I had always saved a little for a rainy day however; I never knew it could be this rainy. This page covers State Disability Benefits, Power of Attorney, Disabled Parking Placard, Social Security Disability, and Health Insurance, including MediCare.
My Mom kept in constant contact with my employer and the company’s health benefits administrator. This action proved very useful. Within the first week of my injury, my Mom approached my bank to get the paperwork to get an Emergency Power of Attorney and keep my finances in order until I could take over my own finances again. She also applied for State Disability Benefits.
California State Disability Benefits:
There is a seven day waiting period before receiving this benefit. After that, a check was sent every 7-14 days. This benefit is only available for up to a year which is explained in the first letter of how much and how often.
My Mom also applied for a temporary Disabled Parking Placard. This requires a Doctor’s certification and six dollars.
SSDI Social Security Disability:
The Social Security Administration (SSA) will not make a determination of disability until 6 months post injury. I have had a truly positive experience with the SSA. It took a few months before I was able to get an appointment for my disability interview. Plan for this delay so you have the smallest time gap between State disability ending and SSDI beginning. You can get State disability and SSDI at the same time, however, SSDI reduces the amount you receive until State disability ends.
Be prepared for your interview. On the SSA website there is a Disability Interview Checklist to help you prepare. They pretty much want a dissertation of your medical history pertaining to the disabling conditions and your previous work history. They will also need an original or, certified copy of your birth certificate. This information took me a few weeks to prepare.
Although SSA will request medical records from the providers who treated your disabling condition, I provided a copy of as many medical records as I could, especially dictated physician reports, to make the process go more smoothly.
On their website, I also researched their accepted disabling conditions. I applied for SSDI benefits under Cerebral Trauma, Central Nervous System Vascular Accident, Contraction of Visual Field (scotoma and hemianopia).
SSA determines you’re disabled if you are unable to do any work, even entry level. When they award you, they will pay back pay from the date they determined you were disabled (for me that was 6 months post-injury). After 24 months of receiving SSDI, you will qualify for Medicare. SSA will do a medical review of continuing disability every couple of years. You are exempt from this medical review if you are currently working with Department of Rehabilitation to learn new vocation skills to try to get back to work.
My experience with SSA has been wonderful. I really feel that they want to help until I can get back on my feet.
In 2012, I began earning wages above the threshold, marked at$720 ….so any month you make $721 or more, you need to report to SSDI. This is called a “trial work period”. Social Security will allow you 9 of these months of consistent earnings over a 5 year period, before they start taking away your SSDI payments. You are allowed to keep MediCare for longer…about 7 years if you continue paying the premium. They bill you quarterly. They want to make sure you become a taxpayer again, but also they want to make sure you can be successful at work. After your payments stop, you have a 3 year period of expedited return to benefits should your disabilities worsen to the point where you can no longer work because of them.
I am trying really hard to make this work! Everyday is not perfect and some days are better than others…
5 years and 8 months post-injury, my SSDI payments ceased because my Trial Work Period ended. The payments did not stop immediately, though, which was frustrating, AND Social Security will eventually ask for their money back. Eventually. If you know you should not be getting SSDI anymore, do not spend the money, tuck it away. When you get that letter requesting you repay them for the overpayment it will be easy to write that really BIG check.
I have Blue Cross PPO. Thankfully my limits were fairly high for both the “Per-Incident Maximum” and “Lifetime Maximum”. These maximums are calculated from the amount billed, not the amount paid. Blue Cross has contracted rates predetermined based on the billed procedures code. I am a “Million Dollar Baby”. To date, my billed medical expenses exceeded six figures.
What is very important is to go to a “Preferred Provider” rather than an “Out of Network Provider”. The easiest way to check for a Preferred Provider is through the health plan’s website. This gives you a more up-to-date and accurate listing, rather than their booklet of Preferred Providers.
I had to meet my medical deductible and the “Stop-Loss”. The Stop-Loss is an amount predetermined between your employer and the health plan and is considered the “maximum out of pocket expense”. My Stop-Loss was in the few thousand dollar range. This gets paid to the providers until you meet your Stop-Loss. Then everything else is covered, with the exception of your plan limits and office co-pay. An EOB or “Explanation of Benefits” will be sent to you from Blue Cross for each visit or procedure. It will outline how much was billed, how much they paid based on the procedures code billed, and how much, if any, you are responsible for. Don’t worry about the difference between the amount billed and what Blue Cross paid; you are not responsible for that difference only if the services were delivered by a Preferred Provider for an authorized service.
Blue Cross gave me an option to enroll in their “Case Management” service. At first I was skeptical of the program and spoke with hospital staff about their experience with Case Managers. I decided to enroll because they would assign one case manager to oversee my case and follow my care. I would have one “go-to” person to get approval or authorization for service. My plan only allowed for 12 physical therapy visits per year. I could get more physical therapy if it was determined a “medical necessity” and, if I was making progress towards my goals. It was nice to have one Case Manager for my therapists to interact with for getting approvals for more visits. I was very fortunate to have an amazing and very experienced and caring case manager who really understood brain injury and the steps needed for recovery. She also helped keep my recovery on track with what I should be doing. On occasion, I still called the customer service line to ask general questions about my plan benefits.
