What are They and Can I Get Them?
Public benefits are government programsthat are set up to help people who needhealth care, cash assistance, food stamps,housing assistance, and other programs.Determining which programs may apply toyou may not be easy. It is wise to get help tomake sure you receive the right benefits. Eachof the Wisconsin AIDS service organizationshave case managers who are experts in helpingindividuals apply for and maintainbenefits. Free legal services may also help youto appeal denials of benefits. Look in theResources chapter for a list of AIDS serviceorganizations and free legal services.
What are disability benefits?
Social Security Disability Insurance (SSDI) andSupplemental Security Income (SSI) provide monthly incometo persons who can't work because they are disabled. Aperson must be diagnosed with a medical impairment like HIVor AIDS and must meet certain requirements to be eligible fordisability benefits. The SSDI and SSI programs have differentfinancial eligibility requirements, but evaluate disability in thesame way.
Social Security has its own way of determining if you aredisabled. Persons diagnosed with HIV are not automatically "disabled"by Social Security rules. If you apply for SSI, SSDI, or both,Social Security will make an initial decision telling you if theyconsider you to be disabled. Remember, you may ask for freelegal help to appeal these decisions (see Resources chapter).You can get applications for both programs at your localSocial Security office or by calling Social Security'stoll-free number, (800) 772-1213. For either program, you can ask for yourapplication to be processed faster than normal if you have AIDS.
What is Social Security Disability Insurance (SSDI)?
SSDI is a disability insurance program for people who (1) are disabled,(2) have a work history, and (3) have had Social Security taxes deducted from past paychecksor have paid taxes from selfemployment. In general, you must have worked 10 years to beeligible for SSDI. However, if you are under age 31, you may beeligible if you worked less than 10 years. The amount of your monthly SSDI benefit is based on theamount of income you earned while working and the number of years you worked.
| NOTE: After you havereceived SSDI for 24 months, you will be eligible to receive Medicare. |
What is Supplemental Security Income (SSI)?
SSI is an income maintenance program for people who are dis-abled, blind, or elderly, have alow income and have little or no assets. Unlike SSDI, no work history is necessary.
If you have an income, it will be supplemented by SSI to reach a minimum income guaranteedby state and federal government. You may be able to get both SSI and SSDI if your SSDI is lowenough and you meet the SSI program asset requirements.
| NOTE: If you receive SSI you will also receive Medical Assistance. |
If you are HIV-positive and meet the SSI financial requirements,you may be able to get what's called "presumptive disability benefits". This means thatfor up to six months while you wait for your SSI application tobe processed, you may receive SSI payments. If you are facing afinancial emergency, you may also ask for a one-time-onlyadvance payment from SSI while your SSI application is pending.However, if you receive payments while Social Security processes your application and itis later denied, you will be required to pay back the money you have received.
How is disability determined for SSDI and SSI?
If you are HIV-positive and you are not currently earning more than $700 a month fromemployment, you may be found disabled and be able to get SSDI and SSI payments.You must also meet one of the following medical criteria to be considered disabled: - You have certain HIV-related opportunistic infections;
- Your HIV-related symptoms, including fatigue and side effects of medication, prevent you from workingfull-time; or
- You have other health conditions like asthma or depression, and the combination ofall your impairments prevent you from working full-time.
Your doctor's role: Your doctor's opinionhelps to convince Social Security that you are disabled and your symptoms are real. The opinionof your doctor is important to Social Security in making a disability determination. It iscrucial to track your HIV symptoms and how they affect you on a daily basis, and to report this toyour doctor.
Your role:Take notes about your symptoms, keep track of them on a calendar, and bring these withyou when you see your doctor. Inform your doctor that you have applied for disabilitybenefits and ask that notes about your symptoms be put in your medical records. You must beable to show the Social Security Administration that your symptoms are frequent and severeenough that you have been or are expected to be unable to work full-time.
What can I do if I am denied benefits?
