Federal entitlement programs for the aged,
blind, or
disabled have their roots in the original Social Security Act of 1935. That Act established an old-age social insurance program to be administered by the Federal Government and an old-age
means-tested assistance program to be administered by the States. Similar programs for the blind or disabled were added to the Act in later years. Means-tested assistance provided a safety net for individuals who were either ineligible for Social Security or whose benefits could not provide a basic level of income.
This means-tested assistance comprised three separate programs—
Old-Age Assistance, Aid to the Blind, and Aid to the Permanently and Totally Disabled. Despite substantial Federal financing, these programs were essentially State programs. Federal law established only broad guidelines for assistance. The Federal Government provided matching funds to support whatever payment levels the States established, with no maximum or minimum standards. Consequently, each State was responsible for setting its own standards for determining who would get assistance and how much they would receive.
Beginning in the early 1960s, this State-operated, Federally-assisted welfare system drew criticism that was directed at the “crazy quilt” eligibility requirements and payment levels. Other criticism centered on specific requirements, such as lien laws and provisions that required certain relatives to bear responsibility for the maintenance of needy family members.
Responding to these concerns, Congress passed and the President approved the SSI program in 1972, reversing the Federal and State roles with regard to adult assistance. Under the new arrangement, SSI would provide a uniform Federal income floor while
optional State programs supplemented that floor. The new program was historic in that it shifted from the States to the Federal Government the responsibility for determining who would receive assistance and how much assistance they would receive.
Prior to the SSI program, the eligibility of aged, blind, or disabled individuals for Federally-funded adult assistance depended on the State in which they lived. Benefit amounts varied from State to State. The SSI program replaced the State-run programs with a national program with uniform standards and objective eligibility criteria. These standards include:
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A uniform definition of disability and blindness. The definitions for individuals age 18 or older are the same as those used for the Social Security Disability Insurance (SSDI) program. In order to be considered disabled, an individual must have a medically determinable physical or mental impairment which is expected to last or has lasted at least 12 continuous months or is expected to result in death and (1) if age 18 or older, prevents him/her from doing any substantial gainful activity 3 or (2) if under age 18, results in marked and severe functional limitations. However, individuals for whom addiction to drugs or alcoholism is a contributing factor material to the determination of their disabilities are not eligible for benefits. In order to be considered blind, an individual must have central visual acuity of 20/200 or less in the better eye with the use of a correcting lens or have tunnel vision of 20 degrees or less.
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Refugees (eligibility generally limited to the 7-year period after their arrival in the United States);
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Asylees (eligibility generally limited to the 7-year period after the date they are granted asylum);
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Cuban and Haitian entrants as defined by Federal statute, including: 1) section 501(e) of the Refugee Education Assistance Act of 1980; 2) former parolees and other aliens who became residents under the Cuban Adjustment Act of 1966; 3) aliens who became permanent residents under the Nicaraguan and Central American Relief Act; 4) aliens who adjusted status as Cuban/Haitian entrants under the provisions of the Immigration Reform and Control Act of 1986; and 5) aliens who became permanent residents under the Haitian Refugee Immigration Fairness Act (eligibility for these categories is generally limited to the 7-year period after the date that entrant status is granted);
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Qualified alien status includes noncitizens (or their parents or children) who have been battered or subjected to extreme cruelty in the United States by a spouse or parent (or a member of the spouse’s or parent’s family) with whom they live, and who have an approved petition, or have a petition pending, setting forth a
prima facie case for adjustment of their immigration status. A complete list of noncitizens who are considered qualified aliens can be found in the Glossary under “Qualified Alien.” However, to be eligible to receive SSI benefits, these noncitizens also must be in one of the categories listed above.
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Students studying abroad for not more than 1 year also may continue to be eligible for payments if the studies are sponsored by a U.S. educational institution but could not be conducted in the United States.
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As a means-tested program, SSI takes into account all income and resources that an individual has or can access. The amount of an individual’s countable income and resources are the measure of his/her need for assistance.
