Disability Advocacy Program DAP Updated October 2019 1122020

Disability Advocacy Program (DAP) Updated: October 2019 11/2/2020 1

Objectives • Define the Disability Advocacy Program (DAP). • Describe how receiving a disability benefit may affect LIHEAP, SNAP, CASH, and MA. • Identify who would be a good DAP candidate. • Explain what an individual can expect during the Social Security application and appeal process. 11/2/2020 2

Objectives Continued • Explain the roles of the caseworker and the DAP Advocate in the DAP Process. • Describe the DAP process including the new electronic referral via the Disability screen, the new DAP Functions Module, and the use of DAP forms. • Recognize the role of MRT (Medical Review Team). 11/2/2020 3

Purpose of DAP • To assist Cash/MA/SNAP recipients with disabilities through the SSI/SSDI application, reconsideration, and appeal process. • To assist disabled MA recipients who are not eligible for SSA benefits due to non-disability reasons with obtaining a disability certification from the MRT. • DAP staff: – Ensure the individual files an initial application. – Assists individuals who fail to file an initial application on their own. – Ensure an appeal is filed timely if the case is initially denied. 11/2/2020 4

Disability • SSA defines disability as: – The inability to engage in any Substantial Gainful Activity (SGA). – By reason of a medically determinable physical or mental impairment. – Impairment is expected to result in death or has lasted or can be expected to last for continuous period of not less than 12 months. 11/2/2020 5

Disability Continued • Components of the disability which must be documented: – Inability to work (engage in SGA). § The annual SGA amounts for blind and non-blind individuals can be found here. – Impairment substantiated by a physician or psychologist – Impairment expected to last 12 months or result in death – this can be 12 months projected into the future 11/2/2020 6

SSA benefits – SSI vs SSDI • SSDI • SSI – – – Benefits based on need Limited income/resources No work credits are required No family benefits Benefit amount based on Federal & State laws – Other income, location and household composition MAY affect benefits – Benefit Types: • Aged (65 and older) • Disability (any age) • Blindness (any age) 11/2/2020 – Benefits based on earnings – No income/resource limit – Must have enough work credits – Provides benefits to eligible family members – Benefit amount based on average lifetime earnings – Other income, location, and HH composition does NOT affect benefits – Benefit Types: • Retirement • Survivor • Disability (includes blindness) 7

Why Apply for SSA benefits? • If the client is found to be disabled by SSA, they could receive income greater than the monthly Cash benefit available. • LIHEAP - Possible supplemental payment. • SNAP - Higher expanded categorical eligibility limit (200% versus 160%). - Eligible for excess medical deductions. - Actual excess shelter deduction. - Can apply the net test using 100% income limit. 11/2/2020 8

Why Apply for SSA benefits? • CASH - Condition of Eligibility. § PA 731 (Individual must agree to apply or verify to be actively pursuing SSA benefits) § FIRM 176 K reimbursement form for RSDI (not SSI) SHB 915 Appendix A - Proof of deprivation. - Exempt from ETP requirements 11/2/2020 9

Why Apply for SSA benefits? • MA - Condition of eligibility if: § Disabled continuously for at least 12 months. § Verified by medical documentation. § Exceptions: ØMAWD ØChildren with Special Needs (in most cases) ØDisability is not verified - Presumptive eligibility – MG, PH 00(D), PJ, and TJ 11/2/2020 10

Referral • • At application or any eligibility review, IMCWs will determine if an individual should be referred to DAP based on the Employability and/or Medical Assessment Forms (such as the PA 1663, PA 635, or PA 586) or medical documentation from an authorized clinician that indicates the individual meets SSI/SSDI disability criteria. IMCWs should review the “Characteristics of SSI/SSDI Individuals” in DAP Chapter 820, Appendix A, of the Supplemental Handbook to determine if an individual has an impairment which may meet the SSA’s disability standards. NOTE: This is not a comprehensive list just a general guideline. • • • The full Listings of SSA impairments for Adults and Children should also be reviewed. As a general guide, an individual should be referred to DAP if: – The PA 1663/635/586 (or other appropriate form) indicates a permanent disability or disability projected to last 12 months or more. – Medical documentation reasonably projects an impairment to last 12 months or longer. – The client is terminally ill (information on compassionate allowances can be found here). IMCWs must ensure proper documentation of the disability is received for any MA budget that would open as a result of the completion of the Disability screen in e. CIS. 11/2/2020 11

