Contents
Module 3 –
Understanding Social Security Disability Benefits and Associated Work Incentives 1
Introduction 1
CWIC Core Competencies 1
Competency Unit 1 –
Disability Evaluation and Determination 3
Understanding Eligibility for Social Security Disability Benefits 3
Disability Defined 3
Childhood Definition of Disability for the SSI Program 4
Understanding How Social Security Determines Disability 4
The Sequential Evaluation Process 6
Continuing Disability Reviews (CDRs) 8
Medical Improvement Review Standard (MIRS) 8
Medical Review Diaries 9
Protection from Medical CDRs 10
Age-18 Redeterminations in the SSI Program 10
The Age-18 Redetermination Process 11
Applying for Social Security Disability Benefits 14
Conclusion 16
Conducting Independent Research 16
Competency Unit 2 –
Understanding Social Security Title II Disability Benefits 19
Introduction 19
Understanding Entitlement for Social Security Benefits 19
Types of Benefits Provided under Title II of the Social Security Act 19
Determining the Relationship 21
Calculating Benefit Amounts 25
Understanding Title II Disability Benefits 27
Types of Disability Benefits 27
Effect of Marriage on CDB and DWB 28
Waiting Period for Title II Disability Benefits 29
Important Concepts Affecting Entitlement to Title II Disability Benefits 29
Comparison of Title II Benefits 30
Entitlement Based on Factors Other than Disability 32
Benefits for the Worker 32
Benefits for Dependent Family Members 33
Independently Entitled Divorced Spouse Benefits 35
The Annual Earnings Test (AET) 37
Confusing Situations 37
Child’s Benefits vs. Childhood Disability Benefits 38
Interaction between SSDI and Retirement Insurance Benefits 38
Disability Benefits and Early Retirement 39
Dual Entitlement to Title II Benefits 40
Title II Disability Payments 42
How Social Security Pays Regular Monthly Benefits 42
Immediate Payment (IP) 42
Returning Payments 43
Conclusion 43
Conducting Independent Research 44
Competency Unit 3 –
Understanding Substantial Gainful Activity 45
Introduction 45
Determining Substantial Gainful Activity 45
Recent SGA Guidelines 46
SGA for Blind Individuals 47
SGA is a Decision 48
Overview of SGA Determinations 48
Work Incentives 49
Earnings 49
Timing of Work Reviews 51
Conducting the Work CDR 51
SGA Determination “Tools” 52
Subsidy and Special Conditions in Wage Employment 53
Impairment Related Work Expenses (IRWE) 57
Definitions Social Security Uses to Determine IRWE Deductions 60
Income Averaging 61
Unsuccessful Work Attempts (UWA) 65
Methods for Making SGA Determinations 67
Countable Income Test for SGA for Beneficiaries 68
Conclusion 72
Conducting Independent Research 72
Additional Resources 73
SGA DETERMINATION DECISION TREE (Countable Income Test) 74
SGA DETERMINATION DECISION TREE (Comparability/Worth of Work Test) 75
Competency Unit 4 –
Understanding the Trial Work Period and Extended Period of Eligibility 77
Introduction 77
The Trial Work Period 77
Determining Wages in a Month 78
What is a Trial Work Period Month? 79
Counting TWP Service Months 80
Determining the Beginning of the TWP 81
Completing the TWP 81
The Trial Work Period and Self-Employment 85
Limitations to Who May Access a Trial Work Period 86
Tracking TWP Months 89
Cessation Month and Grace Period 90
Extended Period of Eligibility (EPE) 92
The Definition of Termination 96
Extended Medicare 96
Conclusion 97
Conducting Independent Research 98
Competency Unit 5 –
Understanding the SSI Program 99
Introduction 99
Eligibility for People who are Blind or Disabled 99
Basic Eligibility Requirements 100
Retroactivity and SSI 101
Federal Benefit Rate (FBR) 101
Optional State Supplements 102
How the SSI Program Defines Income 103
What Isn’t Income? 104
How SSI Treats Earned Income 107
How SSI Treats Unearned Income 111
Deemed Income 116
Deemed Income is Income Attributed to the Beneficiary 116
Deeming Computations 117
In-kind Support and Maintenance (ISM) 118
Determining the Value of In-kind Support and Maintenance 118
Reporting Income in the SSI Program 120
How Social Security Verifies Income– Annual Redeterminations 122
A Closer Look at Retrospective Monthly Accounting 123
How Resources Affect SSI 126
Resource Limits in the SSI Program 127
Resource Determinations 127
Common Resource Exclusions 128
Work Incentives that Create Excluded Resources 128
Transfers of Resources 130
12-month Suspension Period 133
Eligible Couples 134
Marital Relationships and SSI 134
Determinations with Eligible Couples 136
Emergency Advance Payments and Immediate Payments 137
Emergency Advance Payment (EAP) 138
