Benefit Development Resource Toolkit: Benefit Development

Overview

When a person applies for OPWDD services, it is important for agency staff to look at the person’s income and resources, to gather all the information needed to obtain and maintain financial benefits for the person, to assist the person and/or their family in applying for any additional financial benefits to which the person may be entitled, and to notify appropriate benefit-paying agencies of changes in the person’s financial situation or address. The timing of benefit-related actions, including applications and change reporting, is critical to an agency’s operations because benefit eligibility is not always retroactive. The maximum retroactivity for Medicaid (for example) is three months; therefore, if actions are not taken timely, the result could be the loss of benefits for the individual and loss of revenue for the agency.

Agency Responsibilities

Prompt and thorough completion of financial benefit development actions protects and supports the individual as well as the service provider. Applying for Medicaid coverage and HCBS Waiver enrollment and carrying out the actions needed to maintain Medicaid coverage, such as recertification, allows the person to obtain needed services and facilitates provider payments for those services. Because of this, it is strongly recommended that each voluntary provider agency establish procedures and assign responsibility among staff to ensure that all the following occurs:

  • Assign responsibility for financial benefit development actions to specific staff trained on benefit development. The timing of these actions is critical. Staff assigned this area of responsibility must know the financial benefit program requirements and have the time to handle the associated benefit development issues.
  • Evaluate the individual’s potential for financial benefits.  It is important that the person who handles benefit development or assists individuals with those actions knows the financial history of the individuals they are assisting. Information about an individual’s history of benefits and the information needed for benefit applications should be gathered in coordination with the person’s care manager.  This information will help identify financial benefits for which an individual may be eligible and for which an application should be filed.
  • Do protective filings for SSI. An individual’s Supplemental Security Income (SSI) benefit is effective the month after the SSI application is filed or the month after the first month the individual is eligible for SSI, whichever is later. The filing date is the date that a person contacts the local Social Security Administration office to make an appointment. This initial contact is referred to as the “protective filing date”. It is important to be aware of these time frames when developing an SSI benefit for an individual to maximize the person’s benefit.
  • Apply for Medicaid while SSI is still pending. File a Medicaid application when the application for SSI is made. This will maximize the retroactive period for Medicaid coverage.
  • Apply for new financial benefits, report changes, and submit recertification and renewals in a timely manner. It is in the best interest of the individuals served that action be taken promptly. This will ensure that benefits are in place at the earliest possible time and are maintained without interruption.
  • Ensure that all mail, information, and other materials regarding financial benefits are given to the appropriate designated staff and that agency procedures are aligned so this happens. The person who handles benefit development must be able to react to all determinations regarding benefit eligibility and requests for information in a timely manner.
  • Ensure that designated financial benefit development staff attend training related to benefit eligibility requirements and processes. Benefits and Entitlements training, which is offered by OPWDD, provides the basic information needed to obtain and maintain Medicaid, SSI, Social Security, Supplemental Nutrition Assistance Program and Medicare benefits for eligible individuals. Other benefit training and more advanced training is also available through OPWDD. Registration for training can be accessed in the Statewide Learning Management System (SLMS) on the OPWDD website at: https://opwdd.ny.gov/providers/statewide-learning-management-system-slms
  • In addition, Revenue Support Field Offices (RSFO) are available to provide guidance on these and related topics.
  • Maintain all documentation associated with benefits and make copies of the documents. Documentation of all categorical and financial information related to benefit eligibility is required for benefit applications, recertification, renewals and audits. It is important to keep copies of the documents provided to benefit-paying agencies in case the documents are lost. Copies of previously submitted documents also make it easier to know what income, resources, or other eligibility requirements need to be updated at the time of benefit recertification and renewals.
  • Contest denials and overpayment requests. Any decision made regarding financial benefit eligibility or payment can be contested or appealed if there is a reason to believe it is in error. A care manager or family member may assist in completing an appeal of those determinations in order to protect the interests of the individuals.
  • Obtain information needed for future financial benefit development through regular contact with the individual, family, financial representative and other sources. Gather information about the individual, including Social Security number, places of employment, retirement status, health insurance coverage, veteran status, or other information related to benefit eligibility or finances (e.g., the individual’s bank accounts, life insurance policies, trusts, or burial funds) to develop benefits on the individual’s own work or military service record.
  • Plan for future benefits to be developed for the individual when a parent retires, passes away, or begins receiving disability benefits. At admission, gather and record the information that will be needed to file applications for financial benefits for the individual based on a parent’s work or military service record. The basic information needed includes the parents’ full names, dates of birth, Social Security numbers, dates of disability or death, veteran status and benefit claim numbers.
  • Investigate sources of information about the individual and parents. Consider phone or in-person contact with the individual, family, financial representative, and other sources of needed information. Contact can take many forms, such as an annual questionnaire sent to the family or other contacts for completion, telephone conversations, discussions when family and friends visit, and speaking directly to the individual.

