Continuing Disability Review Chances of Losing Benefits at 57 Years Old

The federal Supplemental Security Income (SSI) program provides a greenbacks payment to serve as a minimum level of income for people who accept depression incomes and limited avails and are elderly or meet the Social Security Administration's (SSA) strict rules that define inability. The maximum federal SSI benefit is less than the federal poverty level (FPL), $794 per month or about 74% FPL for an individual, in 2021. Every bit a result of the SSA'southward strict inability determination rules, not all people with disabilities qualify for SSI. States mostly must provide Medicaid to people who receive SSI. This effect cursory describes key characteristics of SSI enrollees, explains the SSI eligibility criteria and eligibility determination process, and considers the implications of changes in the SSI plan for Medicaid, including the effects of the COVID-xix pandemic and resulting economical downturn and proposals supported by President Biden that Congress might consider. Primal findings include the following:

SSA expects disability claims (including SSI and SSDI) to increase by most 300,000 in the second one-half of FY 2021, and over 700,000 in FY 2022, compared to FY 2020. SSA received fewer applications than expected in FY 2020, due to role closures and other disruptions due to the pandemic. Additionally, the Affordable Intendance Act's (ACA) Medicaid expansion was not available during prior economic downturns, and then the extent to which people might forgo an SSI application (as a means to admission Medicaid) because they are eligible for Medicaid through the ACA expansion (in states that have chosen to expand) remains to exist seen. Finally, the extent of chronic disabling illness experienced by people with "long COVID" is not yet fully understood but could effect in a new population seeking SSI due to their disability to piece of work.

Congress created the federal SSI program in 1972, equally a safety net program of "last resort," providing a cash payment to serve equally a minimum level of income for poor people who are elderly or disabled and run into strict federal rules.¹ To exist eligible for SSI, beneficiaries must have low incomes, limited assets, and either be age 65 or older or have an impaired ability to work at a substantial gainful level as a result of significant disability.^two SSI is a split up program from Social Security Disability Insurance (SSDI), which provides cash payments to people who previously worked but are no longer able to work due to inability.^three Notably, states generally must provide Medicaid to people who receive SSI.⁴ By contrast, SSDI eligibility mostly triggers Medicare eligibility subsequently a 24-month waiting catamenia; unlike SSDI and Medicare eligibility, there is no waiting period before an SSI enrollee is eligible for Medicaid.⁵ Box 1 explains other central differences between SSI and SSDI.

The maximum federal SSI benefit is less than the federal poverty level (FPL), $794 per month or nearly 74% FPL for an individual, in 2021.⁶ A couple in which both spouses are eligible for SSI receives a joint maximum federal payment of $1,191 per month, which is i and one-half times the individual benefit amount.^seven Because SSI payments are reduced to account for any earned or unearned income too as support that is deemed or received in-kind from other people, the average federal SSI payment is about $586 per calendar month, as of April 2021.^eight States have the option to make supplemental payments to SSI enrollees, which can vary based on income, living arrangement, and other factors.⁹ This upshot brief describes key characteristics of SSI enrollees, explains the SSI eligibility criteria and eligibility determination process (with additional detail contained in the Appendix), and considers the implications of changes in the SSI program for Medicaid, including the furnishings of the COVID-nineteen pandemic and resulting economic downturn also as proposals supported by President Biden that Congress might consider.

Box 1:  What is the Difference Between SSI and SSDI?

SSI is a federal program administered past the Social Security Assistants (SSA) that ensures a minimum level of income for poor people who are elderly or disabled. To qualify, SSI enrollees must take depression income, limited assets, and either exist age 65 or older or accept an impaired ability to work at a substantial gainful level according to strict federal rules.¹⁰ Unlike SSDI (described below), SSI is available to people regardless of their work history. The maximum SSI do good is set by Congress.¹¹

SSA as well administers Social Security Inability Insurance (SSDI), a separate program from SSI.¹² Dissimilar SSI, there are no income or nugget limits for SSDI eligibility. Instead, to qualify for SSDI, enrollees must have a sufficient work history (generally, forty quarters) and see the strict federal disability rules.¹³ SSA uses the aforementioned rules to determine disability for both the SSI and the SSDI programs.¹⁴ In addition, some people with a inability can qualify for SSDI based on a relative'southward piece of work history. For example, people whose disability began before age 22, known as "disabled developed children," tin can qualify for SSDI based on the work history of their parent who is retired, deceased, or disabled.¹⁵

The amount of SSDI benefits is based on the person's earnings history.¹⁶ It is possible to receive both SSDI and SSI if a person'south SSDI do good amount is less than the maximum SSI payment. In those cases, the person too tin qualify for SSI to cover the deviation betwixt their SSDI benefit amount and the maximum SSI benefit.

