social Security for adults

The Social Security Administration administers two very different programs that may provide funding sources for people with serious injuries or other disabling medical conditions: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. These programs are sometimes referred to by the title number given to the program under the Social Security Act, which is the law that creates the benefit programs. SSDI benefits are called Title II (2) benefits and SSI benefits are called Title XVI (16) benefits.

Both programs require that the injured person establish, through competent medical evidence, that he/she is disabled. Disability is defined as:

Inability to engage in substantial gainful activity, by reason of a medically determinable physical or mental impairment(s) which can be expected to last for a continuous period of not less than 12 months.

The SSDI and SSI programs use the same definition of disability, but the other eligibility requirements are different.

SSI eligibility is based on disability, income, and resources – that is, a disabled person is entitled to receive these benefits if his or her household income and assets fall below a certain level, regardless of whether the individual ever worked. The household income limit depends upon the number of individuals living in the household. Currently, an applicant who lives on his or her own must have an income of no more than approximately $500 per month (the limit is approximately $750 for a couple living together) and total assets of no more than $2,000 ($3,000 per couple), excluding the applicant’s residence, car, certain life insurance policies, and burial plots. If eligibility for SSI is established, the program entitles the patient to Medicaid, payment of Medicare insurance premiums, food stamps and other social services administered through the state’s Department of Public Welfare.

SSDI eligibility is based on work and earnings history. To be eligible, an individual must have earned a minimum number of “work credits,” which are based on income levels in prior years. For most applicants, some of the credits must have been earned in recent years. In general, an applicant over the age of 30 must have worked for 5 out of the last 10 years of employment prior to the onset of disability. A quarter (a three-month period) is counted toward this total if the amount earned exceeds a minimum threshold (as of 2005, this figure is $950 per quarter). An individual who becomes disabled before age 31 must have worked for half the number of quarters between the date the applicant turned 21 and the date of disability, but not less than six quarters.

The amount of the SSDI benefit is based on the applicant’s earnings history. The benefit that an individual is entitled to receive is called the Primary Insurance Amount (“PIA”), and is generally the same amount that individuals would have received at age 65 based upon the existing work history. However, SSDI benefits may be reduced if an individual is receiving or has received (in the recent past) workers’ compensation benefits. In general, Social Security only allows a disabled individual to collect, through combined Social Security and Workers’ Compensation benefits, up to 80% of the largest yearly earnings in the five years prior to disability. The closer the workers’ compensation benefits are to this 80% figure, the smaller the amount of the SSDI benefits.

Family members who are dependents of an individual receiving SSDI benefits may also be eligible to apply for benefits. The maximum amount that a family can receive is 150% of the PIA amount. There are many limitations on benefits available to dependent family members. Eligibility for the family benefit is limited to non-disabled spouses who are 62 or older or who are caring for a child under the age of 16. Non-disabled children are eligible for benefits under this program until the age of 18, or 19 if still in high school. Disabled children over age 19 may be eligible for SSDI benefits on a parent’s account. Earnings by a non-disabled spouse may affect eligibility for these benefits.

SSDI benefits have a waiting period of five full calendar months, measured from the date of onset established by the Social Security Administration. These benefits are retroactive up to a maximum of 12 months prior to the initial application for benefits. If you apply for benefits before the end of the five-month waiting period and are awarded benefits, the benefits will not commence until the end of the five-month waiting period.

Recipients of SSDI are eligible for Medicare, but only after they have received SSD for two years or more, or if they are over 65. Medicare premiums are automatically deducted from the monthly benefits.

In some cases, individuals are eligible for both SSD and SSDI. Those individuals whose SSDI benefits are lower than the amount of SSI benefits can apply for SSI to increase the total benefits up to the level that would otherwise be paid by SSI. People who qualify for both SSDI and SSI become immediately eligible for medicaid / medical assistance. (This can be important, because medicaid / medical assistance coverage is generally broader than medicare coverage.)

The decision about when to apply, and which program to apply to, is an important one. Timing depends in part on the type and severity of the injury or disability. Generally, if there is medical evidence that the disability will continue for at least 12 months, one can apply immediately. If the medical evidence about the length of disability is unclear, then it might make sense to apply once medical evidence becomes available indicating that the disability period will exceed 12 continuous months.

