5101:1-5-60 Supplemental security income case management program.

 

 

 

5101:1-5-60                 Supplemental     security     income    (SSI)     case                            management program objective and structure.

 

 

 

(A)  The SSI case management program is an effort to identify participants applying for or in receipt of disability financial assistance (DA) DFAwho may be potentially eligible for supplemental security income (SSI) and to help the participant in obtaining financial assistance from the social security administration (SSA). The Ohio department of human job and family services and county departments of human job and family services shall cooperate in efforts to assist applicants and recipients who might be eligible for SSI.

 

(B)    The objective of the SSI case management program is to ensure that individuals applying for or in receipt of DA DFAwho are eligible for SSI receive the benefits to which they are entitled and to ensure that medicaid is provided to all eligible participants. Benefits to the assistance group include increased cash assistance through SSI and more comprehensive medical coverage through medicaid.

 

(C)  Overview of SSI application and appeal process

 

(1)   The process of qualifying for SSI begins with the filing of an application at the local SSA office. The local SSA office establishes nonmedical eligibility, determines when presumptive disability exists and authorizes payment of SSI for six months while an application is pending a decision from the Ohio rehabilitation services commission's (ORSC) bureau of disability determination (BDD). BDD is the agency responsible for establishing medical eligibility.

 

(2)   If the application is denied, the claimant may file an appeal. All requests for an appeal at any level of the appeals process must be made within sixty days of each decision.

 

(a)    The first appeal is termed a "reconsideration" and is to be requested in writing by the applicant or the applicant's representative. At reconsideration, effort should be made to present additional information such as progress notes concerning the participant's ongoing treatment.

 

(b)    A denial of the reconsideration may be appealed to a hearing before an administrative law judge. It is at this stage that the participant has the greatest chance of reversing a denial. This is due to the fact that the judges are given much more discretionary authority than is accorded to the BDD disability determiner. It is also the only time that the applicant is seen personally by someone making the disability determination. For this reason it is important that when SSI benefits are denied at application those denials be appealed to the hearing level.

 

 

 

(c)    The final appeal stage, before seeking adjudication through the federal courts, is the appeals council. The appeals council reviews the hearing decision and bases its decision on the information already presented. The appeals council can grant or deny a request for review. If a review is granted, the appeals council can affirm, modify, reverse, or vacate and remand the request back to the administrative law judge.

(D)    Each CDHS CDJFS shall establish an SSI case management program, or join with other CDHS CDJFS to provide a joint SSI case management program in accordance with section 5115.20 of the Revised Code. The CDHS CDJFS may enter into a written contract for services, to applicants for and recipients of DA DFA who might be eligible for SSI benefits, with persons and governmental entities that in the judgement of the CDHS CDJFS have demonstrated expertise in representing individuals seeking SSI benefits. The contract should take into consideration whether a fee will be paid in accordance with paragraph (K)(2) of this rule.

(E)   SSI case management/IM functions shall be set up in such a manner to ensure that the participant does not experience unnecessary delays or hardships throughout the referral process and the determination of the final SSI decision.

(F)    Individuals referred to the SSI case management program shall be required to apply for medicaid. The determination of disability for participants pending an SSI determination is made by the ODHS ODJFS county medical services section (CMS) in accordance with rule 5101:1-39-032 5101:1-39-03.2 of the Administrative Code. Participants who are denied medicaid or disability financial assistance based on a CMS decision shall be given notice of the denial and of the right to a state hearing on the ODHS 7334 JFS 07334. If, as a result of the CMS decision, the CDHS CDJFS determines that SSI case management services shall be denied, the ODHS 7334 JFS 07334 containing the medicaid and/or disability assistance denial must also indicate the denial of SSI case management services.

(G)    The SSI case manager shall not represent the CDHS CDJFS at a hearing when the participant is denied medicaid based on a decision made by CMS.

(H)  SSI case management identification and referral

(1)   Participants applying for or in receipt of DA DFA with potential eligibility for SSI shall be identified and referred to the SSI case manager. Participants shall be identified at intake and at reapplication.

(2)    Referrals shall be made to the SSI case manager by the IM worker, social

services worker, or other agency worker when any of the factors listed below are known to the agency:

(a)   The participant has an SSI application pending.

(b)   The participant meets any of the conditions listed in paragraph (A) of rule 5101:1-39-0315101:1-39-03.1 of the Administrative Code.

