1024 eWall Street
Suite 100
Mt. Pleasant, SC 29464
ph: 843.416.1102
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Whether an individual is struggling with the effects of the aging process, a mental illness, or a physical disability, government benefits may be appropriate. In our practice, we help our clients to obtain Medicaid in order to pay for care in a facility or at home. We also help our clients to obtain Social Security Disability (SSDI) and Supplemental Social Security (SSI) if they are unable to work. On this page, we will share some information on these government benefit programs.
Medicaid
Medicaid is South Carolina's grant-in-aid program by which the Federal and State governments share the cost of providing medical care for needy persons who have low income. South Carolina began participation in the Medicaid Program in 1968.
Individuals who meet financial and categorical requirements may qualify for Medicaid. States are required to cover certain groups (mandatory groups) and states are given the option of covering other groups (optional groups).
Historically, Medicaid eligibility rules have been closely linked to those of the cash assistance programs such as the Family Independence Program (FIP), previously known as Aid to Families with Dependent Children, or the Supplemental Security Income (SSI) program. However, in recent years, Congress has given states more flexibility in establishing policies for the different coverage groups. At the same time, Congress has added more mandatory coverage groups and placed more requirements on some of the services provided.
Because the State and Federal governments share the cost of the Medicaid Program, States are given some flexibility in providing coverage to its needy citizens. For this reason, the rules for Medicaid coverage vary from state to state.
The South Carolina Medicaid Program sponsors the payment of long-term care for those individuals who reside in licensed and certified nursing facilities. Medicaid also pays for special services for those individuals who participate in Home and Community-Based Waiver services. The same eligibility requirements apply for both programs. The difference is that the individuals who need nursing home care, but who choose to stay at home rather than going to an institution, can receive special services through a waiver to help them remain in the home.
The Department of Health and Human Services (DHHS) determines eligibility for all Medicaid programs except Supplemental Security Income (SSI). Individuals who apply for Supplemental Security Income (SSI) through the Social Security Administration, and who are determined eligible, are generally eligible for Medicaid.
Applicants must meet financial and non-financial eligibility standards. To be categorically eligible for Medicaid an individual must be either under age 19 or over age 65, or blind or disabled according to SSI criteria, or pregnant. Low-income families with dependent children may also be eligible.
Individuals eligible for Home and Community-Based Waiver Services are also entitled to these services:
· Hospital Services– Medicaid will pay for inpatient and outpatient hospital services, including inpatient psychiatric services for individuals under age 21 and services for individuals age 65 or older in institutions
· Nursing Home – Medicaid will pay for health services delivered in an inpatient facility that provides 24 hour nursing care, supervision, and services to individuals who are unable to perform their own activities of daily living due to illness or disability
· Pharmaceutical Services - Medicaid will pay for most prescription drugs and some over the counter drugs if the physician writes a prescription for them. Medicaid will pay for no more than three prescriptions per month for each recipient.
· Physician Services - Medicaid will pay for inpatient or outpatient physician services or the services of a certified nurse midwife who is employed by a physician or hospital.
· Dental Services - Medicaid may pay for certain services through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for individuals under the age of 21. Medicaid will also pay for emergency dental services for recipients age 21 and over.
· Community Long Term Care (CLTC) - CLTC is a series of services designed to help individuals who might otherwise require nursing home care remain at home, thereby avoiding unnecessary or premature nursing home placement. These services may include, among other things, personal care aide, attendant care, home management, environmental modification, home delivered meals, adult day health care, respite care and personal emergency response system.
· Other Medicaid Services - This covers a variety of services including, among other things, Vision Care, Rural Health Clinic services, Laboratory and X-ray services, and the purchase of Durable Medical Equipment. Other services covered under this category include Ambulance and Medical Transportation, Podiatrist Services, Home Health Services, and certain therapy services.
· Family Planning - This service includes counseling, diagnosis, treatment, and birth control drugs and supplies prescribed or furnished by a physician.
· Hospice Services - This service is available to recipients who have been certified to be terminally ill with a life expectancy of six months or less.
Social Security Disability--Defined:
In order to be eligible for Social Security disability, you must be "disabled." For Social Security purposes, a person is "disabled" if he/she has a medical problem that prevents that person from working. In addition, the medical problem must be severe enough that it will last at least a year or severe enough where it might result in death.
As a practical matter, Social Security disability is primarily about a person's ability to work. Stated another way, in order to prove that you are disabled, you often need to prove that you cannot work even a simple, unskilled job. For example, imagine yourself working as an packer, where you sit at a table and pack items in a box; imagine yourself as a cashier at a parking lot; imagine yourself as a nighttime security system monitor. Could you perform one of these very simple, low stress, low exertion jobs 8 hours a day, 5 days a week?
Note the emphasis on your ability to perform a simple job. It is not enough to have a serious medical or mental health problem. You must have an identifiable medical problem and that problem must prevent you from functioning in a normal work environment.
