Both the federal and state governments offer statutory health insurance programs. On the federal level, Social Security provides disability income benefits and administers the Medicare program. At the state level, all states have workers compensation laws and Medicaid or a similar form of state-subsidized health care.
Social Security pays four types of benefits: disability income benefits to workers, Medicare benefits, retirement benefits to workers and their dependents, and survivor benefits to a deceased worker’s family.
A special insured status is required if a worker is eligible for disability benefits under Social Security. This status requires that the worker be fully insured and have earned at least twenty quarters of coverage in the forty-quarter period ending with the calendar quarter that the disability begins. Disability benefits are only payable for total disabilities. The amount of the disability benefit is equal to the worker’s Primary Insurance Amount (PIA) which, in essence, is the same as the individual’s monthly retirement benefit. Benefits begin with the sixth full month of disability. Family members may also receive disability benefits as a result of the disabled person’s work record.
Most states require employers to provide workers compensation benefits for their employees. This coverage is designed to help the person who loses income due to injury or illness which occurs as a result of his or her job. In order to be eligible for “workers comp” benefits the disabled individual must work in an occupation which is covered by workers compensation, and must have had a work-related accident or illness. Four types of benefits are available: medical, income, death, and rehabilitation benefits.
Medical benefits are unlimited. An injured or sick employee is entitled to receive all necessary medical and surgical treatment to cure or alleviate his or her condition. Certain maximums or limits may apply to a particular medical item or type of care, but overall benefits are unlimited.
Income benefits are paid to employees who suffer work-related disabilities. An elimination, or waiting, period applies before benefits for lost wages begin. A disability may be total or partial; either type of disability may be temporary or permanent.
Death benefits provide two types of payments: a burial allowance and weekly income payments for a surviving spouse or children. Weekly benefits are equal to 66% of the deceased worker’s wages, with the payments being subject to time- and aggregate payment limits.
Rehabilitation benefits can reduce overall workers compensation costs by helping to return disabled workers to their jobs. Rehabilitation may include therapy; vocational training; wheelchairs and other devices; and the costs of travel, lodging and living expenses while being rehabilitated.
Medicaid, a state program that’s subsidized with federal funds, is designed to provide assistance to people who are unable to pay for their medical needs. It is principally a Medicare supplement for individuals who can’t pay the expenses that Medicare won’t cover. For those not eligible for Medicare, it provides medical assistance for certain categories of people who are medically needy -- the blind or disabled, families with dependent children, or medically needy children under the age of 21. Medicaid covers such services as hospitalization, physician’s bills, diagnostic testing, pregnancies, and more.