Federal and State Benefit Programs

Cancer and its treatment may temporarily or permanently affect a survivor's ability to work at the same job or for as many hours as before his or her diagnosis. During such a time, some survivors may be eligible for medical and/or financial benefits through federal or state benefit programs. Look into these benefit programs if you have concerns about how you can continue to support yourself because of cancer, its treatment or certain physical or emotional aftereffects.

Federal and state benefit programs: detailed information

This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Suggestions document for questions to ask and for more resources.

Cancer and its treatment may affect a survivor's ability to work at the same job or for as many hours as before diagnosis. Whether this situation is temporary or permanent, some survivors may be eligible for federal and state medical or financial benefits to offset a loss of income during this time. Look into these benefit programs if you have concerns about how you can continue to support yourself because of cancer, its treatment, or certain physical or emotional aftereffects.

Federal and state benefit programs provide assistance for many people, including those with disabilities. Although you may not think of yourself as disabled, you may be eligible for disability benefits if your medical condition is severe enough to limit income and interfere with your ability to do work-related activities.

This document provides an overview of eligibility requirements and the application process for the most common federal and state benefit programs. Also included is information on how to appeal a denial of a benefit. The programs discussed include:

• Social Security Disability Income (SSDI)
• Supplemental Security Income (SSI)
• Medicare
• Medicaid

Keep in mind that each benefit program has specific eligibility requirements, as well as a different definition of disability. Full information about eligibility and the application process can be obtained directly from the benefit program. Contact information and the links to the website for each of these programs are provided in this document.

If the application process for these benefit programs seems confusing or too much to handle by yourself, ask a hospital social worker, friend, family member or a representative from a nonprofit legal services group or cancer organization to help you.

Identifying Government Benefit Programs

The following services are also available to help you identify which government benefit programs may be appropriate for you:

• The Benefit Eligibility Screening Tool (BEST) is a free and confidential assessment tool that is found on the Social Security Administration (SSA) Web Site. The BEST cannot be used to apply for benefits. The purpose is to help determine preliminary eligibility for benefit programs administered by the SSA.
• GovBenefits.gov is an online service, developed out of a partnership of federal agencies, which uses the Internet to provide information about and access to government assistance programs. The website contains a screening tool that is free and confidential. GovBenefits.gov will provide a list of government benefit programs you may be eligible for, along with information about how you can apply for benefits.

Eligibility for Federal and State Benefit Programs

Before you begin the process of applying for federal or state benefits, take time to read about the medical requirements for eligibility as well as the other important information.

According to the Social Security Administration, an individual is disabled if:

• It has been medically determined that a physical condition or mental impairment interferes with their ability to do work-related activities and earn more than a certain amount of income, and
• The condition has lasted, or can be expected to last, for a continuous period of 12 months or more or result in death

The SSA online website provides information about benefit programs and subsequent eligibility requirements. The website also describes the benefit application process, how to appeal denial decisions and other things about the program. In addition to going online, you can contact your local Social Security office or the national SSA by phone for more information.

U.S. Social Security Administration
Phone: 1-800-772-1213
TTY: 1-800-325-0778
www.ssa.gov

The website for the Centers for Medicare & Medicaid Services (CMS) provides phone numbers and links to help you find answers to your questions about those two programs. Contact your state or county Department of Health and Human Services (DHHS) for information. The website for CMS provides contact information for all state Health Departments.

Centers for Medicare & Medicaid Services
Phone: 1-800-633-4227
TTY: 1-877-486-2048
www.cms.hhs.gov/contactCMS

Social Security Disability Benefits

The SSA oversees the largest of the federal disability programs: Social Security Disability Income (SSDI) and Supplemental Security Income (SSI). Only people who meet specific requirements such as age, disability, income, and/or resources are eligible for these specific programs. Contact your local Social Security office or the national SSA for more information and to apply for benefits.

U.S. Social Security Administration
Phone: 1-800-772-1213
TTY: 1-800-325-0778
www.ssa.gov

• Social Security Disability Income
  
  SSDI pays wage replacement benefits for eligible people who have a disability, as defined by the SSA guidelines, if they have paid Social Security (FICA) taxes for specified lengths of time (called work credits). There are two different earnings tests: a "recent work" test based on your age at the time you became disabled; and a "duration of work" test to show that you worked long enough under Social Security.
  
