Work Incentives Working Group

State Public Benefits Manual

Returning to Work:
Questions and Answers for People Recieving SSI and/or SSDI

 

State Public Benefits Manual

CHAPTER ONE
SOCIAL SECURITY DISABILITY PROGRAMS

In Chapter One, we will look at federal programs that provide cash assistance to persons with disabilities. The three programs we will look at are:

A. SOCIAL SECURITY DISABILITY INCOME (SSDI);

B. SUPPLEMENTAL SECURITY INCOME (SSI) FOR ADULTS; and

C. SUPPLEMENTAL SECURITY INCOME (SSI) FOR CHILDREN.

After reviewing the specific requirements of each program, we will discuss general rules, procedures and advocacy tips that apply to all three programs. We will break this part of the chapter into three sections with the following captions:

D. HOW TO APPLY FOR BENEFITS;

E. HOW TO FILE AN APPEAL IF BENEFITS ARE DENIED;

F. ADVOCACY TIPS FOR HELPING A CLIENT GET BENEFITS.

In the last two sections, we will review the Social Security Administration's (SSA’s) rules for deciding if a person remains disabled and entitled to benefits (Continuing Disability Reviews). Then, we will look briefly at the rules for overpayments - payments that an individual receives from SSA which exceed the total amount he or she should have been paid. These topics are discussed (appropriately) under the headings:

G. CONTINUING DISABILITY REVIEWS (CDRs); and

H. OVERPAYMENTS.

Summary Security Disability Programs

The Social Security Administration (SSA) disability program provides benefits to people who have severe disabilities that prevent them from performing substantial, gainful work.

SSA disability benefits are available through two primary programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).

SSDI provides benefits to eligible persons with disabilities and their dependents. Eligible persons must have worked under and contributed to the Social Security system. The monthly benefits vary depending on how much the individual contributed to the Social Security system through payroll deductions. An average monthly check is around $750.

SSI is for persons with severe disabilities who fall below a certain income and resource limit. Usually, SSI recipients have limited or no work history. SSI benefits cannot exceed $545 per month in 2002.

Individuals apply for SSI and SSDI at their local Social Security office or by calling the SSA nationwide "800" number – 1-800-772-1213. It takes approximately 3 – 6 months to process a new application.


A. Social Security Disability Insurance (SSDI)

Program Description

Social Security Disability Insurance or SSDI, is insurance; it is not welfare. It is a federal program, administered by the Social Security Administration (SSA). An individual does not have to prove financial need. Eligibility is best thought of in insurance terms. If the individual has paid the premiums (FICA payroll deductions), he/she will be insured against the "covered" events: i.e., disability. An individual applies with SSA, but determinations of disability are prepared by the Bureau of Disability Determination Services (BDDS) located in Springfield, Illinois.

Note: Social Security benefits are also available for blind individuals and for persons who are 65 years old (old age benefits). Early old-age benefits can be paid to an individual who reaches 62 years of age. Benefits can also be paid to an individual’s children, spouse, widow or parents if the individual becomes disabled, retires or dies.

No Income or Asset Limits

Unlike the Supplemental Security Income (SSI) program which is discussed in Section B, there are, for the most part, no income, asset, or immigration status requirements for Social Security benefits. ( Note, however, that to meet SSA's definition, a person applying for SSI or SSDI cannot be engaged in substantial, gainful activity - i.e., earnings must be less than $780 per month.) The "wage earner" is the insured. He or she and his or her dependents are the beneficiaries.

Who Gets SSDI?

The following categories of persons can receive SSDI benefits:

  • Qualified Wage Earners Who Become Disabled. To qualify, the wage earner must have worked in covered employment (employment for which Social Security taxes must be paid) for five of the ten years preceding the onset of the disability. Younger workers may qualify with less work time according to a detailed formula that SSA uses. The definition of disability is the same as for SSI for adults. Benefits are not given to individuals who have substance abuse disorder that is a contributing factor material to the disability determination.
  • Adult Disabled Children. A child over age 18 qualifies if s/he has a disability that began before the age of 22, if one of his or her parents who is covered under Social Security retires, becomes disabled, or dies.
  • Spouses, Ex-Spouses, Widows, Widowers, Parents or Dependent Children of SSDI Recipient in certain situations.

How Does SSA/BDDS Determine Disability for Adults?

Under the Social Security Administration's regulations, a person is considered disabled if she or he has:

Inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. To meet this definition, claimant must have a severe impairment, which makes him or her unable to do prior work or any other substantial gainful activity which exists in the national economy. SSA looks at residual functional capacity, age, education, and work experience when determining if claimant can do any other work.

