TN 6 (03-04)

A. Definition of IRWE

An IRWE means an expense for an item or service which is directly related to enabling a person to work and which is necessarily incurred by that person because of a physical or mental impairment. The IRWE must be needed due to an impairment that the DDS established as the medical basis of disability or another impairment that is being treated by a physician or health care provider. Expenses for an impairment-related item or service may include payment for:

• purchase,

• installation,

• maintenance, and/or

• repair.

NOTE: Unless the repair is for an impairment-related modification such as a wheelchair lift, there can be no separate amount deducted for maintenance and repair of automobiles or vans used for transportation to and from work, since these costs are included in the mileage rates indicated in section DI 10520.010J. For examples of IRWEs see the Red Book: http://mwww.ba.ssa.gov/redbook/

B. Definition of Health Care Provider

The IRWE must be needed due to an impairment that the DDS established as the medical basis of disability or another impairment that is being treated by a physician or health care provider. A health care provider must be a licensed or registered professional. Health care providers may include, but are not limited to: osteopaths; naturopaths; psychologists; chiropractors; audiologists; nurse practitioners; dentists; physical, occupational, and speech therapists; registered dieticians; clinical nutritionists; and licensed counselors.

C. Definition of Reasonable Limits

The law provides that an amount equal to the cost to the person with a disability of attendant care services, medical devices, equipment, prostheses, and similar items and services will be deductible from earnings in determining SGA and SSI countable earned income. The deductible amount, however, is subject to reasonable limits. Generally, the amount paid for medical services, medical devices (durable medical equipment), prostheses, and similar medically-related items and services will be considered reasonable if it does not exceed the standard or normal cost for the same item or service in the person's community. See DI 10520.025D for development and documentation procedures on the issue of reasonable limits.

D. Definition of Attendant Care Services

For purposes of this provision, attendant care services are those forms of assistance which help a person with a disability meet his or her essential needs at home or at work, such as bathing, toileting, dressing, cooking, eating, communicating, traveling to and from work, and similar personal needs. Attendant care services can include services provided to help a person with a disability in performing the functions of his or her job, such as a reader or a job coach. This definition is applicable only to those services which can be shown to be needed to enable the person with a disability to work.

1. Attendant Care at Work or to and from Work

Payments made for attendant care services are deductible as IRWE if the services are needed in the work setting or in assisting the person in traveling to and from work. Payments for attendant care at work or to and from work are deductible when the cost is paid for by the person and not provided by an employer.

2. Attendant Care at Home

Payments made for attendant care services rendered in the home are deductible only if the services relate to preparations for going to work, or to assistance required by the person with a disability immediately upon his or her arrival home from work. Some examples of allowable in-home attendant care services would be those relating to bathing, dressing, cooking, eating, administering medications, or arranging medical devices in the period of time immediately preceding the person's departure for work, or immediately following his or her return home from work. Such services should generally require no more than 2 hours in the morning and/or evening, unless it can be verified that additional hours are necessary for the claimant to prepare for work or to address needs upon arrival back home from work. Examples of attendant care services, which would not be allowable as deductions are those performed on non-workdays, or those performed at any time which involve shopping or general homemaking (e.g., cleaning, laundry).

3. Attendant Care Which Incidentally Benefits Family

Payments made for attendant care of a person with a disability are deductible even if while attending to that person, the attendant performs services which incidentally also benefit the person's family. An example would be a situation in which the attendant, in addition to helping the person bathe, dress, etc., also cooks for him or her and other members of the person's family may incidentally share the meal.

4. Attendant Care to Others

Payments made by the person with a disability for services rendered to someone else are not deductible. Payments are deductible only when the services are provided for, or the items are used by, the person. For example, any payment by a person with a disability to care for his or her child is not deductible.

5. Attendant Care by a Family Member

a. Family Member

For the purpose of this provision, a family member is anyone who is related to the person with a disability by blood, marriage, or adoption, whether or not that person lives with the person.

b. Payment

If a person with a disability pays a member of his or her family to perform attendant care services, such payment will generally not be deductible as an IRWE unless:

• It is established that the family member has been otherwise employed and suffers economic loss by reducing the number of work hours or terminating his or her own employment in order to perform such service; and

• The payment is made to the family member in cash (including checks or other forms of money); payment in kind (e.g., room and board) is not deductible.

c. Documentation and Proration

See DI 10520.025C.3. concerning documentation of attendant care services by a family member and DI 10520.030F. concerning proration of such expenses.

E. Definition of Medical Equipment

Medical equipment is defined as durable medical devices which can withstand repeated use, are primarily used to serve a medical purpose, and are generally not useful to a person with a disability in the absence of an illness or injury. Examples in this category are wheelchairs, hemodialysis equipment, respirators, intermittent positive pressure breathing machines, pacemakers, inhalators, nebulizers, suction machines, traction equipment, braces (leg, arm, back and neck), and similar items.

