Disability Advocacy for E&T Workers “Because Successful Change Happens from Within!” Course...

Disability Advocacy for E&T Workers

“Because Successful Change Happens from Within!”

Course Topics

Review Past Denials

Medical Records

Employment Evaluation

Education Evaluation

Activity Assignment

Work Readiness Evaluation

Introduction & Statistics

Initial Application

Role of a Case Manager

Action Steps

Resources

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Information for this overview was gathered from internal CW Solutions resources as well as the following external sources:

• Bob Hunt, Section Chief for State of Wisconsin DDB• www.ssa.gov• W-2T Workgroup (DWS/DWD workgroup)• DWS, DWD, BPS Training Unit




Individuals who believe that they are disabled may qualify for a disability program. Both adults and children can qualify for disability.

Introduction

This overview focuses on Adult disability programs because they are the primary target population for most case management (Employment & Training) programs.

Eligibility for most disability programs occurs through the Disability Determination Bureau through the Social Security Administration.



Disability Determination Bureau

The DDB is a state agency within the Department of Health and Family Services, Division of Health Care Financing.


The DDB’s role is to determine medical eligibility for disability programs.

Trained examiners and in-house medical consultants render the disability decisions (medical doctors, psychologists, etc.)

The medical rules applied to a disability determination are defined by Social Security Regulations.



Definition of an Adult Disability All three of the following elements must be present in order for an applicant to be approved for disability.

1. A person is unable to engage in full-time work activity,

2. Due to a mental or physical impairment that is medically determined,

3. Which has lasted or is expected to last 12 continuous months, or is expected to result in death.





Social Security Disability Insurance (SSDI)vs. Supplemental Security Income (SSI)

SSDI• Eligibility is earned through working

• No benefits during a five-month waiting period

• Medicare available after 24 months of payments

SSI• Is needs-based, no prior employment earnings needed

• Presumptive disability possible

• Medicaid eligibility effective same month as first benefit.

• Children and Adults may be eligible



Application Levels

There are a number of levels in the application process:


Initial Application Request (takes between 3 – 5 months for decision to be issued, average is 85 days).

Reconsideration – a paper review of denial that includes any new information submitted by the applicant.

Hearing – a review by an Administrative Law Judge.

Appeals Council Review – a paper review of case.

District Court Case – requires legal representation, case is heard in court.



Application Statistics

The DDB completes more than 70,000 claims a year. Nationally, the following percentage of the applications are approved:

37.0% of initial applications

3.2% at reconsideration

11.8% at the Office of Hearings and Appeals

0.1% at the Appeal Council

Overall, 52.1% of applications are allowed.


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Disability Evaluation Steps

Is the person working & earning $830 or more per month?

Is there an impairment that limits the ability to work?

Does impairment meet/equal a Disability Listing?

Can person do his/her usual job full time?

Can person do a less demanding job on a full-time basis?

Initial Application



Initial Application

Impairment Evaluation - If not expedited, it evaluates if the claimant meets a defined Severe Impairment which automatically qualifies the applicant for disability.

Residual Functional Capacity – if a claimant does not meet an Impairment, then a functional capacity evaluation is completed which determines what work functions the person can still do considering the restrictions caused by the medical conditions.

When the DDB receives a new application claim, it completes a three-tiered evaluation process prior to any potential denial.

Expedited Evaluation - When the DDB is made aware of a terminal illness, dire need, or possible “presumptive” disability it expedites the application processing.



Expedited Evaluations

Initial applications are “screened” for probability of approval.

The more information provided at application, the more likely a

quick determination is made.

Initial Application

Age is a significant consideration. Applicants under age 50 have

a more difficult time being determined disabled.

Education is also a major consideration. If an applicant has a

HSD or greater, it decreases the possibility of a disability

determination.



Preliminary eligibility can be made for some SSI applications if the following is met:

It is clear in the claim that the applicant is very likely to be found “disabled”.

Presumptive SSI eligibility is not a common occurrence. It is especially difficult to determine for mental impairment claims.

If approved, the claimant can receive up to 6 months of cash benefits and medical coverage.

The claimant does not have to pay back any benefits if the final decision is a denial of disability eligibility.

Initial Application

Presumptive Eligibility for SSI



Steps to Initial Claims Filing

The SSA Website provides a wonderful array of resources to

assist an applicant with the process before even filing the initial

claim.

Initial Application

General Disability Information

www.ssa.gov/disability

Disability Starter Kithttp://www.ssa.gov/disability/disability_starter_kits_adult_eng.htm



Steps to Initial Claims Filing1. Form completion (forms can be done on-line, telephone, or

through the mail) http://www.ssa.gov/applyfordisability/adult.htm

Describe the medical conditions List treatment sources and addresses Describe past work requirements Describe day-to-day activities and how the medical

conditions have changed individual’s ability to function

(describe on the “Functional” form)

2. Sign consent form authorizing release of medical records and

information from the necessary providers.

3. Interview by local SSA office (in person or over the phone)

Initial Application



Steps to Initial Claims Filing4. Submission of medical and related evidence to the SSA

office.

