Sample case from contact to review

Ideally, you will be referred to us prior to your last date employed so that we can review what your options are prior to leaving work. This happens in less than 2% of the cases we agree to represent.
Of course, many times you are disabled suddenly rather than a gradual onset of disease.
The sooner in the process that we can review your case, the more assistance we are in helping you avoid financial disaster.
We will give you an example of a case where we entered the case by making application for DIB online with our new client:

The client calls our office by referral from their physician’s office when we set an appointment to make the online application; we will mail directions to the office and a list of information that we will be required to have in order to complete the application and disability report; your appointment is usually within 7 days of your initial call and will generally take 1.5 to 2 hours. DIB application for benefits can cover retroactive benefits for as much as 12 months prior to the month of application, however you should apply as soon as you are unable to work to avoid possible loss of monetary benefits. There are certain forms that must be completed after printing and submitted to the local SSA office. If there is any information that was not completely provided, SSA will send a letter asking for correction or clarification, then the case is sent to DDS.
Usually within 30 days you will begin receiving correspondence from DDS such as work history reports, activity of daily living questionnaires, fatigue questionnaire, pain questionnaire, or referral for independent consultative examinations. We will meet with you and complete these forms.
Usually, within 60 days of the last request for information, DDS will make their determination of disability in writing. IF you are approved, you are a member of a very rare group. The American Bar Association conducted a detailed  analysis of the SSA statistics and found that approximately 20% of initial applicants are approved and most of those are catastrophically ill claimants. If you are denied, you will have 60 days from the date the Determination was written and mailed to you (60 days after you receive the Determination, estimating that you received the letter 5 days after it was mailed). Keep all envelopes!! We feel there is rarely a reason to delay the Request for Reconsideration so we will get you into the office to file the Reconsideration as soon as possible. Even if medical treatment is scheduled, do not delay. As soon as the Reconsideration is filed, the local SSA office will send your case file to DDS and you will not have access to the case file information. We suggest that you obtain a copy of the case file so we can review the medical records IMMEDIATELY after getting the Denial. This must be done before your Request for Reconsideration is filed in the local SSA office and before it is sent to DDS.
Occasionally, Reconsideration cases are placed in a hold status because the number of initial applications are so high and take a priority for the DDS staff allocation however when they are not being held, the process will begin again with the same forms and the same time period for a response. Again the chances of being approved are low however the next step, a Hearing by an Administrative Law Judge, has over an 80% chance of getting an Approval. The time to wait for a Hearing can vary from about 9 months to over two years, depending on the ODAR office where your case is located. Some cases can be expedited and a Favorable Decision can be made without a Hearing.

Early Retirement Pending a Determination of Disability

If you have an Application for Disability Insurance Benefits pending with the Social Security Administration, when you become 61and ½ years of age you can request that you be paid under the early SSA Retirement Program pending the Determination of your Disability.

Early Retirement Benefits are substantially lower than your SSA Retirement benefits would be if you retired at the maximum age, however Disability Benefits are generally greater than Early Retirement benefits or Benefits for retirement at age 65.  

Many Claimants are unable to meet the COBRA payments for continuing their health insurance after leaving work without this added income. This is the only benefit that you can obtain from SSA to assist during this period of Disability Determination unless you are the Mother of an Adult Disabled as a Child and you are needed in the home to care for them.

Medicaid will reimburse your COBRA or insurance payments if you are found eligible under the Health Insurance Premium Payment Program. Be aware that many DSS employees do not know about HIPPP. File an Appeal if they do not process you immediately.

When your Disability Insurance benefits are determined, your Early Retirement benefit amount will be “offset”, SSA will reduce the amount they owe you for the DIB period by the amount they have already paid to you under Early Retirement. If you have a Representative, the fee that you will owe your Representative, based on a fee agreement meeting the statutory requirements, would normally include the Early Retirement Benefits paid as part of the Back Award.

After you have Notice that your Disability has been proven, your eligibility for Medicare will be determined by your Disability Onset date, not by your age as under Early Retirement.

If you are Eligible for Medicaid because your household income is below the income limits set, when you become 62 and you have SSA Retirement Benefits that you could apply for, your Medicaid will usually be terminated if you do not apply for the early Retirement Benefits. Virginia Medicaid requires that you Apply for all benefits for which you COULD be eligible. Your Medicaid may be stopped due to excess income after you begin your Early Retirement Benefits or it may continue under a Medicaid spend down.

What do you need to win your Disability Claim?

All Claimants are required to provide medical documentation to support their disability. You cannot obtain benefits, based in disability without a diagnosis and medical documentation of your symptoms.

In Virginia, the Social Security Administration  designates the Disability Determination Services (DDS), a Division of The Commonwealth of Virginia, Department of Vocational Rehabilitation, to evaluate your medical records to determine if you meet the criteria for disability. DDS will request all medical records from medical care providers that you list on your application or that you add to your record; they will analyze those records received and make a written Determination of Disability status based on the information in those records and your responses to forms DDS sends to you.

If medical care providers do not send the records or you do not return forms, you may be denied for lack of information or cooperation.

You do not pay for the medical records obtained by DDS. You should not need to get records from your medical care providers unless they fail to send them to DDS.

If you want copies of your medical records from your medical care providers to compare to what they sent to DDS then you MAY have to pay your medical care providers for copies of medical records to the limits set by the Code of Virginia, Section 8.01-413; check the statutes in your state for the same information. Hospitals are allowed to charge more than medical offices. The medical care provider MUST respond to your request within 21 days of the written request. “Respond” does not mean they have to provide the records in 21 days, only respond and tell you how much you owe for the copies. They cannot withhold your records because you owe treatment care money. Arrange to pay for your records on the day you PICK THEM UP.

