Diane M. DeGroat Staff Attorney HIV/AIDS Law Consortium Training - - PowerPoint PPT Presentation

The Basics for Adult Cases

Diane M. DeGroat Staff Attorney HIV/AIDS Law Consortium

Training Objectives

 Understand the difference between Social Security

Disability (SSD) and Supplemental Security Income (SSI) and the basic eligibility requirements for each benefit program.

 Understand the 5 step process that is used by the Social

Security Administration (SSA) to determine whether an adult applicant is disabled.

 Learn practical steps to support clients/patients who are

applying for Social Security benefits or appealing Social Security denials.

Poll: Who is in our audience?

I am a:

• A. Case/care manager
• B. Social worker
• C. Mental health counselor
• D. Substance use counselor
• E. Peer educator/navigator
• F. Other

Poll: What is your experience/interest in learning about Social Security?

• A. I help clients apply – it’s easy!
• B. I help clients apply – it’s hard!
• C. I have not helped a client apply, but would like to

provide this service in the future.

• D. I can’t help directly with applications, but knowing

more about Social Security disability would help me in my job.

• E. Other

What kinds of Social Security disability benefits are there for adults?

Two types:

• 1. Supplemental Security Income (“SSI”)
• 2. Social Security Disability (“SSD”)

 Also known as Social Security Disability

Insurance (“SSDI”)

May receive only SSI, only SSD, or both SSI and

SSD

Overview: SSD v. SSI

SSD SSI

 “Title II” benefit  Earned benefit  Funded by taxes paid by

workers and employers

 Worker’s benefit can be paid to

disabled worker, or worker’s disabled widow/widower, spouse, or child(ren)

 Additional requirements apply

 No income/resource limits  Amount received based on past

earnings and tax paid

 Recipient eligible for Medicare

after 2 years; may be eligible for Medicaid

 “Title XVI” benefit  Need-based benefit  Funded by general federal

government revenues

 Benefit paid to disabled adult

• r disabled child

 But: different rules for

children’s SSI

 Income/resource limits apply  Amount received based on

living arrangement and other income

 Recipient eligible for State

Supplement Program (SSP)

 Recipient eligible for Medicaid

TRUE or FALSE?

Financial eligibility for Social Security Disability (SSD) is partially based on work history.

• A. TRUE
• B. FALSE

Financial Eligibility: SSD v. SSI

SSD: Financial eligibility for SSD is based on work

• history. An individual

needs to have worked and earned enough income over a certain period of time to be eligible for SSD.

SSI: Financial eligibility for SSI is based on financial need for food and shelter. An individual’s income and resources have to be under certain limits to be

• eligible. A person does

not need to have worked before to be eligible.

Multiple Choice

To be considered disabled, you must have a medical condition that has lasted or is expected to last at least _________________

• A. 6 months
• B. 12 months
• C. 18 months
• D. 24 months
• r is expected to result in death.

Simplified Definition of “Disability”

A person is disabled under Social Security law if:

S/he has a severe physical or mental health

condition.

The condition has lasted or is expected to last

at least 12 months or result in death.

The condition prevents the person from

working 8 hours/day, 5 days/week, or the equivalent, in his/her past work or any other types of work.

How will the Social Security Administration (SSA) decide if you are disabled?

Five Step Analysis

• 1. Are you earning more than “substantial

gainful activity”?

• 2. Do you have a severe physical or mental

impairment?

• 3. Do your conditions meet or equal a Listing?
• 4. Can you do your “past relevant work”?
• 5. Can you do any other work?

The same disability definition and 5 step analysis apply to SSD and SSI.

Step 1:

Are you earning more than substantial gainful activity (“SGA”)?

2017 Income Limit: If you work and earn more than $1,170 per month in gross income and you are not statutorily blind, then you are earning more than SGA. If you earn more than SGA, then you are not disabled.

 Exceptions:

 Accommodations or Employer Subsidy/Sheltered Work  Impairment-Related Work Expenses  Unsuccessful Work Attempt

If you are not earning more than SGA, then SSA goes to the next step.

Step 2:

Do you have a severe physical or mental impairment?

 Impairment is “severe” if:

• it significantly limits your ability to perform basic

work activities; and

• has lasted or is expected to last for a continuous

period of at least 12 months or result in death. If you do not have a severe impairment, then you are not disabled. If you do have a severe impairment, then SSA goes to the next step.

Step 3:

Does your condition meet or equal a Listing?

