Reopening Prior Applications greater than four years prior to current Application

The Rules of Social Security Administration allow for the reopening of prior Claims under specific circumstances up to four years prior.However, in the Fourth Circuit a special Ruling applies which allowed me to reopen a Claim that was Filed seven years prior and never Appealed providing 75 months of retroactive benefits after 16 months of representation in my office. This has been a wonderful case to have won for a client who has been cared for by a dedicated sister for many years with little or no help from other family members, financially or emotionally.

Delay in Filing an Appeal

Many Claimants do not meet the 60 day deadline for Filing an Appeal when they have received Notice of the Determination. There must be an overwhelming reason for the delay or your case must start again from th beginning: new appliction, new disability report AND A MOTION TO REOPEN THE PRIOR CLAIM. A new Claim Filed within a year of the prior Claim Denial, can be considered a Motion to Reopen but at some point in the new Claim you need to actually request that the prior Claim be reopened and that is with a Motion to Reopen with case citations and applicable Regulations, Statutes, SSR, or AR.
Some good reasons for missing the date could be:
you were hospitalized for the majority of the 60 day period
your Appointed Representative was hospitalized for the majority of the 60 day period
neither you nor your Represenative received the Notice of Determination
on the date you had an appointment at the SSA local office you became ill and had to go to the Emergency Room
on the date you had an appointment at the SSA local office, weather closed their office.
You can see, there must be a verifiable and serious reason to miss your date.
When a Claimant is mentally retarded or has significant psychiatric disease, and they were unable to adeqautely understand the Notice giving them only 60 days to Appeal, a Representative may be able to have those cases Reopened.

How important are medical records to a Disability case before SSA?

Social Security requires that you provide medical documentation of your disabling condition(s). If you were getting regular medical care and then lost your insurance and had no means of obtaining medical care, SSA Regulations require that DDS  obtain a Consultative Examination(s) of your conditions. During the most recent years, these have increasingly been performed at "mills" by medical care providers who do not see you in their practice, many do not have a practice and only perform DDS and Workers Compensation evaluations. It is my opinion that Claimants are not served well by these evaluations when done by these groups. I have numerous clients who say that they were not even touched by the examining clinician. There is no way that I am aware of that a clinician can comment accurately about muscle spasms if they do not touch the patient! With this  in mind, it is essential that you have consistent medical records.
FIND a free clinic or a sliding fee scale clinic; APPLY for Medicaid so those medical care providers who do provide treatment and evaluations during this determination period, will be able to bill Medicaid/Medicare for your services when you win. Major medical centers and medical school clinics provide exceptional documentation of disability cases.
The Social Security Administration Regulations require that your medical records meet certain standards. These are not my standards; these are the Rules: generally very little evidentiary weight is given to the records of an LCSW who is not having their records and case work supervised by a PhD in psychology, a LPC (Licenced Professional Counselor), or a MD with a psychiatric specialty; SSA usually will give little weight to the medical opinions of a Nurse Practitioner unless counter signed by a physician. A General Practitioner or Family Practice physician's opinions of mental disease or some other highly specialized disease process, such as anxiety and depression, cancer, diabetes, neuropathy, stroke, cardiac conditions,etc, are given little weight if the symptoms do not require the referral to a specialist You must recognize these limitations when you are seeking medical documentation of your condition(s). I cannot tell you the number of Claimants who have to accept a much later onset date than when they first became disabled by a condition because the Claimant continued to be seen by a physican/medical care provider that SSA does not consider to be adequate to provide treatment and/or diagnosis. Many times, once referred ot the specialist, the Family Practiiotner "supervises" the care prescribed by the specialist, and SSA will accept those records.

Our Philosophy

We believe that a disabled individual needs to have their disability determination completed as soon as possible.

We believe that a Client deserves to have their case processed as rapidly as we possibly can and under whatever exceptions might apply to their case to request that the case be accelerated by Social Security.
We believe that each Client has the right to be informed of each benefit they could apply for and be assisted in making those applications.

Disability Benefits-SSA:DIB, SSI, Medicare; DSS: Medicaid

From the Social Security Administration there are two basic benefits based in Disability: Supplemental Security Income and Disability Insurance Benefits We also specialize in obtaining Medicaid benefits for the disabled, which is administered through the Department of Social Services of the various localities. Our assistance with Medicare coverage, comes through DIB eligibility or End Stage Renal Disease.

DISABILITY

The definition that the Social Security Administration uses for defining disabled is the same for these three benefits: you must not be able to do the work you have done as your primary past relevant work, there are no transferable skills, there are no jobs in the national economy that those transferable skills transfer to that you can do without 18 months of training or more, and your disability is anticipated to last for twelve months, or end in your death. A Representative assists with cases which don’t seem to meet that definition. Very few cases meet that definition when first evaluated by SSA.

SSI

Supplemental Security Income is available to the disabled population who meet certain income and resource limitations. SSI eligibility creates eligibility for many services from the Department of Social Services, such as food stamps, Section 8 housing, and Medicaid. There is no earnings record requirement for this benefit.

DIB

Disability Insurance Benefits is not a resource or income dependent benefit which provides monthly benefits based on the highest five consecutive earnings years or the last full year earnings, if that is highest, as well as benefits to eligible dependents after six full months of a disability anticipated to last at least twelve consecutive months. If you are also drawing Worker's Compensation, your DIB benefits will be "coordinated" with your Worker's Compensation amounts.

EARLY RETIREMENT PENDING DISABILITY DETERMINATION

If you have attained the age of 61 years and 6 months, you can apply for early retirement benefits to be paid to you while you are seeking Disability Insurance Benefits. Generally, Early Retirement benefits are substantially less than your DIB monthly benefit therefore you will receive additional funds when you are approved for DIB.

MEDICAID

Medicaid is administered through the Virginia Department of Medical Assistance Services and provides medical coverage for the disabled who meet the same income and resource limits as set for SSI. 

MEDICARE

Medicare is available to End Stage Renal Disease patients who meet specific medical guidelines, and DIB  recipients after 24 months of benefit eligibility.

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.

When should a SSA Disability Claimant Apply for Medicaid?

           You should apply immedicately either before you Apply for SSI/DIB or immediately after. That was a quick and easy answer; getting the benefits may not be!

It is not easy and it does require that you follow-up, do everything on time, and file Medicaid Appeals when deadline dates are not met by the Department of Social Services.

To begin, if you attempted to apply for Medicaid at the Department of Social Services (DSS) 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 Social Security 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 you would not be eligible if you Apply;

YOU NEED TO FILE A MEDICAID APPEAL IMMEDIATELY! 

HOW TO FILE A MEDICIAD APPEAL:

Call your local DSS and tell them to mail you an Appeal form or go online to your DSS and get a form there. You do not have to explain why you need an Appeal form. If they do not send it in 5 business days … GO THERE AND GET ONE!

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 us. 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 unless you have been declared Disabled by Social Security, then they only have 45 days.

You may get a letter telling you that they are not going to meet the 90 day limit because (whatever they say); IMMEDIATELY file a Medicaid Appeal stating that they have failed to determine your eligibility within the time limit set by the Federal Regulations. There are no exceptions to the 90 day determination of disability by MDU allowed under the Regulations…. NONE!

When you do win your SSA BENEFITS, DSS will reopen this Application and reevulate your eligibility for Medicaid, or a Spend Down Medicaid. Any months you get at least $1.00 of SSI you will have Medicaid eligibility IF YOU FILED THE MEDICAID APPLICATION.