New York Legal Assistance Group | 7 Hanover Sq. New York, NY 10004 | www.nylag.org

Last updated: July 15, 2015

DISABLED ADULT CHILD BENEFITS & MEDICAL COVERAGE

I. DAC Eligibility

An adult disabled before age 22 may be eligible for child’s benefits if a parent is deceased or receiving

retirement or disability benefits .The adult must be (1) unmarried, (2) age 18 or older, and (3) have a

disability that started before age 22. DAC benefits generally end if he or she gets married. However, some

marriages (for example, to another adult disabled child) are considered protected. An adult child must

also not have substantial earnings (SGA). DAC benefits are also known as CDB benefits.

Example: A worker starts collecting Social Security retirement benefits at age 62. He has a 38-year old

son who has had cerebral palsy since birth. The son will start collecting a disabled “child's” benefit on his

father's SSA record.

An adult child already receiving disability benefits should still check to see if benefits may be payable on

a parent’s earnings record. It is possible for an individual disabled since childhood to attain insured status

on his or her own record and be entitled to higher benefits on a parent’s record.

SSA Regulations

§ 404.350. Who is entitled to child's benefits?

(a) General. You are entitled to child's benefits on the earnings record of an insured person who is entitled

to old-age or disability benefits or who has died if—

(1) You are the insured person's child, based upon a relationship described in §§ 404.355 through

404.359;

(2) You are dependent on the insured, as defined in §§ 404.360 through 404.365;

(3) You apply;

(4) You are unmarried; and

(5) You are under age 18; you are 18 years old or older and have a disability that began before

you became 22 years old; or you are 18 years or older and qualify for benefits as a full-time

student as described in § 404.367.

§ 404.353. Child's benefit amounts.

(a) General. Your child's monthly benefit is equal to one-half of the insured person's primary insurance

amount if he or she is alive and three-fourths of the primary insurance amount if he or she has died. The

amount of your monthly benefit may change as explained in § 404.304.

(b) Entitlement to more than one benefit. If you are entitled to a child's benefit on more than one person's

earnings record, you will ordinarily receive only the benefit payable on the record with the highest

primary insurance amount. If your benefit before any reduction would be larger on an earnings record

with a lower primary insurance amount and no other person entitled to benefits on any earnings record

would receive a smaller benefit as a result of your receiving benefits on the record with the lower primary

insurance amount, you will receive benefits on that record. See § 404.407(d) for a further explanation. If

you are entitled to a child's benefit and to other dependent's or survivor's benefits, you can receive only

the highest of the benefits.

§ 404.360. When a child is dependent upon the insured person.

One of the requirements for entitlement to child's benefits is that you be dependent upon the insured. The

evidence you need to prove your dependency is determined by how you are related to the insured. To

prove your dependency you may be asked to show that at a specific time you lived with the insured, that

you received contributions for your support from the insured, or that the insured provided at least one-half

of your support. These dependency requirements, and the time at which they must be met, are explained

in §§ 404.361 through 404.365. The terms living with, contributions for support, and one-half support are

defined in § 404.366.

II. Medicare Eligibility

Medicare works the same for disabled adult children as for recipients of disability (DIB) benefits. Both

groups have a twenty-four month waiting period, with the exception of the individuals noted in the POMS

below. Both groups are required to pay a Medicare Part B premium, unless they are eligible for the

Medicare Savings Program. There is no premium for Medicare Part D (medications) but the individual

must pick a Part D plan and should also make sure that they are receiving Part D Extra Help, if eligible.

SSA Regulations

POMS HI 00801.146. Entitlement to HI [Health Insurance] for the Disabled

In most cases, D-HI entitlement begins after an individual has been entitled (or deemed entitled) to

disability benefits (DIB, DWB, or CDB) for 24 months, i.e., D-HI begins with the first day of the person's

25th month of disability benefit entitlement. […]

EXCEPTION: […]

Since CDB entitlement can begin no earlier than age 18, D-HI entitlement based on CDB entitlement can

never begin before the month the beneficiary attains age 20 (or age 18 if the individual’s disability is

ALS). This is true even though the individual may have been disabled and entitled to child's insurance

benefits for many months prior to age 18. (See example HI 00801.146C.4.)

C4. CDB Entitlement

Sally, who was born 5/7/73, became totally disabled at age 5. In 9/84, when her father died, she became

entitled to minor child's benefits on his record. The 24-month D-HI qualifying period begins with 5/91,

the month she attained age 18, and she is entitled to D-HI beginning 5/93, the month she attains age 20.