Immediate Payment (IP) 138
Comparison of EAPs and IPs 139
Conclusion 140
Conducting Independent Research 140
Competency Unit 6 –
SSI and Work Incentives 143
Introduction 143
How Earned Income Affects SSI Cash Payments – SSI Calculation 143
Earned Income Exclusions in the SSI Program 144
SSI Calculation Sheet 147
Step-by-Step Instructions for Completing the SSI Calculation Sheet 149
Student Earned Income Exclusion (SEIE) 160
Regularly Attending School 161
Additional types of students 162
Eligible Couples and Student Earned Income Exclusion (SEIE) 168
How Social Security Verifies Student Status 170
When Individuals May Deduct IRWEs 171
Blind Work Expenses (BWE) 175
Work Incentive Deductions for Blind Beneficiaries 176
Estimating Monthly Wages 179
SSI and Net Earnings from Self‑Employment (NESE) 180
Conclusion 181
Conducting Independent Research 181
Competency Unit 7 –
Plan to Achieve Self-Support (PASS) 183
Introduction 183
Overview of the Plan to Achieve Self‑Support (PASS) 183
Strengths of the PASS Work Incentive 184
Individuals Who May Benefit from a PASS 185
Likely PASS Candidates 185
Unlikely PASS Candidates 186
Title II Disability Beneficiaries as PASS Candidates 187
PASS Requirements 188
Feasible Occupational Goal 188
Viable Plan for Achieving the Goal 190
Earnings Requirements 191
PASS Expenditures 192
Forbidden Expenses 193
Disbursements – Spending PASS Funds 194
Time Considerations for PASS 194
When a PASS May Begin 195
Administrative Finality and Retroactivity for a PASS 197
Time Limits for Reopening and Revising Social Security Determinations and Decisions 197
Tips for CWICs — Requesting a PASS Start Date 198
Developing and Submitting a PASS 199
PASS Specialists 200
Getting Help with Developing a PASS 201
PASS Progress Checks 201
Making Changes to a PASS 202
Suspending or Terminating a PASS 202
Number of Plans to Achieve Self-Support 203
Using Various Forms of Income to Fund a PASS 204
Using In-kind Support and Maintenance (ISM) to Fund a PASS 204
Using Earned Income to Fund a PASS 207
Using Deemed Income to Fund a PASS 210
Using Title II Disability Benefits to Fund a PASS 214
Budgeting the PASS Excluded Income 218
How PASS Interacts with Other SSI Work Incentives 219
Student Earned Income Exclusion (SEIE) 219
Impairment Related Work Expense (IRWE) 219
Blind Work Expenses (BWE) 220
Section 301 Continuation of Benefits after Medical Recovery 220
Appealing PASS Determinations 221
The CWIC’s Role in Assisting with Plans to Achieve Self-Support (PASS) 222
Strategies for Success: 224
Frequently Asked Questions about Helping Facilitate PASS Development 225
Conclusion 229
Conducting Independent Research 230
Additional Resources 230
PASS Candidate Checklist 231
PASS Monthly Expense Template 233
So, Your PASS was Approved — Now What? 237
PASS Form SSA 545 245
Competency Unit 8 –
Self‑Employment and Social Security Disability Benefits 261
Introduction 261
Telling the Difference between Wage Employment and Self-Employment 261
Social Security and the IRS make Independent Employment Determinations 262
Social Security’s Procedures for Making Employment Determinations 263
Common Law Control Test 263
Types of Self-Employment 266
Small Business Ownership 266
Independent Contractors 266
Statutory Employees 267
Statutory Non-Employees 268
Unusual Self-Employment Situations 269
Ministers and Members of the Clergy 269
Directors of Non-Profit Organizations 270
Artists and Authors 270
Farmers 271
Understanding Net Earnings from Self‑Employment (NESE) 271
Turning Net Income into NESE 272
A Warning about “Owner’s Draw!” 273
Business Structures May Affect How Social Security Counts NESE 275
Officers and Directors of Corporations 276
A Warning about Businesses Structured as Corporations 277
Self-Employment and Title II Disability Benefits 278
The Trial Work Period and Self-Employment 278
Hours in a Business 279
Special Work Incentives for Self-Employed Beneficiaries 279
How IRWEs Apply in Self-Employment Situations 281
SGA Determinations for Self-Employed Beneficiaries 282
Use of Averaging in Self-Employment Cases 290
SGA Determinations When Multiple Work Efforts Exist 290
Final Words about Self-Employment and SGA Determinations 291
SSI Net Earnings from Self-Employment (NESE) 291
Application of SSI Work Incentives for Individuals who are Self-Employed 293
Self-Employment and Medicaid 294
Important Considerations for SSI Recipients who are Self-Employed 295
Small Business Ownership and Resource Determinations for SSI Recipients 296
Self-Employment and PASS 297
Business Plans and PASS 297
Start-up Costs 298
