WIXLIB

What do case managers need to know about consultative exams? . . . . . . . . . . . . . . . . . . . . . . . .50Pulling it all together: Writing a summary letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52Chapter 7—The Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53What does SSA’s initial decision mean? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53How is a Request for Reconsideration filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55What can case managers do after the appeal is filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57How is a request for an ALJ hearing filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58How can a case manager prepare for a hearing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60What is the representative’s role at the hearing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61When should the Appeals Council or Federal Court be used? . . . . . . . . . . . . . . . . . . . . . . . . . . .65Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66Chapter 8—What To Do When Benefits Are Approved . . . . . . . . . . . . . . . . . . . . . . . . . 67How will a case manager know a determination has been made? . . . . . . . . . . . . . . . . . . . . . . . .67What happens after a favorable determination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67How can case managers be sure that calculations are correct? . . . . . . . . . . . . . . . . . . . . . . . . . .69How are retroactive benefits paid? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71How should retroactive benefits be spent?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74Chapter 9—Representative Payees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75What is a representative payee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75When does SSA appoint a representative payee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75What are the responsibilities of representative payees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76What expenditures does SSA deem appropriate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77How does a payee account for benefit payments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77Who can be a representative payee? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78What rights does a beneficiary have? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79What do case managers need to consider before becomingrepresentative payees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81TABLE OF CONTENTSv

Chapter 10—Maintaining Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83How do living arrangements affect ongoing eligibility? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83When are benefits suspended or terminated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85What should case managers know about overpayments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88What are SSA’s work incentive programs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90What if income from work exceeds allowable limits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93Appendix A—Immigration Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Appendix B—SSI and State Medicaid Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Appendix C—Samples from the Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Appendix D—Sample SSA Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Appendix E—Additional Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119For More Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121viSTEPPING STONES TO RECOVERY

INTRODUCTIONThis manual was developed by the SubstanceAbuse and Mental Health ServicesAdministration (SAMHSA) to help casemanagers and others assist adults who arehomeless, especially adults who are homelessand have serious mental illnesses, applyfor the Social Security Administration’s(SSA) disability programs.1 The SocialSecurity Disability Insurance (SSDI)and Supplemental Security Income (SSI)programs are administered by SSA to provideincome support to aged, blind, or disabledindividuals.The decision by SAMHSA to develop thismanual was influenced significantly byfront–line staff who work with people whoare homeless. People who are homelessconfront unique barriers and have aparticularly difficult time applying fordisability programs. This manual identifiesthe challenges, explains why and howthey occur, and offers suggestions to casemanagers and others about how to addressthem.The receipt of disability benefits is crucialfor people who are homeless. Often, thesebenefits provide the foundation from whichindividuals can take the first steps towardrecovery and employability. A case manager’srole in the process of applying for thesebenefits often is critical to an applicant'ssuccess.Applicants and case managers who betterunderstand SSA’s requirements and the needfor appropriate documentation can facilitatethe process, decreasing the time required toissue determinations and reducing the needfor appeals.To meet these objectives, the manual explainsthe various roles that case managers canplay in assisting people who are applying forSSA disability programs. Particular attentionis paid to the disability eligibility criteriaand the disability documentation process socase managers can help applicants furnishthe information that SSA needs to makea decision and determine proper benefitamounts. The manual also describes waysto ensure that people approved for disabilitybenefits receive the correct amount. Itexplains how decisions can be appealed if anindividual believes an application has beendenied in error.1 This manual provides information relevant to SSA disability programs for adults. It does not address any program requirements or restrictions for childrenwho may be eligible. SSA disability programs for children may have different definitions, procedures, and regulations.INTRODUCTIONvii

Perhaps the most important point of themanual is that case managers have a criticalrole to play in assisting people who arehomeless with the application process for SSAdisability programs. The services that casemanagers can provide to assist applicantswith the development and documentationof their disability claim are vital to theapplication process (see Chapter 6).Another key point is the importance ofestablishing direct communication withthe claims representative at the SSA fieldoffice and the disability examiner at theDisability Determination Services (DDS),the State agency under contract with SSA toperform disability evaluations. Establishing acommunication link to the individuals whoprocess the claim is key to learning about theneed for additional details from the applicant.Taken together, improved documentationand increased communication can reduce thetime required to make the determination andcan result in more accurate determinations.More informed decisions may also reduce theneed for appeals.Case managers also should be aware thatthe SSA rules cited in this manual are subjectto change due to revisions in the Federal law,court rulings, or SSA administrative policyupdates. Before relying on any specific SSArules cited in this manual, case managersshould confirm that the information iscurrent and applicable in their locality.Questions can be answered by consulting theSSA Web site at www.socialsecurity.gov.This manual has been developed for peoplewho are homeless. It has been reviewed andimproved by feedback from experiencedindividuals, including case managers,consumers, public policy professionals,viiiSTEPPING STONES TO RECOVERYFederal staff, and others who specialize inthe field. The manual is informative but notexhaustive. Readers are directed to reviewthe table of contents and index if they arelooking for answers to specific questions.Additional technical information is includedin the appendices. Any detail can be checkedby consultation with SSA.The information contained in the manualcovers the application and appeals processesfor both SSI and SSDI. In many respects,these processes are similar. For example, thedisability documentation and determinationprocesses described in Chapters 5 and 6 arethe same for both SSI and SSDI. Differencesbetween SSI– and SSDI–related proceduresare noted in the text.While this manual has been prepared forcase managers working with individualswho are homeless, the information may beuseful for anyone assisting someone with thedisability benefit application process, as wellas for applicants themselves. It is likely tobe helpful whether individuals are disabledby mental or physical illnesses, and whetherthey are homeless or housed.The manual is divided into ten chapters—each designed to answer key questions.Chapter 1 provides a broad overview of theSSI and SSDI programs as well as the Federaland State health insurance options alignedwith each.Chapter 2 addresses the various roles thatcase managers can play to help individualsapply for disability benefits.