Wow -- what a mouthful.

The definition is highly technical and rather confusing. To make it somewhat simpler, SSA has broken it down into a five-step sequence. In the Appendix, you will find a flow-chart that explains this process of determining disability.

Special Rules for Persons with Substance Abuse

In the past, individuals who had a substance abuse disorder could be found disabled under SSA's regulations. Beginning in March 1996, however, the law changed to limit benefits for persons with drug addiction or alcoholism (DAA). A person cannot get SSDI or SSI benefits for DAA if the drug addiction or alcoholism is a contributing factor material to the disability. What does that mean? Essentially, SSA asks if the person would be disabled if he or she stopped using drugs or alcohol. If the person would still be disabled, even without the drug or alcohol use, he or she can get disability benefits. If the person's remaining impairments would not be considered disabling without the DAA, he or she cannot get benefits.

Note: A person with an extremely prolonged use of drugs or alcohol may have some severe physical or mental conditions that resulted from the use of these substances. For example, a long-term alcoholic might have cirrhosis, or organic brain disease. These consequences of DAA can be considered disabling, if they would continue after substance use stopped.

Note: Many claims involving DAA also involve a mental impairment that affects the claimant's ability to work. Often it is impossible to separate the two impairments. Medical experts often cannot determine how severe the mental impairment would be if the claimant stopped using drugs. SSA policy provides that if a medical expert cannot separate the two impairments, a finding that the DAA is "not material" should be made and benefits should be paid.

What Happens if the Individual Disagrees with SSA's Decision?

A decision finding a person not disabled for SSDI purposes can be appealed. The appeals process is fully described in section E below.

Payment of Benefits

Amount of Check Varies
The wage-earner's basic benefit amount is directly related to how much FICA tax he or she has paid. The more paid, the higher the benefit. The average monthly benefit is about $750. Dependents and spouses receive a certain percentage of the wage earner's benefit amount.

When Benefits Begin ****The following rule is confusing****
For SSDI , when SSA finds someone disabled, it will set a date upon which the person first met the definition of disability, called the onset date. There is a five-month waiting period after the onset date before SSDI benefits begin. In addition, past-due SSDI benefits can begin 12 months prior to the date the SSDI application was filed with SSA. Thus, if someone applied for SSDI on January 1, 2001, s/he could be paid starting on January 1, 2022 (paid later in a lump sum) if his/her disability began on or before August 1, 2022 (the five-month waiting period).

Payment to a Representative Payee
In certain situations, SSA will pay an individual’s benefits to a "representative payee." Representative payees are generally used when the beneficiary is legally incompetent or mentally or physically incapable of managing his or her own funds. Representative payees are usually required for beneficiaries under age eighteen.

Individuals with serious psychiatric impairments will frequently need a representative payee. Case managers should try to help clients identify responsible, trustworthy individuals or agencies to take on this role.

Representative payees can be guardians, spouses, other relatives, friends or institutions. All representative payees must use the payments only for the benefit of the beneficiary and in a manner consistent with SSA’s rules and regulations.

Please see handout on Representative Payees in the Appendix.


People in Institutions

Since SSDI benefits are not based on need, but rather on a person’s past earnings, a recipient will not lose entitlement to SSDI during periods of hospitalizations or nursing home stays. If the individual is unable to manage funds while in the institution, a representative payee may be appointed.

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B. Supplemental Security Income (SSI):

Program Description

Supplemental Security Income (SSI) is a federally-funded, needs-based program. It provides monthly cash benefits to individuals who are:

  • age 65 or older;
  • blind (vision in best eye correctable to no better than 20/200); or
  • disabled.

In addition, recipients must meet income and asset/resource tests. The Social Security Administration (SSA) administers the SSI program. An individual applies for SSI benefits with SSA, but determinations of disability are prepared by the Bureau of Disability Determination Services (BDDS) in Springfield, Illinois.

What are the Citizenship Requirements for SSI?

To be eligible for SSI, an individual must:

  • Reside in one of the 50 states, Washington, D.C. or the Northern Mariana Islands; AND be
  • United States citizen or national; or
  • certain American Indians; or
  • lawful permanent resident with 40 work credits; or
  • certain non-citizens with a military service connection; or
  • certain refugee or asylee-type non-citizens during the first seven years in the US; or certain non-citizens in the US or receiving SSI on August 22, 2022

All other non-citizens are ineligible for SSI until they become United States citizens or fall into category of eligible non-citizens. See the Appendix for complete chart on Non-citizen Eligibility for SSI benefits.

