Assisting PATH Clients’ Applications
for Supplemental Security Income (SSI)/
Social Security Disability Insurance (SSDI) Benefits
An Edited Transcript of the
PATH National Teleconference Call
July 8, 2003
PRESENTERS
Yvonne Perret, LCSW-C
Executive Director, Advocacy and Training Center, Cumberland, MD
Jeremy Rosen, B.A., J.D., National Law Center on
Homelessness and Poverty, Washington, DC
Virginia McCaskey, Policy Analyst, Office of Program Development and
Research, Social Security Administration, Washington, DC
MODERATOR
James Winarski, M.S.W.
Advocates for Human Potential, Inc.
For additional information, please contact Advocates for Human Potential (AHP), Inc.
490-B Boston Post Road, Sudbury, MA ~ (978) 443-0055
Assisting PATH Clients’ Applications for SSI/SSDI BenefitsJuly 8, 2003
Welcome and Introductory Remarks
James Winarski
Good afternoon, everyone, and welcome to this PATH national presentation, Assisting
PATH Clients’ Applications for SSI/SSDI Benefits. My name is Jim Winarski, and I’m
the Director of Homeless Programs at Advocates for Human Potential in Sudbury,
Massachusetts. We, in collaboration with Policy Research Associates, are the technical
assistance contractors for the PATH program, and I will be serving as your moderator
for today’s presentation.
There are more than 100 people participating on this call from all over the country,
including staff from PATH-funded service provider agencies and representatives of
State and Federal government. We are pleased to have with us today three nationally
recognized experts in the area of Social Security benefits, who have prepared
presentations specifically for the PATH audience.
Please note that four documents supporting today’s presentation are available for
viewing and downloading at the PATH Web site, www.pathprogram.samhsa.gov. These
documents include, first, the SSI/SSDI review questions that will guide today’s
presentation. Second, there is an audio file of a presentation by Jeremy Rosen and
Yvonne Perret, Access to Public Benefits for People Who Are Homeless, which was
given at the We Can Do This homelessness training conference. Third, there is a link to
the Social Security Administration’s Services to Homeless Web site and a link to the
transcript from our November 2000 PATH national presentation on the eligibility and
appeals process for Social Security Administration (SSA) programs.
Today’s telephone presentation will be divided into the five segments that are described
in the SSI/SSDI teleconference review document that is posted on the PATH Web site.
The segments are as follows:
.. Communication with SSA and Disability Determination Service (DDS) agencies
.. Staff preparation
.. Training
.. Medical records and forms
.. Continuing eligibility and continuing disability reviews
The primary objectives for this telephone conference are to identify critical points in the
application process; to identify actions needed to support applicants at these points; and
to examine resource implications for providing effective assistance, including the
possible use of PATH funding. Our presenters today will provide a brief introduction for
each of these segments. We will open the lines for approximately 10 minutes of
questions and answers after each segment and again at the end of the presentation.
Before I introduce our presenters, I would like to introduce a special guest that we have
with us today, Ed Beane of the SSA, to say a few words of welcome to kick off today’s
presentation. Ed is the team leader at SSA for the services to the homeless workgroup.
He represents SSA at senior policy meetings with the Interagency Council on
Homelessness, and he developed SSA’s homelessness plan and the SSA report to
Congress titled Increasing Access and Services to SSA Benefits by the Homeless.
Edward Beane
Thank you very much, Jim. I also would like to thank Mike Hutner, Director of the PATH
program at SAMHSA. I’m absolutely delighted to participate with you today. As part of
the fiscal year 2003 appropriation, the Senate language required the SSA to do three
things: to participate in the United States Interagency Council on Homelessness; to
prepare an agency-wide plan for the implementation of activities designed to end
chronic homelessness within 10 years; and to provide a status report to the House no
later than September 30, 2002. All three of those activities have been completed, but
we expect to continue and hopefully enhance our activities to provide services to the
homeless population in the demographic group that we serve.
We developed the www.socialsecurity.gov/homelessness page. It contains the SSA’s
homelessness plan, the reports to Congress, and the report to Philip Mangano, who is
the Executive Director for the United States Interagency Council on Homelessness. The
Web page also features thumbnail sketches of some of the collaborations we have
undertaken, including the Health Care for the Homeless program at the Health
Resources and Services Administration, with Jean Hochron; the Serious and Violent
Offender Reentry Initiative at the Department of Justice, with Sherry Nolan; and the
PATH program at SAMHSA, with Mike Hutner.
The Web page contains some compelling policy and related program instructions, as
they relate to homeless populations and our role in serving them. The first one, on
institutionalization and pre-release procedures, is consistent with the Department of
Justice’s Serious and Violent Offender Reentry Initiative: We can adopt procedures with
penal institutions to provide individuals with an opportunity to file for benefits prior to
their release from prison, to minimize the gap from application to receipt of SSI or
disability insurance payments and, hopefully, the ancillary benefit of Medicaid services.
Another related program instruction is that of the Representative Payment Program,
which supports homeless populations with mental illnesses and/or co-occurring
problems, such as drug or alcohol-related illnesses. Representative payees can play a
significant role in managing benefits on behalf of an individual who files for and
successively receives disability insurance and/or SSI.
The booklet titled Understanding SSI is “the Bible” of SSI, and I hope it is beneficial to
community-based organizations and providers. It is available on the SSA Web site. This
morning, I approved the updated booklet for 2003, which contains a spotlight on
homelessness and describes the disability determination process that DDS agencies
use. The document should help everyone who serves homeless populations.
