SocialSecurityDisabilityBenefitsMentalHealthAdvocacyProject,LawFoundationofSiliconValley

(PartiallyRevisedfromMaterialsPreparedbytheHealthConsumerAllianceofCalifornia)

SocialSecurityDisabilityBenefits:Agenda

¢ OverviewoftheSocialSecurityAdministrationandDisabilityBenefits

¢ ApplicationProcess¢ Appealprocess¢ Proving“Disability”totheSocialSecurityAdministration¢ ContinuingDisabilityReviews

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OVERVIEW OF THE SOCIAL SECURITYADMINISTRATION AND DISABILITY

BENEFITS

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SOCIAL SECURITY ADMINISTRATION(SSA)

¢ SSAisafederalagencythatadministerstwodisabilityprograms:� SocialSecurityDisabilityInsurance(SSDIorTitleIIbenefits)� SupplementalSecurityIncome(SSIorTitleXVIbenefits)

¢ Bothdisabilityprogramsrequirethesamefindingofdisability

¢ However,thetwodisabilityprogramshaveuniquenon-medicaleligibilityrules:� SSDIrequiressufficientworkhistorytobeinsured� SSIhasincome/assetlimits

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SocialSecurityProgramsSocialSecurityDisabilityInsurance(SSDI)

¢ a.k.a.TitleII,SSA,DIB,RSDI¢ Insuranceprogram–work

credits¢ Amountbasedonwork

history¢ NoMeansTest¢ NoResourceTest¢ Aged,BlindorDisabled¢ LinkedtoMedicare¢ DistinguishSDI(short-term

statedisability)

SupplementalSecurityIncome(SSI)/StateSupplementaryPayment(SSP)

¢ a.k.a.TitleXVI,SSI/SSP¢ InCA$895.72/mo.formostadults¢ Reducedifotherincome,deeming

orin-kindsupport¢ Needs-basedprogram:Low

Income,LowResources(<$2,000forindividual,$3,000forcouple)

¢ U.S.residentandcitizenshiporqualifiedimmigrationcategory(otherwiseCAPI)

¢ Aged,BlindorDisabled¢ LinktoMedi-Cal

SOCIAL SECURITY DISABILITY INSURANCE(SSDI)

¢ SSDIprovidescashbenefitstodisabledorblindindividualswhoareinsuredbycontributionsthroughpayrolltaxes(FICA)

¢ SSDIbenefitamountdependsonamountanindividualhascontributedthroughFICA

¢ Maximumbenefitisapproximately$2,300/month¢ IftheSSDIbenefittowhichanindividualisentitledislessthantheSSIamountofbenefits,SSIbenefitsmaybeavailabletomakeupthedifference

¢ After24months,anindividualautomaticallystartsreceivingMedicare

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SUPPLEMENTAL SECURITY INCOME (SSI)¢ SSIprovidescashassistancetoaged,blind,ordisabledpeoplewhohavelimitedincomeandresources

¢ Theamountofbenefitsforwhichapersoniseligiblediffers,basedonavarietyoffactors

¢ Tobeeligible,anindividual’smonthlyincomemaynotbegreaterthanthemaximummonthlySSIbenefitamount

¢ Tobeeligible,anindividualmaynothaveresourcesinexcessof$2,000($3,000foracouple)

¢ Financialeligibilityisdeterminedfirst,disabilitydeterminationismadesecond

¢ AutomaticallyeligibleforMedi-CalwithnoShareofCost7

SUPPLEMENTAL SECURITY INCOME (SSI)¢ SummaryofMaximumSSIbenefits(2017):

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Individual EligibleCoupleAdults $895.72 $1,510.14

Adultslivinginhouseholdofanother $654.24 $1,147.75

Blindadults $952.23 $1,661.19

Blindadultslivinginhouseholdofanother $710.76 $1,298.80

Under18,livingalone,withparents,orrelatives

$800.15 N/A

Under18,livinginsomebodyelse’shouse $558.67 N/A

Pleasenotethatthisisnotanexhaustivelistofallthesituationsthatcouldaffectanindividual’sbenefitamount.

APPLICATION PROCESS

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SSDI/SSIApplicationProcess

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Complete Application and Disability Report

Call SSA at 1-800-772-1213 or file claim online to establish a Protective Filing Date (PFD)

SSA Determines Non-Medical Eligibility

SSA Sends Medical Information & Releases to State DDS, Where A Disability Analyst Is Assigned

DDS Processes & Makes Disability Determination

Claimant’s Folder Is Returned To Local SSA Office

SSA Notifies Claimant of Decision By Letter

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DisabilityDeterminationServices(DDS)

¢ DisabilityDeterminationService� StateagencywithSocialServices� Analystrequests&reviewsmedicalrecords� MedicalConsultantreviewsmedicalrecords� Decisionbasedonpaperfile