  This benefit may also pay family members when a primary wage earner in the family becomes disabled or dies. Benefits are payable to those who meet SSDI eligibility requirements, such as disabled workers, widows, widowers and children or adults who have been disabled since childhood. An adult must be unable to work for a consecutive period of 12 months or longer to qualify for SSDI benefits.
  
  If you are approved for SSDI benefits, you will become eligible for Medicare coverage 24 months after you begin receiving benefit payments. Medicare coverage can be extremely important if disabilities make it impossible to work thereby limiting access to ongoing health care coverage. You may be Medicare eligible immediately if you have permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig's disease).
• Supplemental Security Income
  
  The SSI program pays benefits to disabled adults and children who have limited income and resources. SSI benefits are also payable to people 65 and older without disabilities who meet the financial requirements. This program provides cash to meet basic needs for food, clothing and shelter. To apply for this benefit, you must call the SSA to make an appointment to work with one of the SSI representatives who will then assist you with an application.

How to Apply for Social Security Disability Benefits

Apply for Social Security disability benefits as soon as possible if you become disabled and unable to work. You should also apply right away if you are diagnosed with a life threatening illness that will require extensive treatment that could ultimately affect your ability to maintain active employment. If you are later found eligible for benefits, the date you first filed your application is likely to be used as the starting point for retroactive payment of benefits.

Start the process of applying for benefits by calling the toll-free telephone

number or by applying through the SSA Online website. If you do not want to apply over the Internet, you can call the SSA to set up an appointment to apply for benefits by phone or in person. Applications for SSA benefits may be done via the website, by calling the national toll-free number, or by going into the local office and requesting an appointment.

Whatever application method you choose, be certain to be as complete and accurate as possible. Before you begin to fill out the program application, review the specific disability evaluation requirements provided in the "Listing of Impairments" that is available on the SSA website. Have information and dates concerning your medical, work and education history ready when you apply.

At some point in the process, the SSA will ask that your doctor and other accepted medical sources provide documentation of your medical condition. Talk with your medical providers about your decision to apply for benefits and your need to have them clearly document the medical details related to your disability. This medical evidence will play a major role in your eligibility for benefits. On time and accurate reports from your medical team may help speed up the application and eligibility determination processes.

A history of cancer may not be enough to qualify you as disabled. However, if you think you meet a benefit program's definition of disabled, be certain to include documentation with the application. For example, if you have another condition or illness in addition to cancer, be certain to include documentation of that.

Copies of important records, such as the following, can help you prove that a disability exists:

• Medical records that document your current health status and treatments and show that a disabling impairment has not medically improved
• Correspondence from benefit programs that confirms your disability
• If you are applying on behalf of a child, include copies of individualized education plans (IEP) and assessments done by the school related to the child's disability

Federal and state entitlement programs (Medicare, Medicaid and Social Security programs) and legal protections are closely linked. It is important to understand the specific timeline requirements for each program. You also need to know how your eligibility and application may affect access to other benefit programs and protections.

For example, a survivor who stops working due to illness may elect to continue health insurance coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). However, in order to be eligible to receive the extension of benefits, the COBRA insurance plan administrator must be notified that a positive disability determination has been made by an entitlement program within the first 60 days of COBRA coverage. Extended health care coverage may become very important to survivors who are unable to return to work and now have a pre-existing medical condition.

Keep in mind that if you find the process of applying for benefits to be overwhelming, a hospital social worker or representative from a nonprofit cancer program, such as LIVESTRONG SurvivorCare, may be able to help you (www.LIVESTRONG.org/survivorcare). You can ask for assistance with a variety of matters such as coordinating the gathering of information and medical records, initiating the appeals process and going to hearings with you or for you. The SSA will work with a representative of your choice just as they will work with you only when the patient has formally designated the representative using appropriate SSA forms.

The SSA may provide some assistance with your application process if you request it. For example, they may complete application forms for you. If you have a disability or are blind, the SSA may cover some of the expenses involved with having a medical exam, such as the fees for a medical appointment or related transportation costs. However, this is usually only done if requested by the SSA to help make the eligibility decision.

It is extremely important that you provide specific, detailed information about your financial and medical status with your application for SSA benefits. Also, include documentation of support from your medical team with your application to clearly demonstrate your need for benefits. Be sure to request the telephone number of the caseworker who is responsible for your case during the application and approval process. This will enable you to follow-up with an SSA representative who is familiar with your case.

