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In accordance with Nebraska State Statutes, Douglas County programs administered by the Department of General Assistance serve as a "safety net" for individuals waiting for disability determinations and eligibility consideration for other federal/state programs. The length of time it takes for the federal and state governments to make a final determination necessitates the need for county programs in the interim. More often, than not, it can take up to two (2) years or longer to get a favorable decision.

There is no presumptive eligibility for Medicaid under the Aid to the Aged, Blind or Disabled (AABD) program. This is why the medical care falls to the county. As an acknowledgement, of sorts, to the length of time it takes to get Disability, the federal and state governments have provided a mechanism for the counties to be reimbursed for basic living needs (shelter, non-food, clothing).

If/when a person is approved; the date of eligibility is retroactive. He/she receives the monthly eligibility payments in a lump sum back to the month of application. It is out of this lump sum amount that the federal /state governments reimburse the county; the balance of this amount is then sent to the individual.

There is no provision for reimbursement of payments for medical bills for services provided to be taken from the lump sum check. The federal/state governments have, however, made provisions for medical providers to bill Medicaid for services provided on behalf of the newly approved individual during the time federal/state applications were pending.

When the individual is approved for Disability benefits, Douglas County bills Medicaid, when appropriate, for any services that were directly provided by Douglas County. These services may include Primary Health Care Network Clinic services, medications dispensed at the Douglas County Health Care Center Pharmacy, services provided through the Center for Mental Health, etc. As a courtesy, Douglas County Primary Health Care Network staff notifies other medical providers so that they, also, can submit bills to Medicaid for medical services provided.

How is Disability Defined?

Disability under Social Security is based on an individual’s inability to do substantial, gainful work. An individual may be considered disabled if, because of an illness, he/she cannot return to the same job, or same type of work that he/she has done in the past; the medical condition prevents training the individual for some other type of work. The inability to work must be expected to last continuously for up to or longer than twelve (12) months, or result in the loss of life.

If the duration of the disability is less than one year but at least six months, the individual may qualify for benefits through the Nebraska Health and Human Services System under the State Disability Program. Eligibility for this program is contingent with applying for and following through with an application for federal benefits.

Cash payments are determined by an individuals work history and financial contributions to the Social Security Administration. Federal funds are paid under two (2) separate programs, Social Security Disability (SSDI) and Supplemental Security Income (SSI). SSDI payments are determined by the amount of an individual’s contributions to the fund through payroll deductions. SSI benefits supplement the individual’s income with a maximum of $552 per month, covers individuals with little or no work history and children who are disabled due to birth defects and other life-threatening illnesses.

In Nebraska, individuals eligible for SSI are also eligible for Medicaid, under the Aid to the Aged, Blind, or Disabled (AABD) program which is funded by the State with most of the cost reimbursed by the federal government.

Length of Time it Takes to Get a Final Disability Determination

The process of applying for SSDI and SSI is long and cumbersome. Individuals may go through many appeals before being approved. The actual time depends largely on the time needed to receive medical reports or other information, whether other special examinations or tests are required and if the individual appeals any unfavorable decision.

Unless it is apparent and/or extremely obvious that the illness creates permanent disability, it can take up to two (2) years before the individual has gotten through all of the levels of the process. Individuals with mental health issues find it even more cumbersome of a process because it is so much more difficult to prove that the illness will last at least one year. For the most part, the challenge is getting the individual to realize he/she is ill.

Most people get denied federal benefits on the first try. It seems that it is the appeal process that makes it take so long. When an individual is denied, he/she may request an appeal within sixty (60) days. If denied at the appeal level, the next step is to request a hearing before an Administrative Law Judge (ALJ). The ALJ may or may not uphold the original decision. The case may be sent back to the first level for further examination, or he/she may approve the original application. If the ALJ upholds the original decision, the individual may request a review by the Appeals Council, or file suit in federal court. At any point during the appeal process, an individual may choose to start the entire venture over with a new application.

How the Social Security Administration Actions Affect Douglas County

Due to the length of time it takes for the Social Security Administration to make a disability determination, Douglas County serves as a safety net to adult individuals who otherwise would have no medical home. Even more serious, the person would not have access to ongoing medical treatment for life threatening, chronic and/or totally disabling illnesses that prevent individuals from being substantially, gainfully employed.

While hospitals are mandated to treat persons who present themselves to an emergency room, they do not provide for daily medical needs on an ongoing basis. Therefore, Douglas County provides for those needs while the individuals wait for federal benefits. The county is not reimbursed for the administrative costs involved in meeting the health care needs of those who are potentially eligible for other programs. If the county were to pay the medical bills for outside providers, the bill to the taxpayer would be enormous.

 

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