The amount of an individual’s income is used to determine both eligibility for, and the amount of, his/her SSI benefit. As countable income increases, an individual’s SSI benefit amount decreases. Generally, ineligibility for SSI occurs when countable income equals the
Federal benefit rate plus the amount of applicable Federally-administered State supplementary payment (State supplementation is discussed later).
The monthly Federal benefit rate8 is reduced dollar-for-dollar by the amount of the individual’s “countable” income—i.e., income less all applicable exclusions. Countable income is determined on a calendar month basis. The result of this computation determines SSI eligibility and the amount of the benefit payable. These benefit rates are adjusted annually (in January) to reflect changes in the cost of living.
When an individual lives in the household of another and receives support and maintenance in kind (i.e., generally room and board) from the householder, the Federal SSI benefit rate is reduced by one-third in lieu of counting the actual value of the support and maintenance as
unearned income. The value of food or shelter-related items the individual receives in kind from persons other than the householder (including
in-kind assistance from outside the household in which he/she lives) is counted as unearned income.
9 However, the amount that is countable is limited to an amount equal to one-third of the applicable Federal benefit rate plus $20.
SSI law defines two kinds of income—earned and unearned.
Earned income is wages, net earnings from self-employment, remuneration for work in a sheltered workshop, royalties on published work, and honoraria for services. All other income is unearned including, for example, Social Security benefits, other pensions, and unemployment compensation. The distinction between earned and unearned income is significant because different exclusions apply to each type of income.
However, not everything an individual receives is considered to be income. Generally, if the item received is not food or shelter or cannot be used to obtain food or shelter, it will not be considered as income. For example, if someone pays an individual’s medical bills, or offers free medical care, or if the individual receives money from a social services agency that is a repayment of an amount he/she previously spent, that value is not considered income to the individual. In addition, some items that are considered to be income are excluded when determining the amount of an individual’s benefit.
The principal earned income exclusions are:
The principal unearned income exclusions are:
The value of an individual’s resources is used to determine whether he/she is eligible for SSI in any given month. SSI law states that eligibility is restricted to individuals who have countable resources, determined monthly, that do not exceed $2,000 ($3,000 for a couple). Although “resources” is not defined, the law lists those items that are not considered resources.
Regulations stipulate that a resource is cash or other liquid asset or any real or personal property that individuals (or their spouses) own and could convert to cash to be used for their support and maintenance. This definition is consistent with the general philosophy of the SSI program that only items that can be used for an individual’s food or shelter should be used in determining his/her eligibility and benefit amount. Not all resources an individual owns are counted. The value of an item may be totally excluded or counted only to the extent that its value exceeds specified limits.
If an applicant disposes of resources at less than fair market value within the 36-month period prior to his/her application for SSI or at any time thereafter, he/she may be penalized. The penalty is a loss of SSI benefits for a number of months (up to a 36-month maximum).
12 The penalty does not apply if, among other things, the applicant can show that the resources were disposed of exclusively for a purpose other than establishing SSI eligibility.
As the “program of last resort,” SSI benefits are provided to eligible individuals only to the extent that their needs are not met by other sources. That is, after evaluating all other income and resources, SSI pays what is necessary to bring an individual to the statutorily prescribed income “floor.” In keeping with this principle, SSI law requires that SSI applicants and recipients file for other payments for which they may be eligible, such as annuities, pensions, retirement or disability benefits, workers’ compensation, and unemployment insurance benefits.
SSA must provide an individual with written notice of potential eligibility for other benefits and of the requirement to take all appropriate steps to pursue these benefits. The individual has 30 days from receipt of the notice to file for the benefits involved.
State and local governments—rather than the Federal Government—traditionally have taken the financial responsibility for residents of their public institutions. The SSI program continues this long-standing public assistance policy. Residents of public institutions for a full calendar month are generally ineligible for SSI unless one of the following exceptions applies:
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A physician certifies that the recipient’s stay in a medical treatment facility is likely not to exceed 3 months and continued SSI eligibility is needed to maintain and provide for the expenses of the home to which the individual will return. In these situations, the recipient may continue to receive the full benefit for any of the first 3 full months of medical confinement if all other conditions for payment are met.
