Social Security and SSI Practice—Deconstructing a Denial Notice

1. Social Security and SSI Practice—Deconstructing a Denial Notice Thomas Yates Health & Disability Advocates tyates@hdadvocates.org

2. Issues for Discussion—Using Sample Denial As Starting Point • Type of Claim—SSD and SSI (item 1) • Getting Information from the Social Security Administration (item 2) • Disability Standard (item 3) • Application of Standard to Evidence (item 4) • Other Benefits: Medicaid and Medicare (item 5) • The Appeal Process (item 6)

3. Social Security Disability vs. Supplemental Security Income (Item 1 on Denial) • Look at Header on Denial for Type of Benefits (RSDI vs. SSI) • Social Security Disability (SSD) is monthly disability benefit-amount of benefit depends on past work income. • Supplemental Security Income (SSI) is need-based disability program that pays maximum of $637 monthly in 2008.

4. Social Security Disability Basics • Key to Social Security Benefits—Insured Status • Fully Insured Status—worker has at least one credit for each calendar year starting at age 21. • Currently Insured Status—worker has at least six credits in full 13-quarter period prior to death or entitlement to disability benefits. • Disability Insured Status—worker has at least 20 credits in 40-calendar quarter prior to disability. See item 1 on last page of decision. • Credits (Quarters of Coverage)—Credits reflect 3-month periods in which a worker earns a minimum level of wages, etc. In 2008, a worker needs to earn $1,050 to obtain a credit.

5. SSI Basics • Need-Based (based on income and assets). • Covers Blind, Disabled, and Elderly (age 65 or older). • Maximum benefit of $637 in 2008.

6. Getting Information from SSA (Item 2 on Denial) • Look to page 3 for header “If You Have Any Questions.” • Because Social Security claimants are protected by Privacy Act, legal representatives must have signed release from claimant to obtain information from SSA. • Use the SSA-1696 form (I usually contact the District Office and then make arrangements to fax SSA-1696 to DO representative). • If the DO is not listed on the denial notice, use SSA website to find local office address (https://secure.ssa.gov/apps6z/FOLO/fo001.jsp).

7. Disability Standard (Item 3 on the Denial) • Refer to “The Disability Rules” on Denial. • For adults, the disability must last or be expected to last for at least 12 months in a row or result in death, AND • Show disability on the Sequential Evaluation set forth on next slide.

8. Disability Sequential Evaluation • Is the claimant working and grossing more than $940 per month? If yes, not eligible. • Does the claimant have a medical impairment(s) that cause some impact on ability to work? If no, not eligible. • Does the claimant meet or equal the Listings? If yes, patient is disabled. If no, go to step three and one-half. 3.5. Determine the claimant is not able to do in a normal day because of his or her medical impairments? 4. Based on what the claimant cannot do, can s/he do the kind of work that she or he did in the past 15 years? If yes, not eligible. If no, go to step five. 5. Based on what the claimant cannot do, can s/he do any other work, based on medical impairments, age, education, and work experience? If yes, not eligible. If no, patient is disabled.

9. Rules of Thumb for Disability Standard • Claimants under age of 50 who have physical impairments must show inability to do even sedentary work on full-time basis to be found disabled. • Claimants age 50 and older may not need to show as much loss of function-turns on claimant’s age, education, work experience, and residual functional capacity. • Claimants with mental impairments must show inability to sustain even simple, unskilled work to be found disabled.

10. Application of Disability Standard to Evidence (Item 4 on Denial) • Page 4 of Denial is section entitled “Explanation of Determination.” • Lists the evidence that SSA obtained in making the decision. • Advocate needs to review list with claimant to determine whether evidence is missing from list (this means that SSA did not consider) • Advocates then need to obtain that evidence from medical providers or others to support claim on appeal.

11. Other Benefits—Medicare and Medicaid (Item 5 on Denial)

12. Appealing a Denial (Item 6 on Denial) • See “If You Disagree With The Decision” on Denial on page 2. • You need to look to first line of text on page 1 to determine whether denial is at initial or reconsideration level. • Time Limits are very short—65 days from date on adverse notice. • The appeal packet consists of Request for Reconsideration or Request for Hearing, Disability Report, and Authorizations for Release of Information.

13. Social Security Appeal Process • Application: done at Social Security District Offices, by phone (800-772-1213) or on Internet (www.socialsecurity.gov) • Initial decision made by BDDS in Springfield; 60 days to appeal denial • Reconsideration decision made by BDDS in Springfield; 60 days to appeal denial. • Hearing with Administrative Law Judge; hearing offices in Chicago, Evanston, Oakbrook and Orland Park; 60 days to appeal denial. • Appeals Council: paper review; 60 days to appeal • Federal Court