Fighting the Social Security Administration

If you were awarded benefits, why would you need to fight SSA?

If you were awarded benefits, why would you need to fight SSA?

After completing a two year journey through SSA’s disability determination process you have been awarded Social Security Disability benefits. You made contact with the SSA payment center which set you up to receive your back benefits in installments and your monthly benefits going forward. At some point in time you were told by SSA to continue to provide updates about work, medical updates, and any time at all you have any other income. You were also told that at some time SSA may want to review your case to ensure that you are still disabled. At the time, you were excited about finally generating a source of income which you did not have in the prior two plus years.

Three years go by. You received a number of letters from the Administration which describe staying on disability, reminders of what the requirements are, and what you need to report. These letters are only occasional. One letter you received mentioned something about overpayment, but you remembered having an interview with an SSA worker who determined the dollar amount of your benefits. You have received payments in that amount every month for years now and you never did go back to work or won the lottery, so clearly, you were not overpaid.

Your benefits are monthly and you have adjusted to live within your means. You also try to save the benefit checks where you can so once in a while you can go out to eat, see a movie, or buy gifts at the holidays. It is not easy, especially since you need to keep up with your treatment, but since you are single and without child-related costs  you have managed to save and maintain about $1,800 in your bank account for emergencies.

Two Christmases ago, right after you were awarded benefits, your grandmother Millie sent you a $250 check to help get you back on your feet. That was especially nice of her since she usually only sends a sappy card with a $20 bill in it. You deposited that $250 check at the time and forgot about it.

On the three year and one month anniversary of the award of your benefits, you receive a thick packet from SSA. Inside is a letter asking you to report any income you may have received, a function report for you to complete, a release so that SSA can collect medical records, and a statement showing the payment schedule for your benefits with the cost of living adjustments for the next two years, among other documents. You complete these documents and return them to SSA.

Thirty days go by. Your benefits are not deposited into your account as usual. You try calling SSA and the first time you wait on hold until the Administration’s phone system hangs up on you. You call again and get a front desk person who tells you that they are not sure why your benefits have stopped, but that you can talk to a case worker. You call the case worker several times and leave several messages. At the sixty day mark, you receive a letter stating that you have been overpaid, that you owe SSA $26,000, and that you have no defenses because you knew or should have known that you needed to report earnings and did not do so.

You frantically call and call SSA, the case worker, and anyone that would answer the phone. Eventually, the case worker calls you back. They inform you that SSA performed a continuing disability review on your file, and determined that three years ago in December, your bank account showed an amount of $2,050 for two weeks because of unearned income of $250. The case worker further tells you that to remain eligible for your benefits, you can never have a back account balance above $2,000, that you did, and because of that SSA retroactively determined that you were ineligible for benefits. You were also determined to be ineligible because you had unearned income you failed to report. Because of that retroactive determination, you owe SSA all of the money they paid you from that December to present. The case worker further tells you not to waste everyone’s time trying to appeal SSA’s decision because you will lose any appeal you file automatically.

Is there anything to be done? Can SSA really tell someone they owe $26,000 because of some Christmas money that you received three years ago? Don’t SSA’s case workers have the final word on how your disability benefits get paid? Aren’t they right when they tell you that you will lose any appeal?

Look for the answers in our next post!

If you were awarded benefits and you are currently going through a similar experience to the one above please contact us today!

If you are interested in learning more about Social Security Disability please contact us for a free consultation!

“He ain’t disabled…”

The popular misconception.

The popular misconception.

Perhaps one of the most frequent complaints a disability advocate will hear starts out with, “I know somebody collecting disability…” Then there is some description of the person which paints them as the picture of health. The complaint ends with something like, “he ain’t disabled… And if he is, then I should be found disabled too.” While we have touched on how our hypothetical complainer can prove his or her disabilities and begin receiving benefits, we have not talked about people that are already receiving benefits. Specifically, what benefit recipients must do continue receiving benefits.

For the most part, life on disability is the same as life without it. However, there are some requirements that disability beneficiaries must keep to as long as they are collecting benefits.

First off, an applicant for disability must remain disabled. This seems like common sense. However, some disabilities go away: cancer can go into remission, back surgeries are successful more often than not, a psychiatrist can finally find the right medication to control symptoms, etc. If a claimant experiences a significant improvement in medical symptoms he or she must report this improvement. The cynical reader would say this is how so much of the tremendous disability fraud is allowed to happen as the typical claimant is sure to not report these changes.