What are the Income Limits for SSI?

Individuals must have countable monthly income below $530 in 2001 to qualify for SSI. Countable income includes both earned income (e.g., wages from employment), and unearned income (e.g., inheritances, lawsuit settlements, or even SSDI benefits).

In determining countable income, income is deemed from spouses who live in the same household as the claimants, from parents if the claimant is a child under age 18, and from sponsors if the individuals are non-citizens and were sponsored when they entered the United States.

Social Security allows certain deductions from income. Among the deductions allowed are: a) $20 from unearned and/or earned income; b) $65 and one-half of the remaining amount from earned income; and c) income used to pay the costs of impairment-related work expenses.

For an individual who is not working, and is not having income deemed to him or her from a spouse living in the household or a legal sponsor (for non-citizens), she or he will be eligible for some SSI so long as his or her monthly income is less than $550 (in 2001).


What are the Resource Limits for SSI?

Individuals must have countable resources below $2,000 to qualify for SSI. Couples residing together must have countable resources below $3,000.

Social Security excludes many items in determining resource eligibility. Among items that are not counted toward the resource limit are:

  • the individual's home (so long as he or she resides in it);
  • household goods and personal effects so long as their total equity value does not exceed $2,000); and
  • an automobile with a fair market value of $4,500 or less. Some vehicles are not counted at all if they are needed for medical transportation or employment.

How Does SSA/BDDS Determine Disability for Adults?

SSA uses the same disability standard for SSI as for the SSDI program. See page 7 and the Sequential Evaluation Chart in the Appendix.

Benefits

  • Amount of SSI Benefit
    In 2001, the maximum SSI Payment for an individual is $530 per month. The maximum amount for a married couple, if both are SSI eligible is $796. That amount may decrease if an individual or the couple has some income. Also, if an individual or couple who receives SSI benefits lives in the household of another and receives food, clothing or shelter assistance, the check amount may be reduced, to reflect the value of the in-kind support being given. See the handout in the Appendix entitled "Is Your SSI Check Being Reduced Because Someone Is Helping You To Pay Your Expenses?"
  • Start of Benefits
    SSI payments begin the first month after the month in which the application is filed, provided the individual meets all eligibility factors in the month of application. Unlike the SSDI program, no SSI benefits can be paid for months prior to the date of application.
  • Payment to a Representative Payee
    In certain situations, SSA will pay an individual’s benefits to a "representative payee." Representative payees are generally used when the beneficiary is legally incompetent or mentally or physically incapable of managing his or her own funds. Representative payees are usually required for beneficiaries under age eighteen.
    Individuals with serious psychiatric impairments will frequently need a representative payee. Case managers should try to help clients identify responsible, trustworthy individuals or agencies to take on this role.
    Representative payees can be guardians, spouses, other relatives, friends or institutions. All representative payees must use the payments only for the benefit of the beneficiary and in a manners consistent with SSA’s rules and regulations.
    Please see handout on Representative Payees in the Appendix.

People in Institutions

People who reside in certain public institutions such as halfway houses and prisons, for more than 16 persons are generally not eligible for SSI payments. For those who already receive SSI and who must enter a public institution, eligibility for SSI benefits ceases on the first day of the month following admission. Persons who reside in a medical care facility, such as a hospital or nursing home or intermediate care facility, where Medicaid pays for their care, will usually be entitled to SSI benefits at a reduced rate.

Ineligibility continues as long as the individual remains in the institution. Benefits will resume on the earliest day of the month in which the individual is no longer a resident of the institution. However, a transfer from one institution to another, or an absence of less than 14 days from the institution, will keep benefits suspended.

Case managers should help their clients report periods of hospitalization, or other institutional placements promptly so that SSA can stop payments and prevent an overpayment. Case managers should also be sure to let SSA know when a client has returned to his or her home so that benefits can resume immediately.

Garnishment Protection
SSI benefits are protected from garnishment by federal law. Social Security benefits may be subject to garnishment only for child support and/or alimony payments. It is recommended that individuals segregate SSI benefits from other income in an account, as SSA will presume that other deposits made to an account of an individual on SSI are income and/or resources of that individual. In addition, segregation of the public benefits will protect SSI funds deposited into ETA accounts from attachments or garnishment.

Direct Deposit Options
Federal Funds ETA/EFT accounts are low cost accounts offered by banks and Financial institutions to people receiving Federal benefits (including SSA and Social Security). Under ETA regulations, banks that offer ETA accounts also offer other accounts. Participants can contact their financial institution to find out if ETA accounts are offered or call 1-888-382-3311. SSI and Social Security also recipients have the option of using a non-ETA account for direct deposit payments. To sign up for direct deposit, recipients can call the Social Security Administration at 1-800-772-1213.

