Introduction to Public Benefits law

Public Benefits Programs Benefits Administered by the Social Security Administration (SSA) Supplement Security Income (SSI or Title XVI) Social Security Disability Income (SSDI or Title II) Regs are at 20 CFR 404 and 416 POMS online Benefits Administered by the Illinois Department of Human Services (DHS) SNAP (Food Stamps) TANF (Cash assistance) Medicaid (“Medical Card”) Refer to Illinois Admin Code, Online DHS Policy Manual

Two Basic Types of Social Security Supplemental Security Income (SSI) Safety net, means-based program Disabled individuals, kids $733/mo standard benefit; $1,100 for a couple Gets check on the 1st of month Retirement, Survivors, and Disability Insurance Social Security Disability Insurance (SSDI/DI) Amount based on work history/taxes paid into system Spouses, children, disabled adult children, parents can also be paid based on disabled or deceased worker’s record Gets check on day other than 1st of month Retirement It’s Important to Know the Difference! When in doubt: ask the monthly amount, check the notice

Applying for SSI/SSDI Benefits Initial Application (at local Social Security office or On-line) – paper review, usually denied Reconsideration 60 days (+ 5 for mailing) Paper review, usually denied Administrative Law Judge Hearing Best chance for success if you have good medical documentation, comply with your treatment, and provide your records to SSA Appeals Council – 60 days, Federal Court – 60 days

Common Issues with Social Security Cases Cessation of Benefits for “no longer disabled” Overpayment/recoupment of benefits Reduction in benefit amount due to income Termination of benefits for income or assets

“SSA Says I’m No Longer Disabled” All cases are given review date (continuing disability review or “CDR”) If denied, same appeal rights (recon, ALJ…) 60 days to appeal each time, extra “Hearing Officer review” Appeal within 10 days to get continuing benefits See 20 CFR §§ 404.1588, 416.988

Examples Client with severe mental illness, lapses in treatment and compliance with meds Child born premature, now has ADHD Disability evolved over time, but not medically improved

Overpayment Causes SSI Social Security Disability Failure to report household income/composition Being over-resourced (more than $2,000 in assets) Reporting changes, but SSA fails to act on them Pursuing, then losing your appeal Social Security Disability Failure to report earnings or some lump-sum income

Can you work and get benefits? SSDI – Yes, but the work rules change over time and benefits are either turned “on” or “off” The rules are detailed and complex, but basically, you have a bit more than 3 years (starting the first day of work) to test your ability to work. In general, for every month you earn over $1,090, your benefits will be turned off. After 36 months, if you earn over $1090, your benefits will stop completely. See 20 CFR § 404. 1592 et.seq. SSI – Yes, but benefits reduced Work incentive – roughly half of earnings are counted against your benefit No time limits as in SSDI, but if you work more than 12 months over SGA, your disability may be reassessed. See 20 CFR § 416.1110 et.seq. Bottom Line for Both Programs: YOU MUST REPORT YOUR WORK TO AVOID AN OVERPAYEMENT, AND YOU SHOULD APPEAL ANY ADVERSE DECISION THAT YOU DISAGREE WITH AS SOON AS POSSIBLE – PREFERABLY WITHIN 10 DAYS

What about other income and assets? SSDI is insurance program – only earnings, workers’ compensation, and some pensions affect benefit. No asset limit SSI - all income will have an effect on benefits in some way. Money that is “un-earned” or given to you will reduce your benefits dollar for dollar. $2,000 asset limit for a single person, some assets are excluded (the home you live in, 1 car, etc.)

Example SSI – Brain Tumor case Asset went unreported, but client did not have knowledge of the asset until SSA brought it to his attention

Overpayments – What can you do? Appeals Challenge allegation of overpayment Standard 60 day appeal timeframe Waiver Not challenging allegation of overpayment Establish: 1) not my fault; and 2) cannot afford to pay it back Can be requested at any time Waiver request suspends recoupment until final decision reached at local office See 20 CFR §§ 404.502, 416.501 et.seq.

Recoupment SSI – recoupment limited to 10% of benefit Can request different repayment plan (as low as $10/month) SSDI – SSA initially recoups 100% of benefit

Termination of Benefits (Other than Disability Reviews) SSI cases Benefits may be reduced or stopped for earned or unearned income in the household (including income of a spouse that client is living with, or income of a parent if this is a children’s SSI case) Benefits will be stopped if over-asset ($2,000 for one, $3,000 for disabled couple) or if “transferred” assets for less than market value SSDI cases Benefits may be reduced or stopped for not reporting earnings, workers compensation benefits, or some pensions

Examples SSI – A Home in Togo? Benefits ceased because of bad asset determination SSDI – Unreported Work that is Over the Limit Benefits ceased because time period for earning over the limit was expired, but work was actually that of someone who stole ID