Referral Continued • All DAP referrals are entered into the system from the Disability screen in e. CIS by an IMCW. • If a View DAP Functions hyperlink is present on the Disability screen, select the link. DAP history must be reviewed before making a new referral. • The IMCW selects “Yes” to the “Referred to DAP” field. 11/2/2020 12

Referral Continued • The IMCW will then select the appropriate referral type in the “Type of Referral” field-either SSA Referral or MRT Only 11/2/2020 13

For an SSA Referral • Under “Disability Benefit Type”, the IMCW will select the SSD (02) and SSI (03) drop downs in the first two fields • Under the “Disability Benefit Status” for the first two fields, the IMCW will choose the appropriate drop downs of either “Agreed to Apply”, “Pending - Applied for Benefits” or “Under Appeal”. 11/2/2020 14

For an MRT Only Referral • Under “Disability Benefit Type”, the IMCW will select the SSD (02) and SSI (03) drop downs in the first two fields • Under the “Disability Benefit Status” for the first two fields, the IMCW will choose the appropriate drop downs of either “Denied/Ineligible, no appeal” or “Refused to apply”. 11/2/2020 15

Referral Continued • • Once the IMCW commits the case, the DAP referral will be created, the system will create an electronic DAP record in the DAP Functions Module, and a WLD activity alert will automatically be assigned to the DAP Advocate. - The DAP Functions Module will assist the DAP Advocate with tracking the disabled individual’s SSA application, reconsideration, and appeal. - The DAP Functions Module will assist the DAP Advocate with tracking the disabled individual’s progress through the MRT process. - The DAP Advocate must ensure that all work items/alerts are responded to timely and that the module is updated accordingly. The DAP Functions Module will be read only to IMCWs. NOTE: • As a general guide, Cash/MA recipients are required to pursue all potential sources of income, such as SSI/SSDI. -MAWD and PH 95 are the exceptions. • If the individual applied for SSI/SSDI and was denied due to income or resources, the DAP Advocate will receive a DAP 251 alert instructing them to refer the individual for MRT certification. 11/2/2020 16

SSA or MRT Only Referral • Refer to SSA: - Most MA categories or Cash Assistance (Exceptions Apply) • Refer to MRT for MA Card Only: - MAWD or MA for Children with Special Needs (PH 95) • For additional guidance, workers should refer to Supplemental Handbook Chapter 820. 3. • Additional information on the MRT can be found in the Statewide Procedures Manual located here. 11/2/2020 17

Application • • Some individuals referred to DAP are able to file the initial SSI/SSDI application on their own, while others may need DAP staff to assist. If the DAP staff are assisting the individual with filing the SSI/SSDI application, the SSA 1696 -U 4 Appointment of Representative form will need to be completed in order for the SSA to communicate and correspond with the DAP Advocate. - If the individual already has an attorney, the DAP Advocate MUST NOT have the individual complete a SSA 1696. - Once the individual obtains an attorney and the individual completes the SSA 1696 designating the attorney as their representative, DO NOT have the client sign a new SSA 1696 afterwards-SSA only allows individuals to have ONE representative. NOTE: Before DAP advocates are appointed as the individual’s SSA representative, DAP staff should assess the individual’s capabilities and determine if any family, friends, or other social service agency personnel are available to help the individual with his/her SSI/SSDI application. 11/2/2020 18

Application Continued • Individuals may apply for SSA benefits by completing an online application, calling 1 -800 -772 -1213, or by going to their local SSA office. • Information on the SSA application process can be found here. • A checklist to assist individuals with obtaining the needed information and documentation to complete their SSA applications can be found here. • SSA may request the individual complete disability and functional report forms such as the: - SSA 3368 -BK-Adult Disability Report - SSA 3373 -BK-Adult Function Report NOTE: Additional SSA forms can be found here. 11/2/2020 19

Application Continued • The local Social Security Field Office reviews the application for income and resource eligibility. • The file is then sent to the Bureau of Disability Determination (BDD). BDD is the state agency that assists the SSA in determining whether a disabled individual is eligible for SSI/SSD benefits. There are three offices in PA: - Harrisburg - Wilkes-Barre - Greensburg 11/2/2020 20

BDD • The BDD Adjudicator: - Gathers medical evidence. - Reviews social/educational/vocational history. - Uses the SSA listing of impairments (found here) to determine if the client is disabled. 11/2/2020 21

Consultative Exam • If there is not enough information to make a determination, the BDD adjudicator will send the individual to a doctor under contract with the BDD for a Consultative Examination (CE). 11/2/2020 22

Approval/Denial • Average length of time for an initial determination is 4 -5 months. 11/2/2020 23