1. Prostheses

Prostheses include devices that replace internal body organs or external body parts. Examples of prosthetic devices are artificial hips and artificial replacements of arms, legs, or other parts of the body. Payment made for a prosthetic device that is used solely for cosmetic rather than restorative or functional purposes usually is not deductible.

2. Other Impairment-Related Equipment

Other impairment-related equipment means items other than durable medical equipment and prostheses which a person with a disability may need to perform the tasks required in his or her job, or to move from home to mode of transportation, or to control the disabling condition at home or in the work setting to be able to function in a work activity.

Payments for equipment that is impairment-related and necessary for the person with a disability to do his or her job are deductible when the equipment is paid for by the person and not provided by an employer. Costs paid by the person for training in the use of such equipment are also deductible. Examples of such equipment are one-handed keyboards, typing aids (e.g., page-turning devices), measuring instruments, vision and sensory aids for the blind, telecommunications devices for the deaf, technology that people with disabilities use for employment-related purposes; such as software applications and assistance (help), computer support services and special tools which have been specifically designed to accommodate the person's impairment. (Where a self-employed person deducts the costs of such equipment as a business expense, the cost is not deductible as an IRWE in determining SGA or SSI countable earned income.)

F. Definition of Nonmedical Appliances and Equipment

1. Items Essential to Person's Functioning

Payments for devices that are used by a person with a disability who works at home or elsewhere and that are not ordinarily used for medical purposes, such as portable room heaters, air conditioners, humidifiers, dehumidifiers, electric air cleaners and posture chairs, are not generally deductible as IRWE. However, in some situations, the person may be able to establish an impairment-related and medically verified need for such an item because it is essential for the control of the disabling condition both at home and in the work setting. To be considered essential, the item must be of such a nature that if it were not available to the person there would be an immediate adverse impact on his or her ability to function in his or her work activity. If the situation is as described above, payment for the item is regarded as an IRWE, regardless of whether the item is used at home or in the work place. An example is the need for an air cleaner by a person with severe respiratory disease who cannot function in a non-air cleaned environment.

2. Items Used for Physical Fitness

Expenses for items that are used for physical fitness purposes, such as a stationary bicycle or treadmill, are not deductible unless the items are prescribed by the treating physician or health care provider as necessary for treatment of a person's impairment and necessary to enable the person to work.

G. Definition of Residential Modifications

Residential modifications are defined as changes that are made to the person's home in order to accommodate his or her functional limitations. Whether or not the costs of residential modifications are deductible as IRWE, however, depends upon the location of the person’s place of work.

1. Person Employed Outside the Home

A person with a disability who is employed away from home may require changes outside his or her residence that permit the person to get to his or her means of transportation (e.g., the installation of an exterior ramp or special exterior railings or pathways). Getting to one's mode of transportation can be regarded as part of the total process of getting to and from work. Payment for modifications that make possible the person's movement from his or her residence to transportation are deductible, therefore, as an IRWE. However, changes that modify the interior architecture or operation of the person's residence are primarily intended to facilitate his or her functioning in the home environment; therefore, payments for these changes are not deductible as IRWE. Examples of such modifications are the enlargement of doorframes and the lowering or rearrangement of kitchen appliances and bathroom facilities or the installation of a stairway chairlift.

2. Person Works at Home

Payments for modifying the interior of the home in order to create a working space to accommodate a person's impairment are deductible to the extent that the modifications pertain specifically to the work space. Examples of such modifications are the enlargement of a doorway leading into an office or any other type of work area or the modification of the work space to accommodate problems in dexterity. However, when the determination involves payments made by a self-employed person who works at home, the costs of such modifications generally are deductible from gross income as business expenses. Any such costs deducted as business expenses are not deductible as IRWE.

3. Tele-Work Modifications

An employer may establish a special tele-work program to accommodate the needs of employees with disabilities who need home-based work. The costs for the purchase and maintenance of equipment necessary for tele-work are deductible as IRWE when the individual works under such an employer tele-work program which was designed exclusively for one or more employees with disabilities. Examples of items in this category which may be deducted as IRWE include high speed internet service, a second phone line, and computer maintenance. This excludes optional tele-work, temporary off site work, work at home after regular hours, or while traveling.

H. Definition of Drugs and Services

Payments for prescription drugs, over-the-counter drugs, and medical services are deductible only if such drugs and services are prescribed and necessary for control of the disabling condition to enable the person with a disability to work, and if the person pays for them.

Control refers to reducing or eliminating symptoms or slowing down progression of the disease.

Even if the drugs or medical services do not control the impairment, payments for such items are deductible if the drugs or medical services were provided with the medical objective of controlling the condition.

Examples of items in this category are anticonvulsant drugs; blood level monitoring; radiation treatment or chemotherapy; corrective surgery; co-payments and deductibles for drugs and medical services and antidepressant medications.