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C. SSI DISABILITY BENEFITS FOR CHILDREN

Children under 18 years of age may also qualify for SSI benefits on the basis of disability.

Because parents' income is considered available for children under age 18, children's SSI benefits are only available to children in families with income and resources that fall within the SSI standards.
See the income and asset limits in Section B.

The children’s disability standard is different from the adult standard.
Generally, children must establish that they have:

a medically determinable physical or mental impairment which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months…

The Childhood disability flow chart is in the Appendix.

When children reach age 18, they can continue to get SSI only if they meet the adult disability standard.


D. APPLYING FOR SSDI OR SSI

How to Apply for SSDI or SSI

A person can apply for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits by calling the Social Security Administration's toll-free number, 1-800-772-1213. A representative will schedule an appointment for an application to be taken over the phone or at any local Social Security Office. A list of local Social Security offices is included in the Appendix to this chapter. A person can also go to any local office and ask to file an application for disability benefits. Whichever way a person applies, he or she should KEEP COPIES of all documents and forms submitted to SSA. That way, if SSA loses information, an applicant can easily re-submit it.

SSDI applicants will normally need to submit Forms SSA –16 (Application for Social Security Disability) and Form SSA-3368 (Disability Report).

SSI applicants will need to complete Forms SSA –8000 and 8001 (Application for Supplemental Security Income) and Form 3368 (Disability Report).

People who are deaf or hard of hearing can call SSA's toll-free TTY number, 1-800-325-0778. This number operates between 7 a.m. and 7 p.m. on Monday through Friday.

If a person has a disability that limits his or her ability to apply for benefits, the Social Security Administration must make "reasonable accommodations" to assist the person. For instance, SSA will agree to mail forms directly to a claimant, rather than requiring him or her to come a local office. SSA will also communicate with a family member or friend if a person with a disability cannot communicate with the representative directly. Also, many hospitals and residential care facilities have staff members available to assist patients or residents to complete the necessary forms.


When to Apply for SSDI or SSI

A person should apply for benefits as soon as he or she becomes disabled. For the SSI program, benefits can be paid from the first month that SSI determines disability began, or from the first of the month following the date of application, whichever is later. There is no mandatory waiting period for SSI benefits after SSA determines that a claimant is disabled.

For the SSDI Program, disability benefits cannot begin until the sixth full month of disability. This five-month waiting period begins with the first full month after SSA decides that a person's disability began. Note, however, that with the SSDI program, benefits can be awarded retroactively for up to 12 months prior to an application being filed.

SSDI EXAMPLE: John Smith became disabled in January of 2000 and could no longer continue his job at Quaker Oats. John did not apply for SSDI until December 15, 2000. SSA considers John's application and determines that he was disabled as of January 14, 2000. With the five-month waiting period, John can get benefits beginning July 1, 2000. (Benefits can be awarded up to a year prior to the date of application).

SSI EXAMPLE: Mary Jones has not worked since leaving high school in tenth grade. She is now 25 years old. She applied for SSI benefits on August 15, 2000. SSA determined that she has actually been disabled since 1998. However, she is only entitled to SSI benefits starting from September 1, 2000.

Note: A person who is applying for SSDI can also apply for SSI and can receive SSI during the five month waiting period for SSDI if he/she is income asset eligible.

What Should An Individual Take to SSA Office?

A person who wants to apply for SSI or SSDI benefits should take the following documents and information to his or her initial interview:

  • For SSDI and SSI
  • Social Security Number;
  • Birth certificate or other evidence of date of birth;
  • Spouse's birth certificate and SSN if she or he is applying for benefits;
  • Military discharge papers, if claimant has been in the military;
  • Children's birth certificates and SSNs if any children are applying for benefits;
  • Checking and savings account information;
  • Names, addresses and phone numbers of any doctors, hospital, clinics, institutions, counselors that have treated claimant, as well as dates of any treatments;
  • List of current medications;
  • Any medical records, lab tests or results, concerning claimant's condition;
  • List of any employment claimant has done in the past 15 years (name and address of employer and type of work performed);
  • Copy of W-2 Form (wage and tax statement). Self-employed persons should bring copy of federal tax return for the past year;
  • Dates of prior marriages if spouse is applying.

In addition, SSI applicants should also take:

  • Proof of income and assets (payroll slips, bank books, insurance policies, car registration, burial fund records, and other information about income and assets);
  • Mortgage or lease agreements or other documents showing living arrangement.