Reconsideration • If SSA denies the initial application, the first appeal step is for the individual to file a request for Reconsideration. • The Cash/MA recipient must file for Reconsideration within 60 days following the initial denial. • The individual may file their appeal online, calling 1 -800772 -1213, or they may complete and submit the SSA 561, Request for Reconsideration. - In addition to filing the Request for Reconsideration form, the SSA will also need: § SSA-3441, Disability Report-Appeal § SSA-827, Authorization to Disclose Information to SSA 11/2/2020 24

Reconsideration • Reconsideration is a complete review of the individual’s SSA claim by a different SSA Disability Examiner who did not take part in the initial application/initial denial. • At Reconsideration, all evidence used to make the original decision, plus any new evidence provided with the appeal will be analyzed to determine if the original decision stands or if the initial denial can be overturned. 11/2/2020 25

ALJ Hearing • • If SSA denies at Reconsideration, the next appeal step is a hearing before an Administrative Law Judge (ALJ). The Cash/MA recipient must file the ALJ appeal within 60 days following the Reconsideration denial. NOTE: The client is required to file an appeal through the ALJ level. • The individual may file their appeal online, calling 1 -800 -772 -1213, or they may complete and submit the HA-501, Request for Hearing by Administrative Law Judge - In addition to filing the appeal request, SSA will also need: § SSA-3441, Disability Report-Appeal § SSA-827, Authorization to Disclose Information to SSA • • If denied by the ALJ, an appeal can be filed with the Appeals Council. If the ALJ decision is upheld by the Appeals Council, a final appeal can be filed with the U. S. District Court. 11/2/2020 26

ALJ Hearing • During the hearing, the ALJ will ask questions to obtain evidence regarding the client’s vocational and educational background. The ALJ will determine if the skills and physical requirements of previous jobs can be applied to another vocational discipline. • The ALJ may have Vocational and/or Medical Experts at the hearing to provide expertise. • This is the first time in the process that the individual making the disability determination can see/ask questions of the client. The disability decisions made at prior stages of the process are done without interacting and observing the client. 11/2/2020 27

Appeals Council • If denied at the ALJ, the next appeal step is a review by the Appeals Council. – Only file to the Appeals Council if recommended by the client’s attorney. – Appeal must be filed within 60 days of the ALJ denial. – Appeals Council will either affirm the ALJ denial or remand the case back to the ALJ for another review. – Average length of time at Appeals Council is 18 – 24 months. 11/2/2020 28

U. S. District Court • If the Appeals Council upholds the ALJ’s denial, the last level of the appeal process is the United States District Court. – Only file to the U. S. District Court if recommended by the client’s attorney – Appeal must be filed within 60 days of the Appeals Council denial – U. S. District Court will either affirm the ALJ denial, remand the case back to the ALJ for another review, or reverse the denial and find fully in favor of the client – Average length of time at U. S. District Court is 12 – 24 months 11/2/2020 29

Attorney • A recipient has the right to have an attorney represent him or her in an appeal. • DAP staff will assist the individual in obtaining an attorney through local Legal Aid services. – DAP has a contract with Legal Aid to provide representation for our clients. – DAP clients can also choose to utilize private attorneys for representation. – DAP staff cannot tell the client which attorney to choose to represent them. 11/2/2020 30

Medical Review Team • DAP staff may seek advice from the Medical Review Team (MRT) as to whether the individual should pursue an appeal by forwarding the SSA information and the DAP file. • The MRT will: – Recommend whether or not the individual should pursue the appeal any further. – Certify the individual as disabled if enough information is available. – Provide a comprehensive report, including a vocational assessment, for cases they certify as disabled. 11/2/2020 31

Medical Review Team Cont. • MRT reviews two types of cases: – Individuals pursuing Federal disability benefits (SSI/SSDI). § Provides advice to DAP staff on appealing an initial denial to an ALJ. § Attorneys can use the MRT reports at ALJ hearings. Ø DAP staff must have a signed HS 1815 Authorization for Use or Disclosure of Personal Information in order for the MRT reports and/or case development letters or medical documentation received to be shared with the client’s attorney. – Individuals applying for a Federal category of Medical Assistance, including retroactive coverage (and not required to pursue SSI/SSDI benefits or are in the application/appeals process for the SSDI only), that requires a disability certification. § Children with Special Needs (PH 95) § Individuals who were denied SSI/SSDI due to non-disability reasons. § MAWD *For more information as to when the MRT is able to make an independent disability determination, DAP Staff should refer to PMA-19579 -305. 11/2/2020 32