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2021 Lay Advocacy Training

ADVOCACY FOR SENIORS

A How-To Manual

 Download Bet-Tzedek-Manual-2021-Final.pdf

2021 Lay Advocacy Training June 16, 17, 23, 24

Presented by Bet Tzedek Legal Services, with Funding from the Los Angeles County Area Agency on Aging

Training and Manual Provided by Justice in Aging

ADVOCACY FOR SENIORS: A HOW-TO MANUAL 

This program is sponsored by Bet Tzedek Legal Services with funding from the Los Angeles County Area Agency on Aging. The organizers would like to thank the Agency for its generous support. This manual was prepared by Georgia Burke, Eric Carlson, Denny Chan, Amber Christ, Gerald McIntyre, Jenny Chung Mejia, TrinhPhan, Claire Ramsey, Anna Rich, and Tracey Gronniger, current and past attorneys from Justice in Aging, with assistance from attorneys from Bet Tzedek Legal Services.

ABOUT THE ORGANIZATIONS

Bet Tzedek Legal Services is a non-profit, public interest law center which provides free legal services to low- income residents of Los Angeles County. Bet Tzedek means “House of Justice” in Hebrew. Bet Tzedek serves persons of all racial, religious and ethnic backgrounds. Bet Tzedek is an agency of the United Way and of the Jewish Federation of Greater Los Angeles.

3250 Wilshire Boulevard, 13th Floor Los Angeles, CA 90010

323-939-0506

www.bettzedek.org

The Los Angeles County Area Agency on Aging (AAA) is a State-designated agency responsible for identifying unmet needs of older adults and functionally-impaired adults as well as planning, coordinating, and implementing programs that promote the health, dignity, and well-being of the County’s residents. The AAA contracts with agencies county-wide to deliver human services that promote independent lifestyles for seniors.

Los Angeles County Area Agency on Aging 3175 West 6th St.

Los Angeles, CA 90020 800-510-2020

https://wdacs.lacounty.gov/

Justice in Aging is a national organization that uses the power of law to fight senior poverty by securing access to affordable health care, economic security, and the courts for older adults with limited resources. Since 1972 we’ve focused our efforts primarily on fighting for people who have been marginalized and excluded from justice, such as women, people of color, LGBTQ individuals, and people with limited English proficiency.

Justice in Aging assists attorneys and other advocates, publishes newsletters, issue briefs and reports that speak to the legal rights of low-income older adults. Justice in Aging does not represent individual clients.

Table of Contents

CHAPTER ONE: SOCIAL SECURITY——————— 5

CHAPTER TWO: SUPPLEMENTAL SECURITY INCOME——————— 30

CHAPTER THREE: CALIFORNIA CASH ASSISTANCE

PROGRAM FOR IMMIGRANTS (CAPI)——————— 61

CHAPTER FOUR: MEDICARE——————— 68

CHAPTER FIVE: MEDICARE PART D——————— 106

CHAPTER SIX: MEDI-CAL——————— 137

CHAPTER SEVEN: IN-HOME SUPPORTIVE SERVICES——————— 163

CHAPTER EIGHT: QUALITY OF CARE IN LONG-TERM

CARE FACILITIES——————— 192

CHAPTER NINE: PLANNING FOR (AND DEALING WITH)

INCAPACITY——————— 200

CHAPTER TEN: KINSHIP CARE——————— 215

 

CHAPTER ONE: SOCIAL SECURITY

TABLE OF CONTENTS

INTRODUCTION——————— 5

SOURCES OF LAW——————— 7

LANGUAGE ASSISTANCE——————— 8

ACCOMMODATIONS FOR PEOPLE WITH VISUAL IMPAIRMENTS——————— 9

INSURED STATUS——————— 9

RETIREMENT BENEFITS——————— 10

SURVIVORS BENEFITS——————— 12

SOCIAL SECURITY DISABILITY INSURANCE——————— 12

SSA’S ADMINISTRATIVE APPEALS PROCESS——————— 15

GOOD CAUSE FOR LATE APPEAL——————— 16

OVERPAYMENTS——————— 16

SUPPLEMENTAL MATERIALS——————— 18

SUPPLEMENTAL MATERIALS 18

 

Introduction

SOCIAL SECURITY VERSUS  SUPPLEMENTAL  SECURITY INCOME  (SSI)

Both programs are administered by the Social Security Administration (SSA), an independent agency of the federal government.

Social Security is a social insurance program whose benefits are based on an individual’s work history or the work history of the individual’s spouse or parent(s). Social Security is funded by a payroll tax (FICA) paid on wages up

to $142,800 per year in equal amounts by employer (6.2%) and employee (6.2%) for all persons working in a job covered by Social Security. Need is not a factor in making benefit determinations.

Social Security is also referred to as Title II and as OASDI (Old-Age, Survivors, and Disability Insurance). Social Security is linked to Medicare eligibility as is discussed in Chapter 4.

Supplemental Security Income (SSI), on the other hand, is based on need. Work history is not required, with a limited exception for some immigrants. SSI is also referred to as Title XVI.

In California, anyone receiving SSI is automatically eligible for Medi-Cal.

SOCIAL SECURITY IS THE MOST IMPORTANT INCOME SOURCE FOR OLDER AMERICANS

Over 64 million people in the U.S. receive Social Security benefits.

  • SocialSecurity is the single largest source of income for half of married couples and over 7 in 10 unmarried Americans over age  Most of the rest are still working.
  • Forabout 1 in 4 people over age 65, Social Security provides at least 90% of their 
  • Among Asian-Americans receiving Social Security, 26% of married couples and 51% of unmarriedbeneficiaries over age 65 rely on Social Security for at least 90% of their 
  • AmongAfrican-Americans receiving Social Security, 35% of married couples and 58% of unmarried beneficiaries over age 65 rely on Social Security for at least 90% of their 
  • Among Hispanicsreceiving Social Security, 40% of married couples and 61% of unmarried beneficiaries over age 65 rely on Social Security for at least 90% of their 
  • Among unmarried women over age 65 receiving Social Security, 48% rely on Social Security for at least 90%of their 
  • WithoutSocial Security, dire poverty would be the fate of most people in 

SOCIAL SECURITY (OASDI)  AN INSURANCE PROGRAM SERVING SEVERAL PURPOSES 

  • Retirementbenefits including spousal and child benefits
    • 49million people
  • Survivorbenefits serving widow(er)s and children of deceased wage earners
    • 6million people
  • DisabilityInsurance
    • Over9 million disabled workers
    • Over1 million children of disabled workers

Proposal for Changes to Social Security

Under the latest (2020) projections, which do not include the impact of any proposed legislative change or the potential impact of the COVID-19 pandemic, the Social Security Trust Fund is expected to be depleted in 2035. After that, while benefits would still be paid, SSA would only be able to pay approximately three-fourths of a beneficiary’s scheduled benefit amount.

PROPOSED CUTS

Several different groups have seen the current political situation as an opportunity to make significant cuts to Social Security benefits.

One proposal would change the formula for calculating the annual cost of living adjustment (COLA) so that it would be slightly less each year. While this would have very little impact in the first years of retirement, it would have a major impact over time as retirees reach very advanced ages, since the reduction in the COLA would

be compounded each year. An additional problem with this proposal is that it compounds the problems with the existing COLA, which does not adequately reflect the increase in cost of living for retirees and people with

disabilities because they spend a much higher percentage of their income on health care, which is the sector of the economy with the highest rate of inflation.

There have also been a number of proposals to “increase the retirement age.” Advocates of increasing the retirement age often point to increases in longevity and assert the need for people to work longer. However, increasing the retirement age has no bearing on how long people actually work. The retirement age has already gradually increased from 65 to 66, and is continuing to increase to age 67. That increase has not caused people to work any longer, and it is unlikely that future increases would do so.

An increase in the retirement age is nothing more than a reduction in the amount of benefits that people will receive at whatever age they choose to start collecting benefits. People who begin receiving benefits today who are subject to the full retirement age of 66 will receive approximately 6% less than they would have received if the retirement age were still age 65. This is true whether they take early retirement and begin receiving benefits at age

62, or if they wait until age 70 or anywhere in between. If the retirement age is increased to age 70, as some propose, benefits will be almost one-third less than if the retirement age had remained at age 65.

PROPOSALS TO STRENGTHEN SOCIAL SECURITY 

While some people advocate reductions in benefit levels, still others note that benefit levels are already below the levels of a number of other developed countries and advocate for increases in benefits to more adequate levels. They note the reduction in savings and the disappearance of defined benefit pensions, as well as longer life expectancy for some populations and point out that, as a result, Americans in the future are going to rely on Social Security for a greater, not lesser, portion of their retirement income than they do now.

Advocates for strengthening Social Security also are seeking a change in the formula for calculating the COLA, but by moving to the CPI-E or Consumer Price Index for the Elderly, which is based on the living expenses of people age 62 and over. This formula includes out-of-pocket health care expenses, which are much higher for an older population, and would result in a higher annual increase than the current formula, which is based exclusively on the living expenses of the working age population.

Other benefit enhancements that have been proposed include:

  • A5% across-the-board benefit increase
  • An increasein the replacement rate for the lowest paid workers
  • Increasedwidow(er)’s benefits
  • Creatinga special additional monthly benefit for specific Social Security beneficiaries, including beneficiaries age 82 and older and SSI recipients who have reached full retirement age
  • Givingcredits for a certain number of years out of the paid workforce for family caregiving toward benefits
  • Raisingthe cap on the payroll tax or eliminating the cap altogether, so more wages are taxed

Sources of Law

  1. SocialSecurity Act – United States Code, Title 42,  401, et seq.
  2. SocialSecurity Regulations – Code of Federal Regulations, Title 20, Part 404 (Social Security) and Part 416 (SSI). Social Security regulations have the force of  However, be careful, because regulations often do not reflect the most recent changes in the Social Security Act.
  3. Social Security Rulings (SSRs) and Social Security Acquiescence Rulings (SSARs). SSRs are the SocialSecurity Administration’s interpretations of regulations and policy statements on important issues, usually related to disability determinations. SSARs are SSA’s statements of how it will apply a Court of Appeals decision with which it  SSRs and SSARs are published in the Federal Register and are binding at all levels within SSA, although they do not have the force of law.
  4. ProgramOperations Manual System (POMS). The POMS is unpublished, does not have the force of law, and is written in language which is often unintelligible to the  One would think, therefore, that it is of little importance. WRONG! This is the go-to resource for the people who work in the local Social Security office. It is the only comprehensive formulation of SSA policy with which they are most likely to have ready access. Thus, it is important for an advocate to know what the POMS has to say on a client’s issue.
  5. EmergencyMessages (EMs) are transmittals to SSA personnel explaining how to handle a particular  EMs have an expiration date.
  6. Program Circulars aresometimes issued on subjects where SSA policy is thought to require clarification. Unlike the other documents previously mentioned, Program Circulars are often difficult to obtain, and an advocate often has no way of knowing of their existence. However, once you learn of them, SSA is usually willing to provide a 

RESOURCES FOR ADVOCATES 

  1. ssa.gov– The Social Security Administration website is a wealth of useful information for advocates as well as for beneficiaries. It contains the Social Security Act, the regulations, SSRs, SSARs, POMS, and EMs.
  2. Social Security Handbook – This provides a comprehensive explanation in question-and-answer format ofthe programs administered by SSA. It is written in easy-to understand-language. https://www.ssa.gov/OP_ Home/handbook/handbook-toc.html
  3. UnderstandingSupplemental Security Income – This is a useful booklet published by the Social Security Administration, which provides a comprehensive explanation of the SSI program in question-and-answer  It is available on the SSA website. www.ssa.gov/ssi/text-understanding-ssi.htm

Language Assistance

SSA policy is clear that it will provide an interpreter free of charge for anyone who prefers to do business with the agency in a language other than English. The same policy applies for deaf individuals as well. However, SSA field offices vary greatly in how well they apply that policy. The SSA policy on interpreters also applies to the state agencies that make disability determinations for SSA. SSA has a multilingual gateway to its website with a large quantity of useful informational material in 12 different languages and American Sign Language: https://www.ssa. gov/site/languages/en/. While SSA is a leader among federal agencies in its policy on oral interpretation services, its implementation on the ground varies greatly from one local office to another.

SSA staff should never ask someone to bring her own interpreter or bring a family member to interpret. Of course, if an individual prefers to have a family member or friend serve as the interpreter, that is her right as long as the friend or family member is an adult, is proficient in English as well as the other language and understands the obligations of an interpreter. If the individual is applying for disability benefits, it is also important that the interpreter be familiar with medical terms in both languages.

When it comes to written notices affecting an individual’s benefits, the agency is sadly lacking. SSA notices are consistently provided only in English, and often, but not always, in Spanish. Written notices are never provided in any other language.

Accommodations for People with Visual Impairments

Approximately 3,000,000 people who receive Social Security and/or SSI benefits are blind or visually impaired.

Most of them are over the age of 80. Some of them rely on a sighted spouse or other household member to read important communications for them. However, many of them live alone and are unable to read printed material in a standard font.

As the result of a lawsuit, the Social Security Administration has changed its previous policy of refusing to communicate with people who are blind in an accessible format. They now offer to send letters and notices to people with visual impairments in any one of a number of formats. In each case, the selected format will be accompanied by a standard print version. The alternative formats offered are:

  • MicrosoftWord compact disc
  • Braille
  • Largeprint (18 point font)
  • AudioCD
  • Standardprint notice by certified mail
  • Standardprint notice by first class mail with follow-up phone call within 5 days (NOT RELIABLE) An individual can choose a preferred format at ssa.gov/notices.

Insured Status

Benefits Available – Old-Age, Survivors, and Disability Insurance (OASDI) benefits include retirement benefits, disability benefits, dependents benefits, and survivors benefits.

Fully Insured Status – In general, OASDI benefits require that the wage earner be “fully insured” at the time of retirement, disability, or death. Some survivors benefits are an exception to this rule.

As a general rule, an individual is “fully insured” if she has 40 “quarters” of credit in covered employment. Lesser amounts are required for those born before 1929 or who are under 31 years of age. There are some other minor exceptions as well.

“Quarters” – The use of this term is misleading. It has nothing to do with calendar quarters, as one might think. It simply refers to a dollar amount that one must earn in a calendar year to obtain a credit for that year, with four being the maximum number of credits one can earn in a given year. The amount required to earn a “quarter” is indexed and thus normally changes from year to year. In the year 2021, wages of $1,470 are required for one “quarter” of coverage. A chart for calculating quarters of coverage is included at the end of this chapter. (See page 20).

AMOUNT OF BENEFITS

 Social Security Statement – Until 2011, a Social Security Statement was mailed out to wage earners over age 25 about three months before their birthday. The Statement contained useful information as to potential benefits

and also stated the amount of wages for which the wage earner was being given credit. In 2011, the mailing of the Statement was ceased as a cost-saving measure. It has been resumed, but only for people age 60 and over who are not yet receiving benefits and do not yet have a “my Social Security” online account. In May 2012, SSA announced the availability of the Social Security Statement online, https://www.ssa.gov/myaccount/statement.html. A sample statement is included at the end of this chapter. (See page 22).

Retirement Estimator – The SSA website has a retirement estimator (https://www.ssa.gov/benefits/retirement/ estimator.html) that can be used to calculate projected benefits for individuals who have enough Social Security credits to qualify for benefits and do not have a pension for work not covered by Social Security; i.e., certain state and municipal workers. However, unlike the Social Security statement, it does not calculate disability or other benefits and does not display year by year covered wage history.

IMMIGRANT ELIGIBILITY

 Undocumented immigrants are no longer eligible for Social Security benefits unless they filed an application before December 1, 1996. Immigrants filing on or after that date must show that they are “lawfully present” in the United States.

Retirement Benefits

A fully insured individual is entitled to collect full retirement benefits at age 66, whether still working or not.

There is no longer an earnings test for receipt of retirement benefits for those over age 66.

EARLY RETIREMENT

An individual can begin to receive retirement benefits at age 62 if she is fully insured on that date. However, her benefit level is reduced permanently proportional to the number of months before her full retirement age.

The age for early retirement has not been increased. However, as full retirement age increases, the reduction for early retirement will be greater. For example, when full retirement was at age 65, retirement at age 62 meant a 20%

permanent reduction in the benefit level. However, for those whose full retirement age is age 66, retirement at age 62 means a 25% permanent reduction. And for those whose full retirement age is 67, retirement at age 62 means a 30% permanent reduction.

What is the age at which one begins collecting benefits in order to maximize lifetime benefits?

Earnings Test for Early Retirement – It is important to remember that the earnings test remains in effect for those who choose early retirement. Benefits are reduced $1 for every $2 of gross earnings that exceed $18,960 per year until January 1 of the year in which the beneficiary reaches full retirement age. If the beneficiary reaches full retirement age in 2021, benefits are reduced $1 for every $3 of gross earnings that exceed $4,210 per month in the months prior to reaching full retirement age. These exempt amounts are indexed. The earnings test no longer applies beginning with the month in which the beneficiary reaches full retirement age.

What can be done to avoid the potentially disastrous reduction in benefits that comes with early retirement?

SPOUSAL  BENEFIT

A spouse age 62 or older who is at least in their twelfth month of marriage can receive benefits on their retired spouse’s account in an amount equal to one-half the wage earner’s benefit, unless the benefit to which they are entitled on their own account is higher. A divorced spouse is also eligible for the spousal benefit if the following additional requirements can be met: 1) the marriage must have lasted for a minimum of ten years, 2) at least two years have elapsed since the divorce, and 3) the individual seeking spousal benefits has not remarried.

Who Qualifies as a Spouse? As a result of recent Supreme Court decisions, the same marital recognition rules apply for both same-sex and opposite-sex couples.

  • DomesticPartnership – California Registered Domestic Partnerships, regardless of whether between same- sex or opposite-sex couples, are recognized as a marriage for purposes of the Social Security Act. However, this is not true of all domestic partnerships. It depends on the state of or nation in which the domestic partnership was entered  For example, a New York domestic partnership is not recognized by Social Security.
  • CivilUnions – Here too recognition of the relationship depends on the jurisdiction in which the civil union was entered  For example, an Oregon civil union is recognized for Social Security, but a French civil union is not.