The Social Security Administration, though, is not content to take claimants’ words for it. Another major requirement for claimants is that they comply with Continuing Disability Reviews (CDR). CDRs take two primary forms and which form it takes is currently chosen by a computer. According to the Deputy Commissioner of SSA, the agency uses statistical modeling to determine which cases are most likely to need a continuing review. While the deputy commissioner did not specify how this modeling works, it is a reasonable assumption that the more a determination of disability depends upon subjective evidence at the outset, the more likely it is to receive a more intensive review.

CDRs can be done in paper or in a doctor’s office. Many disability claimants will have been required to visit a doctor as part of developing their claim. The examination they receive after they have been approved is essentially the same examination. The most major difference is that the doctor might assume at the outset that the claimant’s conditions were, in fact, disabling when the claimant was awarded benefits and is now looking to see if they still are. The rest of the CDR may involve an interview with the claimant, running earnings reports, and querying bank databases to ensure compliance with earning and asset rules.

A paper CDR is what is assigned to cases that are less likely to see an improvement in symptoms or that were awarded based on very solid objective evidence. In these reviews, the Administration sends claimants function reports, disability questionnaires, and work activity reports, among others, to record statements from the claimants about how they live their lives and what treatment they are getting. Any suspected medical improvement or unreported work will trigger the more intensive CDR.

Beyond the CDRs, claimants are responsible for notifying the agency of any material changes in their lives. This could be a simple change of address or, in some circumstances, things that seem less relevant such as the marriage or death of a dependent. Generally, these requirements are much more stringent for claimants receiving SSI than they are for those only receiving SSDI as these individuals can only exceed the original qualifying criteria under certain circumstances.

For instance, an SSI claimant that is single with no children is required to have $2,000 or less in the bank at all times. If the claimant does not report to SSA even a single time when their bank account may be over the allowable limit (a lump sum child support payment for instance) they can be deemed overpaid and required to repay all of the benefits that they have received after the overpayment occurred. So, in order to maintain benefits, a claimant will need to educate themselves as to the requirements applicable to his or her situation.

While these requirements may not seem to be particularly taxing, the ramifications for an individual who is relying upon these benefits to make ends meet are enormous. So, while it may appear that that neighbor, friend, or relative is not disabled, SSA has reviewed their case and will continue to do so to ensure that they are, in fact, disabled.

If you have questions about maintaining your benefits or applying for disability contact us today!

Why Is It So Easy For People To Get Disability? Part 1

Did Ronald Regan make it so easy to get on disability?

Did Ronald Regan make it so easy to get on disability?

According to, it is very easy to get on Social Security Disability. Not only that, but according to Forbes, there is a 200 billion dollar “disability industrial complex” that has arisen because so many Americans are “gaming the system.” This had led to questions about the solvency on the Social Security trust which funds the Disability Insurance program known as SSDI. Despite the disability trust fund being solvent through at least 2027, politicians maintain that, in addition to the ease with which individuals can get on disability, it is similarly easy for them to commit fraud or other abuses of the system. They maintain that if this “tremendous fraud, waste, and abuse” is eliminated and if it becomes even more difficult to get on disability, the Social Security system would become solvent for all time. These two very common assertions raise the question, why is it so easy to get on disability and game the system?

Of course, to get to the bottom of this, you need to know exactly what you’re talking about, otherwise pundits that purport to know what they are talking about could mislead readers. Forbes contends that the $200 billion in disability payments made each year are paid to people who otherwise might be receiving a form of welfare, and that these people are not motivated to work since a substantial portion of their income is replaced by disability payments. This is one of the ways that Forbes characterized Social Security Disability:

The Social Security Administration pays out benefits in relation to how much money you made when you were working, with some means-testing considerations thrown in. The overall effect is to replace the majority of your income if you’re poor, and a smaller fraction of your income if you were well-paid in your previous jobs.

This is a vague and somewhat disingenuous description that only seems to incorporate the SSDI program. For instance, Forbes’s description seems to imply that just anyone can be awarded benefits. While it is true that the vast majority of people working are in OASDI covered employment (employment that allows you to gain quarters of coverage used toward SSDI eligibility), they are not guaranteed eligibility and the vast, vast, vast majority of OASDI workers would become a technical denial. For example, there are approximately 163 million workers in OASDI covered employment for 2015, but only 2.4 million applications covering 1.47% of all OASDI covered workers (1.7% if we use the greatest number of SSDI applications from the last 15 years, 2.9 million in 2010).