(c)   The participant has a condition which is identified as potentially meeting the blindness or disability criteria as stated in paragraphs (D)(2) and (D)(3) of the rule 5101:1-39-03 of the Administrative Code.

(d)   The participant has been denied SSI in the past twelve months for lack of disability and has not appealed the denial.

(e)    The participant has received a notice of termination of SSI benefits for lack of disability.

(f)   The participant has been identified as potentially disabled through the use of a profile listing and/or survey form.

(g)   Any other time the CDHS CDJFS believes a referral is appropriate.

(3)   The referral to the SSI case manager must contain, at a minimum the following information:

(a)    Identifying information including name, case number, address, contact telephone number, social security number, date of birth, last grade completed, and date and type of last employment.

(b)     A brief description of the disabling condition(s), including how the condition prevents the participant from working and whether the condition has lasted or will last twelve months or more.

(c)   Status and date of SSI application.

(d)     Copies of information pertinent to the participant's SSI application including any existing medical information, as well as a copy of the ODHS 7319 JFS 07319 "Repayment Authorization for Interim Assistance Paid During Initial Eligibility Payment Period" or ODHS 7233 JFS 07233 "Repayment Authorization for Interim Assistance Paid

During Initial Posteligibility Payment Period," if applicable.

(I)  SSI case management program responsibilities

(1)   Participants potentially eligible to receive SSI are to be provided a mechanism for assistance and representation in the SSI application and appeal process. Each SSI case management program shall:

(a)   Identify participants applying for or in receipt of DA DFA who might be eligible for SSI and assist them, as necessary, in applying for such benefits.

(b)    Assist participants applying for or in receipt of DA DFA in securing documentation of disabling conditions where there is need or refer them for such assistance to a person or governmental entity with which the CDHS CDJFS has contracted.

(c)    Inform participants applying for or in receipt of DA DFA of available sources of representation, which may include the SSI case manager, a person or governmental entity with which the CDHS CDJFS has contracted and of the right to represent themselves in reconsiderations and appeals of SSA decisions that deny them SSI benefits.

(2)     The SSI case manager shall review each referral received to determine if potential eligibility for SSI exists and/or the best avenue by which to pursue a reconsideration or appeal. If the SSI case manager cannot determine potential for disability, he may contact the ODHS ODJFS county medical services section (CMS) for technical assistance.

(3)     The SSI case manager shall notify the participant in writing of services available through the SSI case management program. The SSI case manager shall interview the participant to assess the participant's needs and in consultation with the participant shall develop a plan for service. The plan should identify services to be provided to address the participant's needs.

(4)     In accordance with the provisions as set forth in rule 5101:1-5-20 of the Administrative Code and as a condition of eligibility for DA DFA, the SSI case manager shall require participants, who, in the case  manager's judgement, may be eligible for SSI, to apply for such benefits and to pursue reconsiderations and appeals of SSA decisions that deny them SSI benefits.

(5)     Participant's applying for or in receipt of DA DFA shall receive SSI case

management assistance at all stages of the SSI application and appeal process.

(6)   SSI case management program services shall be provided to participants until:

(a)   SSI cash assistance is approved;

(b)   All avenues for seeking SSI assistance have been exhausted;

(c)   DA DFA has been denied or terminated; or

(d)    The  participant  has  been  referred  to  and  is  being  represented  by  an attorney or other source of representation.

(7)   When a DA DFA recipient pending an SSI claim elects to relocate and transfer his assistance from county (A) in which a claim is initially filed, to county (B), then county (B) shall assume responsibility for the SSI case management activities.

(J)   SSI case management duties

(1)    The SSI case manager has duties which are related to advocacy and duties which are related to administration.

(a)   Advocacy duties include the following:

(i)     Arranging interviews with the SSI applicant to discuss the case manager's role; assessing the participant's needs including the ability to complete the application; and determining the participant's status regarding SSI.

(ii)       When necessary, assisting the participant in completing an application for SSI and accompanying the participant to the SSA office for the application interview.

(iii)        Developing, with the participant, a social, medical, and employment history (SSA-3368-BK "Disability Report").

(iv)   Assisting the participant and if necessary acting for the participant, in obtaining available hospital, physician, pharmacy and other medical documentation of disability, including, where appropriate,   help   with   making,   keeping,   and   rescheduling

appointments    with   medical     examiners    and    assisting    with transportation.

(v)       Assisting the participant in obtaining social and vocational documentation.

(vi)     Developing and maintaining contact with local social security administration (SSA) offices and the Ohio rehabilitation services commission (ORSC), bureau of disability determination (BDD).