5. If necessary, complete appointment with a DDB-referred

medical provider for an additional evaluation.

6. Receive determination 2 – 6 months from application

submission date.

7. The denied applicant has 30 days to file a Reconsideration.

Additional information can be submitted to support the claim.

8. If the reconsideration is denied, then a Hearing can be

requested. It can take up to a year to have a hearing held

before a hearing officer.

Initial Application




What can a Case Manager do to help?


A CM can hold as much credibility as a medical provider in

the determination process.

A CM is viewed as an employment expert and has first-hand

knowledge about the impact of the claimed disability on both

employment and personal care. DDB utilizes a Vocational Rehabilitation Counselor to

evaluation the participant but the VR counselor only

completes a paper review, comparing claimed limitations to

prescribed functional lists of jobs. A CM can provide specific

individual information about the labor market and its

demands comparative to the participant’s abilities or lack of

abilities.



How does a CM do this? A CM can track over a period of time the applicant’s ability to

do activity in a work training program.


A CM can assist the applicant with work history and

education level information. A CM can assign activities that help measure an applicant’s

ability or inability to sustain employment. A CM can track the ebb and flow of the disability over a

length of time, providing a better picture of the disability than

a single medical review evaluation. A CM can become an Authorized Representative to facilitate

information processing.



WHY be an Authorized Representative?

The AR receives a copy of all correspondence between DDB and the claimant.


The AR will know what information is being requested.

The AR will know when appointments and exams are scheduled.

The AR can discuss the case with the DDB representative.

There can be more than one AR – with one being the main representative. So, a legal representative may be the main representative while the employment & training worker can be a secondary AR.



HOW to be an Authorized Representative?Discuss option with the customer. Explain it only allows

you to be included on the communications with the DDB.

The customer must complete and sign the SSA-1696 form and turn it in to the Social Security office.





Action Steps

A worker needs to develop a plan of action on how to approach the disability advocacy and what steps need to occur in the process.

Review of past denial letters

Each case is different and customers come in at different stages in the process be the following steps are universal in need and effectiveness. Depending on the stage of the application, some may already be completed. Key actions include:

Review of current medical records

Employment & Education History evaluation

Consolidate identified barriers into single chart

Assign activity that evaluates employment sustainability

Compose summary report for DDB



Past Denial Review

Disability determined not severe – but current evidence suggests it is or it has worsened.

Disability not expected to last more than 12 months – but has now lasted more than 12 months.

Is able to do work in a different field – but retraining is not an option.

Only one issue evaluated - but there are multiple issues that combined together creates a debilitating situation.

Review any past denial letters to identify why it was denied such as:



Review current medical records for the following:

Current Medical Records

Are they supported by concrete medical evidence? If not, they may not hold significant weight by DDB.

Is each medical provider aware of other conditions or treatments?

Are the obvious issues described in the documentation or treatment notes?

Does a functional capacity evaluation need to be scheduled to fill in the “blanks” in the current medical records?



SSA’s Listing of Impairments

This listing is accessible on the Internet at:

The SSA utilizes a listing of conditions (impairments) which represent severe impairments that met the threshold for disability.

http://www.ssa.gov/disability/professionals/bluebook/




Example Impairment: Mental DisorderPart A Diagnosis confirmed Objective findings Severe Disorder that causes

significant impairment Is documented by mental

status findings &/or psychological tests

Part B

Two of four areas must be met: Marked restrictions in daily

activities Marked social problems Concentration problems,

failure to complete tasks Repeated decompensation

under stress




Residual Functional Capacity

If an impairment is not met, the next step is to complete a functional evaluation.

A functional evaluation determines what work functions the person can still do considering the restrictions caused by the medical conditions.




Functional Capacity – for Physical Work

Exertion Capacity - sedentary, light, medium, or heavy. Ability to stand, walk, sit, lift, carry, handle, reach, crawl,

see, hear, communicate.

Endurance for a 40 hour work week.

Ability to perform work functions without frequent rest

breaks.

The following elements are evaluated when determining a person’s physical capacity to work:




Functional Capacity – for Mental WorkThe following elements are evaluated when determining a person’s mental capacity to work:

Ability to understand, remember, and follow simple directions independently.

Ability to respond appropriately to supervisor, co-workers, and usual work situations.

Ability to cope with routine changes or stresses in the work setting.

Ability to concentrate and complete tasks in a timely manner.




What the DDB Collects for Evidence


Evidence is anything the disability applicant or anyone else says about the applicant’s condition (medical evidence) and how it affects the applicant’s ability to function (non-medical evidence).

Evidence Needed:

History of the condition/illness. Medical signs, symptoms, test findings that document ALL physical

and mental problems alleged by the applicant. Copies of testing/assessments (e.g., any done by the W-2 agency). Medication side effects. Information about the onset of the impairment, and current status.

Evidence includes:



The examiner writes to all relevant medical treating sources for

copies of their medical records.

Questionnaires are sent to selected medical providers and

professional contacts.

Other knowledgeable third parties are contacted to complete a

functional form or to provide information over the telephone.