However, you cannot reach the $200 billion mark if you do not also include the approximately $54 billion in SSI payments made each year which, because of math, is clearly what Forbes did. SSI is not funded by the same trust which funds SSDI. It also is primarily means tested and, with very few exceptions, any benefits paid or accrued will be offset by any form of income, earned or unearned, that a claimant may receive. So, in essence, in talking about the program’s solvency, Forbes was already inaccurate by about 25% of their reported figure as any SSDI funding issues would necessarily exclude SSI. This means that the “disability industrial complex” is actually only about $150 billion, 25% less than Forbes’s quoted amount.

The funding figures are relevant in that the amount of benefits an applicant is allegedly guaranteed to receive are too high, and, according to Forbes, that is drawing otherwise able-bodied workers to the program. This is also directly related to the process of obtaining disability benefits as disability applicants must not have any substantial income for twelve months at least in order to qualify.

Funding also becomes relevant because critics like to point out that disability claimants are actively choosing to be paid not to work, since the benefits are so great. But, if claimants are really accepting benefits in order to stay out of work, they are also choosing a lifetime of living around or below to the poverty line that will never improve without them going back to work. Anyone claiming SSI only will have to learn to live on a maximum $773 per month with a state supplemental payment that will be about $50-100. Beyond that, while the maximum benefit an SSDI claimant can receive is $2,663 per month, and the average benefit for SSDI is $1,146 while the average SSI benefit is $510 per month. So, while some people may believe that a person could be set for life collecting disability benefits, if they are an average disability claimant, they would likely be living off of $13,752 per year. The federal poverty line is $11,880 per year or $990 per month which means the average SSI only claimant would be drastically below the poverty line, while the average SSDI claimant would be slightly above the poverty line. In either case, claimants may very well have to rely on programs such as SNAP and TANF, two of the programs that make up welfare as we know it, in order to make ends meet.

Forbes’s contention that disability is the new welfare also comes from the spike in disability applications that comes with higher levels of unemployment. According to Forbes, instead of going to find a job during times of high unemployment, individuals will apply for disability benefits at a greater rate. This is something that can be discerned from SSA’s own data. In 2009, after the beginning of the financial crisis, there was an increase in applications from 2.3 million applications to 2.8 million applications.

There are various ways to look at this. First, this is common sense. During times of high unemployment, there are typically no jobs for people to find regardless of their desire to find them. So, since there are fewer jobs, people necessarily look for alternate means of support. However, the inverse to this is also true, i.e. during times of low unemployment there are fewer applicants. In fact, as the unemployment rate has dropped since 2009, so have the number of applicants down to 2.4 million in 2015. Moreover, levels of high unemployment could also have the effect of making people qualified that might otherwise not be since claimants must be out of work for 12 months. Lastly, Forbes also neglected to mention that technical denials, denials based on an claimant’s lack of basic qualifications, also go up during times of high unemployment while medical denials tend to stay flat. So, while the number of individuals applying may go up precipitously when unemployment is high, actual benefit approvals only tend to increase minimally. This, in and of itself, should show Forbes and other SSA critics that disability is not, in fact, being used to replace “welfare” because you have to be awarded benefits because you can collect them.

Stay tuned later this week when we roll out part II of our answer to the question, “why is it so easy to get disability?”

If you would like to talk to an attorney about disability or have questions about your pending application contact us today via email or call us at 1-866-262-8595!


SSI/SSDI Appeals Process: A/C and Level 5

One thing that any new applicant for disability benefits will hear about shortly after submitting their application is the disability appeals process. It can sound like a daunting and difficult process filled with claimant participation and, occasionally, claimants can come to feel that they are doing more for their case than their representative is doing. Many times, however, these feelings come up because claimants are unaware of what is happening behind the scenes and that their representative . This post will take readers through the last two appeal levels in the SSI/SSDI appeals process.

Level 5 takes you to federal court

Level 5 takes you to federal court

The Appeals Counsel

This level of appeal is generally reserved for SSI and SSDI claims that have been denied by an Administrative Law Judge (ALJ). The appeals counsel has other responsibilities as well, however, most claimants will encounter the Appeals Counsel after a denial. If a claimant disagrees with an ALJ’s decision he or she can write a letter or submit an appeal form saying so. However, having a representative to argue the appeal can be a tremendous advantage because many times the appeals counsel will side with an ALJ if the judge’s reasoning appears to be sound on its face. A representative can point the Appeals Counsel to areas where the judge misconstrued the Agency’s rules, missed a piece of evidence, and other issues that may require a second hearing to resolve.