Who receives SSI?

Nearly 8 million people receive SSI benefits every bit of April 2021 (Figure 1). The bulk of SSI enrollees (57%) are nonelderly adults. Over one-quarter are seniors, and the residuum are children.

Effigy 1: SSI Enrollees by Age, April 2021

The rate of SSI receipt varies by racial/ethnic group (Figure 2). People who are Blackness or American Indian/Alaska Native are more than than twice equally likely to receive SSI compared to White people.

Effigy two: Share of Population Who Are SSI Enrollees by Race/Ethnicity, 2019

Grouped into broad categories, 40 percent of nonelderly adult SSI enrollees had a physical disability as of Dec 2019 (Effigy 3). People age 65 and older are excluded equally they can qualify for SSI based on their age rather than inability condition. The about prevalent types of physical disabilities (using SSA's terminology) were musculoskeletal disorders (generally involving impairment of ane or both arms or legs, every bit well as soft tissue injuries), followed by neurological disorders (such as epilepsy, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), or muscular dystrophy) or loss of vision, speech or hearing; and circulatory disorders. One-third of nonelderly developed SSI enrollees qualified based on a mental health disability. The most prevalent types of mental health disabilities were schizophrenic and other psychotic disorders, followed past mood disorders (such every bit depression or bipolar disorder). One-quarter of nonelderly adult SSI enrollees accept an intellectual or developmental disability (I/DD). Within this category, the most prevalent type was intellectual disability, followed past autism.

Figure 3: SSI Enrollees by Age and Diagnostic Group, December 2019

In dissimilarity to adult SSI enrollees, two-thirds of child SSI enrollees accept an I/DD as of December 2019 (Figure three). The most prevalent blazon of disability within the broad I/DD category was developmental disability. One in five child SSI enrollees have a concrete disability. The nearly prevalent types of physical disabilities amidst child SSI enrollees were neurological disorders or loss of vision, speech or hearing, followed by congenital disorders. Less than 10 percent of child SSI enrollees have a mental health disability. Within this category, the most prevalent inability types were mood disorders, followed by organic mental disorders.

How does a person authorize for SSI?

In addition to coming together the disability criteria (described below), an SSI enrollee must run into several not-medical criteria, including having a low income. SSA has complex rules for determining fiscal eligibility. In general, income is annihilation received in greenbacks, earned or unearned, that can be used to meet a person'south need for food or shelter.¹⁷ Income is countable except for some limited amounts that are disregarded.^eighteen Income likewise includes "in kind" back up, such as any nutrient or shelter provided or paid by another person. In kind back up more often than not is valued at (and therefore reduces SSI payments past) 1-third of the maximum federal benefit amount.¹⁹ SSA also deems a portion of income from a person's spouse or parent/stride-parent (for child applicants) every bit countable income.²⁰ To financially qualify for SSI, a person's countable income cannot exceed the maximum federal do good rate ($794/month for an individual in 2021), and the amount of SSI that a person actually receives is the maximum federal rate reduced by the amount of their countable income.²¹ These rules utilise to SSI enrollees of all ages.

