Social Security Disability (SSDI and SSI) for Adults

Transcription

1 Social Security Disability (SSDI and SSI) for Adults Paula M. Jacobson Law Office of Paula M. Jacobson 604 West 2 nd Avenue Anchorage, Alaska (907) pjacobsonlaw@gmail.com

2 Social Security Benefits For Adults With Disabilities SSA administers two benefits programs for adults (over 18) with disabilities -- Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). The programs differ in certain ways (more about that later) but the basic requirement is the same for both programs Only adults who have a disability (as that term is defined by SSA) and meet the medical criteria (established by SSA) may qualify for benefits under either program. -References (all on-line and surprisingly well written and easy to access): -SSA maintains a huge reference document called Program Operations Manual System (POMS) which contains all of the rules governing the entire SSA program (Social Security Retirement, SSDI, SSI, Medicare) This document is used by all SSA personnel. It is easy to search for topics in the POMS and, for the most part, they are relatively easy to understand, although not always as complete as you might want. POMS are frequently updated, so it is necessary to make sure you are looking at the most recent version. SSA has a series of documents called Spotlights which summarize common issues in SSI, they are also easy to understand (a copy of the Spotlight index is included in this handout. SSA also has a huge library of informational booklets (also on-line) which address common issues and are written for lay people.

3 Disability as defined by SSA In order to receive SSDI and/or adult SSI benefits the individual must be found to be disabled by SSA SSA defines disability differently than you do. The SSA definition of disability is the inability to engage in substantial gainful activity (SGA) because of a medically determinable physical or mental impairment that has lasted or is expected to last for a continuous period of at least 12 months. SGA is defined by SSA as. doing significant physical or mental activities, or a combination of both for a full or part-time period for pay or profit Essentially, in English, rather than Social Security Speak, the claimant is disabled if he can t work because of a verifiable medical diagnosis, which causes certain impairments, for at least a year. The impairment can be physical or mental or both. In other words, it is all about the ability to work. That is the absolute bottom line for SSDI or SSI benefits. If an individual can work and make over $1170/month (SGA monetary limit), he is not disabled under SSA rules

4 The Date of Disability It is SSA, not the individual, and not necessarily the individual s doctor, who determines the date that the disability began. The date the application is made is not necessarily the date of disability The date the application is approved is not necessarily the date of disablity The date of disability is the date that SSA determines the person became disabled based on their standards for disability The date of disability is very important because It can affect whether the person is eligible for SSDI, SSI, or both It affects the date that benefits start being paid It affects the date that Medicare begins It affects the amount of retroactive benefits paid (amount of backpay ) if the claim is approved It affects whether or not the individual gets Medicaid and, if so, when.

5 Who Gets What? SSDI SSDI pays benefits to disabled adults( and dependent family members) if: not presently working or working with wages = to or less than $1170/mo - worked 5 out of 10 years prior to date disability started and paid FICA taxes during that period. If not = not qualified for SSDI, but may qualify for SSI) - meets the SSA definition of disability There are no income or resource limits for SSDI maximum monthly SSDI benefit = $2,687/month. Actual benefit amount depends on length of time worked, earnings history, and offsets. Unlike SSA Retirement benefits, there is no offset for government pensions. There is no offset for VA disability benefits or Alaska workers compensation. Unlike SSI, there is no reduction if the individual is living with someone else, in someone else s household, or someone else pays food and shelter costs. If family dependents are receiving SSDI benefits based on the earnings record of the primary person, his monthly benefit is not reduced. But there is a limit on total amount of SSDI paid to individual and family dependents in same household ( % of SSDI).

6 Who Gets What? SSI SSI pays benefits to disabled adults who have either not worked; worked and not paid FICA taxes; worked sporadically or very little; or not worked for 5 out of the 10 years before the date that Social Security determines the individual is disabled This is one reason why SSI more common than SSDI among younger adults. Individuals applying for SSI must meet certain income and resource limitations, which are, for the most part, the same or similar to the financial requirements for Adult Public Assistance (APA) and APA Medicaid maximum SSI monthly benefit for an individual is $735/month and $1,103 for a couple. The amount of SSI will be reduced if someone else is providing in kind support and maintenance (ISM), which, in general, means that someone else is paying for or providing food and shelter (more on this later). SSI can also be reduced for wages earned (more on this later). Generally, but not always, it is a 1/3 reduction (SSI reduced from $735/mo to $490/mo). No reduction if individual lives with a spouse who provides ISM and no reduction if minor child lives with parents who provide ISM.