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When individuals enter medical treatment facilities in which more than half of the bill is paid by the Medicaid program, their monthly Federal benefit rate is generally reduced to $30, beginning with the first full calendar month they are in the facility. In the case of an individual under age 18, the $30 payment amount is also applicable if more than half of the bill is paid by private insurance or a combination of Medicaid and private insurance. The theory behind this provision is that the individual’s basic needs are being met by the medical treatment facility. In these cases, the SSI program provides up to $30 a month, which is intended to take care of small comfort items not provided by the facility.
In certain situations the income and resources of others are counted in determining whether an individual’s income and resources fall below the levels established by law. This process is called “
deeming” and is applied in cases where an eligible individual lives with an
ineligible spouse, an eligible child lives with an ineligible parent, or an eligible noncitizen has a sponsor.
17 In concept, the practice takes into account the responsibility of the spouse, parent, or sponsor to provide for the basic needs of the eligible individual.
When an eligible individual lives in the same household with a spouse who is not eligible for SSI, the ineligible spouse’s income and resources are deemed to be available to the eligible individual. In determining the amount of income and resources available to the eligible individual, all applicable exclusions are used. In addition, a living allowance is provided for the ineligible spouse, as well as any ineligible children under age 18
18 living in the household. The allowance reduces the amount of income to be deemed. Spouse-to-spouse deeming is intended to result in the same amount of income available to the couple as would be available if both members of the couple were aged, blind, or disabled and eligible for SSI.
Deeming does not apply when the eligible individual is not living in the same household as the ineligible spouse. However, if the ineligible spouse’s
absence is temporary or is due solely to an active duty assignment as a member of the U.S. Armed Forces, deeming would continue to apply.
A child under age 18 is subject to deeming from an ineligible natural or adoptive parent (and that parent’s spouse, if any) living in the same household. Deeming does not apply if a child lives in a household with only the spouse of a parent (i.e., a stepparent) and the natural or adoptive parent has permanently left the household. Certain amounts of the parent’s income are excluded, living allowances are provided for the parent(s) and an allocation is set aside for each ineligible child under age 18 (or under age 22 and a student) who is living in the household. Deeming to a child would continue if the parent is absent from the household but the absence is temporary or is due solely to active duty assignment as a member of the U.S. Armed Forces. If a child lives in a household in which all members are receiving public assistance benefits, that child is not considered to be receiving any support and deeming would not apply.
The income and resources of noncitizens are deemed to include those of their sponsors. The way the income and resources are deemed and the length of the deeming period depend on whether the sponsor signed a legally enforceable
affidavit of support19 or the previous version of the affidavit. Generally, noncitizens who entered the country before 1998 did so under the old version of the affidavit.
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Under the old version of the affidavit, deeming of the sponsor’s income and resources lasts until the noncitizen has been in the United States for 3 years.
21 Living allowances equal to the Federal benefit rate are provided for the sponsor, and allowances equal to one-half of the Federal benefit rate are provided for each of the sponsor’s dependents. Allowances are also provided for the sponsor and his/her family members in determining deemed resources. These allowances reduce the amount of the sponsor’s income and resources deemed to the noncitizen.
For noncitizens admitted into the United States under a legally enforceable affidavit of support, deeming generally applies until the noncitizen becomes a U.S. citizen. Deeming ends before citizenship if the noncitizen has earned, or can be credited with, 40 qualifying quarters of earnings. Children and spouses of workers may be credited with quarters earned by the worker. A quarter otherwise earned after 1996 does not count as one of the required 40 if the noncitizen or worker received Federal means-tested public benefits during the relevant period.
Also for this group of noncitizens, deeming does not apply for specified periods if the noncitizens or their children or parents have been battered or subjected to extreme cruelty while in the United States or if sponsors leave the noncitizens indigent by not providing them with sufficient support.