If a claimant does not have all these documents, he or she should still apply for benefits. SSA personnel will assist the claimant in obtaining information. SSA should also consider a person's eligibility for BOTH the SSI and SSDI programs at the time of application.

What Happens After the Individual Files an Application?

SSA usually takes about 90 - 120 days to process applications for disability benefits. The local office collects information from the claimant. The file is sent to the Bureau of Disability Determination Services (BDDS) in Springfield, Illinois, where an adjudicative team is assigned to the case. This team usually includes a BDDS adjudicator, as well as a medical consultant. The team works to collect relevant medical and vocational evidence, as well as reports from the claimant and others who may have information about the claimant's medical condition. In cases where the adjudicator decides additional medical evidence is necessary, the adjudicator may set an appointment for the individual to see a doctor, psychiatrist or a psychologist. This is called a consultative examination.

The consultative examination process can be stressful for any claimants, but perhaps especially for persons with psychiatric disabilities. Case managers should communicate with the BDDS adjudicator to determine whether a consultative examination is necessary, or if other information can be submitted to document the claimant's condition. When available established, long-term evidence is better than a consultative exam, which can only assess how a person is functioning at the time of the exam. BDDS will be less likely to require a consultative examination where the claimant's file contains the following:

  • Complete medical records,
  • a current mental status examination,
  • a current assessment of adaptive functioning,
  • a longitudinal history of the impairment, and
  • a valid IQ test performed after age 16.

A case manager should work with the client to insure that any available medical records are identified and submitted to BDDS. The BDDS adjudicative team makes the final decision as to whether a consultative exam is needed. If information in the file is inconsistent, for example, an adjudicator may require additional testing to resolve discrepancies. Case managers should explain to their clients why a consultative exam is required, and help them understand the importance of attending any scheduled appointments.

Once all of the evidence is collected, the BDDS adjudicative team determines whether the totality of the evidence supports the finding of a disability. BDDS then returns the file to the SSA local office. The SSA local office sends a written decision to the claimant advising him or her that SSA has made a favorable or unfavorable decision.

Is There Any Way to Get Benefits Sooner?

PRESUMPTIVE ELIGIBILITY: Some individuals who apply for SSI benefits may be entitled to presumptive eligibility - meaning that they can receive up to six months of SSI benefits before a formal decision is made on their application. SSA awards presumptive eligibility benefits to SSI applicants when there is a high degree of probability that they will be found disabled or blind. (They must also meet the income and asset rules for SSI). In cases where impairments are readily observable (i.e., amputations), SSA will find an applicant presumptively disabled or blind without medical or other evidence. Conditions that qualify the individual for presumptive eligibility WITHOUT medical evidence are:

  • Amputation of two limbs;
  • Amputation of a leg at the hip;
  • Allegation of total deafness;
  • Allegation of total blindness;
  • Allegation of bed confinement or immobility without a wheelchair, walker or crutches due to a long-standing condition, excluding recent accident or surgery;
  • Allegation of stroke with continued and marked difficulties in moving after 3 months;
  • Allegation of cerebral palsy, muscular dystrophy;
  • Allegation of diabetes with a foot amputation;
  • Allegation of Down's syndrome or severe mental deficiency.

Other conditions, including mental impairments, can entitle a person to presumptive eligibility, but there must be medical evidence that reflects a high degree of probability that the person will be found disabled. Case managers working with people with mental impairments should help them submit recent treatment records, psychiatric evaluations and other documents that clearly document the disability. If a person is denied presumptive benefits, his or her case will still go through the usual initial application.

Expedited Case-Handling

In any cases where the individual may be terminally ill, or is alleged to be suicidal or homicidal, SSA is required to expedite the application and appeals process.
Advocates who have knowledge of a claimant's terminal illness, or that a claimant may be suicidal or homicidal, should alert SSA representatives immediately.

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E. APPEALING A DECISION IF BENEFITS ARE DENIED

When SSA reviews an initial application, it will issue a written decision to the claimant. The decision indicates whether the decision is favorable, partially favorable or unfavorable.

FAVORABLE DECISION: Claimant is awarded benefits from date of application or date of disability.

PARTIALLY FAVORABLE: Claimant is awarded benefits but the date that SSA determines the disability began is later than the date that claimant alleged in his or her application.

UNFAVORABLE DECISION: SSA decides that claimant is not disabled.

Approximately 30-35% of all initial applications are approved. Many people whose claims are denied at this level will ultimately get benefits on appeal - when more evidence may be available to SSA and BDDS adjudicates.