Self-Employment Combined with Wage Employment 298
Self-Employment and the CWIC 299
Counseling Beneficiaries with Self-Employment Goals – Starting the Process 299
The Business Domain 301
The Business Concept and Business Feasibility 302
The Business Structure Decision 302
Business Plan Development 303
What CWICs Need to Know about Business Financials 304
CWIC Role in Accounting and Financial Record Keeping 305
The Benefits Domain 306
Reporting Self-Employment Income to Social Security 307
Reporting Tips for Title II Disability Beneficiaries 308
Reporting Tips for SSI Recipients 309
Common Mistakes CWICs Make in Reporting NESE 309
Final Words on Supporting Beneficiaries to Achieve Self-Employment Goals 310
Conducting Independent Research 310
Additional Resources 311
So, you want to be self-employed. Have you thought about: 313
Outline of a Business Plan From POMS SI 00870.026 Business Plans 315
Competency Unit 9 –
Understanding Rights and Other Protections Afforded to Beneficiaries of Social Security Disability Benefits 321
Introduction 321
What is Termination? 321
Reapplication under the Title II Disability Program 322
Childhood Disability Beneficiaries (CDB) and Reapplication 322
Disabled Widow(er) Beneficiaries (DWB) 323
Expedited Reinstatement (EXR) 323
Introduction 323
Expedited Reinstatement (EXR) Basics 324
When EXR Applies – Understanding Termination 324
Requesting EXR vs. Reapplying for Benefits 326
How Social Security Determines Provisional Payments under EXR 329
EXR and Work Incentives 332
Important Changes to the EXR Regulations 333
Frequently Asked Questions about EXR 334
Continuation of Payments under Section 301 336
Important Section 301 Facts 337
Eligibility Requirements for Section 301 Payments 338
When Eligibility for Section 301 Payments Ends 338
When Beneficiaries Disagree with Social Security 339
Levels of Appeal 340
Overpayments 341
Options for Repaying 341
Appeal and Waiver Rights 342
Administrative Finality 343
Time Limits for Reopening and Revising Social Security Decisions 343
Conducting Independent Research 345
Competency Unit 10 – The Ticket to Work Program 347
Introduction 347
The Ticket to Work (TTW) 347
Ticket Eligibility 348
MAXIMUS: The Ticket Program Manager 349
Employment Networks 349
Working with an EN 351
The Individual Work Plan (IWP) 352
The Individualized Plan of Employment (IPE) 352
State Vocational Rehabilitation Agencies as ENs 352
Protection from Continuing Medical Reviews (CDR) and Use of a Ticket 353
Using a Ticket and Timely Progress 354
Timely Progress Requirements 355
Assigning a Ticket or Otherwise Using It and Reassigning a Ticket, Extension Periods and Inactive Status 357
The 90-Day Extension Period 357
Inactive Status 358
Retrieving and Reassigning a Ticket 359
Employment Network Payment Systems 360
The Outcome Payment System 361
Outcome Payments to Beneficiaries Who Receive SSDI Only or Who Receive Concurrent Benefits 361
The Milestone/Outcome System 362
Payments when SSI Beneficiaries Become Concurrent Beneficiaries 362
A Note about Becoming Concurrently Eligible 363
Limitations on Payments to ENs 364
Receiving Services from both the State VR Agency and an EN – The Partnership Plus Program 365
How Does Partnership Plus Work? 365
Eligibility for a Second Ticket 368
Dispute Resolution 369
Disputes between Beneficiaries and State VR Agencies 369
Representation of Beneficiaries in Ticket Disputes 372
Role of the WIPA Projects in Working with Beneficiaries on Ticket Issues 372
Role of WIPA Projects in Working with ENs on Ticket Issues 373
Conclusion 377
Conducting Independent Research 377
Additional Resources 378
Timely Progress for Ticket Users Quick Reference Chart 379
I
9
Module 3 – Understanding Social Security Disability Benefits and Associated Work Incentives
Introduction
National research consistently demonstrates that many Social Security disability beneficiaries hesitate to participate in return-to-work efforts because they fear paid employment will cause them to lose critical cash benefits and health insurance. In most cases, this fear is unjustified, as the Social Security disability programs include many work incentives designed to encourage and facilitate employment. The WIPA services that CWICs provide are the single most effective method for communicating correct information to help beneficiaries overcome these fears. However, to be effective in this counseling, CWICs must completely understand Social Security disability programs, their various eligibility requirements, their operational details, and all associated work incentive rules or provisions.
