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Social Security and SSI
Practice—Deconstructing a
Denial Notice
Thomas Yates
Health & Disability Advocates
[email protected]
Issues for Discussion—Using
Sample Denial As Starting Point
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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)
Social Security Disability vs. Supplemental
Security Income (Item 1 on Denial)
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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.
Social Security Disability Basics
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Key to Social Security Benefits—Insured Status
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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 40calendar 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.
SSI Basics
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Need-Based (based on income
and assets).
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Covers Blind, Disabled, and
Elderly (age 65 or older).
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Maximum benefit of $637 in 2008.
Getting Information from SSA
(Item 2 on Denial)
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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).
Disability Standard (Item 3 on the
Denial)
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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.
Disability Sequential Evaluation
Is the claimant working and grossing more than $940 per
month? If yes, not eligible.
2.
Does the claimant have a medical impairment(s) that cause
some impact on ability to work? If no, not eligible.
3.
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.
1.
Rules of Thumb for Disability
Standard
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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.
Application of Disability Standard
to Evidence (Item 4 on Denial)
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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.
Other Benefits—Medicare and
Medicaid (Item 5 on Denial)
Medicare
Medicaid
Social Security
Benefits based
on disability
Eligible for
Medicare in 25th
month of eligibility
for Social Security
benefits
Supplemental
Security
Income (SSI)
Not eligible for
Medicare
Eligible for
Medicaid if
countable income
is less than 100%
of FPL and
countable
resources are less
than $2000 for
beneficiary and
$3000 for couple
Appealing a Denial (Item 6 on
Denial)
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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.
Social Security Appeal Process
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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