7 Why Do Some People Get Both SSDI and SSI? If the individual is disabled and if his/her SSDI monthly rate is lower than $735 (the 2017 maximum SSI rate) because of a low or short wage earning history, SSA will bring the individual up to $735/mo by supplementing the SSDI rate with SSI (that s why it is called Supplemental Security Income). Example: Mary is disabled. She has worked sporadically (although she does have enough work quarters to qualify for SSDI). Her SSDI rate is $600/month. So, she falls below the SSI monthly rate of $735. Assuming she meets the asset and income limitations of the SSI program, SSA will then pay her SSDI benefits of $600/mo and SSI benefits of $135/mo = $735/mo. Who figures all of this out? At the time of approval of the claim, SSA makes the determination that this is a concurrent claim a/ka/a the person is dual eligible and pays accordingly. That is why some people either receive two checks or two auto deposits per month and why you might see two separate 1099s at the end of the year.

8 What Else Does the SSDI Recipient Get? Monthly payments and Medicare Part A & B. The Premium is taken out of the SSDI payment. Medicare becomes effective 29 months after the date that SSA determines the individual is disabled. There is a 24 month waiting period and SSA tacks on another 5 months = 29 months. In many cases, the decision that the individual is disabled is retroactive, so there really isn t a long waiting period. but that is not always the case. Example: Mary applies for SSDI in October In her application, she states that she became disabled in October It takes two (2) years from the date of her application (until October 2019) to finally determine that she is disabled (as of October 2016). Mary will get Medicare right away because she has waited over 36 months for her claim to be approved. Example: Joe applies for SSDI in January In his application, he states that he became disabled in October SSA approves his claim but determines that he really became disabled in December He won t get Medicare until May 2019 (29 months from the date that SSA determines that his disability started).

9 What Else Does the SSI Recipient Get? Monthly payments and Medicaid. Once the SSI recipient has been deemed disabled and determined to meet the income and asset limitations for SSI, he will get Medicaid. Any one who gets $1 of SSI money will get Medicaid (remember that an individual whose SSDI rate is very low will get a supplement from SSI and the amount will depend on SSDI rate). Adult Public Assistance. In general, the SSI recipient will receive a monthly benefit from APA. The amount will depend on several factors, including the living arrangement of the individual. Food stamps. If the individual meets the criteria for food stamp benefits. If the SSI recipient is also receiving SSDI and if he/she has waited the 29 month period, then he/she will also receive Medicare. In that case, Medicaid will pay the Medicare premium payment.

10 SO, HOW DOES SSA DETERMINE THAT SOMEONE IS DISABLED? THE SHORT ANSWER.IT IS VERY COMPLICATED AND (IN MOST CASES) TAKES A VERY LONG TIME REMEMBER: THE SSA DEFINITION OF DISABILITY IS VERY DIFFERENT THAN ANY OTHER DEFINITION OF DISABILITY. ACCORDING TO SSA: YOU ARE DISABLED IF YOU ARE UNABLE TO ENGAGE IN SUBSTANTIAL GAINFUL EMPLOYMENT DUE TO A MEDICALLY DETERMINABLE IMPAIRMENT BOTTOM LINE QUESTION IN ALL SSA DISABILITY CASES (SSDI & SSI): CAN THIS PERSON WORK AT ANY TYPE OF JOB AND MAKE $1,170/MONTH GIVEN HIS DIAGNOSIS AND THE PHYSICAL OR MENTAL IMPAIRMENTS CAUSED BY THAT DIAGNOSIS?

