SSI-Linked Medi-Cal: Frequent Pitfalls

Acting on Bad Information

It can be difficult to find accurate and complete information about Social Security programs. Some social workers and advocates may have limited knowledge or training about the variety of benefits you may have available through Social Security and how work could impact such benefits. Many representatives of federal and state agencies may be experts in a particular field of benefits but may not be trained on other benefit programs. It is important for you to verify that the information you have is accurate and complete.

Basing Decisions on Misinformation

Most of us usually rely on the experience of others to understand how to deal with similar situations. The real problem with this is that benefits are person-centered. Benefit programs fit each individual differently, based on a variety of facts and conditions, such as:

your work history;
how much you earn;
what you own;
how disabling your condition is;
how clearly you report the details of your condition to your medical provider;
how well your medical provider understands or documents these details;
what benefits an employer provides; and
what benefits you have purchased individually.

Denial of Your Disability

It is common for individuals to have periods of time when they deny to themselves, their families, and medical provider(s) that a disabling condition exists. For some, it is an approach to coping with a new condition. During this period of time, the individual’s communication with medical providers may not accurately or fully describe the severity of a condition or how seriously it affects day to day activities.

Working In The First Year Of Receiving Social Security Disability Benefits
Social Security defines disability as an inability to work due to a disabling condition that will continue for at least one year. If you work or return to work (even if only part time) within the first year of disability, Social Security may re-determine your disability status.

Not Knowing Which Social Security Program You Are Enrolled In

You may be eligible for Supplemental Security Income (SSI) or for Social Security Disability Insurance (SSDI). Some individuals are eligible for both programs. Understanding which program you are enrolled in can be confusing because of the many benefit program acronyms used. Although both programs use the same definition of disability, the rules governing each are different. Misidentifying these programs is common. Make sure you know exactly which program is being discussed.

Lack of documentation

The more specifically you document your medical condition, the easier it will be to support a claim and to make a case for continuing benefits. Detailing in a daily journal even the most seemingly insignificant symptoms can be of great value. If you or the individual are too ill, or can't maintain the journal on a daily basis, a friend or relative can log the entries. This journal can also provide you with a way to inform providers about your medical condition.

Not Keeping Complete Earnings Records

It is your responsibility to maintain accurate and detailed records. The earnings you report to Social Security will be verified. Clearly document all communication with Social Security. Make copies of letters and keep records of phone conversations, including the date and time phone calls take place and the name of the individual who was assisting you. These steps can help you avoid pitfalls during the application process and while maintaining eligibility for benefits. Many people keep a journal of Medi-Cal contacts in a spiral notebook.

Underreporting Your Earnings

If you underreport earnings, you may lose eligibility for a Medi-Cal program. Make sure to report all of your gross income. Gross income is the amount paid before taxes are deducted from your paycheck. If you are self-employed, you can report earnings based on your IRS tax return. Earned income, in some cases, may allow you to access a more cost effective eligibility category of Medi-Cal such as the 250% California Working Disabled Program.

Not Reporting Asset Changes
Social Security has specific assets limits on those eligible to receive Supplemental Security Income payments. If you underreport or do not report assets accurately to Social Security, you may be overpaid and then have to repay this amount.

Confusion About Wages and Countable Income Rules

Gross wages paid from working are not what is used to adjust your SSI check or determine Medi-Cal eligibility. These programs use a similar formula that exempts much of the wage amount according to rules that are not hard to follow. These steps are called the countable income calculation.

First, find your Countable Unearned Income. This is your monthly unearned income (an SSDI benefit, for example) minus a $20 “any income exclusion”. If you do not have unearned income, you apply this exclusion to earned income.

Next, find your Countable Earned Income. Take your monthly earned income (wages, for example), and subtract a $65 “earned income exclusion” along with any of the unused portion of the $20 “any income exclusion”, along with any Impairment Related Work Expenses (IRWE). Take the resulting figure and divide by two to find your countable earned income.

Finally, add your Countable Unearned Income to your Countable Earned Income to find your Total Countable Income.

This Total Countable Income is the figure that is used to determine program eligibility and benefit amounts.

Misunderstanding Acronyms

SSA - Social Security Administration, the federal Agency that administers all Social Security programs.
SSI - Supplemental Security Income, the program that supplements low income of the aged, blind, and disabled with limited resources.
SSDI - Social Security Disability Insurance, the program that provides a benefit for people with disabilities paid through FICA taxes of the primary wage earner in the family.

Failing to Share Information With Your Medical Provider

Many people do not clearly discuss their plans to apply for benefits with their medical providers. Ideally, you and your medical provider should share complete information to assess the duration of your disabling condition. If this step is not included, you may end up with an application for disability benefits that does not reflect how long the disabling condition may last or how it affects your day to day activities.

Fear of Losing Medi-Cal

If you are receiving Medi-Cal through SSI, you may have concerns about earning wages that would put your total countable income at the break even point. When income exceeds the break event point you may be at risk of losing Medi-Cal coverage. However, if you meet all of Social Security’s 1619(b) provisions you can continue receiving Medi-Cal. Another option is to apply for a personal threshold amount through Social Security.