With proper documentation and medical support, claims for Social Security benefits can sometimes be approved when they are first presented to the Social Security Administration. Often an individual can prepare the initial paperwork and gather the required medical information. It is important to bear in mind that the paperwork needs to be completed fully and accurately, and that the medical information that is submitted with the application needs to clearly indicate the individual’s disabling condition and any physical and mental limitations. It can be helpful to have these materials reviewed by an attorney who specializes in this area of the law, to make sure that the paperwork and medical documentation are in order, and to ensure that there are no issues that may cause problems in the event of an adverse initial decision and subsequent appeal.

Typically, the Social Security Administration’s initial response to an application is to deny the claim. These adverse decisions must be challenged through an administrative appeals process. The appeals process can be complicated and lengthy, and it is helpful to have the assistance of an attorney who specializes in this complicated area of the law.

The Social Security Administration recently initiated a new program called the “Ticket to Work,” which provides additional choices and opportunities for disabled individuals returning to the work force. Information can be found online at http://www.yourtickettowork.com, or by dialing 1-866-968-7842 or 1-866-833-2967 (TTY).

Social Security for Children

Children with disabilities may be eligible for SSI. A child qualifies as disabled if he or she has a medically determinable impairment (physical or mental) that causes marked or severe functional limitations for more than one year, or is likely to result in death. The Social Security Administration considers the cumulative affects of an impairment. Therefore, some functional limitations in a few different areas will be considered cumulatively.

The amount of SSI a child may receive depends on his or her parents’ income. Generally speaking, the parents’ income must be relatively modest in order for the child to receive SSI. Income eligibility is determined using a complex formula that accounts for many deductibles. Also, a parents’ assets (such as a savings account) can operate to make the child ineligible for payments if the child lives with the parent. If the parent is receiving public assistance, those payments are not considered in calculating the child’s eligibility. top

HOUSING

Sometimes, accommodations to a home or apartment are necessary if a disabled individual is to return to their home or to their community. For example, doorways and entryways may need to be widened to accommodate wheelchairs, and a few simple but significant modifications may be necessary to make bathrooms functional.

Under the Fair Housing Amendments Act of 1988, a landlord is required to allow a disabled individual to alter their home at the individual’s expense. The landlord is allowed to require that the restorations be performed in a workmanlike manner, and can require the renter to create an escrow account to provide for restoring the residence to its original state.

There are two basic forms of housing assistance: public housing units (mostly rental units) and Section 8 vouchers for private rental units. Both programs are administered through the Housing Authority, and both often have waiting lists. The programs are subject to household income requirements.

Individuals using Section 8 vouchers for private rental units only pay 30% of their income towards housing; the voucher covers the difference between that amount and the fair market value for the unit. Because vouchers allow disabled individuals to live in private housing which is normally better integrated with the community, they are usually considered preferable. The waiting list for Section 8 vouchers is currently closed, but will open for the addition of new names at brief intervals. These waiting lists must be closely watched! If you need housing assistance, you should contact the Housing Authority first so that your name can be added to the mailing list.

The Housing Authority also operates, and usually owns, its own housing units.

Federal laws, such as the Federal Fair Housing, Act Section 504 of the Rehabilitation Act, provide requirements that state and local housing authorities must follow for making federally funded housing available for persons with disabilities. While Philadelphia has many accessible housing units, Philadelphia has done a poor job of ensuring that accessible units are actually occupied by persons with disabilities. If a client has identified a particular housing option and has been denied housing either on the basis of the disability or the housing authority’s failure to prioritize a disabled applicant when required to do so, litigation my be appropriate. In addition, if an individual believes that he or she has been mistreated by a public housing official, a claim can be lodged with the Pennsylvania Human Relations Commission or the Office of Housing and Urban Development. top

Here is some housing contact information:

Philadelphia Housing Authority

642 North Broad Street

Philadelphia, Pennsylvania

 

Housing Consortium for Disabled Individuals (Services)

4701 Pine Street

Philadelphia, PA 19143

215-528-5847

 

Public Interest Law Center of Philadelphia (discrimination claims)

125 South 9th Street, Suite 700

Philadelphia, PA 19107

215-627-7100

 

Fair Housing Council of Montgomery County

105 East Glenside Avenue, Suite E

Glenside, PA 19003

215-576-7711

 

Pennsylvania Human Relations Commission

Pennsylvania State Office Building, Room 711

Broad and Spring Garden Streets

Philadelphia, PA 19130

215-560-2496

 

United States Department of Housing and Urban Development

Office of Fair Housing and Equal Opportunity

The Wanamaker Building

100 Penn Square East

Philadelphia, PA 19107

1-800-669-9777

1-800-927-9275 (TDD)

 

Self-Determination Housing Project

119 South Easton Road

Glenside, PA 19038

215-884-2091