11 SequentiTTTheHEEvaluation Step 1 Is the person working? Person is working at SGA level. Denied Step 2 Does person have a severe impairment? Person is not working or is working at less than SGA level. Person has no severe impairment. Person has severe impairment. Denied Step 3 Does impairment meet or equal the listing requirements? Impairment does not meet or equal the listing requirements. Impairment meets or equals the listing requirements. Approved Step 4 Does impairment allow for past relevant work to be done? Person can do past work. Person cannot do past work. Denied Step 5 Can person do any other work, considering diagnosis, age, education, work history? Yes Denied No Approved

12 THE FIVE STEP SSA PROCESS TO APPROVE OR DENY A CLAIM (HOW SSA DETERMINES DISABILITY) Step 1 If claimant is working and earning $1170/mo or more = claim denied Step 2 If claimant does not have a severe impairment = claim denied Step 3A If claimant s diagnosis does not meet a Listing = claim not denied Step 3B-If claimant s diagnosis meets a Listing = claim approved Step 4A If claimant s impairment does not affect his ability to do past work = claim denied Step 4B- If claimant s impairment affects his ability to do his past work = claim not denied Step 5A If claimant s impairment affects his ability to do any other type of job = claim approved Step 5B-If claimant s impairment does not affect his ability to do any other type of job = claim denied

13 How Does SSA Determine That The Application Process: Someone Is Disabled? The claimant him/herself, parent, guardian, conservator, spouse, friend, etc. can apply on line at (SSDI only) or apply in person, telephone, or mail (SSDI and SSI). An interview is scheduled with SSA personnel, either in person or by telephone. The SSA personnel will record basic information. SSA then besieges the claimant with endless duplicative paperwork, requests for medical and other records, questionnaires regarding activities of daily living, physical capacity, mental capacity, medications, living situation etc etc., all of which the claimant has to complete within the time limits set by SSA. Failure to do so can result in denial of a claim regardless of how appropriate it is. SSA is then responsible for gathering the claimant s medical and other records and requesting updates of records. SSA scans all records into the claimant s file and that file (on a CD) can be obtained by the claimant upon request.

14 How Does SSA Determine that Someone is disabled? SSA contracts with Alaska Disability Determination Services (SDS). SDS personnel evaluate all of the medical and other information in the file to determine whether the claimant is disabled. SDS uses the SSA standards for disability to make this determination. SDS may requess that the claimant attend a medical or psychological evaluation with a physician or a psychologist retained by SDS to determine whether the claimant is disabled under SSA standards. If SDS determines that the claimant is disabled the claim is approved (and in the case of SSI subject to SSA determination on whether the claimant meets the SSI income and resource limitations). SDS approves approximately 50% of claims. These are usually the most obvious ones.

15 How does SSA determine that someone is disabled? If SDS denies a claim, the file goes back to SSA. The claimant receives a letter stating that the claim is denied and the claimant has 60 days to ask for a hearing before an Administrative Law Judge (ALJ), who will be the decision maker on the claim.

16 How Does SSA Determine that Someone is Disabled? STEP 1: IS CLAIMANT WORKING? Is the claimant is working and making over $1170/mo (or $1950/mo if blind)? If so, the application is denied. Does the claimant have sufficient earnings history qualify for SSDI. If so, SSA will begin the determination as to whether the individual is disabled. If not, SSA will begin the determination of whether the individual is disabled. (Although it would seem logical that SSA should make sure that the claimant meets the income and resource limits for SSI (in a case where it is clear that the claimant does not qualify for SSDI), they do not always do so at the beginning of the analysis of the claim.

17 How Does SSA Determine Whether Someone Is Disabled? STEP 2: DOES HE HAVE A SEVERE IMPAIRMENT? -DEFINED BY SSA AS: AN IMPAIRMENT OR COMBINATION OF IMPAIRMENTS THAT SIGNIFICANTLY LIMIT The claimant s PHYSICAL AND/OR MENTAL ABILITY, AND AS A RESULT INTERFERE WITH ABILITY TO PERFORM BASIC WORK ACTIVITES OF ANY KIND FOR 12 OR MORE MONTHS -EXAMPLE: claimant HAS BROKEN ANKLE, DOC SAYS HE WILL RECOVER IN 6 MONTHS >> SSDI OR SSI DENIED -EXAMPLE: claimant HAS TRAUMATIC BRAIN INJURY, DOC SAYS HE MAY RECOVER BUT RECOVERY NOT EXPECTED FOR SEVERAL YEARS >>> SSDI OR SSI CLAIM NOT DENIED -SOME DIAGNOSES ARE SO SEVERE THAT SSA AWARDS SSDI and/or SSI BENEFITS AUTOMATICALLY (a/k/a COMPASSIONATE ALLOWANCES. THERE IS A LIST OF 200 DIAGNOSES ON THE SSA WEB SITE THAT FALL INTO THIS CATEGORY. EXAMPLES ARE: TERMINAL CANCER (claimant EXPECTED TO DIE WITHIN 1 YEAR), ALS, AWAITING HEART TRANSPLANT, AND 185 OTHER DIAGNOSES THAT YOU AND I HAVE NEVER HEARD OF

