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

 

 

 

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

 

 

 

(A)  What is the supplemental security income (SSI) case management program?

 

(1)   The SSI case management program is an effort to identify individuals applying for or in receipt of disability financial assistance (DFA) who may be potentially eligible for SSI and to help the individual them in obtaining financial assistance from the social security administration (SSA). The Ohio department of job and family services (ODJFS) and the county departments of job and family services (CDJFS) agency shall cooperate in efforts to assist applicants and recipients who might be eligible for SSI.

 

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

 

(3)    Each county agency shall establish an SSI case management program or join with other county agencies to provide a joint SSI case management program in accordance with section 5115.20 of the Revised Code. For applicants and recipients of DFA who might be eligible for SSI, the county agency may enter into a written contract for services with attorneys and non-attorneys that in the judgment of the county agency have demonstrated expertise in representing individuals seeking SSI. The agreement should take into consideration whether or not a direct-fee payment has been entered into between the attorney/non-attorney with the SSA before a fee will be paid by the county agency in accordance with paragraph (H) of this rule.

 

(4)    SSI case management eligibility determination functions shall be set up to ensure that the individual does not experience unnecessary delays or hardships throughout the referral process and the determination of the final SSI decision.

 

(B)  What is the application and appeals process?

 

(1)   The process for qualifying for SSI begins with filing an application at the local SSA office. The local SSA office establishes non-medical 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)opportunities for ohioans with disabilities (OOD) division of disability determination (DDD). DDD 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 received by SSA within sixty days of each decision unless good cause for a late filing can be established.

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

(b)    A denial of the reconsideration may be appealed to a hearing before an administrative law judge. This is the only time that the applicant is seen in person by someone making the disability determination. For this reason it is important that when SSI benefits are denied, 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 for disposition.

(C)    How and when are individuals identified and referred for SSI case management services?

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

(2)     Referrals shall be made to the SSI case manager by the eligibility, social services or other agency worker when any of the factors listed below are known to the agency:

(a)   The individual has an SSI application pending.

(b)   The individual has a condition which is identified as potentially meeting or meets any of the conditions listed in 42 United States Code (U.S.C.) 1382c (12/2004).

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

(d)The individual has received a notice of termination of SSI benefits for lack of disability.

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

(f)(e) Any other time the county agency believes a referral is appropriate.

(3)   The referral to the SSI case manager shall 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 is expected to last twelve months or more.

(c)   Status and date of SSI application.

(d)     Copies of information pertinent to the individual's SSI application including any existing medical information, as well as a copy of the JFS 07319, "Authorization for Reimbursement of Interim Assistance Initial PaymentClaim or Post Eligibility Case", (rev. 05/2001)(rev. 4/2014) or the JFS 07233, "Authorization for Reimbursement of Interim Assistance Initial Claim or Posteligibility PaymentCase", (rev. 05/2001)(rev. 10/2013) if applicable.

(D)  What are the program responsibilities and how long shall services be provided?

(1)     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 eligibility for disability, he/she may contact the Ohio office of medical assistance's (OMA) disability determination unit (DDU) for technical assistance.

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

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

(4)      Individuals applying for or in receipt of DFA shall receive SSI case management assistance at all stages of the SSI application and appeal process.

(5)   SSI case management program services shall be provided to an individual until:

(a)   SSI is approved;

(b)    All avenues for seeking SSI through administrative appeals with SSA have been exhausted;

(c)   DFA has been denied or terminated; or

(d)     The  individual  has  been  referred  to  and  is  being  represented  by  an attorney or non-attorney.

(6)    When a DFA recipient relocates from county "A" in which a claim is initially filed, to county "B", county "B" shall assume responsibility for the SSI case management activities.

(7) Individuals referred to the SSI case management program shall be required to apply for medicaid. The determination of disability for individuals pending an SSI determination is made by OMA in accordance with rule 5101:1-39-03 of the Administrative Code. If, as a result of the OMA decision, the county agency determines that SSI case management services shall be denied, the JFS 07334, "Notice of Denial of Your Application for Assistance," (rev. 09/2011) shall also indicate the denial of SSI case management services.

(E)  What are the advocacy duties of the case manager?

The SSI case manager's advocacy duties include:

(1)   Arranging interviews with the SSI applicant to discuss the case manager's roles.

(2)       Assessing the individual's needs including the ability to complete the application and if necessary, assisting the individual in completing an application for SSI and accompanying the participant to the SSA office for the application interview.

(3)     Developing with the individual a social, medical and employment history (SSA-3368-BK, "Disability Report-Adult" {www.ssa.gov } eff. 04/201010/2015).

(4)    Assisting the individual and if necessary acting for the individual in obtaining available hospital, physician, pharmacy and other medical documentation of disability, and if needed, help with making, keeping, and rescheduling appointments with medical examiners and assisting with transportation.