If you are told that your records will not be released because you owe treatment costs, explain, nicely, that under Section 8.01-413 Code of Virginia, these are your records and that if they do not provide them to you, you may hire an attorney obtain them by subpoena and their practice may end up paying for the attorney. Usually, the medical care provider either is acting out of ignorance or their employee is uninformed as to the Statutes and placing the practice at jeopardy for the expense for violating this Statute.

If you have a Medicaid Application pending, you might explain to the medical care provider that when you win your Disability case, your Medicaid will be re-evaluted and those medical bills just might get paid by Medicaid,  Medicare, or both.

How do you get your retroactive Medicaid Benefits?

You have won your SSI benefits. Now, how do you get your retroactive Medicaid benefits?

It is not easy and it does require that you mark your calendar and file Medicaid Appeals when deadline dates are not met by Social Services and your medical care providers, as well as your pharmacy. You are asking DSS to do their job and give you the benefits you should have gotten when you Applied for Medicaid… not an easy task in many locations!

  

If you attempted to apply for Medicaid at the Department of Social Services and the following happened:

• DSS (Department of Social Services) told you that you could not be eligible for Medicaid unless you had already won your Disability status with the SocialSecurity Administration;
• DSS denied your Medicaid based on a Denial by Social Security while you were in the SSA Appeal process;             
• DSS denied your Medicaid Application without making an independent determination of disability by MDU
• Someone at the DSS discouraged you from applying, such as telling you that it is a waste of time because you would not be eligible

YOU NEED TO FILE A MEDICAID APPEAL if you did not when you first Filed for SSI! You will be asked why you did not File a Medicaid Appeal within 30 days of the denying event, tell them you did not understand their system and relied upon their "greater knowledge".

On the Medicaid Appeal form you are asked when did the violation of your Rights occur (they ask you when did you get Notice from DSS of the Appeal Issue); they will say you should have Appealed within 30 days, however IF YOU RELIED UPON THE REQUIRED SUPERIOR KNOWLEDGE OF THE DEPARTMENT OF SOCIAL SERVICES PERSONNEL, you have the Right to Appeal based on not knowing your true Rights until you found out this information from this site. On the Hearing day, there may be a “pre-Hearing” discussion on the issue of “good cause” for filing the Medicaid Appeal after 30days. We have never lost a case when the Applicant was able to clearly state that they had relied upon the statements made by DSS employees and the DSS employees were wrong.

Once you have an effective date of Application established, either by Filing the Application or by the Hearing Officer determining what you Application date was, your Medicaid eligibility must be determined for a period of 90 days prior to that Application date.

ELIGIBILITY

You must meet income, resource, and disability restrictions. Any earnings in your household may count toward the monthly maximum allowed amounts. IF YOU APPLIED FOR SSI AND WERE FOUND ELIGIBLE FOR SSI, all of those dates of coverage must be accepted  by DSS as Medicaid eligible dates from the 90 days prior to the date of your Medicaid Application to the last date of SSI eligibility. Periods after SSI eligibility must have a new Medicaid Application and a new determination of resource and income eligibility. You may only be eligible for Medicaid under a Spend Down plan (similar to a “deductible amount” in regular insurances) after your DIB benefits begin. If you continue to receive as little as $1.00 per month of SSI, you will keep your Medicaid.

For example, if SSI approved you for benefits from Jan 1, 2007 through July 31, 2007, and you applied for Medicaid on April 1, 2007 (and got a denial), the full period from 1/1/07 through 7/31/07 will have Medicaid coverage. If you applied for Medicaid November 10, 2006, and got a Denial from DSS, now DSS must determine your eligibility for Medicaid by income and resources and disability from November 10, 2006 through December 31, 2006.

Remember that your MEDICAID APPLICATION DATE limits when your Medicaid coverage can begin. That is why we urge you to APPLY FOR MEDICAID, DO NOT DELAY.

RECOVERY OF MEDICAL FEES AND PRESCRIPTIONS PURCHASED

If you paid for medical or psychological care or prescriptions, you are eligible for receiving that amount, minus your Medicaid co-pay, back form the provider. You MUST have told the provider that you had “Medicaid pending” when you obtained services, except at the pharmacy.  I asked you to obtain a “master printout” from your pharmacy and told you to keep track of the amounts paid to the providers. This information will assist you when you are seeking your funds back.

If you have not kept track or obtained a master printout of prescriptions, do so before you present a Medicaid card to them.

When your Medicaid benefits will be for a period over 12 months prior to the card issue date, the Department of Social Services must provide you with a ”greater than 12 month” letter that your providers can use to file for the Medicaid Coverage prior to the exact date one year ago. You will give each provider a copy if that letter and a copy of the Medicaid card (or allow them to copy these two items) when you provide notice to the provider to refund your money paid. Also tell them that this Claim must be “hand processed”. You should do this in writing, keep a copy and mark the date on your calendar. Your letter should tell them that they have 30 day deadline for refunding your payments, minus your Medicaid co-pays. They will know how much your co-pay was to be for the service they provided. Mark your calendar for 30 days; also mark your calendar for 15 days and on the 15^th day call the person you directed your letter to and confirm that they have everything they need. If the provider tells you that the Claim was denied, tell them to file an Appeal but you have complied with your Regulatory requirements: provided your Medicaid card that covered the period of service, and a letter allowing the billing of services more than 12 months prior to the filing date.

The provider will then file a PAPER CLAIM to Medicaid, placing a qualifier 22 on the claim and attaching a copy of the greater than 12 month letter from DSS.