The Basics of Public Benefits Law

1. The Basics of Public Benefits Law Javan Lapp Health, Income, and Family Support Program Director

2. Public Benefits • Economic Support • Food Stamp Program • Social Security Disability (SSDI and SSI) • Work First Family Assistance • Other: Unemployment Benefits (UIB), LIEAP, EA, Childcare Voucher • Health Care • Medicaid • Medicare • Affordable Care Act • Housing* (discussed during housing training) • Public Housing • Other Subsidized Housing

3. The Importance of Understanding Benefits Law • Holistic Approach • PLS Client Population • Case Planning and Strategy • PLS Applicants have numerous civil legal problems • Filing and Appeal Rights • LEVERAGE for other legal issues- • Ex: Nonpayment of rent

4. Overview of Benefits Law • Largely based on Administrative Law & Practice • Opposing Party often a state agency: Social Services, Division of Medical Assistance, NC DHHS • Local and State Fair Hearings are the most common levels of representation at PLS • Combination of state and federal law depending on the program

5. Food and Nutritional Services (FNS) • Food Stamps • FNS is the Federal Agency that administers • SNAP is the food stamp program • WIC • Basic Eligibility • Income • Household Concept • Citizenship • *Categorical Eligibility • Allocation • Based on a calculation sheet • How to Apply • Local DSS • What is covered • Food-related items • WIC

6. Calculation Worksheet: DSS-1700

7. Food and Nutritional Services (FNS) • Common Legal Issues • Eligibility • Benefits Allotment & Overpayments • State Hearing Level Appeals-90 days to Request Appeal • Denial • Reduction of benefits/Allotment level • Termination • Overpayment of benefits • Agency Error • Inadvertent Household Error • Intentional Program Violation (IPV)* (local hearing first) • Legal Authority • Code of Federal Regulations: 7 CFR § 210-295 • NC FNS Manual: • http://info.dhhs.state.nc.us/olm/manuals/dss/ei-30/man/ • Case Law

8. ABAWD • Able Bodied • Not the same definition of disabilty that Social Security uses • If they have medical evidence they are unfit for work they can show this to DSS • Adults • Between the ages of 18 and 49. • Without Dependents • NOT responsible for the care of a child or incapacitated household member

9. Local DSS Action Administers FNS Program Notice/Appeal rights triggered Deadlines: 90 days / 10 days State Level Fair Hearing * Hearing Officer NOTE: IPV has a local hearing Appeal to Chief Hearing Officer (CHO) Deadline: request within 10 days of the HO State Fair Hearing Decision Appeal to Superior Court 30 days to appeal from the Final Agency Decision (runs from date of receipt of CHO decision) FNS Eligibility Fair Hearing Process

10. Social Security Disability • Social Security Disability Insurance (SSDi) • Supplement Security Insurance (SSI) • 2 Prong Test • Non-disability requirements • Different issues for SSDI and SSI • Takes into account work history, income, and resources. • Disability Determination

11. Social Security Disability Insurance (SSDi) • Federally run benefits program that provides aid to people who are unable to achieve gainful employment due to a permanent disabling condition. Financed by the Social Security tax. • Elements: • Work History: The normal requirement is a total of 40 credits, 20 of which must have been earned in the 10 years prior to the onset of disability, AND • Disability Standard & SGA: suffer from a permanent condition that prevents you from working: substantial gainful activity ($1,130/mo -> 2016) $1,170/mo -> 2017) • NO RESOURCE/ASSET TEST!

