Benefits, Benefits, Benefits: Sorting It All Out

Thursday, April 14, 2011

Most people are utterly confused — and for good reason — about all the different kinds of income and benefits available from the workplace and the government. It is a tangled web of information, bureaucracy, and headache.

The following should help you understand the basics of each type of income replacement benefits.

SSDI - Social Security Disability Insurance

Social Security Disability Insurance pays benefits to you and certain members of your family if you are “insured,” meaning that you worked long enough and paid Social Security taxes. Independent contractors should pay Social Security taxes to qualify for this benefit.

After receiving these benefits for 2 years, you automatically qualify for Medicare. Your checks will be reduced to cover the Medicare share of cost. If you would rather not receive Medicare benefits, you must notify the Social Security Administration.

SSDI benefits are subject to an offset for any other income received. For example, if you are receiving TD benefits (see below), then you will not receive your full SSDI benefit per the TD offset, under what is referred to as the “80% rule”. This rule simply means that your combined benefits from SSDI/SSI/SDI/TD/PD cannot exceed 80% of your highest regular pre-disability earnings in the last 3 months (1 quarter) preceding your disability.

http://www.ssa.gov/dibplan/index.htm

SSI - Supplemental Security Income

Supplemental Security Income pays benefits based on financial need. It is designed to help aged, blind, and disabled people, who have little or no income; and it provides cash to meet basic needs for food, clothing, and shelter. It is not meant to be a primary or sole source of income; hence the term “supplemental”.

A person receiving SSI is eligible to continue working without jeopardizing SSI benefits, provided the other income is below a certain amount, and provided the person has limited resources. California allows a person to make $1000 per month of other income without affecting SSI benefits.

http://www.ssa.gov/ssi/

SDI - State Disability Insurance

Are you out of work due to a non-industrial injury, illness, or pregnancy related condition? Disability Insurance (DI) provides partial wage replacement to eligible workers who are unable to work because of a disability.

Disability is defined as any mental or physical illness or injury which prevents you from performing your regular or customary work according to California Unemployment Insurance Code, Section 2626.

The Disability Insurance Branch of the California Employment Development Department (EDD) administers three disability insurance plans:

State Plan. The majority of employees in California are covered by this plan, and most of the information provided on the Disability Insurance portion of this site pertains to the State Plan.

Voluntary Plan. This is a private plan that employers and employee groups may apply to EDD for approval of a Voluntary Plan if the majority of employees and the employer agree to do so. If covered by a Voluntary Plan, the provisions of this site may not apply to you. Obtain information about your coverage and file a voluntary plan claim through your employer.

Elective Coverage. Employers and self–employed persons, including general partners, individuals in family employment not subject to the California Unemployment Insurance Code may elect coverage. For additional information on Elective Coverage or to apply for Elective Coverage, contact the Elective
Coverage Unit at 916-654-6288.

http://www.edd.ca.go … bility_insurance.htm

Unemployment Insurance - Employment Development Department (EDD)

The Unemployment Insurance Program, commonly referred to as UI, provides weekly unemployment insurance payments for workers who lose their job through no fault of their own. The UI program is 100% funded by employers who pay taxes on wages paid to employees.

http://www.edd.ca.go … ployment/default.htm

TD - Temporary Disability

Temporary disability is a benefit payable if a job-related injury or illness results in an inability to work for more than 3 calendar days. In cases where hospitalization is required, the employee is disabled as a result of a criminal act of violence or, the loss of time exceeds 14 days, temporary disability is paid for the first three days. The waiting period starts the first day following the date of injury. No charge is made for absence on the day of injury.

The waiting period need not consist of consecutive days. Portions of days of absence for doctor’s appointments or because the employee is unable to work subsequent to date of injury may be accumulated to full days and charged to the waiting period.

Most disabled state employees qualify for Industrial Disability Leave. See SAM Section 2583.11. Industrial Disability Leave may be paid in lieu of temporary disability. In many cases the disabled, sate employee will be able to choose between Industrial Disability Leave or temporary disability with or without supplementation by their leave credits. Those disabled employees who qualify for and choose temporary disability are allowed to use any accrued sick leave, vacation time, or excess time credits to make up the difference between the temporary disability payments and normal salary. (Government Code Section 19863.) The maximum weekly temporary disability payment is $266 for injuries occurring on or after January 1, 1990.

Hours lost subsequent to a full work release for such things as routine doctor’s appointments or therapy may not be accumulated and reported to the State Fund as full days lost for purposes of temporary disability. However, under certain conditions, employees may qualify for temporary partial disability payments. See SAM Section 2583.12.

The benefit normally ceases when the employee returns to work or the medical condition has stabilized. See SAM Section 2583.10 for an exception to this rule.

http://sam.dgs.ca.go … /TOC/2500/2583.1.htm

PD - Permanent Disability

When the injured’s condition has stabilized (the treating physician says it will get no better nor worse), the employee may be entitled to permanent disability payments.