Why is a Benefit Eligibility Investigation Important?

Because many factors can affect an individual’s eligibility for different financial benefit programs, it is important to conduct a full benefit eligibility investigation when an individual first applies for services. Collecting complete and accurate information on an individual is critical to financial benefit development. This is because needs-based benefit programs such as Supplemental Security Income (SSI) and Medicaid have specific income and asset limits for eligibility, and entitlement programs such as Social Security (SSA) and Medicare are based on the work history of an individual, or certain family members.

In some cases, it may be difficult to determine whether an individual may be eligible for certain financial benefits (e.g., in the case of non-citizen applicants), however, OPWDD encourages benefits personnel to apply for all possible benefits. The benefit-paying agency will make the eligibility determination. If necessary, OPWDD will advise on appeals if the determination is unfavorable and there is reason to believe the individual is indeed eligible.

Note: A Benefit Eligibility Investigation Questionnaire has been developed to assist agencies with collecting necessary information; see:

Benefit Eligibility Questionnaire at https://opwdd.ny.gov//benefit-eligibility-questionnaire 

The Benefit Eligibility Investigation Process

The Benefit Eligibility Investigation involves collecting information about:

  • the individual
  • the type of Medicaid coverage the individual needs
  • the individual’s income
  • the individual’s resources
  • life insurance the individual may hold
  • health insurance coverage the individual may have
  • the individual’s parents and spouse

Each step in the Eligibility Investigation process is described below.

Collecting Information about the Individual

Obtaining information about the individual right from the start is critical for establishing financial benefits. It is also important to keep in mind that while the individual might not be eligible for a specific type of benefit at the time of application, the individual could become eligible in the future. Collect as much relevant information about the individual as possible, including:

  • Name
  • Date and Place of Birth
  • Social Security Number
  • Veteran Status (if applicable)
  • Marital Status
  • Spouse’s Name (if applicable)
  • Date and Place of Marriage/Divorce (if applicable)
  • U.S. Citizenship Status
  • Alien Registration Number (if not a U.S. citizen)
  • Date of Entry to the U.S.
  • Port of Entry to the U.S.
  • Court Appointed Representation (if applicable) - Legal Guardian, Conservator or Committee, or Trustee

Note:  Acceptable forms of documentation are listed later in this section.

Collecting Information to Determine the Type of Coverage the Individual Needs

For individuals who will receive services through OPWDD, it is very important that the correct Medicaid coverage be in place; otherwise, payment for these services may be denied. Filing for full coverage[1] is recommended whenever possible.

Many factors must be considered when applying for benefits for an individual. These include the individual’s specific living arrangement (whether or not it is an OPWDD-certified living arrangement), whether the individual is enrolled in the Home and Community Based Services (HCBS) Waiver program, and if the individual has already been documented as disabled. To ensure the correct type of Medicaid coverage, ask the following questions and compare the answers to the coverage needs for the individual:

  • Is the individual under the age of 21?
  • Does this individual live with their parents?
  • Is this individual already covered by Medicaid?
  • If covered by Medicaid, what is the Client Identification Number (CIN)?
  • If not already covered by Medicaid, has a Medicaid application been filed?
  • If a Medicaid application has been filed, what was the application date?
  • If a Medicaid application has been denied, what was the date and reason for denial?
  • Is this individual already enrolled in the Home and Community Based Services (HCBS) Waiver program?
  • If not already enrolled in the HCBS Waiver program, has an HCBS Waiver application been filed?
  • If an HCBS application has been filed, what was the application date?
  • If an HCBS application has been denied, what was the date and reason for denial?

Note:  Acceptable forms of documentation are listed later in this section.

Collecting Information about the Individual’s Income

Eligibility for certain types of financial benefits depends not only on an individual’s living situation, as indicated above, but also on the amount and type of an individual’s income.

Income is defined as any payment received from any source. Income may be received on a recurring basis (e.g., monthly), or as a one-time payment. The categories of income are “Earned” and “Unearned”.

Earned income is received as a result of work activity, including:

  • Wages
  • Salaries
  • Tips
  • Commissions
  • Self-employment

Unearned income is income paid because of a legal obligation or entitlement rather than for current services performed.  Unearned income includes:

  • Pensions
  • Government benefits such as:
  • Supplemental Security Income
  • Social Security
  • Railroad Retirement
  • Veterans benefits
  • Unemployment Insurance benefits
  • Dividends
  • Interest
  • Insurance compensation
  • Support payments

Note:  Acceptable forms of documentation are listed later in this section.