Termination of Benefits – What can you do? If a client’s benefits have been reduced or stopped: Client has 60 days (+ 5 for mailing) from the date of their notice informing them of the change to file an appeal SSI CLIENTS SHOULD FILE WITHIN 10 DAYS for continuing benefits (until the local office makes a final decision after the informal conference). If they are beyond 10 days, they should still ask! Clients on SSI will then be scheduled for an “informal conference” at which time they can present their evidence regarding income, assets, etc. (SSDI clients don’t have this option) If appeal denied after a personal conference, client has 65 days to request an ALJ hearing (also done at local office)

IL Dep’t of Human Services Assistance aka “Public Aid” Medicaid Cash Assistance (“TANF”) Food Stamps (“SNAP”)

Medicaid Single adults between 19 and 64 without disabilities can now get Medicaid! (up to 138% FPL) Children under 19 and custodial parents get Medicaid (up to 200% FPL) Disabled Adults and those 65+ get “traditional” Medicaid financial eligibility up100% FPL and $2000 asset limit If over the income or asset limit, you “spend down” your income/asset each month to get covered

Common Issues with Medicaid Cases “Redetermination” problems Eligibility for the program is periodically redetermined. Clients must cooperate, turn in necessary documents, etc. If fail to do so on time, benefits will cease. Termination of benefits Likely for exceeding income limits Access to care issues Restrictions on some medications – 4 prescription limit Pre-approval problems Managed care issues

Cash Assistance (TANF) Temporary Assistance for Needy Families Kids under 18 Income test (no asset limit) Parent with 2 kids gets $432/month 60 month limit, with exceptions Disabled with pending SSI case Domestic Violence Caring for disabled family member Work Requirement, with exceptions Medical barrier Domestic violence Education Programs (GED, ESL, bachelors) Mental health or drug treatment programs

Common Issues with TANF Cases “Redetermination” problems Eligibility for each program is periodically redetermined. Clients must cooperate, turn in necessary documents, etc. If fail to do so on time, benefits will cease. Change in benefit amount Usually based on change in income or household composition (ie – if one person moves out of household, or child turns 19) DHS often doesn’t know who is in the household, which leads to errors (ex: “spouse in the house” cases) Termination of benefits Sanctioned for not complying with work activities without good cause (called a Responsibility and Service Plan, or “RSP”). Ist stage – reduction of benefits is 50% until cooperate, then 50% for at least 3 months, then 100% for at least three months No longer “categorically” eligible (exceeding the 60 month clock, or no longer caring for minor relative children) Overpayment/recoupment of benefits Unlike Social Security cases, no “waiver” process. Only appeal available. Recoupment – 10%, not to exceed $75/month

Food Stamps (SNAP) Amount received is based on income and expenses (rent, utilities, and medical expenses) – no asset test Household – buy and prepare food together Issued on a “Link” card Emergency Benefits – within 5 days if income and liquid assets less than your rent and utilities U.S. Citizen children are always eligible, even if living in mixed-eligibility household

Common Issues with SNAP Cases “Redetermination” problems Eligibility for food stamps is periodically redetermined. Clients must cooperate, turn in necessary documents, etc. If fail to do so on time, benefits will cease. Change in benefit amount Usually based on change in income or household composition (ie – if one person moves out of household, food stamps will decrease) Overpayment/recoupment of benefits Unlike Social Security cases, no “waiver” process. Only appeal available. Maximum recoupment for overpayments that were not due to fraud is 10% Statute of limitations – 12 months for “agency error”, 60 months for anything else Intentional program violations IPVs usually result when a client used their SNAP benefits at a grocery store that was determined to be guilty of fraud Automatic right to a hearing – do not need to appeal Sanctions administered if you admit to fraud, are found guilty of fraud, or even waive your right to a hearing

Appeals for IDHS 60 days for cash or medical 90 days for Food Stamps For IPV cases, no need to appeal – a hearing is given automatically. Client should be told NOT to send in “waiver of hearing” form they will receive in the mail. File before “date of change” on notice – get benefits pending the appeal Appeals can take months – many can be resolved administratively SO file new application too File by phone – 800-435-0774 or 312/793-2618, get confirmation number

Examples Medicaid TANF Food Stamps – Prior approval issues, pain meds Requiring disabled individual to work, or insisting on impossible job locations Food Stamps – “Spouse in the House”

TIPS FOR WORKING WITH ANY AGENCY Go in person (if you have time to wait, it’s the best way to get your questions answered) Keep copies (of all records you turn in, and of everything you file). Check for dates (copies of appeals won’t help you to proof you appealed on time unless they are dated) Get receipts (insist of a file-stamps, a receipt, or other confirmation that you: showed up, turned in the required documents, or did whatever else you were instructed to do. If you can’t go in, think fax confirmation, certified mail, etc.)

TIPS FOR WORKING WITH ANY AGENCY Appeal Deadlines are VERY STRICT you must meet them to keep your case alive. If you miss a deadline, you have to prove you had “good cause” for missing it – a very high standard REPORT REPORT REPORT! You must report your changes in income or assets (and keep proof that you reported) in order to avoid an overpayment