Drugs, medical, dental, or optical services that are not directly related to the impairment(s) cannot be deducted as IRWE. The cost of premiums for health and/or life insurance cannot be deducted as IRWE.

Prescription drugs that are a violation of Federal law (e.g. medical marijuana) cannot be deducted as an IRWE, even if allowed by State law.

1. Diagnostic Procedures

Payments for diagnostic procedures are deductible only if the objective of the procedures is related to the control of the disabling condition to enable the person to work, and the person pays for such procedures. For example, payment for a diagnostic procedure is deductible if it is performed to ascertain how the impairment is progressing or to determine what type of treatment to provide for the impairment.

Examples of items in this category are electroencephalograms, brain scans, or tests to determine appropriate medications.

2. Drugs and Services for Minor Physical or Mental Conditions

Payments for drugs or medical services which are used by the person with a disability only for minor physical or mental problems not resulting in any significant loss of function are not deductible. Examples of such items and services are: yearly routine physical examinations, allergy treatment (when such condition does not constitute a disabling condition), dental examinations, optician services and eyeglasses (when unrelated to a disabling impairment).

3. Medical Supplies and Services

Payment for medical supplies and services are deductible if the supplies and services are related to the control of the disabling condition to enable the person with a disability to work and if the person pays for them, and includes payment of deductibles and co-payments. Included are physical therapy, and medical supplies of an expendable nature, such as incontinence pads, catheters, bandages, elastic stockings, face masks, irrigating kits, and disposable sheets and bags.

I. Definition of Service Animal

Expenses paid by a person with a disability in owning a guide dog or other service animal are deductible as an IRWE if the animal enables the person to overcome functional limitations in order to work. The animal does not have to meet the ADA definition of a service animal. To accurately assess the need for a service animal, documentation is required. (See DI 10520.020, and DI 10520.025). Deductible expenses include the costs of purchasing the animal, training, food, licenses, and veterinary items and services. Other costs directly related to the care of the animal are also deductible as IRWE, such as transportation for training and veterinary services.

J. Definition of Transportation Costs

Transportation costs paid by a person with a disability for travel to and from work are deductible if certain conditions are met. See chart below to assist with determining if transportation cost can be an IRWE.

1. Modified Vehicles

A person with a disability may have deductible transportation costs if his or her impairment(s) requires structural or operational modifications to a vehicle in order to drive or be driven to work. The modification must be critical to the operation or use of the vehicle, and must be directly related to the person’s impairment(s). The cost of the modification, but not the cost of the vehicle, may be deducted as an IRWE. The maintenance and repair costs for the impairment-related modification may also be deducted as an IRWE, but not the cost for maintenance and repair of the automobile or van. A mileage allowance for the trip to and from work is also deductible. See DI 10520.030G.

Vocational rehabilitation (VR) agencies will often agree to pay for modifications to vehicles purchased by a person with a disability; the costs of such modifications paid by the VR (or any other source) may not be deducted from the person's earnings.

Most cases involving modifications to a vehicle will be clear-cut, but if necessary, verify the need for the modification through the treating physician or VR agency.

2. Unmodified Vehicle

If a person’s impairment(s) prevents him or her from taking available public transportation (see DI 10520.030H) and he or she must drive an unmodified vehicle to and from work, deduct a mileage allowance as an IRWE according to DI 10520.030G. No separate amount can be deducted for maintenance and repair of the automobile or van. A physician, VR counselor, or other medical provider must verify the person’s inability to use available public transportation.

3. Other Transportation Situations

If a person’s impairment(s) prevents him or her from taking available public transportation and he or she must use driver assistance, taxis, or other hired vehicles to work, deduct amounts paid to the driver as IRWE (see DI 10520.030H). If the person’s own vehicle is used in this process, we will also deduct a mileage allowance according to DI 10520.030G. The inability to use available public transportation, the need for driver assistance, or the use of taxicabs must be verified by a physician, VR counselor, or other medical provider. See DI 10520.010D.5 for driver assistance provided by a family member.

4. IRWE Transportation Decision Chart

K. Definition of Services Received In or Through a Community Residence Program

Community residence living, whether for physically, mentally or emotionally disabled persons, will generally require attendant care or support services which, to some extent, will entail IRWE. Community residence programs may include group homes, foster care arrangements, and supervised person or group apartments.

Expenses for services received in or through a community residence program may be deductible as IRWE provided the usual criteria applicable to other allowable services are met:

• the service must be impairment-related;

• the person with a disability must need the service in order to sustain work activity (i.e., the service must be directly related to enabling a person to hold and function in a job);

• it must be verified that a service available to the person was actually used by the person;

• the person must pay for the service (i.e., cannot be funded, subsidized or reimbursed for the amount paid); and,

• the amount of the expense must be within reasonable limits.