When to Appeal

Any decision denying, terminating, or reducing SSI or SSDI benefits is appealable. An appeal must be filed within 60 days of receipt of the adverse decision. Receipt is presumed to occur 5 days after the date on the face of the decision. There are "good cause" provisions under which late filings might be excused. However, "good cause" decisions are discretionary and difficult to successfully appeal. Thus, always file appeals within 60 days. Appeals are filed on appeal forms supplied at local SSA offices.

Levels of Appeal

SSA has a four-step appeal process. Initial decisions, made on applications for benefits, are appealed by filing a request for reconsideration. Approximately only 10% of all requests for reconsideration result in approval of benefits. If the request for reconsideration is denied (and 90% are denied), the individual may request a hearing before an Administrative Law Judge. New evidence may be submitted at the hearing. At the hearing, the individual testifies under oath and may be represented by an attorney or other legal representative. Expert medical or vocational witnesses may testify also. Formal rules of evidence are not observed. Approximately 50-60% of all cases heard by an ALJ result in approval of benefits.

If the hearing decision is unfavorable, the individual may request review by the Appeals Council. New evidence may be submitted if it was unavailable at the time of the hearing and if it relates to the time before the hearing decision, and if it is new and not cumulative. The Appeals Council may deny review, in which case the hearing decision becomes the final decision, or it may grant review and make a new decision. Chances of winning at the Appeals Council level are slim, also around 10%.

If the Appeals Council denies review or makes a final decision denying benefits, the claimant may file an action for judicial review in the federal district court within 60 days after receipt of the Appeals Council decision.

Appeal Chart

SSI and SSDI APPEALS PROCESS

INITIAL APPLICATION FOR SSI/SSI APPROVED (30-35% of claims approved)



DENIED(60 days to request reconsideration)

RECONSIDERATION APPROVED (10% of claims approved)



DENIED(60 days to request a hearing)



HEARING BEFORE AN
ADMINISTRATIVE LAW JUDGE APPROVED (50-60% of claims approved)



DENIED(60 days to request Appeals Council review)



APPEALS COUNCIL ALJ REVERSED AND CLAIM APPROVED Review

Either the Review will be Denied OR

The Revew will be Granted

ALJ Denial Upheld



(60 days to appeal in federal district court)
FEDERAL COURT

Late Filed Appeals and Reopening Prior Applications

Normally, if an individual fails to appeal an adverse determination within the prescribed appeal period, he or she loses all rights to further review. There are, however, important exceptions to this rule. Under certain circumstances, late-filed appeals will be accepted or prior unappealed applications reopened. Late appeals should be accepted if the individual has "good cause" for the late filing. "Good cause" includes misinformation given by an SSA employee, inability to appeal on time because of circumstances beyond the individual's control, or a misunderstanding of the requirements of the Act.

A request to file an appeal after the 60-day appeal process has expired must be done in writing and presented to staff at the person’s local social security office.

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F. ADVOCACY TIPS: HELPING YOUR CLIENT GET AND KEEP SSI OR SSDI BENEFITS

How Do I Help an Individual Apply for SSI or SSDI Benefits?

1. Explain SSI and SSDI to the individual. Let him or her know the basic eligibility requirements. Discuss how the application and appeals process works. Explain to individuals that they may need a representative payee if they cannot manage their finances on their own.

2. Identify the individual's medically determinable impairments. What are the primary impairments? Consider both physical and mental impairments. Consider whether the individual has any functional limitations as a result of the impairments.

3. What records/reports are available to support individual's claim of disability?

  • Hospital records
  • Record of doctors, psychiatrists, psychologists, therapists, and chiropractors
  • School Records
  • Physical or Occupational Therapists

Help client obtain names and addresses of all treating sources and be sure to include them on application forms.

4. Work History. List of places individual has worked in last 15 years. What kind of work was performed? Heavy lifting or sedentary work? What skills were required? What training was necessary? Why couldn't individual still do this job? Individuals with psychiatric impairments may have difficulties holding jobs due to their social functioning. Be sure to help the individual accurately explain a sporadic work history. Did they fail to follow instructions? Were they unable to get along with co-workers? Did anxiety prevent them from even getting to work? Be sure to detail the impact of their disability on their work attempts.