Content in this area will focus on the Title II and SSI disability programs and how wage employment affects eligibility for benefits and cash payment amounts. This module will discuss in detail and provide examples of all work incentives associated with the disability programs. This module will also include a separate unit on how beneficiaries can use PASS as an employment tool and how Net Earnings from Self-Employment (NESE) affect Title II and SSI benefits. Finally, this module will cover rights and protections provided to beneficiaries under the Social Security disability rules and regulations, including Expedited Reinstatement (EXR), Section 301 payments, and appeals.
CWIC Core Competencies
· Demonstrates knowledge of the Social Security disability evaluation and continuing disability review (CDR) process, including eligibility criteria for Title II disability and SSI programs and other non-disability programs administered by Social Security.
· Demonstrates the ability to analyze the effects of wage employment on Title II and SSI disability benefits including eligibility and cash payment status.
· Demonstrates the ability to individualize and apply the relevant work incentives using complex, multi-phase case scenarios involving Title II disability benefits, SSI, and concurrent beneficiary examples (e.g., PASS, Student Earned Income Exclusion, Blind Work Expenses, TWP/EPE, Subsidy & Special Conditions, IRWE, etc.)
· Demonstrates the ability to analyze the effects of self-employment on Title II and SSI disability benefits, including knowledge of Social Security and IRS regulations that define self-employment, the manner in which business structures affect Social Security benefits, methods for determining earnings from self-employment, and the application of work incentives that may assist beneficiaries to achieve or maintain a self-employment goal.
· Demonstrates the ability to advise beneficiaries regarding their rights and protections under the Social Security disability rules and regulations, including Expedited Reinstatement (EXR), Section 301 payments, and appeals.
· Assists beneficiaries to participate in the Ticket to Work program by providing counseling on Ticket eligibility, assignment and unassignment procedures, reporting requirements, timely progress requirements, and making referrals to Employment Networks (ENs) and state Vocational Rehabilitation (VR) Agencies.
Competency Unit 1 – Disability Evaluation and Determination
Understanding Eligibility for Social Security Disability Benefits
This unit provides the reader a broad understanding of how Social Security defines disability and gives an overview of the initial application and disability adjudication process. WIPA services are restricted to individuals who are eligible for Social Security disability benefits. CWICs are prohibited from assisting individuals who are in initial application status. However, it’s still important for CWICs to understand the eligibility determination process, as some concepts are relevant even after Social Security establishes entitlement.
In addition, some Social Security disability beneficiaries receiving WIPA services may be eligible for additional benefits. Part of a CWIC’s job is to screen for potential eligibility for additional benefits or services and make referrals to other agencies or programs as needed.
It’s essential to understand that the CWIC’s role in establishing eligibility for Social Security benefits is very limited. While it’s important that CWICs gain a basic understanding of the eligibility determination process, there is NO expectation that they develop expertise in this area. Social Security prohibits CWICs from assisting with this process.
Disability Defined
To meet the definition of disability under the Social Security Act, “a number holder (NH) must be unable to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months.” SGA means “the performance of significant physical and/or mental activities in work for pay or profit, or in work of a type generally performed for pay or profit, regardless of the legality of the work” (See POMS DI 10105.065).
NOTE: The definition of disability under the Social Security Act quoted in the section above has three criteria: