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Aug 27, 2019

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Coalition Makes Major Strides with Disability Benefits Reform

by | Aug 27, 2019

Coalition building, Equity work, Health, Legislative Updates

Editor’s note: This vignette originally appeared in Colorado Center on Law and Policy’s 2018-19 Annual Report. 

Federal cash assistance programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) provide a monthly income to people living with disabilities. The programs provide about $730 per month– or potentially more for people that qualify for SSDI. Recipients use the benefit to obtain stable housing, get enough food to eat, and cover other critical basics while they are unable to work.

Unfortunately, for many disabled individuals, the income can be long-delayed or simply unobtainable. Due to the complexity of the application process, only 25 percent of people that apply are approved on their initial application and that number is only 10 percent for applicants experiencing homelessness. Most applicants that get denied at the initial level are ultimately approved, but many give up; and those who appeal wait an average of 18 months for resolution of their cases.

Recognizing the delay, several states, including Colorado, established interim assistance programs that provide some support while individuals wait for SSI or SSDI benefits. These state programs provide resources that help people get some extra food and afford transportation. But what happens when the state program also fails to work for the people that need it most? Until recently, that was the case for Colorado’s interim assistance program – Aid to the Needy Disabled (AND).

AND provides just $217 per month to people that have a mental or physical disability that prevents them from working. Until recently, the requirements to qualify for AND were set almost impossibly high. Case in point: applicants were required to get a medical professional to sign a form (commonly known as the “Med 9” form) attesting that the individual is “totally and permanently disabled” and incapable of working – and submit the form within 10 days after receiving it.

“It’s hard for anybody to get a doctor’s appointment within 10 days,” said CCLP Health Care Attorney Allison Neswood. “AND is supposed to be available for a people that have no income and that are dealing with significant disabilities. That timeline was just impossible for too many.”

A similarly impossible rule required AND applicants to verify that they had applied for SSI within 10 days of applying for AND. It can take months to complete these applications properly, even when a person has the help of an expert.

To further complicate matters, in order to meet the disability standard for the program, health care providers had to mark on an applicant’s form that the applicant had a “total and permanent disability.” Mental health professionals were especially reluctant to characterize their patients that way. So, even when patients had a serious mental illness, providers would mark that the patient had a temporary disability. When this happened, the applicant would not be considered disabled unless a county worker — not trained in disability — determined the applicant faced functional limitations that, in combination with social factors, prevented them from working.

Furthermore, the list of providers who could sign the Med 9 was unnecessarily restrictive. For example, Licensed Clinical Social Workers (LCSWs), psychologists and Licensed Professional Counselors were unable to verify that their patients couldn’t work due to a disability. Such mental health professionals are often are often more aware of their clients’ physical and mental limitations than doctors or psychiatrists, and are more accessible.

Working on solutions
With frustrations around the Med 9 process and restrictions reaching a fevered pitch, a work group consisting of CCLP, Colorado Cross-Disability Coalition, Bayaud Industries, Easter Seals, the Colorado Coalition for the Homeless and the Denver Chapter of the National Alliance of Mental Illness came together in late 2014 to tackle some of the barriers that stood between people with severe disabilities and their benefits.

“Our approach was multi-pronged,” Allison said. “We knew there were some things that could start to alleviate the problems that didn’t require regulatory or statutory change.”

As a first step, the group reached out to mental health professionals to understand their issues with the Med-9 and worked with CDHS to develop a simple one-page cover letter that accompanied the Med 9 form. The letter was designed to inform the providers why they are being asked to sign the form and to clear up some misunderstandings, regarding liability and the definition of “totally and permanently disabled” that gave many professionals pause. The easy-to-read letter is now standard with every Med 9 form.

Next, the work group took aim at regulatory changes, including the disability assessment completed by county workers, the AND timelines. They worked with employees the Colorado Department of Human Services on several rules to bring to the State Human Services Board. The rules gave clients more time to prove that they have a qualifying disability, expanding the timeline from 10 days to 30 days.

The changes also give clients 60 days to complete their SSI application and, while the old rules required an SSI application be completed before a person could begin receiving AND, the new rules allow AND applicants to begin receiving AND while they work on their SSI application so they can take advantage of that full 60-day timeline. The new rules also took county administrators out of the business of determining a client’s ability to work. Finally, the rules expanded the list of providers who can verify that an AND client has a qualifying disability as a result of a statutory change in 2018 that we worked on concurrently.

The Human Services Board was very receptive to the proposed rules and unanimously approved them during a September 2018 meeting in Durango. They were implemented in November, 2018.

Legislation assists applicants
With the rule changes regarding the AND application process already in the works, CCLP and its coalition partners turned their attention toward legislation that would provide services to help people successfully apply for SSI/SSDI.

Among other things, the services would assist applicants with getting a documentation of their medical and employment history, schedule and honor appointments, facilitate communication with government agencies, review and submit application forms, and appeal if the application is denied. A similar pilot program was tested due to legislation passed in 2014, with encouraging results.

The legislation, House Bill 1223, was introduced in the 2019 legislative session, but there were concerns that a $3.8 million fiscal note made it a tough sell to legislators.

“It didn’t look like it was going to go through,” Allison said. “We thought there was no chance of getting money because of too many competing priorities.”

Thanks to strong testimony from partners during a hearing, and the persuasive point that investing in assistance services would actually save the state $3 million a year through federal reimbursements from SSI/SSDI and reducing the wait times and AND payments, the bill passed through its first committee by a vote of 8-1.

“Our coalition did a good job identifying, rallying and bringing their strong voice and perspective to the Capitol,” Allison said.

The program secured $1.5 million from marijuana revenue in its first year, which will become a $3.8 million line-item in subsequent years. The bill was approved in both chambers with bipartisan support and signed by the governor. Now that the legislation is law, CCLP is working on implementation by identifying recommendations for CDHS and working on a formula for allocating the money to the counties.

The difference we make
These comprehensive reforms will make a difference for Coloradans seeking income assistance for a physical or mental disability. CCLP deeply appreciates the support, passion and expertise its advocacy partners contributed in making the changes happen and it appears that they value our role as well.Looking back, Allison said this successful effort is a great example of how systems change works at CCLP and in the advocacy world in general.

“You have to look at multiple types of advocacy, use multiple skills sets and approach things from multiple directions,” she said. “In order to make the system work better, we had to look at administrative process forms and procedures, regulations and state statute. That systemic view of the problem is what helped us identify the appropriate solution. In the end, this is about getting people who aren’t working into the most stable income program in the country: SSI/SSDI. It’s step one for the financial security of this population.”  

 

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

Health First Colorado is the name given to Colorado’s Medicaid program. Medicaid provides public, low-cost health insurance to qualifying adults and children. It is an entitlement program funded by the federal, state, and county governments and is administered by counties in Colorado. Those who are required to pay must pay a small co-pay when receiving certain health care services.

State Department: Department of Health Care Policy and Financing

Eligibility: Most adults 18 to 64 are eligible for Medicaid in Colorado if their household income is at or below 133% of the federal poverty limit (FPL). Pregnant women are eligible with incomes of up to 195% FPL, while children under 18 may be eligible if the live in a household with income at or below 142% FPL. Some adults over 65 may also be eligible for Medicaid.

Program Benefits: Through Medicaid, low-income Coloradans are eligible for a range of health care services at little to not cost. Services provided include doctors visits, prescription drugs, mental health services, and dental care. Co-pays for certain individuals may be needed for certain services.

Program Funding and Access: Colorado funds our Medicaid program through state and federal dollars. Medicaid is an entitlement program, which means that all who are eligible for Medicaid can access the program, regardless of the funding level in a given year. This does not mean that it is always easy to access Medicaid, even when eligible. And since the program is administered by counties, funding levels for county staff and other administrative roles can make it easier or harder for Coloradans to access the program. On top of this, not all medical providers accept Medicaid which limits the ability of Coloradans to seek health services even if enrolled, such as if the nearest provider is a 2+ hour drive away.

Note: This data is from before the pandemic and does not reflect changes in enrollment rules during the COVID-19 pandemic and public health emergency.

Statewide Program Access 2015-19: Over the study period of this report, an average of 89.0% of the population at or below 133% of FPL (i.e., the population who is likely to be eligible for Medicaid) were enrolled in Medicaid in Colorado.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

The Supplemental Nutrition Assistance Program or SNAP helps low-income Coloradans purchase food by providing individuals and families with a monthly cash benefit that can be used to buy certain foods. SNAP is an entitlement program that is funded by the federal and state governments and administered by counties in Colorado.

State Department: Department of Human Services

Eligibility: Currently, Coloradans qualify for SNAP if they have incomes below 200% FPL, are unemployed or work part-time or receive other forms of assistance such as TANF, among other eligibility criteria. Income eligibility for SNAP was different during the study period of this report than today—it was 130% FPL back in 2019 for example. The US Department of Agriculture uses the population at or below 125% FPL when calculating the Program Access Index (or PAI) for SNAP. We follow this practice in our analysis despite Colorado currently having a higher income eligibility threshold.

Program Benefits: SNAP participants receive a monthly SNAP benefit that is determined by the number of people in their household and their income. Benefit amounts decrease as income increases, helping households avoid a sudden loss of SNAP when their incomes increase, even by a minor amount. Benefits are provided to an Electronic Benefit Transfer (EBT) card that can be used to purchase eligible food items, such as fruits and vegetables; meat, poultry, and fish; dairy products; and breads and cereals. Other items, such as foods that are hot at their point of sale, are not allowable purchases under current SNAP rules.

Program Funding and Access: SNAP, like Medicaid, is a federal entitlement program. This means that Colorado must serve any Coloradan who is eligible for the program. As such, funding should not be a limit to how many Coloradans can be served by the program. However, funding for administration of SNAP at the state and county level can limit the ability of county human service departments to enroll those who are eligible. Other program rules and administrative barriers can make it difficult for Coloradans to receive the benefits they are legally entitled to receive.

Statewide Program Access 2015-19: Over the study period of this report, an average of 61.1% of the population at or below 125% of FPL (i.e., the population who is likely to be eligible for SNAP) were enrolled.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children, also know as WIC, provides healthcare and nutritional support to low-income Coloradans who are pregnant, recently pregnant, breastfeeding, and to children under 5 who are nutritionally at risk based on a nutrition assessment.

State Department: Department of Public Health and Environment

Eligibility: To participate in WIC you must be pregnant, pregnant in the last six months, breastfeeding a baby under 1 year of age, or a child under the age of 5. Coloradans do not need to be U.S. citizens to be eligible for WIC. In terms of income, households cannot have incomes that exceed 185% FPL. Families who are enrolled in SNAP, TANF, Food Distribution Program on Indian Reservations (FDPIR), or Medicaid are automatically eligible for WIC. Regardless of gender, any parents, foster parents, or caregivers are able to apply for and use WIC services for eligible children.

Program Benefits: WIC provides a range of services to young children and their parents. These include funds to purchase healthy, fresh foods; breastfeeding support; personalized nutrition education and shopping tips; and referrals to health care and other services participants may be eligible for.

Program Funding and Access: WIC is funded by the US Department of Agriculture. The state uses these federal funds to contract with local providers, known as WIC Clinics. In most cases, these are county public health agencies, but that is not the case in all Colorado counties. Some WIC Clinics cover multiple counties, while others are served by multiple clinics. Private non-profit providers are also eligible to be selected as a WIC Clinic.

Statewide Program Access 2015-17: Between 2015 and 2017, an average of 52.2% of the population eligible for WIC were enrolled in the program in Colorado.

Financial Security:
Colorado Works

Colorado Works is the name given to Colorado’s program for Temporary Assistance to Needy Families or TANF. It is an employment program that supports families with dependent children on their path to self-sufficiency. Participants can receive cash assistance, schooling, workforce development and skills training depending on the services available in their county.

State Department: Department of Human Services

Eligibility: In general, Coloradans are eligible to enroll in TANF if they are a resident of Colorado, have one or more children under the age of 18 or pregnant, and have very low or no income. For example, to be eligible to receive a basic cash assistance grant through TANF, a single-parent of one child could not earn more than $331 per month, with some exclusions—and would only receive $440 per month (as of 2022). That said, there are other services provided by counties through TANF that those with incomes as high as $75,000 may be eligible for. In addition to these, participants in TANF are required to work or be pursuing an eligible “work activity” or work-related activity. Any eligible individual can only receive assistance if they have not previously been enrolled in TANF for a cumulative amount of time of more than 60 months—this is a lifetime limit that does not reset. Counties may have additional requirements and offer benefits that are not available in other counties in Colorado.

Program Benefits:  While the exact benefits that one is eligible for under TANF can vary, all qualified participants are eligible to receive a monthly cash payment, call basic cash assistance. Other than cash assistance, counties are have a lot of choice in how to use their TANF funding; generally a use of TANF funds is appropriate so long as it advances one or more of the four purposes of the program: (1) provide assistance to needy families so that children can be cared for in their own homes or in the homes of their relatives; (2) end the dependence of needy families on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families.

