The family center disability webinar for share sept 2017

SOCIAL SECURITY DISABLITY BENEFITS

AND METASTATIC BREAST CANCER

PRESENTED BY:

© 2017 THE FAMILY CENTER, INC. ALL RIGHTS RESERVED.

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• This presentation provides a broad overview only. These are very complex topics and many additional rules, processes, and requirements apply that are not discussed here.

• This presentation does not constitute legal advice. No attorney-client relationship is formed based on your participation in this workshop.

• We cannot give advice about what you should do or answer questions about your specific situation in this presentation.

• It is always recommended to consult with an attorney or other expert about complex individual questions.

• These rules relate to adults only. There are very different rules and processes involved for children with cancer or other disabilities.

Disclaimers


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Disability-Related Social Security Benefits

• Both programs administered by Social Security Administration (SSA) for people who meet SSA’s definition of “disabled”

• Same medical eligibility / definition of disability for both programs

Spoiler: Their definition of disability is all about your ability to work.

• Only for people with long-term disabilities

• Different financial and other eligibility requirements

• Some people may receive both SSDI and SSI


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Social Security Disability Insurance (also called SSD, SSDI, DIB, Title 2, Title II)

Supplemental Security Income (also called SSI, Title 16, Title XVI)

Social Security Disability Insurance (SSDI)

OVERVIEW

• Provides benefits to people who are insured through the program (based on their work history) at the time that they become disabled.

• Eligible individual receives monthly payments. Amount of benefit varies based on personal work history.

• May be able to get additional monthly benefits for certain dependent family members (minor children, disabled adult children, or spouse)

• Eligible for Medicare coverage after 24 months of entitlement to SSDI

• There is a 5-month waiting period after the date the person is determined to be disabled (not necessarily the same as date of application) before SSDI benefits can be paid.

If applicant meets other eligibility rules for SSI (low income/assets), they may be able to receive SSI during the waiting period.

• Can receive benefits retroactively for up to one year before application date (depending on when claimant became disabled).


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Social Security Disability Insurance (SSDI)

BASIC ELIGIBILITY REQUIREMENTS

• Must be “disabled” per SSA definition

• Must be “insured” based on work history (“earnings record”)

Must have worked both long enough and recently enough

Only work done “on the books” (with Social Security taxes paid) counts

Need a specific number of “credits” or “quarters of coverage”

Can earn up to four credits per year worked, depending on income

Specific requirements vary based on age at which disability starts (younger people need fewer credits)

• Income: Generally cannot be earning more $1,170 / month in 2017 (amount changes annually), otherwise won’t be considered disabled (some exceptions apply).

Incentive programs and exceptions exist for people who return to work after becoming disabled, etc.

No limit on unearned income

• Resources/Assets: No resource/asset limit

• Citizenship/Immigration: Non-U.S. Citizens must have certain specified immigration statuses


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Supplemental Security Income (SSI)

OVERVIEW

• Monthly cash payment to elderly, blind, or disabled individuals who have limited income and assets to assist in paying for basic needs (food, clothing, shelter).

• Work history does not matter.

• Maximum monthly benefit amount (“Federal Benefit Rate” or FBR) is set each year ($735/month for 2017).

Actual amount that a person receives is based on their other income (earned and unearned, including “in-kind support”) and living arrangement.

People who live alone may be eligible for a higher benefit amount than people who live with others.

Different amount if both spouses in a married couple receive SSI ($1,103/month per couple for 2017).

• Some states supplement the federal benefit amount with state funds (“State Supplement Program” or “SSP”).

See https://www.ssa.gov/ssi/text-benefits-ussi.htm for more on state supplements

• No additional benefits for family members.

• Automatically eligible for Medicaid. No related Medicare eligibility.

• Benefits can only begin as of month after application, regardless of when disability began.


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https://www.ssa.gov/ssi/text-benefits-ussi.htm





Supplemental Security Income (SSI)

BASIC ELIGIBILITY REQUIREMENTS • Must be aged (65+) or blind or “disabled” according to SSA definitions.

• Income:

Claimant’s earned income generally cannot be above $1,170 /month in 2017 (amount changes annually), otherwise won’t be considered disabled (exceptions may apply).

Special rules and incentive programs may allow higher earned income for people who return to work after being determined disabled.

Total “countable” income (earned and unearned) must be below the relevant FBR.

Some income is not counted.

Your spouse’s income is “deemed” to you.

Amount of benefits paid will be adjusted based on income each month.

• Resources/Assets: Must have less than $2,000 in countable assets for an individual (or $3,000 for a married couple).