Keep in mind that the application process for Social Security benefits may go on for four to six months or more before an eligibility determination is made. In addition, even after you have been found eligible for SSDI benefits, there is a five-month waiting period before you will actually begin to receive monthly payments. If you are very ill and need your application or appeal to be expedited, ask the SSA representative if that can be done.

Since October 2008, the SSA began its Compassionate Allowances initiative to expedite the processing of disability claims for applicants whose medical conditions are so severe that their conditions obviously meet Social Security's standards. This initiative enables the SSA to make decisions on these cases in a matter of days, rather than months or years.

SSA launched this expedited decision process with a total of 50 conditions. Over time, more diseases and conditions will be added. A list of the first 50 impairments -- 25 rare diseases and 25 cancers -- can be found at www.socialsecurity.gov/compassionateallowances.

Appealing a Social Security Administration Denial Decision

Following your application for benefits, the SSA will send you a letter advising you of their decision and how you can appeal if you have been denied benefits. Filing an appeal is a common occurrence, and it usually means that you will need to submit more information. If you decide to file an appeal, you must make that request in writing within 60 days from the date you receive the denial letter.

The SSA will take a new look at the entire decision that was made regarding your case during the appeals process. There are four levels of appeal open to an applicant: reconsideration, hearing by an administrative law judge, review by the Appeals Council, and a Federal Court review. The full appeals process can take up to 24 months or more to complete.

Some applicants are able to handle the appeals process with free help from the SSA. Others get assistance from a representative who works for a nonprofit cancer organization or from an attorney, family member or a friend who is knowledgeable about Social Security benefits and the appeals process. Still others decide to do a combination, such as filing the initial application for benefits and using an attorney to go through the appeals process if their eligibility for benefits is denied at the second level.

Some representatives, such as a cancer organization or nonprofit legal services office, may not charge you to help you with the appeal process. Other representatives, such as an attorney, may charge for their services. However, federal law has established a maximum fee that a representative can charge to provide help with the Social Security benefit application and appeals processes. If you choose to use an attorney, you may want to find one who charges only a contingency fee. A contingency fee is one that is paid only when and if you are found eligible and begin receiving benefits.

Federal and State Medical Benefits

Many people think that Medicaid and Medicare are the same. However, they are two different programs. Medicaid is a partially federally-funded health care program administered by the individual states. Medicaid provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under the Medicaid program.

Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact your local medical assistance agency, social services or welfare office.

The Centers for Medicare and Medicaid Services administers the federal Medicare program and oversees the state-run Medicaid programs. The CMS website provides specific information about these different types of programs.

• Medicare
  
  Medicare is the federal health insurance program that includes coverage options for prescription medication, doctor services and hospital visits. This program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care. Medicare services are for people with certain disabilities and for citizens or lawfully admitted residents of the United States who are 65 years of age or older.
  
  A portion of the payroll taxes that are paid by employers and employees finances Medicare. It is also partially funded by monthly premiums that are deducted from Social Security checks. Generally, you or your spouse must have worked for at least ten years in Medicare-covered employment to qualify for benefits.
  
  The Medicare program has four parts:
  
  Part A (Hospital Insurance): This benefit helps pay for certain types of hospital care, short-term skilled nursing care and some home health care. Most people get Part A automatically when they turn age 65, and they do not have to pay a monthly premium. If you are 65 years or older and are not entitled to Social Security because you did not work or have not paid enough Medicare taxes, you may be able to purchase coverage. A person with a disability who loses Medicare coverage because they returned to work may also be able to buy coverage.
  
  Part B (Medical Insurance): This benefit covers doctors' services, outpatient care and other medical services not covered by Part A. Part B is financed through monthly premiums paid by enrollees along with contributions from the federal government. The premium amount is set each year by the CMS. The amount changes due to inflation and typically increases every year. Those beneficiaries with higher incomes will pay a higher premium based on a sliding scale for adjusted gross income. You can sign up for Part B starting three months before you turn age 65 and up to three months after.
  
  Part C (Medicare Advantage): These plans, formerly known as Medicare + Choice, are available in many areas. Beneficiaries with Medicare Parts A and B can choose to receive all of their health care services through on of these provider organizations under Part C.
  