18 HOW DOES SSA DETERMINE WHETHER SOMEONE IS DISABLED? STEP 3: DOES HIS DIAGNOSIS MEET THE CRITERIA IN THE SSA LIST OF IMPAIRMENTS? THE LIST OF IMPAIRMENTS IS AN ARCANE AND UNINTELLIGIBLE REFERENCE BOOK PUBLISHED BY SSA. IT LISTS ALMOST EVERY MEDICAL CONDITION KNOWN TO HUMAN-KIND AND DESCRIBES THOSE CONDITIONS IN TERMS NOT USED SINCE THE CIVIL WAR. EXAMPLE: MULTIPLE SCLEROSIS IS A LISTED DIAGNOSIS. BUT SIMPLY BECAUSE THE CLAIMANT HAS BEEN DIAGNOSED WITH MS IS NOT ENOUGH -- THE CLAIMANT MUST ALSO HAVE IMPAIRMENTS CAUSED BY THE DISEASE, WHICH ARE SIGNIFICANT ENOUGH TO KEEP HIM FROM WORKING IN ORDER MEET THE LISTING FOR MS: -examples of significant impairments caused by MS, which would keep the claimant from working: consistent substantial weakness of both arms or tremors of both hands, on a consistent basis (occurring 6 hours out of an 8 hour day). IF THE claimant MEETS THE LISTING THE CLAIM IS APPROVED. IF THE claimant DOES NOT MEET THE LISTING THE CLAIM IS NOT DENIED. NEEDLESS TO SAY, IT IS VERY DIFFICULT TO MEET A LISTING

19 HOW DOES SSA DETERMINE WHETHER SOMEONE IS DISABLED? STEP 4A: WHAT IS HIS RESIDUAL FUNCTIONAL CAPACITY A/K/A WHAT WORK CAN HE STILL DO DESPITE IMPAIRMENT? IF THE claimant DOES NOT MEET A LISTING, THE CLAIM IS REVIEWED TO DETERMINE THE claimant s RESIDUAL FUNCTIONAL CAPACITY WHICH IS A SNAZZY TERM THAT REALLY MEANS: WHAT CAN THE claimant STILL DO DESPITE HIS DIAGNOSIS AND SYMPTOMS? IT IS ALWAYS FOCUSED ON THE ABILITY TO DO WORK-RELATED ACTIVITIES. THIS IS AN INCREDIBLY SUBJECTIVE (AND OFTEN UNFAIR) DETERMINATION MADE BY SOMEONE WHO HAS NO MEDICAL TRAINING &HAS NEVER EXAMINED OR EVEN SEEN THE claimant. FOR EXAMPLE: FOR A PHYSICAL DIAGIOSIS, THE QUESTION IS ALWAYS HOW LONG CAN THE PERSON SIT, STAND, WALK, USE HIS HANDS, BEND, KNEEL ETC ETC. FOR EXAMPLE: FOR AN MENTAL/COGNITIVE DIAGNOSIS SSA LOOKS AT PPC PERSISTENCE, PACE, AND CONCENTRATION, E.G. CAN THE claimant STAY ON TASK, WORK AT RESONABLE PACE, OR CONCENTRATE ON WORK RELATED (OR ANY OTHER) TASK. IN MY OPINION, IT IS EASIER TO GET SSDI OR SSI FOR AN claimant WITH A MENTAL/COGNITIVE IMPAIRMENT THAN A PHYSICAL IMPAIRMENT