We convened our interagency workgroup on homelessness last November. I was
extremely pleased to have in attendance not only Philip Mangano, but also one of our
presenters here today, Jeremy Rosen. As most of you know, and I quickly learned, Mr.
Rosen has played a large role in successfully advocating for additional funding for SSA
outreach to homeless populations, regardless of benefit eligibility. I was very pleased
that Jeremy could help kick off the workgroup meeting.
We meet monthly to discuss issues and activities relevant to homeless populations. In
addition to that, I attend bi-weekly senior policy meetings in Washington to discuss how
all the Federal agencies, such as the departments of Housing and Urban Development,
Health and Human Services, and Justice, can collaborate in an intergovernmental way,
hopefully to bring chronic homelessness to an end within 10 years. From my
perspective, the senior policy managers and senior staff at the agencies are committed
to doing so, as a result not only of congressional assistance, but also of the President’s
initiative.
Again, thank you for inviting me here today. Issues related to homelessness will be my
focus for the immediate and foreseeable future, and I welcome the opportunity to work
with you, Mike Hutner, and other Federal agencies to bring homelessness to an end
within 10 years. Thank you, Jim.
Speaker Introductions
James Winarski
Thank you, Ed. We appreciate you taking the time to be with us this afternoon. At this
time I’d like to introduce our featured experts in their order of appearance: Yvonne
Perret, Jeremy Rosen, and Virginia McCaskey.
Yvonne Perret is a psychiatric social worker who was the program director of the SSI
Outreach Project in the Community Psychiatry Division of the University of Maryland
Medical System from 1993 through 2002. She also managed the intensive case
management program, which helps homeless adults who have serious and persistent
mental illnesses gain access to SSI and other benefits and explore the possibility of
presumptive SSI benefits. In 2001, the SSI program was named a best practice
program by the National Alliance to End Homelessness. Ms. Perret has 25 years of
social work experience, and she has worked in the areas of foster care, geriatrics, child
abuse, child neglect, and mental health. She is the author of several articles and of
Children with Disabilities: A Medical Primer, currently in its fourth edition.
Ms. Perret was president of the Mental Health Association of Maryland from 2000
through 2002. She is vice president of the Adult Services and Prevention Committee
and a board member of the National Mental Health Association. She also is the
recipient of several awards for advocacy and social work. Ms. Perret will present our
first four segments and respond to questions throughout.
Second, we have Jeremy Rosen, who is a staff attorney at the National Law Center on
Homelessness and Poverty in Washington D.C. Mr. Rosen received a B.A. from the
University of Wisconsin, Madison, in 1994 and a J.D. from George Washington
University of Law School in 1998. Before joining the center, Mr. Rosen was a staff
attorney with Legal Services of Greater Miami, where he co-directed the Homeless
Legal Assistance Project and specialized in government benefits law. At the National
Law Center, Mr. Rosen focuses on issues relating to the receipt of SSI, food stamps,
Temporary Assistance for Needy Families (TANF), and other mainstream public benefit
programs used by homeless people. He monitors nationwide activity affecting the
access of homeless people to benefits, and he devises legal and policy strategies to
ensure that Federal and State agencies take affirmative steps to help more homeless
people receive the income assistance to which they are entitled. Mr. Rosen will present
our fifth segment today and respond to questions throughout the conference call.
Third, we have Virginia McCaskey, who works as a policy analyst in the SSA’s Office of
Program Development and Research. She has been with SSA for almost 6 years and
has worked in a variety of settings, including the Office of Employment Support, which
develops work incentive policies and materials, and the Office of Disability Programs,
which develops policy on disability determination processes. Prior to entering Federal
service, Ms. McCaskey worked in community mental health in Indiana for 16 years.
Virginia will respond to questions throughout the conference call.
At this time I’d like to turn our telephone conference over to our first presenter, Yvonne
Perret.
Yvonne Perret
Thanks, Jim. Initially I’d like to give a very brief introduction to explain why we focus so
much on SSI and SSDI. The first and most obvious reason is that it is extremely difficult
to serve homeless people unless they have a stable place to live and access to needed
services, which they cannot get unless they have a steady source of income. SSI can
provide that source. Once SSI is acquired, it can also be used as a building block for
people to begin or return to work and to further their recovery, which obviously are
extremely difficult to do if their basic needs are not met.
As State deficits continue to build and cuts are made, State entitlements are
increasingly threatened. It is extremely important for all mental health providers to know
how to access Federal dollars through SSI and Medicaid. In addition, “block granting”
of benefits, such as TANF, is increasing as a Federal strategy, and it can pose very
difficult problems for people with disabilities. Also, a proposal to cap Medicaid benefits
is in the works. We need to focus on ensuring that all people who are eligible for
mandatory Medicaid benefits receive them, and certainly SSI is an avenue to access
Medicaid.
There is a pressing need for providers who are skilled in helping individuals gain access
to benefits. We want to use this call to listen to your program needs and to begin to
provide information to help programs evaluate their services related to SSI and SSDI.
Your questions are a jumping-off point for starting this dialogue.
Communication with SSA and DDS Agencies
Yvonne Perret
As you know, the SSI/SSDI eligibility determination process is a collaborative one
between SSA and the State DDS agencies. The DDS agencies are located in State
departments of government, such as the department of education or rehabilitation
services. Homeless people have particular issues with the SSI/SSDI process. For
example, they may have very severe illnesses that impede their ability to provide
information. They often lack the ability to follow through with appointments, due to
illness or practical reasons, such as transportation. Homeless people also lack an
address and phone, which obviously affects their ability to participate in the process.
