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In This Issue:
HCV PI Therapy for HIV/HCV Coinfection
Alan Franciscus, Editor-in-Chief
HealthWise: Searching for Supplements—Part 2
Lucinda K. Porter, RN
Lucinda K. Porter, RN
Disability & Benefits: Taxation of Disability Benefits
Jacques Chambers, CLU
HCV Advocate Eblast
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HCV PI Therapy for HIV/HCV Coinfection
—Alan Franciscus, Editor-in-Chief
A group of experts have issued guidelines for the off-label use of the HCV protease inhibitor (PI)—boceprevir and telaprevir—plus PEG/RBV therapy to treat chronic HCV genotype 1 HIV/HCV coinfected patients. The panel recommended that treatment with PI’s plus PEG/RBV should be made on a patient-by-patient basis and that the benefit of the HCV protease inhibitor combination therapy should outweigh any potential harm. Another important consideration is that the new HCV PI’s should only be used in combination with other drugs that have been tested for drug-drug interactions. This is important because of the possible drug-drug interactions between HCV medications and HIV medications that could reduce or increase the effectiveness of the medications.
In an ideal world we would want to have comprehensive clinical data and the FDA approval before using the new HCV protease inhibitor(s) to treat coinfected people with chronic HCV genotype 1 HIV/HCV. There are, however, many coinfected people who can’t wait and should be treated (under careful supervision of a medical provider) since HCV disease progression can be much faster in someone who is HIV/HCV coinfected.
Source: Provisional Guidance on the Use of Hepatitis C Virus Protease Inhibitors for Treatment of Hepatitis C in HIV-Infected Persons, DL Thomas et al., Clinical Infectious Diseases Advance Access December 14, 2011—online: www.aidsetc.org/aidsetc?page
Merck issued an important warning about drug-drug interactions between Victrelis (boceprevir) and certain HIV medications that could reduce the effectiveness of the medications when given together. The excerpt below is from the warning letter issued by Merck on February 06, 2012.
“In the pharmacokinetic study, concomitant administration of Victrelis with Norvir (ritonavir) in combination with Reyatax (atazanavir) or Prezista (darunavir), or with Kaletra (lopinavir/ritonavir) resulted in reduced exposures of the HIV medicines and Victrelis. Specifically, Victrelis reduced mean trough concentrations of ritonavir-boosted atazanavir, lopinavir, and darunavir by 49%, 43% and 59%, respectively. Mean reductions of 34% to 44% and 25% to 36% were observed in AUC and Cmax of atazanavir, lopinavir, and darunavir. Coadministration of ritonavir-boosted atazanavir with Victrelis did not alter the exposure of Victrelis, but coadministration of Victrelis with lopinavir/ritonavir or ritonaivr-boosted darunavir decreased the exposure of Victrelis by 45% and 32%, respectively.
Source: Merck press release.
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HEALTHWISE: Searching for Supplements—
—Lucinda K. Porter, RN
Last month, I reviewed research on the use of dietary supplements to treat chronic hepatitis C virus (HCV) infection. In addition to the milk thistle derivative, silibinin, I highlighted seven (7) supplements that were tested, but showed no clear evidence to recommend them. This month I discuss supplements that hold promise for HCV patients, albeit preliminarily.
Before discussing individual supplements, it is worth mentioning a small, but interesting study of 50 subjects. Using a combination of seven oral substances (glycyrrhizin, schisandra, silymarin, ascorbic acid, lipoic acid, L-glutathione, and alpha-tocopherol), along with four different intravenous preparations (glycyrrhizin, ascorbic acid, L-glutathione, B-complex) it was administered twice weekly for 10 weeks. Subjects were followed for an additional 20 weeks after the cocktail was stopped.1 Nearly half of the subjects had a small reduction in ALT levels; more than a third had improved liver biopsy results. Twice weekly intravenous infusions may seem drastic for small results, but I think this study opens the door to more research, especially if the results come with minimal side effects.
Here are some supplements I am watching:
• Naringenin is a type of flavonoid found in grapefruit. Researchers at Massachusetts General Hospital discovered that when HCV is secreted from liver cells, it is bound to the destructive cholesterol known as very low-density lipoprotein (vLDL).2 This viral secretion can infect other cells, and naringenin may block this secretion. The research is theoretical at this point, and until we see results from human studies, I am not increasing my grapefruit intake.