Note the duration requirement. Your medical problem must prevent you from performing work, and your problem must be serious enough that it will last a year or longer, or result in death.
The 365 day requirement does not mean that you must wait one year before you apply - you can and should apply if you think that there is a reasonable chance that you will be out of work for a year. If it turns out that you can go back to work you can cancel your Social Security disability application. Because SSDI and SSI cases take so long to be processed through the system, it makes sense to apply as soon as you realize that your medical or mental health condition may be a long term problem.
There is no such thing as short term disability for Social Security purposes. There is also no partial disability. Either you meet the definition or you do not.
As you might expect, you cannot simply walk into a Social Security office, announce that you are "disabled" and start collecting checks. In the disability system, you, as the claimant, have to prove that you meet Social Security's definition of disability.
The Social Security Administration also looks at your work history to determine what type of benefit you will receive. The Disability program is available to you if you have worked at least five out of the past ten years (the work requirements can be slightly different for younger workers). If you do not have sufficient earnings paid into the system, you will not be eligible for Title II Disability, but you may be eligible for Supplemental Security Income.
Social Security's disability claim evaluation process has evolved into a complex and often confusing system that involves multiple levels of appeals and review. Your appeals must be filed within 60 days from the date of your denial. The application process starts when you contact Social Security to file a claim. It ends when a disability adjudicator or an administrative law j judge makes a decision in your case.
When or Why Should I hire an Attorney to Help Me with My Disability Claim?
You can hire a lawyer to represent you at any stage in the disability application process. You may wish to hire a lawyer early in the process when:
Some people choose to represent themselves at the initial application and during the reconsideration appeal. Most of the communication you will have with Social Security will be through written forms and you will not have to appear before any judge at initial or reconsideration. If you do choose to represent yourself prior to requesting a hearing remember:
Very few people try to represent themselves at a hearing and that is a good thing. Although Social Security hearings are more informal than typical state court hearings, there are rules of evidence and procedure that need to be considered. In addition, you may be required to cross examine a medical doctor serving as a medical expert or a vocational expert serving as a vocational witness.
More significantly, if you do not have a clear theory of your case that brings into play both the medical basis of your case and the vocational implications, you will find it difficult to effectively present yourIf you choose to hire an attorney, most cases are handled on a "contingency" basis, meaning that the attorney is paid only if the case is won. An attorney's fee is typically 25% of any past due benefits collected for you not to exceed $5,300.00. As a rule, you should always hire a lawyer to assist you at your hearing.
Note that an experienced lawyer can be very helpful to you in many ways. First, your lawyer can make sure that you have applied for all disability programs for which you are eligible. For example, disability claims offices sometimes "lose" files or fail to process them timely. Just about every claimant's lawyer has had to argue that any evidence of a communication with Social Security is enough to prove that an application was filed, thereby counting as a "protective filing" and preserving the claimant's rights.
A lawyer can also determine if you are eligible to "reopen" old applications. In some cases, a prior application, even one filed three or four years earlier, can be reopened, thereby making you eligible for years of back benefits and thousands of dollars. If you ever filed an old application, or even if you simply called Social Security to inquire about benefits, you could lose our if you fail to look into reopening an old application. Make sure to tell your lawyer about any old applications or communications with the Social Security Administration.
Your lawyer can evaluate your case and suggest a strategy to win your case. After handling hundreds of cases, most attorneys have a fairly good perspective as to what cases are winnable and what cases are not, and what it takes to win a case. While an attorney's opinion is not a determination of how your case will end up, he/she can offer you the benefit of experience. More importantly, if you decide to hire an attorney, he/she will make sure that your case file is up-to-date with all medical records. In addition, he/she will work with your doctors to "translate" your medical problems into work limitations so that Social Security can evaluate your claim proper.
Social Security Disability (SSDI)
Applying for social security disability and SSI benefits, with or without an advocate can be difficult due to how long a claim may take and the high chance of being denied. But those who are denied disability can win benefits by utilizing the appeals process. To increase the chances of winning, applicants should learn about the system and file an appeal when a claim is denied.
1. Regardless of what anyone tells you, it's good advice, if you are disabled and unable to work, to pursue a claim for Social Security disability, or ssi based on disability, and get it filed immediately. Reason: disability claims can take a very long time to process. This isn't true in all cases, but it is in most. Unfortunately, many claimants for disability benefits have experienced severe problems and hardship simply because they had no idea how long the process would be, and only realized when it was too late that they should have filed an application much much sooner.
2. If you are denied on your Initial Claim, it's good advice to get an attorney or non attorney Representative to provide representation and help you with your claim for continuing and past due benefits (back pay).Reason: the way the disability system works, a claimant will, typically, either be approved on an initial application...or will be forced to follow the appeal route, at least to the point where their case is brought before an Administrative Law Judge at a social security disability hearing. This is not always the case, but it is generally a predictable rule of thumb (*reconsiderations usually have a much higher rate of denial than initial claims--and initial claims are denied 60 to 70 percent of the time, depending on the state in which you filed. For this reason, most claimants will have to go to a hearing if they hope to be approved--and going to a hearing unrepresented is foolish).