It is critical that homeless providers ensure that these issues are addressed and that
homeless individuals are an integral part of the process. Setting up meetings with local
SSA managers, inviting the DDS professional relations staff to meet with you, and
understanding the intricacies and requirements of the application process are ways of
moving things along and having effective communication.
Toward that end, we have asked you to talk about the questions that were sent to you.
The first question concerns whether your organization has a designated person to be
the liaison to the local SSA and DDS offices, or whether this function is performed by a
number of staff persons. A related point concerns whether or not you have contact with
a professional relations officer in your State DDS office. Both are key strategies for
helping to facilitate communication with SSA and DDS agencies.
Question and Answer Period
Q. I’m the discharge planner here at the guidance clinic. Many of my homeless clients
don’t have their birth certificate and Social Security card when they apply for Social
Security disability benefits or SSI. How can we get past that point?
Jeremy Rosen
Sometimes it’s important for case managers and other staff at homeless programs to
work with people to reconstruct documents they either never had or lost while they were
homeless. Birth certificates are an important form of identification for obtaining photo
identification and a replacement Social Security card. One way to begin is to work with
the person to request a copy of the birth certificate from the vital records office in the
State where the person was born.
Technically, however, an identification document is not required when applying for SSI.
If applicants know their Social Security number, they should be able to go to the Social
Security office and give their number to the claims representative, who can then access
personal information such as date of birth, location of birth, and parents’ names. The
representative can have the applicant verify the information by asking questions such
as, “When were you born?” “Where were you born?” “What was your mother’s maiden
name?” If the applicant responds accurately, the representative can accept the
application without ever seeing a photo ID.
Edward Beane
A Social Security card and/or a Social Security number are not even necessary. We
can obtain a record based on the individual’s name and year of birth, querying our own
databases to obtain a number. The lack of a Social Security number should not be a
barrier.
Yvonne Perret
We have used that approach a lot, sometimes when an individual has a number that is
unclear.
Q. My question pertains to missing Social Security cards. What if an individual is not
from this country but did obtain a Social Security card and, having lost it, has no
other identification? Can they go through the same system to get it replaced?
Edward Beane
The person can request a replacement card if they have proof of identity. I believe it
also depends on your age.
Yvonne Perret
We have been able to use medical records to show identity.
Jeremy Rosen
Yvonne has an excellent point. Sometimes it’s necessary to get creative at finding ways
to verify identity for people who lack immigration papers, a passport, or other
documents. Medical records, school records, military records, and other types of public
records can be used. The Social Security Web site lists the types of documentation that
may be used and provides a printable copy of the form for requesting a new card, along
with instructions.
Yvonne Perret
It obviously would be difficult to get a birth certificate for an individual who was not born
in this country, so you may want to use some alternate form.
Virginia McCaskey
For a number of reasons, it would be helpful to try to reconstruct or get copies of any
original identity documentation. When I worked in community mental health, this issue
came up often. At times, depending on their status, immigrants can request help from
the Immigration and Naturalization Service (INS), but family members in the country of
origin often can obtain copies of records. It takes time, but individuals who were not
born in this country may want to try to obtain copies of their identity documentation.
Q. I work with the Asian population. In my experience, when someone lost his or her
Social Security card and we wanted to apply for a new one, the Social Security
office sent us to the INS office to obtain documentation before beginning the
process to get a new number—even though the person’s record had been coded to
show lawful alien status.
Jeremy Rosen
Yes, that’s been my experience.
Yvonne Perret
Also, lawful alien status is not always coded when a card is issued.
Edward Beane
We require an unexpired document issued by what is now the Department of Homeland
Security (DHS). I lead the workgroup for the Asian-American/Pacific Islander Executive
Order. Often our staff sends applicants from U.S. territories for Social Security number
applications (SS5s). Frankly, this is the first time I’ve heard of this issue, even from the
Asian community; I didn’t know we had an Asian homeless community as well.
James Winarski
An Internet listener has suggested getting a baptismal certificate to help obtain other
replacement identification.
Jeremy Rosen
I suggest looking at the Social Security Web site. In fact, I am looking at it right now
and can confirm that the SSA requires both evidence of identity and evidence of
citizenship or lawful immigration status for those born outside of the United States. The
Web site contains a detailed list of documents that satisfy those requirements. My best
advice is that sometimes, especially for those born outside the United States, it’s
necessary to get creative. I’ve actually had people contact relatives in other countries to
send documents.
Q. There’s no documentation for those who left countries such as Cambodia, Laos, and
Vietnam 20 or 30 years ago, even if they have a relative in their home country.
Yvonne Perret
Also, sometimes it is difficult for programs to fund the process of obtaining immigration
papers, because it is expensive and time-consuming.
Staff Issues
Yvonne Perret
The next segment focuses on staffing, including what kind of staff programs have and
what kind of staff are needed to be effective in gathering and developing information for
disability determination. Programs need clinically skilled, curious, creative, and
energetic staff who are flexible and understand the information that is needed for
disability determination. Outreach workers who engage homeless people and maintain
contact with them are essential to helping them through the disability determination
process, which can be fairly lengthy.
