Chapter VII - B

Financial Measures

Availability of Comparable Services and Benefits

Comparable services and benefits are defined as any appropriate service or financial assistance available to a individual with a disability from a program other than Vocational Rehabilitation to meet, in whole or in part, the cost of services to be provided to an eligible individual (Section 361.53 of Federal Regulations). The State VR agency must ensure, in all instances where comparable benefits are required, that there has been a determination of available comparable services and benefits. If comparable services or benefits exist under any other program, but are not available to the individual at the time needed to satisfy the rehabilitation objectives in the individual's Individualized Plan for Employment (IPE), the agency shall provide vocational rehabilitation services until those comparable services and benefits become available. Comparable services or benefits are not required if waiting for such services or benefits would place the customer's job in jeopardy.

Note:  Customers receiving Social Security benefits under Titles II or XVI of the Social Security Act are exempt from consideration of financial need for vocational rehabilitation services.
The VR services for which comparable services and benefits, including post-employment services, must be considered are:

1. Physical restoration and treatment;
2. Maintenance;
3. Tuition for college and vocational training programs;
4. Occupational licenses, tools, equipment, and initial stocks and supplies; and
5. Transportation.

Comparable benefits DO NOT need to be considered for VR services, including post-employment services, for the following:

1. Assessment to determine eligibility and priority for services;
2. Assessment to determine vocational rehabilitation needs;
3. Counseling and guidance;
4. Personal and vocational adjustment;
5. Job placement; and
6. Rehabilitation technology.

It is the policy of Vocational Rehabilitation of the Virginia Department for the Blind and Vision Impaired to make maximum use of the customers' "comparable benefits" to meet the costs of the customers' Vocational Rehabilitation programs. Utilization of comparable services and benefits is mandatory.
Relationship between Comparable Services and Benefits and the Customer’s Participation in the Cost of Services
It is important to remember that comparable services and benefits and the customer’s participation in the cost of services are not synonymous. A customer may not have to participate in the cost of services and still have to utilize whatever comparable services and benefits may be available to meet the cost of the VR services listed above. Examples: An SSI/SSDI recipient who is a college student must apply for a Pell Grant and also must use the SSA income as a "comparable benefit" for maintenance; a customer who does not have to participate in the cost of services and needs eye surgery must use his/her medical insurance before VR funds are expended.

1. Medicare

The Medicare program is a federal health insurance program for people 65 or older and certain disabled people. It is operated by the Health Care Financing Administration of the U. S. Department of Health and Human Services. Social Security Administration offices across the country take applications for Medicare and provide general information about the program. An individual must apply for Medicare before he/she can receive it.

There are two parts to the Medicare program: Hospital Insurance (Part A) helps pay for in-patient hospital care, some inpatient care in a skilled nursing facility, home health care, and hospice care. Medical Insurance (Part B) helps pay for medically necessary doctor services, out-patient physical therapy and speech pathology services, cataract glasses, and other medical services and laboratory tests. It covers certain prescribed purchases or rental of medical equipment.

1. Deductible, Coinsurance, and VR
   Medicare is first payee. VR will be financially responsible for only those services not covered by Medicare or Medicare allowable fee. The payment cannot exceed those fees established in the DRS Service/Item Reference Manual, Volume II. VR cannot make payment until after the physician's office, hospital, outpatient clinic/office, or the customer/patient have sent a Medicare payment verification (EOB) to the counselor.
   
   The physician, hospital, and outpatient clinic/office receive "Summary Statements" from Medicare. The customer/patient receives an "Explanation of Medicare Benefits", and if the customer loses this explanation, he/she can call Medicare for a duplicate copy. Providers commonly refer to the statement they receive as "EOBs"--Explanation of Benefits. The Medicare toll-free number is 1-800-552-3423.
   