Verification of the nature of the service, its relationship to work, and the person's need for, use of, and payment for the service should be accomplished through the professional staff who provide the service and the physician (if any) who attends the person.

Each case must be developed individually to determine the extent to which the resident actually uses a service that is potentially deductible as an IRWE.

L. Definition of Fees for Supportive Living Programs

Monthly fees required for supportive living arrangements may cover a variety of charges including room, board, support services, attendant care, transportation, etc. Furthermore, fees may be paid from a combination of sources including State and/or Federal funding, title II and/or title XVI benefits, and the person's earnings. Since both deductible and nondeductible services are provided in community residence programs and the person may, in effect, pay only a portion of the total expense of deductible services, the monthly program fees and the person's payment to the program must be prorated to determine how much the person actually pays for deductible services.

1. Procedure when Person Pays Entire Monthly Fee

When the person with a disability pays the entire program fee, the FO should first try to learn whether there is an agreement or contract between the residence program and the person that specifies how the monthly fee is apportioned between the various services provided by the program.

a. Agreement or Contract Exists

If an agreement or contract has been made, the terms of the agreement should be followed. For example, if the agreement specifies that 20 percent of the person's total fee is attributable to support services, and half of those services are identified as work-related, then 10 percent of the person's monthly fee can be deducted as IRWE for such services.

b. No Agreement or Contract Exists

If no agreement or contract has been made, the monthly amount paid by the person for deductible services may be determined in one of two ways:

• Apportion Total Budget of Residence Program

  The amount of IRWE for work-related attendant care or support services may be determined by how the total budget of the residence program is divided into its various services, e.g., room, board, attendant care, etc. The proportion allotted for each service would be applicable, at the same rate, to the fee paid by the person. For example, if the residence program spends 20 percent of its budget on support services, and half of those services are identified as work-related, then 10 percent of the monthly fee paid by the person with a disability can be deducted as IRWE.

• Estimate Portion Paid by Person

  If the kind of information needed for the above procedure is not available, it will be necessary to estimate what portion of the total amount paid by the person to the residence program can be attributed to work-related attendant care or support services. Such an estimate may be reached by inquiring about the various services the person with a disability actually receives (e.g., room, transportation, attendant care, etc.), and by assigning a value to each of those services in terms of the total amount paid for them by the person. The help of the person and the professional staff in the residence program will be needed to identify those services which are work-related and to establish a reasonable apportionment of monthly fees to such services.

2. Procedure when Person Pays Only Part of Monthly Fee

When the person with a disability pays only a portion of the total monthly program fee and the balance is paid from State or Federal funds or some other source, the FO should try to learn whether the supplemental funds paid by the other source are prescribed by law (or other agreement) for specific items or services (e.g., only housing, or only counseling).

NOTE: Where the SSI person's payment to the facility is not payment in full and the payment can be attributed towards either IRWE or food and shelter, attribute the payment in the manner more advantageous to the person.

a. Supplemental Funds Are Prescribed

If supplemental funds are prescribed for specific items or services, the amounts for those items or services cannot be deducted as IRWE because the person with a disability did not pay for them.

b. Supplemental Funds Are Not Prescribed

If supplemental funds (or any portion of them) are not prescribed, the FO should first try to learn whether there is a stated agreement or contract between the residence program and the person specifying how the monthly fee is apportioned for the various services provided.

• Agreement or Contract Exists:

  When there is an agreement, its terms should be followed. Only that portion of the expense for attendant care or support services that is paid by the person can be deducted.

  Example: The agreement specifies that $200 of the total monthly fee is attributable to attendant care or support services. If half of these services are work-related, then $100 can be deducted. If the total cost of maintaining the person in the residence is paid equally by the person and some other source, then one-half of this amount, or $50, can be deducted as an IRWE for the work-related services.

• No Agreement or Contract Exists:

  If the person with a disability pays only a portion of the total monthly residence fee, and there is no agreement for how the fee is to be apportioned, the FO may follow one or the other of the two procedures outlined above (i.e., by proration of the residence budget, or by estimation of the costs of attendant care or support services) to determine:

  • What portion of the total monthly cost of maintaining the person in the residence is attributable to attendant care or support services;

  • What percentage of those services can be identified as work-related; and

  • What portion of the total monthly cost is attributable to the person?

    Example: If the total monthly fee for community residence is $1,000, and the resident pays $700 ($350 from earnings, $350 from title II benefits), and the balance ($300) is paid with unassigned State funds, then the person is paying seven-tenths of any particular expense from his or her own funds. If attendant care or support services constitute 20 percent of the total monthly fee, and half of those services are identified as work-related services, then 10 percent of the total monthly fee ($100) can be attributable to deductible services. Since the person can be said to pay seven-tenths of any particular expense, then $70 can be deducted as an IRWE for the service.