  Part D (Medicare Prescription Drug Coverage): This prescription drug plan option is available to everyone with Medicare. This coverage may lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance that is provided by private companies. Participants choose their drug plan and pay a monthly premium. If you choose not to enroll in the Part D drug plan when you are first eligible, you may have to pay a penalty if you choose to join later. Extra help may be administered through the SSA to assist those who are Medicare eligible with their medications. More information can be found online at: http://www.socialsecurity.gov/pubs/10509.htm.
  
  
  How to Apply for Medicare
  
  If you have limited income and resources, your state may help you pay for Part A and Part B coverage. Contact your local Social Security office or the national SSA for more information about these assistance options. Although CMS is the agency that oversees the Medicaid program, you must apply for Medicare through the SSA.
  
  Contact CMS through their website or by phone to obtain more detailed information about Medicare.
  
  Centers for Medicare & Medicaid Services
  Phone: 1-800-633-4227
  TTY: 1-877-486-2048
  www.cms.gov/ContactCMS/
  
  Contact your local Social Security office or the national SSA to apply for Medicare.
  
  U.S. Social Security Administration
  Phone: 1-800-772-1213
  TTY: 1-800-325-0778
  www.ssa.gov
• Medicaid
  
  Medicaid is a partially federally-funded health care program administered by the individual states. Each state sets its own income and disability eligibility requirements and service guidelines. Medicaid does not pay income benefits but sends payments directly to the health care providers, such as doctors and hospitals.
  
  Many states extend Medicaid coverage to people who qualify for SSI benefits. However, a number of states use their own eligibility rules for Medicaid and some require a separate application. For example, some states are primarily income-based in their requirements for eligibility. Other states consider income but also require that an applicant fall into a specific category, such as "permanently and totally disabled."
  
  State-only programs provide limited services for specific individuals who have income needs but do not qualify for the Medicaid program in most states. For example, a state or county Department of Health and Human Services may provide general assistance income benefits or cover medical care services for certain qualified individuals. As state-only programs, there is no federal participation. Contact your state department of health for more information about programs that exist in your area.
  
  
  How to Apply for Medicaid
  
  If you are uninsured, immediately apply for Medicaid as soon as you receive the diagnosis of cancer. Also, apply for Medicaid if your income is low and you meet the requirements of an eligibility group. Specific coverage may vary from state to state, but Medicaid is generally for people who are citizens or lawfully admitted residents of the United States that meet resource guidelines, and belong to a covered group. These covered groups consist of people who have certain disabilities or are over 65 years of age. Children and pregnant women may also be eligible for benefits.
  
  Individuals must meet the requirements of a covered group prior to meeting income/resource guidelines. These covered groups primarily consist of individuals who are seniors (over 65), blind, disabled, pregnant, or families with children under the age of 18.
  
  If you or someone in your family needs health care, a qualified caseworker for your state Medicaid program should evaluate your situation to see if you qualify for benefits. For example, in spite of income level or assets, someone who has had too many medical expenses and is medically needy might be eligible for Medicaid benefits. Contact your state Health Department about Medicaid benefits, services and eligibility requirements for assistance.
  
  Many groups of people are covered by Medicaid, but certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged. Your income and resources (like bank accounts, real property, or other items that can be sold for cash) are also taken into account. In addition, whether you are a U.S. citizen or a lawfully admitted immigrant is considered. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for disabled children living at home.
  
  A child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if the parents are not. However, there is a 5-year limit that applies to lawful permanent residents. Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.
  
  In general, you should apply for Medicaid if your income is low and you match one of the descriptions of the Eligibility Groups. Even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation.
  
  In some states, a "Medicaid spend-down or share of cost" provision exists. If an individual has high medical bills, he or she may be able to qualify. A Medicaid spend-down is for individuals that meet all the criteria for Medicaid except income. A spend-down works much like an insurance deductible. The patient is required to provide unpaid medical bills in an attempt to reach the deductible. If the patient reaches the spend-down liability or "deductible" then he or she may qualify for Medicaid. If you are denied Medicaid due to excess income, ask the eligibility specialist at your local department of social services to evaluate your situation to see if you qualify under this provision.
  
  Medicaid coverage may start retroactive to any or all of the three months prior to application, if you would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most states have additional "state-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for state-only programs.
  