   The hospital deductible amount gives Medicare coverage for 60 days from the date of hospital admission. If a customer must go into the hospital twice and, if 61 or more days elapse between the date of first discharge and the date of second admission, then the hospital deductible amount must be paid again in order for the customer to have this Medicare coverage. In counting days in such a situation, the day of first discharge is not counted.
   
   All Part B services (ambulatory surgical centers, outpatient hospital, physicians, etc.) are subject to the annual deductible (see Chapter 7A for annual deductible fee) (January through December), and Part B will pay 80 percent of allowable charges. The beneficiary is responsible for 20 percent of the allowable charges.
   
   
2. Ambulatory Surgical Centers (ASC facility)
   Part B also covers outpatient facility services called "Ambulatory Surgical Centers" (ASC facility).
   
   
3. Outpatient Hospital Services
   The "Ambulatory Surgery Program" includes outpatient hospital services, and it has a listing of over 1,400 procedures. This Medicare medical insurance helps pay for covered services received as an outpatient from a participating hospital for diagnosis or treatment of an illness or injury.
   
   Major outpatient hospital services covered are:

   a.   Services in an emergency room or outpatient clinic;
   b.   Laboratory tests billed by the hospital;
   c.   X-rays and other radiology services billed by the hospital;
   d.   Medical supplies such as splints and casts;
   e.   Drugs and biologicals which cannot be self-administered; and
   f.    Blood transfusions administered as an outpatient.

4. Durable Medical Equipment
   Medicare can also help pay for durable medical equipment, such as oxygen equipment, wheelchairs and other medically necessary equipment that a physician prescribes for use in the home. Medical equipment may be rented or purchased. In general, durable medical equipment that costs more than $150 must be rented. Inexpensive medical equipment can be either purchased or rented.
   
   
5. Intraocular Lenses
   In most instances, Medicare pays for intraocular lenses in outpatient hospital services and at the Ambulatory Surgical Centers. Part A pays for these lenses when inpatient hospital services are provided. VR will not pay for intraocular lenses when the lenses are included in the Medicare allowable charges.
   
   
6. Assignment
   When the physician or other service provider accepts assignment, the medical insurance payment is directly received from Medicare. By law, the service provider who accepts assignment can only claim the deductible, coinsurance (20 percent of allowable fee), and services not covered by Medicare. The difference(s) between the bill charges and Medicare allowed charges cannot be billed to the patient or any other third party (VR). However, the service provider can charge for any services that Medicare does not cover.
   
   A directory called "Accepts Assignment on Medicare Claims" is usually published annually, and a free copy can be ordered by calling the Medicare 800 number.
   
   
7. Non-Participating Physicians
   These physicians can bill the patient the balance of medical charges after Medicare pays 80 percent of the allowable charges. The customer/patient receives the payment from Medicare.
   
   A non-participating physician can accept assignment on an individual basis. When this occurs, the guidelines in number six (6) apply.

8. * Medicare law requires doctors who do not take assignment for elective surgery to give you a written estimate of your out-of-pocket costs if the total charge is $500 or more.
   
   
9. VR Authorizations under Medicare
   When VR services are authorized under Medicare, Part B, the counselor will authorize up to 20 percent of the established fee in the DRS Service/Item Reference Manual, Vol. II. If the Medicare payment to the service provider exceeds the DRS allowable fee, DBVI will not make any additional payment. If the payment is less than the allowable DRS fee, DBVI may pay the difference up to 20 percent of that fee.
   
   On the Hospital Authorization Form, show dollar amount of surgeon's fee $______* (which is 20 percent of the VR fee) and an asterisk after the dollar amount. In order to provide an explanation as to how the amount being authorized was derived, type an asterisk after specialist fee with the following statement: *$_______ is 20 percent of VR fee, less Medicare payment.
        