12. Supplement Security Income (SSI) • Supplemental Security Income (SSI) is a Federal assistance program designed to provide income to aged, blind, or disabled people who have limited assets with which to support themselves. • The SSI program is managed by the Social Security Administration (SSA), but financed by the general tax fund. Because the program is not financed by Social Security taxes, there are no work requirements necessary to qualify for SSI. • Eligibility • Low income, AND • HH1: resources less than 2k and monthly income less than $733 • HH2: resources less than 3k and monthly income less than $1100 • Disabled by SSA standard, 65+, or blind • Automatic eligibility for Medicaid

13. SSDi vs. SSI

14. Social Security Disability: SSDi and SSI • Apply at Local Social Security Administration • 60 days to appeal a denial for either SSDi or SSI • SSA Form: Request for Reconsideration • Can receive a combination of both SSDi and SSI • How? • SSDI benefit is lower than the SSI maximum, so SSI will supplement to bring the payment up to $733/mo (of course, dependent on meeting the resource limits for SSI)

15. SOAR Program at PLS • Social Security Outreach, Access and Recovery • Mission: • To increase the number of successful applications for SSI and SSDI for eligible people who are homeless or at risk of homelessness in order to facilitate their recovery and enable them to become successful, contributing members of their communities. • Funded for a much larger area than PLS normally covers through a combination of grants • Requirements • Homeless • Not literally homeless, but at risk of homelessness • Disabled

16. SOAR Program Only about 15% of homeless applicants are typically approved on initial application. • Path to recovery is extraordinarily challenging when basic needs are unmet • SSI/SSDI application and disability determination process can seem complex • Disconnect between the experience of homelessness and the disability application process • Medical information is often incomplete • Appeals take years and these individuals need housing and services immediately • SOAR focuses on the initial application – “Getting it Right the First Time” • SOAR Case Workers take on the role of SSA 1696 Representative • SOAR Case Workers gather medical records and interview applicant before submitting the application to SSA • SOAR Case Workers write a Medical Summary Report

17. Social Security Disability • Common Legal Issues • Local Appeal and ALJ Hearing- • Reduction of benefits • Resource determinations (SSI) • Overpayment of benefits • Request for Reconsideration (60 days) • Waiver • Questions about eligibility/resources/the application process • Questions about SSI and inheritance/long-term planning • What PLS does not handle: Disability Determinations* • Legal Authority • Title II of the Social Security Act (SSDi) • Title XVI of the Social Security Act (SSI) • 20 CFR Parts 404 and 416 • Social Security POMS • Case Law • *Outside of SOAR, PLS refers SSA disability cases to private SSA Disability Attorneys

18. Work First Family Assistance (WFFA) • North Carolina 's Temporary Assistance for Needy Families (TANF) program is called Work First • Through Work First, parents can get short-term training and other services to help them become employed and self-sufficient • Most families have two years to move off Work First Family Assistance.

19. Work First Family Assistance (WFFA) • Time-Limited Cash Assistance + Employment Services • Called Work First Benefits (WFB) • 24-month time limit • DSS has discretion for certain reasons to stop the clock • Exemption: single parent of child < 1 year old • At the end of 24 months can appeal or request extension • There are some extensions available • Children under age 18 (19 if in HS) • Grandparents can apply • Eligibility • Income • Resources • Citizenship • Benefits Diversion • One-time cash payment • Up to 3 months of Medicaid • Child care if needed

20. Work First Family Assistance (WFFA) • Apply • Local Department of Social Services • Common Legal Issues • Denial • Terminations • Sanctions: Child Support Enforcement & DV • Work Requirements • Legal Authority • North Carolina General Statutes 108A-27.11 • WFFA NC Manual • Case Law

21. Health Care Benefits • Medicaid • Categorical Eligiblity • ACA Coverage • Between 100% and 400% of FPL, a citizen, and not otherwise covered • Medicare • 65 years old • 2 years of SSDI

22. Medicaid & Healthcare Reform in NC • Affordable Care Act (ACA) • US Supreme Court Decision • Upheld Individual Mandate • Ruled Medicaid Expansion is optional • NC has elected NOT to expand Medicaid • Expansion: eliminate categories and based off income • Created a gap in coverage, known as the Medicaid Gap