20 HOW DOES SSA DETERMINE WHETHER SOMEONE IS DISABLED? STEP 4B: CAN HE RETURN TO HIS PAST WORK GIVEN HIS PHYSICAL OR MENTAL IMPAIRMENT? CAN HE GO BACK TO THE YPE OF WORK HE USED TO DO? EXAMPLE: claimant WHO USED TO BE A COMPUTER PROGRAMER IS IN ACCIDENT AND NOW PARAPLEGIC, BUT CAN USE HANDS AND ARMS AND HAS NO COGNITIVE DISORDER. CHANCES ARE PRETTY GOOD THAT SSA WILL SAY HE CAN RETURN TO PAST WORK CLAIM FOR SSDI PROBABLY DENIED EXAMPLE: claimant WHO USED TO BE CONSTRUCTION WORKER (NO OTHER JOB HISTORY) IS IN ACCIDENT AND NOW PARAPLEGIC. CHANCES ARE GOOD THAT SSA WILL SAY THAT HE CANNOT RETURN TO PAST WORK CLAIM FOR SSDI NOT DENIED

21 STEP 5: Can the claimant do any type of work at all? THIS IS THE MOST IMPORTANT STEP, WHERE MOST SSDI & SSI APPLICATIONS ARE ULTIMATELY DENIED IN MAKING THE DECISION, SSA MUST CONSIDER THE claimant s AGE, EDUCATION & VOCATIONAL TRAINING, SKILLS, DIAGNOSIS, SYMPTOMS, AND RESIDUAL FUNCTIONAL CAPACITY. ONCE AGAIN, THIS IS FREQUENTLY A VERY SUBJECTIVE DETERMINATION SSA USES VOCATIONAL EXPERTS (HIRED BY SSA) TO DETERMINE WHETHER THERE ARE ANY JOBS AVAILABLE TO THE claimant GIVEN THE ABOVE LIMITATIONS. ALL THE VOC EXPERT HAS TO DO IS FIND A JOB, NO MATTER HOW DUMBED DOWN, THAT THE claimant CAN DO AND THE CLAIM WILL BE DENIED. IN OTHER WORDS, THE claimant MUST BE SO PHYSICALLY OR MENTALLY IMPAIRED AS A RESULT OF THE DIAGOSIS AND RESULTING SYMPTOMS THAT HE CANNOT DO ANY JOB IN THE ANY WORK PLACE. LOCATION IS IRRRELEVANT. IT DOES NOT MATTER THAT THE JOB IS NOT AVAILABLE WHERE THE PERSON LIVES. HE JUST HAS TO BE ABLE TO DO IT IF IT WAS AVAILABLE HERE S WHAT DOES MATTER: AGE (THE OLDER THE claimant THE MORE LIKELY THAT THE CLAIM WILL BE APPROVED), A REALLY GOOD CONSISTENT WORK HISTORY, (THE BETTER THE PRE-IMPAIRMENT WORK HISTORY IS, THE MORE LIKELY THE CLAIM WILL BE APPROVED), (SKILLS (THE MORE EDUCATED AND SKILLED THE WORKER THE MORE LIKELY CLAIM WILL BE DENIED BECAUSE THE ASSUMPTION IS HE CAN FIND OTHER WORK), HISTORY OF SUBSTANCE ABUSE INTERFERRING WITH EMPLOYMENT, MEDICAL RECORDS HINTING THAT THE claimant IS A MALINGERER THESE ARE THE KISSES OF DEATH FOR A CLAIM.

22 What happens when a claim for disability is denied? -The claimant has 60 days from the date of the denial letter to appeal the decision. This is an absolute drop dead deadline. -In general, failure to appeal within 60 days is deemed a final denial. The claimant must then file a new claim unless he/she can prove a really good reason for failure (a fruitless and time consuming endeavor for the most part). -If the claimant wants to appeal a medical decision (e.g. that the claimant is not disabled), he fills out a form called Request for Hearing by Administrative Law Judge. This form starts the appeal process (available online or at SSA office). This must be done within 60 days of the date of the denial. It can be done on-line (although SSA is totally impossible and frustrating to deal with, it has a really good web site for filing claims). -This is also the beginning of SSA Purgatory because you are now dealing with the SSA Office of Disability Adjudication and Review (ODAR), which is very very difficult for an unrepresented claimant. -If done on-line, make sure that you print a receipt for the appeal. Also, make sure that you keep every letter and piece of paper received from SSA and follow all directions and instructions exactly (assuming you can figure out what they are saying). If the appeal form is delivered in person to the SSA office, make sure you get a receipt. Do not, I repeat, do not mail an Appeal form to SSA. It is a recipe for disaster.