Permanent disability payments are due if there are lasting effects from the job-related injury or illness. Permanent disability payments are not supplemented with leave credits.

If an employee is released from temporary disability compensation and starts receiving permanent disability compensation, then he/she may still be able to return to work at his/her prior position. This decision is based upon the medical restrictions placed upon the individual by the treating physician in the final report. If an employee receiving permanent disability is not able to return to work, the department is required to initiate one of the actions outlined in Government Code 19991.4.

Medicare

The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation’s largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

Medicare consists of four parts: A, B, C, and D.

Part A

Medicare Part A (Hospital Insurance)

What Is Part A (Hospital Insurance)?
Part A is hospital insurance that helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care.

How Much Does Part A Cost?
Most people don’t pay a Part A premium because they paid Medicare taxes while working. This is called “premium-free Part A.”

If you aren’t eligible for premium-free Part A, you may be able to buy Part A if you meet one of these conditions:

You’re 65 or older, you’re entitled to (or enrolling in) Part B, and you meet the citizenship or residency requirements.
You’re under 65, disabled, and your premium-free Part A coverage ended because you returned to work. (If you’re under 65 and disabled, you can continue to get premium-free Part A for up to 8.5 years after you return to work.)
In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B.

How Do I Get Part A?
Some people automatically get Part A. Learn how and when you can sign up for Part A.

What Does Part A Cover?
To find out if Part A covers something specific, visit Your Medicare Coverage. In general, Part A covers:

Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
Inpatient care in a skilled nursing facility (not custodial or long term care)
Hospice care services
Home health care services
Inpatient care in a Religious Nonmedical Health Care Institution
Note: Staying overnight in a hospital doesn’t always mean you’re an inpatient. You’re considered an inpatient the day a doctor formally admits you to a hospital with a doctor’s order. Being an inpatient or an outpatient affects your out-of-pocket costs. Always ask if you’re an inpatient or an outpatient. Read “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” for more information.

http://www.medicare. … benefits/part-a.aspx

Part B

What Is Part B (Medical Insurance)?
Part B helps cover medically-necessary services like doctors’ services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Check your Medicare card to find out if you have Part B.

How Much Does Part B Cost?
If you have Part B, you pay a Part B premium each month. Most people will pay the standard premium amount. Social Security will contact some people who have to pay more depending on their income. If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.

How Do I Get Part B?
Some people automatically get Part B. Learn how and when you can sign up for Part B.

What Does Part B Cover?
To find out if Part B covers something specific, visit Your Medicare Coverage. Part B covers two types of services:

Medically-necessary services — Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
Preventive services — Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

http://www.medicare. … benefits/part-b.aspx

Part C

What is a Medicare Advantage Plan (Part C)?
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

Different Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) Plans
Preferred Provider Organization (PPO) Plans
Private Fee-for-Service (PFFS) Plans
Special Needs Plans (SNP)
There are other less common types of Medicare Advantage Plans that may be available:

HMO Point of Service (HMOPOS) Plans— An HMO plan that may allow you to get some services out-of-network for a higher cost.
Medical Savings Account (MSA) Plans—A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.
How Much Does a Medicare Advantage Plan Cost?
In addition to your Part B premium, you usually pay one monthly premium for the services included. Each Medicare Advantage Plan can charge different out of-pocket costs. Your out-of-pocket costs in a Medicare Advantage Plan depend on:

Whether the plan charges a monthly premium.
Whether the plan pays any of your monthly Part B premium.
Whether the plan has a yearly deductible or any additional deductibles.
How much you pay for each visit or service (copayments or coinsurance).
The type of health care services you need and how often you get them.
Whether you follow the plan’s rules, like using network providers.
Whether you need extra benefits and if the plan charges for them.
The plan’s yearly limit on your out-of-pocket costs for all medical services.
What Does a Medicare Advantage Plan Cover?
In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

How Do I Get a Medicare Advantage Plan?
Not all Medicare Advantage Plans work the same way, so before you join, take the time to find and compare Medicare Health Plans in your area. Once you understand the plan’s rules and costs, you may be able to join by completing a paper application, calling the plan, or enrolling on the plans website. Medicare also has information on quality to help you compare plans.

A Few Extra Things You Should Know about Medicare Advantage Plans
New—Making changes to your coverage after December 31 Between January 1–February 14, 2011, if you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.

During this period, you can’t do the following:

Switch from Original Medicare to a Medicare Advantage Plan.
Switch from one Medicare Advantage Plan to another.
Switch from one Medicare Prescription Drug Plan to another.
Join, switch, or drop a Medicare Medical Savings Account Plan.
As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease.
You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.

http://www.medicare. … benefits/part-c.aspx

Part D - Prescriptions

Medicare prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. There are two ways to get Medicare prescription drug coverage:

Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

Medicare Advantage Plans (like an HMO or PPO) are other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”
If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other credible prescription drug coverage, you will likely pay a late enrollment penalty.