Note: Grapefruit juice interferes with the metabolism of some drugs, many of them common. If you take prescription or over-the-counter medications, or dietary supplements, stay up to date on all potential interactions.
• S-adenosyl-L-methionine (SAMe), a substance found in the body, has many functions, particularly in the liver. Used with peginterferon, it may promote antiviral response.3 However, there is no information about it when used with protease inhibitors. Regarding HCV, I put SAMe on my optimistic watch but wait list. I would use it for other reasons, such as depression, but not specifically to help HCV.
• Green Tea is one substance that consistently attracts research interest. In a recent study published in Hepatology,4 researchers noted that one of the components of green tea, epigallocatechin-3-gallate (ECEG) interferes with HCV’s ability to enter the liver cell. The use of green tea is being investigated as a possible strategy to prevent recurrence of HCV infection following liver transplantation. Green tea was found to be safe in healthy volunteers who consumed 8 to 16 servings a day.
Note: There are reports of hepatotoxicity from patients taking green tea extracts. However, I believe these are from contamination and not from green tea. Also, green tea may decrease clotting ability, so if you have blood clotting problems, such as those caused by cirrhosis, and you are about to embark on a major increase in green tea consumption, talk to your medical provider. Be aware that green tea has caffeine, so if you increase your consumption, you will be increasing your caffeine intake. There are decaffeinated green teas, but without research, I cannot comment on the effectiveness of this alternative.
A Cautionary Note
If you are taking HCV or HIV medications, particularly a protease inhibitor, such as boceprevir or telaprevir, do not take any supplement unless medically advised. Many drugs and supplements compete for the same metabolic pathway, meaning that you may get less of one or both substances. If I were going through treatment, I’d want to be sure I got the maximum amount of medication, without concern that a supplement was interfering with the HCV drugs. I might use raspberry leaf, chamomile, or ginger tea for nausea. Instead of ingesting oral supplements, I might turn to healing arts that don’t pass through the liver, such as acupressure, acupuncture, or other physical-based modalities.
“A Problem with Science”
I have been consuming green tea on a daily basis for many years, so naturally I am delighted to see this research. I eat an occasional grapefruit, but I will wait for more naringenin studies before adding more of this fruit in to my regular diet. Although the SAMe research is not compelling enough for me to take this supplement, I will continue to watch for future research.
This leads me to one of the problems with science. Sometimes I might sound a bit smug, as if I rely solely on science to tell me what to take. Honestly, if I thought that daily Brussels sprouts really made me feel better, then I’d be hard pressed to stop if research proved otherwise. I never underestimate the power of placebo, and if someone tells me that a supplement helps him or her, who am I to say otherwise?
In short, science does not have all the answers, although it is an excellent starting place. Research helps me sift through the possibilities and make an informed choice that is best for me. And in the end, that is what each of us must do as we figure out how best to live with HCV.
- Melhem A, et al. Treatment of Chronic Hepatitis C Virus Infection via Antioxidants: Results of a Phase I Clinical Trial Journal of Clinical Gastroenterology September 2005 Volume 39, Issue 8 - pp 737-742
- Nahmias Y, et al. Apolipoprotein B–Dependent Hepatitis C Virus Secretion Is Inhibited by the Grapefruit Flavonoid Naringenin Hepatology Volume 47, Issue 5, pages 1437–1445, May 2008
- Feld J, et al. S-Adenosyl Methionine Improves Early Viral Responses and Interferon-Stimulated Gene Induction in Hepatitis C Nonresponders Gastroenterology March 2011 Volume 140, Issue 3, Pages 830-839
- Ciesek S, et al. The Green Tea Polyphenol, Epigallocatechin-3-Gallate, Inhibits Hepatitis C Virus Entry Hepatology Volume 54, Issue 6, pages 1947–1955, May 2008
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—Lucinda K. Porter, RN
—Alan Franciscus, Editor-in-Chief
Article: HCV Receptor Expression in Human Brain Tissue – N Fletcher, et al.
Source: Gastroenterology published online December 2011
Although chronic hepatitis C virus (HCV) infection is primarily a liver disease, the virus affects other organs and body systems, including the central nervous system. This research examined cognitive dysfunction, seeking to understand whether this was related to liver function, virus infection in the central nervous system, or HCV as a systemic disease.