23 Some Bad News and Not So Bad News for Alaska claimants Approval rate of claims reviewed by SDS-DDS is average among 50 states, Puerto Rico, and Guam Approval rate of claims reviewed by Alaska Administrative Law Judges (ALJs) is the lowest among 50 states, Puerto Rico and Guam. TAKE AWAY: If claim denied by SDS-DDS, chances are not particularly good that it will be approved by ALJ

24 COMMON SSA ISSUES: LIVING ARRANGEMENTS & SSI ADJUSTMENTS Applies to SSI only. Inapplicable to SSDI. -SSA considers the payment of food and/or shelter by someone else to be income to the SSI Recipient (R ). Called In-kind Support and Maintenance or ISM. This can reduce the SSI benefit under certain circumstances. Here are some basic examples: -R lives in own home and pays own rent food & shelter = no reduction of SSI -R lives with spouse and no one outside house pays for food & shelter (although spouse may) = no reduction of SSI -R lives in another person s house and pays his pro-rata share of food & shelter = no reduction of SSI (if R does not pay his pro-rata share, there will be a reduction of SSI -R lives in another person s house and does not pay for food and shelter = SSI reduced by 1/3 (from $735 to $490) -R lives in his own home and someone outside the home pays a portion of rent ($100/mo). SSA considers the $500 to be ISM and reduces as follows: $100 -$20 = $80 ($20 is a general exclusion from ISM ) $735 - $80 =$655/mo. -R lives in ALF, nursing home for more than a month and Medicaid pays for over ½ the cost of care = SSI reduced to as little as $30/mo -Homelessness is irrelevant = SSI not reduced -

25 COMMON SSA ISSUES: RECIPIENT IN JAIL Different rules for SSI and SSDI SSI benefits suspended while in jail for 30 days or more Can be reinstated the month after release if sentence not more than 12 months If more than 12 months, benefits terminated and have to reapply after release SSDI benefits suspended while in jail for 30 days or more Reinstatement available the month after release regardless of length of sentence Dependent s SSDI benefits are not suspended while R in prison regardless of length of sentence

26 Common SSA Issues: Dependent s benefits for minor children if parent receiving SSR (Soc Sec Retirement) Minor Children, disabled or not, can qualify for SSA benefits if living parent receiving SSR or SSDI (not SSI alone) Minor Child must be unmarried and under age 18 Benefits paid to child do not decrease the benefits paid to the parent Within a family, each qualified child can receive a monthly payment of up to 50% of the parent s benefit, but the total benefits paid to all family members in household is generally % of the parent s full benefit amount

27 Common SSA Issues: Dependent s benefits (spouse) if the other spouse is receiving SSR Even if spouse has never worked she may be able to get benefits if she is least 62 yo and her spouse is receiving SSR. Spouse will also get Medicare at 65 If spouse has an earning record, SSA will pay her benefit amount first and then pay her additional benefits based on her spouse s earning record The total benefit to the spouse is capped at the highest of the two benefit amounts

28 Common SSA Issues: Survivor benefits for widows Widow of person who worked long enough to qualify for SSR can begin receiving survivor benefits as early as age 60. Disabled widow can begin receiving survivor s benefits as early as age 50 if her disability started before/within 7 years of the date of the death of her spouse. Amount of widow s benefit is based on amount of SSDI or SSR paid to deceased spouse Survivor s benefits are between % of deceased spouse s benefit. Depends on amount of benefit & age of widow. Disabled widow receiving benefits on deceased spouse s work record can receive Medicare after a 24 month waiting period

29 Common SSA Issues: Survivor benefits for minor child A minor child can receive up to 75% of a deceased parent s SSDI or SSR benefit if the deceased parent was receiving benefits at time of death The amount of benefits paid to minor child depends on amount that was being paid to deceased parent There is no benefit payment to a minor child if deceased parent was receiving only SSI at time of death. In other words, a minor child cannot collect benefits based on the fact that the parent was receiving SSI at time of death. However, the minor child may qualify for his own SSI if he is disabled and meets other SSI Program requirements.