COBRA is very expensive but, it allowed me to continue my health coverage. There is Federal COBRA and State COBRA both of which has time limits of enrollment and requirements but, allows up to 36 months of health coverage. Most of my disability check goes towards paying COBRA, the Stop-Loss and deductible but, without it, I would be responsible for the full amount billed. You are allowed to go on Federal COBRA for 18 for months after your employer stops paying your premium. If SSA determines you are disabled while being on COBRA, you may be eligible for federal disability extension of benefits, an 11 month continuation of the benefits you had when employed which is 150% of the premium your employer pays. After that, you can qualify for Cal-COBRA, which is a 110% of the premium your employer pays and is medical only. Hopefully before COBRA ends you will already be back to work or on Medicare.
Applying for Disability and keeping track of medical expenses is an arduous process yet, very important and good therapy. I suggest involving a financially responsible, capable, and trusted individual to help you dot your i’s and cross your t’s until you’re able to take over these tasks on your own. Set up a very good organization system and keep a log going of out-of-pocket medical expenses with documentation, medical miles driven for tax purposes. Keep up on this log after each medical visit.
As of February 1, 2010, I qualify for Medicare. This is 30 months post injury. As mentioned earlier, Social Security will not make a determination of disability until 6 months following the disabling event. Then, you must receive SSDI payments for 24 months before being able to enroll for Medicare. Because I am under 65, there are less options for Medicare supplemental insurance or health plans.
There is original Medicare and then the Medicare Advantage HMO and PPO plans. The Medicare Advantage PPO and HMO plans look enticing because they are less expensive and usually include part D (prescription coverage). When I began calling these plans, I started to uncover they were not as good as they seemed. The one that looked the best did not have UCSF Medical Center as their preferred provider network…..that is where I recieve my medical care and the plan not having them as a preferred provider sent up a huge red flag…..warning! Listen to your common sense and internal warnings. These Medicare advantage plans had more rules, deductibles and in my head averaged out to be more expensive. I decided that buying the supplemental coverage “MediGap”, “Medicare plan F” coverage to pay for any gaps between what Original Medicare pays and what you might owe. I also purchased a Medicare Part D plan to cover prescriptions.
I was very confused with all the options so, I met with HICAP, health insurance counseling and policy advocates. They helped giove me a Medicare 101 lesson and my available options. I highly recommend meeting with HICAP in your state if you are confused about Medicare. In setting up your appointment, specify special needs like “under 65”. My counselor was very prepared and did a lot of groundwork for plans available to me. With the information she gave me, I felt I made an informed choice and was relatively inexpensive. I chose USAA for my Medicare Part F supplemental coverage and Humana for my prescription coverage. My recommendation to you for deciding which Medicare is best for you: 1) read the MediCare and You booklet, 2) determine your typical medical needs and appointments, 3) Meet with HICAP in your state, 4) Compare your needs with the various plans offered, 5) Talk with each company you are considering, and 6) make an informed choice. Each year, Medicare offers the opportunity to change plans, if necessary, during open enrollment. Hopefully, with being an informed consumer, you will be satisfied with the choice you made and the plan will meet your needs.
Going back to Work and Medicare
If you still meet Social Security disabled criteria, you are eligible to keep Medicare for a good period of time as you test returning to work. My 2 cents would suggest waiting until you pass probation before signing up for employer sponsored health insurance…because, the employer insurance will be primary and Medicare will be secondary. I learned that Medicare will not cover the deductible of the employer insurance, which means your supplemental Medicare policy will not cover it either.
Mistakenly, I thought I was doing the right thing by signing up for employer health coverage. But, check this out, I paid the premium for that, the premium for Medicare A, B, D, and F…not to mention the cost for prescriptions. This equals way too much money for little coverage. My employer coverage stopped at one point and then Medicare became primary, again. If you are 100% employed, past probation, and not feeling like your disabilities impact your ability to perform, by all means switch to the employer sponsored insurance. At the beginning of 2013 I have had worsening symptoms from returning to work and needed a little extra time to make sure I would make it. Please ask a lot of questions because the Social Security brochure lead me to be misinformed. So, you are able to continue with Medicare for about 72 months. They will bill you quarterly because the payment is not automatically deducted. I am keeping Medicare in my back pocket until the 3 year window of expedited return to SSDI closes. I plan to begin employer sponsored healthcare during open enrollment now that I am not longer on probation. Keeping Medicare, for a just in case rainy day is only for my piece of mind…call me cautious.
WORD TO THE WISE: Once you complete your trial work period and your monetary benefit stops, the payment side of the house continues to send you money while the databases synchronize. Put this over-payment in a bank account because they want it back 30 days after they realized they overpay you.