SSI benefits provide a basic level of assistance for individuals who are blind or disabled with limited earnings capacity due to their impairments. Nonetheless, for recipients who want to work, the SSI program is designed to encourage and support their work attempts in order to help them achieve greater degrees of independence. The SSI program includes a number of work incentives that enable recipients who are blind or disabled to work and retain benefits or to increase their levels of work activity without the loss of SSI disability status or Medicaid. These incentives provide higher amounts of income or resource exclusions as recognition of the expenses associated with working or as inducements to seek rehabilitation services and support for work efforts.
The SSI program also includes provisions to help disabled recipients obtain vocational rehabilitation and employment support services. These provisions were revised by legislation establishing the Ticket to Work program, which is described in section
III.
E.
7.
The first $65 ($85 if the individual has no income other than earnings) of any monthly earned income plus one-half of remaining earnings are excluded for SSI benefit computation purposes. This general earned income exclusion is intended to help offset expenses incurred when working. It assures that SSI recipients who are working will be rewarded for their efforts.
In calculating these expenses, amounts equal to the costs of certain attendant care services, medical devices, equipment, prostheses, vehicle modifications, residential modifications to accommodate wheelchairs, and similar items and services are deductible from earnings. The costs of routine drugs and routine medical services are not deductible unless these drugs and services are necessary to control the disabling condition. They are paid for by the individual, and they are not reimbursable from another source such as Medicaid.
Any earned income by a blind individual that is used to meet expenses needed to earn that income is excluded from earned income in determining SSI eligibility and benefit amounts. A deductible expense need not be directly related to the worker’s blindness; it need only be an ordinary and necessary work expense of the worker.
The student earned income exclusion is an additional exclusion for an individual who is under age 22 and regularly attending school. It is intended to help defray the cost of educational training. Under current regulations, up to $1,640 of earned income per month but no more than $6,600 per year may be excluded.
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A plan to achieve self-support (PASS) allows a disabled or blind individual to set aside income and resources to get a specific type of job or to start a business. This may involve setting aside funds for education or vocational training. Funds can even be set aside to purchase work-related equipment or pay for transportation related to the work goal. The income and resources that are set aside are excluded under the SSI income and resources tests.
The individual must have a feasible work goal, must have a specific savings or spending plan, and must provide for a clearly identifiable accounting for the funds which are set aside. The PASS must be approved by SSA. The individual must then follow the plan and negotiate revisions as needed. SSA monitors the plans by reviewing them periodically to evaluate the individual’s progress towards attaining the work goal.
This work incentive generally is referred to by its section number in the Social Security Act, section 1619. Under section 1619(a), disabled individuals who would cease to be eligible because of earnings over the substantial gainful activity level may receive special cash benefits so long as they:
In determining whether individuals’ earnings are not sufficient to provide them with the equivalent benefits they would be eligible for if they stopped working, their earnings are compared to a threshold amount for their State of residence. Section 1619(b) status continues if the earnings are at or below the threshold. If earnings exceed the State threshold, an individualized assessment of the need for Medicaid is made and 1619(b) status may continue.
Since the beginning of the SSI program, State Vocational Rehabilitation (VR) agencies have provided services to those blind or disabled SSI recipients whom they have accepted as clients. SSA has traditionally reimbursed the VR agency for services provided in situations where the services result in the individual’s working at the substantial gainful activity level for a continuous period of 9 months and in certain other limited situations.
The Ticket to Work and Work Incentives Improvement Act of 1999 established a Ticket to Work and Self-Sufficiency program under which a blind or disabled beneficiary may obtain vocational rehabilitation, employment, and other support services from a qualified private or public provider, referred to as an “employment network” (EN), or from a State VR agency. In addition, the Ticket legislation provided that ENs would be compensated under an outcome or outcome-milestone payment system.