Ideally, a team approach that includes medical staff and other mental health staff,
psychiatrists, nurses, social workers, and case managers can be tremendously effective
in providing needed service and gathering information. Even if staff are not housed in
one program, helpful collaborative and cooperative agreements can be made. Often,
homeless people have had inconsistent treatment histories and may need additional
medical or psychiatric workups, as well as a host of other services.
We want to think not only about staff credentials, but also about whether we have the
positions and staff that have the creativity, flexibility, and passion for doing this work
effectively. Fostering relationships with other providers, such as medical and
psychiatric providers, also can serve the client well. We’re asking you to think about
and ask questions about how you deal with staff issues and what kinds of concerns you
have.
Question and Answer Period
Q. Ed, I wanted to ask you a question about people who are going into local lock-ups
and lose their SSI. Is that automatic? Is there any way we could streamline that
approach in terms of reinstatement?
Edward Beane
It is automatic. If they’re incarcerated more than 1 month, they become ineligible.
Jeremy Rosen
The rule specifically states that individuals who are in jail for an entire month will have
their benefits suspended. If they are in jail for more than 12 months, their status will
change from suspended to terminated. That requires them to start over from scratch
and reapply, which becomes very difficult. Individuals with suspended status, such as
those who are incarcerated for 2 months, must go to the local Social Security office
upon release with a copy of their release paperwork, and benefits should be restarted
fairly promptly. To reiterate, a person’s benefits are suspended when they’re in jail for a
full month. If someone is arrested and is in jail for a few days, their benefits should be
unaffected.
Edward Beane
The actual payment status is N02, eligible but not payable. If an individual record is
eligible and not payable for 12 consecutive months, then that record is terminated, and
the benefit payments can’t be reinstated without a full application.
Yvonne Perret
It is very important that individuals bring their release papers with them when they go to
the Social Security office upon release. There is no way to speed the process; they are
not eligible until release, and it’s very difficult to do any re-determination while they’re
still in prison. However, a Social Security field representative or a community worker
may obtain the paperwork and visit the person in prison to begin completing it, so that
the paperwork can be put through quickly upon his or her release.
Virginia McCaskey
Specific questions are arising that, ideally, could be answered by calling your field office
and asking someone you know. I hear similar questions every time I speak with
providers who serve homeless people. I want to underscore the importance of
communication with SSA and DDS agencies. Relationships with field office staff can be
helpful in getting to the root of recurring problems and resolving them.
Q. I do outreach. When my team picks people up upon discharge from the hospital who
have no identification and are from another country, it’s difficult to help them
because INS is about 6 months behind. Obviously, 6 months to wait for
replacement of a lost green card is a lengthy period for a person with no source of
funding and nowhere to live. Are there are any ideas that I could share with my team
on how we could better assist these individuals?
Edward Beane
When I was in New England and had relationships with the regional INS staff there, I
could call them and get information.
Q. That’s not how it works in Chicago, unfortunately. In the past, there was a number
you could call to get information, but it is no longer in service. You can stand in a
line that is several blocks long on Mondays, Wednesdays, or Fridays, and the
client’s name may or may not be called. Also, clients are asked for their 18 or 22-
digit green card number, which most clients don’t have. Even with the number, there
is a waiting period of at least 6 months for a green card. I’ve worked with people
who have paid the $135 fee and not received their card within 6 months. Can you
offer us any problem-solving strategies? Is there someone at SSA who could deal
directly with these kinds of cases?
Edward Beane
This is an ideal issue to address at the senior policy level. The Department of
Homeland Security sits on the Interagency Council on Homelessness. I don’t know if
this issue has arisen before with DHS, but hopefully, we could work together to expedite
a resolution.
Yvonne Perret
It’s worth calling the manager of the Social Security office you deal with and
brainstorming with him or her about how the issue can be addressed, because it is a
problem for both your program and SSA. Explore whether a link can be established with
INS to facilitate a resolution while the larger policy questions are being discussed.
People need to understand what you’re up against, and sometimes they don’t until you
sit down with them and say, “These are the issues we run into, particularly with our
homeless clients. How can we work together to facilitate better service?” If that is
ineffective, bring the issue to the next level within the office.
Edward Beane
If it doesn’t work and you’re having difficulty dealing with a manager, e-mail me at
ed.beane@ssa.gov.
Jeremy Rosen
In my experience, in Miami, there was a relationship between the Social Security office
and the local INS office, and the Social Security office sometimes was able to obtain
documentation. If that’s not possible, there are important things that Social Security
staff can do if they understand the problem. For example, if you apply for benefits and
can’t verify immigration status, the application typically is denied. However, because
I’ve developed a relationship with local Social Security offices, the offices have agreed
to hold applications open with the understanding that I was actively trying to get the
documentation. Although it may take several months to obtain the documentation, it’s
useful to have the application held open, because if it is approved, the client will receive
retroactive benefits. It’s much better, for example, to apply today, have the application
held open for a few months pending documentation, have it processed, and receive
benefits dating back to today. Waiting 3 months to obtain documents before applying
may result in the client missing out on 3 months of benefits.
James Winarski
It’s time for us to move on to our next segment. We are pleased that we have had so
many questions regarding frontline issues, but we also wanted to encourage
administrators to raise issues or questions about programmatic, strategic responses for
developing relationships with SSA offices, keeping in mind that PATH funding may be
available to support those strategies.
Training
Yvonne Perret
Training is a critical issue for all staff. It’s not just about making sure people know what
to do. It is about making sure that all of the observations that each staff person makes
about a client’s behavior are put together appropriately and comprehensively. To do
that, we all have to understand the requirements of the disability determination process.