(vii)   Submitting all completed medical documentation as required under rule 5101:1-39-032 5101:1-39-03.2 of the Administrative Code to the ODHS ODJFS county medical services section (CMS) when the CDHS CDJFS assigns this duty to the SSI case manager.

(viii)    Establishing and maintaining communication with CMS and taking the necessary action as stated on the ODHS 3600 JFS 3600 "County Medical Services Section Disability Determination." This includes taking any necessary action regarding recommended consultative examinations.

(ix)    Reviewing SSI denial notices and medical reports, and consulting with CMS for technical assistance to determine the feasibility of appealing the decision.

(x)   Assisting the participant in appealing any SSI denial and gathering additional medical information, if necessary.

(xi)   Assisting the participant in submitting forms required for each level of appeal within the specified time frames, and advocating for the participant at the appeal or at the hearing.

(xii)   Assisting the participant in securing an attorney or other source of referral to provide appropriate representation if the participant desires or when the SSI case manager deems it to be in the participant's best interest.

(xiii)    Representing the participant in appealing an SSI denial if the CDHS CDJFS offers this service to participants.

(xiv)    Signing the SSA-1696 "Appointment of Representative" during the   SSI   application   process,   if   the   SSI   case   manager   is

representing the participant. This will result in a copy of all notices sent to the participant also being sent to the SSI case manager, with information pertaining to appointments for consultative examinations, noncompliance on the part of the participant, etc.

(b)   Administrative duties include the following:

(i)     Ensuring that the interim assistance (IA) agreement is signed in accordance with rule 5101:1-5-70 of the Administrative Code.

(ii)       Informing the appropriate IM worker, if applicable, of the participant's failure to keep scheduled appointments.

(iii)    Notifying the IM worker, if applicable, of the status of each SSI applicant's case, including the outcome of the initial application decision and subsequent appeals. The status can be tracked through use of third party query (TPQY) ODJFS state verification and exchange system (SVES).

(iv)   Notifying the IM worker, if applicable, of the participant's failure to pursue reconsiderations or appeals of SSA decisions that deny them SSI benefits.

(v)     Notifying the IM worker, if applicable, to approve and initiate medicaid coverage when SSA approves the application for six-month presumptive disability or when CMS approves physical and/or mental disability.

(vi)   Performing the IM duties associated with the participant's DA DFA and/or medicaid case when the CDHS CDJFS assigns these duties to the SSI case manager.

(vii)      Sending an ODHS 7365 JFS 07365 to each attorney or representative source to whom a participant is referred for representation.

(viii)    Assuring that participants who are denied through the reconsideration stage are aware of the right to be represented through the administrative and judicial levels of appeal.

(ix)   Maintaining a tracking system of all participants and their progress.

This  applies  even  when  a  participant  has  been  referred  to alternative representation.

(K)  Representation on SSI appeals.

(1)   The SSI case manager shall inform participants applying for or in receipt of DA DFA, of all available sources of representation in reconsiderations and appeals of social security administration (SSA) decisions that deny them SSI. Each CDHS CDJFS should contact its county bar association for a list of attorneys willing to handle SSI cases. Another option is for the individual to represent himself. In addition, the CDHS CDJFS may offer representation by the SSI case manager if it concludes that such service is feasible. The case manager shall allow the individual to make his own choice for representation.

(2) In those cases in which an SSI only claim is awarded and representation for the participant is provided by an attorney or other source of representation, the CDJFS shall pay a fee from the interim assistance reimbursement it receives from SSA on behalf of the participant.

(3) In those cases in which a concurrent social security disability (SSD)/SSI claim is awarded and representation for the participant is provided by an attorney or other source of representation, the fee is issued by the SSA for the SSD portion directly to the attorney or other source of representation on behalf of the participant. Depending on the amount of the SSD attorney fees paid, it is possible that additional fees may be authorized by the CDJFS from the interim assistance reimbursement it receives from SSA on behalf of the participant.

(4) There shall be no interim assistance reimbursement fee payable by the CDJFS to a participant who may elect to represent himself in the SSI claim process or to a CDJFS or to a CDJFS employee who may be representing a participant in the SSI claim process.

