General Assistance Handbook SSI Advocacy 29. SSI Advocacy · Update 14-04 Revised: 04/09/14 General...

General Assistance Handbook page 29-1SSI Advocacy

29. SSI Advocacy

Assembly Bill 2779 allows Social Workers to provide Supplemental Security Income (SSI) Advocacy services to the recipients of the General Assistance (GA) program.

The SSI Advocacy Program is a specialized program that assists disabled General Assistance (GA) clients who have physical and/or mental problems that are expected to last twelve months or more, and that prevent them from engaging in substantial gainful employment.

The Social Workers assist disabled clients through the Social Security application and/or appeal process with the ultimate goal of an SSI and/or Retirement, Survivors, Disability Insurance (RSDI) approval for the client.

29.1 History

The SSI Advocacy program was established in 1985 by the Board of Supervisors in order to assist disabled General Assistance recipients with their applications for SSI benefits. Advocacy services are provided to those General Assistance recipients who are unable to attend to the complexities of the SSI eligibility process on their own. The county is reimbursed for General Assistance funds that are paid to the recipients after the date of the SSI application. The dedicated and committed Social Workers have the expertise necessary to assist disabled clients move productively through the SSI system. They also depend on the help and cooperation of other community agencies and resources to provide clients with support systems and to meet various basic needs during this process.

In 1989, the State of California with SSA agreement revised the IAR authorization to allow for reimbursement between California counties known as Inter-County reimbursements.

Update 14-04 Revised: 04/09/14

2 General Assistance HandbookSSI Advocacy

29.2 SSI Advocacy Program

29.2.1 Purpose

The SSI Advocacy Program is designed to focus on GA clients who are required to apply for SSI. The program utilizes social work intervention and assistance in order to:

• Help clients follow through with the SSI application process,• Secure additional and more precise medical/psychiatric information, and• Provide representation at the various appeal levels in the SSI process.

The SSI Advocate may pursue an SSI application denied at any level of the five-step appeal process.

Note:All GA clients who are potentially eligible must apply for SSI.

29.2.2 EWs SSI Advocacy Criteria Chart

The following SSI Advocacy Criteria Chart contains a list of referral reason codes along with the corresponding referral reason descriptions. The appropriate reason code is to be entered on CalWIN’s Manage Referral Detail window when the EW completes an online referral to the SSI Advocacy Unit.

Referral ReasonCode Referral Reason Description

A. Permanent Mental and/or physical disability

B. Medically and/or physically disabled for 12 months or more

C. 12 months or more of continuous GA eligibility and 50 years of age or older

D. 2 or more years duration on GA

E. Do not use

F. Do not use

G. Form SCD 1400 or Medical Verification is attached

H. Medical verification not attached. Write an explanation after the letter “H”

Revised: 04/09/14 Update 14-04


29.3 Case Assignment

29.3.1 Process for Case Assignment

SSI Advocacy Social Work Supervisor receives a printed copy of the online SSI Referral and assigns it to the appropriate social worker. The printed copy with assigned social worker is then forwarded to designated clerical staff for processing.

• SSI Advocacy Social Worker receives the new case assignment and schedules an appointment for assessment.• Prints CSF-Appointment Notice and mails to client.• Submits form for IDM process.

• Social Worker has appointment with client. Greets client in lobby and escorts to interview area:

• Assist client in completing the initial SSI application. • Gives completed application to the client and contacts SSA to schedule an

appointment for the client, if necessary. • Provides transportation and accompanies client to the appointment if

needed.

• Social Worker develops case and determines if any additional information is needed for an SSI/SSP approval. This could include:

• Requesting additional medical records.• Referring client to on site psychiatrist.• Contacting collateral, i.e., probation officers, parole officers, therapists,

relatives, attorneys, etc.

• Social Worker reviews and updates the SSI/SSP Detail Tab and the Advocacy Hearings Tab if required, by accessing the Display Individual Demographics Summary Subsystem selecting the Collect Individual Demographics Detail window and clicking the [SSI/SSP] button [Refer to “The SSI Advocacy Web Application must be used for Tracking Applications and to ensure accurate case load listings.,” page 29-24] for details on completing the SSI/SSP Tabs.

• Documents all necessary information in CalWIN on the Maintain Case Comments window.



• SSI Advocacy Social Worker monitors their SSI cases to ensure they are closed when benefits case closes.

29.4 Case Development

29.4.1 Assigned Case and Process

The basic steps in the case development process are as follows:

• Once a case is assigned it is expected that the client will be contacted to have the social worker introduce themselves. The social worker explains who he/she is, what they do and why the case was assigned to them.

• An appointment must be scheduled in order to conduct an extensive interview with the client. This may occur in the office, in the client’s home, or anywhere agreed upon by both the social worker and the client.

• A helpful tool for the first interview is to solicit the information requested on the SCD 1541 intake form. This will help to gather information that will be needed later on. It may also help as a starting point in gathering more detailed, personal information that will entered into the CalWIN SSI Tracking System for each client assigned to the social worker.

• Enough information needs to be gathered to be able to write or begin to write a psychological-sociological evaluation about the client. This is helpful in providing information to the disability analyst at the State, or to the in-house psychologist, and/or to an attorney if and when a client needs to proceed in the appeal process at the hearing level.

• When meeting with the client, all necessary paperwork, forms, releases etc. should be taken in order to have them signed by the client. This may save time later on in the process.

In the initial process, the social worker’s skills will be invaluable, the skills will need to be utilized more often and will really be put to the test. Many clients are homeless, mentally ill, recent parolees, immigrants and/or seniors. All of them share financial limitations and are claiming some degree of disability. Several visits over a period of time with these clients may be needed in order to complete a thorough evaluation. Usually when the client sees that the social worker is sincere, they begin to open up more about themselves. Also, the social worker may begin to observe significant behaviors that are signs and symptoms of disabilities.



29.5 SSI Law

The SSI Law can be found in:

• The Social Security Act of 42 U.S.C Sec. 401 et. Seq. http://www.ssa.gov/OP_Home/cfr20/401/401-0000.htm

• The Regulations 20 CFR 404.1 et.seq.:20 CFR 416.101 et. Seq http://www.ssa.gov/OP_Home/cfr20/404/404-0000.htm http://www.ssa.gov/OP_Home/cfr20/cfrdoc.htm

• Social Security Rulings http://www.ssa.gov/OP_Home/rulings/ssi-toc.html• POMS/Hallex //https://secure.ssa.gov/apps10/poms.nsf/Home?readform• Caselaw http://www.ssa.gov/history/law.html.

29.6 SSI Sequential Evaluations

The analysis of the client’s sequential evaluation consists of the following 5 Steps:

StepsSSI Sequential Evaluations If... Then...

1. Substantial Gainful Activity

There IS Substantial Gainful Activity,

Disability does Not exist.

There is NOT Substantial Gainful Activity,

Go to Step 3.

2. Severe Impairment

There IS Severe Impairment, Go to Step 3.

There is NOT Severe impairment,

Disability does NOT exist.

3. Meets or Equals the Listings

The Impairment DOES Meet or Equal the Listing,

Disability exists.

The Impairment does NOT Meet or Equal the Listings,


4. Perform Past Relevant Work

The client CAN Perform Past Relevant Work,

Disability does NOT exist

The Client CANNOT Perform Past Relevant Work,

Go to Step 5.



29.7 SSI Levels

29.7.1 SSI Approval-Process

To Qualify for SSI, an individual must:

• Be 65 years of age or older, blind, or disabled• Be financially needy• Reside in the USA, and• Have United States citizenship or be a legal immigrant with a qualifying

exemption, a military service exemption or be a refugee/asylee.• File an Initial Application - completes and/or signs the following forms:

• Disability Report-Adult, Form SSA-3368• Appointment of Representative, Form SSA-1696• Authorization to Disclose information, Form SSA-827

To schedule an appointment to file the Initial Application claim for SSI call 1-800-772-1213. You will be asked to provide the following information regarding the claimant:

• Social Security Number• Name• Address• Phone number• Onset of disability• Diagnosis• Income and resources• Request a face to face interview.

5. Perform Other Work

The client CAN Perform Other Work,


The client CANNOT Perform Other Work,

Disability exists.

StepsSSI Sequential Evaluations If... Then...