30 Common SSA Issues: Benefits for Disabled Adult Children (DAC) SSA definition of adult disabled child: Must be over 18 years old Must meet SSA definition of adult disability (which is slightly different than definition of child disability Disability must have started before age 22 -unmarried

31 Common SSA issues: SSI Benefits for DAC Requirements for SSI benefits for DAC : Regardless of whether DAC has been receiving SSI as a child, he is eligible for his own SSI as an adult, as long as he: Is 18 yo or more meets the SSA definition for disabled adult, meets the SSI rules regarding income and resources, and Has a disability that started before age 22. Family income is not a bar to SSI for a DAC (as it can be for a minor child). So DAC can continue to live with parents and parents income and resources are not counted for purpose of SSI qualification. Only DACs income and assets are counted for SSI qualification If DAC marries, income & assets of spouse are counted for purpose of SSI

32 Common SSA Issues: Benefits for DAC Minor children who were receiving SSI must file a new application for SSI when they turn 18. It is not an automatic rollover to adult SSI 18 year olds who were not receiving SSI as minor children (perhaps because their parents did not meet the income & asset limitation for SSI) should file a new application for SSI The application will be evaluated using the SSA standard for adult disability If the child is incapacitated, a DAC s guardian can apply for benefits

33 Common SSA Issues Dependent s Benefits for DAC (cont). -If parent of DAC is receiving SSDI or SSR, the DAC is generally entitled to dependent benefits based on the parent s earning record. No such entitlement if parent only receiving SSI -If parent of DAC is deceased and was receiving SSDI or SSR, DAC is entitled to survivor benefits based on parent s earning record DAC can be entitled to up to 75% of parent s benefit. If more than one parent on SSDI or SSR, use the higher benefit parent to calculate -Household limitations apply: generally % of benefit per household if all members getting benefits on parent s earning record. (If there is another parent in the home who is collecting SSR on her record, those benefits are not counted in the % limit record -Parent s SSR or SSDI benefit amount not reduced because DAC is getting benefits based on parent s earning record

34 COMMON SSA ISSUES: BENEFITS FOR DAC (CONT.) DAC receiving SSDI or SSR on parent s earning record may still qualify for his own SSDI if he has worked DAC receiving SSDI or SSR from parent and SSDI on his own earnings record may also qualify for SSI. It depends on the amount of dependent s benefits he is receiving from parent and the amount of SSDI he is receiving on his earning work record All DAC should apply for all benefits. It is possible that even if a DAC is receiving benefits on parents earning record and/or his own earning record he may still qualify for SSI. Remember: $1 of SSI = Medicaid However, it is possible that a DAC may opt not to apply for SSI if his SSDI rate high enough and he does not need Medicaid. Have to balance the pros and cons of limiting he DAC s income and assets as required by SSI and the limits on paying for food and shelter under the SSI program. Perhaps cons of SSI program will outweigh pros for DAC who is eligible for dependent s benefits. It will depend on circumstances.

35 Common SSA Issues: Benefits for DAC (cont.) What happens when the parent of a DAC on SSI dies, or begins receiving SSR, or begins receiving SSDI? DAC on SSI now eligible for up to 50% of living parent s benefit amount or, if parent deceased up to 75% of deceased parent s benefit amount (sometimes a grandparent). SSA will want to pay these benefits first before paying SSI, which could potentially disqualify DAC from SSI. If parent s benefit is higher than SSI rate ($735/mo), DAC s SSI will be terminated. DAC will be eligible for Medicare 24 mo after first payment of parent s benefit If DAC loses eligibility for SSI, he or she can continue Medicaid under certain circumstances (additional income from parent s benefit excluded as countable income for purpose of Medicaid eligibility) if DAC otherwise would qualify.

36 COMMON SSA ISSUES: SSDI, SSI, and SSA Retirement Benefits SSDI will automatically convert to SSA Retirement at age 66 (not at age 62, which is the earliest an individual can collect SSA Retirement). The amount of the benefit will remain essentially the same. SSI rules are different because SSI recipients are required to apply for all available cash benefits that may be available to them. It is possible that an SSI recipient at retirement age may have had a work history and may be entitled to some amount of Social Security Retirement. If that is the case, SSA will require the SSI R to apply for Social Security Retirement age 62. In that case, he will begin to receive SSA retirement benefits and if less than $735, he will receive SSI to bring him up to the maximum payment of $735. If he continues to receive SSI, his Medicaid will continue. Assuming he paid Medicare taxes while working, he will be eligible for Medicare at age 65 like any other retiree.