Staff often have had some experience and training in this process, but sometimes they
do not have the whole picture and feel frustrated and discouraged. Ensuring that all staff
are thoroughly trained means better service and more accurate determinations for our
clients. Staff will put their effort where it will have the most impact. Training also can
lead to improved morale when staff feel more effective.
Training is a priority for making work effective. That is why we’re asking you to consider
the questions we sent on training.
Question and Answer Period
Q. For several years, I have been the sole benefits specialist for the department of
mental health. Previously, I was a disability examiner for a DDS agency. Why don’t
DDS agencies use presumptive disability more often, for those who meet the strict
eligibility requirements of the department of mental health and receive case
management? DDS could accept a letter from us and fulfill the presumptive
disability, allowing the client to receive benefits while we fill in the blanks.
Virginia McCaskey
That would be an attractive solution. You know, as a past examiner, that DDS agencies
have a vested interest in making a fast decision. The problem with presumptive
disability is fear of reversals; it’s likely that examiners would be judged harshly on the
basis of reversals. There is nothing that would prevent DDS agencies from using
presumptive disability, if they were certain that the evidence was solid.
Q. The problem is that presumptive disability is usually found in individuals who have a
fatal illness or are blind. When it comes to mental illness, even a letter by the
treating physician stating the diagnosis and prognosis does not result in presumptive
disability. It would be wonderful if they taught medical students how to write reports
for Social Security, so they could provide us with the correct information needed for
a determination.
Virginia McCaskey
If you allege an impairment that meets one of about 13 severe conditions, such as a
terminal illness or Down Syndrome, SSA regulations permit the field office to make a
decision of presumptive disability.
DDS agencies are State offices and have more discretion. The agencies can use
presumptive disability at any point during the development of the case if they feel
certain that the claim will be successful. There is, however, some variation. DDS
agencies are subject to regulations, but we have contracts with the States that allow
them discretion in terms of how they implement the requirements. If the DDS agency in
your State is not willing to use presumptive disability, schedule a meeting with the
administrator and/or the medical relations officer at the DDS to discuss it.
Yvonne Perret
One possibility is to propose a pilot approach toward using presumptive disability,
saying, “Let’s try it with x number of individuals. We will submit the information, gather
everything to prove it, and see the outcome.” That minimizes the risk of reversals and
allows for problems to be addressed.
Edward Beane
A manual we’re producing in collaboration with the PATH program is going to be helpful
in addressing this issue. Also, field offices can make presumptive disability and
blindness decisions. The Understanding SSI booklet lists the criteria for presumptive
disability that allow the claims representative in the Social Security field office to make
an immediate decision. Did you want to know why the DDS agencies don’t take
advantage of presumptive disability?
Q. Yes, especially because of two factors. First, the department of mental health
eligibility requirements are very strict. Second, the requirements correspond to those
of Mass Health, which provides the Medicaid function in the State and uses the
same manual that the DDS agency uses. Individuals that meet Mass Health or
Medicaid eligibility may be denied eligibility for Social Security by the DDS agency,
even though the requirements are exactly the same.
Virginia McCaskey
We encounter the same issue in Indiana, where I work. Indiana is a 209B State, which
means that it makes separate determinations. There are about 12 States that do not
adopt the SSI decision.
Regarding guidelines and training for physicians, SSA has a professional relations
branch that has developed a number of training materials for physicians, including a
module on mental health. The materials are not yet available, but when they are
released, I can make them available for dissemination through the PATH program.
Q. I’m very interested in the idea of developing a relationship with someone in the SSA
office, and I hadn’t heard of the title or position of professional relations officer
before. Is a professional relations officer available in every local office? Also, are
the managers and supervisors in the local offices aware that their role includes
having a relationship with different agencies to help answer questions?
Virginia McCaskey
The position of professional relations officer—or, as some States call it, medical
relations officer—exists in the State DDS agency. There is one officer in every agency.
The officers are coordinated at the national level by the professional relations branch in
the Office of Disability Programs at the central SSA office. You can call the state DDS
agency and ask for the professional relations officer or medical relations officer by title.
These officers have two main functions. One is to find consultative examination
providers and establish contracts with them to provide for consultative exams. This is a
problem in some areas, particularly with specialty providers, and can delay disability
decisions. The other responsibility that the officers have is to educate medical providers
in the State about SSA evidentiary requirements, including reports, and to try to
establish good relationships with providers. In many States, the medical relations
officer is available to make presentations or train staff in your organization.
Yvonne Perret
Our medical relations officer, in Maryland, is wonderful and does a lot of work with
community providers. I encourage you to contact the officer in your State and discuss
ways to collaborate.
Jeremy Rosen
In addition, I would stress the importance of developing a relationship with a supervisor
or manager, particularly at a local office that is used frequently by your clients. That
person is able to make decisions such as whether to hold open a claim while you gather
evidence, rather than issuing a denial, or otherwise facilitating or accommodating
particular applications.
Virginia McCaskey
It might help to make a brief explanation about the role of the field office and the DDS
agency. The field office handles administrative functions, including the development of
income and resources, the verification of applicants’ identity, and the identification of
benefits that individuals may receive if they are found medically eligible. The DDS
agency deals with medical eligibility questions. It is important to contact the correct
office. For example, if you call the DDS agency to discuss immigration issues, you will
be referred to the field office.