• What are LISTINGS?
• Legal definitions of different physical and mental

conditions

• Ex.: major dysfunction of a joint; disorders of the spine; anxiety

disorders; depressive disorders; intellectual disorder; chronic heart failure; asthma; chronic pulmonary hypertension

• Found in Social Security regulations
• Includes diagnosis, symptoms, and limitations that a person

must experience

• Elements must be documented in medical records

Summary: Listing 14.11 Human Immunodeficiency Virus (HIV) Infection

Need documented HIV/AIDS diagnosis PLUS:

• Documented diagnosis of one of the listed related illnesses; OR
• CD4 count of 50 cells/mm3 or less; OR
• CD4 count of 200 cell/mm3 or less or CD4 percentage of less than

14% PLUS BMI of less than 18.5 or hemoglobin measure of less than 8.0 g/dL; OR

• Complications of HIV infection requiring at least 3 hospitalizations

in 12 month period, at least 30 days apart, lasting at least 48 hours each; OR

• Repeated manifestations of HIV infection resulting in significant

documented symptoms or signs AND marked limitations in activities of daily living, social functioning, or completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.

Step 3:

Does your condition meet or equal a Listing?

If your condition meets or equals a Listing, then you will be found disabled. If your condition does not meet or equal a Listing, then SSA will go to the next step.

Step 4:

Can you do your past relevant work?

Past Relevant Work:

 Work that you have done within the past 15 years;  That was substantial gainful activity (SGA);

 Note: SGA limits change year to year

 That lasted long enough for you to learn how to do it.

Step 4:

Can you do your past relevant work?

SSA will consider your age, education level, and the limitations you have, and then SSA will determine if you are able to do your past relevant work as it was actually and generally performed.

 If you can do any of your past relevant work, you are not

disabled.

 If you cannot do your past relevant work, then SSA goes to

the last step.

Step 5:

Can you do any other work?

• SSA will decide whether you can do any other types of

jobs that exist in significant numbers in the national economy, taking into account your age, education, experience, limitations, and skills that you acquired in your past jobs.

• The jobs do not have to exist in New York.
• The jobs do not have to be jobs that you have done

before.

Step 5:

Can you do any other work?

• If you can do any work that exists in significant numbers

in the national economy, then you are not disabled.

• If you cannot do any work that exists in significant

numbers in the national economy, then you are disabled.

HYPOTHETICAL

Jane Doe is HIV+, and she suffers from anxiety and

• depression. Her viral load is undetectable, and she is

asymptomatic for HIV. Based on her medical records, she will not meet the HIV Listing. If Jane applies for Social Security disability benefits, will her application be denied because she does not meet the HIV Listing?

• A. YES
• B. NO

C.

NEED MORE INFORMATION

HYPOTHETICAL

Jessica Doe is pregnant, and she works full-time as an

• ffice assistant. Jessica’s doctor puts her on bed rest for

the last four months of her pregnancy due to medical

• complications. She is not able to work while on bed rest.

She is expected to be able to return to work once she has the baby, and she has no other medical conditions. Would Jessica qualify for Social Security disability benefits while she is on bed rest?

• A. YES
• B. NO

C.

NEED MORE INFORMATION

HYPOTHETICAL

John Doe has arthritis in his knees and back, and he suffers from depression. John works as a grocery store cashier, and his income is about $900 per month. If John applies for Social Security benefits, will his application be denied because he is working?

• A. YES

B.

NO

C.

NEED MORE INFORMATION

Drug Addiction & Alcoholism

TRUE OR FALSE? A person cannot qualify for Social Security disability benefits if they have active substance abuse.

• A. TRUE
• B. FALSE

Drug Addiction & Alcoholism

 People with active drug addiction and alcoholism (DAA)

may still be eligible for SSD/SSI.

 If DAA are present, then SSA will decide if the DAA is

material to the determination of disability.

 DAA are material if the person would not meet the

definition of disability if s/he were not using drugs or alcohol.

 If DAA are material, then the person is not disabled.  If DAA are not material, then the person may still be

found disabled based on their other impairments.

Drug Addiction & Alcoholism

DAA Material – Not Disabled

 Only severe impairment is a substance use disorder

 Ex. Alcohol Use Disorder; Opioid-Related Disorder

 Other impairments are not severe or disabling by themselves

 Ex. mild osteoarthritis of the hip; anxiety disorder that does not prevent

a person from doing her past work

DAA Not Material - Disabled

 Have other severe and disabling impairments

 Ex. intellectual disability; back disorder that meets listing

 Acquired disabling impairment while using substances

 Ex. Quadriplegia because of car accident while driving under influence of

alcohol; acquired listing-level HIV due to intravenous drug use

 DAA medically caused disabling impairment, but impairment is

irreversible or could not improve to point of non-disability

 Ex. Cirrhosis of the liver; substance-induced persistent dementia

How Do I Apply for Social Security Disability Benefits?