5. Help client fill out application forms, daily activities reports, disability report, etc. Case managers should try to be with client as he or she completes form and when he or she speaks with BDDS adjudicator. This will help minimize any inconsistencies between medical records and client's self-reporting on forms. It is important to list all treating sources. It is also important to discuss all individual's problems. Now is not the time to highlight accomplishments in life. Discuss all problems that affect the individual's ability to do work, to do daily activities such as shopping, cleaning, taking public transportation, etc. Discuss impact of depression, emotional disorders, pain, or other factors.

How Do I Help An Individual Appeal?

During Initial Determination and Reconsideration Stage of Appeal

6. An advocate can communicate with the adjudicator at the Bureau of Disability Determination Services BDDS) who is handling the individual's case. To find out which adjudicator is working on the case, an advocate can call 1-800-225-3607 (if you wait through the entire recorded BDDS message, an operator will pick up the call). The advocate will need to have the client's name, social security number, and a signed appointment of representative form (SSA Form 1696), in order to discuss the case with the BDDS adjudicator. An Appointment of Representative form is in the Appendix. The advocate can find what information the adjudicator needs and offer to help obtain it. The advocate can also suggest what additional information might be necessary (i.e., psychological examination). The advocate can offer his or her impressions of the client's abilities, and can also identify others who might be able to offer valuable insights (e.g., landlords, family members, former employers). The advocate should strive to establish a good (not nagging) relationship with the adjudicator.

7. Help client attend scheduled appointments with doctors and psychologists.
Many individuals never get SSI because they fail to attend consultative examinations that SSA has scheduled. Problems with transportation, fear of doctors, childcare, and many other factors may prevent an applicant from getting to an appointment. An advocate can help remind client, arrange transportation, and do whatever may be necessary to get the client to the scheduled examinations.

8. If a client has extensive evidence about his conditions available from treating sources, a consultative examination may not be necessary. Advocates should therefore communicate with an individual's treating doctors and obtain medical records and narrative reports about the individual's condition.

9. Advocates may also want to help the client get a complete psychological examination. This is not the same thing as a consultative psychological examination scheduled by BDDS. It is a far more comprehensive report, completed after the psychologist meets with the client for several hours, and completes appropriate psychological tests. A psychological examination can be paid for by the Illinois Department of Human Services if the client is receiving Transitional Assistance benefits from DHS and gets prior approval for the examination.

10. Help clients with medical/psychological needs get appropriate treatment. If an individual has a substance addiction disorder, try to help them get into treatment.

11. Encourage individual to file prompt appeals of any denials.

AT ALJ HEARING STAGE

12. At this stage, it is often important to find an attorney who understands Social Security law to assist the claimant. Local legal aid and legal services agencies often represent claimants at the ALJ stage. A list of these agencies is included in the Appendix. The SSI Coalition at 312/223-9600 can also help make appropriate referrals for claimants. Usually, lawyers who help clients with SSI or SSDI cases at the ALJ hearing stage enter a fee agreement with the client. If the client is awarded SSDI/SSI retroactive benefits by the ALJ, the attorney usually receives about 25% of the back benefits or $4,000, whichever is less. If the client does not win on appeal, the lawyer does not collect attorney fees.

13. Review SSA Administrative Case File located in Office of Hearings and Appeals. Compare evidence in record with new evidence, determine what needs to be obtained and submitted. Obtain and submit additional medical and school records, statements from doctors, teachers, case managers, etc. to SSA as soon as possible with support from legal representative, help prepare the claimant and any witnesses for the hearing. Help them get to the hearing on time.

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G. CONTINUING DISABILITY REVIEWS

What Are CDRs?

Most SSI and Social Security disability recipients assume that once they have navigated the complicated application process and started receiving benefits, their monthly check will continue indefinitely. The Social Security Administration (SSA), however, is required by law to conduct periodic checks of a person's medical condition to determine if they continue to meet disability standards. These periodic evaluations of a person's disability status are called Continuing Disability Reviews (CDRs).

When and How Does SSA Conduct CDRs?

SSA utilizes a different standard for CDRs from the standard used in initial disability determinations. The Disability Benefit Reform Act of 1984 established the medical improvement standard, which is now used in CDRs. SSA has issued extensive regulations to interpret this medical improvement standard. CDRs for Children’s SSI Cases

Any child who receives SSI disability benefits will have their eligibility reviewed at least once every three years.

CDRs for Adult SSI and SSDI Cases

Most adults who receive SSI or Social Security disability benefits will be subject to a continuing disability review at some point. The time frame for the CDR depends on how the case was initially categorized.

SSA generally places adult cases in the following categories and sets CDRs for the corresponding time period:

Category:
MINE (Medical Improvement Not Expected) - Review every 7 years;
MINE cases usually involve extremely severe conditions that will likely remain static or be progressively disabling. Examples might be Parkinsonian syndrome, schizophrenia, mental retardation or organic brain disorder.