The claimant’s role in at this level of appeal is greatly reduced. He or she can and should submit medical updates to their representative, but generally the appeals counsel will be deciding the appeal based on the information provided by the claimant at the prior three levels. The only real exceptions to this occur when an ALJ made a decision before an important piece of evidence was received or the claimant underwent new tests or procedures which revealed that their conditions were of a greater severity than initially believed by their doctors. In these cases, the new or missed evidence should be submitted to the representative who can submit the information to the Appeals Counsel.

In addition to submitting any relevant new information from the claimant, the representative’s primary role is to brief the appeals counsel on the issues of that which generated the appeal. Most of these issues will be related to the decision made by the ALJ, however, it can also include procedural missteps such as not allowing a certain witness at a hearing or ignoring medical records because of an erroneously enforced local rule.

Federal District Court

This is the “last” level of appeal for a disability application. But, in point of fact, the Supreme Court of the United States is the definitive last level. There are two reasons for this. First, since the Social Security Administration is an agency of the executive branch of the U.S. Government, appeals that go to the courts of the judicial branch require a lawsuit against the Agency’s commissioner. Secondly, the Supreme Court has jurisdiction over cases within the federal judicial branch, meaning that a suit against the Commissioner of SSA is within the Supreme Court’s jurisdiction. All of this being said, there is a very low probability that any SSI or SSDI application will even reach the federal district court level. Here, the roles of claimant and representative will be similar to those in any other lawsuit conducted by an attorney on behalf of a plaintiff. If a claimant made it through the prior four levels of the process without an attorney and wants to continue to the federal district court level, this would be the time to find one. A skilled attorney at this level will state the issues in a manner that fits the law which is most important since it gives a federal district court judge a better look at why the claimant/plaintiff believes that there is an issue and what remedies would be available to the claimant.

The drawback of “level five” is that it takes years to get there and, as long as the ALJ presiding over the hearing did even a middling job of sticking to SSA’s rules, the court may very well side with SSA. This is one of several reasons why there are very few level five cases. Attorneys are reluctant to take cases against SSA that do not have a clearly appealable issue. While that may not seem fair to claimants, it affords them the opportunity to file a new application where they may very well have a better chance at approval the second time around and cuts off additional months of waiting to a process that has been years in the making. Moreover, most attorneys would have to front the costs for taking an appeal to court and may receive little in the way of reward as attorneys fees are still governed by the Social Security Act. While a disability case may be slightly less expensive, even taking a basic automobile accident to court can cost about $17,000. Since attorney’s fees are capped at $6,000 and can only be increased based upon a fee petition, you can see why many lawyers are reluctant to take a case this high.

Having attorneys wait for bright line issues, though, also means that the cases that do make it to federal district court have a much stronger chance of success. If a case is successful in court, it will be remanded down to the original ALJ for a new hearing with instructions to the ALJ to make proper findings. This process can repeat itself over and over until there is a final disposition, but to avoid such a feedback loop, a case will only be remanded to the original ALJ once. If the ALJ insists on repeating his findings, the case will again be remanded, but to a different ALJ.

If you have been denied at any level of the process, or have read our appeals series and have questions, please contact us!

The Appeals Process: Hearing Level

One thing that any new applicant for disability benefits will hear about shortly after submitting their application is the disability appeals process. It can sound like a daunting and difficult process filled with claimant participation and, occasionally, claimants can come to feel that they are doing more for their case than their representative is doing. Many times, however, these feelings come up because claimants are unaware of what is happening behind the scenes and that their representative . This post will take readers through some brief descriptions of the steps in the appeals process and the roles of the claimant and representative are at each stop.

Today’s post is going to discuss the third level of the SSI/SSDI appeals process.

The Hearing

In some ways, having a disability case at the hearing level is like starting your claim over again. It takes about the same amount of time as the first two levels of appeal, your representative will request as many or more records than they and SSA did in the first two levels, and you generally will also have a new SSA office to speak with since your case will now be at the Office of Disability Adjudication and Review (ODAR). Because there is a substantial wait to even be scheduled for a hearing, many people will lose interest in their cases and some will even forget that they have a pending claim with SSA. However, most claimants are harshly reminded that their claim is pending when they receive a notice that they have been scheduled to appear before a judge.