There are penalties for transferring or giving away assets in order to become eligible.

Your spouse’s assets will be “deemed” to you and considered to be yours.

Not all assets are “countable.”

• Citizenship/Immigration: Additional restrictions and requirements for non-U.S. Citizens

See https://www.ssa.gov/ssi/spotlights/spot-non-citizens.htm for more info.


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https://www.ssa.gov/ssi/spotlights/spot-non-citizens.htm







Medical Eligibility (Definition of “Disability”)

To Social Security, the term “Disability” means:

“inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months” (Social Security Act)

SSA uses a 5-Step “Sequential Evaluation” to apply this definition.


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Medical Eligibility (Definition of “Disability”)

Step 5: Ability to do Other Work Could you do any other kind of work?

YES: NOT DISABLED NO: DISABLED

Step 4: Ability to do Past Work Could you go back to doing any of your past jobs from last 15 years?

YES: STOP - Not Disabled NO: Go to Step 5.

Step 3: Listing of Impairments Do(es) impairment(s) satisfy criteria for a condition described in SSA’s “Listing of Impairments”?

YES: STOP - Disabled. NO: Go to Step 4.

Step 2: Severity and Duration of Impairment Is/are impairment(s) severe AND expected to last 12 months or result in death?

YES: Go to Step 3. NO: STOP - Not Disabled

Step 1: Current Work Activity Are you currently working and earning more than “SGA” amount?

YES: STOP - Not Disabled. NO: Go to Step 2.


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Sequential Evaluation: Step 1

Step 1: Are you currently “engaging in Substantial Gainful Activity” (meaning working and earning more than a specified dollar amount per month)?

• Engaging in Substantial Gainful Activity (“SGA”) is defined as earning more than a specific dollar amount per month through work.

• “SGA level” changes each year.

• 2017 SGA level is $1,170 per month.


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If working and earnings average more than $1,170 per month, you will not be found disabled, regardless of medical condition.*

* Except in specific limited circumstances. Speak to an attorney or other expert.

If not working, or working but earning less than $1,170 per month (in 2017), proceed to Step 2.


Step 2: Do you have a severe medical impairment that is expected to last at least 12 months or result in your death?

• Must have one or more medical or mental health condition(s) diagnosed by an appropriate medical professional.

• Severe means impairment(s) interfere with ability to do basic work-related activities like walking, sitting, standing, lifting, following instructions, making decisions, completing tasks, interacting with others, etc.

• Condition(s) must be expected to remain severe for at least 12 months, or to result in death. (SSA does not provide benefits for short-term disability, regardless of how severe).

• Must consider condition itself and side effects of any treatment.


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If your condition does not satisfy any one of these requirements, you will not be found disabled and the evaluation ends.

If your condition satisfies all of these requirements, proceed to Step 3.


Step 3: Does your medical condition match the criteria for a condition in Social Security’s Listing of Impairments?

• SSA regulations include a list of medical conditions (the “listing of impairments” or “listings”).

• Each condition has specified medical criteria, such as test results, symptoms, anatomical findings, treatment requirements, etc. The criteria are chosen such that they would only be met if the condition were so severe that it would likely prevent someone from working.

• In Social Security lingo, this is called “meeting a listing”. You can also “equal a listing” (if condition is of “equal medical significance”, but not exactly the same as a listed condition or criteria. Often requires expert opinion.)

• Listings are available at www.ssa.gov/disability/professionals/bluebook/AdultListings.htm


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If your medical records show that your condition satisfies all of the specified criteria for one or more listing, then you are disabled and medically eligible for SSI or SSDI benefits.

If, based on your medical records, your condition does not match the criteria for one of the listings, proceed to Step 4.

https://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm

Listing: Breast Cancer

13.10 Breast Cancer (except sarcoma—13.04) (See 13.00K4.) A. Locally advanced cancer (inflammatory carcinoma, cancer of any size with direct extension to the chest wall or skin, or cancer of any size with metastases to the ipsilateral internal mammary nodes).

OR B. Carcinoma with metastases to the supraclavicular or infraclavicular nodes, to 10 or more axillary nodes, or with distant metastases.

OR C. Recurrent carcinoma, except local recurrence that remits with anticancer therapy.

OR D. Small-cell (oat cell) carcinoma.

OR E. With secondary lymphedema that is caused by anticancer therapy and treated by surgery to salvage or restore the functioning of an upper extremity. (See 13.00K4b.) Consider under a disability until at least 12 months from the date of the surgery that treated the secondary lymphedema. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.