(2)(5) In those instances in which representation for the participant is provided by an attorney or other source of representation, the CDHS shall pay a fee from the interim assistance reimbursement it receives from SSA on behalf of the participant. There shall be no interim assistance reimbursement fee payable by the CDHS to a participant who may elect to represent himself in the SSI claim process or to a CDHS or to a CDHS employee who may be representing a participant in the SSI claim process. The interim assistance payment shall not exceed the amount of the interim assistance reimbursement as defined in rule 5101:1-5-70 of the Administrative Code and shall be payable by the CDJFS only when the following has occurred:

(a)   The attorney/representative has represented the participant in a successful reconsideration or appeal of the SSI denial; and

(b)     The attorney/representative has filed an ODHS 7365 a JFS 07365 , "Application for Release of Interim Assistance Reimbursement to Attorney/Representative of an SSI applicant" with the CDHS CDJFS. The ODHS 7365 JFS 07365 must be filed within sixty days of the issuance of the SSI award letter, and must include the following:

(i)     A copy of the reconsideration or appeal order which grants SSI eligibility to the participant; and

(ii)     Either a signed waiver of the attorney's/representative's right to collect a fee from the participant, or a copy of the SSA or court order which authorizes the attorney/representative to collect a fee (or, a copy of the application for such order and estimate as to when it will be available and for warded forwarded to the CDHS) CDJFS or attorney/representative). In those cases in which a concurrent SSD/SSI claim is awarded, the attorney/representative will receive two separate fee notices from SSA, one for the SSD claim and one for the SSI claim; and

(iii)   The attorney's/representative's bill for services rendered.

(L)   Upon receipt of a completed application (including, if applicable, a copy of the SSA or court order which authorizes the attorney/representative to collect a fee) the CDHS CDJFS shall within fifteen days either deny the application, stating the reason for the denial on the ODHS 7365 JFS 07365, or approve the application and indicate on the ODHS 7365 JFS 07365 the amount of the interim assistance reimbursement received by the CDHS CDJFS and the amount of the reimbursement to be paid as a fee. The CDHS CDJFS shall provide a copy of the ODHS 7365 JFS 07365 to the attorney/representative and to the SSI claimant. The fee shall be paid within thirty days of the CDHSCDJFS approval and shall be the lesser of the following:

(1)   Twenty-five per cent of the participant's SSI award;

(2)    The amount of the interim assistance reimbursement received by the CDHS CDJFS;

(3)   The amount of fee authorized in the case by SSA or court order; or

(4)   The amount billed by the attorney/representative.

(M) In concurrent cases, if the SSD attorney/representative fee paid is less than the SSA maximum payment, an additional fee may be approved for the SSI claim as set forth in paragraph (L) of this rule, not to exceed the SSA maximum payment.

(M)(N) Any attorney/representative who has made application for a fee but who feels that the CDHS CDJFS has made an incorrect decision on the application, may within fifteen days of the decision file a written request for a review with the "Ohio Department of Human Job and Family Services, Office of Legal Services, 30 East Broad Street, 31st floor, Columbus, Ohio 43266-0423." The review request must include a copy of the CDHS CDJFS decision on the ODHS 7365 JFS 07365 , an explanation of why the decision is incorrect, and any supporting documentation. Based upon this review the ODHS ODJFS may affirm, reverse, or modify the CDHS CDJFS decision. The availability of this review, whether or not utilized, is not intended to restrict the availability of any judicial remedy the attorney/representative may have against a CDHS CDJFS.

(N)(O)  Coordination  with  local  alcohol,  drug  addiction,  and  mental  health  services boards.

(1)   If the SSI case manager finds that the SSI applicant may have significant mental health problems and is in need of mental health services, the participant may benefit from a referral for mental health services provided under a local alcohol, drug addiction, and mental health services board. Several county alcohol, drug addiction, and mental health services boards have initiated a program to expedite SSDI/SSI mental impairment claims. The CDHS CDJFS is encouraged to work with their local alcohol, drug addiction, and mental health services boards to arrange a referral agreement for those persons having significant mental health problems. Mental health professionals who treat, counsel and/or coordinate care of persons having mental health problems are key sources of information and assistance in the SSI application process.

(2)     The CDHS CDJFS is encouraged to coordinate the SSI case management responsibilities through the local alcohol, drug addiction, and mental health services boards, where appropriate.

Effective:                                07/01/2003

CERTIFIED ELECTRONICALLY

Certification

06/27/2003

Date

Promulgated Under:   111.15

Statutory Authority:   5115.20

Rule Amplifies:           5115.20

Prior Effective Dates: 2-1-88 (Emer.), 5-1-88,

5-2-88, 10-1-90, 10-1-91

(Emer.), 12-2-91, 11-1-92,

7-1-98