The following are examples of medical coverage under Medicare:

a.   The provider (physician) bills for intraocular lens surgery (CPT 66980) at $2,000 to Medicare, which means the provider accepts assignment. The VR fee is $1,100. The Medicare deductible has not been met, and Medicare allows $1,500 for the procedure (surgery):

i.    Billed by provider $2,000;
ii.    Medicare allowed 1,500;
iii.   Deductible 75
iv.   Coinsurance 285 ($1,500 - $75=$1,425x20%=$285);
v.   Medicare pays $1,140 ($1,500-$75-$285=$1,140);
vi.   VR pays $ -0- (The $1,140 Medicare payment exceeds $1,100 VR allowable fee.); and
vii.  The $1,140 Medicare payment exceeds the $1,100 fee. The customer/patient should not have to pay the $285 coinsurance because the “authorized fee(s) is for payment in file.” And
viii. Inpatient hospital surgery—VR will only pay the hospital deductible.

2. Medicaid 
   The Medical Assistance Program (Medicaid) was established under Title XIX of the Federal Social Security Act to enable states to provide medical care for public assistance recipients and medically-needy persons; i.e., persons of low income who can meet their maintenance needs but have insufficient income to provide the cost of medical care. The program is financed by state and federal funds.
   
   Virginia law provides that the Medicaid Program be administered by the State Department of MEDICAL ASSISTANCE SERVICES. Determination of eligibility for medical assistance and the provision of related social services are the responsibility of local departments of social services under the supervision of the State Department of Social Services.
   
   The groups of individuals to which VR may sometime provide services and who are eligible for Medicaid are: welfare recipients other than GR (General Relief) and SSI recipients (some exceptions: category-related, medically-needy persons and recipients of auxiliary grants). The Medical Assistance Program (Medicaid) coverage would equal or exceed the amount specified in the VR Fee Schedule (DRS's Services/Item Reference Manual, Vol. II). VR cannot pay a vendor who already has accepted Medicaid funds.
   
   Medicaid is first payee for VR customers. Providers that enroll as Medicaid providers agree to accept Medicaid payment as payment in full. Therefore, Medicaid covered services cannot be authorized for VR customers. VR will not pay for medical services when the customer is a Medicaid recipient. Therefore, the customer must use a service provider that accepts Medicaid. Authorizations can be issued for a VR customer who has a pending Medicaid application if the medical services needed require immediate attention.
   1. The Medicaid "Spend-Down" - Customers and their immediate families who otherwise meet the eligibility requirements, but who have income in excess of the established amount, are ordinarily ineligible for medical assistance at the time of application (an exception may be the person in a nursing home); but may become eligible if the excess is insufficient to meet the total cost of needed medical care, and such excess has been incurred or applied to the cost of medical care.
   2. Spend-down Deductions - Only those medical expenses that are the obligation of an applicant or members of the Medicaid family unit are deducted from the spend-down amount. Medical expenses covered by Medicare or other medical insurance are not obligations of the individual or family unit members.
   3. Retroactive Eligibility - A VR customer can request coverage of unpaid medical bills for a Medicaid covered service within three months (90 days) from the date of entitlement. Entitlement begins the first day of the month in which the service was received, provided all eligibility factors were met during those months.
   4. Resources - The Department of Medical Assistance Services sends a monthly report on "Medicaid eligible cases and recipients for program designation codes" to DBVI. The regional office WSS/Intake worker keeps these printouts, and also maintains portions of or all of the Medicaid Manual.
      
      During the first week of each month, Medicaid recipients receive their monthly blue and white Medicaid card.
      
      
3. Private Medical Insurance
   VR requires that a customer's medical insurance claim (such as Blue Cross) be settled before VR pays. VR will pay the difference between the amount specified in the DRS Service/Item Reference Manual, Volume II, and the amount which the insurance paid (assuming that the insurance payment was less than the amount allowable in the DRS Services/Item Reference Manual, Volume II). If the insurance paid an amount equal to or greater than the amount specified in the VR Fee Schedule, then VR cannot pay anything. Of course, VR can pay for necessary goods or services not covered by the customer's insurance.
   