37 Common SSA Issues: General Resource Rules for SSI There are no resource limits for SSDI only SSI. SSI Resource allowance: $2,000 for individual, $3,000 for couple Primary Home is exempt resource, one vehicle is exempt LIP with face value of $1,500, burial plot, burial plan with value of $1,500, household goods, property used in trade or business (tricky area). All exempt resources. Special Needs Trusts (SNTs) are exempt assets if drafted and administered correctly and approved by Medicaid and SSA (another tricky area). ABLE accounts are exempt asset. SSA allows deposits of $14,000/year and allows ABLE account to accrue up to $100,000. Just like Medicaid, SSA has very specific rules for transfer of assets for less than fair market value for the purpose of qualifying for SSI (yet again a tricky area). SSA has a grace period if claimant is trying to sell resources for the purpose of qualifying for SSI.

38 Common SSA Issues: Income Limits SSDI: Generally earned income limited to $1170 (unless in trial work period ) no limitation on unearned income. Income of spouse or others in household not counted. SSI: Much more complicated: $735 for individual. $1103 for couple. However, some income is not counted and some income is reduced by earned income exclusions. Spouse s income is counted ( deemed ) and in kind support and maintenance (ISM) is counted.

39 Common SSA Issues: Trial Work Period (SSDI) SSA allows R to return to work for a 9 mo period (does not have to be consecutive) and still receive SSDI benefits. Definition of trial work period is one in which R makes more than $840/mo or works more than 80 hours per month. After completion of trial work period, R can try to continue working. If he makes more than $1170/mo he doesn t get his monthly SSDI benefit. If he makes less than $1170/mo, he does get his SSDI benefit, even if working. After 36 mo of making more than $1170/mo, SSDI terminates. If, however, he then can no longer work, he is entitled to an expedited review of a new application for SSDI.

40 Common SSA Issues: SSI Recipient Works SSDI Recipient Works -If SSI R works his benefit amount will be reduced as follows: subtract $85 from his gross monthly wages, then divide the amount of wages remaining by 2. Subtract that amount from the monthly SSI payment. The result is the amount of SSI the recipient will get per month. Example: Joe receives $735 in SSI and makes $505/mo in wages $505 - $85 = $420 $420/2 = $210 $735 (SSI payment) - $210 = $525 (remaining SSI payment) If Income goes over limit, the recipient will be terminated from SSI, but can be reinstated if work ceases or income decreases Income must be consistently reported to SSA and SSI monthy benefit will be adjusted accordingly If SSDI R works and wages exceed SGA ($1170/mo) he will be terminated unless he has requested a Trial Work Period.

41 Common SSA Issues: Reporting Work Activity AlI SSI and SSDI recipients (or their Representative Payees) must report the following work related activity to SSA: The start and stop date of any job Any changes to hours worked, wages, job duties Any work related expenses If reporting done by telephone, it must be done by the 6 th of the next month (SSA has toll free automated wage reporting telephone system) Wages can be reported on-line If reporting done by mail, it must be done by the 10 th of the next month Spouses of SSI Rs must report wages as wwll

42 Common SSA Issues: Continuing Medicaid While Working SSI recipients can continue to qualify for Medicaid if they return to work as long as they: -were eligible for SSI cash payment for at least 1 month before return to work -are still disabled -still meet other SSI requirements (e.g. resource limitations) -need Medicaid benefits to continue to work -have gross earnings that are insufficient to replace SSI, Medicaid, and PCA or ALF services In Alaska, the yearly gross income threshold for working disabled Medicaid is $ 56,204. In other words, R can earn up to $56,204 and still be eligible for Medicaid, if disabled and working

43 Common SSA Issues: Overpayment Overpayments occur when R receives a higher benefit payment than he should. This can be caused by changes in circumstances e.g. work related activity, marriage, changes in living situations. The R will receive the dreaded overpayment notice SSDI overpayment: SSA will withhold the full amount of the benefit until overpayment paid in full. Begins 30 days after notice of overpayment. SSI overpayment: 10% of monthly benefit will be withheld each month. Begins 60 days after notice of overpayment. R can file appeal (Request for Reconsideration) if he believes he was overpaid or amount is wrong R can ask for waiver if he believes that overpayment notice is accurate but doesn t believe the overpayment is his fault or payment of overpayment is unfair or would create financial hardship. While appeal or request for waiver is pending, overpayment will not be deducted as long as appeal and/or waiver was requested within 30 days of Notice of Overpayment.