Category:
MIP (Medical Improvement Possible) - Review every 3 years;
These cases cover impairments where improvement cannot be predicted based on current knowledge. Examples might include hyperthyroidism, chronic ulcerative colitis, or affective disorders, such as major depression.

Category:
MIE (Medical Improvement Expected) - Review every 18 months or less.
Examples of MIE cases are fractures, or cases where corrective surgery is planned and recovery can be anticipated. In the category of mental impairments, MIE cases might include eating disorders where patient is responding well to treatment.

CDR Rights and Procedures

Notice
Social Security and SSI recipients have certain important rights when SSA begins the CDR process. Recipients are entitled to notice that a CDR will be conducted, why the review is happening, how the medical improvement standard works, that review could result in the termination of benefits, and that the recipient has the right to submit medical and other information. If SSA determines that disability benefits should stop, it must provide written notice of the termination, as well as information about the right of appeal.

**Note** Case managers should alert clients that they might receive CDR notices and that they should always read through mail from SSA. If clients are unable to understand mailings, they should be sure to have their case manager or representative payee review all notices they receive. Case managers should be prepared to help clients respond to SSA inquiries about their medical condition or work experiences

Benefits Paid Pending Appeal

SSI and SSDI recipients can receive benefits during the appeal of a CDR termination decision. To do so, they must elect benefits by filing a Request for Reconsideration within 10 days of receiving the unfavorable CDR decision. If a recipient does not wish to request benefits during appeal, he or she has 60 days from the date of the decision to file a Request for Reconsideration.

If someone elects continuing benefits, and that person is ultimately found not disabled, s/he must pay those benefits back to SSA unless they have a waiver of repayment granted. To have a waiver granted, the person must fill out the waiver form at Social Security and show they cannot afford to pay the money back and that they cooperated with Social Security during the CDR process.

Benefits generally can continue through the appeals process through the date of an ALJ hearing decision, as long as the recipient re-requests continued benefits within 10 days of the Reconsideration denial.

If a recipient misses the deadline for requesting benefit continuation, but has good cause for missing the deadline, he or she may still be entitled to receive the benefits during appeal.

Legal Help
The CDR process can be extremely confusing. Persons who receive a CDR notice should seek legal help and take immediate steps to request benefits pending appeal. Legal help is available through local legal aid and legal assistance agencies. A list is included in the Appendix.

H. OVERPAYMENTS

An overpayment occurs whenever SSA asserts that an individual received a benefit payment that the individual was not legally entitled to receive. Overpayments frequently occur in SSI cases because of excess resources (over $2,000) and excess income. Most individuals on SSI who return to work will receive overpayment notices because of excess income.

Overpayments occur in SSDI cases when an individual has completed a trial work period and continues to earn over the substantial gainful activity amount per month. Frequently, an individual does not track his or her trial work period months, and it may take SSA months or even years to notify him/her that an overpayment has occurred.

There are two ways to challenge an overpayment: appeal and waiver.

Appeal: To challenge the fact that an overpayment occurred, or the amount of the overpayment, an individual should file an appeal. The appeal procedures outlined in Section E should be followed. An individual on SSI is entitled to a personal conference at reconsideration; SSDI recipients are not entitled to a personal conference.

Waiver: If an individual loses the appeal of an overpayment, or decides not to challenge the fact or amount of the overpayment, he/she can file a waiver request. There are two requirements for waiver: First, the individual must not be at fault in the overpayment. Second, the individual must show that recovery of the overpayment would defeat the purpose of the Social Security Act by depriving the recipient of income and resources needed for "ordinary and necessary living expenses. " Waiver requests can be filed at any time - with the reconsideration request, or even when the overpayment has been paid back.

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CHAPTER TWO
HOW TO WORK AND MAINTAIN SOME SSDI OR SSI BENEFITS

CHAPTER THREE
STATE ADMINISTERED BENEFITS

CHAPTER FOUR
HOW THE MEDICAL ASSISTANCE PROGRAMS WORK

CHAPTER FIVE
MEDICARE

CHAPTER SIX
OTHER STATE AND LOCAL PROGRAMS THAT PROVIDE CASH OR MEDICAL ASSISTANCE

CHAPTER SEVEN
FOOD STAMPS

CHAPTER EIGHT
OFFICE OF REHABILITATIVE SERVICES (ORS)

CHAPTER NINE

OTHER BENEFITS AND/OR PROTECTIONS