Q. How can we assist people whose benefits are suspended when they are
hospitalized? While we are working to have their benefits reinstated, they have no
resources for medications or housing, and they are forced to live on the street.
Yvonne Perret
For individuals who are receiving benefits and paying rent when they enter the hospital,
and who expect to be released within 90 days, the hospital can provide a statement
confirming that their release is expected within that time frame. Their SSI check then will
continue to be issued for up to 90 days if the funds are needed to pay rent and maintain
housing, so that individuals will not lose their living situation. For individuals who are
hospitalized for more than 90 days, you can do a pre-release procedure to complete
some of the paperwork, but the individuals are not eligible until they are released from
the hospital.
Edward Beane
That is true except for individuals with no other source of income whose hospital stay
was being paid by Medicaid. Those who were receiving a full SSI payment and no
Social Security Disability or Veterans Administration payment are covered by the
provisions of Section 9115, which provides for payment continuation in the case of
hospitalizations of 90 days or less. Otherwise, individuals’ benefits are capped at $30
per month. For those who have another source of income, reinstatement of SSI
requires the field office to be notified of their release from the hospital.
Medical Records, Forms, and Procedures
Yvonne Perret
For our purposes, a discussion of medical records should include procedures that
programs use to submit medical records that are essential to disability determination.
Program staff should keep in mind that, because the DDS agencies use medical
records to make disability determinations, the submission of the records is absolutely
critical.
It’s extremely important to ensure that the information from the record that is provided is
comprehensive, addresses the person’s illness and impairments that are being treated
by your program, and is sent quickly. Often, processing releases from the medical
records department is handled by staff who are unfamiliar with the process, and helpful
information from the records is not included. Outreach staff must ensure 1) that all
pertinent information from the records is sent; 2) that the DDS agency knows about all
of the relevant treatment sources; 3) that ongoing contact is made with the agency
about information that has been sent and received; and 4) that releases of information
are done in accordance with HIPAA and State regulations. Otherwise, the DDS
examiner and the medical records staff are unaware that important information is
missing. Outreach workers and case managers must ensure that comprehensive
information is sent to DDS, or the claim will be decided based on incomplete
information.
Jeremy Rosen
It is important not only to provide information from your own agency, but also to
recognize that it may be necessary to get medical information from individuals’ previous
treatment providers, possibly for follow-up by SSA or the DDS agency. Staff who work
with clients must be cognizant of the need to ask clients about other places where they
have been treated in the past and to try to complete missing information, sometimes
using detective work.
Virginia McCaskey
One of the questions we sent to you concerns faxed medical records. Faxing records to
the DDS agency can be very important because it saves time. The DDS agencies
maintain vendor files, and they send out automated requests for information to the
address that your agency has identified as the place for medical records requests to be
sent. If you have not previously identified yourself as a contact—for example, on the
green disability report form—it’s very helpful to include a cover letter with the medical
records that you send. The letter should include your direct phone number so that the
examiner can contact you to request additional evidence if necessary.
Provide your contact number up front. If you have medical evidence, you can bring it to
the field office when you file the claim or you can mail it. In other words, don’t wait for
the office to send a request.
Yvonne Perret
If an individual is hospitalized or receives an additional diagnosis or new treatment, that
information should be provided. It doesn’t have to be submitted at the beginning of the
process. It is helpful to provide information as things change, because sometimes
individuals are connected with services along the way. As long as the process
continues, you should continue submitting information.
Question and Answer Period
Q. Our agency has moved to computerized records, and the records are not very
specific. In the past, we have tried to include a letter from our psychiatrist or
physician describing symptoms and providing other information, but we have had
some difficulty with obtaining disability determinations in relatively clear situations.
Are there specific issues that should be included in the letters, or if there is a better
way to provide that information?
Yvonne Perret
Typically, records are fairly good concerning diagnosis and treatment, but they don’t
address how a person’s impairment affects his or her day-to-day functioning. That is
one of the critical pieces for a finding of disability, in the context of functioning related to
work. For example, if a person has a great deal of difficulty maintaining personal
hygiene due to depression, it would be difficult to maintain a job. There are four
categories of functional issues that SSI and the DDS agency use that need to be
addressed. Those issues may not be included in your records or letters. The four
categories are activities of daily living, social functioning, concentration, and persistence
and pace. The latter concerns a person’s inability to sustain his or her attempt to work.
In a fairly broad way, activities of daily living include what we all need to do to be able to
work. We need to be able to get up on time, get clean, get dressed, feed ourselves,
maintain a stable living situation, pay our bills, and either drive or use public
transportation. For our purposes, activities of daily living go beyond the minor ones that
we think of for occupational therapy evaluations, for example.
Social functioning concerns a person’s ability not to be sociable, but to communicate
and interact clearly with other people in a sustained way and to continue to function.
Can the individual communicate clearly? Is he or she comfortable around other people?
Does the person easily become agitated or aggressive? You can gather information on
how individuals function in terms of relationships by determining how they relate to
people in their lives, including you. In conversation, are they able to be with you? Do
you notice them getting very anxious? Is the conversation difficult to follow?
Concentration, persistence, and pace concern a person’s ability to stay on task and
complete the task in a way that’s comparable to other people. In terms of work settings,
can the individual remember and follow directions? Can they follow them consistently
for more than one day? These questions are related to cognitive functioning.
Persistence and pace also concerns whether a person has tried to work three or more
times in the last year, become symptomatic, and been unable to sustain the effort to
work.