23 By expanding the pool of providers and giving the providers incentives for achieving success, this program seeks to expand a disabled beneficiary’s access to these services in order to assist the beneficiary in finding, entering, and retaining employment and reducing his/her dependence on cash benefits.
The Ticket to Work program has been in operation nationwide since November 2003. Under this program SSA provides eligible individuals who receive SSI benefits due to blindness or disability with a ticket. These individuals may use the ticket to obtain the vocational rehabilitation services, employment services, and other support services needed to return to work or go to work for the first time. The Ticket to Work program provides that as long as the beneficiary is “using a ticket” SSA will not initiate a continuing disability review to determine whether the beneficiary has medically improved.
ENs and State VR agencies are the only providers of VR services to disabled SSI recipients that can be compensated for those services by SSA. All ENs are compensated through the outcome-based system. State VR agencies are compensated under the traditional VR reimbursement system unless they have elected to participate as an EN for specific cases. Any services provided by the State VR agencies to SSI recipients who are not yet eligible for a ticket will be compensated under the traditional VR reimbursement system.
Individuals who improve medically and, therefore, are no longer considered disabled or blind may continue to receive SSI benefits if they are actively participating in the Ticket to Work program or another approved program of VR services, employment services, or other support services. In addition, SSA must determine that continuing or completing the program will increase the likelihood that they will be permanently removed from the SSI rolls. SSI benefits and Medicaid generally continue until the approved program is completed or until the individual ceases to participate in the program.
In 2008, SSA revised the Ticket to Work regulations to enhance beneficiary choice and improve the effectiveness of the program. The revisions extended the program to all adult SSDI and SSI blind or disabled beneficiaries, removed disincentives for ENs to participate in the program, provided incentives for ENs to support beneficiaries through a more gradual return to work and positioned ENs to better support ongoing retention of employment. The regulations also encourage partnership between State VR agencies and ENs to provide long-term services to a beneficiary by allowing the beneficiary to assign a ticket to an EN after receiving VR services.
A disabled or blind individual whose eligibility for SSI payments ended because of earnings can request expedited reinstatement of his/her SSI benefits without filing a new application. To qualify for expedited reinstatement, the individual must make the request within 60 months after his/her eligibility ended and must have a disabling medical condition that: (1) is the same as (or related to) the disabling medical condition that led to the previous period of eligibility and (2) prevents him/her from performing substantial gainful activity. In determining whether the individual is disabled or blind, the medical improvement review standard is applied. Normal nonmedical requirements for SSI eligibility still apply.
An individual requesting expedited reinstatement may receive up to 6 months of provisional benefits while his/her request is pending. These benefits generally are not considered an overpayment if the request is denied. Provisional benefits may include Medicaid but do not include any State supplementary payments.
The framers of the SSI program chose SSA to administer the SSI program because the basic system for paying monthly benefits to a large number of individuals was already in place in the form of the Social Security program, and SSA had a long-standing favorable reputation for dealing directly with the public.
Individuals can apply for SSI benefits at any one of the approximately 1,300 SSA field offices around the country or through SSA teleservice centers. Although many of the eligibility requirements for the Social Security program and the SSI program are different, the application process is very similar. Many times, individuals file for benefits under both programs at the same time.
SSA corroborates information provided by applicants for SSI through independent or collateral sources. Generally, the basic responsibility for obtaining evidence lies with the claimant, although SSA often gives advice and assistance on ways to obtain the needed information. Because of the special circumstances of the SSI population (for example, financial need, old age, or illness), SSA makes special efforts to assist claimants in obtaining the necessary proofs.
SSI applications have no retroactivity and become effective in the month after the month of filing or the month after all eligibility requirements are met, whichever is later. Eligibility for benefits in a month is based on income received in that month. The amount of the monthly benefit is generally calculated using income in the second month preceding the month for which the benefit is paid.
25 However, at the start of a period of eligibility or re-eligibility, the amount of benefits for the first and second months are both determined using the income received in the first month.