   
4. Pell Grant
   Pell Grant funds are available to economically eligible individuals attending approved:
   1. Colleges;
   2. Community/junior colleges;
   3. Vocational schools;
   4. Technical institutes;
   5. Hospital schools of nursing; and
   6. Other select post-high school institutions.
            See Chapter 9A College Training for additional information on this subject.
      
      
5. Other Grants and Scholarships
   

   Customers enrolled in institutions of higher learning are also required to apply for whatever grants or scholarships may be available. This is especially important in the case of graduate students who are categorically ineligible for the Pell Grant. The case folder documentation and IEP items are the same as for the Pell Grant (see D of this Chapter).
   
   Title IV of the Higher Education Act states that in order to receive a grant, loan, or any work assistance, a student must not owe a refund on funds previously received or be in default on any student loan (20 U.S.C. Section 1091 (a)(3)). Therefore, a customer who has defaulted on a student loan should make every effort to clear the default status before seeking VR sponsorship for higher education.
   
   There may be occasions when it would be a true hardship for a customer to repay the loan and, therefore, the customer would not have available comparable benefits and services. A "true hardship" is defined as an individual who has limited or no financial resources available and cannot work out a satisfactory repayment agreement with the lender. In this instance, VR assistance may be appropriate. The VR counselor must staff the customer's individual situation with his/her supervisor and then document the decision in an AWARE Case Note.

6. Monetary Merit Awards
   Monetary merit awards are those awards provided by civic, professional, social, or customer organizations
   
   These awards will not be considered a comparable benefit in most instances; such as, when the award is provided for "educational purposes" but not restrictive enough to be considered a comparable benefit.
   
   The award must be considered a comparable benefit when the monetary merit award (scholarship) is restricted by the donor; for example, for tuition, fees, etc. (See Chapter 9A for a further discussion of these awards).

7. SSI/SSDI Benefits for Maintenance
   Although technically not defined by RSA as a comparable benefit, SSI and SSDI benefits must be considered to meet or help meet a customer's maintenance costs if the customer leaves his/her home area to participate in a VR training program. If a customer's SSI or SSDI income does not cover his/her maintenance costs while away from home participating in a rehabilitation program, VR funds can be used to pay any difference. The Service Plan page of the IEP must show the customer's SSI or SSDI income, the amounts which the customer and/or VR will pay, and the payment or billing arrangements. "Maintenance" is defined to include the following cost categories:
   1. Food;
   2. Shelter;
   3. Personal incidental expenses; and
   4. Clothing.

   A customer who is an SSI/SSDI recipient cannot be paid a personal incidental allowance, even when training is outside his/her home area, unless it can be shown that all the customer's SSA benefits are being utilized already for food, shelter, and clothing.
   VR can only consider the SSI/SSDI recipient's contractual obligations when determining the monetary amount of the customer's participation. A good example of a contractual obligation is when it can be shown that the customer must maintain a house or apartment in his/her home area during the time that the customer is away participating in a rehabilitation program. This occurs when a customer must maintain a home for spouse, children, or other dependents while the customer is away. Such instances must be documented on the Service Plan. In cases where the customer must use his/her SSA benefits to maintain a household while the customer is away in training, VR funds can be used to pay for the customer's maintenance expenses. These exceptions must be documented on the Service Plan.

8. Other Sources of Comparable Benefits

In addition to the most common categories of comparable benefits mentioned above, the following is a listing of comparable benefit programs for which some VR customers may be eligible. The VR counselor should be knowledgeable about comparable benefit programs and utilize them whenever possible in his/her casework.

1. State and local hospitalization funds;
2. Workers' Compensation;
3. Community mental health services;
4. Veterans Administration;
5. Crippled Children's Bureau;
6. Job Training and Partnership Act (J.T.P.A.); and
7. Virginia Employment Commission; (VEC) Programs.