It is important to assess how a person functions and whether impairments are tied to the
illness. If they are, you must articulate that. It can be stated in very simple language,
rather than in psychiatric language, such as, “Yvonne is so depressed that she cannot
get up on time in the morning and only bathes once a month.”
Virginia McCaskey
It’s probably more effective if you give very specific examples. Within the DDS agency,
all cases are sent to a psychiatrist or psychologist for review. There must be a sufficient
description of symptoms to support the diagnosis you provided. The functional
categories are critical.
In addition, we must take into account the effects of structured settings. For example, if
someone is being released from the hospital and must move to a group home because
he or she is unable to function independently, it should be noted that the person’s
functioning is fairly high because of the effects of the structured setting. Also, discuss
other types of assistance, such as outreach provided by case managers to a semi-
independent apartment setting.
The effects of medication or other treatment also should be discussed. Your reports
definitely should note whether an individual experiences significant side effects or has
developed long-term problems, such as Tardive Dyskinesia, that cause symptoms. For
a person undergoing a series of electroconvulsive treatments, the reports should note
whether they have developed memory or drowsiness problems.
Jeremy Rosen
This issue cannot be stressed enough. I used to work as an attorney trying to put
together individual disability cases. We routinely contacted treating physicians and
asked them to provide just this type of letter. We always provided a one-page guidance
document about the kinds of things that would be helpful to include in the letter.
Unfortunately, physicians are very busy and sometimes didn’t look at the document.
Sometimes we received a letter that, instead of providing information, states a
conclusion. It is important to note that it is the SSA’s job to make the conclusion about
whether or not a person is disabled. It doesn’t particularly help to just have a conclusion
in the letter, such as, “This person has schizophrenia, they’re disabled, and they can’t
work.” What’s important is that Social Security receives the information, the diagnosis
of schizophrenia, and all of the information about the person’s functioning and, most
likely, inability to function. By providing that information, you allow SSA to reach the
conclusion that the person is disabled and unable to work.
Yvonne Perret
Your role is to provide observations of behavior that lead to the conclusion that the
person has a disability.
Virginia McCaskey
We do need an acceptable medical source to provide a diagnosis and support for that
diagnosis so that we can find that the person does indeed have an impairment. The
other types of information on functioning can be provided by a case manager or by a
social worker at the agency that has contact with the patient. We can accept
information about functioning from family members and from treatment providers who
are not psychiatrists or psychologists.
Continuing Eligibility and Continuing Disability Reviews
Jeremy Rosen
As we move into this last segment of the call, we’re shifting gears a bit. What we’re
talking about now is what happens after the individual receives a favorable decision and
is ready to begin receiving benefits. The work of the individual client, and you as the
case manager in assisting that person, is not over at this point. There are several more
steps in the process that are extremely important and that may require your help.
First, you must ensure that your clients remain financially eligible for benefits, so that
they don’t run into any problem with income, resources, immigration status, or anything
that derails them from having their benefit checks start. Second, you may need to help
your client find a representative payee to manage his or her benefits, or you may decide
to become a representative payee yourself.
Third, you may need to help a client who is having a continuing disability review. Every
few years Social Security will re-evaluate an individual’s case to be certain the person
continues to be disabled. This involves a new review process where Social Security
determines whether or not the person has had any medical improvement. The case
manager can help clients turn in documents and fill out forms to help demonstrate,
typically, that the individual has not improved.
Question and Answer Period
Q. I want to expand on the point of co-occurring disorders and how the Social Security
Administration is going to consider this diagnosis in making any future
determinations. Typically if alcohol and drugs are documented, the disability is not
accepted. I’m wondering if this is going to be considered in the future as part of
determination.
Jeremy Rosen
I think it’s important to be clear about the current rules because I know there is a lot of
confusion about what they are. The actual Social Security rules do not say that
because there is alcohol or drug use a person will be denied. That is not the case.
What the rules actually do say is that Social Security should evaluate these claims by
determining whether or not the individual would remain disabled if, hypothetically, the
drug and alcohol use ceased.
For example, I used to represent homeless clients who had a long history of alcohol
use, and many of them received disability benefits based on cirrhosis of the liver,
because that was an ongoing condition that disabled them. Even if they stopped
drinking tomorrow, hypothetically, they had been drinking for so long that this disabling
condition would not go away. It was, at that point, a chronic condition. So that, I think,
is a standard under which claims should be evaluated.
Yvonne Perret
When you’re looking at someone with a mental illness and a substance use disorder, it
is very difficult, sometimes, to tease out what affects what. Often, if you can get a
comprehensive enough understanding of the substance use and its context, you can
arrive at a more accurate conclusion as to whether the person would remain disabled
even if he or she became sober. This involves asking a lot about past history, including
trauma history and past symptoms of the mental illness that may not have been treated
but were there. So it’s not necessarily a question of when the person started treatment
and for what, but what was going on in their lives.
It behooves to get a much better understanding of what led to the substance use, what’s
going on with it now, and why the person picks particular substances. Usually it’s not a
random choice; it’s because a certain drug leads to a certain feeling. Sometimes this
drug use may be to deal with symptoms of their illness. So if we can find out more
about that and explain it, it becomes clearer both to the treatment folks and to the DDS.
I hope that helps.