Other non-medical criteria to qualify for SSI include having limited assets and a qualifying citizenship or immigration status. SSI eligibility requires that a person's countable avails non exceed $2,000 for an individual and $3,000 for a couple in which both spouses are eligible for SSI.²² As with income, SSA deems a portion of assets from a person's spouse or parent every bit countable.²³ Examples of avails that are excluded from the limit include the individual's home, household furnishings, and one machine.²⁴ SSI eligibility also generally is express to U.Southward. citizens.²⁵

SSA uses a five-step process to make up one's mind whether a nonelderly adult qualifies as disabled for purposes of receiving SSI (Figure 4). ²⁶ By dissimilarity, people age 65 and older tin can qualify for SSI based on their age. The first stride in the inability decision process for nonelderly adults considers whether the person currently has earned income at or higher up the amount that SSA considers a "substantial gainful level." The next question is whether the person has a "severe" damage," defined every bit a medically determinable damage that lasts at least 12 months or results in death.²⁷ The third stride involves examining whether the person meets SSA'south strict rules that ascertain whether the medical harm meets the definition of disability. If a person does non run into SSA'due south disability definition, the final two steps consider their power to return to their past work or to exercise whatever work. SSA's procedure to determine disability for purposes of SSI eligibility for children differs in some respects from the process used for adults to business relationship for differences in functioning between the two populations.²⁸ More item is provided in the Appendix.

Figure 4: SSI Disability Decision Process for Adults

Every bit a result of the strict SSA disability determination rules, not all people with disabilities qualify for SSI. For instance, using one definition of functional inability, more than 6 in 10 nonelderly Medicaid adults who report a functional inability do not receive SSI (Figure 5²⁹). The definition of functional disability here includes people who report serious difficulty with hearing, vision, cognitive functioning (concentrating, remembering, or making decisions), mobility (walking or climbing stairs), self-care (dressing or bathing), or independent living (doing errands, such as visiting a md's office or shopping, lonely).^thirty Nonelderly adults with disabilities who do not receive SSI can qualify for Medicaid through other eligibility pathways including those based solely on their low income, such as the ACA's Medicaid expansion or Section 1931 parents, or those based on disability, such equally the state selection to embrace people with disabilities upward to the federal poverty level or a home and community-based services waiver.³¹

Figure five: Disability and SSI Status of Nonelderly Adults with Medicaid, 2019

A notable share of initial decisions denying SSI eligibility are reversed on appeal (Figure 6). The overall "allowance rate," awarding SSI benefits in cases involving medical determinations (excluding those denied for "technical" reasons such as such equally income or assets) beyond all adjudicative levels in 2018, was 45 percent.³² However, the charge per unit of SSI awards varies past adjudicative level. Thirty-5 percent of applications involving medical determinations were canonical at the initial awarding phase.³³ Among cases involving medical determinations that were denied at the initial application and appealed, very few (11%) were awarded benefits at the first appeals level (reconsideration).³⁴ However, nigh xl percent of cases involving medical determinations that were denied at both the initial application and reconsideration levels and were appealed further ultimately had benefits awarded, at an authoritative law guess (ALJ) hearing or higher appeals level.³⁵ The appeals process tin can accept a long time and can exist hard for individuals to navigate on their ain without legal representation. For example, the boilerplate wait fourth dimension between an ALJ hearing asking (the second entreatment level) and a hearing engagement ranged from v months to over 16 months, depending on the hearing office location, in March 2021.³⁶

Effigy six: SSI Application Allowance Charge per unit for Medical Decisions by Adjudicative Level, 2018

Subsequently the initial eligibility decision, SSI enrollees are subject to "continuing inability reviews." The timeframes for these reviews are established based on whether and when SSA expects the person's medical condition to better. SSI eligibility besides is reviewed for other reasons, such as a return to work, increased wages, or completion of vocational rehabilitation training.³⁷ Additionally, child enrollees who turn 18 take their eligibility reviewed using the adult disability determination rules.³⁸

How has the COVID-19 pandemic and associated economic downturn affected SSI and Medicaid?

Working people with disabilities experience disproportionate job loss, compared to workers without disabilities, during economic downturns,³⁹ and SSI applications generally increment when the unemployment rate increases (Figure 7). This trend held during the Great Recession and subsequent economic recovery.^forty One exception to the general trend is the period from 2003 to 2007, when SSI applications continued to rise despite falling unemployment.⁴¹ Possible explanations for this anomaly include factors such as the lagged outcome of federal welfare reform (passed in 1996) leading TANF enrollees to switch to SSI and "persistently high poverty rates."⁴² The aforementioned report too establish that the likelihood of applying for SSI significantly increases during extended periods of high unemployment.⁴³

Figure 7: Percent modify in SSI Applications Filed past Adults Ages xviii-64 and U.S. Unemployment Rates, 1991-2019

SSA projects an increase in disability applications in the second half of FY 2021 and in FY 2022.⁴⁴ Specifically, SSA expects to consummate nearly 300,000 more claims in FY 2021, and over 700,000 more claims in FY 2022, compared FY 2020.⁴⁵ While SSA received about 190,000 fewer inability applications than anticipated in FY 2020, the agency expects "many of these individuals to utilise for benefits equally we emerge from the pandemic" and notes that some people may have been unable to obtain the help they needed to apply earlier in the pandemic.⁴⁶ (SSA does not separately discuss SSI vs. SSDI applications in these projections.) Additionally, the extent of chronic disabling affliction experienced by people with "long COVID" is not yet fully understood but could result in a new population seeking SSI due to their inability to work.

The pandemic has presented additional challenges that accept not been nowadays during other economical downturns. For case, the need for social distancing measures has closed SSA offices to the public since mid-March 2020. In April 2021 testimony before the Senate Finance Committee, the SSA Deputy Commissioner for Operations acknowledged the importance of in-person services for many populations served by SSA, such as seniors, people with low incomes, those with express English proficiency, those who are homeless, and those with mental illness, and described SSA'southward outreach efforts to these groups.⁴⁷ SSA explained that earlier the pandemic, about or all tasks could be completed at the first betoken of contact in the function, while collecting show and documentation by mail service or telephone has slowed the process down, often requiring multiple contacts.⁴⁸ Additionally, SSA cited mail delays, people who no longer receive mail at their accost of record considering they were forced to movement during the pandemic, and hesitancy in accepting phone calls due to phone scams every bit factors that take exacerbated challenges resulting from office closures.⁴⁹ SSA also noted that "at least 30 per centum of all disability applications require a consultative examination to determine disability," and the pandemic has fabricated it more difficult for people to schedule and access these appointments with medical providers and to obtain testify from schools and social service agencies.⁵⁰ SSA reported that these tasks are "taking almost twice as long now, up from 21 days before the pandemic to 37 days during the pandemic."⁵¹ Consequently, SSA is facing a backlog of initial inability applications that "grew by approximately 115,000 cases" between September 2019 and April 2021.⁵²

As of mid-March 2021 , KFF analysis of Census survey data shows that 4.six 1000000 people had practical or attempted to apply for SSI during the pandemic, or think they will employ in the next 12 months, with those in households that experienced chore or income loss more probable to practise so.⁵³ People in households where someone experienced a job or income loss were more than three times as likely to take applied, attempted to employ, or program to apply for SSI, compared to those in households without job or income loss.⁵⁴ Among those who take applied, tried to utilise, or plan to apply, one quarter said the pandemic led them to utilise earlier than expected, while fifteen% said the pandemic led them not to apply or utilise subsequently than expected.⁵⁵

SSI enrollment remained relatively stable in the early on months of the pandemic but began to subtract as the pandemic continued.⁵⁶ When the pandemic began, SSA "temporarily deferred" some piece of work, such as continuing disability reviews and SSI redeterminations, "to protect beneficiaries' income and healthcare during a disquisitional time."⁵⁷ SSA "resumed processing adverse deportment in September and October of 2020."⁵⁸ This likely has contributed to the decrease in the number of SSI enrollees from nearly eight.1 million in April 2020 to simply under seven.9 million in April 2021.⁵⁹ Historically, SSI enrollment increased annually from 2000 through 2013. And so, outset in 2014, annual SSI enrollment has declined slightly each year. 2014 is the commencement yr that the ACA's Medicaid expansion went into effect, and the extent to which the availability of this new Medicaid pathway may have influenced SSI enrollment declines is unclear. The overall subtract in enrollment from April 2020 to April 2021 is consistent with the general recent trend of annual SSI enrollment declines since 2014.

Medicaid enrollment increased in every state during the COVID-19 pandemic.^lx Medicaid enrollment grew past 11.viii% (7.6 million enrollees) nationally from actual adjusted February to preliminary November 2020 data.⁶¹ While enrollment increased for both children and adults during this period, adult enrollment grew at a greater pace.⁶² This reflects changes in the economy (every bit more people lost income and jobs and became eligible for and enrolled in Medicaid) also as provisions in the Families First Coronavirus Response Act that require states to ensure continuous coverage for current Medicaid enrollees through the cease of the month in which the COVID-19 public wellness emergency ends, as a condition of receiving a temporary increase in the Medicaid federal matching rate.⁶³

Implications for Medicaid

Considering SSI eligibility generally is a pathway for Medicaid eligibility, changes that make it more difficult to obtain or retain SSI can affect the ability of people with disabilities to access Medicaid. For example, in January 2021, the Biden Administration withdrew a notice of proposed rule-making issued by the Trump Assistants that would have increased the number and frequency of continuing inability reviews and was expected to result in some people losing SSI eligibility.⁶⁴ Increasing the frequency of SSI continuing disability reviews could create administrative barriers that can result in eligible people losing not but SSI but also Medicaid.⁶⁵ An increase in the number of people losing SSI besides could increase state authoritative costs because state Medicaid agencies must determine Medicaid eligibility on all other bases before terminating coverage if people lose eligibility through their current pathway.⁶⁶

On the other hand, changes that seek to increase and stabilize access to SSI could take like furnishings on the ability of people with disabilities to obtain and retain Medicaid coverage. For case, President Biden and a grouping of Congressional Democrats accept proposed increasing the maximum SSI benefit to 100% FPL; eliminating the SSI "spousal relationship penalization" (referring to the fact that two SSI enrollees who marry receive the couple charge per unit, described to a higher place, which is less than twice the individual rate); eliminating rules that reduce SSI benefits by one-tertiary based on "in-kind back up and maintenance;" and raising the asset limits, which terminal increased in 1989.⁶⁷ President Biden backed these policy changes during his campaign, and a grouping of Congressional Democrats supports including them in the American Family Plan.⁶⁸

The availability of the Affordable Care Deed's (ACA) Medicaid expansion as an culling pathway to affordable health insurance coverage can impact decisions almost whether to utilise for SSI during the current economical downturn. The ACA expansion was not available during prior economic downturns, and then the extent to which people might forgo an SSI awarding (as a means to access Medicaid) because they are eligible for Medicaid through the ACA expansion is non even so fully understood. Limited research indicates possible federal and state savings due to decreased SSI participation associated with the ACA Medicaid expansion.⁶⁹ Although it is non oft thought of in these terms, the ACA expansion provides a pathway to Medicaid eligibility for many people with disabilities, though without the limited cash benefits SSI provides and without the need to navigate SSI's disability determination process. While it is true that disability condition is not one of the eligibility criteria to qualify for the ACA expansion group, nonelderly adults with disabilities who practise not receive SSI tin can qualify for Medicaid based solely on their income through the expansion group.^seventy Many people in the ACA expansion grouping were previously ineligible for Medicaid, and eligibility remains limited in the 12 states that have not adopted the Medicaid expansion to date, where eligibility limits for parents remain very low, and there is no eligibility pathway for childless adults, regardless of income (except in Wisconsin).⁷¹ Medicaid eligibility pathways based on inability other than SSI receipt, such equally the pathway to cover seniors and people with disabilities upward to 100% FPL, are offered at state choice and therefore not universally available.⁷²

Access to affordable health insurance, such as Medicaid, helps people with disabilities access services to meet daily cocky-care and independent living needs, such as bathing, dressing, and eating. Medicaid also supports working people with disabilities by covering the health and long-term intendance services they need to exist able to piece of work. For example, the optional Medicaid buy-in for working people with disabilities allows Medicaid eligibility to continue for people who lose SSI due to earned income, if losing Medicaid would "seriously inhibit [the person's] power to continue working" and earnings are insufficient to provide a "reasonable equivalent of benefits. . . which would be available" if not working.⁷³ Together, SSI and Medicaid are cardinal sources of support for low-income seniors, nonelderly adults, and children with disabilities.

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Source: https://www.kff.org/medicaid/issue-brief/supplemental-security-income-for-people-with-disabilities-implications-for-medicaid/

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