OTHER DEPENDENTS

The child of a Social Security beneficiary may also qualify for benefits on the retired parent’s account if they are unmarried and (1) under age 18, (2) age 18 to 19 years old and a full-time student (no higher than grade 12), or (3) an adult child with a disability that started before age 22. A spouse under age 62 can receive benefits when caring for

the wage earner’s child under age 16. Unmarried stepchildren and grandchildren also may qualify if they are able to demonstrate dependency as defined by Social Security regulations.

Survivors Benefits

Spouse – Survivors benefits are payable to a surviving spouse or divorced spouse over the age of 60 of a deceased wage earner, who is not entitled to a higher benefit on her own earnings record and was married for at least 9 months (10 consecutive years in the case of a divorced spouse). There are a few specific limited exceptions to the

  • monthrule, and none to the 10-year rule for a divorced  The age requirement is 50 for a spouse who is able to establish disability under the Social Security disability standard.

Parents – The parent of a deceased wage earner who was dependent on the wage earner for support may be entitled to benefits if the parent is over age 62.

Children – Unmarried children of the deceased wage earner are entitled to benefits until age 18 (or up to age 19 if they are attending elementary or secondary school full-time). A surviving spouse of any age is entitled to benefits while caring for the deceased wage earner’s children under age 16.

Disabled Adult Children – Unmarried, disabled adult children of the deceased wage earner are entitled to benefits if the onset of disability occurred before age 22.

Currently Insured Status – It is possible to receive children’s benefits or disabled adult child’s benefits even if the decedent was not fully insured at the time of death, if the decedent had credits for 6 of the 13 consecutive quarters ending with the quarter of death. This is referred to as “currently insured” status. Currently insured status also is sufficient for receipt of benefits as a spouse caring for a child under age 16.

Social Security Disability Insurance

Social Security Disability Insurance is also often referred to as SSDI or simply DI. While SSDI accounts for only about 15% of all Social Security Title II beneficiaries, it accounts for the overwhelming majority of contested claims because an individualized disability determination must be made in each case.

In addition to the disabled worker, others who can receive benefits on the disabled worker’s earnings records include:

  • Thedisabled worker’s spouse or divorced spouse if over age 62,
  • Anunmarried child under age 18 (or between age 18-19 if child is a full-time student in a grade no higher than grade 12),
  • Anunmarried disabled adult child if the onset of disability was prior to age 22, and
  • Aspouse caring for a child, under age 16, who is entitled to 

Eligibility for SSDI – In order to receive SSDI, the individual must be: (1) disabled; (2) fully insured; and (3) “disability insured.”

“Disability Insured” Status – A person has “disability insured” status if she has worked 20 of the last 40 quarters preceding onset of disability. A special rule exists for individuals under age 31. SSA has adopted a five step

sequential evaluation process that the state agencies must use to determine if someone meets the disability standard mandated by the Social Security Act.

Increased Importance of SSDI for Older People – SSDI has assumed increased importance as an alternative to early retirement because of the increase in the full retirement age and the resultant greater reduction in benefits for early retirement. It also increased in importance because of the large number of wage earners over age 60 who lost their jobs in the recession with little prospect of finding new employment. These older individuals must still meet SSA’s disability standard to receive SSDI benefits.

SOCIAL SECURITY DISABILITY STANDARD

The adult standards for determining disability for SSDI, SSI, and Medi-Cal are all the same. However, the Social Security disability definition is different from the definitions used in other programs, such as the Americans with Disabilities Act (ADA), state disability insurance, or Veterans benefits.

The Social Security Act defines disability as:

“inability to engage in 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.”

The combined effect of a person’s impairments must be “of such severity that he is not only unable to do his previous work but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.”

STATE AGENCIES MAKE DISABILITY DETERMINATIONS

State agencies make all initial and reconsidered disability determinations, subject to appeal to SSA. In California, it is the California Department of Social Services Disability Determination Service Division (DDSD) that makes these disability determinations.

SEQUENTIAL EVALUATION PROCESS 

SSA has adopted a five-step sequential evaluation process that the state agencies must use to determine if someone meets the disability standard mandated by the Social Security Act.

  • Step One – Is the claimant currently working and, if so, are they engaging in “substantial gainful activity(SGA)?” If the answer is yes and the claimant is engaging in SGA, the evaluation process comes to an end and the claim is  If the answer is no, then the evaluation proceeds to Step Two.
    • SGA is determined by reference to gross wages unless there is a subsidy or special circumstanceinvolved and the amount paid does not fully reflect the work performed by the  In that case, the subsidy is subtracted from gross wages to determine whether the claimant is engaged in SGA.
    • Also,if the individual has Impairment Related Work Expenses (IRWE), then those expenses are subtracted from gross wages to determine if there is 
  • Whatis SGA? SSA uses an earnings test to determine if work activity constitutes  For work done in 2021, earnings of $1,310 per month ($2,190 for blind people) indicate SGA. This amount is changed annually to reflect the change in average wages.
  • StepTwo – If the claimant is not engaging in SGA, the next question is whether they have a “severe” medically determinable impairment or combination of medically determinable  If the answer is no, the claim is denied. If the answer is yes, then the evaluation proceeds to Step Three.
    • Theseverity test is a relatively minimal  It requires that the impairment or combination of impairments “significantly” limits the “physical or mental ability to do basic work activities.” Where there is a combination of impairments, it is not necessary that any single one be “severe,” only that the combination of impairments be “severe.”
  • ClaimantsAge 72 or Over – SSA has issued special instructions for claimants applying for SSI who are age 72 or  For anyone age 72 or over with a medically determinable impairment, there will be no need to show that the impairment is severe. Severity will be presumed.
  • StepThree – If the claimant has a severe impairment or combination of impairments, the next step is to see if the impairment meets or equals a listing in SSA’s Listing of  If the impairment meets or equals a listing, then the claimant is disabled. If not, the evaluation proceeds to Step Four.
  • Whatis the Listing of Impairments? The Listing of Impairments is a list of impairments with specific detailed medical criteria for each disease or  If these criteria are met or equaled, it is assumed that there will be functional limitations to such a degree that a person will not be able to work regardless of age, education, or work experience.
  • StepFour – The question at Step Four is whether the claimant retains the residual functional capacity to return to past relevant  If the answer is yes, then the claim is denied regardless of whether the work is available or even exists in the national economy. This step can pose a particular problem for immigrants whose previous job in another country may not exist in the United States.
  • Step Five – If the claimant cannot return to past work, the next and final step is to determine, takinginto account the claimant’s age, education, and work experience, whether there are other jobs which exist in significant numbers in the economy that the claimant can  This is the step at which age is an advantage. SSA assumes that the older a person is, the more difficult it will be for them to adjust to a new job. Thus, it is far more likely that a claim will be allowed for a claimant of “advanced age” (55 or over) at this step than it is for a “younger individual” (under age 45).

CONTINUING DISABILITY REVIEWS (CDRS)

Anyone receiving SSDI or SSI Disability is likely to be subject to Continuing Disability Reviews (CDRs) to determine if she still is disabled and should continue to receive benefits. The frequency of CDRs depends on the nature of the impairment and whether improvement is expected. Unlike the initial application process where the burden is on the individual to show disability, in the CDR context the burden is on the agency to show that there has been medical improvement related to the ability to work since the initial determination was made, and that the individual no longer meets the disability standard.

CDRs are conducted by the state agency (DDSD in California). If DDSD determines that the individual is no longer disabled and that benefits should cease, a hearing can be requested before a disability hearing officer at the state agency. If the state disability hearing officer affirms the determination that the claimant is no longer disabled, the decision can be appealed to a Social Security Administration Administrative Law Judge (ALJ). In medical cessation cases the claimant has a right to continue receiving benefits through the ALJ decision, if the determination is appealed within ten days from receiving notice of the adverse determination. An additional five days are allowed for mailing.

Return to Work – If an SSDI beneficiary returns to work, earnings must be reported to SSA. However, full benefits are paid for a trial work period which continues until the beneficiary has completed nine (not necessarily consecutive) months with earnings of at least $940 per month, after deduction of impairment-related work expenses (IRWEs). After the Trial Work Period, there is a 36-month period of extended eligibility. During this period, the beneficiary can receive benefits for any month in which earnings fall below the SGA level ($1,310 in 2021).

SSA’s Administrative Appeals Process

SSA has a four-step administrative appeals process. It applies to both Social Security and SSI.

  • StepOne: Initial Determination – The initial determination is made in the SSA District Office, except disability determinations which are made in the state agency (DDSD in California). The individual should receive a written notice of that determination advising her that she has 60 days (SSA allows another five days for mailing) in which to appeal.
  • Step Two:Reconsideration – This step also takes place at the District Office (or DDSD in the case of disability determinations) or a regional program  For all Social Security cases, except appeal of an adverse decision on a continuing disability review (CDR) or on a request for waiver of recovery of an

overpayment, reconsideration comes in the form of a “case review.” Different procedural options exist for some SSI cases.

  • A “case review” is a review of the paper record and does not involve a personal appearance or anopportunity to present  The percentage of claimants who win at this stage is quite low.
  • In the case of an appeal from a CDR decision, there is a right to an oral hearing at DDSD.Continued benefits are paid pending the hearing decision if the beneficiary requests the hearing within ten days (plus five days for mailing) of the notice of an adverse CDR 
  • StepThree: Administrative Law Judge (ALJ) Hearing – If the claim is denied on reconsideration, the individual has 60 days (plus five days for mailing) to further appeal to the Social Security Administration’s Office of Hearings Operations (OHO). This time, it will be for an evidentiary hearing before an Administrative Law Judge (ALJ). At the ALJ hearing, the claimant can present witnesses and can request the

ALJ to subpoena witnesses and documents. This step is the same for all types of appeals. In medical cessation cases, benefits continue through the ALJ decision if the appeal from reconsideration is filed in time.

  • Unlike reconsideration, a high percentageof cases get reversed at this stage of the process. Most claimants are (and should be) represented by counsel at the ALJ  It is extremely important that all relevant issues be raised at the ALJ hearing, as it may not be possible to raise additional issues later in the process.
  • ALJs,although employed by SSA, have a great deal of independence from the  Unlike the people who make initial and reconsideration decisions, they are not bound by the POMS or other subregulatory statements of agency policy. They are, however, bound by SSA regulations.

The overwhelming majority of cases that reach the ALJ stage of appeal and beyond are disability determination cases. As a result, this is the area in which ALJs have the greatest degree of expertise. Their knowledge may be comparatively lacking when it comes to other issues that may reach an ALJ.

  • StepFour: Appeals Council – A claimant has 60 days (plus five days for mailing) to request the Appeals Council review of an adverse ALJ  Review by the Appeals Council is discretionary and in the overwhelming majority of cases they simply deny review. Although it does not happen often, the Appeals Council can also take a case on “own motion” review to review an ALJ decision that was favorable to the claimant. The Appeals Council is the last step within the SSA administrative appeal process.

Good Cause for Late Appeal

The Social Security regulations contain liberal good cause provisions for filing an appeal after the deadline has passed. These regulations apply at any stage, but most often come into play with respect to late requests for

reconsideration, often because the beneficiary did not understand the notice or did not understand the importance of acting in a timely fashion.

Common reasons for good cause for a late appeal include limited facility in English and cognitive or mental impairments that prevented the individual from either understanding the content of the notice or appreciating the importance of a timely appeal. The regulation contains a useful list of possible reasons for good cause, but it should be remembered that the list is not exhaustive. While the regulation is a good one, it should never be regarded as a substitute for timely filing an appeal. A copy of the good cause regulation for Social Security is included at the end of the chapter. (See page 28). The SSI regulation on good cause for late filing is identical.

Overpayments

An overpayment occurs when a beneficiary receives a greater amount of benefits than the amount to which she is entitled in a given month. Overpayments are relatively rare for Social Security beneficiaries, except for those who are receiving SSDI. For SSDI beneficiaries, the most common source of overpayment results from the continued payment of benefits when a beneficiary has returned to work, has exhausted the Trial Work Period, and is engaged in Substantial Gainful Activity (SGA). Overpayments also result when a beneficiary dies and the spouse or other family member continues to receive their benefits. Similarly, excess earnings in early retirement can result in an overpayment.

If the beneficiary disputes either the existence or amount of the overpayment, the assessment of the overpayment can be appealed through SSA’s administrative appeals process. If, on the other hand, the beneficiary does not dispute the existence or amount of the overpayment and the amount of the overpayment is $1,000 or more, the best option for those who have the means to do so is simply to return the money. Unfortunately, most beneficiaries facing overpayments do not have the means to do that.

Another option is to request waiver of collection of the overpayment. There is a right to waiver if (1) the beneficiary was without fault, and (2) recovery would either (a) defeat the purpose of Title II or (b) be against equity and good conscience. Recovery is considered to defeat the purpose of Title II if the beneficiary uses substantially

all of her income to meet “ordinary and necessary living expenses,” and if resources are less than $3,000 for an individual or $5,000 for a couple, plus $600 for each additional dependent.

Also, if the amount of the overpayment is less than $1,000 and a waiver is requested, SSA generally will grant the waiver as a matter of administrative convenience.

Supplemental Materials

SOCIAL SECURITY ADMINISTRATION POSTER ON INTERPRETIVE SERVICES

QUARTERS OF COVERAGE UNDER TITLE II OF THE SOCIAL SECURITY ACT

Year Required Wages for One Quarter of Coverage Required Wages for Four Quarters of Coverage
2021 $1,470 $5,880
2020 $1,410 $5,640
2019 $1,360 $5,440
2018 $1,320 $5,280
2017 $1,300 $5,200
2016 $1,260 $5,040
2015 $1,220 $4,880
2014 $1,200 $4,800
2013 $1,160 $4,640
2012 $1,130 $4,520
2010-2011 $1,120 $4,480
2009 $1,090 $4,360
2008 $1,050 $4,200
2007 $1,000 $4,000
2006 $970 $3,880
2005 $920 $3,680
2004 $900 $3,600
2003 $890 $3,560
2002 $870 $3,480
2001 $830 $3,320
2000 $780 $3,120
1999 $740 $2,960
1998 $700 $2,800
1997 $670 $2,680
1996 $640 $2,560
1995 $630 $2,520
1994 $620 $2,480
1993 $590 $2,360
1992 $570 $2,280
1991 $540 $2,160
1990 $520 $2,080
1989 $500 $2,000
1988 $470 $1,880

 

Year Required Wages for One Quarter of Coverage Required Wages for Four Quarters of Coverage
1987 $460 $1,840
1986 $440 $1,760
1985 $410 $1,640
1984 $390 $1,560
1983 $370 $1,480
1982 $340 $1,360
1981 $310 $1,240
1980 $290 $1,160

Beginning January 1, 1978, and continuing, quarters of coverage (earning credits) are granted on the total wages for the calendar year.

Year Required Wages for One Quarter of Coverage Required Wages for Four Quarters of Coverage
1977

and earlier

$50 $200
  1. Wageshad to be earned during the calendar year quarter of credit (the 3 month period ending 3/31, 6/30, 9/30, 12/31), except for farmworkers who could earn it anytime during the 

WANDA WORKER

456 ANYWHERE AVENUE

MAINTOWN, USA 11111-1111 January 2, 2021

Your Social Security Statement

Are you thinking about retirement? Are you ready for retirement?

We have tools that can help you!

  • Estimateyour future retirement benefits

at socialsecurity.gov/estimator

  • Applyfor retirement, spouse’s,

Medicare, or disability benefits

at socialsecurity.gov/applyforbenefits

  • Andonce you receive benefits, manage your benefits at socialsecurity.gov

Your Social Security Statement tells you about

how much you or your family would receive

in disability, survivor, or retirement benefits. It also includes our record of your lifetime earnings. Check out your earnings history, and let us know right away if you find an error. This is important because we base your benefits on our record of your lifetime earnings.

Social Security benefits are not intended to be your only source of income when you retire. On average, Social Security will replace about

40 percent of your annual pre-retirement earnings. You will need other savings, investments, pensions, or retirement accounts to live comfortably when you retire.

To see your Statement online anytime, create a my Social Security account at myaccount.socialsecurity.gov.

Social Security Administration

Your Estimated Benefits

*Retirement You have earned enough credits to qualify for benefits. At your current earnings rate, if you

continue working until…

your full retirement age (67 years), your payment would be about………………………………………………..$ 2,061 a month age 70, your payment would be about ……………………………………………………………………………………….$ 2,561 a month

age 62, your payment would be about ……………………………………………………………………………………….$ 1,426 a month

*Disability You have earned enough credits to qualify for benefits. If you became disabled right now,

your payment would be about …………………………………………………………………………………………………..$ 2,027 a month

*Family If you get retirement or disability benefits, your spouse and children also may qualify for benefits.

*Survivors You have earned enough credits for your family to receive survivors benefits. If you die this year, certain members of your family may qualify for the following benefits:

Your child………………………………………………………………………………………………………………………………$ 1,520 a month Your spouse who is caring for your child …………………………………………………………………………………..$ 1,520 a month

Your spouse, if benefits start at full retirement age……………………………………………………………………..$ 2,027 a month

Total family benefits cannot be more than …………………………………………………………………………………$ 3,700 a month

Your spouse or minor child may be eligible for a special one-time death benefit of $255.

Medicare You have enough credits to qualify for Medicare at age 65. Even if you do not retire at age 65, be sure to contact Social Security three months before your 65th birthday to enroll in Medicare.

* Your estimated benefits are based on current law. Congress has made changes to the law in the past and can do so at any time. The law governing benefit amounts may change because, by 2035, the payroll taxes collected will be enough to pay only about 80 percent of scheduled benefits.

We based your benefit estimates on these facts:

Your date of birth (please verify your name on page 1 and this date of birth) April 5, 1961

Your estimated taxable earnings per year after 2018 ………………………………………………………………….. $52,769 Your Social Security number (only the last four digits are shown to help prevent identity theft)……… XXX-XX-1234

ow Your Benefits Are Estimated

To qualify for benefits, you earn “credits” through your work — up to four each year. This year, for example, you earn one credit for each $1,470 of wages or self-employment income. When you’ve earned $5,880, you’ve earned your four credits for the year. Most people need 40 credits, earned over their working lifetime, to receive retirement benefits. For disability and survivors benefits, young people need fewer credits to be eligible.

We checked your records to see whether you have earned enough credits to qualify for benefits. If you haven’t earned enough yet to qualify for any type of benefit, we can’t give you a benefit estimate now. If you continue to work, we’ll give you an estimate when you do qualify.