III. Medicaid Eligibility

Disabled Adult Child -- (DAC) individuals age 18+ who lose SSI eligibility because of the receipt of

Social Security Disabled Adult Child (DAC) benefits, or because of an increase in the amount of these

benefits, are eligible for Medicaid if certain criteria are met. Individual must have become disabled or

blind before age 22, and lost SSI as the result of entitlement to a DAC benefit, or an increase in the DAC

benefit. If the individual would be eligible for SSI benefits if the amount of the initial entitlement or an

increase in the DAC benefit were disregarded, the individual is eligible for Medicaid.

SSA Regulations

POMS SI 01715.015B4. Disabled Adult Children (Childhood Disability Beneficiaries)

Section 1634(c) of the Act requires States to consider title II childhood disability beneficiaries (also

known as disabled adult children, DACs, or childhood disability beneficiaries, CDBs) who lose SSI

eligibility as if they were still SSI recipients for Medicaid purposes so long as they would have remained

otherwise eligible for SSI benefits but for their entitlement to (or increase in) title II benefits on or after

July 1, 1987.

SSA notifies the 1634 States about members of this group through the SDX. Starting on or about May

1995, members of this group in all States will get special Medicaid referral notice paragraphs numbers

1140 and 1141 (NL 00804.110) in their automated Notices of Planned Action when:

they lose SSI eligibility due to excess income in a month of title II entitlement; and

they are at least age 18; and

the SSI computer record reflects title II continuing income with a Beneficiary Identification Code

(BIC) of “C”.

Medicaid Regulations

DOH Medicaid Reference Guide, Disabled Adult Child (DAC) Beneficiaries, p. 95-96 (attached)

IV. OPWDD Waiver & Services

The OPWDD Waiver, operated by the NY State Office for Persons with Developmental Disabilities

(OPWDD), is a program of supports and services that enables adults and children with developmental

disabilities to live in the community as an alternative to Intermediate Care Facilities (ICFs). These

services can include many things not normally covered by the Medicaid program. Unlike other waivers,

this waiver is not administered by the Department of Health, but instead by OPWDD.

The services that may be provided to a participant in the OPWDD waiver include: Medicaid Service

Coordination; Consolidated Supports and Services; Residential Habilitation; Housing/Individual Support

Services; Family Support Services; Respite Services; Crisis Intervention; Supportive and Supervised

Residences; and Supported Employment Services.

Applying for OPWDD Services

You must have all the required documentation for eligibility determination. Once you have the paperwork

together, you will need to contact the Front Door and attend a Front Door information session.

The Front Door is OPWDD’s process for establishing access to services for people who are new to

OPWDD, or those seeking to modify existing services. During this process, eligibility for services will be

determined. An assessment of the individual’s strengths and needs will be done in order to identify and

authorize appropriate supports. Part of this process also includes participation in an education session,

which is required prior to implementation of services. The DDRO Front Door team is flexible in

providing these training sessions for families, individuals, and professionals. For more information on the

Front Door, you can check the OPWDD website at http://www.opwdd.ny.gov/welcome-front-door/home.

The contact number for all regions in New York State can be found on the OPWDD website (Home »

Services & Supports » Front Door).

OPWDD requires everyone applying for services to provide:

A recent comprehensive psychological evaluation including an IQ score and an adaptive behavior

assessment.

A psychosocial evaluation documenting the individual’s developmental history.

Medical documentation of the individual’s diagnosis may be required.

An annual physical.

If the individual is over the age of 22, they will need to provide proof that the disability

manifested itself prior to the age of 22. This is often referred to as “age of onset documentation.”

The Developmental Disabilities Regional Office (DDRO) may request additional documentation

regarding the person’s disability. For more detailed information regarding evaluations, see the Metro

DDRO guidelines (pdf).

Age of onset documentation can be obtained by requesting old school records, evaluations or other

clinical documentation from doctors or professionals involved with the individual. For individuals who

attended NYC schools, you may submit a documentation request to the NYC Department of Education

using this sample document request letter. Be sure to document all efforts to obtain this documentation. If

you have tried to obtain information and have been unsuccessful, letters from people who have known the

individual since childhood can be used as supporting documentation. The YAI Network can provide the

required comprehensive psychological and psychosocial evaluation. Call YAI LINK at 212.273.6182 to

make a referral or find out more information about the evaluations.

Once you have the required documents, you will need to contact the Front Door. For more detailed

information on eligibility criteria for OPWDD services, visit opwdd.ny.gov or parenttoparentnys.org. You

can also call LINK and an intake specialist will answer your questions and discuss your specific situation.

Go to: http://yailink.org/eligibility/ for more detailed information.