SSI benefits generally are paid on the first day of each month. If the first of the month falls on a weekend or legal public holiday, benefit payments are delivered on the first working day preceding such Saturday, Sunday, or holiday. While SSA strongly encourages all SSI beneficiaries to receive their monthly benefits by direct deposit, benefit payments are also made by check if individuals do not wish to use direct deposit. Monthly benefit payments include both the Federal SSI and State amounts if the recipient lives in a State in which SSA administers the State supplementary payment. (See section
III.
G.)
In addition to these nonmedical reviews, medical reviews are conducted on disabled or blind recipients in order to determine if they continue to be disabled or blind. For administrative efficiency the medical reviews are done most often on those disabled or blind recipients whose medical conditions are likely to improve. Medical reviews are required for disabled or blind recipients under the following circumstances:
Applicants and recipients are required to report events and changes of circumstances that may affect their SSI eligibility and benefit amounts. Such reports are required, for example, when an individual has a change in the amount of his/her income or resources, changes living arrangements, or leaves the United States. Failure or delay in reporting such a change can result in monetary penalties or ineligibility for SSI benefits.
The basic “failure to report” penalty is $25 for the first such failure or delay, $50 for the second such failure or delay, and $100 for each subsequent failure or delay. However, in cases of fraud or false representation of material facts, SSA’s Inspector General can assess civil monetary penalties in amounts as large as $5,000. SSA also has the authority to suspend eligibility to SSI benefits for periods of 6, 12, or 24 months.
Additionally, SSA may use an accelerated rate of overpayment recovery to encourage accurate reporting. Overpayments to SSI recipients are generally recovered by withholding from the monthly benefit an amount equal to 10 percent of the individual’s countable monthly income. For many recipients whose only income is SSI, this amounts to 10 percent of their monthly SSI payment. However, if SSA determines that the recipient misrepresentated or concealed material information, 100 percent of the monthly SSI benefit may be subject to recovery.
When SSI recipients are incapable of managing their benefits or are declared legally incompetent, SSA appoints representative payees for them, and their SSI benefits are sent to the representative payees. In many cases the representative payee is a spouse, a parent, or other close relative who will act in the recipient’s best interest. In some cases, SSA approves an organization to serve as a payee. SSA authorizes certain types of organizations to collect a fee from the benefit for acting as payee. The fee cannot exceed the lesser of 10 percent of the benefit amount or a specified amount ($37 a month in 2009
27) .
Representative payees may use an SSI recipient’s benefit only for the use and benefit of the recipient and must account for all benefits received. Representative payees also are required to report any changes that may affect SSI recipients’ eligibility and payment amount and may be held liable for certain
overpayments that occur. In cases in which a child is due a retroactive payment that exceeds six times the Federal benefit rate, the representative payee is required to establish a dedicated account at a financial institution to maintain the
retroactive payment. Expenditures from the account must be used primarily for certain expenses related to the child’s impairment.
Recipients must receive advance notice of adverse actions SSA plans to take and may request that their benefits continue while a decision at the first level of appeal is pending. Recipients may qualify for payment continuation when they appeal an adverse action within 10 days of receiving the advance notice. Slightly different rules apply to medical cessation cases. When appealing medical cessation cases, individuals may elect to have their benefits continued at both the reconsideration and hearing levels of appeal.
At any time, an individual may appoint a representative in any dealings with SSA. If such a representative is an attorney, he/she must be in good standing, have the right to practice law before a court, not be disqualified or suspended from acting as a representative in dealings with SSA, and not be prohibited by any law from acting as a representative. If the individual is not an attorney, he/she must meet qualifications specified by SSA (e.g., be of good character and able to provide valuable service to claimants).
A representative may charge and receive a fee for his/her services, but SSA generally decides how much the fee will be. The representative may request authorization to charge and receive a fee under either a fee agreement or fee petition. The fee that may be authorized under a fee agreement is currently limited to the lesser of 25 percent of the retroactive payment or $5,300 .