It is important to note that those eligible for TANF are also eligible for many of the other programs we’ve included in this report, such as SNAP, Medicaid, and CCCAP.

Program Funding and Access: Colorado funds its TANF program through funds received from the federal government through the Temporary Assistance for Needy Families block grant. Most of the federal funds are allocated by the state to counties, which are required to provide a 20% match of state funding. Federal and state rules allow the state and counties to retain a portion of unspent funds in a TANF reserve.

Statewide Program Access 2015-19: Over the study period of this report, an average of 50.7% of the population at or below 100% of FPL (i.e., the population who is likely to be eligible for TANF) were enrolled in TANF in Colorado.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

The Colorado Child Care Assistance Program provides child care assistance to low-income families and caregivers living in Colorado in the form of reduced payments for child care. It is a program funded by the federal, state, and county governments and is administered by counties in Colorado. The share owed by parents/caregivers is determined on a sliding scale based on the family’s income.

State Department: Department of Early Childhood Education

Eligibility: Counties set eligibility for families separately, but must serve families with incomes at or below 185% of the Federal Poverty Limit. Families accepted to the program are no longer eligible once their income exceeds 85% of the state median income. Parents or caregivers must be employed, searching for work, or engaged in another approved activity to be eligible for CCCAP. Parents and caregivers enrolled in Colorado Works (Temporary Assistance to Needy Families or TANF) or in the child welfare system are also eligible to participate in CCCAP. Generally, CCCAP serves families with children under 13, although children as old as 19 may be eligible under certain circumstances.

Program Benefits: If a family is eligible for CCCAP and has income, they may likely have to pay a portion of their child’s or children’s child care costs each month. The amount that families owe is based on their gross income, number of household members, and the number of children in child care in the household. As such, households tend not to experience a benefit cliff with CCCAP when they see their incomes increase

Program Funding and Access: Colorado funds the CCCAP program using federal dollars it receives from the Child Care and Development Block Grant program. The state allocates federal and state funds to counties using a formula that takes into account factors like current caseloads and the number of eligible residents. Assistance is available until the county’s funds are spent, so the number of families that can be served is often a function of how much funding is available and the income and composition of the household that applies. It is not uncommon for counties to overspend or underspend their allocations of funds. The state reallocates unspent funds from counties who underspent to those who overspent. While underspending could indicate a problem with the way a county administers its CCCAP program, it could just as likely be a sign that there are few providers in the county who participate in CCCAP—or a lack of providers generally.

Statewide Program Access 2015-19: Over the study period of this report, an average of 10.8% of the population at or below 165% of FPL and younger than age 13 (i.e., the population who is likely to be eligible for CCCAP) were enrolled in CCCAP.

Housing:
HUD rental assistance programs

The US Department of Housing and Urban Development (HUD) has three housing assistance programs that we look at together: Housing Choice Vouchers (Section 8), Project-based Section 8, and Public Housing. In Colorado, these programs provided assistance to over 90% of the households who received federal housing assistance from all HUD programs. Through federally funded, local or regional public housing agencies (PHAs) are the agencies that administer these programs, through not all are available in all counties. These are not the only programs available in Colorado that assist households afford the cost of housing, such as units funded through federal and state tax credit programs.

State Department: Department of Local Affairs

Eligibility: Generally, households with incomes under 50% of the area median income (AMI) of the county they live in are eligible for these rental assistance programs, although PHAs have discretion to select households with incomes at higher percentages of AMI. That said, HUD requires that 75% of new vouchers issued through the Housing Choice Voucher/Section 8 program in a given year are targeted to households with incomes at or below 30% of AMI. PHAs are also able to create criteria that give priority to certain types of households who are on waiting lists for these programs.

Program Benefits: These rental assistance programs help households afford the cost of housing by reducing their housing costs to around 30% of their household income. In the case of the Housing Choice Voucher program, the PHA pays the voucher holder’s landlord the remaining portion of the rent.

Program Funding and Access: Funding and access are both challenges for these rental assistance programs. In addition to limitations on the number of public housing units or housing vouchers a PHA can manage or issue, lack of funding compared to the need constrains the ability of PHAs to assist low-income households. In 2020, Coloradans were on waitlists for Housing Choice Vouchers for an average of 17 months. Waitlists also exist for the other rental assistance programs.

Statewide Program Access 2015-19: Over the study period of this report, an average of 21.1% of renter households with incomes at or below 50% AMI (i.e., the population who is likely to be eligible for HUD rental assistance programs) were living in subsidized housing.