How Much Does Medicare Prescription Drug Coverage Cost?
Each plan can vary in cost and drugs covered. The Medicare Drug Plan Finder can help you find and compare plans in your area.
Your Part D monthly premium could be higher based on your income. This includes Part D coverage you get from a Medicare Prescription Drug Plan, or a Medicare Advantage Plan or Medicare Cost Plan that includes Medicare prescription drug coverage. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount, you will pay a higher monthly premium. For more information, visit Social Security’s website.

Many people qualify to get Extra Help paying their Medicare prescription drug costs but don’t know it. Most who qualify and join a Medicare drug plan will get 95% of their costs covered. Don’t miss out on a chance to save. Extra Help and other programs (like Medicare Savings Programs) may help make your health care and prescription drug costs more affordable.

How Do I Get Medicare Prescription Drug Coverage?
To join a Medicare Prescription Drug Plan, you must have Medicare Part A or Part B. To join a Medicare Advantage Plan, you must have Part A and Part B. You must also live in the service area of the Medicare drug plan you want to join.

Remember, costs and coverage varies with each plan. Check out the Medicare Drug Plan Finder can help you find and compare plans in your area. Medicare also has information on quality to help you compare plans.

If you have employer or union coverage, call your benefits administrator before you make any changes, to before you sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependants.

Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, or enrolling on the plan’s Web site or on the Medicare Drug Plan Finder. You can also enroll by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1‑877-486-2048. When you join a Medicare drug plan, you will have to provide your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card. Note: Medicare drug plans aren’t allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this.

How Does My Other Insurance Work with Medicare Drug Coverage?
If you have other insurance, find it below to understand how it works with, or is affected by, Medicare prescription drug coverage.

Employer or Union Health Coverage
This is health coverage based on your, your spouse’s, or other family member’s current or former employment. If you have prescription drug coverage based on employment, the employer or union will notify you each year to let you know if your drug coverage is creditable. Keep the information you get.
If you join a Medicare drug plan, you, your spouse, or your dependants may lose your employer or union health coverage. Call your benefits administrator for more information before making any changes to your coverage.

COBRA
This is a Federal law that may allow you to temporarily keep employer or union health coverage after the employment ends or after you lose coverage as a dependent of the covered employee.

There may be reasons why you should take Part B instead of COBRA. However, if you take COBRA and it includes creditable prescription drug coverage, you will have a special enrollment period to join a Medicare drug plan without paying a penalty when the COBRA coverage ends. Talk with your State Health Insurance Assistance Program (SHIP) to see if COBRA is a good choice for you.

Medigap (Medicare Supplement Insurance) Policy with Prescription Drug Coverage
Medigap policies are no longer sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. But you may want to join a Medicare drug plan instead, because most Medigap drug coverage isn’t creditable.
If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information.

The types of insurance listed below are all considered creditable prescription drug coverage. If you have one of these types of insurance, in most cases, it will be to your advantage to keep your current coverage.

Federal Employee Health Benefits Program (FEHBP)
If you join a Medicare drug plan, you can keep your FEHBP plan, and your plan will let you know who pays first. For more information, contact the Office of Personnel Management at 1-888-767-6738, or visit the Office of Personnel Management website. TTY users should call 1-800-878-5707. You can also call your plan if you have questions.

Veterans Benefits
You may be able to get prescription drug coverage through the U.S. Department of Veterans Affairs (VA) program. You may join a Medicare drug plan, but if you do, you can’t use both types of coverage for the same prescription. For more information, call the VA at 1-800-827-1000, or visit the VA website. TTY users should call 1-800-829-4833.

TRICARE (Military Health Benefits)
Most people with TRICARE who are entitled to Part A must have Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you aren’t required to join a Medicare drug plan. If you do, your Medicare drug plan pays first, and TRICARE pays second. If you join a Medicare Advantage Plan with prescription drug coverage, TRICARE won’t pay for your prescription drugs. For more information, call the TRICARE pharmacy contractor at 1 877 363 8779, or visit the TRICARE website. TTY users should call 1-877-540-6261.

Indian Health Services
If you get prescription drugs through an Indian health pharmacy, you pay nothing and your coverage won’t be interrupted. Joining a Medicare drug plan may help your Indian health provider with costs, because the drug plan pays part of the cost of your prescriptions. Talk to your benefits coordinator - they can help you choose a plan that meets your needs and explain how Medicare works with your health care system.

http://www.medicare. … benefits/part-d.aspx

Medicaid / MediCal

Medi-Cal is California’s Medicaid program. This is a public health insurance program which provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS. Medi-Cal is financed equally by the State and federal government.

To see if you qualify, or to apply for MediCal, please click on the following link: http://www.dhcs.ca.g … es/MCIndividual.aspx[/code][/code][/code]

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