[1] “Full Medicaid Coverage” is defined as the minimum level of Medicaid coverage necessary to pay for the services being requested or received.

Determining Income Eligibility Levels – Questions to Ask

Income eligibility levels change on an annual basis.  To assist in determining income eligibility for certain financial benefits, the following questions should be asked:

  • Does the individual receive income from any source, such as:
  • Social Security Disability Insurance (SSDI)
  • Supplemental Security Income (SSI)
  • Veteran’s Administration (VA)
  • Is this individual currently working?
  • Where does the person reside or expect to reside?

Note:  Acceptable forms of documentation are listed later in this section.

Collecting Information about the Individual’s Resources

Full disclosure of both an individual’s current and future resources is important so as to ensure the individual is within the resource limits of the specific needs-based benefit programs. Needs-based benefits include Supplemental Security Income (SSI), Medicaid, certain VA benefits, and SNAP.

Different financial benefit programs have different resource limits that may change on an annual basis. Resources should be monitored because benefits will be affected if resources are not within the specific limits for the benefit.

Determining Current Resources– Questions to Ask

In order to obtain information about an individual’s current resources, the following questions should be asked:

  • Has the individual sold, given away or transferred any cash, real estate, or other asset(s) during the last 60 months? Note: This question should be asked only if the individual will be residing in an Intermediate Care Facility (ICF) or has a trust.
  • Has the individual placed any asset(s) into a trust or have any disbursements been made from a trust established for the individual’s benefit?
  • Does the individual have any bank account(s), credit union account(s), certificates of deposit, annuity, 401(k), other retirement account, stocks, bonds,
  • securities, or interest in real property (including home ownership)?
  • Does this individual have a burial fund?
  • Does the individual have a pre-need funeral contract, a burial trust, a burial plot or other burial space items?

Note:  Acceptable forms of documentation are listed later in this section.

Determining Future Resources– Questions to Ask

There are times when it is anticipated that an individual will receive money in the future. This could affect the individual’s needs-based benefits. Obtain as much information as possible regarding any future resources to avoid potential problems with the individual’s financial benefits. If the information is known ahead of time, resources can be protected for the individual so that they remain eligible for benefits.  The following question should be asked:

  • Does the individual have an interest in, possible interest in, or expect to receive an inheritance, lawsuit settlement, trust fund or other asset?
Collecting Life Insurance Information about the Individual

Having life insurance may affect an individual’s financial benefits. It is therefore necessary to determine whether the individual has life insurance and if so, to monitor policies to ensure that they remain within benefit limits.

Life insurance that has a cash surrender value and is owned by the individual is excluded from SSI and Medicaid countable resources if the total face value of all policies that are owned is $1,500 or less. However, if the total face value of life insurance is more than $1,500, the total cash surrender value (the amount that the insurer will pay upon cancellation of the policy before death or maturity) of the insurance counts as a resource.  If specifically designated as funds set aside for burial, up to $1,500 can be excluded from the individual’s resources for that purpose.

Note:  Acceptable forms of documentation are listed later in this section.

Collecting Health Insurance Information about the Individual

Because Medicaid is the payer of last resort, it is important for the local Department of Social Services to know about any other health insurance coverage an applicant may have.

The following questions should be asked:

  • Does the individual have Medicare? If yes, is it:
    • Medicare Part A (Hospital Insurance)
    • Medicare Part B (Medical Insurance)
    • Medicare Part C (Medicare Advantage Plan)
    • Medicare Part D (Prescription Drug Plan)
  • If the individual has Medicare Part A or Part B, what is the effective date and the Medicare claim number?
  • If the individual has Medicare Part D or Part C, what is the effective date of coverage, the plan name and number, and the policy number?
  • Is the individual covered by any other type of health insurance through an employer or a family policy?
    • If so, what is the effective date of coverage, the policy number, group number, subscriber’s name and name and address of the group/employer?

Note:  Acceptable forms of documentation are listed later in this section.

Collecting Information about the Individual’s Parents and Spouse

Individuals may become entitled to certain financial benefits based on the work record of a parent or spouse (if applicable). It is important to be aware whether the person’s spouse and parents are working, retired, disabled or deceased, and to take timely action to apply for benefits when the status of a spouse or parent changes. The following information about the individual’s spouse and parents should be obtained to apply for benefits on behalf of the individual:

  • Full Name at Birth/Maiden Name
  • Date of Birth
  • Place of Birth (City, State)
  • Social Security Number
  • U.S. Citizenship Status
  • U.S. Veteran Status (if applicable)
    • Serial Number of Veteran
    • Claim Number of Veteran
  • If the parent/spouse is already receiving a disability/retirement benefit
    • If so, what is the date of the disability/retirement?
  • If the parent/spouse is deceased
    • If so, what was the date and place of death?