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Listing: Ovarian Cancer

13.23 Cancers of the female genital tract (carcinoma or sarcoma, including primary peritoneal carcinoma)

…

E. Cancer of the Ovaries, as described in 1 or 2:

1. All cancers except germ-cell cancers, with at least one of the following: a. Extension beyond the pelvis; for example, implants on, or direct extension

to, peritoneal, omental, or bowel surfaces.

b. Metastases to or beyond the regional lymph nodes.

c. Recurrent following initial anticancer therapy.

OR

2. Germ-cell cancer--progressive or recurrent following initial anticancer therapy.


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Step 4: Do you have the physical and/or mental capacity to do any of your past relevant work?

•SSA will first consider the ways that your impairments limit your physical and/or mental functioning, and then what you can still do despite these limitations (your “residual functional capacity” or “RFC”).

•Your physical RFC is often expressed in your ability to do work at various “exertional levels” (sedentary, light, medium, heavy, etc.). A mental RFC should also be assessed.

•SSA will then consider the physical and mental demands of all your “past relevant work” (work in which you earned more than the SGA level for that year, during the previous 15 years), based on how you specifically performed the job or how it is usually performed.

•They will then determine whether, given your limitations and RFC, you could still theoretically perform any of these past jobs. (It doesn’t matter whether that job still exists, whether the company still exists, etc. )


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If you still have the physical and mental capacity to do any of your past relevant work, you are not disabled and the evaluation ends.

If your impairments prevent you from doing any of your past jobs from the previous 15 years, then proceed to Step 5.


Step 5: Do you have the physical and/or mental capacity to perform any other kind of work on a full-time basis?

• SSA will consider your RFC, physical/mental limitations, AND your age, education, past work experience and skills, to determine whether there are any other types of jobs that you could do on a full-time basis.

• It does not matter whether in reality you would actually get hired for such a job, only that such job exists and theoretically you could do it. Only requirement is that this type of job must exist in “significant numbers” in the national economy.

• Reference is made to certain publications regarding occupations, statistics, etc., from the Department of Labor.

• Short-cut “Grid Rules” for people who have only physical/exertional impairments.


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If SSA can come up with any job(s) that you could still do full-time, then you are not disabled and cannot receive SSDI or SSI benefits.

If SSA determines that there are no other jobs that you could do based on your impairment(s), then you are disabled and medically eligible for SSDI or SSI benefits.

How to Apply

WAYS TO APPLY:

• Online (for SSDI and many categories of SSI applicants): https://secure.ssa.gov/iClaim/dib

• Call 1-800-772-1213 to schedule an appointment or phone-based interview if home-bound.

• Visit your local Social Security Office (be prepared for a long wait).

APPLICATION PROCESS:

• Generally, SSA will take applications for both SSI and SSDI together. In some situations it might make sense to apply only for SSDI. This should be discussed with an expert.

• Must establish identity, citizenship/immigration, other eligibility before considering medical.

For SSI, you must provide information and documents regarding income, living situation, payment of expenses, etc. to determine financial eligibility.

• SSA will interview you and you’ll fill out forms about medical conditions, disability, limitations, medical treatment, medical providers, education, work history, etc.

• SSA will have you sign releases for them to obtain medical records from your treating medical providers.

You can and should submit medical records, doctors’ notes, statements from family/friends, etc.

• Checklist of information needed to apply: https://www.ssa.gov/hlp/radr/10/ovw001-checklist.pdf

• You may be sent for evaluation by a medical provider contracted by SSA (“consultative examination”).

• Disability Determination Service will review documents and information and apply five-step evaluation process to determine if you meet SSA definition of disability

• Notified of decision by mail, usually takes around 3-6 months, sometimes more or less.


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https://secure.ssa.gov/iClaim/dib

https://www.ssa.gov/hlp/radr/10/ovw001-checklist.pdf



Compassionate Allowance Program (CAL)

• Allows SSA to quickly identify medical conditions that, by definition, meet their standards for disability and to process these cases more quickly.

• Helps reduce waiting time to reach a disability determination for individuals with the most serious disabilities. Applications can be approved in days sometimes, instead of months.

Depends on how long it takes to receive medical evidence confirming condition.

• Same list of Compassionate Allowance conditions for both SSI and SSDI

• Not a separate set of rules/processes. Still have to meet all other eligibility requirements for SSDI or SSI program (i.e., not working over SGA-level, etc.).

• 5-month waiting period still applies for SSDI.

• List of conditions and more info at: https://www.ssa.gov/compassionateallowances/


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https://www.ssa.gov/compassionateallowances/



Compassionate Allowance – Breast Cancer

Breast Cancer with Distant Metastases or Inoperable or Unresectable

• “Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings.