• 1. IN PERSON: at your local Social Security office

 Can call in advance to schedule an appointment  Office locator: https://secure.ssa.gov/ICON/main.jsp

• 2. BY PHONE: Social Security Administration Hotline



1-800-772-1213

• 3. ONLINE: https://secure.ssa.gov/iClaim/dib

SSI Applications:

 Previously could only be done by phone and in person.  Beginning 3/25/17, can be done online in limited

circumstances.

How Do I Apply for Social Security Disability Benefits?

If you want to apply for Social Security benefits, notify the Social Security Administration right

• away. This creates a “protective filing date” and

gets the application process started. If you wait to notify SSA or wait to submit an application, it can affect the amount of benefits you receive if your application is approved.

What Information Do I Need?

In general, you will need:

 Name, address, phone number, DOB, SSN.  Marriage and divorce information.  U.S. military service information.  Employment information and job history for the past 15

years.

 List of medical conditions.  List of doctors, health care professionals, hospitals,

and/or clinics that have provided medical care to you.

 List of medications and/or medical tests performed.  Education and/or training information.

What If I Am Found Not Disabled And Get A Denial Letter?

 File a request for a hearing as soon as possible.  Request must be done in writing.

 Hearing request form (Form HA-501-U5) may be enclosed

with denial letter or is available online and at SSA office.

 May submit by mail, fax, email, online, or in person.  Deadline to request a hearing: in general, 65 days from

the date of the denial letter.

 60 days from receipt of letter, SSA assumes receipt 5 days

after mailing date.

It may take up to 24 months to get a hearing date once the hearing request is filed.

If I Am Found Disabled, Will I Always Receive Benefits?

• No. Under certain circumstances, your benefits can stop.

1.

SSA can review your case to see if your condition has

• improved. If your condition has improved to the point

where you can work, your SSI and SSD can stop.

2.

If you start working and make too much money, then your SSI and SSD can stop.

3.

For SSI only: If you go to jail/prison for 12 months or more consecutively, your benefits will stop and you will have to reapply when you are released. * This is not an exhaustive list!

I’m Not a Doctor or a Lawyer. How Can I Help a Client/Consumer Get SSD/SSI?

 Information gathering/organizing for application or appeal

 Maintain list of medical providers with contact information  Help prepare medication lists  Track changes in providers or care; help notify SSA

 Support in obtaining and maintaining medical treatment

 Referrals for primary care, specialists, mental health, and substance

abuse treatment

 Document issues like unavailable providers or waitlists

 Transportation support  Appointment and treatment reminders  Attend appointments, if needed and with client consent

 Help ensure that client is communicating medical/mental health issues

and symptoms to medical providers

 Help ensure client is understanding and following prescribed treatment

I’m Not a Doctor or a Lawyer. How Can I Help a Client/Consumer Get SSD/SSI?

 Paperwork

 Assist with completing and submitting application and/or forms  Review notices received by client  Keep copies

 Document, document, document!

 Help obtain and submit medical records to SSA  Keep detailed case notes regarding symptoms and limitations that

you observe – these can be used as evidence for a Social Security application or appeal

 Ex. difficulty keeping track of appointments, difficulty understanding

notices, issues with activities of daily living, issues with social functioning/getting along with others, etc.

 Letters of Support: letter to SSA detailing support services

provided and symptoms/limitations observed

LASNNY Programs

 LASNNY may represent adults and children in Social

Security disability cases.

 Clients may qualify for assistance in Social Security cases

through the following programs:

 Housing  Disability Advocacy Program  Children’s Law Project  HIV/AIDS Law Consortium

 Clients may call for assistance regarding applications,

appeals, overpayments, and other SSA matters.

LASNNY Programs

 General referrals:

 Have client call main intake line:

 Albany Office: 518-462-6765  Toll Free: 1-800-462-2922

 Intake for clients who are living with HIV/AIDS:

 Have client call HIV/AIDS Law Consortium directly:

 Diane DeGroat, Staff Attorney  Direct Phone: 518-533-5930

Questions?

Diane M. DeGroat Staff Attorney HIV/AIDS Law Consortium Legal Aid Society of Northeastern New York 55 Colvin Ave., Albany, NY 12206 Direct Phone: 518-533-5930 Fax: 518-427-8352 Email: ddegroat@lasnny.org

Special Thanks

This PowerPoint presentation is an adaptation of “Social Security 101: The Basics for Adult Cases,”

• riginally prepared and presented by Shubh McTague,

Esq., and Michael Telfer, Esq., LASNNY.