Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 16 Disability Income Insurance and Disability Benefit Programs Insurance Handbook for the Medical Office 13 th edition
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance and Disability Benefit Programs 1. Define terminology and abbreviations pertinent to disability insurance and disability benefit programs. 2. Describe benefits and exclusions contained in individual and group disability income insurance. 3. Name federal disability benefit programs. 4. Differentiate between SSDI and SSI. 2 Lesson 16.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance and Disability Benefit Programs (cont’d) 5. State eligibility requirements, benefits, and limitations of SSDI and SSI. 6. Explain disability benefit programs for disabled active military personnel, veterans, and their dependents. 7. Name states that have state disability insurance plans. 8. State eligibility requirements, benefits, and limitations of state disability plans. 9. Explain voluntary disability insurance plans. 3 Lesson 16.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance and Disability Benefit Programs (cont’d) 10. Describe topics and contents of a medical report. 11. List guidelines for federal disability claims. 12. Explain procedures for state disability claims. 13. Recognize forms used for processing state disability plans. 4 Lesson 16.1
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Claims Disability income insurance Provides benefits under certain conditions when the insured is unable to work due to illness, disease, or injury Does not provide benefits if the insured is unable to work as a result of a work-related event 5
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved History 1880s – emergence of disability income policies for accident and illness early 1900s – first noncancelable policy 1956 – Congress extended Social Security program to disabled adults over 50 years old 1965 – Social Security program expanded to cover workers regardless of age 6
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Individual Provides specific income if disabled Insured pays premiums Medical expenses not covered Disability must not be work-related Insured must meet specific policy criteria 7
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Waiting period Time from beginning of disability to beginning of first benefit payment Benefit period Maximum span of time that benefit will be paid to the disabled party 8
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Benefits Residual benefits Benefits are paid if disability is partial or limits the capacity to work full-time Supplemental benefits Specific provisions may increase payments Accidental death and dismemberment benefit Special clause addresses accidents that result in death or permanent disability 9
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Types of disability Total disability Person cannot perform most normal work duties Partial disability Person cannot perform all normal work duties Temporary disability Person cannot perform all normal work duties for a limited period of time 10
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Clauses Policies can be guaranteed renewable or noncancelable, with a waiver of premium Exclusions Examples are preexisting conditions, mental conditions, or other disabilities AIDS/HIV Consent and notice form is needed for testing 11
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Insurance Group Some employers offer as an optional benefit Contracts are between the insurer and the employer Employer pays premiums, with or without employee contributions Policy terminates when employee leaves the company 12
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Federal Disability Programs Disability benefit programs Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Civil Service Retirement System (CSRS) Federal Employees Retirement System (FERS) Armed Services Disability Veterans Affairs (VA) Disability Program 13
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Benefit Programs Social Security Disability Insurance Long-term plan provides benefits to workers and self-employed who meet eligibility criteria Insured also may be eligible for Medicare after 24 months Converts to retirement benefits at age 65 14
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Benefit Programs Supplemental Security Income Long-term disability program provides benefits to adults and children regardless of employment history Many persons also qualify for Medicaid Benefits are intended for those with limited income and few other resources 15
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Benefit Programs Civil Service and Federal Employees Retirement System Disability Benefits are payable for life to individuals who qualify. Armed Services Disability Benefits are payable for life if disability occurs or is aggravated while person is on active duty. 16
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Benefit Programs Veterans Affairs Disability Service-connected disability is eligible for outpatient treatment if filed within 1 year of injury. Non-service-connected disability may be eligible for same benefits if criteria are met. 17
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved State Disability Insurance Nonindustrial disability insurance programs exist in only five states and Puerto Rico To fund the programs, a percentage of wages is deducted from paychecks, or the employer pays the plan costs Eligibility ceases upon retirement 18
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved State Disability Insurance Restrictions Time limit for filing exceeded Condition covered under workers’ compensation insurance Unemployment benefits beyond a specified amount Employer has a voluntary disability plan and does not participate in state plan 19
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Voluntary Disability Insurance Designed for persons who reside and work in states without state disability insurance programs Local private insurance carrier arranges coverage If disabled, the person receives fixed weekly or monthly income, usually for 6 months 20
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claims Submission Guidelines Disability income claims Person must provide completed proof of loss to establish disability Attending physician usually must complete portions of this form Medical report may be attached to the form for additional explanation of disability and treatment 21
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Claims Federal disability claims SSA has teledictation service for physician to dictate medical report directly over the phone Only data less than 1 year old is allowed Prognosis should be based on medical findings Claim should include functional assessment of work-related activities 22
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Claims Veterans Affairs disability outpatient clinic claims Processing of claims is usually long and complicated Consider billing VA monthly to avoid payment delays Follow instructions on patient’s ID card closely 23
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Disability Income Claims State disability claims Residents of states with disability benefits must obtain claim forms from nearest state filing office Physician must substantiate disability for claim to be processed Additional forms/filings may be required if disability is prolonged 24
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 25