Claims Filing Process - Evidence

Obtaining evidence by DDB:




Substantial weight is given to opinions of treating doctors because they see the patient over time.

When determining the applicant’s ability to function, DDB must adopt the treating doctor’s opinion on this IF it is supported by the medical findings and consistent with other evidence.


Treating Doctor’s Opinion




DDB always obtains existing medical records first (and gives such evidence the most weight).

If these records aren’t detailed enough for a decision, then DDB may purchase an exam.

In the end, the disability examiner needs sufficient objective medical findings to:

support the diagnosis, and

determine the level of functioning..


Consultative Examinations




Applicant’s own statements ,

Professional Contacts (including Case Managers, Social Workers, etc.),

Statements from family, friends, employers, etc.


Non-Medical Evidence:

In addition to medical evidence, DDB considers the following non-medical evidence in the decision process:




Pain (and other symptoms) must be considered in disability determination.

Make sure the extent of any pain is fully described.

Credibility comes into play when there are conflicts in the evidence.

Be sure to share information from other sources in support of the applicant’s allegations.


Other Evidence:




Disability examiners do not see the applicant in person (so need to be informed about any unusual circumstances).

Not all limitations are identified. Individual limitations may not be severe, but a combination of limitations may warrant disability.

Doctors may not include everything in their treatment notes because:


Things that complicate the determination:

Treatment notes are kept for their own purpose, not to meet DDB’s needs.

Current notes state current complaints but may not include old findings

Obvious limitations are not always stated in the notes.




Employment Evaluation

Identify the length of the employment.

Identify the starting and ending wages.

Describe duties and skills used or developed on the job.

Describe difficulties on job caused by disability or why it would be difficult now that the disability has manifested.

Determine if it would help to get statements from co-workers or the supervisor.

Evaluate if customer could return to that type of work with accommodations. Utilize JAN resources @ www.jan.wvu.edu/

Review all prior work history. DDB generally only has access to employment dates and wages so details are helpful and eliminates guess work by DDB and their vocational specialist.



Education Evaluation

Identify highest education level of customer (such as HSD,

GED, AA, etc.)

Evaluate any prior training experiences including on-the-job

training and short-term courses.

Consider current disability and medications being taken – do

they affect the customer’s ability to learn or retain

information?

It is important to determine the education and training background as well as how it impacts future learning.



Multiple Barrier Consideration

What impact does the combination of barriers have on the customer’s ability to work?

Do the barriers, as a whole, indicate they meet the disability threshold?

Are the treatment plans by different providers taking into account all issues and treatments?

Individually, some medical issues may not meet the disability threshold, but in combination with others can meet the disability definition. Therefore, make a consolidated barrier document in order to help answer the following:



Activity Assignments

Test basic work skills such as organization, follow through, and task retention through simple assignments.

Track productive vs. non-productive days the customer has.

Complete occupation aptitude and interest assessments that may be viable with the customer’s disability.

Evaluate ability to complete retraining activities and/or actually attempt retraining activities.

Provide simulated or accommodated work experience activities.

So, what are you doing in the program to help evaluation the customer’s employment viability? Do not let a customer dangle in advocacy status without ENGAGEMENT. Things to do include:



Work Readiness Report

Brief description of the program the customer is in.

Details on the past work and education history.

Description of the disabilities with length an treatment.

Description of program assignments along with successes and failures of the customer with those assignments.

Conclusion by the program regarding the customer’s viability for sustained employment for local labor market.

A summary report such as a work readiness determination document should be submitted to the DDB by the case manger. It should include:

This type of document often provides enough information to expedite the decision early in the application process.



Additional Steps

Coordinate family members to attend key medical exam appointments to share their experiences about the customer.

Attend key medical exam appointments, especially DDB-scheduled appointments to provide information to examiner.

Make sure all involved medical providers know about each other and the corresponding plans.

Consider coordinating a joint meeting with medical and service providers to discuss overall treatment plans for customer.

Send new and developing information to the DDB representative as it is gathered.

Other actions to consider:




Call DDB’s main number (608-266-1565), but realize Call DDB’s main number (608-266-1565), but realize that confidential information can only be shared with that confidential information can only be shared with Authorized Reps. (Applicants may call 1-800-423-Authorized Reps. (Applicants may call 1-800-423-1938, toll free.)1938, toll free.)

Contacting the Examiner

Resources

The applicant (or authorized representative) will The applicant (or authorized representative) will receive the letter with the examiner’s name and receive the letter with the examiner’s name and phone number as soon as the application is assigned.phone number as soon as the application is assigned.



Social Security Administration: 1-800-772-1213

SSA website: www.ssa.gov

Disability/SSI Information: http://www.ssa.gov/d&s1.htm

Disability Starter Kit:

http://www.ssa.gov/disability/disability_starter_kits_adult_eng.htm

DHFS/DDB website: www.dhfs.state.wi.us/ddb/index.htm

DDB contact (a receptionist will direct your call):608-266-1565 or 800-423-1938 (toll free for applicants)

General Contact Information

Resources


Disability Advocacy for E&T Workers “Because Successful Change Happens from Within!” Course...

Documents

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