Virginia McCaskey
I don’t have any argument with anything that either Jeremy or Yvonne just said. The
way that SSA actually approaches this issue is based on changes in the law Congress
made a few years ago that no longer permit us to pay benefits on the basis of a
substance abuse diagnosis alone. So when there are co-occurring disorders, the way
that Social Security approaches the determination is to make a decision first about
whether the person is disabled. Then we apply a standard about whether the
substance abuse is what we call material to a finding of disability. As Jeremy noted, the
fundamental question is, if the person stopped using today, would he or she still be
disabled?
So one of the other issues that you might want to address is the client’s psychiatric
history. Very often, if you go back far enough, you find that some form of depression or
other type of psychiatric disorder pre-dated the substance use. This is one of the things
that’s important in looking at materiality. The other thing is the possible presence of
end-stage organ damage or neurological problems that are the result of long-term
drinking and that are not going to improve even if the person stops drinking. So those
are the kinds of things that I would urge people to address in the medical records that
they send to SSA.
Q. How can basic income security help clients achieve recovery and employment
goals?
Edward Beane
That’s a great question. We’ve begun discussions between our employment programs
and the Department of Labor. I look at it in terms of access to mainstream programs.
But what happens from there? I think that if you asked a homeless person what he or
she wanted, he or she would say, “I want a place to live.” So if we can get someone
into a supportive housing situation and help them gain access to treatment, we’ve
elevated them to some degree. There are many programs, such as IDAs and PATH
programs, that can help individuals who receive SSI to obtain homes and resources.
There are even programs that allow individuals to set aside money to buy their own
homes.
Yvonne Perret
It’s extremely difficult to think about managing and recovering from depression or a
psychotic illness when I’m in a living situation that is so unstable and so frightening,
quite frankly. So I think that SSI can provide, as Ed said, a beginning for gaining
stability and a place to live, and ensuring that I have the food and other things that I
need. Then I can focus on things that go beyond survival. Cleary, we have to address
the fundamental needs first, because that’s what all of us as humans need on a very
basic level. When we talk about SSI, it’s certainly not true that people get to have
whatever they need, but it’s a start. So we who are working with folks really need to
think of it as a start and not as an end-point. Sometimes we feel like getting SSI is such
a struggle that we breathe a sigh of relief and say, “There, that’s done.” Well, actually
it’s just the beginning.
Edward Beane
I couldn’t agree with you more. What focuses it even more in my own mind is sitting
with other senior policy folks from other agencies. It seems to me that every Federal
agency does a wonderful job of articulating what programs and policies they administer,
and it ends there. There’s no discussion of how we can work together toward a
common goal. The key, I think, is going to be Federal agencies educating each other.
The current thinking seems to be that if we all hold hands and stick together, we can get
something done. But that’s just the beginning.
Yvonne Perret
It is important to have input in calls like this and other kinds of forums from people who
are really out there doing this work, so that what you intend to have happen when
policies are passed is really what happens, because sometimes there are unintended
consequences.
Concluding Comments
Yvonne Perret
It’s clear to me from the questions that there a lot of concerns about how this whole
process works. However we can brainstorm to help answer these questions, I certainly
am willing to do so. I think it’s hard sometimes to ask questions when some of the parts
of the process are unknown. So we’ll just keep plugging away at it.
Jeremy Rosen
I agree. Before we end, I’d like to put in a plug for something which may be of
assistance, at least in the future. Both Yvonne and I, along with Michael Hutner and the
PATH program, and along with Ed and Ginny from Social Security, have spent quite a
lot of time working on an SSI manual. The manual is designed to take people through
this process from beginning to end, and it includes material that would answer a lot of
the questions that we’ve heard today on this call. We hope this manual will be available
by the end of this year or by early next year. I believe it will go to all PATH programs
and also will be available on the Internet.
Virginia McCaskey
I’d first like to thank everybody for calling in today. We got a lot of really great
questions, not all along the lines of what we were expecting, but it certainly gives us
things that we want to continue to work on, such as the immigrant issues and the pre-
release procedures and getting information out to people about these issues.
I worked for a long time in community mental health, and if I had known then what I
know now, I probably would have been able to get Social Security benefits for
everybody the first time. We wouldn’t have had too many denials. There is a lot of
information out there already, a lot of resources on our Web site and in other places,
and it really is worth it to educate yourself about the process to try to do a better job of
assisting your clients. If there are further questions or suggestions for Social Security
on how we can improve the quality of our information to the public and to service
providers, let us know.
James Winarski
I like to thank our presenters today—Yvonne Perret, Ed Beane, Jeremy Rosen, and
Virginia McCaskey. Your expertise is most impressive. You did a wonderful job, and I
thank you for being a friend of the PATH program. Your help means a great deal to us.
Also, I want to thank our director, Mike Hutner. He’s the Director of the PATH program
at SAMHSA, and he has been upfront on this issue for a long time. He deserves a
great deal of credit for really pushing it forward, because it’s an issue of critical
importance for the population we serve. It means a great deal.
Also, a special thank you to Margaret Lassiter, who is with Policy Research Associates;
Margaret did a tremendous amount of work on this call, the documentation, and the
Web site.
Thank you, especially, all of you in the audience, for your interests, for your continued
efforts, and for your dedication to serving the most vulnerable people in our nation. My
hat’s off to you all. I hope this was helpful to you. I encourage you to use the resources
that are listed on our Web site and to remember that the audio link, as well as a
transcript of this call, will be posted soon. If you know other folks who weren’t able to
attend the call, please let them know that this information is available.
This is the end of our call.