What we assumed — If you have enough work credits, we estimated your benefit amounts using your average earnings over your working lifetime. For 2021 and later (up to retirement age), we assumed you’ll continue to work and make about the same as you did in 2019 or 2020. We also included credits we assumed you earned last year and this year.

Generally, the older you are and the closer you are to retirement, the more accurate the retirement estimates will be because they are based on a longer work history with fewer uncertainties such as earnings fluctuations and future law changes. We encourage you to use our online Retirement Estimator at www.socialsecurity.gov/estimator to obtain immediate and personalized benefit estimates.

We can’t provide your actual benefit amount until you apply for benefits. And that amount may differ from the estimates stated above because:

  • Yourearnings may increase or decrease in the 
  • After you start receiving benefits, they will be adjustedfor cost-of-living 
  • Yourestimated benefits are based on current  The law governing benefit amounts may change.
  • Yourbenefit amount may be affected by military service, railroad employment or pensions earned through work on which you did not pay Social Security tax. Visit socialsecurity.gov to learn more.

Windfall Elimination Provision (WEP) — In the future, if you receive a pension from employment in which you do not pay Social Security taxes, such as some federal, state or local government work, some nonprofit organizations or

foreign employment, and you also qualify for your own Social Security retirement or disability benefit, your Social Security benefit may be reduced, but not eliminated, by WEP. The amount of the reduction, if any, depends on your earnings and number of years in jobs in which you paid Social Security taxes, and the year you are age 62 or become disabled. For more information, please see Windfall Elimination Provision (Publication No. 05-10045) at www.socialsecurity.gov/WEP.

Government Pension Offset (GPO) — If you receive a pension based on federal, state or local government work in which you did not pay Social Security taxes and you qualify, now or in the future, for Social Security benefits as a current or former spouse, widow or widower, you are likely to be affected by GPO. If GPO applies, your Social Security benefit will be reduced by an amount equal to two-thirds of your government pension, and could be reduced to zero. Even if your benefit

is reduced to zero, you will be eligible for Medicare at age 65 on your spouse’s record. To learn more, please see Government Pension Offset (Publication No. 05-10007) at www.socialsecurity.gov/GPO. 

Total Social Security and Medicare taxes paid over your working career through the last year reported on the chart above: 

Estimated taxes paid for Social Security:   Estimated taxes paid for Medicare:  
You paid: $73,110 You paid: $17,585
Your employers paid: $75,047 Your employers paid: $17,585

Note: Currently, you and your employer each pay a 6.2 percent Social Security tax on up to $142,800 of your earnings and a 1.45* percent Medicare tax on all your earnings. If you are self-employed, you pay the combined employee and employer amount, which is a

12.4 percent Social Security tax on up to $142,800 of your net earnings and a 2.9* percent Medicare tax on your entire net earnings.

*If you have earned income of more than $200,000 ($250,000 for married couples filing jointly), you must pay 0.9 percent more in Medicare taxes.

Help Us Keep Your Earnings Record Accurate

You, your employer and Social Security share responsibility for the accuracy of your earnings record. Since you began working, we recorded your reported earnings under your name and Social Security number. We have updated your record each time your employer (or you, if you’re self-employed) reported your earnings.

Remember, it’s your earnings, not the amount of taxes you paid or the number of credits you’ve earned, that determine your benefit amount. When we figure that amount, we base it on your average earnings over your lifetime. If our records are wrong, you may not receive all the benefits to which you’re entitled.

Review this chart carefully using your own records to make sure our information is correct and that we’ve recorded each year you worked. You’re the only person who can look at the earnings chart and know whether it is complete and correct.

Some or all of your earnings from last year may not be shown on your Statement. It could be that we still were

processing last year’s earnings reports when your Statement was prepared. Your complete earnings for last year will be shown on next year’s Statement. Note: If you worked for more than one employer during any year, or if you had both earnings and self-employment income, we combined your earnings for the year.

There’s a limit on the amount of earnings on which you pay Social Security taxes each year. The limit increases yearly.

Earnings above the limit will not appear on your earnings chart as Social Security earnings. (For Medicare taxes, the maximum earnings amount began rising in 1991. Since 1994, all of your earnings are taxed for Medicare.)

Call us right away at 1-800-772-1213 (7 a.m.–7 p.m. your local time) if any earnings for years before last year are shown incorrectly. Please have your W-2 or tax return for those years available. (If you live outside the U.S., follow the directions at the bottom of page 4.)

3

Some Facts About Social Security

About Social Security and Medicare…

Social Security pays retirement, disability, family and survivors

benefits. Medicare, a separate program run by the Centers for Medicare & Medicaid Services, helps pay for inpatient hospital care, nursing care, doctors’ fees, drugs, and other medical services and supplies to people age 65 and older, as well as to people who have been receiving Social Security disability benefits for two years or more. Medicare does not pay for long-term care, so you may want to consider options for private insurance. Your Social Security covered earnings qualify you for both programs. For more information about Medicare, visit www.medicare.gov or call 1-800-633-4227 (TTY 1-877-486-2048 if you are deaf or hard of hearing).

Retirement — If you were born before 1938, your full retirement age is 65. Because of a 1983 change in the law, the full retirement age will increase gradually to 67 for people born in 1960 and later.

Some people retire before their full retirement age. You can retire as early as 62 and take benefits at a reduced rate. If you work after your full retirement age, you can receive higher benefits because of additional earnings and credits for delayed retirement.

Disability — If you become disabled before full retirement age,

you can receive disability benefits after six months if

you have:

  • enough credits from earnings (depending on your age, youmust have earned six to 20 of your credits in the three to 10 years before you became disabled); and
  • aphysical or mental impairment that’s expected to prevent you from doing “substantial” work for a year or more or result in 

If you are filing for disability benefits, please let us know if you are on active military duty or are a recently discharged veteran, so that we can handle your claim more quickly.

Family  If you’re eligible for disability or retirement benefits, your current or divorced spouse, minor children or adult children disabled before age 22 also may receive benefits. Each may qualify for up to about 50 percent of your benefit amount.

Survivors  When you die, certain members of your family

may be eligible for benefits:

  • yourspouse age 60 or older (50 or older if disabled, or any age if caring for your children younger than age 16); and
  • your children if unmarried and younger than age 18, stillin school and younger than 19 years old, or adult children disabled before age 

If you are divorced, your ex-spouse could be eligible for a widow’s or widower’s benefit on your record when you die.

Extra Help with Medicare — If you know someone who is on Medicare and has limited resources and income, Extra Help is available for prescription drug costs. The Extra Help can help pay the monthly premiums, annual deductibles

and prescription co-payments. To learn more or to apply, visit www.socialsecurity.gov or call 1-800-772-1213 (TTY 1-800-325-0778).

Receive benefits and still work…

You can work and still get retirement or survivors benefits. If you’re younger than your full retirement age, there are limits on how much you can earn without affecting your benefit amount.

When you apply for benefits, we’ll tell you what the limits are and whether work would affect your monthly benefits. When you reach full retirement age, the earnings limits no longer apply.

Before you decide to retire…

Carefully consider the advantages and disadvantages of early retirement. If you choose to receive benefits before you reach full retirement age, your monthly benefits will be reduced.

To help you decide the best time to retire, we offer a free publication, When To Start Receiving Retirement Benefits (Publication No. 05-10147), that identifies the many factors you should consider before applying. Most people can receive an estimate of their benefit based on their actual Social Security earnings record by going to www.socialsecurity.gov/estimator. You also can calculate future retirement benefits by using the Social Security Benefit Calculators at www.socialsecurity.gov.

Other helpful free publications include:

  • RetirementBenefits (No. 05-10035)
  • UnderstandingThe Benefits (No. 05-10024)
  • YourRetirement Benefit: How It Is Figured (No. 05-10070)
  • WindfallElimination Provision (No. 05-10045)
  • GovernmentPension Offset (No. 05-10007)
  • IdentityTheft And Your Social Security Number (No. 05-10064)

We also have other leaflets and fact sheets with information about specific topics such as military service, self-employment or foreign employment. You can request Social Security publications at our website, www.socialsecurity.govor

by calling us at 1-800-772-1213. Our website has a list of frequently asked questions that may answer questions you have. We have easy-to-use online applications for benefits that can save you a telephone call or a trip to a field office.

You also may qualify for government benefits outside of Social Security. For more information on these benefits, visit www.benefits.gov.

If you need more information  Visit www.socialsecurity.gov on the Internet, contact any Social Security office, call

1-800-772-1213 or write to Social Security Administration, Office of Earnings Operations, P.O. Box 33026, Baltimore, MD 21290-3026. If you’re deaf or hard of hearing, call TTY 1-800-325-0778. If you have questions about your personal information, you must provide your complete Social Security number. If your address is incorrect on this Statement, ask the IRS to send you a Form 8822. We don’t keep your address if you’re not receiving Social Security benefits.

Form SSA-7005-SM-SI (01/21) 4

Thinking of retiring?

www.socialsecurity.gov

Some things to consider

etirement can have more than one meaning these days. It

can mean that you have applied for Social Security retirement benefits or that you are no longer working. Or it can mean that you have chosen to receive Social Security while still working, either full or part-time. All of these choices are available to you. Your retirement decisions can have

very real effects on your ability to

maintain a comfortable retirement.

If you retire early, you may

not have enough income to enjoy the years ahead of you. Likewise, if you retire late, you’ll have a larger income, but fewer years to enjoy it. Everyone needs to try to find the right balance, based on his or her own circumstances.

We hope the following information will help you as you plan for your future retirement and consider your retirement options. 

What is the best option for you?

Everyone’s situation is different. That is why Social Security has created several retirement planners to help you decide what would be best for you and your family. Social Security has an online calculator that can provide immediate and accurate retirement benefit estimates to help you plan for your retirement.

The online Retirement Estimator is a convenient, secure, and quick financial planning tool. It uses your own earnings record information, thereby eliminating any need to manually key in years of earnings information. The estimator also will let you create “what if” scenarios. You can, for example, change your “stop work” date or expected future earnings to create and compare different

retirement options. To use the Retirement Estimator, go to our website at www.socialsecurity.gov/estimator.

There is one more thing you should remember as you crunch the numbers for your retirement. You may need your income to be sufficient for a long time, because people are living

longer than ever before, and generally, women tend to live longer than men. For example:

  • Thetypical 65-year-old today will live to age 83;
  • Onein four 65-year-olds will live to age 90; and
  • Onein ten 65-year-olds will live to age 

Once you decide on the best age for you to actually retire, remember to complete your application three months before the month in which

you want retirement benefits to begin.

It’s so easy to apply

online for benefits

The easiest way to apply for Social Security retirement benefits is to go online at www.socialsecurity.gov/ applyforbenefits. If you do not have access to the Internet, you can call 1-800-772-1213 (TTY number,

1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday, to apply by phone. You also can apply at any Social Security office. To avoid having to wait, call first to make an appointment.

Receiving benefits while you work

When you reach your full retirement age, you can work and earn as much as you want and still receive your full Social Security benefit payment. If you are younger than full retirement age and if your earnings exceed certain dollar amounts, some of your benefit payments during the year will be withheld.

This does not mean you must try to limit your earnings. If we withhold some of your benefits because you continue to work, we will pay you a higher monthly benefit amount when you reach your full retirement age.

In other words, if you would like to work and earn more than the exempt amount, you should know that it will not, on average, reduce the total value of lifetime benefits you receive from Social Security—and may actually increase them.

Here is how this works: after you reach full retirement age, we will recalculate your benefit amount to give you credit for any months in which you did

not receive some benefit because of your earnings. In addition, as long as you continue to work, we will check your record every year to see whether the additional earnings will increase your monthly benefit.

Many people can continue to work and still receive retirement benefits. If you want more information on how earnings affect your retirement benefits, ask for

How Work Affects Your Benefits (Publication No. 05-10069), which has current annual and monthly earnings limits, and is available on our website.

Retirement age considerations

Full retirement age

For persons born during the years 1943-1954, the full retirement age is 66. If you were not born in this period, you can find your full retirement age on page 2 of your Social Security Statement.

Retiring early

If you’ve earned 40 credits (credits are explained on page 2 of your Statement), you can start receiving Social Security benefits at 62 or at any month between 62 and full retirement age. However, your benefits will be reduced based on the number of months you receive benefits before you reach full retirement age.

If your full retirement age is 66,

benefits will be reduced:

25 percent at age 62;

20 percent at age 63; 13⅓ percent at age 64; or 6⅔ percent at age 65.

Delaying retirement

You may decide to wait beyond your full retirement age before choosing to receive benefits. If

so, your benefit will be increased by a certain percentage for each month you don’t receive benefits between your full retirement age and age 70. This table shows the rate your benefits increase if you delay retiring.

 

Year of birth Yearly increase rate

1941 – 1942 7.5%

1943 or later 8.0%

Rules that may affect

your survivor

If you are married and die before your spouse, he or she may be eligible for a benefit based on your work record. If you start benefits before your full retirement age,

we cannot pay your surviving spouse a full benefit from your record. Also, if you wait until after your full retirement age to begin benefits, the surviving spouse benefits based on your record will be higher.

Social Security Administration SSA Publication No. 05-10054 January 2019 (Destroy prior editions)

GOOD CAUSE FOR MISSING THE DEADLINE TO REQUEST REVIEW

Code Of Federal Regulations

  • 404.911.Good cause for missing the deadline to request review.
  • Indetermining whether you have shown that you had good cause for missing a deadline to request review we consider—
    • Whatcircumstances kept you from making the request on time;
    • Whetherour action misled you;
    • Whetheryou did not understand the requirements of the Act resulting from amendments to the Act, other legislation, or court decisions; and
    • Whetheryou had any physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) which prevented you from filing a timely request or from understanding or knowing about the need to file a timely request for 
  • Examplesof circumstances where good cause may exist include, but are not limited to, the following situations:
    • Youwere seriously ill and were prevented from contacting us in person, in writing, or through a friend, relative, or other 
    • Therewas a death or serious illness in your immediate family.
    • Importantrecords were destroyed or damaged by fire or other accidental 
    • Youwere trying very hard to find necessary information to support your claim but did not find the information within the stated time 
    • Youasked us for additional information explaining our action within the time limit, and within 60 days of receiving the explanation you requested reconsideration or a hearing, or within 30 days of receiving the explanation you requested Appeal Council review or filed a civil 
    • Wegave you incorrect or incomplete information about when and how to request administrative review or to file a civil suit.
    • Youdid not receive notice of the determination or 
    • Yousent the request to another Government agency in good faith within the time limit and the request did not reach us until after the time period had 
    • Unusual or unavoidable circumstances exist, including the circumstances described in paragraph (a)(4) ofthis section, which show that you could not have known of the need to file timely, or which prevented you from filing 

[45 FR 52081, Aug. 5, 1980, as amended at 59 FR 1634, Jan. 12, 1994]

CHAPTER TWO

SUPPLEMENTAL SECURITY INCOME (SSI)

TABLE OF CONTENTS

INTRODUCTION 30

ELIGIBILITY 31

FINANCIAL ELIGIBILITY 31

TRANSFER OF RESOURCES 36

SSI PROPOSALS 38

STATE LEVEL ADVOCACY 38

ADMINISTRATIVE APPEALS PROCESS 39

OVERPAYMENTS 39

CALFRESH ELIGIBILITY 40

IMMIGRANT ELIGIBILITY 42

SSI FOR SAME SEX COUPLES 44

ASSISTING INDIVIDUALS DURING THE PANDEMIC 45

SUPPLEMENTAL MATERIALS 46

Introduction

SSI BASICS

Supplemental Security Income (SSI), also known as Title XVI, is a federally financed, needs-based program administered by the Social Security Administration (SSA). SSI guarantees a minimum income level for people who are aged (65 and older), blind, or meet the Social Security disability standard with low incomes and resources.

The federal government provides $794 per month for an eligible individual and $1,191 for an eligible couple. This amount is adjusted annually and is known as the Federal Benefit Rate (FBR). There was a 1.3% increase in the federal Cost of Living Adjustment (COLA) in 2021 which resulted in increases of $11 per month for an eligible individual and $16 per month for an eligible couple from 2020 to 2021.

Some states supplement these amounts. Until April 30, 2009, California provided a $233 per month state supplement for aged and disabled individuals and a $568 per month supplement for aged and disabled couples. The state supplement has since been reduced to the current level of $160.72 per month for an individual and $407.14 for an eligible couple, which reflects a one-time state COLA of 2.76% in 2017. Thus, the current combined state and federal SSI benefit rate in California is $954.72 per month for an individual and $1,598.14 for an eligible couple.

Persons who are blind or lack access to adequate cooking or food storage facilities are paid a somewhat higher amount.

 
   

RELATED BENEFITS

Medicaid – Most states, including California, automatically provide Medicaid (Medi-Cal) to persons who qualify for SSI. These states do not make their own Medicaid eligibility determinations for SSI recipients.

In these states, SSA shares SSI eligibility information electronically with the state Medicaid agency. When an individual loses SSI eligibility, and, therefore, automatic Medicaid eligibility, the state Medicaid agency must redetermine Medicaid eligibility and provide due process, i.e., notice and the opportunity for hearing.

Food Stamps – In California, SSI recipients were previously not eligible for Food Stamps. As the result of a state policy change in 2019, SSI recipients are now eligible to receive Food Stamps.

Dependents – Unlike Social Security, the SSI program has no benefits for dependents.

Eligibility

OVERVIEW 

An applicant for SSI must meet several different eligibility criteria:

  • CategoricalEligibility – Age (65 years or older) or blindness or 
  • FinancialEligibility – Resource and income 
  • ImmigrantEligibility – Discussed later in this 
  • Residence -Residence in the United States is a requirement even for citizens, and residence in California is required to receive the California state 

Whether to Apply as a Couple or as an Individual – Don’t worry about this. SSA will make the decision for you. If you are married and living in the same household and both are over age 65 or disabled, you must apply as a couple. For information on recognition of domestic partnerships and civil unions for same sex and opposite sex couples, see p.19 of this chapter. Also, if you are living with another person and leading people to believe you are

married and both of you are over age 65 or disabled, then you must apply as a couple. On the other hand, if you are separated or if only one spouse is over 65 or disabled, then you must apply as an individual.

Financial Eligibility

RESOURCES 

Resources of an SSI recipient may not exceed $2,000 in “countable resources” for an individual or $3,000 for a couple.