3. If you think you may have problems doing the paperwork for your social security disability Claim, take some advice and find qualified assistance immmediately. An extraordinary number of persons who apply for benefits, or file an appeal following a denial, fail to properly complete their paperwork, or fail to submit their forms in a timely manner (*all appeals for disability must be filed within 60 days of the date of the last denial).
4. Advice: Since your Social Security Disability or ssdi claim will be evaluated completely on the basis of your medical records, the best advice is to get regular, ongoing medical treatment.Reason no.1: Even if your past medical records indicate that you are disabled, an examiner or judge will not be able to approve your claim for continuing benefits if current medical records are not available to substantiate your claim.
Reason no.2: If you attempt to get a supporting statement from your doctor (an RFC is much better), you may have difficulty getting your physician to cooperate if he/she has not seen you recently. If you lose your medical coverage before your claim for benefits is approved, as is usually the case, try to be seen at a free clinic, county health department, or emergency room. While these treatment sources are not the best, they are, simply put, better than nothing. Another avenue to pursue may be with your state's Vocational Rehab department. Very often, VR can assist claimants in getting certain testing and examinations paid for. Though this is always for the purpose of developing a VR claim, vr counselors are usually willing to supply these records to a claimant's representative as well.
Just remember this advice: as a general rule you cannot be approved for social security disability or ssdi based on disability if you are not seen by a medical provider at least once every two months.
5. Advice: Try your best to stay compliant with your prescribed medications. In the end, whether you took your prescribed medicine or not may affect how your impairments are viewed. In fact, judges will often deny claims in which claimants did not take what was prescribed. The fact that the claimant had no means by which to obtain their needed meds is generally irrelevant to an ALJ at a disability hearing.
6. Stay friendly with the people working on your case, even if your case has experienced problems along the way (long waits, misplaced paperwork, etc). This includes the people at Social Security and Disability Determination Services, as well anyone who might represent you. The disability process can be anxiety-provoking at times, but maintaining good relations with the individuals working on your case is good advice to practice. The truth is: these individuals usually have very many cases to work on and literally hundreds of phone calls each week to deal with (this is absolutely true). How you last communicated with one of these individuals can make the difference as to whether or not your case gets more attention, or less.
7. Have your treating physician complete an RFC form on your behalf. RFC stands for residual functional capacity. RFC forms are used by DDS examiners (each examiner must have their unit physician or psychologist complete the appropriate physical or mental RFC form before a claimant's case can be closed) and carry great weight, particularly at hearings held by Administrative Law Judges.
8. Never call the Social Security Administration's 1-800 information number to get updates on a disability claim. The information supplied by the call center reps at the 1-800 number is routinely and consistently incorrect. Speaking from experience, in the last couple of years, we have spoken with no fewer than forty or fifty disability claimants who had questions and were given blatantly wrong information regarding the disposition of their claims, causing them great anxiety as a result. To get updates on a disability case, call either the social security office where you filed, or the disability examiner at Disability Determination Services. And, if a hearing has been requested, call (or, better yet, have your representative call) the Office of Hearings & Appeals since, at that point, the social security office will know very little about the pending status of a disability claim.
9. Always (repeat: always) keep copies of everything you ever submit to either the social security office, Disability Determination Services, or the Office of Hearings & Appeals. Though items generally get where they should after being mailed, some social security field and district offices are notorious for losing mail or claiming never to have received mail (The Durham, North Carolina District Office is exceptionally well-known for this).
10. Never presume that something you have mailed to either the social security office, disability determination services, or the office of hearings and appeals...actually arrived. In other words, several days after mailing documents (an application, appeal, medical records, etc), make a followup call to verify that the recipient agency actually received what was sent.
11. Prepare financially. Many, if not most, disability claimants do not realize how long the process may literally take. In the majority of instances, it may take as long as 2 years or more to win an approval (simply because most claimants will be denied at the initial and reconsideration levels and will then have to request, and wait for, a hearing to be scheduled).
Therefore, claimants should never rely on the time estimates offered by the social security offices where they have filed. Why? Because CR's (social security claims reps) do not process disability claims. They simply take disability applications, which are then forwarded to DDS and assigned to examiners. Once a case is at DDS, it may stay there for 30 days, or 230 days. There is simply no way to know how long a case will take to process (though a claimant can potentially speed up this process by assisting in the gathering of medical records).
With this in mind, then, claimants should be extremely careful regarding their finances. In fact, claimants with mortgages may wish to consider restructuring their debt load to "ride out" the disability process.
Copyright 2010 Lowcountry Law Office on Aging, Mental Health & Disabilities, LLC. All rights reserved.
1024 eWall Street
Suite 100
Mt. Pleasant, SC 29464
ph: 843.416.1102
acf