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Find answers to frequently asked questions.

Question:
If an applicant is approved for SSI/SSDI, will they lose their medicaid and be placed on medicare? If they can have both, which would be their primary insurance?

If a person is approved for both SSI and SSDI they will maintain Medicaid because SSI benefits include Medicaid. However, some states require a separate Medicaid application, (https://www.ssa.gov/disabilityresearch/wi/medicaid.htm).

Medicaid coverage for services varies from state to state. Here is a link that will take you to your state's Medicaid agency: https://www.medicaid.gov/about-us/contact-us/contact-state-page.html.

SSDI benefits include Medicare, but there is typically a 24 month waiting period before the SSDI beneficiary can begin to have Medicare coverage (see Page 12 at https://www.ssa.gov/pubs/EN-05-10029.pdf).

Once the beneficiary has both Medicaid and Medicare, Medicare is typically the primary insurance.

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Question:
If the applicant is working at or above Substantial Gainful Activity (SGA), is there a process that SSA can declare the applicant is disabled but on a non-pay status?

No. SSA would find that the claimant is ineligible for disability benefits because they are able to work at or above SGA level. At Step 1 of the Sequential Evaluation, the applicant would be found ineligible for benefits which includes both cash and health insurance.

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Question:
Please explain what is considered skilled and unskilled work.

A SKILL is the knowledge of the principles and the processes of a job and the ability to apply them in practice in a proper and approved way. Examples of a skill are making precise measurements, reading blueprints, setting up and operating complex machinery. SSA will determine the claimant’s skill level by the types of work he has done in the past. SSA classifies jobs as unskilled, semiskilled and skilled. SSA will look at the jobs the claimant performed in the last 15 years and determine if they were unskilled, semiskilled or skilled. The SSA will consult authoritative vocational sources such as the Dictionary of Occupational Titles to help them determine which category the claimant’s past work should fall into.

1. UNSKILLED work needs little or no judgment to do simple duties that can be learned on the job in a short period of time. This is usually 30 days or less. An example of an unskilled job is one that involves putting materials on or in, or taking them off or out of a machine. A person does not gain skills by doing unskilled work.

2. SEMISKILLED work needs some skills but does not require complex work duties. An example of a semiskilled job would be one that requires alertness and close attention to watching machine processes.

3. SKILLED work requires that a person use judgment. For example, a skilled job may require that a person determine the machine and manual operations to be performed in order to obtain the proper forms.

Practice Tip: The lower the skill level the claimant has the more likely the claimant will be found disabled. You want to try to place your client in the lowest skill level possible. For example, unskilled is better than semi-skill and semiskilled is better than skilled in a disability claim.

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Question:
Where can you find information about Medical-Vocational Guidelines (Grids)?

Here is the SSA link to the Medical Vocational guidelines, also called Grids: https://www.ssa.gov/OP_Home/cfr20/404/404-app-p02.htm

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Question:
What exactly is "equaling" a listing- does that just mean the claimant's specific condition is not listed under the body system but meets severity criteria?

If the claimant does not have an impairment that is not described in the Listings, First, SSA will find the Listing (or Listings) that is closely analogous to the claimant’s impairment. SSA will then take the medical findings related to the claimant’s impairment and compare them to those in the closely analogous listed impairment. The claimant will equal the Listing if the medical findings related to his impairment are at least of equal medical significance to those in the closely analogous listed impairment.

Under Social Security regulations, an impairment will be found medically equivalent to a Listed impairment “if the medical findings are at least equal in severity and duration to the Listed impairments.” This is done by comparing the claimant’s symptoms, signs, and lab findings with those specific for the Listed impairment; or if the condition is not Listed, with that Listing most similar to the claimant’s impairment.

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Question:
What is the link for the Dictionary of Occupational Titles (DOT)?

Dictionary of Occupational Titles: https://occupationalinfo.org/

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Question:
Should I actually include information from the Listings and Grids in the MSR, or should I wait until the applicant is denied?

The SAMHSA SOAR TA Center recommends that you don’t cite the Listing and Grid numbers, e.g.) Ms. Jones meets Listing 12.04, and the alternative Grid rule 203.03. Rather, at the DDS level (initial and reconsideration) we suggest providing a description of how the applicant meets a particular Listing(s) or Grid rule through specific examples from the medical records, applicant quotes, and other collateral sources.

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Question:
Should I file a SSI/SSDI claim when there are no medical records available?

Yes, you should file a SOAR-assisted application because even if you don’t have access to the medical evidence, DDS will request directly from prior treating sources and/or schedule appropriate Consultative Examinations (CE) to obtain diagnoses. Remember, SSA needs a diagnosis to make a disability determination. Remember, to write in the “Remarks Section” on SSA forms, about your efforts to obtain medical information so that DDS will know what they need to do to medically develop the claim.

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Question:
How do we determine the initial Residual Functional Capacity (RFC) that shows us where to begin? Is this based on the RFC that comes from DDS? How do we determine RFC before that?

If you are working on an appeal, you will want to review the file to see DDS’s RFC which was the basis for denial. DDS officially determines the RFC. DDS’ opinions take the form of RFC assessments, physical, mental, or both. Essentially, the DDS physician reviews the claimant’s medical records, including narrative reports or CEs, and prepares a written opinion. Taking the form of an RFC assessment, the opinion is expressed in terms of the physical and mental limitations that the DDS physician believes accurately describe the claimant’s capability. To find the right Grid rule, determine the claimant’s maximum RFC (and find the correct table). You are looking for the table that fits the claimant’s exertional level (sedentary, light, medium), and find the rule that fits the claimant’s other characteristics, e.g.) age, education, skill level. The specific rule will mandate a conclusion of disabled and not disabled. Remember, for a rule to apply it must be consistent with all the claimant’s characteristics. In no grid rule fits, then all evidence and factors must be considered independent of the Grids.

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Question:
Regarding SSA’s sequential evaluation, when is it considered severe in step 2 to move to step 3?

You shouldn’t worry too much about Step 2. DDS uses this step to weed out frivolous claims. At the second step, SSA considers the medical severity of an individual’ impairment(s), e.g.) health problems. An individual must have a medically determinable physical or mental impairment, (or a combination of impairments) that is severe and meet the duration requirement. To be severe, an impairment or impairments must interfere with basic work-related activities. To meet the duration requirement the impairment(s) must be expected to last twelve months or to result in death. If the impairment(s) are not severe or do not meet the duration requirement, the individual is found not disabled. If the impairment(s) are severe and meet the duration requirement, the adjudicator goes to question three.

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