¢ Mightnotgetallexistingmedicalrecords¢ Donotseeorexamineclaimantdirectly¢ MaySendtoConsultativeExam(CE)withanon-treatingclinician

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ConsultativeExams(CEs)

¢ ScheduledifInsufficientorConflictingEvidencefromTreatingSources� Non-TreatingDoctorsContractw/DDS� TypicallyProvideBrief,OneTimeExams� DDSpayssetlowrates� Reportsaretypedintotemplate&includeassessmentoffunctionallimitations

� Reportsaretypicallynothelpful� Treatingdoctorispreferredsource

APPEALS PROCESS

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InitialDecision

Reconsideration

DistrictCourt

AdministrativeLawJudgeHearing

AppealsCouncil

StateAgency

StateAgency

SocialSecurity

SocialSecurity

FederalJudge

33%allowed

13%allowed

44%allowed/remanded

48%allowed

18%allowed/remanded

AppealsProcess

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RequestingAppeals¢ Deadline:60days(+5formailing)fromnoticedate

� 1st RequestforReconsideration(SSA-561)� 2nd RequestforHearingbyALJ(HA-501)

¢ Laterequestsacceptedonlyif“goodcause,”e.g.:� SeriousillnessthatpreventedclaimantfromcontactingSSA� Deathorseriousillnessinclaimant’simmediatefamily� Claimantdidnotunderstandrequirementsduetophysical,

mental,educational,orlinguisticlimitation

¢ Ifdeniedathearingstage,individualshaverighttoreviewthroughSSA’sAppealsCouncilandthenatFederalDistrictCourt

PROVING “DISABILITY”TO THE SOCIALSECURITY ADMINISTRATION

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Representative’sDuties¢ Governedbyfederalregulations(20CFR404.1740)¢ RepresentativesMust:

� Actwithreasonablepromptnesstoobtaintheinformationandevidenceinsupportoftheclaim&forwardinformationtoSSA

� Assistclaimantincomplyingwithrequestsforinformationorevidence

¢ RepresentativesMustNot:� Knowinglypresentfalseormisleadingstatements� Knowinglycauseunreasonabledelays� Divulgeinformationwithoutclaimant’sconsent

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SocialSecurity’sDefinitionofDisability

¢ Inabilitytodoany SubstantialGainfulActivity(“SGA”)� Workearnings>$1,170/monthin2017or,ifblind,workearnings>$1,950/monthin2017

¢ Duetomedicallydeterminablephysicalormentalimpairment

¢ Haslastedorcanbeexpectedtolastforacontinuousperiod12monthsormore,orresultindeath� (notashort-termmedicalcondition)� See20CFR§§ 404.1505,416.920.

¢ DecisionmadebyStateDisabilityDeterminationServices(DDS)

¢ DDSmayrequestmedicalrecords,mayrefertoowndoctors

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Istheclaimantengagedinsubstantialgainfulactivity?Ifyes,notdisabled.Ifno,proceedtostep2.

Doestheclaimanthaveasevereimpairment?Ifno,notdisabled.Ifyes,proceedtostep3.

Doestheclaimanthaveanimpairmentthatmeetsorequalsalistedimpairment?Ifyes,disabled.Processstops,youwin!Ifno,proceedtostep4.

Cantheclaimantreturntohisorherpastrelevantwork?Ifyes,notdisabled.Ifno,proceedtostep5.

Cantheindividualdoanytypeofworkthatexistsinsignificantnumbersinthenationaleconomy?Ifyes,notdisabled.Ifno,disabled.Youwin!

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5-StepDisabilityEvaluationProcess

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Step3:TheListings¢ SocialSecuritylistingsprovideexamplesofconditionsthatarepresumedtobedisabling

¢ Compareanindividual’sdiagnosis,symptoms,clinicalfindings,andfunctionallimitationstothecriteriaofthelistings

¢ Ifmedicalrecordsshowclaimant’sconditionmeetsorequalsalisting,thenpatientshouldbefounddisabled

¢ Organizedinto14BodySystems� Musculoskeletalsystem� Specialsensesandspeech� Respiratorydisorders� Cardiovascularsystem

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Step3:TheListings¢ 14BodySystems,continued:

� Digestivesystem� Genitourinarydisorders� Hematologicaldisorders� Skindisorders� Endocrinedisorders� Congenitaldisordersthataffectmultiplebodysystems� Neurologicaldisorders� Mentaldisorders� Cancer(malignantneoplasticdiseases)� Immunesystemdisorders

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SampleListing– MentalDisorder¢ 12.02Neurocognitivedisorders:

� Characterizedbyaclinicallysignificantdeclineincognitivefunctioning.Symptomsandsignsmayinclude,butarenotlimitedto,disturbancesinmemory,executivefunctioning(higherlevelcognitiveprocesses,suchasregulatingattention,planning,inhibitingresponses,decision-making),visual-spatialfunctioning,languageandspeech,perception,insight,judgment,andinsensitivitytosocialstandards.