  The website for CMS provides contact information for all state Health Departments.
  
  Centers for Medicare & Medicaid Services
  Phone: 1-800-633-4227
  TTY: 1-877-486-2048
  www.cms.gov/ContactCMS/

Appealing a Medicaid Denial Decision

Grievances (complaints), appeals and fair hearings are some of the protections that exist for Medicaid benefit applicants and recipients. If you receive a denial or have a concern related to the Medicaid process, you have the right to file a grievance and request a fair hearing.

Federal law and regulations require states to have procedures established to review the concerns of Medicaid beneficiaries or applicants if they are dissatisfied with decisions related to their eligibility, enrollment or health services. Many hearings occur by telephone or videoconference, but you may request an in-person hearing if you prefer. If an appeal is requested within the time specified by the state, it may be possible for benefits to be extended until a hearing decision is reached.

Many states have Medicaid health assistance or ombudsmen (complaint investigator) programs that can help you understand the fair hearing process and prepare their case for a fair hearing. These programs may be operated by government agencies or by nonprofit community organizations. A nonprofit legal services program may be able to help with the Medicaid application process, as well as representation during a fair hearing. Some states provide contact information for a health assistance program on their denial of care notices. Other states will furnish a list of health assistance programs to individuals who are requesting a Medicaid fair hearing.

Getting Help to Apply for Benefits

Although it can be challenging to understand federal and state programs and the steps involved in applying, there is no need to give up. Knowing about these programs is an important first step.

Ask for help if you need it. In addition to the information available through the Social Security Administration and Centers for Medicare and Medicaid Services, there are nonprofit organizations that specialize in providing this type of assistance at no charge. Other professionals, such as hospital social workers and attorneys, may also be available to help you. Finally, there may be family members or friends who have had experience with federal and state benefit programs and would be willing to share their knowledge with you.

This document was produced in collaboration with:

David S. Landay, Esq., author of Be Prepared: The Complete Financial, Legal and Practical Guide for Living with Cancer, HIV and Other Life-Challenging Conditions.

Works Cited

"How You Qualify for Social Security Disability Benefits." Social Security Online: Disability Planner. U.S. Social Security Administration. 13 March 2009.
www.ssa.gov

Landay, David S. Be Prepared: The Complete Financial, Legal and Practical Guide to Living with Cancer, HIV and Other Life-Challenging Conditions. New York: St. Martin's Press, 1998.

"Medicaid Program – General Information." Centers for Medicare & Medicaid Services. U.S. Department of Health & Human Services. 13 March 2009.
www.cms.gov

"Medicare." The Official U.S. Government Site for People with Medicare. U.S. Department of Health & Human Services. 13 March 2009.
www.medicare.gov

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Federal and State Benefit Programs: Suggestions

The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information.

Consider whether you have a disability that allows you to qualify for Social Security benefits.

• GovBenefits.gov will provide a list of government benefit programs you may be eligible for, along with information about how you can apply for benefits.
• The Benefit Eligibility Screening Tool (BEST) is a free service to help determine eligibility for benefit programs administered by the SSA.

If you decide to apply for Social Security benefits, collect the documents and information you will need for the application process, including:

• Proof of birth
• Tax records for the past year
• Military documents, if applicable
• Bank account information
• Social Security number for yourself, your spouse and any dependents
• Proof of residency or citizenship

You will also need documentation that provides:

• Proof of your current medical condition, such as a copy of your medical records
• Contact information for the physicians seen during the last two years
• Information about how your ability to work is affected

Before you begin the application process for Social Security benefits, review the specific disability evaluation requirements provided in the "listing of impairments" on the SSA website.

Ask yourself:

• Are you able to work and be paid for your work?
• Do you have a physical or mental impairment that has lasted, or is expected to last, at least 12 consecutive months?
• How do factors such as your work history, age and education affect your ability to work?

Keep track of your application process for Social Security benefits by doing the following:

• Maintain contact with the representative at the Social Security Administration (SSA) to be certain that they have the necessary documentation and medical information.
• Keep a record of each phone call, correspondence and in-person contact you have with the SSA including the dates, names of people you have talked with and a description of what you discussed.
• Make certain that all appeals are filed within the strict timeframe established by the SSA. If you miss the appeals deadlines, you may be required to start the application process all over again.

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