Chapter 3 discusses options for filing anapplication and provides an overview ofthe documentation needed to complete anapplication.Chapter 4 outlines SSA’s income andresource criteria for the SSI program. Thischapter also includes a brief discussion ofhow immigration status may affect eligibilityfor benefits.Chapter 5 describes SSA’s process todetermine whether individuals are disabled,with particular attention to disabilitiesassociated with mental illnesses, co-occurringmental illness and substance use disorders,and co-occurring mental and physicaldisorders.Chapter 9 covers issues related torepresentative payees: when payees areneeded; how they are selected; theirresponsibilities; and how, when appropriate,responsibility of receiving and managingbenefits eventually can be transferred to therecipient.The last chapter, Chapter 10, providestips on how to maintain benefits forapplicants. Specific topics include how livingarrangements affect benefit levels, issuesrelated to suspensions and terminations,what to do about overpayments, andinformation about work incentives.Chapter 6 focuses on how case managerscan participate in the process of assemblingand/or obtaining information pertinent toa disability determination and provide suchinformation to the relevant State’s DisabilityDetermination Services (DDS).Chapter 7 provides an overview of theappeals process, including guidelines for casemanagers who may need to represent anapplicant at a hearing.Chapter 8 looks at what needs to be doneonce a favorable decision is made on an SSIapplication. Payment and expenditure ofretroactive benefits are discussed.INTRODUCTIONix

xSTEPPING STONES TO RECOVERY

CHAPTER1An Overview of the Social SecurityAdministration’s Disability ProgramsThis chapter provides a broad overview of Supplemental Security Income (SSI) and SocialSecurity Disability Insurance (SSDI), the two major Federal programs that provide cash benefitsbased on disability. It also briefly outlines the health insurance options aligned with each program.Many people who are homeless qualify for SSI; some may qualify for SSDI instead of, or inaddition to, SSI.What are SSDI and SSI?Social Security Disability Insurance (SSDI)and Supplemental Security Income (SSI)are the two Federal disability programsadministered by the Social SecurityAdministration (SSA).SSDI provides benefits to disabled or blindindividuals who are “insured” based oncontributions paid into the Social Securitytrust fund, as authorized by the FederalInsurance Contributions Act (FICA). Toqualify for SSDI benefits, an individualmust have worked long enough and recentlyenough under Social Security to receivebenefits. A person also may qualify as anSSDI beneficiary through parents or aspouse. Disabled widows/widowers age50 or over may qualify for benefits on aspouse’s earnings. In addition, an adultfound to have become disabled before age22 may qualify for benefits if his or herqualifying parent is deceased, disabled, orreceiving SSA retirement benefits. An alienwho obtained a Social Security numberon or after January 1, 2004, must meetadditional requirements to meet eligibilityfor SSDI. Since the SSDI benefit amountdepends on the average earnings of the wageearner, the benefit amount will be differentfor each beneficiary.In contrast, SSI provides benefits to lowincome people who are disabled, blind, orelderly. To qualify for SSI, an applicant mustmeet strict income and resource guidelinesto establish that he or she has low or noincome and minimal resources, and criteriaestablishing that he or she is aged (age 65and older), blind, or disabled, as defined bySSA. People can be eligible for both SSI andSSDI if their SSDI benefit is lower than thefull SSI Federal Benefit Rate (FBR).In some states the SSI benefit issupplemented by money from the state.CHAPTER 11