29.8 GA to SSI

29.8.1 GA Recipient Required to Apply for Disability Benefits

A General Assistance recipient who has been determined to be disabled or unemployable by a physician due to a health situation or a condition that will last for 12 months or longer or is terminal is REQUIRED to apply for SSI.

If the client worked and paid FICA taxes for at least 20 of the 40 quarters prior to the onset of disability, the recipient is required to apply for either Title II (SSDI), Title XVI (SSI) or both.

In order to meet the SSI disability requirement, a client must be unable to engage in any substantial gainful activity by reason of a medically determined physical or mental impairment which can be expected to last for a continuous period of not less than 12 months or that will result in death.

29.9 SSI Application and Appeal Process

29.9.1 Application and the Five Step Appeals Process:

• Initial Application• Reconsideration• Administrative Law Judge Hearing• Appeals Council Review• Federal Court Review• United States District Court

29.9.2 Initial Application

In the Initial Application stage an application can be completed by:

• Telephone Interview with Social Security Administration.• Face to Face interview at Social Security Administration.• Online application with Social Security Administration.



All initial applications for SSI and SSDI:

• Must have work history for the past 15 years.• May have medical & psychological records.

The time period from application to decision is approximately 180 days.

• If the client is approved for Interim Assistance Reimbursement (IAR) refer to General Assistance Handbook, [Refer to “Interim Assistance Overview,” page 33-2] for processing information.

• If approved, benefits are paid.• If denied, appeal must be filed within 60 days of the denial date.

Note:The burden of proof is on the claimant to provide their medical records.

29.9.3 Reconsideration of Denial

The Reconsideration stage is completed by the SSI Advocacy Social Worker or at the SSA Office by:

• Completing the Disability Report/Appeals form online, or• Manually completing and submitting the form to the SSA office.• Submitting any new medical or psychological information. [Refer to “Forms

used in Filing and Developing a Case,” page 29-33.]

The time period from application to decision is approximately 180 days:


• If approved, benefits are paid.• If denied, must file another appeal within 60 days of the denial date.

29.9.4 Process for Administrative Law Judge Hearing

At this point the case is referred to an attorney. The SSI Advocate may facilitate working with the attorney by completing the:

• Paperwork with the attorney or at the SSA office.• Request for Hearing by Administrative Law Judge (HA-501) form.• Disability Report - Appeal (SSA-3441) form.



Reminder:The SSA-3441 form may be completed online or manually.

The SSI Advocate may further assist by:

• Gathering all the claimant’s current medical and psychological information.

• Requesting a decision from SSA prior to going to hearing. This is a formal request which documents the claimant’s disability as it relates to medical evidence/severity of impairment, past work, education and ability to perform other work.

Note:The claim can be approved or denied at this point without a formal hearing.

The time period from the time of appeal to the decision is approximately 6-9 months:


• If approved, benefits are paid. • If denied, the attorney must file an appeal within 60 days of the date of denial.

(At this stage the claimant might be asked to file a new SSI claim)

Reminder:MUST file legal brief on Record.

29.9.5 Appeals Process

Appeals Council - This stage is completed by the assigned attorney with legal briefs. The SSI Advocate can help with the gathering of information. Time from appeal to decision can be up to 3 years.

United States District Court - This stage is completed by the assigned attorney with legal briefs. SSI advocates can help with gathering of information. The time period from appeal to decision can be up to 3 years.

United States Court of Appeals - This stage is completed by the assigned attorney with legal briefs. SSI advocated can help with the gathering of information. The time period from appeal to decision can be up to 3 years.



29.10Failure to File an Appeal

29.10.1 General Assistance (GA) Discontinuance

GA benefits will be discontinued if the recipient (or the SSI Advocacy Unit on behalf of the client) fails to file either a timely:

• Appeal with the Social Security Administration, or• Waiver (based on good cause) of the time limit.

The client will remain ineligible until cooperation is achieved with all aspects of the SSI application process, including all necessary medical examinations.

GA may not be discontinued for the above reason unless it can be proven that the client was aware of their responsibility to file an appeal. The client's signature on the “Important Information for Applicants and Recipients of General Assistance” (GA 14) form is sufficient evidence that the recipient understood his/her responsibilities.

The only time that the SSI Advocacy Social Worker would not file an appeal is when he/she:

• Receives notification of a denial too late to file an appeal within the required time limit, or

• Determines the appeal to be inappropriate.



29.11Notification of SSI Denial and Speedletter 918

If the SSI application was denied the following actions must be taken:

Who Action

EW Receives notification of SSI denial or copy of SSI denial letter

• Make an online referral to the SSI Advocacy Unit

• Generates Speedletter “GA/GR Verify SSI/SSP Application Status” (Spltr 918) in CalWIN and forwards a copy to the SSI Advocacy Unit.

• Submits the SSI denial letter and Speedletter 918 for IDM processing.

• Completes the SSI/SSP tab in the Display Individual Demographics Summary window

• Documents information into CalWIN Maintain Case Comments window

SSI Advocacy Social Worker

Receives notification of SSI denial or copy of denial letter:

• Receives Speedletter 918 from the EW

• Mails or takes Speedletter 918 to SSA to be completed by SSA.

• Schedules an appointment with the client [Refer to “Case Assignment,” page 29-3] of the GA Handbook for process.

• Completes the SSI/SSP tab in the Display Individual Demographics Summary window.

Note: Information on Speedletter 918 is vital and is used for processing an SSI appeal.



29.12Interim Assistance Reimbursement (IAR)

Santa Clara County has elected to participate in the program to receive reimbursement for Interim Assistance as described in Public Law 93-368. Participation in the Interim Assistance Program allows the county to collect the General Assistance (GA) paid to (or on behalf of) a client who is found eligible for SSI/SSP benefits. [Refer to “Interim Assistance Overview,” page 33-2].

All GA program benefits which are paid to or on behalf of a client during the time the SSI/SSP application is pending are called “Interim Assistance Reimbursement” (IAR) payments. Once SSI/SSP is approved, then the amount of GA paid during the “Interim Assistance” period is to be repaid to the County from the client’s retroactive SSI/SSP.

29.12.1 Social Security Administration’s SSI eIAR Web Application

Social Security Administration (SSA) developed a web application that was implemented on November 23, 2009, which is known as the SSI Electronic Interim Assistance Reimbursement (eIAR). This application is available through SSA’s Government-to-Government Services Online web site. The eIAR allows participating Interim Assistance (IA) counties to view and acknowledge SSA communications, and query information regarding an IAR case. Future eIAR releases will allow participating IAR County Agencies to request IA case reimbursement through this web site.

The Electronic Interim Assistance Reimbursement (eIAR) service provides a mechanism for state IA agencies to access and communicate interim assistance reimbursement (IAR) information to Social Security Administration (SSA) electronically. The Query IA case function allows users to access information on IAR cases through pre-defined queries available.

• Acknowledge communications from SSA.

• Query IA cases.

[Refer to http://www.socialsecurity.gov/gso/gsowelcome.htm]


http://www.socialsecurity.gov/gso/gsowelcome.htm


Currently the eIAR web application is accessed by designated staff, GA/IAR and CAPI Program Coordinators, the SSI Advocacy Social Workers and Recovery & Legal/Collections/Accounts Receivable.

The main contact person is the Manager in Recovery & Legal/Collections/ Accounts Receivable. The Accounts Receivable staff attended a Net Meeting on August 19, 2008, conducted by SSA’s Central Office in Baltimore, MD. The purpose of the meeting was for Interim Assistance agencies to view and provide feedback on the eIAR accounting process

[Refer to GA Handbook Chapter 33, Section 33.11, “Social Security Administration’s SSI eIAR Web Application,” page 33-33 for the process and more information.]

29.13Assessment Services

29.13.1 Assessment Services Provided

The SSI Advocacy Unit will provide assessment services to assist the recipient in the SSI application process. The assessment services include, but are not limited to the following:

• Educational abilities• Employment history• Medical history• Agency history• Criminal history• Institutional history • Immigration and Naturalization process• Referrals to Medical Treatment.

29.13.2 Other Support Services

In addition, the SSI Advocacy Unit provides the following supportive services:

• Obtains medical records and documentation which are critical to the SSI appeal process.

• Obtains and completes case relevant correspondence on behalf of the client.• Conducts collateral interviews.• Provides representation at legal proceedings.



• Makes legal referrals.• Makes referrals to other resources.• Provides help with Immigration/Naturalization.• Makes referrals to medical treatment.

29.14 Resources

Resources are a critical component of the case development process. Internal and external resources are listed below:

29.14.1 Adult Protective Services (APS)

Investigates incidents of elder and dependent adult abuse. This includes physical abuse, emotional abuse, neglect and financial abuse. As a Santa Clara County Social Service employee you are MANDATED reporters and as such, you are required to report all SUSPICIONS of adult abuse and neglect by phoning either (408) 975-4900 or 1-800-414-2002.

29.14.2 Department of Family & Children's Services (DFCS/CPS)

The mission of this department is to protect children from abuse and neglect, promote their healthy development and provide services to families that will preserve and strengthen their ability to care for their children. The department is responsible for prevention, intervention, advocacy, and public education related to the protection of children and their need for consistency in their care and nurturing. As a Santa Clara County Social Service employee you are MANDATED reporters and as such, you are required to report all SUSPICIONS of child abuse and neglect to (408) 299-2071.

Referral for Department of Employment and Benefit Services (DEBS) recipients on SSI should/can be referred to DEBS: SSI/SSA Coordinator at (408) 271-7445.



29.14.3 Health and Hospital Services

Santa Clara County Medical Center provides comprehensive inpatient and out patient medical care.

Santa Clara Valley Medical Center 751 South Bascom Avenue San Jose, CA 95128 1-888-334-1000 (408) 885-5000

East Valley Medical Clinic 1993 McKee Road San Jose, CA 95116 1-888-334-1000

County Mental Health (408) 888-5673, and 1 - 800 704-0900 Downtown Mental Health Center 1075 E. Santa Clara Street San Jose, CA 95112 (408) 792-2140

Legal Resources: Bay Area Legal Aid 2 W. Santa Clara St. 8th floor San Jose, 95112 (408) 283-3700

Legal Aid of Santa Clara County 480 N. First Street San Jose, CA 95112 (408) 283-1535

Veterans Services County Vets Services Center 68 N. Winchester Blvd. San Jose, CA (408) 553-6000

US Immigration and Citizenship 1887 Monterey Road San Jose, CA (408) 918-4097

Housing Authority of Santa Clara 505 West Julian St. San Jose, CA 95110 (408) 275-8770

29.14.4 In Home Supportive Services (IHSS)

IHSS provides assistance to those eligible aged (65 and over), blind and disabled individuals who are unable to remain safely in their own homes without this assistance.

Eligibility for IHSS services requires that the applicant is a California resident, lives in his/her own home, and currently receives SSI/SSP benefits; or meets all SSI/SSP eligibility criteria, but has too much income for a cash grant, and meets applicable share of cost obligations. For more information, please contact: IHSS INTAKE SCREENER (408) 792-1600.

29.15Commonly Requested Resources

Twenty Commonly Requested Resources:

(1) Assistance Application Center (AAC) - (408) 758-3800

(2) Adult Protective Services (APS) - 1-800-414-2002 or (408) 975-4900



(3) Benefits Service Center - (408) 758-3600

(4) Child Abuse Reporting (CPS) 24 hour - (408) 299-2071

(5) County Mental Health - 1-800-704-0900

(6) Free Wheelchair/Able People Foundation - (408) 263-8000

(7) Fiscal Accounts Receivable (SSI back payment) - (408) 755-7223

(8) Food Connection - 1-800-984-3663

(9) GATEWAY Drug & Alcohol - 1-800-488-9919

(10) Housing Authority - (408) 275-8770

(11) Immigration Naturalization Service (INS) - 1-800-375-5283

(12) In Home Support Services (IHSS) - (408) 792-1600

(13) Mental Health Advocacy Project - 1-800-248-MHAP or (408) 294-9730

(14) Need Food - 1-800-984-3663

(15) OUTREACH - (408) 436-2865

(16) Rep. Payee Program - Fiduciary and Community Services (408) 292-9096

(17) Shelters Hotline - 1-800-774-3583

(18) Social Security National Hotline - 1-800-772-1213

(19) Unemployment Office (SDI benefits) - 1-800-480-3287

(20) Veterans Benefits - (408) 553-6000



29.16Bus Tokens

The SSI Advocacy Unit may provide bus tokens to assist the GA recipient in completing the SSI application process (e.g. transportation to Social Security and/or medical appointments.)

29.17Commonly Used Medical Record Providers

Alliance Community Care 2001 The Alameda San Jose, 95136 (408) 261-7777 FAX (408) 248-6520

Alta Bates Summit Hospital 350 Hawthorne Ave. Oakland, CA 94609 (510) 204-4444

Auburn Faith Community Hospital 11815 Educations St. Auburn, CA 95602 (530) 885-7201

Benny Mckeown 1281 Fleming Ave San Jose, 95127 (408) 259-1983

California Prisons (916) 358-1900

Central California Women’s Facility P.O.Box 1501 Chowchilla, CA 93610-1501 (559) 665-5331 X 5040

Central Medical Center 2344 El CaminoReal Santa Clara, CA 95050 (408) 249-1212

Central Mental Health 2221 Enborg Lane San Jose, CA 95128 (408) 885-6550

Chanwell Clinic Dr. Abalos-Galito, Dr. A Chant, and Dr. Mandreza: 2690 S. White Rd. #10 San Jose, CA 95148 (408) 436-5588

Concord Health Center 3052 Willow Pass Concord, CA 94519 (925) 646-5502

Dr. Seed 909 Coleman Ave San Jose, 95110 (408) 277-1825

Dr. Sheila B Snyder Clinical Psychologist 230 California Ave. Suite 108 Palo Alto, CA 94306 (650) 327-1941

DNTN Mental Health 1075 E.Santa Clara Street San Jose, CA 95116 (408) 299-6175

East Valley Clinic 1993 Mckee Rd. San Jose, CA 95116 (408) 254-6333 FAX (408) 254-6484

Elmwood - Men's Attn.: Medical Health Information Clerk 701 S. Able St. Milpitas, CA 95035 (408) 957-5820

Elmwood - Women's Attn.: Medical Health Information Clerk 701 S. Able St. Milpitas, CA 95035 (408) 957-5832



El Camino Hospital 2500 Grant Rd. San Jose, CA 94040 (650) 940-7000

ESP 817 Enborg Ct. San Jose, CA 95128 (408) 885-6100 FAX (408) 885-3547

FairOaks Mental Hlt 660 South Fair Oaks Sunnyvale, CA 94086 (408) 991-4800

Fremont Hospital 39001 Sundale Dr. Fremont, CA 94538 (510) 574-4827

Folsom State Correctional Prison Folsom, CA 95630 (916) 985-2561

Foothills Family Medical Clinic 2448 Story Rd. San Jose, CA 95122 (408) 729-4282

Gardner Mental Health 195 East Virginia St. San Jose, CA 95112 408) 287-6200

Gilroy Mental Health 1215 First St. Gilroy, CA 95020 (408) 848-4442

Good Samaritan Hospital Health and Info Department 2425 Samaritan Dr., San Jose, CA 95124 (408) 559-2011 FAX (408) 559-2662

Good Samaritan Medical Group 656 Lincoln Ave. San Jose, CA 95101 (408) 278-3180

Highland Hospital 1411 East 31st Street Oakland, CA 94601 (510) 437-4800

Juvenile Hall Mental Health Unit 840 GuadalupePkwy San Jose, CA 95111 (408) 278-5823

Kasier-Santa Clara 710 Lawrence Expwy Santa Clara, 95051 (408) 236-6400

Kaiser-Santa Teresa 250 Hospital Pkwy. San Jose, CA 95119 (408) 972-3000

Las Plumas Mental Health 1650-K Las Plumas Ave. San Jose, CA 95133 (408) 729-5382

Los Gatos Community Hospital 815 Pallard Rd. Los Gatos, CA 95032 (408) 378-6131

Mariposa 9500 Malech Rd. San Jose, CA 95151 (408) 281-6555 FAX (408) 463-0337

N.County Mental Hlt. 231 Grant Ave. Palo Alto, CA 95133 (650) 321-5545

Napa State Hospital Health Information Management 2100 Napa Vallejo Hwy. Napa, CA 94558 (707) 253-5654

Narvaez Mental Health 614 Tully Rd. San Jose, CA 95111 (408) 299-4734

Neena Madireddy 12 N. White Rd. San Jose Ca, 95127 (408) 258-6820

O'Connor Hospital 2105 Forest Ave. San Jose, CA 95128 (408) 947-2500

Park Alameda Clinics 976 Lenzen Avenue San Jose, CA 95126 (408) 792-5680

Positive Pace Cl. 2400 Moorpark Suite #316 San Jose, 95128 (408) 885-5935 FAX (408) 585-4699 Att. Gloria Garcia

Puentes Clinic 2524 Enborg Lane San Jose, CA 95128 (408) 885-8546 FAX (408) 885-4055

Regional Medical Center 225 North Jackson San Jose, CA 95116 (408) 259-5000

San Francisco General Hospital 1001 Potrero Ave RM 2B San Francisco, CA 94110 (415) 206-5116

San Jose Medical Center 675 East Santa Clara Street San Jose, CA 95112 (408) 998-3212



29.18 Social Security Administered Disability Programs

29.18.1 Social Security Disability

Social Security can be administered through two programs:

(1) Social Security Disability Insurance Benefits Title II (SSDI), and

(2) Supplement Security Income Title XVI (SSI).

San Mateo County General Hospital 222 West 39th Ave. San Mateo, CA 94403 (650) 573-2655

San Quentin State Prison San Quentin, CA 94974 (415) 454-1465

Santa Clara Valley Medical Center 751 S. Bascom Ave San Jose, CA 95128 (408) 885-5000 FAX (408) 885-5170

Silver Creek Family Practice 1620 E Capitol Express Way San Jose, CA 95121 ((408) 494-7511

South Valley Clinic 90 Highland Ave. San Martin, CA 95046 (408) 686-2200

Stanford Medical Center RDS Correspondence 300 Pasture Dr. Room HC 032 Stanford, CA 94305 (650) 723-5072

Tulare District Hospital 869 Cherry Ave. Tulare, CA 92374 (209) 688-0821

UC Davis Medical Center 2315 Stockton Blvd. Sacramento, CA 95817 (916) 734-2011

UCSF Medical Center - Attn.: Medical Records 400 Parnassus Ave. Room A-68 San Francisco, CA 94143 (415) 476-1000

Ujima 2680 Zanker Rd. San Jose, CA 95134 (408) 928-1700

VA San Jose Attn.: Medical Records 80 Greatoaks BLVD San Jose, 95119 (408) 363-3000

Valley Health Center at Tully 500 Tully RD San Jose, 95111 (408) 817-1445 FAX (408) 817-1449

Washington Hospital 2000 Mowry Ave. Fremont, CA 94538 (510) 608-3203

Watsonville Community Hospital 75 Nielson St. Watsonville, CA 95076 (831) 724-4741

West Berkeley Family Practice 2031 6th St. Berkeley, CA 94710 (510) 704-6000

West Valley Mental Health 375 Knowles Dr. Los Gatos, CA 95030 (408) 356-2128



29.18.2 Title II (SSDI)

Title II (SSDI) criteria is as follows:

• Must be totally disabled.• Worked and paid FICA taxes for at least 20 of the 40 quarters before onset of

disability.

29.18.3 Title II (SSDI) Program Provisions

• Pays monthly benefits to claimant and eligible dependents.• Annual COLAs.• Medicare eligibility 24 months after onset date.• Protects retirement account.• Trial work period.

29.18.4 Title XVI (SSI)

Title XVI (SSI) criteria are as follows:

• Must be totally disabled• Must be indigent-single individual• Can not have more than $2000 in non-exempt resources• Spouses assets and income are deemed• Medicaid, and *CalFresh.

*CalFresh (Does not apply to the State California).



29.19Social Security Administration Offices & Liaisons

Social Security Administration Toll Free Number 1-800-772-1213

Master Files Oakland (501) 622-3296 or (510) 622-3506

Master Files Fresno (559) 440-5000

Master Files Roseville (916) 774-4100

Downtown San Jose (960) 280 S. First St., Room 244 San Jose, CA 95113 (866) 331-2305 FAX (408) 565-5255 Liaisons: Daniel Biller (866) 331-2305 x15907 and Janette Kallman (866) 331-2305

South San Jose Office (E41) 6140 Cottle Rd. San Jose, CA 95123 (888) 397-4823 FAX (408) 224-8863 Liaison: Lisa Tovar (888) 397-4823 Ext 14234

Mountain View Office (A83) 700 E. El Camino Real, Suite 350 Mt. View, CA 94040 (877) 319-0161 FAX (650) 961-5313 Liaison: Jacqui Dulis (877) 324-8199

East San Jose Office (385) 2500 Fontaine Rd. San Jose, CA 95121 (866) 931-4496 FAX (408) 291-4259 Liaisons: Esther Khon (866) 931-4496

Campbell Office (D38) 770 W. Hamilton Ave. Campbell, CA 95083 (866) 331-6997 FAX (408) 291-4688 Liaisons: Thuhang Nguyen (866) 331-6997 Ext 12702

Gilroy Office (561) 1059 First Street Gilroy, CA 95020 (877) 452-4198 FAX (408) 842-6734 Liaison: Gloria Rodriguez (877) 452-4198

29.19.1 Social Security Contacts

Social Security Administration Key Contacts:

• Downtown San Jose Office (408) 866-331-2305 Initial Claims and Reconsideration: Kunthea King

• East San Jose Office Contact - Irene Aldape-Percelle Irene will also schedule for : South San Jose Office - 6140 Cottle Rd., and Campbell Office - 770 W. Hamilton Ave.



29.20SSI Legal Assistance

If an SSI application is denied at the Initial and Reconsideration stages, the client will need legal representation for the Hearing stage.

29.20.1 Non-Profit Agencies

Asian Law Alliance 991 W. Hedding St., Suite 202 San Jose, CA 95126 (408) 287-9710

Bay Area Legal Aid 2 West Santa Clara St., 8th Fl P.O. Box 1840 San Jose, CA 95109 (408) 283-3700 (408) 850-7066

Mental Health Advocacy Project Santa Clara City Bar Assoc. Law Foundation 152 N 3rd St. San Jose, CA 95112 (408) 293-4790

Outreach 926 Rock Ave., Suite #10 San Jose, CA 95131 (408) 436-2865

Senior Adult Legal Assistance (SALA) 160 E. Virginia St., Suite #260 San Jose, CA 95112 (408) 295-5991 or 3140 Story Road San Jose, CA 95127 (408) 258-2753



29.20.2 Attorneys Who Practice Social Security Law

Note:This is not an endorsement of these attorneys or a comprehensive list that includes all attorneys who practice social security law.

Angelina Valle, Esq. 1671 The Alameda, Suite 302 San Jose, CA 95126 (408) 881-0200 FAX (408) 881-0208 Email: [email protected] Languages: English & Spanish

Terry LaPorte, Esq. 125 S. Market St., Suite1075 San Jose, CA 95113 (408) 293-8810 (800) 735-3425 FAX (408) 292-7673 Email: [email protected] Languages: English & Spanish

Health Advocates Avi Leibovic 901 Campesi Way Campbell, CA 95008 (408) 260-6860 FAX: (408) 260-8060 Email: [email protected] Languages: Cantonese, English, Spanish, Tagalog, & Vietnamese

Cynthia G. Starkey, Esq. 1153 Saratoga Ave San Jose, CA 95129 (408) 247-3454 FAX (408) 247-7954 Email: [email protected] Languages: English, Spanish & Vietnamese

The Carlo Law Group 1210 Park Avenue San Jose, CA 95126 (408) 292-2003 FAX: (408) 292-0350 Christopher Carlo: [email protected] Caroline Dant:[email protected] Daniel Saban: [email protected] Languages: English & Spanish

29.21Referrals

A referral to the SSI Advocacy Unit must be made through the online SSA Advocacy Referral process or form “SSI Advocacy Communication” (GA 16) when:

• The EW believes that the client would benefit from SSI Advocacy services

• The recipient is unable to comply with the SSI appeals process


• The client's SSI claim has been denied at the Reconsideration Level, or any other level

• There have been repeated denials of SSI for failure to follow through with the SSI process

• The recipient has been on GA (as an unemployable recipient) for a year or longer and has been denied for SSI

• The applicant/recipient is 64 years and 10 months of age or older, or

• Requested by the SSI Advocacy Unit.

Referrals to the SSI Advocacy Unit may be made by the EW. However, the SSI Advocacy Supervisor must screen all referrals.

29.21.1 On-Line Referral Process

SSI Advocacy Supervisor receives the printed Online Referral from clerical staff and:

• Reviews the reason for the referral (for example: GA Unemployable applicants/recipients claiming abuse).

• Assigns the referral to the appropriate SSI Advocacy Social Worker

• Forwards the assigned referral back to clerical staff for appropriate processing.

29.22 SSI Tracking Systems

29.22.1 SSI Advocacy Tracking System

The SSI Advocacy Web Application must be used for Tracking Applications and to ensure accurate case load listings.



29.22.2 CalWIN SSI Tracking System

The CalWIN Collect Individual SSI/SSP Detail window must be completed. This window is used to review, add, change or delete SSI/SSP details for all members of the household including excluded/members. There are two Tabs on this window:

• SSI/SSP Details tab - Used to collect and display detailed information related to the Individual’s application for and/or receipt of SSI/SSP benefits.

• Advocacy and Hearing Details tab - Used to collect and display details about the individual’s SSI/SSP hearing including information related to the SSI Advocacy. The information entered on this tab is for tracking purposes only and is not used by EDBC to determine eligibility.

Since current or past applications for, or receipt of, SSI/SSP benefits impacts the eligibility status of so many different Programs, it is vital that this information is entered correctly as follows:

Step Action

1. Click Intake & Case Maintenance Navigate CalWIN window.

2. Double-click the Data Collection heading in the “Action” group box.

3. Click on Display Individual Demographics Summary window:

• Enter the Case number.• Click [Open]. The Display Individual Demographics Summary

window appears with the Case Number and Name pre-filled.• Select the Name of the Individual for whom you wish to enter SSI/SSP

information.• Click the Detail Icon on the toolbar, or double click the highlighted

Name.

4. The Collect Individual Demographics Detail response window appears. Click the [SSI/SSP] button.

5. The Collect Individual SSI/SSP Detail response window appears with the SSI/SSP Details tab displayed. Complete the fields on this tab beginning with the:

• Effective Begin Date filed: Enter today’s date in this field.

6. Complete the Receiving field - Receiving [Y/N]:

• If you enter Yes it will discontinue the GA program.• If you enter No Continue.

7. Complete the Status field: Select Applied (regardless of actual Status).

(Chart page 1 of 2)



8. Complete the Status Date field: Enter the Actual SSI Application date.

9. Complete the Result field Drop down section:

• Approved (if selected):• For a GA case there is no impact.

Note: If the Result field is changed from Approved to another Result, the Receiving field MUST be changed to [N].

• Pending (if selected): There is no impact to the case.

• Denial (if selected): Continue to the next step.

Note: For GA cases when Denial is selected enter the actual reason for the Denial. CalWIN will NOT discontinue the GA Case.

10. Complete the Result Date field: Enter the Actual Date that Results were received.

11. Complete the Verification field: Select the appropriate verification from the drop down list.

12. Complete the Status Reason field:

• For the GA Program: Enter the actual reason from the drop down field, it will NOT discontinue the case.

13. Complete the Sources field:

• Use the actual Source from the drop down field.• Click the Save Icon in the tool bar.

Step Action

(Chart page 2 of 2)



29.22.3 SSDI and SSI Program Comparison:

SSDI SSI

Wage Earner must have sufficient work “quarters” of Coverage

• No work history is required• An individual may receive benefits 30

days after the date of application

From the date one becomes Disabled, there is a five-month waiting period prior to receipt of benefits

• No waiting period. • An individual may receive benefits 30

days after the date of application.

Provision for Payment up to 12 months before the date of application.

Paid on the first day of the month following the month of application.

Claimants may receive Retroactive Benefits up to one year before the date of application.

Retroactive benefits to the first day of the month following the month of application.

Only Worker’s Compensation or Other Federal or State Disability payments may affect payment level.

Any income (earned or unearned) affects benefits.

No resource limit • Resources must be below $2,000 for an individual.

• $3,000 Resource Limit for an eligible couple

Checks are paid one month in arrears, i.e. May 3 is recipients April check.

Checks are paid for the month in which they are received.

Eligible for Medicare 24 months after establishing eligibility for SSDI

In two-third of states, there is eligibility for Medicaid (Medi-Cal in California) if receiving even $1.00 of SSI benefits.

29.23Home/Field Visits

29.23.1 SSI Advocates Home/Field Visits

SSI Advocates must make periodic visits to the clients they serve. The purpose of these visits is to provide the Advocates with the opportunity to visually observe the clients within their environment in order for them to make a full assessment of their medical limitations.



SSI Advocates are also required to accompany the Eligibility and Vocational Services staff when necessary to provide assistance in the application process for those clients who are deemed severely disabled; and are unable to come into the office. Depending on the client’s needs, these visits can take place in the following locations:

• SSA offices• Attorneys office• Client’s Home• Homeless Shelter/Community Center/Parks• Hearing office• INS office• Doctors office/hospital/clinic• HUD office.

29.24Destination: Home

Destination: Home is a community-based organization that works with government and private agencies to create programs that will more effectively and efficiently address the needs of homeless men, women and families throughout Santa Clara County.

Destination: Home’s community-benefit partners developed and implemented a One Stop Homelessness Prevention Center and a medical respite facility. There are two locations in San Jose:

• The Georgia Travis Center - InnVision 297 Commercial Street, San Jose, CA 95112: Will help homeless families and those at risk of homelessness.

• Boccardo Reception Center - EHC LifeBuilders 2011 Little Orchard Street, San Jose, CA 95112: Offers services focusing on the chronic and street homeless population.

29.24.1 Referrals from One Stop Homelessness Prevention Center

The SSI Social Worker Lead will receive “SSI Advocacy Data Tracking Form” (DH 03) from the “Destination: Home” Intake Worker and will review the form. The SSI Social Worker Lead will also verify past history and case status in MEDS and



the SSI Advocacy Tracking System. The case will be assigned to the respective SSI Social Worker when necessary. [Refer to [Refer to “Accessing and Completing the SSI Advocacy Application System,” page 65-27 in the Common Place Handbook.]

29.25Medical Evaluations

29.25.1 Medical Releases/Disclosures

Due to Health Insurance Portability and Accountability Act (HIPAA) some hospitals and clinics only accept their own medical disclosure forms; these forms need to be signed by the client and then sent to the treating source to obtain medical records. If a medical facility has not provided their release form then use the generic release form that was especially prepared for us by County council.

The following hospital and clinics have provided us with their own releases forms, copies of which are available in the SSI Advocacy library:

• Santa Clara County Health and Hospital Systems including all the clinics• Kaiser Permanente• Veteran Affairs

29.25.2 Consultative Evaluations

Circumstances often arise where a first or second medical opinion is needed by the Social Security Administration or by SSI Advocacy Social Workers.

This may occur if the client’s medical sources cannot or will not give SSA sufficient medical evidence therefore SSA may ask a claimant to have one or more physical or mental examinations or tests. SSA will pay for any medical examinations arranged by them. Furthermore, reasonable notice of the date, time, and place will be given. If a client fails or refuses to go to a consultative evaluation without good reason, SSA may find that he/she is not disabled or blind. For additional information regarding Consultative Evaluations, please refer to Code of Federal Regulations Section 416.917-416.919t.


http://intranet.ssa.co.santa-clara.ca.us/calwin/calwin_bp/ga_ssi_advocacy_bp.pdf


The SSI Advocacy Social Worker can utilize the in house psychologist for mental health evaluations. However, for specialized physical tests or examinations the SSI Advocacy Social Worker must request a Director’s Exception, by following the steps outlined in the General Assistance Handbook, [Refer to “Director Exceptions for GA Clients,” page 29-31.]

29.26 Mental Health Applications

SSI Advocacy Social Work Supervisor receives out of office Mental Health applications. The application packet includes an Accommodation Request form; all is reviewed for completeness. The Packet is then assigned to an EW who calls Mental Health Advocate within three days from the date that the application was faxed.

29.26.1 Process for Three Day Accommodation Request

• Faxed copy of application packet is received by SSI Advocacy Social Work Supervisor that includes, SCD 41, GA1, SAWS 2, and Accommodation Request form.

• SWS/SW Lead reviews the application packet for completeness and gives it to the Administrative Assistant for assignment to the Information Supervisor.

• Information Supervisor assigns the application to an EW and gives packet to the appropriate clerical staff for entry into CalWIN.

• Clerical completes the Application Registration and Case Assignment processes in CalWIN and hands copy of the SCD 41 to the assigned EW. Ensures that all necessary paperwork is processed for scanning into IDM.

• EW calls the Mental Health Advocate within three days from the date that the application was faxed, and gives them an appointment to process the application.



29.27 Director Exceptions for GA Clients

29.27.1 Definition for Director Exceptions

Per County Policy [GA 113] as outlined in the GA Handbook [Refer to “Director’s Exceptions,” page 11-1], the Director of the Department may grant exceptions to the General Assistance (GA) policies to alleviate extreme hardship in emergency and unusual situations. A record of such exceptions shall be maintained by the Department. A decision by the Director on a request shall be final and not subject to appeal.

29.27.2 Categories

The Director of the Department (or designee) may approve a Director's Exception request if one of the following conditions exists:

• A sponsored non-citizen family is denied or discontinued from CalWORKs and the sponsor is not able to provide support.

• A destitute undocumented individual(s) is gravely physically or mentally handicapped (such as paraplegic, quadriplegic, or comatose)*

• An individual receiving GA Interim Assistance who requires psychiatric, psychological, and/or medical testing in order to establish disability for SSI.**

• A person is Permanently Residing In The United States Under Color Of Law (PRUCOL)

• A CalWORKs individual or family is a participant in the Family Wellness Court (FWC).

• A sponsored noncitizen is abused or abandoned by his or her sponsor.

*Social Workers in Advocacy can be called upon to assist with this type of request at the discretion of the SSPM. [Refer to “Gravely Disabled Undocumented Individual(s),” page 11-13] of the GA Handbook.

**This is the type of request SW in Advocacy will initiate most often for the disabled clients that need a specialized mental health or medical evaluation from an outside provider. Usually the service is not provided within the County Health and Hospital



System or the service is not accessible to the clients in a timely manner. All Director Exceptions have to be approved by Administration prior to the service being provided. [Refer to “Interim Assistance Testing,” page 11-15 of the GA Handbook.]



29.27.3 Process for Director Exceptions

The Social Worker completes “Request for Director’s Exception” (GA 5) according to the specifications in the GA Handbook, [Refer to “Forms,” page 11-2] Handbook, stating the reason for the payment and the cost. Following is the process:

The Social Worker:

• Completes the GA 5 form, justifying needed funds for the request• Secures an estimate from the treating source and includes it on the Directors

Exception• Sends the request to the Social Worker Supervisor who reviews and signs the

request.

The Social Worker Supervisor:

• Reviews the case for accuracy of payment and to insure that all necessary work has been completed

• Signs the request• Forwards it to the SSPM for approval

The SSPM:

• Reviews and signs the request and gives to the Administrative Assistant for processing.

29.28 Forms used in Filing and Developing a Case

Internal and external forms are required in filing and developing a case. The charts identify the most frequently used forms.



29.28.1 Internal Forms:

Form Number Description

GA 16 SSI Advocacy Communication Form

GA 17 SSI/Advocacy Case Data

SCD 165 On-line Referral for Services

SCD 169 Referral To/From Social Services

SSP 14 Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligiblity Payment

SCD 1400 GA-Request for Medical Information

SCD 1541 SSI Advocacy Unit Intake

None Kaiser Authorization for Medical Release or Disclosure

None Referral for Medical Service with Dr. Snyder on-site Psychologist

None VMC - Authorization for use and/or Disclosure of Protected Health Information.

29.28.2 External Forms:


SSA 561 U2 - Request for Reconsideration

SSA 827 Authorization to Disclose Information to the SSA

SSA 1696 U4 - Appointment of Representative

SSA 3368 BK The Initial SSI Application form or the Green Form

SSA 3441 Disability Report - Appeal

SSA 8011 Statement of Household Expenses and Contributions

SSA 8125 Notice of SSI Approval



29.28.3 Forms Used In Preparing To File An Initial SSI Claim:

FORMS COMPLETED


SCD 1541 SSI Advocacy Unit Intake

SSP 14 Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligiblity Payment.


SSA 3368 Disability Report Adult form

SSA 827 Authorization to Disclose Information to the Social Security Administration

SSA 1696 Appointment of Representative form, and

N/A Additional Medical Release form.

FORMS GATHERED


SCD 1521 Verification of Benefits

SSP 14 Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligiblity Payment


SSA 8011 Statement of Household Expenses, and

N/A Bank Statements.



29.28.4 Forms and Completion

The IAR process can only be accomplished if the recipient agrees to the repayment in writing. To be eligible every applicant must complete a reimbursement agreement. As a condition of eligibility an individual must be ineligible for SSI. Therefore, the following forms must be completed as follows:

• “Referral To/From Social Security” (SCD 169) MUST be completed for ALL applicants. An SCD 169 must also be completed at redetermination. [Refer to ““Referral To/From Social Security” (SCD 169),” page 33-3 of the GA Handbook].

• Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligiblity Payment (SSP 14). The SSP 14 is required for GA Interim Assistance (IA) cases to obtain reimbursement as of June 2008. The purpose of obtaining a signed SSP 14 is to recover from an individual's initial retroactive or post eligibility Supplemental Security Income (SSI) payment. Interim Assistance is the amount the county provides the individual for meeting basic needs while the individual's SSI application is pending or during the time the SSI benefits are suspended or terminated and subsequently reinstated. Therefore, it is vital that an SSP 14 be obtained and a copy is in IDM. Without a current copy, the County cannot recoup the IAR. [Refer to ““Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment” (SSP 14),” page 33-4 of the GA Handbook].

• “Notice of SSI Approval” (SSA 8125) is normally received by Financial Management Services-Accounts Receivable (AR) via SSA’s eIAR system and copies are forwarded for calculation/collection processing and to the EW for appropriate action to discontinue the client.



29.29 Case Filing

29.29.1 Case Structure

Flap Divider Item

1 Top Divider SSI Advocacy Communication Form (GA 16)

2 Top Divider SSI Advocacy Case Data Sheet

Bottom Divider

Permanent Verification (Driver’s License Green Card, Passport, Birth Certificate, INS data)

3 Top Divider Out going Mail (letters, e-mail’s memo’s and/or any kind of requests to client and/or any other party) also, out going FAX

Bottom Divider

Incoming Mail (letters, memo’s, CE notice, SCD1521, SCD 169 and SCD 523U forms except medical, psychological and special education records) and incoming FAX

4 Top Divider Appointment of Rep. SSA 1696 (Representative copy)

Bottom Divider

Medical Release Forms (original release forms that have been signed and retained for future use including SSA 827)

5 Top Divider Appeals Council (everything submitted when filing the claim)

Next Divider Hearings (everything submitted when filing the claim i.e. HA 501, and SSA-3441)

Next Divider Reconsideration (everything submitted when filing the claim, i.e. copies of ADL’s, SSA-561, and SSA-3441)

Bottom Divider

Initial Claim (everything submitted when filing the claim i.e. copies of ADL’s, SSA-3368, and SSA-8011)

6 Top Divider Miscellaneous (SCD 1257 Interpreters form and any other document that does not fit in any other flap)

7 Top Divider Medical Records (psychological records, special education school records, SCD 1400, doctor’s notes and etc.)



29.30Medical Eligibility Data System (MEDS)

29.30.1 Option List

The options listed below contains data for a client:

29.31Difference Between Medicare Vs. Medicaid

29.31.1 Medicare

Medicare is a Federal Health Insurance Program administered by Social Security Administration. It provides health insurance benefits to eligible persons age 65 or over, and to blind and disabled persons who have been entitled to Social Security disability (RSDI) or Railroad Retirement disability benefits for at least 24 consecutive months. A person in need of rental dialysis or a kidney transplant may also qualify for Medicare.

Code Definitions

Q1 MEDI-CAL/CMSP - Special 1 (GR/CAP)

QF Food Stamp

QA Address Information

QB BUY-IN and BENDEX

QD Change Dates and Authorized Rep. Information

QE Other Client's Eligibility Information

QP Pending/Denied Application and Appeals

QT BENDEX Title II Information

QX Title XVI - SSI/SSP

Q8 Food Stamp History (36 Months)

WA Worker Alert



Medicare is federally financed under Title XVIII of the Social Security Act which provides hospital insurance (Part A), health insurance (Part B), Medicare Advantage plans (Part C) and prescription drug coverage (Part D) for the aged, 65 and over, blind or disabled.

Medicare Parts:

(1) Part A is Hospital Insurance - Most people do not have to pay for Part A.

(2) Part B is Medical Insurance - Most people pay monthly for Part B.

(3) Part C is Medicare Advantage Plans - Medicare Advantage plans are offered by private insurance companies as an alternative to Original Medicare; plans are government subsidized and regulated.

(4) Part D is Prescription Drug coverage - Part D Plans are offered by private companies to provide coverage for prescription drug costs; plans are governmental subsidized and regulated.

29.31.2 Medicaid

Medicaid is a Federal Health Insurance Program administered by State agencies. The federal name is Medicaid (some states use this name). The single state agency in California is the State Department of Health Services (DHS) and that program is called Medi-Cal. Medi-Cal is the name of California’s federally mandated medical assistance program and the medical benefits available under that program.

This program pays for medical care received by persons and families whose resources are within certain limits. Persons and families with income above prescribed levels must pay or obligate the excess income toward the cost of medical care. The Medi-Cal program pays for the reminder of the program covered medical care received.

A person or family may be eligible for Medi-Cal under one of several programs. The scope of benefits available to a Medi-Cal beneficiary is a very complex subject. Eligibility to obtain a given Medi-Cal service depends on many factors such as diagnosis, prognosis, age, and medical necessity. The Medi-Cal regulations are found in Title 22, Divisions 3, of the California Administrative Code or refer to the Social Service Agency’s Medi-Cal Handbook.



29.31.3 Interface

SSI Advocacy Social Worker assigned to the client will periodically review the MEDS system to verify the client's SSI status. If after an appropriate “time period has passed” and our County Code 43 is NOT showing in the MEDS system, the social worker should contact the SSA office Claims Representative (CR) to find out what has happened. These cases should be brought to the attention of the SSI Advocacy Supervisor for the purpose of contacting the SSA liaison.



29.31.4 MEDS Payment Status Codes, Appeal Levels and Decision Codes

MEDS Payment Status Codes

StatusCode Definitions

Blank Disability determination or other verification is pending.

C01 Current Pay.

E01 Eligible for Federal and/or State benefits based on the eligibility computation, but no payment is due based on the payment computation.

E02 Eligible for benefits but not payable in that month due to the new application date.

H10 Hold, Living arrangement change in process.

H20 Hold, Marital status change is in progress.

H30 Hold, Resource change is in progress.

H40 Hold, Student change is in progress.

H50 Hold, Head of Household change is in progress.

H60 Hold, Pending receipt of date of death.

H70 Hold, Pending transmission of one-time payment data.

H80 Hold, Early input, disability determination pending.

H90 Hold, Systems Limitation involved. (No Longer applicable)

M01 Forced Payment case - Manually established, recipient may be in current payment or nonpayment status.

M02 Force due, case may be in current payment.

N01 Nonpay, Recipient’s countable income exceeds Title XVI payment amount and his/her State’s payment standard. Also used for 1619(b) participants.

N02 Nonpay - Recipient is inmate of public institution.

N03 Nonpay, Recipient is absent from U.S.

N04 Nonpay, Non-excludable resources exceed Title XVI limitations.

N05 Nonpay, Unable to determine if eligibility exists.

N06 Nonpay, Recipient failed to file for other benefits.

N07 Nonpay, Recipient’s disability ceased. Not disabled.



N08 Nonpay, Recipient’s blindness ceased. Not blind.

N09 Nonpay, Recipient refused vocational rehabilitation without good cause.

N10 Nonpay, Failure to comply with drug addiction treatment plan.

N11 Nonpay, Recipient refused treatment for alcoholism treatment plan.

N12 Nonpay, Recipient voluntarily withdrew from program.

N13 Nonpay, Not a citizen or an eligible alien.

N14 Nonpay, Aged claim denied for age.

N15 Nonpay, Blind claim denied. Applicant not blind. (No longer applicable)

N16 Nonpay, Disability claim denied. Not disabled. (No longer applicable)

N17 Nonpay, Applicant does not wish to pursue claim.

N18 Nonpay, Failure to cooperate.

N19 Nonpay, Recipient voluntarily terminated participation in SSI program.

N20 Nonpay, Recipient failure to provide required report or information.

N22 Nonpay, Claimant is an inmate of penal institution

N23 Nonpay, Claimant is not a legal resident of the United States

N24 Nonpay, Claimant has been convicted of a felony of fraudulently misrepresenting residence in two or more States, or administrative sanction for providing false or misleading statements to obtain benefits.

N25 Nonpay, Claimant is fleeing to avoid prosecution for, or custody or confinement after conviction for a crime which is a felony under the laws of the place from which he/she flees, or is violating a condition of probation or parole imposed under Federal or State law.

N27 Nonpay, Disability termination due to Substantial Gainful Activity (SGA)

N30 Nonpay, Slight impairment, medical consideration alone, no visual impairment.

N31 Nonpay, Capacity for SGA customary past work, no visual impairment.

N32 Nonpay, Capacity for SGA-other work, no visual impairment.

N33 Nonpay, Engaging in SGA despite impalement, no visual impairment.

N34 Nonpay, Impairment is no longer severe at time of adjudication and did not last 12 months, no visual impairment.

N35 Nonpay, Impairment is severe at time of adjudication but not expected to last 12 months, no visual impairment.

N36 Nonpay, Insufficient or no medical data furnished, no visual impairment.




N37 Nonpay, Failure or refusal to submit to consultative examination, no visual impairment.

N38 Nonpay, Applicant does not want to continue development of claim, no visual impairment.

N39 Nonpay, Applicant willfully fails to follow prescribed treatment, no visual impairment.

N40 Nonpay, Impairment(s) does not meet or equal listing (disabled child under age 18 only), no visual impairment.

N41 Nonpay, Slight impairment medical condition alone, visual impairment.

N42 Nonpay, Capacity for SGA, customary past work, visual impairment.

N43 Nonpay, Capacity for SGA-other work, visual impairment.

N44 Nonpay, Engaged in SGA despite impairment, visual impairment

N45 Nonpay, Impairment no longer severe at time of adjudication and did not last 12 months, visual impairment.

N46 Nonpay, Impairment is severe at time of adjudication but not expected to last 12 months, visual impairment.

N47 Nonpay, Insufficient or no medical evidence furnished, visual impairment.

N48 Nonpay, failure or refusal to submit to consultative examination, visual impairment.

N49 Nonpay, Applicant does not want to continue w/ claim, visual impairment.

N50 Nonpay, Applicant willfully fails to follow prescribed treatment, visual impairment.

N51 Nonpay, Impairment(s) does not meet or equal listing (disabled child under age 18 only), visual impairment

N52 Nonpay, Deleted from State rolls before January 1973 payment.

N53 Nonpay, Deleted from State rolls after 12/73 payment

N54 Nonpay, Unable to locate applicant.

N55 Nonpay, Impairment due to DAA, no visual impairment

N56 Nonpay, Impairment due to DAA, visual impairment

P01 Provisional, Possible reinstatement pending development of SGA

S01 Suspended, Suspension of payments due to report of death by Treasury.

S04 Suspended, System is awaiting disability determination (system generated).




S05 Suspended, SGA decision pending.

S06 Suspended, Recipient's address unknown.

S07 Suspended, Returned check for other than death, e.g., wrong address.

S08 Suspended, Representative payee development pending.

S09 Suspended,Temporary institutionalization suspense (system generated).

S10 Suspended, Adjudicative suspense; systems generated.

S20 Suspended, Potential rollback cases or disability made prior to July 1973 (inactive).

S21 Suspended, Recipient, presumptively disabled or blind, has received 6 months of payments.

S90 Suspended, PR1 change in process

T01 Terminated, Death of recipient.

T20 Terminated, Received duplicate payment under 2 different numbers.

T22 Terminated, Received duplicate payment under 2 different account numbers, termination resulted from electronic screening.

T30 Terminated, Manual termination (payment previously made). Change in record composition requires termination of existing record.

T31 Terminated, Systems generated termination (payment previously made).

T32 Terminated, Systems generated termination of a paid record.

T33 Terminated, Manual termination (previous payment made) will eventually replace T30.

T50 Terminated, Manual termination (no prior payment made).

T51 Terminated, systems generated termination (no prior payment made).




Appeal Levels:

Appeal Decision Codes:

[Refer to User’s Guide to State Systems Handbook, “Overview,” page 1-1 for more information.]

Code Definitions

A Appeals Council Review

C Court Activity

H Hearing

O Class Action

R Reconsideration

Code Definitions

AD Dismissed/Abandoned

FA Favorable/SSA Appealed

FC Full/Partially Favorable

FF Fully Favorable

FN Favorable/SSA not appealed

OT Closed: Other

PF Partially Favorable

T1 Dismissed: Claimant Deceased

UA Unfavorable/appealed by recipient

UF Unfavorable

UN Unfavorable/not appealed by recipient

WC Dismissed/Withdrawn

WD Dismissed: Withdrawn “MEDS/CDB Overview,” page 1-1

1D Dismissed: Can not be appealed

2D Dismissed: Filed by improper requestor

3D Dismissed: Filed late without good cause

4D Dismissed: Withdrawn



29.32 Closings

When closing an SSI Advocacy case the reason MUST always be documented appropriately in the Maintain Case Comments window of CalWIN and in the SSI Advocacy Tracking System. The entries must include the reason the case is being closed and the dates of SSI/CAPI approval, the level it was approved and when the approval was effective. For instance when closing a case that was approved at recon on 12/12/03. The case was approved effective 12/01/02, so the client will probably get retro money back to 12/01/02.

29.32.1 Closing Codes for SSI Advocacy Cases.

1. In the First Field of the SSI Advocacy Tracking System select one form from the list below:

• Approved for SSA/SSI Benefits• Death of Recipient• Recipient not eligible for Advocacy Services• Recipient no longer eligible for G.A• Loss of contact• Recipient moved out of county

2. In the Second Field select:

• Services Achieved• Services Not Achieved



29.33Glossary

The following are Glossary references for the purpose of the SSI Advocacy Program:

29.33.1 Appeals Council

The Appeals Council looks at all requests for review, but it may deny a request if it believes the hearing decision was correct. If the Appeals Council decides to review your case, it will either decide your case itself or return it to an administrative law judge for further review.

29.33.2 Affidavit of Support (I-134)

For sponsored noncitizens that entered the United States prior to 12/97, sponsors signed the “Affidavit of Support” (I-134). The deeming requirement under the old Affidavit of Support was limited to three years.

29.33.3 Affidavit of Support (I-864)

Any noncitizen that is sponsored and entered the United States on or after 12/19/97 will have an “Affidavit of Support” (I-864).

29.33.4 Blindness

Statutory blindness is central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which has a limitation in the field of vision so that the widest diameter of the visual field subtends an angle no greater than 20 degrees is considered to have a central visual acuity of 20/200 or less.

29.33.5 Cash Assistance Program (CAPI)

Assembly Bill (AB) 2779 established the Cash Assistance Program for Immigrants (CAPI) to provide cash assistance to aged, blind, and disabled immigrants who could no longer be eligible for the Supplemental Security Income/State Supplementary Payment (SSI/SSP) Program. The Cash Assistance Program for Immigrants (CAPI) is entirely state-funded.



29.33.6 Concurrent Claim

A claimant can apply for SSI and SSDI. They can also be approved for both the combination of benefits which will not exceed the full amount of an SSI award.

29.33.7 Consultative Examination (CE)

A Consultative Examination (CE) is a physical or mental examination performed by a treating source or another medical source including pediatrician, when additional information is needed (e.g., clinical findings, laboratory tests, diagnosis, and prognosis) to make a disability determination.

29.33.8 Credits (Social Security Credits)

Previously called “Quarters of Coverage.” As you work and pay taxes, you earn credits that count toward your eligibility for future Social Security benefits. You can earn a maximum of four credits each year. Most people need 40 credits to qualify for benefits. Younger people need fewer credits to qualify for disability or survivors' benefits.

29.33.9 Director’s Exception

The Director of the Department may grant exceptions to the General Assistance (GA) policies to alleviate extreme hardship in emergency and unusual situations.

29.33.10 Disability

The law defines disability as the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

29.33.11 Disability Insurance Benefits (DIB)

DIB (1st year) same as SSDI is State Disability Insurance (2nd year).



29.33.12 Hearing

If a claimant disagrees with the reconsideration decision, they may ask for a hearing. The hearing will be conducted by an administrative law judge who had no part in the first decision or the reconsideration of your case.

29.33.13 Initial Determination

This is a determination SSA makes about a client’s eligibility and/or a client’s continuing eligibility for benefits or about any other matter.

29.33.14 Interim Reimbursement Assistance Program (IAR)

Participation in the Interim Assistance Reimbursement Program allows the county to collect the General Assistance (GA) or Cash Assistance Program for Immigrants (CAPI) paid to (or on behalf of) a client who is found eligible for SSI/SSP. IAR is also known as “Interim Assistance Program” (IAP).

29.33.15 Medi-Cal

A joint federal and state program that helps with medical costs for people with low incomes and limited resources. It comes with SSI but not necessarily to SSDI recipients.

29.33.16 Medicare

A nationwide, federally administered health insurance program authorized in 1965 to cover the cost of hospitalization, medical care, and some related services for most people age 65 and over. For SSDI recipients.

29.33.17 Presumptive Disability

SSA may pay benefits before they make a formal finding of whether or not he/she is disabled or blind. In order to receive these payments, SSA must find that he/she is presumptively disabled or presumptively blind. SSA may make these payments for a period not longer than 6 months.



29.33.18 Reconsideration

Reconsideration is a complete review of a client’s claim by someone who did not take part in the first decision. All the evidence submitted when the original decision was made will be reviewed along with any new evidence.

29.33.19 Representative

Means an attorney who meets all of the requirements or a person other than an attorney who meets all of the requirements and who the client appoints to represent him/her in dealings with the Social Security Administration.

29.33.20 Representative Payee

If Social Security benefits or Supplemental Security Income are being received and the client becomes unable to handle his/her own financial affairs, after a careful investigation, SSA appoints a relative, a friend, or an interested party to handle his/her Social Security matters.

29.33.21 Social Security Benefits

Social Security Retirement (SSR) and Social Security Disability Insurance (SSDI) are based on a simple concept: while you work, you pay taxes into the Social Security system, and when you retire or become disabled; you, your spouse and your dependent children receive monthly benefits that are based on your reported earnings.

29.33.22 Sponsorship

A SPONSORED NONCITIZEN is a noncitizen whose entry into the United States was sponsored by a person, or a public or private agency or organization, which executed an affidavit of support or similar agreement on behalf of the noncitizen as a condition of the noncitizen's entry into the United States.

29.33.23 Substantial Gainful Activity (SGA)

The level of work activity used to establish disability. A finding of disability requires that a person be unable to engage in substantial gainful activity.



29.33.24 Supplemental Security Income (SSI)

A federally administered program (often with State supplementation) of cash assistance for needy aged, blind, or disabled persons. SSI is funded through the General Fund of the Treasury and administered by the Social Security Administration.

29.33.25 State Supplemental Payment (SSP)

State Supplemental payment-monies paid by the State of California in lieu of CalFresh. SSP is connected to SSI benefits.

29.33.26 Title II

Same as SSDI.

29.33.27 Title XVI

Same as SSI.

29.34Charts, Tables (appeal process, flow charts, etc.)

Use the SSI Chart Book [Refer to “SSI Payment Standard (January 1, 2014),” page 6-1] for charts/payment rates.


General Assistance Handbook SSI Advocacy 29. SSI Advocacy · Update 14-04 Revised: 04/09/14 General...

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Transcript of General Assistance Handbook SSI Advocacy 29. SSI Advocacy · Update 14-04 Revised: 04/09/14 General...