The extension of COBRA Benefits, Medicare and Medicaid for a disabled individual is determined based on the Social Security definition of being disabled which is much more stringent than most people believe.
The definition for disability according to Social Security is that to be found disabled, a person must be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that is expected to result in death or has lasted, or can be expected to last, for a continuous period of 12 months. (The law specifically provides that a person shall not be considered disabled if alcoholism or drug addiction would be a contributing factor material to a determination that he or she is disabled.)
Initial disability determinations are generally made by State Disability Determination Services (DDSs) on the Social Security Administration’s behalf. The DDSs, which are fully funded by the Federal government, are responsible for developing medical and other evidence. In cases where the existing medical evidence is insufficient to render a determination, the DDS will ask a claimant to attend one or more consultative medical examinations at the Social security Administration’s expense.
When there is evidence that a person is not able to manage or direct the management of Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits in his or her own best interests, the Social Security Administration will appoint a representative payee to handle the person’s benefits. Persons who have been determined legally incompetent are required to have representative payees.
Source: Social Security Administration
COBRA
Normally COBRA benefits are extended to a qualified beneficiary for a maximum of 18 months. However, a qualified beneficiary who is determined to be disabled by the SSA under Title II or XVI before or at any time during the first 60 days of COBRA coverage may be eligible to extend coverage from 18 to a possible maximum of 29 months. The employer and insurer must receive a copy of the SSA Notice of Award letter prior to the end of the original 18-month continuation coverage period.
Source: COB Notice (R 09/2003). The insured’s premium for the first 18 months can be 102% of the actual premium. For the next 11 months the premium can be 150% of the actual premium. At the end of the COBRA period, if the qualified beneficiary is not eligible for Medicare or Medicaid then they are eligible for a continuation of one policy from their insurance provider. Normally these policies are more limited and expensive than the current group coverage and are specific to the insuring company.
Medicare
Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States. If you aren’t yet 65, you might also qualify for coverage if you have a disability or with End-Stage Renal disease. For a disability, if you are 65, you can get Part A without having to pay premiums if you have received Social Security or Railroad Retirement Board disability benefits for 24 months.
Source: www.medicare.gov. The definition for this is, for Social Security purposes, the inability to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or to last for a continuous period of not less than 12 months. Special rules apply for workers aged 55 or older whose disability is based on blindness. The law generally requires that a person be disabled continuously for five months before he or she can qualify for a disabled worker cash benefit. An additional 24 months is necessary to qualify under Medicare.
Source: Centers for Medicare & Medicaid Services
Medicaid
States are required to include certain types of individuals or eligibility groups under their Medicaid plans and they may include others. States’ eligibility groups will be considered one of the following: categorically needy, medically needy, or special groups.
Source: COB Notice 09/2003. Disabled individuals may fall into either categorically needy if they are Supplemental Security Income recipients or if they are medically needy. The definition for medically necessary is determined by using the SSI program standards.
This information is given as general information. Since every case and case worker is different, information specific to a particular individual should be evaluated with the local Social Security office for determination of benefits.
© R. Allen Greer, Jr., 2007