This can cause some panic for claimants. This can be doubly so when an advocate wants to re-interview them about their medical history and medical providers. This is a very standard and necessary practice. The medical records that SSA would have on file would now be over one year old. Presumably claimants would have received some treatment for their conditions and it is necessary to show that their conditions remain when they reach the hearing by securing updated medical records. It also does not make much sense to try to collect medical records until about sixty to ninety days from the hearing. Many ALJs will require records more or less through the date of the hearing, so requesting them too far out will mean that the advocate will need to do another round of requests. It usually saves everyone time if the records are submitted close to the hearing.

This is the level where the claimant is presented with his or her day in court, and often will have the first real opportunity to explain to a person that would listen what their conditions are and how their symptoms effect them. This is also the part of the process that takes the longest. Generally, the wait for a hearing takes over a year from the date of the request. The reason for this is that, based on 2015’s numbers, there were about 1.1 million claimants that requested a hearing, and about 1,800 judges to hear their cases. That breaks down to about 611 hearings per judge. Since each hearing is about an hour long, that leaves about 1,400 hours in the year (based on a 2,080 hour, i.e. 9-5 job’s work year) for ALJs to write decisions, decide fee petitions, correspond with medical experts, hear overpayment cases, and perform all of their other duties. There are simply not enough judges to hear cases and, so, the process is relatively drawn out.

At this level, the claimant’s responsibilities will be generally the same as at reconsideration with one notable difference. The claimant will also need to testify at a hearing. This testimony is usually presented through questions asked by both their attorney and the ALJ through questions about their conditions, what treatment they have received, how they spend their days, and many other topics.

The representative will prepare for the hearing in a number of ways. First, they will ensure that any and all relevant medical records have been brought up to date as it becomes the advocate’s responsibility to complete the record. They will also make sure that, not only have the records been received, but that they have been submitted to SSA. The representative will also renew any requests for consultative examinations, respond to those reports, make motions for subpoenas for any non-responsive record providers, collect medical source statements, and write and submit a pre-hearing memoranda to the judge, among others. The representative will also conduct the hearing and will have prepared for it by reviewing all of the records, researching the claimant’s conditions in detail, studying the listings of impairments related to those conditions, and interviewing the claimant to get the best possible idea of how they are effected by their symptoms. The advocate will also have the responsibility of addressing any issues that come up at the hearing through the submission of additional or missing records or post-hearing briefs to the judge on specific topics.

Probably more than any other part of the appeals process, the hearing level is where a claimant will benefit from an attorney’s help the most. Many ALJs will be understanding enough with pro se applicants and will try to get them through a hearing. However, most claimants have no little knowledge of what will and will not constitute evidence of a disability, will not be able to properly brief the judge on their conditions, or how to cross examine a vocational witness. It is by allowing the claimant to leverage their knowledge and experience that attorneys and advocates can benefit claimants.

If you are currently in the appeals process and would like to speak with an attorney contact us today!


The Appeals Process: Reconsideration

One thing that any new applicant for disability benefits will hear about shortly after submitting their application is the disability appeals process. It can sound like a daunting and difficult process filled with claimant participation and, occasionally, claimants can come to feel that they are doing more for their case than their representative is doing. Many times, however, these feelings come up because claimants are unaware of what is happening behind the scenes. This post will take readers through some brief descriptions of the steps in the appeals process and the roles of the claimant and representative are at each stop.


Requesting reconsideration is like asking SSA to redo the work it did during the initial application process. In doing this, SSA will send the application and supporting documents to a different decision maker to see if they come out with a different result. The claimant is allowed to submit additional information or request that SSA go out and get some additional records. This process usually works on the same 3-6 month timeline as the initial application, but can often be quicker since much of the case development was begun in the application stage.

For reconsideration, the claimant should have fewer responsibilities. The most major of these is providing his or her representative with information about recent doctor’s visits, new diagnoses, or new tests. The other important responsibility the claimant will have is completing some paperwork that SSA is going to send to the claimant. These papers can be filled out by the representative, however, most of what the claimant will receive will be questionnaires about their activities of daily living or symptoms they regularly experience making the claimant the best person to complete them.