28 There is no limit on the amount of the fee that may be authorized under a fee petition; a reasonable fee is authorized for specific services provided by the representative. A representative cannot charge or receive more than the fee amount authorized.
The SSI program has traditionally differed from the Social Security program in that amounts could not be withheld from an individual’s SSI benefits to pay for attorney fees. SSI claimants were responsible for paying such fees directly to their attorneys. However, beginning February 28, 2005, direct payment of attorney fees has temporarily been extended to the SSI program.
29 As in the fee process for the Social Security program, attorneys are now charged an assessment of the smaller of 6.3 percent of each authorized fee withheld or $83. The flat-rate cap is adjusted based on annual cost-of-living adjustments, rounded down to the next lower dollar.
In addition, SSA is conducting a nationwide demonstration project extending fee withholding to non-attorney representatives under Social Security and SSI. In order to be eligible to participate in the demonstration project, non-attorney representatives will have to meet specified prerequisites that include: having a bachelors’ degree or equivalent; having experience in representing claimants before SSA; having liability insurance; passing a criminal background check; and passing an examination given by SSA that tests relevant knowledge of the Social Security Act and recent court decisions. The authority for both SSI fee withholding and the demonstration project expires after 5 years.
The SSI program has procedures which help to respond to the immediate needs of new claimants. These procedures are in addition to State and local programs designed to help those in need, pending decisions on their SSI status.
A new claimant who faces a financial emergency, and for whom there is a strong likelihood of being found eligible, may receive up to 1 month of SSI benefits; i.e., the Federal payment amount plus any applicable State supplement. The amount paid is recovered from later SSI payments (in full from the first payment or in increments over no more than a 6-month period, depending upon the circumstances). However, if the claim is subsequently denied because the claimant is not disabled or blind, repayment would be waived. If the claim is denied for other reasons, the amount paid would be an overpayment and processed as such.
A claimant applying for benefits based on disability or blindness may be paid up to 6 months’ benefits when the available evidence reflects a high degree of probability that his/her impairment will meet the definition of disability or blindness and he/she is otherwise eligible. These payments are not considered overpayments if the individual is later determined not to be disabled or blind. If the claim is disallowed for other reasons, the amount paid would be an overpayment and processed as such.
In designing the SSI program, Congress recognized that States,30 in many instances, may want to provide a higher level of income maintenance than was available under the Federal program. At the same time States were given the option either to provide no supplementation to the Federal assistance payments or to supplement those payments based on their views of the needs of their citizens. Congress also mandated that States assure that their citizens would not receive lower benefits under the Federal program than they had under the former State program. The following paragraphs describe the various forms of State supplementation that currently exist. Table
III.H1 summarizes State-specific participation in these programs as well as other programs requiring State and Federal coordination as discussed in section
III.H.
For individuals who first became eligible for SSI in 1974 or later, each State could supplement Federal payments to whatever extent it found appropriate with respect to the needs of its citizens and resources of the State. Currently, 46 States have optional State supplementary payment programs.
Some States provide supplementary payments to all individuals eligible for SSI benefits, while others may limit them to certain SSI recipients such as the blind or residents of domiciliary-care facilities or may extend them to persons ineligible for SSI because of excess income. States’ flexibility in setting supplementary payments, however, has been significantly restricted by the passalong provisions (see Passalong Provisions section below).
States are required31 to maintain the December 1973 income levels of individuals who were transferred in 1974 from the former State adult assistance programs to the SSI program, except for Texas which has a constitutional bar against mandatory State supplementation. Over the years, many individuals who were converted to SSI from the State benefit rolls have died and others have had their incomes increased above the December 1973 level. As a result, there are few individuals who continue to receive mandatory State supplementary payments.
A State may administer its supplementary program or enter into an agreement under which SSA will make eligibility determinations and payments on behalf of the State. Under State administration, the State pays its own program benefits and absorbs the full
administrative costs. Under Federal administration, States are required to pay SSA a fee for each supplementary payment issued. In fiscal year 2009, the fee is $10.45 per payment issued. Fees are subject to change in succeeding fiscal years, based on increases in the CPI.