23. Medicaid • Federal and state-funded health care coverage in NC • Numerous categories of eligibility • Age (65+) (MAA) • Disability (MAD) • Children/Families (MAF, MIC) • Pregnant women (MPW) • Long-Term Care (LTC) • Special Assistance (SA) • **NCHC • All categories of eligibility depend on income and some have a resource test

24. Medicaid • Apply • Local Department of Social Services • Common Legal Issues: 2 Categories • (1) Eligibility • Local and State Level Fair Hearing • (2) Medicaid Services (for current recipient) • OAH Appeal Process • Legal Authority • 42 U.S.C. 1396 et. Seq. • 42 C.F.R. 430 et. seq. • North Carolina General Statutes 108A-54 et. Seq. • State Admin Rules: 10A N.C.A.C. Chapters 21-22 • Medicaid NC Manual • Case Law

25. Medicaid: Eligibility Issues • Discouragement of Application • Income Determinations • Resource Determinations • Notice Requirement • Examples: • Counting a house as a resource that App doesn’t own • Denying eligibility for disability • Hearing Process: • Local Hearing (non-decision maker DSS official) • State Hearing (Hearing Officer) • Appeal to CHO • Appeal to Superior Court

26. Medicaid: Service Issues • Coverage Denials • Termination of Services • Reduction in service • Transportation • Mental Health Services • MCO: Currently WHN, soon to be merger of WHN and Smokey Mountain • Notice Requirement • Examples: • Termination in PCS Services • Denial of orthodontic request for minor • Deadlines • 10 days to appeal to maintain current service level • 30 days to reinstate service level (possible interruption) • Reimbursement of services is unlikely an issue, but a possibility • Hearing Process (OAH) • File Appeal • Mediation (within 25 days) (Mediation Network of NC) • Hearing (ALJ) (generally within 55 days of appeal; continue with good cause) • Issue (generally): Medical Necessity • Appeal to Superior Court (venue is county of residence or wake county)

27. Medicaid: Other Issues • Medicaid Estate Recovery • Medicaid Transfer of Assets • Nursing Home Medicaid Eligibility

28. Medicare • Federally Funded • Eligibility • Automatic Eligibility at age 65 • Under age 65 when on SSDi • people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). • Medicare Part A: hospital insurance • Medicare Part B: medical coverage/premium • Medicare Part C: Medicare advantage • Medicare Part D: prescription coverage

29. Medicare • Basics • Hospital coverage • Skilled Nursing Coverage (up to 100 days; patient co-pay) • Medical Coverage • Monthly premium • Generally 80% of covered services • Does NOT include: • Long-term nursing care • Low-Income Medicare Recipients • Can get Medicaid • Called MQB (Medicare Qualified Beneficiaries) • Supplemental Coverage or Premium payments

30. Medicare • Apply • Local Social Security Administration • MQB-Local DSS • Common Legal Issues • Denial of Claim • Penalty for Late Enrollment • Questions about Nursing Home Bills • Discharge for nonpayment • Legal Authority • 42 C.F.R. Chapter 4 • CMS.gov • Case Law

31. Important Considerations • Due Process • A public assistance applicant or recipient has a right to appeal adverse decisions and receive a fair hearing • Notice and Opportunity for a Fair Hearing (14th Amendment) • File Review (we go through DSS first) • Right of applicant/recipient to examine file • Standard of Review • State Hearings: de novo • New evidence can be submitted

32. Insurance Requirements • Minimum Essential Coverage – 60% • Essential Health Benefits • Emergency Services, Hospitalization, Mental Health, Labs, Rehab, etc • https://www.healthcare.gov/coverage/ • Free Preventative Care • No Pre-Existing Conditions • Premiums determined by Age, Location, Tobacco Use, Level of Care, Family vs. Individual

33. Health Care Big Picture • Between Medicare, Medicaid, and ACA most people can get health coverage either free or subsidized. • The only people who get no help are: • Undocumented Immigrants (except for emergency) • Those over 400% FPL • Those under 100% FPL who are not parents, aged, blind, or disabled. • This just happens to be a lot of our clients.