At this stage, the representative will provide updated medical information to the agency, renew any requests for consultative examinations, respond to the examination reports, and likely add arguments to be presented to the new decision maker(s) reviewing the case. For more severe cases, the representative may also attempt to provide specialist opinions, medical source statements, or vocational opinions that refute the Agency’s reasons for denying at the application stage. Additionally, an attorney or advocate will also spend a good amount of time ironing out issues with medical record providers.

The Social Security Administration ultimately bears responsibility for collecting medical records during the initial application and reconsideration stages of the process. However, most providers are corporations and have requirements for being reimbursed for records. They also seem to assume that SSA is demanding the records for free (despite usually receiving a request for an invoice to be paid by the Administration). Depending upon the state, SSA (and disability lawyers) not only will require that the records be free of charge, but will do so because the state legislatures have enacted laws making it illegal to charge for records meant to support an SSI/SSDI claim. In this type of conflict between law and corporate policy, the law generally wins, but unless someone explains how the laws governing medical records works to a provider, or obtains a subpoena from an ALJ to require them to be released, the records may simply never be returned. Thus, this becomes a time consuming responsibility for your representative during the Reconsideration and hearing stages.

The SSI/SSDI Appeals Process


One thing that any new applicants for disability benefits will hear about shortly after submitting their application is the disability appeals process. It can sound like a daunting and difficult process filled with claimant participation, occasionally making the claimant feel responsible for keeping the process moving. However, most times, while the claimant will be asked to fill out some paperwork, go to an interview, or a doctor’s visit, the process for claimants can be relatively seamless. This post (and the parts that come after it) will take readers through some brief descriptions of the steps in the appeals process and what the roles of the claimant and representative are at each stop.

The Application

The application is actually the first step in the appeals process. Most people think of the application as only beginning their claims for benefits. However, even the best compiled application can fall into the 60-65% of applications that are denied. Well thought out applications and supporting documents will lay the foundation for any subsequent appeals that may be necessary.

At this stage of the process a claimant should gather everything that they can to provide to SSA either directly or through their representative. This information is going to include doctors’ names, addresses, and dates of treatment; former employers and dates employed, education history, bank account information, and more. It is a lot of information to provide, but the more of it you have on hand, the more complete your application will be; the more complete your application is, likely means the quicker the response from SSA will be and with a greater chance of success.

For the application, the representative will have the responsibility of compiling the information from the claimant in a way that makes sense to SSA. This is going to mean several things. First is literally organizing the information. When completing an application for a claimant a representative will be required to enter this information in a certain order for an online application and then mailing, faxing, or both the packet of information collecting from the claimant to the Administration. The representative will have to find out which office it goes to, to whom the case has been assigned, and whether to request that SSA take certain actions such as requesting a consultative exam.

They will also be responsible for pointing SSA to the locations of the claimant’s medical records so the agency can procure everything relevant to the claim. Many representatives will do more to develop the record such as collecting medical source statements, collecting letters from collateral witnesses, and drafting briefs. The representative may also work closely with an SSA case worker on more detailed cases or SSI cases which are dependent upon the confirmation of detailed information and subjective valuations (i.e. blue book value vs. true car vs. eBay auction value) of assets such as homes and cars.

In a nut shell, it benefits the claimant to present as much information as possible when submitting a disability application. So, the representative’s role is generally to assist them in collecting it and communicating it to SSA in a manner that is easily digested by the agency.

Stay tuned for the next part of our discussion of the roles of the representative and the claimant during the appeals process! If you have questions about this before our series is done please do not hesitate to contact us!

A Brief Guide to Public Benefits: Medicare, Medicaid, and Social Security Disability Insurance

Many people do not understand the difference between Medicare and Medicaid and fewer still don’t understand the relationship between these programs and Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). This is not surprising given the similarities and complexity of these programs. Simply put, both Medicare and Medicaid help cover costs for qualified individuals’ medical expenses.

Medicaid is administered by individual states. The District of Columbia, Guam, Puerto Rico, United States Virgin Islands, American Samoa, and Commonwealth of the Northern Mariana Islands also have Medicaid programs, bringing the total to 56 separate Medicaid Programs. These programs are funded by a combination of state/territory taxes and federal taxes. Because each of these programs is independent, the requirements to qualify for Medicaid varies from state to state. Generally speaking, to qualify for Medicaid you must have limited income and limited financial resources. Additional requirements may include, being 65 years of age or older, being disabled, or being younger than 19 years of age. Medicaid can cover doctor visits, hospital stays, prenatal and maternity care, mental health care, and medications, as well as vision and dental care for children.