Documenting the Information that has been Collected

When applying for benefits, documentation of information collected about the individual and the individual’s resources is required. The following is a list of accepted documentation:

Citizenship or Current Immigration Status

Verification must be provided when applying for SSI, SNAP or Medicaid or when renewing eligibility for any person whose status has changed in the past 12 months. Any one of the following is acceptable verification:

  • U.S. Birth Certificate
  • U.S. Passport
  • U.S. Baptismal Certificate
  • Official U.S. Hospital/Doctor Records
  • Certificate of Naturalization (N-550 or N-570)
  • Permanent Resident Card (I-551) issued by the Department of Homeland Security (DHS)
  • One of the following, issued by the U.S. Citizenship and Immigration Services (USCIS):
    • Arrival/Departure Record (I-94)
    • Voluntary Departure Notice Letter (I-210)
    • Order of Supervision (I-220B)
    • Memorandum of Creation of Record of Lawful Permanent Residence (I-181)
    • Employment Authorization Document (I-766)
    • Notice of Action (I-797)
Residency/Home Address

Benefit payment programs may require documentation of the individual’s residence address at application and/or at renewal. Acceptable verification can be one or more of the following:

  • ID card with address
  • Driver’s license or non-driver’s ID issued within past six months
  • Letter/lease/rent receipt with home address from landlord
  • Property tax records or mortgage statement
  • Postmarked envelope, postcard, or magazine label with name and date
  • Utility bill (gas, electric, cable), bank statement, or correspondence from a government agency
Income and Resources

Anyone applying for or renewing a needs-based benefit must submit proof of income and resources.  Acceptable verification is as follows:

Income
  • Earned income from employer – current paycheck/stubs (four consecutive weeks) or letter from employer.
  • Self-employment income – current signed income tax return or record of earnings and expenses
  • Rental/roomer-boarder income – letter from roomer, boarder, tenant or check stub
  • Unemployment benefits – award letter/certificate, benefit check stub, correspondence from NYS Department of Labor
  • Private pensions/annuities – statement from pension/annuity
  • Social Security benefits – award letter/certificate, benefit check stub, correspondence from Social Security Administration
  • Employment-based sick pay/disability income – award letter/certificate, benefit check stub, correspondence from source of income
  • Child support/alimony – letter from person providing support, letter from court, child support/alimony check stub
  • Worker’s Compensation – award letter, check stub
  • Veteran’s benefits – award letter, benefit check stub, correspondence from Veterans Administration
  • Military pay – award letter, check stub
  • Interest/dividends/royalties – statement from bank, credit union, or financial institution, letter from broker, letter from agent
  • Support from other family members – signed statement or letter from family member
  • Income from a trust – photocopy of trust document or a sheet with details about the trust, including the source of the money, the name of the trustee, location of
  • the trust, account number and the value of the trust
  • Other income not listed above- signed statement or letter from the person/source providing the income
Resources
  • If the individual has sold, given away or transferred any cash, real estate, or other resource(s) during the last 60 months – information about the type of asset, name of the person receiving the bank statements or holding the records
  • If the individual has any bank account(s), credit union account(s), certificates of deposit, annuity, 401(k), other retirement account, stocks, bonds, securities, or interest in real property (including home ownership) – description and details of
  • the resource(s), bank statements, deed or appraisal for real estate, copies of stocks, bonds, or securities
  • If the individual has a burial fund, pre-need funeral contract, a burial trust, a burial plot or other non-burial items – a copy of the contract(s)
  • If the individual has life insurance – insurance company’s name and address, the policy number, the face value of the policy and the name and address of the person holding the policy. A copy of the policy is preferred.
  • Private or Employer Based Health Insurance – copy of the insurance policy, premium statement, and insurance card. If the person is no longer covered, a termination letter is needed.
Responsibility for Maintaining Individuals’ Benefits

The person or entity responsible for developing and maintaining financial benefits, including filing all applications, recertifications, and meeting all reporting requirements for each benefit for which the person is eligible/entitled, depends on the person’s living arrangement and other factors. The following should be used as a guide to determine primary responsibility for benefit development/maintenance:

If the individual resides in a certified residential setting:

  • Residential agency staff is responsible if the residential agency is or will be Representative Payee for the person’s SSI and/or Social Security benefits and Authorized Representative for Medicaid and/or SNAP benefits.
  • The care manager is responsible for assisting the person if the person handles their own benefits.

If the individual resides in the community, the care manager is responsible for assisting the person as needed.  If the person has a parent, other family member or friend serving as Representative Payee, the care manager should assist the Representative Payee if requested to do so.

The above clarification does not remove any of the responsibilities placed on providers under the Liability for Services regulations to ensure the individuals they serve obtain and maintain the coverage necessary to pay for the services they receive.