(5)   Assisting the individual in obtaining social and vocational documentation.

(6)   Developing and maintaining contact with the local SSA and DDD.

(7) Submitting all completed medical documentation as required under rules 5101:1-5-20 and 5101:1-39-03 of the Administrative Code to OMA when the county agency assigns this duty to the SSI case manager.

(8) Establishing and maintaining communication with OMA. and taking the necessary action as stated on the JFS 03600, "Ohio Department of Job and Family Services County Medical Services Section Disability Determination," (rev. 5/2006).

(9)(7) Reviewing SSI denial notices, medical reports, and assisting the individual in appealing any SSI denial and gathering additional medical information, if necessary and consulting with DDU for technical assistance to determine the feasibility of appealing the decision.

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

(11)(8) Assisting the individual in submitting forms timely as required for each level of the SSI appeal and advocating for the individual at the appeal or at the hearing.

(12)(9) Assisting the individual in securing an attorney or non-attorney to provide appropriate representation if the individual desires or when the SSI case manager deems it to be in the individual's best interest.

(13)(10)  Representing  the  individual  in  appealing  an  SSI  denial  if  the  county agency offers this service to individuals.

(14)(11) Signing the SSA-1696-U4, "Appointment of Representative," ({www.ssa.gov} eff. 03/20117/2014) during the SSI application process if the SSI case manager is representing the individual. This will result in a copy of all notices with information pertaining to appointments for consultative examination, noncompliance on the part of the individual, etc. sent to the individual also being sent to the SSI case manager.

(F)   What are the administrative duties of the case manager? The SSI case manager's administrative duties include:

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

(2)(1) Informing the appropriate eligibility worker, if applicable, of the individual's failure to keep scheduled appointments.

(3)(2) Notifying the eligibility 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 the ODJFS state verification and exchange system (SVES).

(4)(3) Notifying the eligibility worker, if applicable, of the individual's failure to pursue reconsiderations or appeals of SSA decisions that deny SSI benefits.

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

(6)(4) Performing the eligibility worker duties associated with the individual's DFA and/or medicaid case, when the county agency assigns these duties to the SSI case manager and sending a JFS 07365, "Application for Release of Interim Assistance Reimbursement (IAR) to Attorney or Representative of an SSI Applicant," (rev. 10/2007) to whom an individual has chosen for representation.

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

(8)(6) Maintaining a tracking system of all individuals and their progress. This applies even when an individual has been referred to alternative representation.

(G)  How are individuals informed about representation and appeals?

(1)    The SSI case manager shall inform participants applying for or in receipt of DFA, of all available sources of representation in reconsiderations and appeals of SSA decisions that deny them SSI. Each county agency should contact its county bar association for a list of attorneys willing to handle SSI cases.

(2)   The sources of representation include:

(a)   Attorney;

(b)   SSA approved non-attorney;

(c)   SSI case manager;

(d)  Non-attorney not approved by SSA; or

(e)   Self-representation.

(H)  How is payment to the attorneys and SSA-approved non-attorneys made?

(1)    Section 302 of the Social Security Protection Act (SSPA) of 2004 extends the current attorney fee withholding and payment process under title II of the Social Security Act (as amended as of the effective date of this rule) (the Act) to claims for benefits under title XVI of the act. Section 303 of the SSPA has implemented the same fee withholding and payment process for non-attorneys approved by the SSA through an examination process. Title II of the act refers to the retirement, survivor's and disability insurance (RSDI) and Title XVI of the act refers to the supplemental security income (SSI) program. The SSA will make a direct payment of fees to an attorney or SSA approved non-attorney who successfully represents an SSI claimant from the

beneficiary's past-due benefits.

(a)   For cases in which a fee agreement and representation authorization by the attorney/approved non-attorney is on record with the SSA (of which, the attorney/approved non-attorney has not waived a fee or waived direct payment) and the case is approved after February 28, 2005, SSA is required to pay the attorney fee from the RSDI or SSI past-due benefits that result from a claim even if the claim was filed before the February 28, 2005 effective date.

(b)    For RSDI claims, the attorney/approved non-attorney shall be issued a written notice from the SSA of the dollar amount of the past-due benefits. The claimant shall also be issued a written notice from the SSA of the dollar amount of the past-due benefits payable to the claimant. For SSI claims, the attorney/approved non-attorney shall be issued a notice from the SSA regarding the amount of the fee and the claimant shall be issued a notice from the SSA of the amount of the retroactive payment.

(c)   Each case involving interim assistance reimbursement (IAR) to the county agency which also involves an attorney/approved non-attorney, SSA will submit a SSA-L8125-F6, "IAR Payment Pending Case: State Due Payment******Priority Handling" ({www.ssa.gov} eff. 03/20064/2012) at the time that the individual has been awarded an SSI claim for benefits.