In Massachusetts, the Medicaid program is called MassHealth. For individuals under the age of 65, there are three Medicaid programs available through MassHealth:  1) Standard; 2) CommonHealth; and 3) Long-Term Care. See Table 1 for the general requirements for these programs. It is important to note that this table only includes the general requirements.

Table 1:  General Standards for MassHealth for Individuals 21-64 Years of Age.

  Standard CommonHealth Long Term Care
Disability Requirement ·       Legally Blind, Determined by Massachustts Commission for the Blind

·       Disabled, Determined by Social Security Administration

·       Disabled, Determined by MassHealth Disability Determination Unit

·       Legally Blind, Determined by Massachustts Commission for the Blind

·       Disabled, Determined by Social Security Administration

·       Disabled, Determined by MassHealth Disability Determination Unit

·       Be eligible for MassHealth Standard as a disabled person or pregnant; AND

·       Determined to require long-term care by MassHealth

Assets Requirement ·       Assets are NOT considered ·       Assets are NOT considered ·       Less than $2,000 in countable assets
Income Requirement ·       Less than or equal to 133% of the Federal Poverty Line ·       Less than or equal to 133% of the Federal Poverty Line; OR

·       Have income above 133% of the Federal Poverty Line, and pay a one-time detuctible

·       Is currently working 40 hours a week or more; OR

·       Is currently working and has worked at least 240 hours over the 6 months preceding the application

·       Less than or equal to 100% of the Federal Poverty Line.

Medicare is administered by the federal government and funded by federal taxes. It is available to individuals 65 years of age and older, individuals under 65 years of age with certain disabilities, and individuals with end-stage renal disease (ESRD). It is a large program with four main components, parts A through D. Part A, Hospital Insurance covers inpatient stays at hospitals, skilled nursing facilities, hospice care, and home health care. This is typically available for free provided you or your spouse paid Medicare taxes while working. Part B, covers doctor care, outpatient care, home health care, durable medical equipment, and some preventative care. This is typically available for a set premium. Part C, covers all the benefits in Parts A and B, and may cover the benefits of Part D and additional benefits, for additional fees. Part C is run by Medicare-Approved, private insurance companies.  Part D helps cover prescription drug costs and is also run by Medicare-Approved, private insurance companies.

It is possible to qualify for both Medicare and Medicaid.  Individuals who qualify for both programs are called “duel eligibles.” Between the two programs, most medical expenses are probably covered.

SSDI and SSI are distinct and separate programs from Medicaid and Medicare, but qualifying for one of the former may allow you to qualify for one of the latter sooner. Often individuals who apply for SSDI and SSI either already receive Medicaid or begin to receive Medicaid after they are awarded benefits. Individuals who receive SSI are automatically eligible for MassHealth. Individuals under 65 years of age who are awarded SSDI are eligible for Medicare Part A, at no cost, 24 months from the date when they were entitled to receive SSDI benefits. Individuals may begin receiving SSDI benefits as early as one year before their application date. There is always a 5-month waiting period from the onset date of a disability to the date that an individual in entitled to receive SSDI. Also, individuals are only entitled to SSDI benefits for a maximum of 12 months prior to the application date. Therefore, the earliest individuals can qualify for Medicare via SSDI is 24 months after their application date. That is assuming they were found to be disabled at least 17 months prior to their application date. Since Medicare is often an important benefit to disabled individuals, it is important to file SSDI claims earlier rather than later.

Once individuals qualify for Medicare Part A at no cost, they will be eligible for Parts B, C, and/or D. These will typically require a monthly premium for coverage; however, some states have programs which will help low-income individuals pay these costs.

Medicaid and Medicare can help you obtain vital medical care at little or no cost. All of these programs are much too complex to cover comprehensively in a blog post. There are numerous exceptions and caveats to the rules and requirements covered in this blog. If you are considering applying for SSDI or SSI, it is important to discuss the details of your particular case with an experienced attorney or a representative from the Social Security Administration so that you understand when and how you will qualify for these programs. The important thing to remember is that each day you delay in applying for SSDI and/or SSI, not only are you potentially losing cash benefits, you are also increasing the time you will have to wait to qualify for Medicaid and/or Medicare.

A few links with more information about these programs: standards