What is a Resource? SSA Regulations define a resource as: “[C]ash or other liquid assets or any real or personal property that an individual . . . owns and could convert to cash to be used for his or her support and maintenance.”

How are Resources Counted? Resources are generally counted on the basis of the equity an individual has in the resource, i.e., market value minus encumbrances.

When are Resources Counted? Resources are counted only once a month on the first moment of the first day of the month. Resources held in the middle of a month are irrelevant, although a period of ineligibility may be imposed for transfer of a resource, as is discussed later in this chapter.

Excluded Resources – Certain resources are excluded and do not count toward the resource limit. A partial list of the principal exclusions follows. A list containing additional excluded resources with reference to the POMS section that describes each of them is attached to these materials. Resources that are not excluded are “countable resources.”

Because Medi-Cal eligibility rules must track SSI eligibility rules, these exclusions must apply to Medi-Cal eligibility also. See Chapter 6, infra.

  • Home – The home in which the SSI recipient resides and all contiguous land is excluded, regardless of value.However, if the recipient lives elsewhere, the home is  If the recipient has the intent to return to

the home — no matter how unrealistic the intent — the home still is excluded. This rule is important for a resident of a residential care facility or a nursing facility who is prevented from moving home by a medical condition. The “intent to return home” also is discussed in Chapter 6, the Medi-Cal chapter.

  • Automobile– One automobile is excluded regardless of 
  • Personalor Household Goods – No limit on 
  • BurialFunds and/or Life Insurance Policies – Up to $1,500 combined value of all burial funds together with face value of life insurance policies for the beneficiary or his/her  These funds must be separately identified and set aside. If the funds are used for another purpose, the individual may face a substantial overpayment.
  • Burial Plot– A burial plot is excluded regardless of  This is in addition to the burial funds.
  • JointlyOwned Property – Undue hardship – Jointly owned property is excluded where the sale would cause undue hardship to the co-owner because of loss of 
  • Past-due Social Security and SSI payments – These payments are excluded from resources for a nine-month 
  • EarnedIncome Tax Credit and Child Tax Credit – These payments are excluded from resources for twelve months, beginning with the month after 

For additional resource exclusions, see POMS SI 01130.050, infra p. 2-20.

Resource and Income Deeming – Deeming is when money or property of one person is considered available to another person.

There are three circumstances in which a portion of the income and resources of another person will be considered available to the SSI applicant regardless of actual availability. The formula for determining the amount of the income and resources available to the individual is different in each of the three circumstances.

  1. Spousal Deeming– The income and resources of an ineligible spouse living in the same household are deemed to the individual. It must be noted that spousal deeming does not apply when the spouses are  It should also be noted that spousal deeming applies only when one spouse is categorically eligible for SSI (aged, blind or disabled) and the other is not. If both are categorically eligible and they are living together, then they must apply as a couple.
  2. Parentto Child Deeming – The income and resources of a parent living in the household are deemed to the 
  3. Sponsorto Alien Deeming – Not all immigrants are  Deeming applies only to some sponsored immigrants, primarily those whose sponsors signed affidavits of support on or after December 1997. These “new affidavits” provide for sponsor deeming to continue until naturalization or until the immigrant has 40 quarters of covered employment, whichever comes first. Earlier affidavits of support provided for sponsor deeming for only a three-year period.

INCOME

Income for SSI purposes is a term of art. Income is defined in the SSI regulations as “anything you receive in cash or in kind that you can use to meet your needs for food and shelter.” In other words, if it cannot be used to obtain food or shelter, it is not income for SSI purposes.

Even if something is income under the SSI definition, it still might not be “countable income” under the SSI income counting rules. Only countable income affects SSI eligibility and the amount of the grant.

What is Not Income? SSA has compiled a long, but not exhaustive, list of items that are not considered to be income. Among the items on the list are:

  • Impairmentrelated work expenses (IRWEs);
  • Giftsof domestic airline tickets if they are not cashed in;
  • Assistancebased on need from a state or local government;
  • Proceedsof a loan;
  • Incometax refunds;
  • Replacementof income previously received;
  • Theportion of a grant, scholarship or fellowship used for tuition, fees, or other necessary educational expenses;
  • Billspaid directly to the supplier by someone else for goods or services other than food or shelter;
  • Receipts fromthe sale, exchange, or replacement of a resource, even if the sale price is higher than the purchase price;
  • Interestand dividend income on countable resources; and
  • Infrequentor irregular income – up to $60 per quarter of unearned income and $30 per quarter of earned 
 
   

How Much Income Is Allowed? In order to be eligible for SSI an individual cannot have more countable income than the SSI payment level applicable to the individual’s living arrangement. By far the largest category is that of aged or disabled individuals living independently with cooking facilities. The benefit rate [Federal Benefit Rate (FBR) + State Supplementary Payment (SSP)] and thus the maximum countable income allowed for these individuals is $954.72 per month. The benefit rate for similarly situated eligible couples is $1,598.14 per month. Charts containing benefit rates for other categories of SSI recipients in California are attached at p. 2-23.

When Is Income Counted? Income is counted on a monthly basis in the calendar month in which it is received.

Income for the current month determines eligibility for the month. Income from the previous two months will determine the amount of the benefit for the current month. This is retrospective monthly accounting or RMA. However, income in the first month of eligibility determines the amount of the grant for the first three months, except that non-recurring income in the first month will not be counted in the second and third months.

Types of Income – The Social Security Act divides income into two categories for SSI purposes – earned and unearned income. The distinction is of crucial importance because the two types of income are calculated separately and with very different rules.

Unearned Income – Unearned income is defined in Social Security regulations by what it is not, i.e., it is not earned income. Of those SSI recipients who have income, the overwhelming majority have only unearned income, and for the majority of those with unearned income, the only income they have is a Social Security benefit.

For those who have only unearned income, the calculation of countable income to determine SSI eligibility and benefit amount is very simple. In order to determine the individual’s countable income, simply take the individual’s unearned income for the month from all sources, except excluded income (as discussed on the following page) and subtract an unearned income disregard of $20. The result is countable income for the month.

EXAMPLE

Assume that Javier applies as an individual whose only other income is a $520 monthly Social Security check. Is he income eligible? If so, how much is his grant?

The answer to the first question is “yes.” He has total unearned income of $520. From this, subtract the $20 unearned income disregard. This yields total countable income for the month of $500. Since this amount is less than $954.72, he is eligible. The amount of the grant is determined by subtracting his countable income of $500 from the SSI payment level of $954.72, leading to an SSI grant of

$454.72 per month.

Change the facts for Javier. Assume that in addition to his Social Security check, he receives a $420 monthly pension check for a total monthly unearned income of $940. Is he still eligible?

The answer again is “yes,” because his countable income ($940 – $20) is only $920. Thus, he receives a monthly benefit of only $34.72. But, keep in mind he also gets automatic Medi-Cal eligibility with no share of cost deductible. Also, note that although he has two sources of unearned income, he only gets to use the $20 unearned income disregard once.

Change the facts again. Javier still receives his $520 a month Social Security retirement check. However, he has just married Josefina, who receives a $920 a month Social Security disability check. Are either of them entitled to SSI? If so, who? How much? Do you need more information?

Earned Income – A very small percentage of all SSI recipients have earned income, about 3%. For elderly recipients it is even smaller, about 1.3%. However, the rules for counting earned income are more generous than those for counting unearned income. The steps for calculating countable earned income are as follows:

  • StepOne – Add up all earnings for the month using gross 
  • StepTwo – Subtract any Impairment Related Work Expenses (IRWE), but only if the beneficiary is receiving SSI on the basis of disability or was receiving it on the basis of disability the month before reaching retirement 
  • StepThree – Subtract the earned income disregard of $65 per 
  • StepFour – Subtract the $20 income disregard, but only if the $20 has not already been applied to unearned 
  • StepFive – Divide the remaining amount by  The result is countable earned income.

EXAMPLE

Anna earns $1,785 in gross wages per month. She has no other income and has no Impairment Related Work Expenses. Is she eligible for SSI as an individual? If so, how much is her grant?

She is eligible, and is entitled to a grant of $104.72 per month. The calculations are: gross wages of

$1,785 minus earned income disregard of $65 equals $1,720, minus unearned income disregard of

$20 equals $1,700. $1,700 divided by 2 equals countable income of $850. Subtracting $850 from the monthly payment level of $954.72 leaves a monthly grant of $104.72.

Take another example. Harry is married to and lives with Wanda. Both are 75 years old. Harry does not work. The couple’s only income comes from Wanda’s job at Costco, where she earns $2,985 per month. Wanda has a disability which requires that she spend an additional $300 per month to go to and from work. Neither of them has ever received SSI before. Who, if anyone, is eligible for SSI?

From the start it is clear that either both or neither one is eligible. Why? Since both of them are categorically eligible (i.e., aged, blind, or disabled), and they are husband and wife living together, they must apply as a couple. The arithmetic shows that they are in fact eligible as a couple. First, since they qualify for SSI on the basis of age, they cannot subtract IRWEs even if she has such expenses.

Subtracting the $65 and $20 income disregards from her $2,985 in gross wages leaves $2,900. Dividing that by two leaves countable income of $1,450 per month. That means they are eligible for a

$148.14 SSI grant, because the monthly SSI/SSP grant standard is $1,598.14 for an eligible couple. Both are eligible for Medi-Cal without a share of cost.

In-Kind Support and Maintenance (ISM) – There are special rules for counting in-kind support and maintenance (ISM). One is the so-called one-third rule, and the other is the presumed value rule. Before discussing the two counting rules, there are two other important points to clarify. The first is that not everything received

in-kind is counted; only in-kind food and shelter, or that which can be used to obtain food and shelter. The second point is that items provided with the understanding that the individual will later repay do not constitute ISM. This is a loan. This most frequently occurs when a friend or relative helps out while the SSI application is

pending, although it also happens later after the individual is receiving benefits. However, the loan needs to be well- documented.

One-Third Rule – The one-third rule applies when the individual is living in the household of another and that person is providing the individual with both food and shelter. When this rule applies, an amount equal to one- third of the SSI Federal Benefit Rate ($794 ÷ 3 = $264.66, in 2021) is added to the individual’s countable income. This addition is made regardless of the actual market value of the food and shelter provided.

Many factual questions arise in the application of the one-third rule. For example, when a beneficiary is paying something to the owner or prime tenant of a house or apartment, if the amount is the beneficiary’s pro-rata share of expenses, then there is no in-kind support and maintenance. However, if the beneficiary is paying something less than the pro-rata share, then it is ISM, assuming that both food and shelter are provided.

Presumed Value Rule – The presumed value rule applies when there is in-kind support and maintenance but the rules for the one-third rule do not apply, i.e., (1) either food or shelter are provided but not both; or (2) the individual is not living in the household of the other person. Under the presumed value rule, the ISM will have a presumed value equal to one-third the FBR plus the $20 income disregard ($264.66 + $20 = $284.66, in 2021). This amount will be added to the individual’s countable income in calculating the amount of the grant, unless the individual can demonstrate that the actual value of the support is less. The ISM cannot be valued at a greater amount regardless of actual market value.

 

Transfer of Resources

INTRODUCTION 

The Foster Care Independence Act of 1999 added a transfer of resources penalty to SSI. The Act establishes a 36-month look-back period and a period of ineligibility of up to 36 months for the transfer of a resource for less than Fair Market Value (FMV). It is important that anyone receiving SSI or considering the possibility of applying for SSI within the next three years, consider this provision.

What Is A Resource? Anything that fits within the SSI resource definition is a resource for purpose of the transfer penalty.

How is the Penalty Period Calculated? The period of disqualification is calculated by dividing the uncompensated value of the resource by the monthly benefit rate applicable to the individual. The result when rounded down gives the number of months for which the individual is ineligible.

EXAMPLE

Zack, who is 80 years old, decided in May 2021 that he was no longer able to drive. He gave away one of his two cars to his grandson in that month. The car had a fair market value of $12,000. In June 2021, Zack applied for SSI as an individual and is otherwise eligible. At this time the fair market value of the car is $10,000. Does the transfer affect his eligibility?

The answer is “yes.” The transfer took place during the 36-month look-back period immediately preceding the SSI application. Since Zack did not receive fair market value, the penalty applies. The duration of the penalty is determined by the amount of the uncompensated value ($12,000) divided by the monthly combined benefit rate (FBR + SSP or $954.72). This yields 12.57, which is rounded down to 12 months of ineligibility. Since the period of ineligibility begins on the first of the month following the transfer, Zack is ineligible beginning June 1, 2021 and will not become eligible until June 2022.

What if Zack sold the car to his grandson for $5,000, knowing that his grandson could not afford to pay more?

Now the uncompensated value is $7,000. Dividing $7,000 by $954.72 yields 7.33, resulting in a 7-month period of ineligibility.

  1. Ifthere were no transfer penalty, what would be the impact of the $5,000 Zack received in May 2021 on his SSI eligibility for that and subsequent months?

Answer:

Disclaimer of Inheritance: Disclaimer of a right of inheritance is also considered a transfer of a resource for less than Fair Market Value.

EXCEPTIONS TO TRANSFER PENALTY 

Fortunately, there are exceptions to the transfer penalty. Exceptions include:

  • AllResources Returned – In the example above, if the grandson returned the car, Zack would not have a period of ineligibility, even for the period prior to the return of the 
  • Transfer of a Home To Certain Family Members – This exception applies to a transfer to a spouse, a childunder 21, or a child of any age who is blind or  It also applies to a transfer to a sibling with an ownership interest (including a life estate) who resided in the home for at least a year immediately prior to the individual’s institutionalization. The home transfer exception applies as well to a transfer to an adult son or daughter who resided in the home for at least two years prior to institutionalization, and provided care to the individual allowing that person to live at home instead of an institution.
  • Non-Home Transfers toCertain Family Members – There is an exception for non-home transfers to a spouse, or a blind or disabled child, or for the sole benefit of a 
  • Transfersto Certain Trusts – There is an exception for transfers to three types of trusts: (1) a trust for a blind or disabled child; (2) a trust for the sole benefit of an individual (including the grantor) who is under 65 and blind or disabled; (3) a trust that is a countable 
  • Transfers fora Purpose Other Than to Obtain SSI – There is a presumption that a transfer is for the purpose of obtaining SSI which can only be overcome by convincing evidence that the transfer was exclusively for another purpose. Examples of transfers that might satisfy this exception include: (1) court- ordered transfers; (2) transfer occurring prior to the traumatic onset of a disability or blindness that created eligibility for SSI; (3) transfer occurring prior to a diagnosis of a previously undetected disabling condition that created eligibility for SSI; or (4) transfer occurring prior to an unexpected loss of other income or resources that would have precluded SSI eligibility in any 
  • Transfer of a Resource That Would Have Been Excludable in the Month Of the Transfer – Thisexception allows for transfer of the home as long as the individual was residing there at the time of 
  • Undue Hardship – This exception applies only where failure to receive SSI would result in loss of food orshelter, and the individual’s total available funds do not exceed the applicable monthly payment rate for the individual’s living 
  • TransferOf A Small Amount – This exception applies if the transferred amount, when combined with other resources, is less than the $2,000 ($3,000 for a couple) resource 

FINAL REMINDERS ON TRANSFERS 

  • Giftsof cash are transfers of resources and will incur a period of ineligibility if, when added to the individual’s other resources, they exceed the resource 
  • Repaymentof a loan which one has a legal obligation to repay is not a transfer for less than fair market  A written document is helpful, but not absolutely necessary.
  • Repaymentof a moral obligation may provoke a period of 
  • Anindividual spending money on herself will never create a period of 

 

SSI Proposals

SSI RESTORATION ACT OF 2019 (H.R. 4280)/ (S. 2753) 

The Act was introduced in Congress to protect and preserve seniors and people with disabilities from the harms of poverty by updating some aspects of the SSI program that have not been changed in decades. The Act was reintroduced in the House and the Senate in the fall of 2019. An updated version of the SSI Restoration Act is likely to be introduced in this Congress.

Under the Act several needed updates to the SSI eligibility rules would be made:

  1. Updatethe General Income Disregard from $20 a month to $123 a  This amount has not changed since 1972 even though $20 in today’s money is equal to approximately $34 in 1972 dollars.
  2. Updatethe Earned Income Disregard from $65 a month to $399 a  This figure also has not changed since 1972.
  3. Update the Resource Limit from the current $2,000 ($3,000 for a couple) to $10,000 ($20,000 for acouple). The resource limit has only increased 33% since the program was enacted in 1972 even though the cost of living today is many times greater than it was 
  4. Eliminatethe In-Kind Support and Maintenance Reduction where someone is receiving in-kind food and/ or shelter.
  5. Eliminatethe Transfer Penalty for transferring a resource for less than fair market 
  6. Remove the Marriage Penalty for SSI Couples. Increase the SSI couples’ rate to equal two times the SSIindividual 
  7. Conform Treatmentof State and Local Government Earned Income Tax Credits and Child Tax Credits for SSI. Simplify administration of the SSI program by excluding State EITCs and CTCs, in the manner in which similar federal tax payments are 

State Level Advocacy

A strong grassroots movement has developed over the last several years to restore the California state supplementary payment (SSP), which has been cut from $233 in 2009 to $160.72 today; and to equitably end SSI cash-out, the state policy that previously denied SNAP (CalFresh) benefits to persons enrolled in SSI. The group, Californians for SSI, has the participation of over 200 organizations as well as a number of SSI recipients with the goal of raising the combined SSI/SSP grant to at least the federal poverty level.

In 2017, the first post-Recession restoration of the state (SSP) portion of the grant occurred when a one-time 2.76% cost of living adjustment (COLA) was applied to the SSP grant. In 2019, the state ended SSI cash-out while holding harmless households that would have seen a reduction in SNAP benefits due to the change, and also restored the SSP COLA starting in 2022. At the time this chapter was written, state leaders were considering a proposal to increase the SSP grant for an individual by 6.4%, bringing it up to $171. However, even with this increase the state supplement for individuals would still be well below the 2009 payment level of $233. Moreover, there is no proposed increase for couples receiving SSI/SSP, who have faced the same cost increases in housing, food and other essentials in the past decade, let alone more recent costs due to COVID-19.. The website for Californians for SSI is https://ca4ssi.org/.

Administrative Appeals Process

The administrative appeal process is the same as for Social Security, with the exception of the first level of appeal (reconsideration) when adverse actions (suspension, termination or reduction of benefits) are taken. When SSA proposes to reduce, suspend or terminate SSI benefits, SSA must offer the individual the opportunity for continued payment of full benefits through decision on the first level of appeal, if the adverse action is appealed within ten days (plus five additional days for mailing) of the notice of adverse action. There is no opportunity for continued benefits beyond the reconsideration stage except in the case of an appeal from an adverse CDR (Continuing Disability Review) decision for medical improvement, in which case continued benefits can continue through an Administrative Law Judge (ALJ) decision.

It should be noted that the “good cause” provision governing late filing of appeals applies as well to situations causing an individual to miss the deadline for receiving continued payment of benefits pending appeal. A copy of the good cause regulation (section 416.1411 of Title 20 of the Code of Federal Regulations) is included at the end of this chapter, p. 2-27.

In an adverse action in an SSI case, SSA also must offer the individual a choice of three different processes for reconsideration at the SSA District Office level. The case review is the option most frequently selected and probably the least appropriate for someone facing a proposed suspension or reduction. This is strictly a paper review and offers very limited opportunity to find out more about the agency’s case. The other options are informal conference and formal conference, both of which involve a face to face appearance before the decision-maker. At the formal conference there is also the opportunity to request that documents and witnesses be subpoenaed. There is also a written summary of the proceedings.

 
   

Overpayments

APPEAL OF OVERPAYMENT DETERMINATION 

Overpayments are far more common in the SSI program than in Social Security because of the need to comply with the program’s income and resource eligibility requirements on a monthly basis. If an individual disputes the existence or amount of the overpayment, the determination can be appealed through SSA’s administrative appeals process as described above.

WAIVER 

While there is a 60-day time limit for appealing the existence or amount of an overpayment, a waiver can be requested at any time. No matter when waiver is requested, the waiver request should stop all collection efforts until after the waiver request has been considered at a personal conference. The waiver must be granted when (1) the individual is without fault; and (2) collection of the overpayment would either (a) defeat the purpose of the SSI program, (b) be against equity and good conscience, or (c) impede efficient or effective administration of the SSI program due to the small amount involved (generally under $1,000).

For overpayment amounts over $1,000, the most common strategy is to pursue the second prong of the waiver test by demonstrating that collection of the overpayment would defeat the purpose of the SSI program. The individual must show that “the individual’s income and resources are needed for ordinary and necessary living expenses.” An individual currently receiving SSI is considered to have met this requirement if total income does not exceed the FBR plus the SSP, plus the $20 general income disregard. In other words, in July 2021 an individual SSI recipient living independently with cooking facilities in California will be considered to have met this test if total income, including SSI, does not exceed $974.72.

It is important to remember that although the term “waiver” has a discretionary ring to it, once the individual has met the conditions for a waiver, the individual has a right to waiver. If the waiver is denied, the denial may be appealed through SSA’s appeal process.

Generally, recovery of the overpayment out of future benefits is limited to 10% of total monthly income or the total monthly SSI benefit, whichever is less. The amount being recouped can be further reduced on a showing that the individual will not be left with enough to meet “current ordinary and necessary living expenses.” It should be noted that the 10% limit on recoupment does not apply in cases of fraud, willful misrepresentation or concealment of material facts.

CalFresh Eligibility

Since 1974, people who receive SSI had been barred from receiving CalFresh benefits because of a state policy called“cash-out.” In part due to strong grassroots advocacy by the Californians for SSI coalition, the state ended this “cash-out” policy on June 1, 2019. Seniors and people with disabilities who receive SSI are now allowed to receive CalFresh (SNAP) benefits. CalFresh eligibility is not automatic, and individuals who currently receive SSI will need to apply for CalFresh.

Ending cash-out is generally a positive change with many SSI recipients now able to receive both SSI/SSP and CalFresh.

However, a small number of households would have lost CalFresh benefits when a previously excluded household member who receives SSI was added to the CalFresh household.

To help mitigate this loss, the state created two new nutrition benefits for these households, the Supplemental Nutrition Benefit for households that experience a loss, and the Transitional Nutrition Benefit for households that experienced a total loss.

CALFRESH RULES TO KEEP IN MIND 

In working with individuals applying for CalFresh, keep in mind the rules described below that help seniors and people with disabilities who receive SSI to qualify for and continue receiving CalFresh.

Housing Costs – SSI recipients who are approved for CalFresh will receive a benefit that will vary depending on individual circumstances like household size, income, and expenses. Those with higher housing costs qualify for a higher benefit because the CalFresh calculation provides a shelter cost deduction that is uncapped for households that include a senior or person with a disability.

Medical Expense Deduction – Seniors and people with disabilities can also take a deduction for medical expenses, which can help them qualify for a higher CalFresh benefit. CalFresh provides a standard deduction of $120 if there are verified medical expenses between $35.01 and $155 per month; individuals with expenses

above $155 can claim a deduction of the actual amount above $35. Expenses can include medical and dental care, prescription medications, over-the-counter medications approved by a medical professional, costs to obtain and maintain service animals, transportation (including mileage) and lodging needed to obtain medical treatment, or medical equipment and supplies.

Minimum Benefit – A CalFresh household consisting of one person who receives SSI or two people who both receive SSI will qualify for at least a $16 minimum CalFresh benefit.

Keeping Benefits – CalFresh households with only seniors or people with disabilities and no earned income qualify for rules that make it easier to stay on CalFresh. These households are recertified for CalFresh every 36 months (instead of every 12 or 24 months) and do not need to do a recertification interview.

CalFresh Households – Some individual SSI recipients who share a home with others may qualify to be their own CalFresh household, which can result in higher CalFresh benefits overall. When people live together and purchase and prepare food together, they are considered one CalFresh household. Households apply together and share a CalFresh allotment calculated based on shared income and expenses. There are two situations where a senior or person with a disability can be a separate CalFresh household:

  1. People who share a home but do not purchase and prepare food together can apply for CalFreshindependently of one another. Thus, people who are elderly or disabled may apply for CalFresh separately from other people living with them (including roommates, siblings, or adult children) if they do not purchase and prepare food with others in the  However, there are two groups of people who must apply together, regardless of whether or not they purchase and prepare food together: married couples living together, and parents living with their children under age 22.

In the example on the previous page, if Karen begins purchasing and preparing food separately from Jeremy and the grandchildren, Karen can become a separate CalFresh household. This may result in higher benefits overall, as there would be two CalFresh households from that point forward, each receiving their own CalFresh benefit.

  1. A special household rule allows certain seniors who live in low-income households to be their own CalFreshhousehold, even though the senior purchases and prepares food with the rest of the household, if the senior meets all three of the following criteria:
    • Theperson is both elderly and disabled,
    • Is unable topurchase and prepare meals separately because of a disability, and
    • Theincome of the rest of the household does not exceed 165% of the federal poverty level.
 
   

Immigrant Eligibility

At one time immigrant eligibility was very simple. Before 1996, lawful immigrants were eligible for SSI on the same basis as citizens. The Public Responsibility Work Opportunity and Reconciliation Act of 1996, coupled

with the Balanced Budget Act of 1997, established complex special requirements that greatly restricted immigrant eligibility for SSI and other benefits. Unfortunately, SSA personnel are very often not familiar with the details of these requirements, resulting frequently in inappropriate denials. First, any non-citizen who was receiving benefits on August 22, 1996, is grandfathered in and will continue to be eligible for SSI assuming she/he continues to meet other eligibility requirements, i.e., income, resources, etc.

This is true even if benefits are terminated for a period of a few years, and he subsequently reapplies for benefits. It should be noted that anyone whose benefits may have been suspended between August 22, 1995 and August 22, 1996, is considered to have been receiving benefits on Aug. 22, 1996.

For every other non-citizen, it is necessary to look to the individual’s date of entry into the United States, because one set of rules applies to those who entered before August 22, 1996, and another more restrictive set of rules applies to those who entered on or after that date. However, as a threshold matter for both groups, it is a prerequisite for eligibility that the individual is among a limited group of non-citizens who are considered “qualified aliens.” This group includes lawful permanent resident aliens (LPRs), refugees, asylees, persons granted withholding of deportation, Cuban-Haitian entrants, persons paroled into the United States for at least a year or more, and certain domestic violence victims. It is important to remember that this is just a threshold qualification. Inclusion in this group does not by itself establish eligibility.

PRE 8/22/96 ENTRANTS 

There are three categories of non-citizens — other than those who were grandfathered in, i.e., those who entered the United States before 8/22/96 who are eligible for SSI today.

  1. Qualifiedaliens who are blind or disabled and who were“lawfully residing” in the United States on 8/22/96. This group is largely elderly, although eligibility is based on disability rather than age. The overwhelmingly majority of the elderly immigrants who apply for SSI are determined to be disabled on the initial 
  2. Certainveterans, their spouses, and 
  3. Lawfulpermanent residents who entered the S. before 8/22/96 and who have 40 qualifying quarters of credit under the Social Security Act. This group will be able to receive SSI on the basis of age without the need to prove disability. Unlike Title II of Social Security, an individual in this situation can use not only his own quarters, but also can use quarters earned by a spouse while the couple was married, and quarters earned by parents before the individual turned 18. However, no quarters earned after December 31, 1996, can be used if the individual received a means tested public benefit at the same time.

POST 8/22/96 ENTRANTS 

  1. Lawfulpermanent residents who entered the S. on or after 8/22/96 may not be eligible for SSI for the first five years as a LPR even if they have 40 qualifying quarters of coverage.
  2. Refugees,asylees, persons for whom deportation is withheld, Cuban-Haitian entrants and certain Amerasian immigrants who can receive time-limited benefits based on age, blindness or  Eligibility for this group is limited to a period of seven years from the date their immigration status was granted. Almost all of them are eligible for the California Cash Assistance Program for Immigrants (CAPI) upon the expiration of the seven-year period.

SSI For Same Sex Couples

 
   

Social Security Administration policy requires that people in a same sex relationship applying for SSI today are to be treated the same as those in an opposite sex relationship when it comes to determining marital status

and “holding out” as married. This means that if they are living with someone to whom they are lawfully married or with whom they are in a California Registered Domestic Partnership, or with whom they are holding out as married, they will be treated as married for the purpose of SSI eligibility and benefit amount. Couples who entered into a domestic partnership or civil union in some, but not all, other states or nations will also be recognized as married.

However, prior to the June 26, 2013 decision of the U.S. Supreme Court decision in U.S. v. Windsor, the Defense of Marriage Act (DOMA) prohibited any agency of the federal government from recognizing a marriage between two people of the same sex. As a result, a person married to a person of the same sex was recorded in SSA records

as single and SSI eligibility was determined on that basis even when the person presented their marriage certificate upon filing the application. This almost invariably resulted in the payment of significantly more benefits than the person would be entitled to if the marriage were recognized.

While SSA began to process new applications in California from people married to someone of the same sex in the beginning of 2014, they did not take any action to recognize the marriages of those already receiving SSI until a year or more after Windsor, when they began to do so on a rolling basis. In the process, they reduced future benefits as they should have done beginning in July 2013, and issued overpayment notices for the period from July 2013 demanding repayment of thousands of dollars.

As a result of a lawsuit, Held v. Colvin, SSA changed its policy and agreed to stop trying to collect overpayments from those who were married to someone of the same sex and receiving SSI prior to Windsor. Instead SSA will waive recovery of all overpayments based on delayed recognition of a marriage to someone of the same sex and will return any money already collected.

When SSA began recognizing marriages between two people of the same sex in California, they did not apply the “holding out” provision to same sex couples. However, when SSA recognized marriages of same sex couples nationwide after another Supreme Court decision, Obergefell v. Hodges, they did begin to apply the “holding out” provision on new applications from same sex couples who led others in the community to believe they were married. However, SSA will not be able to identify those who are holding out as married and already receiving SSI until the case comes up for a financial redetermination.

Since SSI redeterminations are done on a rolling basis, there may still be some same sex couples, one or both of whom are receiving SSI, who have not had a redetermination based on the Windsor decision and who are still receiving a greater amount of SSI than they should.

Assisting Individuals During the Pandemic

COVID-19 ALERT

Social Security’s physical offices closed to the public in March 2020 due to the COVID-19 pandemic. However, employees of the local SSA offices continue to serve the public by phone and can assist with any issue for which an individual would have gone to the office before the closure. Use the office locator to find the phone number and fax number for any local office: https://secure.ssa.gov/ICON/ main.jsp In addition, the national toll-free number and online services that were available before continue to be available now.

Economic Impact Payments – Federal pandemic relief legislation passed in 2020 and 2021 provide for three one-time payments for individuals including SSI and Social Security recipients. For SSI eligibility, these payments do not count as income and also do not count as a resource for 12 months.

  • $1,200for every individual with a Social Security number, plus $500 for each dependent child under age  Payments were issued automatically to SSI and Social Security recipients in April and May 2020.
  • $600 for every individual with a Social Security number, plus $600 for each dependent childunder age  Payments were issued automatically to SSI and Social Security recipients at the end of December 2020.
  • $1,400for every individual with a Social Security number, plus $1,400 for each qualifying  Note that qualifying dependents for this third stimulus payment is not age- restricted and can include seniors and adults with disabilities. Payments were issued automatically to SSI and Social Security recipients in April 2021.

Individuals who did not receive these stimulus payments automatically will need to file a tax return for 2020 to receive the payments.

Golden State Grant – State pandemic relief legislation passed in 2021 provides a $600 state supplement payment for each individual who receives SSI. Payments will be issued via paper checks and will be sent weekly by zip code beginning on May 24, 2021 and ending the week of June 21, 2021. The payment is not counted as income the month it is received, but any amount that remains the following month will be counted toward the $2,000 / $3,000 resource limit.

For CAPI recipients, The Golden State Grant Program provides a $600 one-time payment to all CAPI recipients. Payments will be issued via paper checks and will be sent weekly by zip code beginning on May 24, 2021 and ending the week of June 21, 2021. Receipt of this payment is not counted as income for CAPI recipients and will not count as a resource for 12 months.

Supplemental Materials

POMS SI 01130.050, GUIDE TO RESOURCE EXCLUSIONS

 
   

CALIFORNIA SSI PAYMENT STANDARDS

 

SAMPLE NOTICE TO SSI RECIPIENT

Social Security Administration Supplemental Security Income Notice of Planned Action

 

Social Security Office 2500 Fontaine Road

San Jose, CA, 95121-2131

Claim Number: 012-34-5678

February 2, 2010

 

 

 

Mr. John Doe

1890 Schulte Drive, Apt. 4 San Jose, CA 95133

 

Dear John Doe

PAY108

Your payments (or those of the individual named above) will change as follows: TBL010

Month Amount due each month
MONTH YEAR $0.00

MIS016 (optional) and continuing

Your Payment Is Based On These Facts (PAYC22) 

New UTI

We have reviewed the information available for your case. You are not eligible to receive Supplemental Security Income (SSI) based on The Extension for Elderly and Disabled Refugees Act. You do not have a pending or approved application for naturalization with the U.S. Citizenship and Immigration Services (USCIS) or you chose not to pursue U.S. citizenship.

You Can Review the Information in Your Case (INFC31)

INF087

The decisions in this letter are based on the law and information in our records. You have a right to review and get copies of the information in our records that we used to make the decisions explained in this letter. You also have a right to review and copy the laws, regulations, and policy statements used in deciding your case. To do so, please contact us. Our telephone number and address are shown under the heading “If You Have Questions.”

If You Disagree With The Decision (ALSC04)

ALS033

If you disagree with the decision, you have the right to appeal. We will review your case again and consider any new facts you have. A person who did not make the first decision will decide your case.

  • Youhave 60 days to ask for an 
  • The60 days start the day after you get this  We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.
  • Youmust have a good reason if you wait more than 60 days to ask for an 
  • Youhave to ask for an appeal in  We will ask you to sign a form

SSA-561-U2, called “Request for Reconsideration.” Contact one of our offices if you want help.

Please read the enclosed pamphlet, “Your Right to Question the Decision Made on Your Social Security Claim.” It contains more information about the appeal.

Appeal In 10 Days To Keep Getting The Same Payment (ALSC17)

ALS035

If you appeal within 10 days, you will continue to get the same payment amount until we decide your case.

  • The10 days start the day after you get this 
  • Ifyou lose your appeal, you might have to pay back some or all of this

However, even if you appeal in 10 days, we may stop the payment in MONTH/YEAR as shown above if both of the following are true:

  • Ournew decision is the same as the one you appealed, and,
  • Wesend or give you a letter with our new decision in time to stop the 

How To Appeal (RPNC26)

MIS094

There are three ways to appeal. You can pick the one you want. If you meet with us in person, it mav help us decide your case.

  • CaseReview: You have the right to review the facts in your  You can give us

more facts to add to your file. Then we will decide your case again. You will not meet with the person who decides your case.

  • InformalConference: You will meet with the person who decides your  You can tell that person why you think you are right. You can give us more facts to help prove you are right. You can bring other people to help explain your case.
  • FormalConference: This is a meeting like an informal  The difference

is we can make people come to prove you are right. We can make them bring important papers about your case, even if they do not want to help you. You can question these people at your meeting.

If You Want Help With Your Case (ALSC09)

REP002

You can have a friend, representative or someone else help you. There are groups that can help you find a representative or give you free legal services if you qualify. There also are representatives who do not charge unless you win your appeal. Your Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.

If You Want An Interpreter To Help You (CAPC55) 

INF082

We provide free interpreter services to help you conduct your Social Security business. These interpreter services are available whether you talk to us by phone or in the Social Security office. Call our toll-free number. 1-800-772-1213, press 2 if you need an interpreter in Spanish, and stay on the line until a representative answers. An interpreter who speaks Spanish will be contacted to help with your call. If your business cannot be completed by phone, we will make an appointment for you at a local

Social Security office and arrange for an interpreter to be there at the time of your visit.

If You Have Questions (REFC01) 

REF032

For general information about SSI, visit our website at www.socialsecurity.gov on the Internet. You will find the law and regulations about SSI eligibility and SSI payment amounts at www.socialsecurity.gov/SSIrules/.

For general questions about SSI or specific questions about your case, you may call us toll-free at 1-800-772-1213 or call your local Social Security office at 555-123-4567. If you call or visit our office, please bring this letter with you and ask for (Name of SSA technician).

 

APT054

If you plan to visit an office you may call ahead to make an appointment. This will help us serve you more quickly.

 

John Doe District Manager

 

 

Enclosure(s):

GOOD CAUSE FOR MISSING THE DEADLINE TO REQUEST REVIEW 

Code Of Federal Regulations

  • 416.1411.Good cause for missing the deadline to request review.
  • Indetermining whether you have shown that you have good cause for missing a deadline to request review we consider—
    • Whatcircumstances kept you from making the request on time;
    • Whetherour action misled you;
    • Whetheryou did not understand the requirements of the Act resulting from amendments to the Act, other legislation, or court decisions; and
    • Whetheryou had any physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) which prevented you from filing a timely request or from understanding or knowing about the need to file a timely request for 
  • Examplesof circumstances where good cause may exist include, but are not limited to, the following situations:
    • Youwere seriously ill and were prevented from contacting us in person, in writing, or through a friend, relative, or other 
    • Therewas a death or serious illness in your immediate family.
    • Importantrecords were destroyed or damaged by fire or other accidental 
    • Youwere trying very hard to find necessary information to support your claim but did not find the information within the stated time 
    • Youasked us for additional information explaining our action within the time limit, and within 60 days of receiving the explanation you requested reconsideration or a hearing, or within 30 days of receiving the explanation you requested Appeals Council review or filed a civil 
    • Wegave you incorrect or incomplete information about when and how to request administrative review or to file a civil suit.
    • Youdid not receive notice of the initial determination or 
    • Yousent the request to another Government agency in good faith within the time limit and the request did not reach us until after the time period had 
    • Unusual or unavoidable circumstances exist, including the circumstances described in paragraph (a)(4) ofthis section, which show that you could not have known of the need to file timely, or which prevented you from filing 

[45 FR 52096, Aug. 5, 1980, as amended at 59 FR 1637, Jan. 12, 1994]

REQUEST FOR RECONSIDERATION

 
   

CHAPTER THREE

CALIFORNIA CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI)

TABLE OF CONTENTS

INTRODUCTION 61

BENEFITS 61

ELIGIBILITY 61

IMMIGRATION STATUS 62

APPEALS 63

SUPPLEMENTAL MATERIALS 64

Introduction

California established the Cash Assistance Program for Immigrants (CAPI) in 1998 to provide benefits for certain immigrants who previously would have been able to receive Supplemental Security Income (SSI), but who are no longer eligible for SSI because of the restrictions placed on non-citizen eligibility in the 1996 federal welfare legislation. The program is fully funded by the state and is administered by the California Department of Social Services through contracts with the counties. The primary beneficiaries have been elderly immigrants who entered the United States before August 22, 1996 and do not have 40 quarters of earnings. However, an increasing number of people who entered the United States on or after August 22, 1996 have also become eligible. Unfortunately, awareness of the program in many immigrant communities is quite low.

Benefits

CAPI provides a monthly benefit that is the same as the comparable SSI benefit for an individual and an eligible couple. Thus, the monthly CAPI benefit rate for 2021 for an aged and/or disabled individual is $954.72 and

$1,598.14 for an aged and/or disabled couple. As in SSI, rates are slightly higher for recipients who are blind and for those who lack access to adequate cooking or food storage facilities. Unlike SSI, CAPI does not confer automatic Medi-Cal eligibility, although individuals can file separately for Medi-Cal. CAPI recipients may be eligible for Food Stamp (Supplemental Nutrition Assistance Program) benefits.

Eligibility

The eligibility requirements for CAPI are the same as for SSI, except for the immigrant status requirements.

Income and resources are calculated according to the SSI rules.

Also, if an individual qualifies for SSI, that individual is not eligible for CAPI. It is only those who are ineligible for SSI solely because of immigration status who are potentially eligible for CAPI. Indeed, the county Department of Public Social Services (DPSS) will probably require someone applying for CAPI to apply for SSI in order to establish SSI ineligibility.

Immigration Status

As with SSI, there is a big difference between non-citizens who entered the United States before 8/22/96, and those who entered on or after that date. Anyone who entered before 8/22/96 who would have been eligible for SSI on the immigrant status rules in effect before that date, automatically meets the immigrant status rules for CAPI if they no longer qualify for SSI solely because of immigration status.

Non-citizens who entered the United States before 8/22/96 are no longer able to file new claims for SSI on the basis of age unless they qualify for the veteran exception or 40 quarters exception. They can receive CAPI on the basis of age without the need to prove disability. However, they will be required to pursue an SSI claim based on disability, and will be required to sign an interim assistance reimbursement agreement with the county. Under the terms of this agreement, if the individual does eventually receive SSI, the county will be reimbursed out of the SSI payment for past due benefits that otherwise would have gone to the individual. Once SSI is approved, this must be reported to DPSS and the CAPI benefits will cease. If the SSI claim is denied, the individual will continue to receive CAPI.

Prior to 8/22/96, there was an immigrant eligibility category for SSI known as PRUCOL or Permanently Residing Under Color of Law. These individuals no longer qualify for SSI on any basis, unless they are grandfathered in. However, they may be eligible for CAPI on the basis of age, blindness or disability regardless of date of entry.

Lawful permanent residents who entered the United States on or after 8/22/96 no longer qualify for SSI unless they meet either the veteran or 40 quarters exception. They are eligible for CAPI, but with a significant limitation. Their eligibility is subject to deeming of their sponsor’s income and resources for a period of 10 years from the date they were granted lawful permanent residence status. It should be noted that some people who may have previously been denied CAPI benefits because of the deeming requirement may now be eligible if the ten-year deeming period has since expired.

Generally, deeming of the sponsor’s income makes an individual financially ineligible for benefits. However, there are exceptions to the deeming requirement for (1) victims of abuse, which includes the non-citizen, non- citizen’s minor child, or non-citizen’s parent; and (2) someone who would go “hungry or homeless” without assistance.

Someone is considered likely to go “hungry or homeless” without assistance if their total income is less than the SSI Federal Benefit Rate (FBR), which is $794 for an individual and $1,191 for a couple in 2021. However, awareness of the “hungry or homeless” exception appears to be limited in immigrant communities and in the county agencies that are required to apply the exception.

Refugees, Asylees Cut Off SSI After 7 Years Can Receive CAPI – There is also a group of humanitarian immigrants (refugees, asylees, persons for whom deportation is withheld, Cuban- Haitian entrants, Amerasian immigrants) with a seven-year time limit on SSI eligibility. Upon expiration of the seven-year period, these individuals are eligible for CAPI. They should apply for CAPI at the start of their last month of SSI eligibility.

Appeals

Appeals from adverse determinations in the CAPI program are heard by Administrative Law Judges (ALJs) employed by the California Department of Social Services. A request for a hearing must be filed within 90 days after the date of the adverse determination. As with SSI, in the case of suspensions, terminations or reductions of benefits, there is a right to continued assistance pending decision on the first level of appeal.

Supplemental Materials

CAPI PAYMENT STANDARDS 

 
   

CHAPTER FOUR

MEDICARE

TABLE OF CONTENTS

INTRODUCTION 68

ELIGIBILITY 69

ENROLLMENT IN MEDICARE 70

COVERED SERVICES 72

HOSPITAL DISCHARGE PLANNING 79

MEDICARE MANAGED CARE ORGANIZATIONS 82

MEDICARE PART A & B APPEALS 85

MEDICARE ADVANTAGE MANAGED CARE APPEALS 87

EXPEDITED APPEALS PROCESS FOR MEDICARE ADVANTAGE MANAGED CARE ENROLLEES 88

PRIVATE MEDICARE SUPPLEMENTAL INSURANCE 89

PROGRAMS TO HELP LOW-INCOME MEDICARE

BENEFICIARIES WITH MEDICARE COSTS 90

CLAIMS PROCESSING 91

SUPPLEMENTAL MATERIALS 93

Introduction

WHAT IS MEDICARE? 

Medicare is a federal health insurance program that is a primary source of coverage for adults 65 and over as well as certain individuals with disabilities. Eligibility is usually based on the work history of an individual or the

individual’s spouse. Some individuals may qualify even without a work history: if they are low income, they may get premium assistance, and if not, they may pay privately.

Medicare does not cover all medical needs, and most beneficiaries have additional insurance (Medi-Cal, a private supplement, etc.). There are four “Parts” to Medicare: A, B, C & D.

MEDICARE PARTS A, B, C, & D 

There are four “Parts” to Medicare. Part A and Part B are referred to as “original fee-for-service” Medicare, or sometimes as “traditional” Medicare. Part C is a version of Medicare called “Medicare Advantage” – which is offered through private health care insurers. Part D is prescription drug coverage and is discussed in Chapter 5.

Low income individuals may qualify for special programs to assist with Parts A/B/C (see 4-25), and/or for the Low-Income Subsidy for Part D (see Chapter 5).

Medicare Part A is commonly known as “hospital insurance.” Under certain conditions, Medicare Part A pays for a stay in a hospital or nursing home, or pays for certain expenses of home health care. In addition, Medicare Part A pays for certain expenses of hospice care provided to a terminally ill person.

Medicare Part B is commonly known as “medical insurance.” Medicare Part B pays for certain expenses of physician services, therapies, tests, x-rays, and medical equipment. Under some circumstances, Medicare Part B will pay for particular services provided in a nursing home or for home health care.

Medicare Part C is Medicare Advantage, an alternative to fee-for-service Medicare. It is a system where Medicare pays a private plan to manage a beneficiary’s health care. Medicare Part C coverage can include health maintenance organizations (HMOs); preferred provider organizations (PPOs); private fee-for-service plans (PFFs); special needs plans (SNPs); and medical savings accounts (MSAs).

Medicare Part D is the Medicare Prescription Drug program. Each year, prescription drug plans participating in the program are announced for the following year. Enrollment runs from October 15 to December 7 each year. A low income subsidy is available for those who qualify; applications for the subsidy are processed by Social Security. You can read more about Medicare Part D in Chapter 5.

Eligibility

Most individuals are entitled to free Medicare Part A based on their work history. However, some individuals may be eligible to enroll without this history.

PART A ELIGIBILITY WITHOUT PREMIUM 

In general, eligibility for Medicare Part A is based on the work history of an individual or that of his or her spouse. In the most common type of eligibility, someone is at least 65 years old, and either the individual or spouse has a work history that creates an entitlement to Social Security retirement benefits (usually 40 quarters, or the equivalent of 10 years of work history). Married individuals, including those in same-sex marriages, can qualify for Medicare Part A coverage based on a spouse’s work history. Certain divorced individuals, widows, and widowers can also rely on their spouse’s earnings record. Eligibility does not extend to those in civil unions or domestic partnerships.

Part A eligibility is also available to persons who have been receiving Social Security disability benefits or railroad retirement disability benefits for at least 24 months. For people with ALS (“Lou Gehrig’s Disease”), the 24-month waiting period is waived. There also are special rules for people with end-stage renal disease (kidney failure).

PART A ELIGIBILITY WITH PREMIUM 

If, due to an insufficient work history, an individual is not eligible automatically for Part A coverage, the individual nonetheless may be able to purchase Part A coverage. To purchase Part A coverage, an individual must be:

  1. Atleast 65 years old;
  2. Eithera S. citizen or a lawful permanent resident (green card holder) with five years of continuous residence; and
  3. Enrolledin Medicare Part B (by paying a further premium).

The 2021 premium for Medicare Part A is either $259 or $471 monthly, depending on work history.

Those who do not qualify automatically for Part A may choose to purchase only Part B coverage. However, as explained above, an individual wanting to purchase Part A coverage must also enroll in Part B.

 
   

PART B ELIGIBILITY 

Medicare Part B coverage is available to anyone who is eligible for Part A benefits and/or is at least 65 years old and either a U.S. citizen or a permanent resident who has resided in the United States for the five years prior to enrollment for Part B.

Those receiving Medicare Part B coverage must pay a monthly premium—$148.500 for 2021. The premium is deducted from the enrollee’s Social Security, Railroad Retirement or Civil Service Retirement, or disability payment.

Medicare will send a bill every three months to enrollees who do not receive any of these retirement benefits.

People who do not qualify for automatic Part A eligibility may choose to purchase only Part B coverage. However, as explained in the discussion of “Part A Eligibility With Premium,” to purchase Part A coverage, they must also purchase Part B coverage.

 
   

PART B DEDUCTIBLE

The beneficiary is responsible for a yearly deductible of $203 in 2021.

PART B CO-PAYMENT: 20 PERCENT 

Medicare Part B payments can be made either to the beneficiary or the health care provider (physician, hospital, etc.). In general, if a provider accepts the Medicare approved amount as payment in full, Medicare will pay 80% of the cost to the provider, and the beneficiary is responsible for the other 20%. If the provider does not limit the costs of the services to the Medicare approved amount, Medicare will pay the claim to the beneficiary and the beneficiary will be responsible for the full payment to the provider, unless a limiting charge applies. Limiting charges apply only to physician and therapist services.

A more detailed explanation of the Part B co- payment, including an explanation of the Part B “limiting charge,” is set forth later in this chapter.

 
   

Enrollment in Medicare

PART A ENROLLMENT 

Enrollment is automatic for individuals who, at age 65, have started receiving benefits from either Social Security or the Railroad Retirement Board. For people who became disabled prior to age 65, enrollment is effective two years after the start of Social Security disability benefit eligibility, although the two-year waiting period is waived if the disability resulted from kidney failure or ALS.

An individual who does not begin receiving retirement benefits until after age 65 must apply for Medicare benefits when turning 65. The individual may apply during the seven-month “Initial Enrollment Period,” which begins three months before the month of the individual’s 65th birthday and ends three months after that.

PART B ENROLLMENT 

There are three enrollment periods for Medicare Part B.

  1. Initial Enrollment Period: If an individual is turning 65 and has not yet applied for Social Security orRailroad Retirement benefits, or Medicare Part A, the individual can enroll in Part B during the seven- month Initial Enrollment Period, which begins three months before the month of the individual’s 65th birthday and ends three months after that month.
  2. General Enrollment Period: If the Initial Enrollment Period has passed, an individual may sign up duringthe General Enrollment 
    • TheGeneral Enrollment Period runs from January 1 to March 31 each 
    • Coveragestarts on July 1 of the year 
  3. Special EnrollmentPeriod: This period is available to an individual who waited to enroll in Part B because the individual or spouse was working and had group health plan coverage through an employer or  Individuals can sign up any time while still covered by the group health plan, or during the eight months following the date that the group health plan coverage ends, or employment is terminated, whichever comes first. People who qualify for this special enrollment period are not assessed a penalty for late Medi care enrollment.
 
   

Penalty for Late Enrollment – The cost of the premium will rise by 10 percent for each 12-month period in which someone who was eligible for Part B coverage did not enroll, except in special cases. This increase will apply as long as the individual receives Part B coverage.

 
   

Covered Services

INPATIENT HOSPITAL CARE UNDER MEDICARE PART A 

Medicare covers up to 90 days of hospital services in each benefit period, including a semi-private room, meals, general nursing, and other hospital services and supplies. Medicare does not cover private duty nursing, a television or telephone in the room, or a private room (unless the private room is medically necessary). Medicare also will cover an additional 60 “lifetime reserve” days, each of which can only be used once.

A “benefit period” (or “spell of illness”) begins when the beneficiary is admitted to the hospital and ends when the beneficiary has been out of the hospital for 60 consecutive days and has not received Medicare-covered care in a nursing home.

For each benefit period, the beneficiary pays:

  • Adeductible of $1,484 per hospital stay;
  • Afterthe deductible has been met, a zero co-pay for days 1-60;
  • $371per day for days 61-90 of a hospital stay; and
  • $742per day after day 90 in a benefit 

SPECIALIZED FACILITIES UNDER MEDICARE PART A 

Medicare covers care in a specialized facility – such as a rehabilitation hospital or a psychiatric facility – for up to 190 days during a beneficiary’s life.

NURSING HOME CARE UNDER MEDICARE PART A1 

Introduction – Many clients (and some advocates) are surprised by the very limited availability of Medicare Part A reimbursement for nursing home expenses. It is important to keep in mind that the Medicare program was never intended to be a comprehensive health insurance plan. For example, a general exclusion in the Medicare law forbids Medicare payment for any service or item deemed “custodial” in nature.

Maximum Duration of Payments – At most, Part A of the Medicare program pays for 100 days of nursing home care per benefit period, and only the first 20 days are paid in full. During days 21 through 100, the beneficiary must pay a daily co-payment of $185.50 in 2021.

1 This guide’s discussion of Medicare payment for nursing home care is taken in part from the Nursing Home Companion (Bet Tzedek Legal Services) and Chapter Eight of Eric M. Carlson, Long-Term Care Advocacy (Matthew Bender & Co.).

Qualifying Hospital Stay – Medicare Part A may pay for a beneficiary’s nursing home stay only if the individual has entered the nursing home within 30 days after being hospitalized in a hospital for at least three nights. Generally, the resident must begin receiving the Medicare-qualifying level of care (see below) within this 30- day period, although there is an exception if that level of care was not “medically appropriate” until after the expiration of the

  • day

Advocates should also be aware that sometimes, although an individual has spent three nights in a hospital, part or all of that time may not count for a qualifying hospital stay because the individual was in “observation status” and not considered to be an admitted patient. Hospital expenses for patients in observation status are treated as outpatient expenses and covered under Medicare Part B, which usually means that the individual pays more than if the individual had been admitted as an inpatient.

 
   

Level of Care – Medicare Part A pays nursing home charges only for residents who need “skilled nursing or skilled rehabilitation services.” For example, “skilled” nursing services (as defined by the Medicare program) include intravenous feeding, the treatment of widespread skin disorders, and the monitoring of residents who require relatively sophisticated evaluations. “Skilled” rehabilitation services include, for example, “range of motion” exercises, services provided by a speech pathologist, and physical, occupational, and speech therapy.

Note that a resident may qualify for Medicare Part A payment of their nursing home charges if they require only one “skilled” service. Note also that the “skilled” services mentioned in the preceding paragraph are examples only. The Medicare regulations clearly state that a variety of conditions may qualify a resident for Medicare Part A payment of nursing home charges.

For residents receiving therapy, nursing homes frequently – but falsely – claim that Medicare Part A cannot pay unless a resident’s condition is improving. Prescribed therapy can justify Medicare Part A reimbursement even

without current progress, if progress can be reasonably expected in the foreseeable future, or if therapy is necessary to maintain a resident’s condition or slow decline.

It should be noted, however, that most long-term residents of nursing homes are not receiving “skilled” services as defined by Medicare and their stay is not being paid by Medicare. The Medicare regulations state that the need for routine personal care services such as administration of medications, the maintenance of catheters, and the turning of residents do not qualify an individual for Medicare Part A payment of nursing home charges.

 
   

Determining Level of Care – The nursing home makes the initial decision on whether a resident is qualified for Medicare Part A payment of nursing home charges. Consequently, a resident or family member immediately and consistently should emphasize the “skilled” services required by the resident.

If at any time (including the time of admission) the nursing home decides that the resident is not qualified for Medicare Part A payment of nursing home charges, the nursing home must give the resident written notice of the nursing home’s decision. If the resident or family member feels that the resident is qualified medically for Medicare Part A payment of nursing home charges, and thus disagrees with the nursing home’s decision, the resident or family member may appeal the nursing home’s decision. The resident or family member begins the appeal by returning the written notice to the nursing home after checking a box that states:

“Yes. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicaid makes its decision. If Medicare denies payment, I agree to

be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare’s decision.”

While the Medicare program considers an appeal of a nursing home’s decision, the nursing home cannot bill the resident for the nursing home charges in dispute. If the Medicare program eventually agrees with the nursing home and concludes that the resident was not qualified medically for Medicare Part A payment of nursing home charges, the resident or family member can appeal the Medicare program’s decision as well. During this second appeal, however, the nursing home can bill the resident for the charges in dispute.

If a nursing home fails to provide a resident or the resident’s family members with the required notice, a resident or family member should request in writing that the nursing home submit a bill to Medicare Part A, even if the resident’s medical condition may not meet the requirements described earlier in this chapter. Under Medicare law, a nursing home’s failure to give adequate notice may excuse the resident from paying the charges incurred during certain weeks or months, if the Medicare program finds that the resident could not have known that Medicare Part A would not be covering the charges incurred during that time period.

 
   

HOME HEALTH CARE UNDER MEDICARE PART A 

The Basics of Home Health Care – Home health care is skilled care that is provided at the beneficiary’s home, rather than in a nursing home. The home may be a residential care facility for the elderly or a similar facility.

If skilled care is required, other non-skilled services may be provided as well.

The Medicare home health benefit may include the following services or supplies:

  • Skillednursing care on a part-time or intermittent basis;
  • Physical,speech and/or occupational therapy;
  • Homehealth aide services on a part-time or intermittent basis;
  • Medicalsocial services;
  • Medicalsupplies (not including drugs); and
  • Medical

The Medicare home health benefit does not pay for:

  • Around-the-clockcare at home;
  • Prescriptiondrugs;
  • Home-deliveredmeals;
  • Shopping,cleaning or laundry service; or

Beneficiary Must Be Homebound – Home health care can be provided only to those beneficiaries considered “homebound,” based on the reasoning that those who are not homebound can travel to a hospital or clinic for routine health care. A beneficiary is considered “homebound” if leaving the home is a very difficult process. In determining whether a beneficiary qualifies as “home- bound,” the beneficiary is not penalized for leaving home to receive health care treatment or to attend an adult day care program. Also, attending religious services does not limit a beneficiary’s ability to be considered homebound.

 
   
 
   

Part-Time or Intermittent Care – Medicare will provide home health care only if the need for skilled nursing care is part-time or intermittent. This means that care is given less than seven days a week, or less than eight hours a day, with no more than 28 hours per week (although this may be increased to 35 hours on a case-by-case basis)

Skilled Services – The nursing care or therapy services must be “skilled.”

Nursing care is considered “skilled” if a nursing service requires the expertise of a licensed nurse. For example, treatment of a wound and administration of an injection are skilled nursing services that qualify for Medicare reimbursement. On the other hand, bathing and helping with dressing are services that do not qualify as “skilled” services. For therapy services to be considered “skilled,” the expertise of a licensed physical therapist or certified speech therapist must be required.

 
   

Home Health Aide – If a beneficiary requires skilled nursing services or skilled therapy, the Medicare home health benefit may also be able to provide the part-time assistance of a home health aide, as appropriate given the beneficiary’s care plan.

A home health aide is a health care worker who doesn’t have a nursing license. At least 75 hours of training is required. Home health aides help with non-medical care such as bathing, dressing, or exercising.

Authorization of Services – A physician must order home health care, and a care plan must be developed. Care must be provided by a Medicare-certified home health agency.

No Deductibles or Copayments – Medicare pays the full amount of all covered services, with a very limited exception: for durable medical equipment only, the beneficiary is responsible for 20% of the approved amount.

If a Home Health Agency Believes that Medicare Will Not Pay – If a home health agency believes that Medicare will not pay for services, and as a result decides to deny or cut back care, the home health agency first must give the beneficiary a Home Health Advance Beneficiary Notice (ABN). This notice must explain why the home health agency believes that Medicare won’t pay for the services, and must describe how the beneficiary can contest the agency’s decision.

Forcing a Home Health Agency To Bill Medicare – If a beneficiary is given a notice of non-coverage, the beneficiary may require that the home health agency bill the Medicare program. The bill submitted by the agency is called a “demand bill.”

When a demand bill has been submitted, the home health agency still can require the beneficiary to pay in advance for the services for which Medicare has been billed.

If the Medicare program subsequently pays for those services, the home health agency must reimburse the beneficiary.

Appeal – When the Medicare program denies payment of a bill (including a demand bill), the notice will contain instructions for filing an appeal. The appeals process is described later in this chapter, starting on page 4-25.

HOSPICE CARE UNDER MEDICARE PART A 

What is Hospice?– Hospice care is specialty care for terminally-ill individuals and their families. Hospice care includes both medical care and counseling services. Hospice care focuses on keeping the resident comfortable – physically and emotionally – and does not attempt to cure the illness that is expected to cause the beneficiary’s death. For example, a hospice program might put extra emphasis on pain reduction, supportive services, and/ or respite care.

Eligibility for Hospice Care – A Medicare recipient who is terminally ill – i.e., certified by a physician as likely having a life expectancy of no more than six months – may elect to receive hospice care under Medicare Part A, in exchange for waiving the right to receive treatment under Part A for the terminal condition. The beneficiary retains the right to Medicare funding for treatment of medical conditions other than the terminal condition. At any time, the beneficiary may elect to leave hospice and return to original Medicare.

A beneficiary is entitled to two 90-day periods of hospice care, and an unlimited number of subsequent periods of 60 days each. For each period, the beneficiary must be certified by a physician as being terminally ill.

Very Limited Cost to Beneficiary – Hospice care has no deductibles and very limited co-payments. A beneficiary pays a five percent co-payment for outpatient drugs and inpatient respite care.

What Services Are Provided?– The Medicare hospice benefit is similar to the home health benefit, and covers the following services:

  • Physicianservices;
  • Nursingservices;
  • Medicalequipment;
  • Medicalsupplies;
  • Medicationfor symptom control and pain relief;
  • Short-termhospital care;
  • Homehealth aide and homemaker services;
  • Physical,speech and occupational therapy;
  • Socialworker services;
  • Dietarycounseling; and
  • Griefand loss counseling for the patient and the 

The inpatient care is used for pain control, chronic symptom management, and/or providing a respite to regular caregivers.

 
   
 
   

Care Plans and Services – The hospice organization works with the beneficiary and the physician to form an individualized plan of care. Hospice care may be provided by a physician, a nurse, counselors and clergy members, social workers, home health aides, and trained volunteers.

Where Is Care Provided? – Hospice services mostly are provided where the beneficiary is living, whether the beneficiary is living in a house, apartment, assisted living facility, or nursing home.

Inpatient care is available for pain control and chronic symptom management. Also, for periods of no more than five days at a time, the Medicare hospice benefit may cover inpatient care to give at-home caregivers a respite from the rigors of caregiving.

SERVICES UNDER MEDICARE PART B 

Part B covers a wide range of medical services and supplies, including (but not limited to) the following:

  • Annual wellness visit withno deductible or co-pay;
  • Physicianservices;
  • Outpatienthospital services;
  • Homehealth care;
  • Outpatientphysical therapy, speech therapy, and occupational therapy;
  • Psychologistand clinical social worker services;
  • Durablemedical equipment (wheelchairs, walkers, braces, oxygen equipment, )*;
  • Medicalsupplies (ostomy bags, surgical dressings, splints, )*;
  • Artificiallimbs*;
  • Ambulanceservices;
  • X-rays;
  • Laboratoryand other diagnostic tests;
  • Immunosuppressivedrugs;
  • Pneumoniaand Hepatitis B vaccine (no co-pays). other vaccines are covered with co-pays;
  • Fluvaccine (no co-pays);
  • Diabetesself-management training and supplies;
  • Glucosemonitors and testing strips;
  • Annualglaucoma screening for beneficiaries at a high risk for glaucoma;
  • Papsmears and pelvic exams once every two years, or annually for high-risk women;
  • Yearly mammograms for women age40 and above (for those 35-39, one baseline mammogram);
  • Annualprostate cancer screening test for men age 50 and above; and
  • Colorectalcancer screening for beneficiaries age 50 and 
  • Expandedopioid use disorder treatment and therapy, including methadone
  • Expandedtelehealth coverage
 
   
  • Specialrules apply in the Competitive Bidding program for durable medical equipment, prosthetics, orthotics, and  In 2021, Competitive Bidding rules only apply to off-the-shelf back and knee braces, but they will expand to other items in future years.

No Co-Payment for Some Services – No co-payment is required for clinical laboratory services such as blood tests and urinalysis. Also, no co-payment is required for covered opioid treatment services, and for home health care, with the exception of the 20% co-payment that a beneficiary is required to pay for durable medical equipment provided as a part of the home health care. Also, there are no out-of-pocket costs for a wide range of preventive services, such as screenings for various cancers (including breast, colon, prostate, and cervical), heart  disease, osteoporosis, glaucoma, diabetes, and mammograms.

 
   

SERVICES NOT COVERED UNDER MEDICARE PART B 

Medicare Part B does not offer comprehensive coverage of health care services. Among those services and items not included in the Part B benefit are the following:

  • Dentalservices;
  • Eyeglassesor contact lenses (except as a follow-up to cataract surgery); and
  • Hearingaids
 
   

SUBMISSION OF MEDICARE PART B CLAIMS 

Part B claims must be submitted by a Medicare Part B provider. The beneficiary generally does not submit these claims directly to the Medicare carrier. The time limit for submitting a claim to Medicare generally is the close of the calendar year after the year the services were provided.

Refusing to Accept Assignment – When a provider does not accept an assignment, the beneficiary is liable for the 20% co-payment plus the amount by which the provider’s charge exceeds the Medicare-approved amount. The beneficiary pays the provider directly, and Medicare will pay the beneficiary rather than the provider.

To protect beneficiaries from exorbitant charges, Medicare imposes a “limiting charge” of 115% of the Medicare- approved amount on physician services, and the charges of independent occupational, speech or physical therapists. Providers bound by the charge limit must accept 115% of the Medicare-approved amount as payment in full.

 
   

Hospital Discharge Planning

Federal Medicare law requires hospitals to provide Medicare-covered patients with discharge plans. A discharge plan should be prepared by the hospital staff in conjunction with the beneficiary and family.

A discharge plan describes the care and services a beneficiary may need after leaving the hospital and explains how such services may be provided. Also, a discharge plan gives the beneficiary guidance in how to improve or maintain health after leaving the hospital.

CHALLENGING HOSPITAL DISCHARGES

Expedited Appeals of Part A Hospital Discharge Decisions  Notice of Non-Coverage – A Medicare beneficiary must be provided with notice of discharge rights twice during the course of the hospital stay (this occurs when a beneficiary is given a notice called “An Important Message from Medicare” (IM) within two days after admission and again two days to four hours before discharge; if the stay is three days or less, once is sufficient). The information provided must include a description of the beneficiary’s hospital discharge appeal rights.

The IM notice must contain explicit information about 1) the process for requesting appeals of discharge decisions, 2) the right to remain in the hospital without charge if an expedited decision is requested, and 3) the right to receive a detailed notice of the reasons for discharge.

 
   

BFCC-QIO Expedited Review – If the beneficiary believes that they are not medically ready to be discharged from the hospital, the beneficiary has the right to appeal the discharge in an expedited appeal process. The appeal is made to Livanta, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for California. Contact Livanta online or by phone at 1-877- 588-1123 or 1-855-887-6668 (TDD for the hearing impaired). The patient may remain in the hospital at least until noon of the day after the BFCC-QIO decision.

If the beneficiary’s physician agreed with the discharge decision, the beneficiary has the right to appeal the decision by requesting an expedited review. The beneficiary should contact the BFCC-QIO before noon of the first working day after the date the Notice of Non-Coverage was received and ask the BFCC-QIO to review the case.

This request may be verbal or written.

If the BFCC-QIO issues a favorable decision, Medicare will continue to pay for the care.

If the BFCC-QIO is contacted within the above time limit and decides against the beneficiary, the hospital may charge the beneficiary for any costs incurred starting at noon of the day after the day the BFCC-QIO decision is received.

 
   

QIC Expedited Reconsideration – If the BFCC-QIO decision is unfavorable, the beneficiary has the right to request a reconsideration by the Quality Independent Contractor (QIC). The QIC for California is Maximus

Federal Services. The request for a reconsideration must be made by no later than noon of the calendar day following the receipt of the BFCC-QIO decision. If the beneficiary requests the reconsideration within this timeframe, the hospital may not bill the beneficiary until the QIC makes a decision.

If the QIC is not contacted in a timely manner, the beneficiary will be liable for all costs of hospitalization starting at noon of the day after the receipt of the Notice of Non-Coverage.

If the beneficiary does not file a request for reconsideration within this specified timeframe, they must use the standard appeal process.

Expedited appeal rights around hospital discharge decisions are equally available to beneficiaries in fee-for-services Medicare and to those who are members of Medicare managed care plans.

Additional Appeal Rights for Hospital Discharge – Following the expedited reconsideration, the beneficiary can appeal a hospital discharge using the same appeal rights available for standard Medicare Part A appeals.

Expedited Appeals of Skilled Nursing Facility, Home Health, Hospice, and Comprehensive Outpatient Rehabilitation Facility Services – A beneficiary has the right to an expedited appeal when services are terminated by a skilled nursing facility, home health agency, hospice or comprehensive outpatient rehabilitation facility. The provider must provide written notice to the beneficiary at least two days or two visits before the services are to be terminated.

Expedited Determination – If the beneficiary wants to appeal the decision to terminate services, they must request an expedited determination by Livanta, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for California. Contact Livanta online or by phone at 1-877-588-1123 or 1-855-887- 6668 (TDD for the hearing impaired). Contact Livanta by noon of the day prior to the termination of services.

The beneficiary can make this request online, in writing, or by phoning. The provider must provide a second notice that includes detailed information regarding why the services were terminated. The provider must also continue to provide services until two days after the first notice was given or until the service termination date (whichever is later).

Once the request for an expedited appeal is made, Livanta has 72 hours to make a determination. The decision is communicated by telephone, and a written decision is also provided. The determination must provide an explanation of the decision, the beneficiary’s liability for services, and information on the beneficiary’s appeal rights.

Expedited Reconsideration – A beneficiary has the right to appeal the expedited determination. To do so, the beneficiary requests an expedited reconsideration by Maximus, the Quality Independent Contractor (QIC). The request can be made by phone or in writing and must be submitted by noon of the calendar day following the decision by Livanta. The QIC must make a decision within 72 hours of receiving the expedited reconsideration request. The QIC decision may be communicated by phone with a written notice that follows. The notice

must provide the same type of information that is given in the determination decision. If the reconsideration is unfavorable, the beneficiary has the right to continue using the standard fee-for-service appeals process.

 
   

Medicare Managed Care Organizations

INTRODUCTION 

Medicare managed care plans provide hospital, outpatient and other health care services to Medicare beneficiaries who have assigned their Medicare benefits to these health plans. Medicare managed care plans are called Medicare Advantage (MA) plans in federal Medicare law. Most Medicare MA plans include prescription drug coverage and are referred to as MA-PD plans.

Many Medicare beneficiaries join Medicare MA plans in order to reduce their out-of-pocket medical expenses and to obtain benefits not covered by fee-for-service Medicare, such as the dental care and vision care offered by some plans.

The Medicare program pays a Medicare MA plan a monthly capitation payment for each Medicare enrollee.

Medicare MA plan members must use the plan for all their medical care needs except in certain circumstances such as emergency and urgent care situations. If they use a provider outside the plan’s network without plan authorization, they will have to pay a higher co-payment or, in many cases, the full cost of the service. Because the Medicare program pays the plan a flat fee in advance, the Medicare claims process does not exist in MA plans.

 
   

A Medicare beneficiary must have Medicare Parts A and B in order to join a Medicare MA plan.

All Medicare beneficiaries are eligible to enroll in a Medicare MA plan. A Medicare MA plan cannot screen out applicants based on health history or disability. Medicare beneficiaries receiving hospice care may enroll in a Medicare Advantage plan. Their hospice benefit will be covered under original Medicare.

 
   

Some Medicare Advantage Plans, called Special Needs Plans (SNPs) can limit enrollment to particular groups of individuals. SNPs are required to show that they are designed to meet the particular needs of the population they serve. There are three types of SNPs: those for people dually eligible for Medicare and Medicaid (D-SNPs), those for people with certain chronic conditions (C-SNPs) and those for people needing institutional care (I-SNPs). Most SNPs are D-SNPs.

 
   

CAL MEDICONNECT 

California is one of several states participating in a demonstration project that combines Medicare benefits with Medicaid benefits through enrollment in a managed care plan. Cal MediConnect plans are available in Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara counties. Cal MediConnect is part of a broader program in California called the Coordinated Care Initiative (CCI). For more about the CCI, go to Chapter 6.

PACE 

Programs for All-Inclusive Care for the Elderly (PACE) are available in many California counties, including Los Angeles, and provide comprehensive community-based care for older adults who have high care needs. To qualify for PACE, a Medicare beneficiary must be 55 or older, live in the service area of a PACE organization, be certified by the state as needing a nursing home-level of care and, at the time of enrollment, be able to live safely in the community with the help of PACE services. A large majority of PACE participants are dually eligible and they receive both their Medicare services and their Medi-Cal services through PACE. Medicare beneficiaries who do not qualify for Medi- Cal can also enroll in PACE, but are required to pay a monthly premium for the long-term services portion of the PACE benefit and a premium for Medicare Part D drugs.