States that administer their own supplementary payment programs to title XVI recipients establish their own eligibility criteria for the supplementary payments. States with Federally-administered programs may supplement the Federal benefit among a limited number of geographical and living arrangement variations for title XVI recipients.
32
When the SSI program began in 1974, Congress did not require States to maintain their efforts with regard to levels of State supplementary payments. However, in 1976 in reaction to States reducing their supplementary payment amounts when SSI payments were increased, Congress mandated that States pass along SSI benefit increases resulting from cost-of-living adjustments.
To meet the passalong requirement, a State may either maintain each State payment level from year-to-year—the “
payment levels” method—or it may spend the same amount of money, in the aggregate, that it spent for supplementary benefits in the 12-month period preceding the increase in the SSI benefit rate—the “
total expenditures” method. Currently, 41 States use the levels method and 9 use the expenditure method. West Virginia has no optional supplementary plan and was not required to establish a mandatory plan because Federal SSI income standards exceeded all payments made under the State’s adult assistance programs in 1973.
SSI benefits are not the only form of assistance available to needy aged, blind, or disabled individuals. Medicaid, food stamps, and temporary State assistance also are important in keeping individuals from sliding further into poverty. SSA plays a limited but important role in helping States with regard to administration of Medicaid and Food Stamp programs, and provisions in the SSI statute ensure that payments made by States or under the Social Security program are not duplicated by SSI benefits.
If a person receives SSI payments and is later determined to be entitled to retroactive Social Security benefits, such retroactive benefits are reduced by the amount of SSI payments the person would not have been eligible for had the Social Security benefits been paid in the month they were due. This process is called the “windfall offset” and was enacted to prevent windfall payments to individuals when Social Security and SSI payments were paid for the same period.
Generally, SSI recipients are categorically eligible for Medicaid. A State may either use SSI eligibility criteria for determining Medicaid eligibility or use its own criteria so long as the criteria are no more restrictive than the State’s January 1972 medical assistance standards. Forty States use SSI criteria and 11 States use eligibility criteria more restrictive than those of the SSI program.
States also may enter into agreements with SSA for SSA to make Medicaid eligibility determinations on their behalf, so long as the eligibility requirements of the State’s Medicaid plans are the same as those for the SSI program. Under these agreements, SSA determines only when an individual is eligible for Medicaid; SSA does not determine Medicaid ineligibility. SSA has Medicaid determination agreements with 33 States.
Continued Medicaid eligibility is provided for certain Social Security beneficiaries who lose SSI eligibility due to entitlement to Social Security benefits or due to a change in Social Security benefits resulting from:
SSI recipients in all States, except California,33 may be eligible for food stamps. Under agreements entered into by the Department of Agriculture and SSA, Social Security offices notify Social Security and SSI applicants and recipients of their potential benefits under the Food Stamp Program and make food stamp applications available to them.
The law also provides for Social Security offices to take food stamp applications from eligible or potentially eligible SSI households that are not already receiving food stamps and do not have a food stamp application pending. Food stamp applications from SSI households may be taken in connection with initial SSI claims or at the time of a redetermination. Food stamp applicants have the option of applying at Social Security offices or applying at State food stamp offices if expedited service is required. Social Security offices forward the food stamp applications and any supporting documents to the local food stamp offices within 1 day of taking the application. Eligibility is determined by the food stamp office.
SSA may enter into agreements under which States or local governments are reimbursed for basic needs assistance provided during the period that either an eligible individual’s SSI application for benefits was pending or the individual’s SSI benefits were suspended and subsequently reinstated (the interim period).
Under these interim assistance reimbursement agreements, if the individual has given SSA written authorization, SSA first reimburses the State, then pays the remainder in installments to the recipient or his/her representative payee. In certain disabled children cases, SSA pays the remainder in installments into special dedicated financial institution accounts for the children.Thirty-nine States have interim assistance agreements with SSA.