The Bottom Line: Researchers sampled the brain tissue of those with HCV and found very low levels of HCV RNA, and proof that brain cells support HCV entry and replication.
Editorial Comment: This research does not answer the question of whether or not HCV-related cognitive impairment is related to liver function, virus infection in the central nervous system, or HCV as a systemic disease. However, it does add weight to the notion that HCV may directly affect the brain and its function. There is other research to support this, including research published online by the Journal of Hepatology (Effects of Anti-Viral Therapy and HCV Clearance on Cerebral Metabolism and Cognition, Valerie Byrnes, et al. October 2011). This small but compelling study showed improved cognitive ability following a sustained response to HCV treatment. These recent studies deepen our understanding of HCV’s affect on the body and the potential benefit of treating this chronic condition (LKP).
Article: A Multi-Disciplinary Approach to Treating Hepatitis C with Interferon and Ribavirin in Alcohol-Dependent Patients with Ongoing Abuse – C Le Lan, et al.
Source: Journal of Hepatology January 2012; Volume 56, Pages 334–340
The standard recommendation for alcohol-dependent HCV patients is to delay antiviral therapy until there has been at least six (6) months of sobriety. This study enrolled 73 alcohol-dependent subjects, and administered peginterferon and ribavirin treatment per standard protocols. Abstinence from alcohol was encouraged but not mandated; participants were offered substance abuse help.
Results were compared to a control group taken from a database of nearly 4000 patients.
During treatment, 20 (27%) subjects abstained from alcohol, 23 (32%) controlled their alcohol intake, and 24 (33%) had excessive consumption. Six (6) subjects dropped out of the study due to side effects. Two subjects died during treatment but no evidence indicated that the deaths were research-related.
The Bottom Line: Subjects in this study were almost as likely to achieve a sustained viral response (SVR) to treatment as the control group (48% vs. 49%). Patients who consumed excessive alcohol during treatment were less likely to achieve an SVR. Longer abstinence was associated with a higher chance of SVR.
Editorial Comment: One of the most compelling outcomes of this study was that 22 (30%) patients remained sober by the end of the follow-up period, suggesting yet another potential benefit of HCV treatment. This study offers hope for a subset of HCV patients who are often left out of the loop of treatment, and who are at high risk for advanced liver disease. In short, this study opens the door for HCV treatment for those who cannot or will not stop alcohol use (LKP).
Note: For those interested in finding out more about treating injection drug users (IDUs), read “Cost-Effectiveness of Hepatitis C Virus Antiviral Treatment for Injection Drug User Populations,” by Natasha Martin, et al., in the January 2012 issue of Hepatology. This research makes the argument that it is cost-effective to treat IDUs despite risk of HCV re-infection.
Article: Preliminary Study of Two Antiviral Agents for Hepatitis C Genotype 1 – A Lok, et al.
Source: New England Journal of Medicine January 19, 2012; Vol. 366, No. 3: 216-214
This study included 21 subjects with chronic HCV genotype 1 infection who had not responded to previous treatment. Eleven participants (Group A) were randomly assigned to receive daclatasvir (an NS5A replication complex inhibitor) and asunaprevir (NS3 protease inhibitor). Ten participants (Group B) received daclatasvir/asunaprevir in combination with peginterferon alfa-2a and ribavirin. Treatment lasted 24 weeks with 12 and 24-week follow-up period. Diarrhea was the most common adverse event in both groups.
The Bottom Line:
- Group A – 4 subjects (36%) had a sustained virologic response (SVR) at 12 and 24 weeks
- Group B – All 10 had an SVR at 12 weeks; 9 had an SVR at 24 weeks
Editorial Comment: This was a small study, so you may wonder why it is this being included. Because initially this group of people did not respond at all to peginterferon and ribavirin. The results in Group B are fabulous, and even Group A’s modest 36% is impressive. The New England Journal of Medicine (NEJM) is one of the most prestigious journals, and research published in the NEJM is noteworthy. Another article worth reading in this same issue is “A Watershed Moment in the Treatment of Hepatitis C,” by Raymond Chung. Similarly, Douglas Dieterich’s “The End of the Beginning of Hepatitis C Treatment” appeared in Hepatology (January 2012). The world of hepatitis C is changing quickly (LKP).