(i)   The county agency shall complete the section titled "States Account of Reimbursement Claimed" and must return the form to the SSA within ten working days;

(ii)    The SSA will then reimburse the county agency for the IAR paid upon the approval of SSI benefits; and

(iii)     The attorney/approved non-attorney shall be paid directly by the SSA.

(d)     Notification of either approval or denial is sent by the SSA to an attorney/approved non-attorney in all cases where a representative agreement has been filed with the SSA. In cases where a fee is not charged, the claimant receives a notice from the SSA that the attorney/approved non-attorney agreed not to charge a fee.

(e)     If a county agency receives a JFS 07365 from an attorney/approved non-attorney for payment of a successful SSI claim, the county agency shall request a copy of the SSA notification. If the attorney/approved non-attorney reports that he or she has not received a notice from the SSA and has filed with the SSA to represent the claimant, the county agency shall refer the attorney/approved non-attorney to the local SSA office to resolve the issue and provide verification. SSA notice verification will ensure that fees are not paid to the attorney/approved non-attorney by both the SSA and the county agency when claims have been approved.

(2)   An individual may be eligible for reimbursement from the county agency when a contract has been entered into with the county agency in accordance with section 5115.20 of the Revised Code provided the individual has not received or applied to receive payment from the SSA.

(3)   In IAR cases where the attorney/non-attorney has not waived the right to collect a fee, the county agency shall request that the representative provide verification from the SSA that he has not received payment or has not applied for payment on the SSA claim. Once verification is provided, the county agency shall follow the claim procedure outlined in rule 5101:1-5-70 of the Administrative Code.

(I)  How are payments made to non-attorneys that are not approved by SSA?

(1)      In accordance with the provisions set forth in this rule, a non-attorney representative who does not meet SSA qualifications may still represent DFA individuals who apply for or have been denied SSI benefits. The non-attorney representative who successfully appeals an SSI claim may receive payment from the county agency for services rendered when the requirements set forth in paragraph (J) of this rule for fee payment by the county agency have been met.

(2)   Non-attorney representatives who do not meet the qualifications set forth by the SSA may not receive a direct fee payment for representation of approved SSI claim awards from the SSA.

(J)   When are fees paid by the county agency?

(1)     Fees shall be payable by the county agency only when the following has occurred:

(a)     The attorney/non-attorney who has not received notice of SSA direct payment has represented the DFA individual in a successful reconsideration or appeal of the SSI denial;

(b)   The attorney/non-attorney has filed a JFS 07365 with the county agency within sixty calendar days of the issuance of the SSI award letter;

(c)   The attorney/non-attorney has provided the following documents:

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

(ii)      Either a signed waiver of the right to collect a fee from the individual or a copy of the SSA or court order which authorizes the attorney/non-attorney to collect a fee; and

(iii)   A bill for services rendered.

(2)   Upon receipt of a completed application (including, if applicable, a copy of the SSA or court order which authorizes the right to collect a fee) the county agency shall within fifteen calendar days either deny the application, stating the reason for the denial on the JFS 07365, or approve the application and indicate on the JFS 07365 the amount of the IAR received by the county agency and the amount of the reimbursement to be paid as a fee. The county agency shall provide a copy of the JFS 07365 to the attorney/non-attorney representative and to the SSI claimant. The fee shall be paid within thirty calendar days of the county agency approval and shall be the lesser of the following:

(a)   Twenty-five per cent of the individual's SSI award;

(b)   The amount of the IAR received by the county agency;

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

(d)  The amount billed by the attorney/non-attorney.

(3)   There shall be no IAR fee payable by the county agency to an individual who elected to represent himself in the SSI claim process or to a county agency or county agency employee who may be representing an individual in the SSI

claim process.

(4)   An attorney/non-attorney who has made an application for a fee with the county agency and believes that the county agency has made an incorrect decision on the application may, within fifteen calendar days of the decision, file a written request for a review with the "Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825." The review request shall include a copy of the county agency decision on the JFS 07365, an explanation of why the decision is incorrect and any supporting documentation. The availability of this review, whether or not utilized, is not intended to restrict the availability of any judicial remedy the attorney/non-attorney may have against a county agency.

(K)    Is it required for a county agency to coordinate with local alcohol, drug addiction, and mental health services for SSI case management?

(1)   The county agency SSI case managers are encouraged to work with their local alcohol, drug addiction, and mental health services boards where applicable to assist each applicant or recipient with securing support from the most appropriate source or program available as set forth in Ohio Revised Code section 5115.22.

(2)   If the SSI case manager finds that the SSI applicant may be in need of mental health services, the individual 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. . 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.

Effective:                                                             10/01/2016

Five Year Review (FYR) Dates:                         08/01/2018

CERTIFIED ELECTRONICALLY

Certification

09/19/2016

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 (Emer.),

12/2/91, 11/1/92, 7/1/98, 7/1/03 (Emer.), 9/30/03,

7/1/08, 8/15/13