• “Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.

• Documentation:

A pathology report and an operative report are the preferred methods for documentation.

They may accept a physician's opinion (letter from treating doctor) that indicates the cancer is inoperable or unresectable based on described objective findings.


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Compassionate Allowance – Ovarian Cancer

Ovarian Cancer With Distant Metastases or Inoperable or Unresectable

• “Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings.

• “Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.

• Documentation:

A pathology report and an operative report are the preferred methods for documentation.

They may accept a physician's opinion (letter from treating doctor) that indicates the cancer is inoperable or unresectable based on described objective findings.


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6 Tips for a Successful SSI/SSDI Application

• Apply as early as possible, especially if applying for SSI

But be careful about applying while still working if earnings are close to or above SGA-level

• Collect and Submit your own Evidence

Medical records

Letters from your doctor about disease, treatment plan, prognosis, etc.

Pathology/operative report showing metastases

Other medical evidence of listing/CAL criteria

• In application forms, list every single medical and mental health condition that you have (even if it seems like it’s not a big deal)

• List every doctor, hospital, clinic, etc. that you have seen since the date you think you became disabled

• Review your calendar and/or journal so you know dates of treatment, all hospitalizations, changes in work activity

• Speak to family and friends about whether they have noticed any new limitations or problems that may be related to your medical conditions


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Appeals

• Denial notice should include information about how to appeal.

Online (https://www.ssa.gov/forms/ssa-3441.html).

In-person at local SSA Office

Completing and mailing appropriate forms.

Can call SSA hotline (1-800-772-1213) for more information or to request appeal forms.

• Must appeal within 60 days of the notice of the adverse decision.

Deadline can be extended if there is “good cause” for not requesting timely appeal.

• States have different processes for appealing a disability determination. In many states, there is an initial “reconsideration” process, in which a new person, not involved with the initial decision, reviews all the evidence in your file. Some states skip this step.

• The next level is appeal of a medical determination involves an administrative hearing before an Administrative Law Judge (“ALJ”). In some states this is the first level for appeal.

• There can be a very long wait for a hearing (close to two years in some places).

• Should get confirmation of request for hearing within a few weeks of appeal request

• If found disabled after appeal, you can receive benefits going back to the time you should have started receiving, if initial application had been correctly approved (or back to a different date if determined by judge).

• Next level of appeal is to Social Security’s Appeals Council, after that is appealing to Federal Court.


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https://www.ssa.gov/forms/ssa-3441.html)




Ongoing Requirements for SSI/SSDI Recipients

• Report changes to SSA (Notices from SSA give detailed list of reporting requirements).

Household income

Household composition, living arrangement, marital status, moving, etc.

Work activity (back to work, more hours, more earnings)

Resources/Assets (for SSI only)

• Monitor assets/resources (for SSI Recipients):

Countable assets/resources (including bank accounts, investments, excess vehicles, etc.) for SSI recipients cannot exceed $2000 (or $3000 for a couple).

You cannot be eligible for SSI in any month in which your assets were over the limit as of the 1st of the month. If assets exceed limit, you will be discontinued from benefits, and may owe SSA money for benefits previously paid.

• Every few years, most recipients will be subject to a “continuing disability review” (“CDR”) in which SSA gathers new medical information to determine whether recipient still meets definition of disability, or whether condition has improved to the point of no longer being disabled.

Length of time before CDR depends on specific condition/likelihood of improvement.


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Working While Receiving SSI or SSDI

• SSA wants people to go back to work and has many rules and programs to incentivize this.

• Include rules that allow you to try working while keeping your benefits, and vocational training programs that can help you find appropriate work.

• Different rules and programs for SSI and SSDI.

• For more information about work incentives, see https://www.ssa.gov/redbook/index.html.


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The rules about working while receiving SSI or SSDI benefits are very complex. Speak to an attorney or other expert before going back to work (or increasing hours or earnings) so that you can understand the consequences and plan appropriately. Be careful earnings do not exceed SGA-level ($1,170 in 2017), especially during first 12 months after onset of disability. This could show that you did not meet SSA’s definition of “disability” and may make you ineligible for benefits.

https://www.ssa.gov/redbook/

https://www.ssa.gov/redbook/

Questions?


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SOCIAL SECURITY DISABILITY BENEFITS AND METASTATIC BREAST CANCER

This presentation is the property of The Family Center, Inc. and may not be altered, reproduced, or distributed without explicit permission from The Family Center.

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The family center disability webinar for share sept 2017

Healthcare

Transcript of The family center disability webinar for share sept 2017