Article: Hepatocellular Carcinoma in Olmsted County, Minnesota, 1976-2008 – Ju Dong Yang, et al.
Source: Mayo Clinic Proceedings January 2012; Pages 9-16
Hepatocellular carcinoma (liver cancer or HCC) is the third major cause of cancer deaths worldwide. This study analyzed all newly diagnosed cases of HCC for people over age 20, from 1976-2008 in one county.
The results showed:
- 1976-1990 – 3.8 cases of HCC per 100,000; Most common risk factor was alcohol use.
- 1991-2000 – 3.8 cases of HCC per 100,000; Most common risk factor was alcohol use.
- 2001-2008 – 6.9 cases of HCC per 100,000; Most common risk factor was HCV.
The Bottom Line: The incidence of liver cancer is rapidly increasing, primarily due to HCV.
Editorial Comment: To put this study into perspective, it is worth mentioning an editorial about HCV and HCC that appeared in this same issue of Mayo Clinic Proceedings. “Hepatitis C Virus Infection and the Rising Incidence of Hepatocellular Carcinoma” written by Denise Harnois, DO, stresses that patients who are at risk are not being adequately screened for HCC. HCC has a very high death rate, a rate that could be lowered with earlier surveillance.
The other reason why this research is included in this month’s HCV Snapshots is to remind those who are waiting for non-interferon based HCV treatment to be sure you have regular screening for HCC (LKP).
Article: Classical and Emerging Roles of Vitamin D in Hepatitis C Virus Infection – Gutierrez JA, Parikh N, Branch AD.
Source: Semin Liver Dis. 2011 Nov;31(4):387-98. Epub 2011 Dec 21
A review of existing studies was conducted by the authors and the main findings validated what we have known about the importance of Vitamin D in regards to people who are infected with hepatitis C and HIV/HCV coinfection.
Key findings: Vitamin D is important for maintaining bone mineral density, low Vitamin D levels are associated with lower HCV treatment response, increased liver inflammation and fibrosis progression.
The Bottom Line: Everyone with HCV should have their Vitamin D levels tested and those who are deficient should be prescribed Vitamin D supplementation. It was also recommended that patients should have follow-up tests to make sure that their Vitamin D levels return to normal. In addition to improving the overall health in someone with HCV there are additional benefits of Vitamin D supplementation when needed such as improved bone mineral density (for general health and to counter the possible side effects of ribavirin therapy), decreased liver inflammation and scarring, and it increases the chance of a successful treatment outcome.
Editorial Comment: Vitamin D deficiency is common in people with HCV. Vitamin D is a fat soluble vitamin that is stored in the liver and for this reason it should not be taken in high doses unless under the supervision of a medical provider.
See also: “Vitamin D: An Innate Antiviral Agent Suppressing Hepatitis C Virus in Human Hepatocyte,” in the January 2012 HCV Advocate “Snapshots.” (AF)
Article: Transmission of Hepatitis C Virus Infection Through Tattooing and Piercing: A Critical Review – Tohme RA, Holmberg SD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia.
Source: Clin Infect Dis. 2012 Jan 30. [Epub ahead of print]
This review was done using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A total of 62 studies between 1994 and 2011 were reviewed. The authors reported that there was no evidence to support transmission of HCV among people who received a tattoo and/or piercing in a professional tattoo/piercing salon. It was reported that there was a significant risk of HCV transmission from receiving a tattoo and/or piercing in prisons or receiving one from a friend. Transmission of HCV can occur when prevention measures are not being followed. In the case of tattoos transmission is more likely when needles and ink are being reused and when equipment is not sterilized. Separate ink pots, new needles and all other equipment should be sterilized using an autoclave.
The Bottom Line: Professional tattoo and piercing parlors do not carry a risk of HCV transmission–that is if safety guidelines are carefully followed. In other settings that do not practice blood borne pathogen protections the risk of HCV transmission is greatly increased.
Editorial Comment: This validates what we know about the importance of following safety precautions to prevent the transmission of blood borne pathogens including hepatitis C. If you are interested in reading more about safe tattooing, visit our Website www.hepatitistattoos.org. (AF)
Article: Upper Limits of Normal for Alanine Aminotransferase Activity in the United States Population – C.E., Ruhl, et al.