Medicaid Financial Criteria

Single: The same as the income level for community-based Medicaid recipients ($825/month in 2015).

Married: The difference between the allowance for one-person and two-person households under the

regular community Medicaid levels ($384/month in 2015). The applicant spouse is treated as a household

of one and only their income is counted.

Resources: Single $14,850 Married: $21,750

If the individual is put on a HCBS Waiver waiting list, you should not wait before applying for

Medicaid. The individual can apply for Medicaid on their own or with the help of a Medicaid Service

Coordinator. However, many social work agencies that provide Medicaid Service Coordination have

waiting lists for their services. It is easier to move up their waiting list the individual already has

Medicaid. Medicaid Service Coordinator Agencies are here: http://providerdirectory.opwdd.ny.gov/

(Select “service coordination”). It is recommended that the individual get on the list at a few of

them. The turnaround time to process a Medicaid application is 45 days.

UPDATED: AUGUST 1999

95

CATEGORICAL FACTORS MEDICAID EXTENSIONS/CONTINUATIONS

DISABLED ADULT CHILD (DAC) BENEFICIARIES

Description: Section 6 of Public Law 99-643 (42 U.S.C. 1383c(c)), provides that individuals who lose 551 eligibility because of the receipt of Social Security Disabled Adult Child (DAC) benefits, or because of an increase in the amount of these benefits are eligible for Medicaid if certain criteria are met.

Policy:

DAC Social Security benefits are received upon the disability, retirement or death of a parent. An individual is eligible for Medicaid as a DAC beneficiary if all of the following criteria are met:

(1) the individual is at least 18 years old;

(2) the individual became certified blind or certified disabled before reaching the age of 22;

(3) the individual was receiving SSI benefits on the basis of blindness or disability;

(4) the individual lost SSI benefits on or after July 1, 1987; and

(5) the individual's loss of SSI benefits was the result of entitlement to a DAC benefit, or an increase in the benefit.

When the criteria are met, and the individual would be eligible for SSI benefits if the amount of the initial entitlement or an increase in the DAC benefit were disregarded, the individual is eligible for Medicaid.

References: ADMs 95 ADM-11

LCMs 92 LCM-41 (February 28, 1992)

Interpretation: For an individual who lost SSI eligibility because of the initial entitlement to a DAC benefit, the entire amount of the DAC benefit is disregarded in the determination of countable income, including any subsequent increases in the benefit. When ineligibility for SSI was due to an increase in the DAC benefit, the amount of DAC benefits received in the month prior to the termination of SSI is the amount of DAC benefits that are counted in determining eligibility. Any subsequent increase(s) in DAC benefits is disregarded. If the

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UPDATED: AUGUST 1999

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CATEGORICAL FACTORS MEDICAID EXTENSIONS/CONTINUATIONS

DISABLED ADULT CHILD (DAC) BENEFICIARIES

individual would be eligible for SSI (SSI income and resource levels) by disregarding the DAC benefit or increase(s) in the benefit, s/he remains eligible for Medicaid under the DAC provision.

NOTE: When determining Medicaid eligibility for individuals who have been identified as DACs, districts first determine eligibility under the DAC provision, even if the individual appears to have income under the medically needy level. If eligibility cannot be established under the DAC provision, SSI-related budgeting procedures apply.

When a Medicaid recipient eligible under the DAC provision has an increase in either income (other than the DAC benefit) or resources that would have resulted in a loss of SSI eligibility, the recipient will also lose DAC status for Medicaid. By budgeting the DAC benefit, the individual may be subject to a spenddown requirement. If the income and/or resources are reduced to the point where the individual would again be entitled to SSI benefits except for the increase in or entitlement to the DAC benefit, the individual would again become eligible for Medicaid under the DAC provision.

Individuals who are eligible for Medicaid under the DAC provision are evaluated for QMB eligibility. The individual's actual gross income (without disregarding the DAC benefit) is used when determining QMB eligibility (See 89 ADM-7). Regardless of QMB eligibility, individuals who are eligible for Medicaid under the DAC provision are eligible for Medicaid payment of Medicare Part B premiums as is done for the original buy-in groups including SSI recipients and persons qualifying under Sections 503 (Pickles) and 1619(b) of the Social Security Act (Public Law 99-509).

NOTE: In determining the amount of income available for the cost of care under chronic care budgeting, (See INCOME CHRONIC CARE BUDGETING METHODOLOGY FOR INSTITUTIONALIZED SPOUSES and CHRONIC CARE BUDGETING METHODOLOGY FOR INDIVIDUALS) DAC benefits are considered available income and added to all other sources of available income.

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