Sep 23, 2016

What's The Solution?

     From WATE:
A young disabled Knoxville woman has lost her Social Security disability and Medicare assistance. She has epilepsy and until a year ago, had uncontrollable seizures. ...
Over the last 15 months, Amy Schnelle’s mom says her daughter’s health improved dramatically with the help of anti-seizure medications. Now, however, Amy Schnelle’s Medicare is ending and she can’t afford to buy the pills. Everything changed when Social Security sent a letter in May of this year saying her $1,200 a month check would be ending. ...
The Schnelles say what Social Security didn’t take into account is once her disability was dropped, she no longer can get the medications needed to control her condition. ...


Anonymous said...

Could she work while being on the medication? If the answer to that is yes, then rather than pay disability, why doesn't the government provide the healthcare and medicine she needs to work? Does this sound unreasonable? Don't we want people in the workforce? Don't most people who are disabled want to contribute if they're able?

Sounds like the government has no clue what they should be doing to really help people,

Anonymous said...

File under ACA for health coverage. If low income she will have assistance, if very low income she will have Medicaid until a point is reached where she can work and get employer coverage. In the short term why she is waiting, direct contact to the medication manufacturer for assistance is always a possibility. Many ways to skin this cat.

Anonymous said...

Additionally she should contact her local CIL (Center for Independent Living) and the Epilepsy Foundation for assistance and techniques for transitioning off of Disability. CILs have community resources folks with backgrounds in Information and Referral to connect people to programs and services in the area.

Anonymous said...

Hmm, well $1200 suggests Title II unless they are including child benefits.

Hmm...I just did a little research. Warre in the Ninth Circuit, and Burnside in the Fifth Circuit address the issue rather succinctly. Basically the inability to afford treatment is good cause for failure to follow prescribed treatment, but the Courts are not willing to require SSA to be responsible for providing preventative treatment to prevent disability. Although, in Warre, the Ninth Circuit does appear to find such a result is in line with the purpose of the Social Security Act, just concluding Congress and SSA would be responsible for such a change. That is about the nicest thing I can say about Warre. Frustrating case. Not sure on the Sixth Circuit where this individual resides, but it isn't looking good.

In regard to administratively, any overpayment could be argued under POMS GN 02250.100 given the circumstances as recovery would defeat the purpose of the Social Security Act given indigency. In regard to continuation of benefits, 20 CFR § 404.1594(c)(3)(iv) does permit benefits to continue despite temporary remission of symptoms...if treating physicians say that the seizures will return if treatment does not continue, and indigency is good cause for failure to follow treatment, you could make the argument that her seizure disorder is in temporary remission ad infinitum.

Anonymous said...

@ 10:13, without SSI, there's no Medicaid in Tennessee unless you're a child under 21, a parent, or pregnant. A single individual with no kids, not pregnant, has absolutely no Medicaid availability in TN if they're not on SSI.

Anonymous said...

so she either needs to

a) have kids
b) leave her home state, or
c) go off meds and rack up a lot of medical debt and then get back on disability

Nice job, TN.

Anonymous said...

@1:51 then file the ACA with limited income for subsidy assistance with premium.

Anonymous said...

No Medicaid in NC either, and if no source of income, no ACA subsidy available.

Anonymous said...

How to calculate your subsidy in four easy steps

The size of your subsidy is based on your income, the number of people in your household, and the price of the benchmark Silver plan in your region.

To calculate the size of your subsidy:

1) Use this table to find out whether your income and household size makes you eligible for a subsidy in 2017 (these numbers are based on the 2016 federal poverty guidelines. Since open enrollment for 2017 begins in 2016, these numbers will be used during open enrollment and throughout 2017).

For instance, as the table indicates, a family of three with household income up to $80,360, and a family of five with income up to $113,640, would be eligible to receive a tax credit, depending on the cost of a Silver plan in their area.

Percent of Federal Poverty Level (FPL)

Household Size 100% 133% 150% 200% 300% 400%
1 $11,880 $15,800 $17,820 $23,760 $35,640 $47,520
2 $16,020 $21,307 $24,030 $32,040 $48,060 $64,080
3 $20,160 $26,813 $30,240 $40,320 $60,480 $80,640
4 $24,300 $32,319 $36,450 $48,600 $72,900 $97,200
5 $28,440 $37,825 $42,660 $56,880 $85,320 $113,760
6 $32,580 $43,331 $48,870 $65,160 $97,740 $130,320
For each additional person, add $4,160 $5,533 $6,240 $8,320 $12,480 $16,640

2) Find out how much the Affordable Care Act expects you to contribute to the cost of your insurance by consulting Table 2. The expected contribution is adjusted slightly each year – these percentages are for 2017. If you decide not to buy insurance, you won’t have to pay a premium, but you will have to pay a penalty that will be at least$695 per uninsured adult in 2016 (this applied in 2016, and will be adjusted for inflation in 2017), or 2.5 percent of taxable household income above the filing threshold, whichever is higher. And the penalty does not purchase anything—you wouldn’t have coverage if you needed medical care.

If you earn

Your expected contribution is

Up to 133% of FPL 2.04% of your income
133%-150% of FPL 3.06%-4.08% of your income
150%-200% of FPL 4.08%-6.43% of your income
200%-250% of FPL 6.43%-8.21% of your income
250%-300% of FPL 8.21%-9.69% of your income
300%-400% of FPL 9.69% of your income

The subsidy will make up the difference between the amount an individual is expected to contribute (based on income) and the actual cost of the area’s second-lowest-cost silver plan.

3) Determine out how much a benchmark Silver plan costs in the area where you live. You can scroll through the available quotes in your state’s exchange and see what the second-lowest-cost silver plan’s premium would be for you and your family, or you can call the exchange. It’s important to note that the benchmark plan changes from one year to another; carrier A might have the second-lowest-cost Silver plan one year, but due to premium fluctuations, carrier B might take over that spot the following year.

4) See Table 2. Subtract the amount that you are expected to contribute (based on your income) from the cost of your benchmark silver plan. For instance, let’s say your silver plan costs $3000 a year, and you are expected to contribute $1000. You will receive a subsidy of $2,000

Anonymous said...

She has benefit continuation nincluding Medicare and payments up through the ALJ decision which as you all know can be a year or two. In that time she can hopefully secure a job with medical insurance.

Anonymous said...

First, why are her benefits being ceased. Was there a finding of medical improvement, in which case there is no provision for extended Medicare. She is left at the tender mercies of Tennessee Medicaid. My understanding is that thanks to the Republican party, Tennessee has not accepted the Medicaid expansio and she is out of luck.

If she is working and that is the basis of the cessation, after her TWP, then there would still be entitlement to Medicare beyond the cessation. Moreover, if she is working and her unreimbursed medical expenses (IRWE) needed to permit her to work cause a reduction in her income to the point that she is no longer considered engaging in SGA and could still be entitled to benefits. If still entitled to benefits, then she would still be entitled to Medicare which then possibly leads to her medication covered under Part D or some other program which reduces the IRWE and may mean her benefits are still suspended.

This illustrates just how complicated the interaction of disability benefits, medicare, medicaid, and politics can get.

Anonymous said...

She was ceased for medical improvement according to the article.. She is entitled to benefit continuation for both payments and Medicare providing she made a timely appeal both after the initial cessation decision and after the DHO decision until the ALJ decision. In addition per her social media she is attending school. She may be entitled to continued benefits under the 301 provisions.