Source: Hepatology. 2012 Feb;55(2):447-54. doi: 10.1002/hep.24725
The current study evaluated the upper limit of normal (ULN) of alanine Aminotransferase (ALT) in the United States in an effort to establish a cut-off for screening for hepatitis C infection. It should be noted that different laboratories and different regions of the country use different ULN’s which makes it difficult to establish a universal cut-off. The study examined various factors that could increase the likelihood of elevated ALT levels and determined that the maximum correct classification for men should be 29 IU/L and 22 IU/L for women. This cut-off would, unfortunately, classify 36.4% of men and 28.3% of women as having abnormal ALT levels, which would make it impractical and costly to test for hepatitis C if these ULN’s were followed.
The Bottom Line: Elevated ALT levels indicate possible liver inflammation and damage, but ALT is considered a non-specific indicator because it could indicate hepatitis C infection, hepatitis B infection, obesity, fatty liver, diabetes, etc., and for this reason it is almost impossible to establish a cut-off that would prompt a test for hepatitis C that would be cost-effective and realistic.
Editorial Comment: The ULN has been used in the past as a tool for medical providers to test for hepatitis C, but has not been validated on a national level to establish useful cut-off levels. Because of the growing epidemic of obesity and the possible resulting fatty liver (as well as other factors) it seems that it is unreasonable to use ULN as a marker for hepatitis C liver disease. One of the best approaches to test for HCV is one based on risk-factors. Another useful approach to testing for hepatitis C is the aged-based approach that is slowly being rolled out nationally (AF).
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Disability & Benefits: Taxation of Disability Benefits
—Jacques Chambers, CLU
There are special rules regarding the taxation of disability benefits. It is NOT true that disability benefits are never taxable, as many claim. Persons collecting disability benefits may still need to file and may actually owe income taxes on their disability payments. This is true whether the disability payments come from Social Security or from disability insurance plans or both.
While most states’ tax laws tend to mirror those of the IRS, there may be minor differences that should be checked when filing. This article deals strictly with federal income taxation by the IRS.
It should also be noted that any earnings from part-time work while also collecting disability would be considered taxable income under regular tax rules and may have an effect on how the disability benefits are taxed. http://www.irs.gov/individuals/article
Social Security Benefits
Benefits paid by Social Security are all taxed in the same manner, whether retirement, survivors, dependents, or disability. The two main disability programs are:
Supplemental Security Income (SSI) - Because SSI is a needs-based program for persons with limited income, it is the rare exception that a person collecting any portion of SSI benefits would owe income taxes. Persons receiving SSI benefits, as their only source of income would not be taxed on that benefit. You may not need to file a tax return; the website at
will help you determine whether or not you need to file.
Social Security Disability Insurance (SSDI) – Most persons receiving SSDI benefits will need to file an income tax return, even if there may be little or no tax due. However, if there is additional income to SSDI benefits, such as wages, self-employment, interest, dividends, pension or taxable disability insurance, this can cause a portion of the SSDI benefits to also be taxable.
Rather than provide a separate, lower tax table for Social Security benefits, the IRS provides a break by taxing only a portion of the Social Security benefits depending on the amount of other income. No one pays federal income tax on more than 85 percent of his or her Social Security benefits based on Internal Revenue Service (IRS) rules. If you do have to pay taxes on your Social Security benefits, you can make quarterly estimated tax payments to the IRS or choose to have taxes withheld from your benefits. For more information about taxation of benefits, see IRS Publication 915, Social Security and Equivalent Railroad Retirement Benefits.
Every January you will receive a Social Security Benefit Statement (Form SSA-1099) showing the amount of benefits you received in the previous year. You can use this statement when you complete your federal income tax return to find out if your benefits are subject to tax. The IRS states regarding Social Security payments:
Base amount. Your base amount is:
$25,000 if you are single, head of household, or qualifying widow(er),
$25,000 if you are married filing separately and lived apart from your spouse for all of 2011,
$32,000 if you are married filing jointly, or
$-0- if you are married filing separately and lived with your spouse at any time during 2011.
Worksheet 11-1. You can use Worksheet 11-1 to calculate the amount of income to compare with your base amount. This is a quick way to check whether some of your benefits may be taxable.