Even if you are HIV-positive or have AIDS, the Social Security Administration may deny yourapplication. Do not assume that you are not eligible for benefits if you are denied after you firstapply. Many applicants are successful after appealing. Under both SSDI and SSI, you havethe right to appeal the denial of your claim for disability benefits. Usually, appeals must be madewithin 60 days of receiving a first denial. You may appeal at your local Social Security office or bycalling (800) 772-1213. If you are denied benefits when you first apply, continue keeping track of your symptoms; follow up with your doctor. This will be important if you appeal. If yourappeal is denied, you can always reapply later.
For a list of free or low cost legal services to help you appeal adenial of Social Security benefits, see the Resources chapter.
What is Medical Assistance (also called MA, Medicaid, Title 19)?
Medical Assistance is a free health insurance program for disabled, blind or elderly individualswho have little or no income and resources. In Wisconsin, it is often called"Title 19." Medical Assistance may pay for prescription drugs, doctor services, hospital care,skilled nursing care, nursing home care, dental care and more.
| NOTE: If you receive SSI,you will automatically receiveMedical Assistance. If youreceive SSDI, you mayapply for Medical Assistance. |
If you earn more than MedicalAssistance allows, but you meetthe other eligibility requirementsfor this program, you may stillqualify for the medically needyprogram. Under this program,you must pay or receive medicalbills during a six-month perioduntil you "spend down" to thequalifying income level. You canalso use old, unpaid bills to meetyour deductible. At this point,Medical Assistance pays for anyremaining medical bills duringthat six-month period. Every sixmonths a new "spend down" amount is determined and theprocess repeats.
How do I apply for Medical Assistance?
If you are on SSI, you should automatically receive MedicalAssistance and do not need to apply. If you are not on SSI, callthe Wisconsin Division ofHealth Care Financing at(608) 266-0150 or your AIDSservice organization (phonenumbers are in the Resourceschapter) to learn how to apply.
What is the Community Options Program?
This program pays for your homecare if the home care could keepyou out of a nursing home.Funding is limited and based onfinancial need. Call (608)267-9719 for more information.
What is Medicare?
Medicare is a federal government health insurance plan for disabled and elderly people.Eligibility is not based on financial need.
| NOTE: If you have beenreceiving SSDI benefits for 24months, you are also entitled toreceive Medicare. |
However, under Medicare, you must paydeductibles, co-payments, andpremiums out of your ownpocket. Medicare also does notpay for drug prescriptions.If you have a low income orare not working, you may beeligible for state MedicalAssistance to help pay forMedicare expenses. If you canafford them, you may also buy"Medicare supplemental policies,"described below, whichcover many of these expenses.There are three main parts toMedicare:- Hospital Insurance (Part A),
- Supplementary Insurance (Part B),
- and Choice (Part C).
Part A automaticallycomes with Medicare. Everyonereceiving Part A is also eligibleto choose either Part B or PartC, for which you must pay amonthly premium. Part C may be more complicated andrestrictive than Part B.
Medicare Hospital Insurance (Part A)
Medicare hospital insurance coverssome of the cost for hospitalization,home health, nursinghome, and hospice care. There isno monthly premium for Part A.
Medicare SupplementaryInsurance (Part B)
Medical supplementary insurancecovers 80% of reasonablecharges for your doctor's fees andservices provided outside of thehospital. If you receive Part B,you will have to pay a monthlypremium. Part B covers you forcertain services that Part A doesNOT cover. These services caninclude: doctor visits; homehealth care; durable medicalequipment; diagnostic tests; andeven the hepatitis B vaccine.Some doctors accept Medicare'spayment as payment in full fortheir services. If a doctor doesnot accept Medicare as paymentin full, medicare supplementaryinsurance may pay for the part ofthe bill which Medicare does notcover. If you rely on Medicare,when choosing a doctor be sureto ask them if they takeMedicare as partial payment,payment in full, or not at all.You may choose to go to anydoctor as long as s/he will takeMedicare as payment.
Medicare + Choice (Part C)
Some HMOs currently offer PartC Medicare plans that will provideyou with their own Medicarepackage that you may choose tojoin instead of enrolling in PartsA and B. Under this type of plan,you would not be able to go to anydoctor -- you would have to usethe doctors, hospitals and nursinghomes within that Part C HMOpackage. Each Part C plan is different.Currently in Wisconsin,there are Part C plans availablein Milwaukee, Racine and selectareas in the state. There may notbe one in your area.
Only choose a Part C plan ifyou have weighed all the factorsand decided that it is better thanthe regular Part B plan. If youare thinking about a Medicare +Choice plan, take the time tostudy the plan's rules, itsproviders, and whether or notyou can easily get out of the planif you decide it is not right foryou. If you want help, call yourAIDS Service Organization(see the Resources chapter forphone numbers).
| NOTE: if you do notchoose Part C, you will automaticallyreceive Part A and,if you choose, Part B. |
Can I get coverage for health care costs not covered by Medicare?
Yes. If you enroll within six months of becoming eligible for Medicare, you can get a Medicaresupplement policy to fill in the gaps of coverage in Medicare insurance. These are often called"Medigap" policies. There are several Medigap policies which provide different amounts ofcoverage. Enrollment in these policies is optional. If you choose this coverage you will pay amonthly premium for it. If you receive SSDI, the premium is deducted from your SSDI check.It is a good idea to get help when deciding whether to choose this coverage. For more information, callthe Medigap helpline at (800) 242-1060.
Are there other kinds of public health insurance that I can get aside from Medical Assistance and Medicare?
Yes. Below is a list of other public health insurance plans.Your local AIDS service organization can help you figure out which plans you are eligible for.HIRSP. The state of Wisconsin offers the Health Insurance Risk Sharing Plan (HIRSP). You may be eligible forHIRSP if you have been diagnosed with HIV in the last 9 months, your health insurance was cancelled or the payments became much more expensive, or there was a big decrease in what your health insurancewould cover. HIRSP covers basic in-patient and out-patient services, prescription drugs, homehealth care, and durable medical equipment. There is a yearly deductible as well as insuranceco-payments. HIRSP also offers a Medicare supplement policy. For more information, call (800) 828-4777.
Ryan White Title III. If you are HIV-positive and have no or not enough health insurance,you may be able to receive this federal government health care plan. Ryan White Title IIIprovides general health care and referrals to HIV clinics and clinical trials. It does not pay forhospitalizations or emergency room visits. You can work and get Ryan White Title III at thesame time. You will have to pay a premium. For more information, call (608) 263-9346.For poor families. BadgerCare is a state program which uses Medicaid funds to providehealth care for parents and their children. You may receive BadgerCare coverage if your family income isnot more than 185% or 200% of the federal poverty level. You do not have to be HIV-positive to receive BadgerCare. You may have to pay a monthly premium. For more information, call the state Medicaid hotline at(800) 362-3002.
Wisconsin AIDS/HIV Health Insurance Premium Subsidy Program. This plan may pay all or most of your premiums to get insurance through COBRA, HIRSP, a Medicare supplement plan, or a private company. Tobe eligible, you must be HIV-infected, meet the eligibilityrequirements, and your family income must not exceed 300% of the federal poverty level. You must also have a note from your doctor saying you cannot work due to HIV, have to take an unpaid medical leave from work,or would lose your group health insurance because you need to reduce your hours at work. Formore information, call the Health Insurance Premium Subsidy Program Administrator at (800) 991-5532.
How can I pay for my medications if I don't have insurance to cover it?
The Wisconsin AIDS/HIV Drug Reimbursement Program will pay for approved AIDS/HIVmedications if your family income is not more than 200% of the federal poverty level. For more information on the Drug Reimbursement Program or to see if you qualify, call the program at (800) 991-5532 or yourAIDS service organization. Also, some drug companies provide their drugs free to patients with low incomes. Formore information on these programs, ask your doctor, pharmacist or an AIDS service organization.
Last updated: January 1999 |