These funds provide disabled individualswith more money to meet their shelter,food, and health care needs. The size of thesupplement varies from state to state.Eligibility criteria for supplements differ bystate.1For both SSI and SSDI,the definition of disabilityis based on an inabilityto do significant work.How does SSA define disability?For both SSI and SSDI, disability is based onan inability to work at the level of substantialgainful activity (SGA). SGA is work thatinvolves significant mental and physicalactivity completed for pay or profit. Anindividual will be considered disabled bySSA only if he or she cannot do work thatwas done before and if SSA decides thatthe individual cannot adjust to other workdue to his or her medical condition(s). Anindividual’s disability also must have lastedor be expected to last for at least a year or toresult in death.SSA has an extensive process for determiningwhether a person is disabled for the purposeof receiving disability benefits. This manualdescribes the process in detail. The goal ofthis manual is to provide information to casemanagers that will improve their ability tohelp people who are homeless and who havemental illnesses apply for SSI and/or SSDI.What is the difference betweenSSI and SSDI?Both SSDI and SSI use the same definitionof disability. However, there are notabledifferences. The amount of the monthly SSDIbenefit depends on earnings while employedor self-employed, and on work history,while SSI benefits are based on a recipient’sincome or resources. Further, most peoplewho are entitled to SSDI must first serve afive–month waiting period (starting with thedate of onset of the disability) before theycan receive benefits. However, this can beretroactive, and individuals may receive upto 12 months of benefits before the date ofapplication. SSI payments cannot begin untilthe month following the date of application.It is important to note that, before receivingany SSI payments, an individual must haveapplied for other benefits to which he or shemight be entitled (i.e., SSDI, VA benefits,Workers’ Compensation, etc.). Case managersshould ensure that such applications arecompleted so payments by SSA are made in atimely fashion if an individual is approved.SSA should review an individual’s eligibilityfor SSI and SSDI whenever a person appliesfor either.1 A list of states that provide supplementary SSI payments can be viewed at rity–income/text–benefits–ussi.htm. These payments are administered by the state, by the Social Security Administration, or by both.2STEPPING STONES TO RECOVERY

Figure 1. Comparison between SSI and SSDI for Persons who are DisabledSSISSDIMust meet the definition of “disabled or blind”Must meet the definition of “disabled or blind”Not based on any requirement of insured statusBased on insured status of individual oranother qualified personIncome and resource limitsNo income or resource limitsMonthly benefit amount (Federal Benefit Rate(FBR) and State supplement, if any)Benefit amount based on contributionsduring work historyNo work history requirementWork history generally requiredLiving arrangements may affect eligibilityand benefit amountLiving arrangements have no effect oneligibility or benefit amountAutomatic Medicaid eligibility in most statesMay be eligible for MedicaidNot eligible for Medicare, unless also entitled to SSDIEligible for Medicare 24 months afterentitlement to SSDI benefits 2Some of the differences between SSI andSSDI are summarized in Figure 1.What about health insurance?Two publicly–funded health insuranceprograms exist for individuals who aredisabled: Medicaid and Medicare. In moststates, people eligible for SSI automatically areeligible for Medicaid, a Federal–State healthinsurance program with fairly comprehensivebenefits, including prescription drugcoverage. 3 While SSI and some SSDIbeneficiaries are eligible for Medicaid, onlythose people receiving SSDI benefits areeligible for Medicare. Most SSDI beneficiariesqualify for Medicare 24 months afterbecoming eligible for benefits. A beneficiaryreceiving both SSI and SSDI may be coveredby both Medicaid and Medicare.Medicare routinely covers physician visitsand hospital services, and it requirescopayments, deductibles, and monthlypremiums for outpatient services. Recentamendments to the Medicare statutehave allowed recipients access to partialprescription drug coverage through a varietyof third–party providers.2 Since July 2001, people with Amyotrophic Lateral Sclerosis (ALS or Lou Gherig's disease) do not have to serve a 24–month waiting period. Also,beneficiaries who have end–stage renal disease and are undergoing a course of dialysis or who have had a kidney transplant may not have to wait 24months. However, there is still a five–month waiting period for SSDI eligibility.3 Seven states and the Northern Mariana Islands use the same rules to determine Medicaid eligibility as SSA uses for SSI, but require individuals to file aseparate application. Eleven additional states not only require a separate application, but also use their own rules to determine if an individual is eligible forMedicaid. For further information, see Appendix B of this manual and/or refer to the National Association of State Medicaid Directors Web site:www.nasmd.org.CHAPTER 13

Medicaid benefits differ from state to statebut are required by Federal statute to coverprescription drugs. It should be noted,though, that not all States’ rules allowcoverage for all dru

Center for Mental Health Services Rockville, MD www.samhsa.gov DHHS Pub. No. SMA 05-4051. i ACKNOWLEDGEMENTS . Rosen, J. and Perret, Y., Stepping Stones to Recovery: A Case Manager's Manual for Assisting Adults Who Are Homeless, with Social Security Disability and Supplemental Security Income Applications. DHHS Pub. No. SMA 05-4051 .