Worksheet 11-1: A Quick Way To Check if Your Benefits May Be Taxable
Enter the amount from box 5 of all your Forms SSA-1099 and RRB-1099. Include the full amount of any lump-sum benefit payments received in 2011, for 2011 and earlier years. (If you received more than one form, combine the amounts from box 5 and enter the total.)
Note. If the amount on line A is zero or less, stop here; none of your benefits are taxable this year.
Enter one-half of the amount on line A
Enter your taxable pensions, wages, interest, dividends, and other taxable income
Enter any tax-exempt interest income (such as interest on municipal bonds) plus any exclusions from income (listed earlier)
Add lines B, C, and D
Note. Compare the amount on line E to your base amount for your filing status. If the amount on line E equals or is less than the base amount for your filing status, none of your benefits are taxable this year. If the amount on line E is more than your base amount, some of your benefits may be taxable. You need to complete Worksheet 1 in Publication 915 (or the Social Security Benefits Worksheet in your tax form instructions). If none of your benefits are taxable, but you otherwise must file a tax return, see Benefits not taxable, later, under How To Report Your Benefits.
Although you're not required to have federal taxes withheld from your Social Security benefits, you may find it easier than paying quarterly estimated tax payments. To have taxes withheld from your Social Security payments, you should complete IRS Form W-4V (Voluntary Withholding Request). This form is available on line at http://www.irs.gov
/irs-pdf/fw4v.pdf or by calling the IRS at 1-800-829-3676.
On the W-4V, you can select what percentage of your monthly benefit amount you want withheld—either 7%, 10%, 15% or 25%. Only these percentages can be used. Flat dollar amounts are not acceptable. After you've made your selection, sign and return the form to your local Social Security office by mail or in person.
For more information about Social Security benefits and your taxes, there are two IRS publications you will find helpful:
Publication 554, Tax Information for Older Americans and
Publication 915, Social Security Benefits and Equivalent Railroad Retirement Benefits.
You can order these by calling the Internal Revenue Service's toll-free telephone number, 1-800-829-3676, or you may access them on line at http://www.irs.gov.
Disability Insurance Benefit Payments
For private disability benefits, the IRS looks to tax either the premiums paid for the disability insurance or the benefits paid to the claimant, but not both. This can best be explained by examples:
A person buys individual disability insurance from an insurance company. He/she pays the premiums with after-tax dollars, that is, the premiums are not deducted from taxable income as a business expense or otherwise. Because the premiums were included in taxable income, any benefits that person receives from the policy due to disability are not income taxable.
An employer provides short term and long term disability to all eligible employees, and provides them as an employee benefit without cost to the employees. Because the employer deducts such payments from its income as a business expense, the premiums are not taxed so any disability benefits received by disabled employees are fully income taxable.
An employer provides, without cost to the employees, a long term disability plan that pays 50% of their salary if disabled. Each employee has the right to additionally purchase, through payroll deduction, an additional 16 2/3% benefit to bring the total disability benefit up to 66 2/3% of income. The employee’s portion of the premium withheld from the paycheck is included in the W-2 earnings and therefore taxable. In this case, the disability benefits are taxable in proportion to how the premiums were paid. Since the employer deducted the premiums for its coverage, any benefits received from that portion of the plan would be taxable, however, the benefit that comes from the portion the employee purchased with after tax dollars would be income tax free.
Some employers who usually purchase long term disability for their employees will allow employees to elect to pay for their long term disability coverage with after tax dollars through payroll deduction, just for the purpose of making any future disability benefit payments tax free. If your employer offers this alternative, it is recommended that you seriously consider taking advantage of it. Having disability benefits income tax free can greatly enhance quality of life when your income is already lowered by the disability itself.
It should be noted that there is a three year look-back period to this rule. This means that once you have paid the premiums with after tax dollars for three years, your benefits will be entirely tax free. If, however, you become disabled before the three years expires, your benefits will be taxable in the same proportion as the premiums paid. If you had paid the premiums for only one year and your employer paid the two prior years, only one-third of the benefit would be tax free. These rules apply to both short-term and long term disability.
As you can see from the explanations above, the taxation of disability benefits whether from Social Security or private insurance is a complicated issue. Persons starting to file taxes for the first time while on disability should either retain experienced tax counsel or take advantage of one of the many programs that offer free income tax assistance.
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