� Anindividual’smentaldisordermustsatisfytherequirementsofbothparagraphsAandBortherequirementsofbothparagraphsAandC.

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SampleListing– MentalDisorder¢ 12.02Neurocognitivedisorders:

� ParagraphA:Medicaldocumentationofasignificantcognitivedeclinefromapriorleveloffunctioninginoneormoreofthecognitiveareas:¢Complexattention¢ Executivefunction¢ Learningandmemory¢ Language¢Perceptual-motor;or¢ SocialCognition

� ParagraphB:Extremelimitationsofone,ormarkedlimitationoftwo,ofthefollowingareasofmentalfunctioning:¢Understand,remember,orapplyinformation¢ Interactwithothers¢Concentrate,persist,ormaintainpace¢Adaptormanageoneself

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SampleListing– MentalDisorder¢ 12.02Neurocognitivedisorders:

� ParagraphC:Yourmentaldisorderinthislistingcategoryis“seriousandpersistent;”thatisyouhaveamedicallydocumentedhistoryoftheexistenceofthedisorderoveraperiodofatleast2years;andthereisevidenceofboth:¢Medicaltreatment,mentalhealththerapy,psychosocialsupport(s),orahighlystructuredsetting(s)thatisongoingandthatdiminishesthesymptomsandsignsofyourmentaldisorder;and

¢Marginaladjustment,thatis,youhaveaminimalcapacitytoadapttochangesinyourenvironmentortodemandsthatarenotalreadypartofyourdailylife

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Step3– MeetsorEqualsaListing¢ EqualsaListing:DoNothaveRequiredSpecificClinicalCriteriatoMeetListing� butfunctionallimitationisassevereasalistedimpairment

¢ CouldbeCombinationofImpairments:� Combinedeffectofseveralimpairments,includingeffectsofobesity,createsfunctionallimitationsequaltothatofalisting

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Steps4&5:AbilitytoWork¢ Basedon“ResidualFunctionalCapacity”:

� Themostthepersoncandodespitetheirphysicalandmentallimitations

¢ ExertionalLimitations� Sedentary,light,medium,heavy� Abilitytostand,walk,sit,lift,carry,etc.� Postural,ManipulativeorEnvironmentalLimitations

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Steps4&5:AbilitytoWork¢ Non-ExertionalLimitations

� LimitationsinAbilityto:¢maintainadequateconcentration,persistenceandpace

¢completetasks¢maintainsocialfunctioning¢performdailyactivities¢keepregularattendance

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Step4:AbilitytoWork¢ CantheClaimantReturntohisorherPastRelevantWork?� basedonResidualFunctionalCapacity

¢ PastRelevantWork=SubstantialGainfulActivitywithinpast15years

¢ IfYes,NotDisabled(EndsHere)¢ Ifno--gotoStep5

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Step5:AbilitytoWork¢ Step5:AbletoDoAnyWorkThatExistsinSignificantNumbersintheNationalEconomyDespiteLimitations?� Anyjob- neednotbeactuallyavailable� BurdenshiftstoSocialSecurity

¢ IfYes(candoahypotheticaljob)à NotDisabled¢ IfNoà Disabled

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MedicalRecordsNeededtoDocumentImpairment(s)

¢ TreatingSourceShouldbeGivenMostWeight� Ifconsistentwithrecord� Longerrelationship=moreweight� Tip:cansignoffassupervisorofatreatmentteam

¢ Examining>Non-Examining¢ Specialists>Non-Specialists

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AdditionalHurdle:DrugAddiction&Alcoholism(DA&A)

¢ IfthereisevidenceofDA&A,mustshowthatimpairmentswouldstillmeetdisabilitycriteriawithoutDA&A� Donotneedtobecleanandsobertoqualify(SSR13-2p)

¢ IsDrugAddictionorAlcoholismMaterialtoaFindingofDisability?� Tip:Doproblemsoccurwhens/heissoberoronlywhenusing?

� Documentfunctionalimpairmentsthatpre-datesubstanceuseorexistwhensober.Lookfororganicimpairment.

� Ifactiveuse:documenthistoryexploringonsetofimpairments,historyoftraumaorabuse,fostercareoreducationrecords

CONTINUING DISABILITY REVIEWS

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SSDI/SSICONTINUING DISABILITYREVIEWS (CDRS)

¢ SSAconductsCDRsapproximatelyevery3years¢ Conductedmorefrequentlywhendisabilityisexpectedtoimprove

¢ IfSSAdecidesthatanindividual’sdisabilityhasended,SSAwillnotifytheindividualthattheirbenefitswillend� Individualmayfileanappealwithin10days(plus5daysfor

mailing)tocontinuereceivingbenefitswhileappealispending

� Otherwise,individualhas60days(plus5daysformailing)toappealdecision

� Ifappealisdenied,individualhastherighttoseekahearinginfrontofanAdministrativeLawJudge(ALJ) 33

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Questions?

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