ENROLLMENT IN MEDICARE ADVANTAGE PLANS 

Enrollment Process and Effective Enrollment Date – Beneficiaries enroll in a Medicare Advantage plan by filling out and signing a Medicare Advantage enrollment form and submitting it to the Medicare Advantage plan. Beneficiaries also can enroll online at the Enrollment Center section of the Medicare website, www.Medicare.gov. Beneficiaries also can contact the Medicare Advantage plans to enroll by phone.

The effective date of the Medicare Advantage enrollment depends on when the beneficiary has applied for enrollment. If the enrollment occurs during an open enrollment period, October 15 through December 7, the enrollment is effective on January 1.

A beneficiary may also disenroll from a Medicare Advantage Plan from January 1 to March 31, and return to original fee-for-service Medicare and a Part D plan or change to another Medicare Advantage plan.

Enrollment Periods – There are four types of enrollment periods during which a Medicare beneficiary can enroll in a Medicare Advantage plan. Some of these enrollment periods overlap, and the enrollment rules are complicated.

  1. InitialCoverage Election Period (ICEP) – The initial coverage election period is the time period during which a person becomes newly eligible for Medicare A and  The ICEP is the same seven-month  period as the initial enrollment period in Medicare Part B; it begins three months before an individual is eligible, includes the month of first eligibility, and ends three months later.
  2. OpenEnrollment Period (OEP) – The open enrollment period is the time period during which a beneficiary can change from one Medicare Advantage plan to another or enroll in and disenroll from a Medicare Advantage  The OEP extends from October 15 to December 7 of each year. Enrollment changes made during the OEP are effective January 1 of the following year.
  3. MedicareAdvantage Open Enrollment Period (MA OEP) – An individual who enrolls in an MA plan may

switch to another Medicare Advantage plan or return to original Medicare and a Part D plan during the first three months of a year, January 1 to March 31. If the individual is new to Medicare and Medicare eligibility begins mid-year, the three-month period begins the first month of MA plan enrollment.

  1. SpecialEnrollment Period (SEP) – Medicare provides for special enrollment periods for Medicare Advantage  They can enroll at any time in a plan that receives a five-star quality rating from Medicare. Enrollees who receive the Low Income Subsidy have an opportunity to change plans once each quarter. Those in nursing homes can change plans at any time. Special Enrollment Periods also are available in a variety of circumstances including:
    • theenrollee no longer lives in the Medicare Advantage plan service area
    • theMedicare Advantage plan no longer contracts with Medicare or no longer provides services in the service area
    • thebeneficiary wishes to enroll in a Medicare Advantage plan with a 5-star rating or to disenroll from a plan identified by CMS as a poor performing plan
    • theenrollee has enrolled in or disenrolled from a Medicare Advantage plan due to bad information or action by a federal employee
    • the beneficiary has lost creditable retiree drug coverageor the coverage has been reduced so that it is no longer creditable
    • othersituations that are approved by CMS (Medicare)

See the Supplemental Materials at the end of Chapter 5 for a full list of Special Enrollment Periods.

Disenrollment from Medicare Advantage – Medicare beneficiaries can disenroll from a Medicare Advantage plan only during one of the prescribed enrollment periods. Signing up for another plan automatically causes disenrollment from the old plan. A beneficiary also can disenroll by completing, signing and submitting a disenrollment form to the Medicare Advantage plan or by calling 1-800-MEDICARE. The effective date of the disenrollment depends upon the enrollment period. If the beneficiary disenrolls during the annual open enrollment period, it will be effective January 1.

 
   

Medicare Part A & B Appeals

INTRODUCTION 

As discussed in earlier sections of this manual, Medicare Part A and B claims are processed by Medicare contracting carriers and intermediaries. These Medicare contractors are responsible for processing the initial claim determination on Medicare claims and for some of the earlier stages of the Part A and B appeals process.

In this section of the manual, we will discuss the Medicare Part A and B appeals process in detail.

Detailed descriptions of the Medicare Advantage and Part D appeals processes are outlined in the respective sections on Medicare Advantage plans and the Part D program.

OVERVIEW OF THE PART A AND B APPEALS PROCESS 

Medicare Part A and B fee-for-service appeals follow a standard pattern of steps:

  1. Initialdetermination made by a Medicare carrier or intermediary;
  2. Redeterminationmade by the same Medicare carrier or intermediary;
  3. Reconsideration,an external review that is made by an independent entity that contracts with Medicare;
  4. AdministrativeLaw Judge hearing;
  5. MedicareAppeals Council review;
  6. FederalDistrict 

INITIAL DETERMINATION 

When a Medicare carrier or intermediary processes a claim, a Medicare Summary Notice (MSN) is sent to the Medicare beneficiary. MSNs are mailed once each quarter unless the beneficiary is due a payment from Medicare. The notice informs the beneficiary whether Medicare has approved payment of the claim for services and the amount of that payment. If Medicare has not approved payment, the notice provides information on why the claim was denied or partially paid. The notice informs the beneficiary of their appeal rights.

REDETERMINATION 

The first level of the fee-for-service appeal process is called redetermination. A beneficiary who wants to appeal an initial determination must file a written, signed request for redetermination to the Medicare carrier/

intermediary within 120 days of the initial determination. Medicare providers and suppliers can also file a request for redetermination. The Medicare carrier/intermediary must issue a redetermination decision in 60 days.

Expedited Appeals of Hospital, Skilled Nursing Facility, Home Health, Hospice and Comprehensive Outpatient Rehabilitation Facility Services – The Medicare appeals process provides for an additional expedited or “fast track” independent review when hospital, skilled nursing facility, home, health, hospice and comprehensive outpatient rehabilitation facility services are terminated. See pp. 14-16 of this chapter.

RECONSIDERATION 

A beneficiary can appeal a redetermination decision by filing a request for reconsideration. Beneficiaries have 180 days to request a reconsideration of a redetermination. Providers and suppliers also can file reconsideration requests. Reconsiderations are conducted by Medicare Qualified Independent Contractors (QICs). The QICs are responsible for conducting an external, independent review of redeterminations. The QIC for California is Maximus.

QICs must issue a reconsideration decision within 60 days. Beneficiaries can request a 14-day extension if needed to provide more evidence. If a QIC does not issue a decision within the required timeframe, the beneficiary can request an administrative law judge hearing. This is called a request for “escalation.” The QIC then has five days to issue a decision or send the case to the ALJ (Administrative Law Judge) level. If an appeal is escalated to the ALJ level, the ALJ has 180 days, rather than the standard 90-day timeframe to make a decision.

ADMINISTRATIVE LAW JUDGE (ALJ) HEARING 

Beneficiaries who want to appeal a reconsideration decision have the right to request an administrative law judge hearing. Beneficiaries have the right to an ALJ hearing only if the amount of money at issue is at least $180. The request for an ALJ hearing must be filed within 60 days of receiving an unfavorable reconsideration decision. An ALJ has 90 days to issue a decision, but the timeframe can be extended to review additional evidence, to permit an in-person hearing or because of an escalated request from a QIC.

ALJ hearings are conducted by the Department of Health and Human Services (HHS). In most cases, the hearings are conducted by telephone or video teleconference. In-person ALJ hearings are conducted only if the beneficiary can show “good cause” for an in-person hearing. When a request for an in-person hearing is granted, the 90-day decision deadline is waived.

 
   

MEDICARE APPEALS COUNCIL  (MAC) 

The Medicare Appeals Council review is conducted by the Departmental Appeals Board of HHS. A beneficiary who wants to appeal an unfavorable ALJ decision has 60 days to request a MAC review. This review is generally a paper review where a decision is made without a hearing. The time frame for a MAC decision is 90 days but can be extended.

FEDERAL DISTRICT COURT 

A beneficiary can appeal a MAC decision by filing a lawsuit in federal district court. The suit must be filed within 60 days of receiving an unfavorable MAC decision. To appeal at this level, a beneficiary must show that at least $1,760 is at issue.

Medicare Advantage Managed Care Appeals

Medicare provides an appeals process for Medicare Advantage managed care plan members who have disputes with their Medicare MA plans. Medicare beneficiaries may use the appeals process to:

  • Obtain paymentfor emergency or out-of-area urgently needed services;
  • Seekpayment for health services furnished by a provider not in the MA plan’s network that the MA plan member believes are covered by Medicare and should have been furnished, arranged or paid for by the MA plan; or
  • Challengethe MA plan’s refusal to provide services or the MA plan’s termination of  There are five steps in the appeals process:
  1. OrganizationDetermination – Requests for claim payment for non-MA plan services or requests for medical services from the MA plan should be considered requests for an organization 

There are different time frames for service and claim payment requests. Claim payment requests must be reviewed in 60 days. Service requests must be reviewed in 14 calendar days. All of the following situations should be treated as an organization determination that is a denial:

  • The planhas denied the level of care requested, but approved another level of care. For example, the request for skilled nursing care was not authorized, but home health services were approved;
  • Theplan has denied the request for service or has not approved the amount of service requested;
  • Theplan has reduced or discontinued services;
  • Theplan has failed to approve, provide or arrange the requested health care services in the time frame required;
  • Theplan has denied payment of the claim submitted or only partially paid the 

If the organization determination is a denial, it must be in writing and must provide the following information:

  • Thereason for the denial; and
  • Informationon how to appeal the denial and on the expedited appeal 
  1. Reconsideration– If the organization determination results in a partial or total denial, or the MA plan fails to issue a written determination within the specified time frames, the member may request  The reconsideration review is performed by the MA plan. The member must file the reconsideration request with the MA plan within 60 days of the date of the organization determination. The beneficiary or their representative is entitled to present evidence, either in person or in writing.

The MA plan has 60 days to reconsider a claim payment denial. On service request denials, however, the MA plan has 30 days, but it may extend this 30-day period by an additional 14 days if the member requests an extension, or if the MA plan can show that additional information is needed and that the extension will benefit the member’s reconsideration request.

  1. OutsideReview by Independent Review Entity – If the MA plan decides to uphold the organization determination, in whole or in part, it must forward the case to Maximus/Center for Health Care Dispute Resolution, the Independent Review Entity (IRE) that is contracted to review reconsideration cases for the federal  The MA plan also must inform the member, in writing, either that the claim has been approved in full, or that the case has been forwarded to the Independent Review Entity for further review. Depending on the case, the Independent Review Entity has up to 60 days to make a decision.
  2. AdministrativeLaw Judge Review – The beneficiary has 60 days from the date of an unfavorable determination from the Independent Review Entity to request a hearing before an Administrative Law  At least $180 must be at issue.
  3. MedicareAppeals Council – If the decision from the Administrative Law Judge is unfavorable, the beneficiary has 60 days to request review by the Medicare Appeals 

Federal Review – If the Medicare Appeals Council decision is unfavorable, further review may be sought in federal District Court. The amount in controversy must be at least $1,760.

 
   

Expedited Appeals Process For Medicare Advantage Managed Care Enrollees

A Medicare Advantage (MA) plan member has the right to request an expedited review if the timeframe for a standard appeal could seriously jeopardize the member’s health or ability to gain maximum function. This faster appeal process can be used to request medical care from the MA plan, and to appeal an MA plan denial of service or termination of care. An expedited appeal must be decided within 72 hours.

A request for expedited review by the MA plan can be made in person, by phone, or in writing. If the member requests the expedited review, the plan has the option to deny expedited processing. If, however, a physician requests expedited treatment, the MA plan must review the case within the 72-hour timeframe. An MA plan member who wants an expedited review should contact the MA plan’s member services department.

Medicare Advantage plan members also have the right to a special fast track appeal directly to the BFCC-QIO when hospital, skilled nursing facility or home health services are terminated. In the case of skilled nursing facility or home health services, the provider must give the member a written notice at least two days before the services are terminated. To request a fast track appeal, a member must contact Livanta (1-877-588-1123) by noon of the day before coverage ends.

Private Medicare Supplemental Insurance

INTRODUCTION 

“Medicare Supplemental Insurance” is insurance that supplements fee-for-service Medicare coverage and meets specified coverage standards. It is usually paid for out-of-pocket, or may be offered by an employer or former employer.

 
   

A Medicare Supplemental Insurance policy, often referred to as a “Medigap” policy, is designed to cover part or all of Medicare’s co-payments and deductibles. Medigap policies are available primarily to persons 65 and over who have both Medicare Part A and Part B. Policies are available to under-65 beneficiaries with disabilities on a

more limited basis. Because Medigap policies are designed to go along with, or track, Medicare, most of the services excluded or denied by Medicare are also excluded or denied by Medigap policies.

 
   

When evaluating any Medigap policy, beneficiaries and their advocates should remember that Medigap policies won’t cover all health care expenses not paid for by Medicare. Medigap insurance pays for only a portion of the remaining costs.

 
   

BASIC BENEFITS 

Insurance companies may offer standardized Medigap policies, labeled A, B, D, G, K, L, M, and N. Insurers may no longer offer plans labeled C, E, F, H, I, & J. Because all plans are standardized, consumers will receive the same benefits within a category regardless of which insurer they choose.

PART A HOSPITAL BENEFITS 

All new policies must offer:

  • Allcoinsurance for hospital days 61-90 in a benefit period;
  • Coinsurancefor the 60 hospital lifetime reserve days; and
  • 100%of the cost for hospital care beyond the Medicare-covered days in a benefit period, up to a maximum of 365 days.

OTHER BENEFITS 

  • Allplans provide coverage for Part B coinsurance and copayments, the first three pints of blood, and hospice co-insurance. Coverage is at 100% except for plans K and L, which provide coverage at the 50% and 75% level 
  • Coveragefor skilled nursing coinsurance, Part A deductibles, Part B deductibles, and emergency health care during foreign travel varies among plan 
  • 100%of Part B Excess  These are the Part B physician charges that exceed the Medicare-approved amount up to the physician charge limit of 115% of the approved amount. For example, if Medicare approves $100 of a $115 physician bill, this benefit will pay both the 20% of the Medicare approved amount and also the $15 excess amount. Note that some plans sold before June 1, 2010 have a more limited 80% excess charge benefit.
  • Medigapplans sold to people newly eligible in January 2020 or later do not cover the Part B  Note that the Part B deductible is covered by some older policies.
 
   

For a good source on Medicare supplements go to: https://www.cms.gov/medicare/health-plans/medigap/index.

Programs To Help Low-Income Medicare Beneficiaries With Medicare Costs

Low-income Medicare beneficiaries may be eligible for Medi-Cal in addition to Medicare (see Chapter 6). In addition, they may be eligible for one of the following Medicare Savings Programs (MSP): QMB, SLMB, or QI (see below for MSP descriptions). Persons who may qualify for any of these programs should apply at the county (in Los Angeles, at the Department of Public Social Services).

QUALIFIED  MEDICARE  BENEFICIARY  (QMB) 

The QMB program is for individuals and couples with low incomes but with resources up to $7,970 for individuals, and $11,960 for couples. In 2021, the QMB income limit for a single person is $1,094 per month and

$1,472 per month for a couple (these include a $20 disregard that applies to all income). These figures change early each calendar year when the annual income poverty guidelines are issued.

See the Supplemental Material for a California QMB/SLMB/QI application.

The QMB program will pay the Medicare Part A premium (if not already free), the Medicare Part B premium, and all Medicare cost-sharing (deductibles and co-payments), and automatically entitles the individual to the Medicare Part D Low-Income Subsidy (see Chapter 5).

 
   

Providers may not bill any QMB (most dual eligibles are also QMBs) for Medicare deductibles, co-pays or co- insurance. This protection applies both to beneficiaries in fee-for-service Medicare and to those in Medicare Advantage plans. For more information on improper billing of QMBs and dual eligibles, see Justice in Aging’s

Improper Billing Toolkit: https://www.justiceinaging.org/our-work/healthcare/dual-eligibles-california-and-federal/ improper-billing/

SPECIFIED  LOW-INCOME BENEFICIARY (SLMB) 

SLMB is a program similar to QMB, for individuals and couples with monthly incomes too high for QMB but no more than $1,308 for an individual, or $1,762 for a couple (these include a $20 disregard that applies to all income). These figures change early each calendar year when the annual income poverty guidelines are issued.

The resource requirements are the same as for QMB ($7,970 for individuals, and $11,960 for couples). The SLMB program pays the Medicare Part B premium only. It does not cover deductibles and co-pays.

QUALIFIED INDIVIDUAL (QI) 

Again (as is the case for QMB and SLMB), the resource limit is $7,970 for an individual, or $11,960 for a couple.

The income limits for the QI program are $1,469 for an individual and $1,980 for a couple. These figures change early each calendar year when the annual income poverty guidelines are issued.

Like SLMB, the QI program pays the Medicare Part B premium. QI is only available to individuals who do not also qualify for another Medi-Cal program.

 
   

Claims Processing

Role of Medicare Administrative Contractors – Payments for fee-for-service Medicare Part A and Part B services are administered by private companies known as Medicare Administrative Contractors (MACs).

Medicare contracting providers are required to submit Medicare claims to the MAC for the region where the service was provided. After the claim is processed, a Medicare Summary Notice is generated and sent to the beneficiary each quarter. The Medicare Summary Notice informs the beneficiary that a claim has been processed for a particular provider and date of service. The notice includes information on the status of Medicare payment, along with the beneficiary’s appeal rights.

Coordination with Medigap Policies – After a beneficiary receives a Medicare Summary Notice (MSN), there are three ways to make a claim with a supplemental insurance policy (Medigap) or retiree plan:

  1. Medicare may have an electronic claims processing arrangement called “crossover” with the insurancecompany or retiree 
  2. Ifthe provider accepts Medicare assignment, the provider may submit the claim to the insurance company or retiree 
  3. Ifneither Medicare nor the provider submits the claim, the beneficiary will need to take the following steps:
    • Ifrequired, fill out the claim form provided by the insurance 
    • Ifrequired, attach copies of the bills being submitted for  Attach copies of the MSN related to those bills.
    • Makecopies of everything for personal  Mail the claim packet to the insurance company.

The beneficiary subsequently will receive an Explanation of Benefits (EOB) from the insurance company or retiree plan.

 
   

 

Supplemental Materials

 

SAMPLE MEDICARE SUMMARY NOTICE PART A

 

Page 1  Your Dashboard

Your New MSN: Part A | Page 3

 

 

 

 

 

 

 

 

 

 

 

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