SR 13-12 Dated 07/13

 

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

 

DFA SIGNATURE DATE:

September 3, 2013

FROM:

OFFICE OF THE DIRECTOR, DFA JSO for Terry R. Smith

AT (OFFICE):

Division of Family Assistance

TO:

District Office Supervisors

 

SUBJECT:

Revised Policy Regarding Ineligibility for Aid to the Permanently and Totally Disabled (APTD) Cash Assistance When the Social Security Administration (SSA) Denies SSA Benefits Due to the APTD Applicant or Recipient Not Meeting SSA Medical Disability Criteria

RETROACTIVE EFFECTIVE DATE:

July 12, 2013

 

SUMMARY

 

This SR rescinds the Director’s Memo dated February 27, 2012, subject line, Final Instructions for Aligning APTD Cash and Social Security Eligibility, and releases the following clarifications related to eligibility for Aid to the Permanently and Totally Disabled (APTD) cash assistance when the individual is denied Social Security Administration (SSA) benefits due to not meeting the SSA medical criteria:

 

·      Where previously there was no time limit as to when an SSA denial due to not meeting the SSA medical criteria occurred, now only such denials that have occurred within 12 months prior to the individual’s application for APTD cash assistance will impact the individual’s eligibility for APTD cash assistance. Applicants and recipients are required to provide information related to SSA denials within:

-     30 calendar days from the date of application for APTD cash assistance for any SSA denials received within 12 months prior to applying for APTD cash; and

-     10 calendar days of having received the denial for any SSA denials received after the APTD application has been filed.

·      Previously, APTD cash assistance recipients were not allowed continued receipt of the APTD cash benefit pending an administrative appeal if the recipient filed the appeal because APTD cash assistance was terminated due to receipt of a denial of SSA benefits based on not meeting SSA medical criteria. Now, an APTD cash assistance recipient may receive continued receipt of the APTD cash benefit pending their appeal in this circumstance, when all of the following criteria are met:

-     The request for continued receipt of APTD cash assistance pending the appeal is received within 15 days from the date on the notice of the termination of APTD cash assistance. See DFA SR 13-19 for more information on the policy change from 10-days to 15-days to request continuation of benefits when requesting an appeal; and

-     Within that same 15-day time period, the individual provides documentation signed and dated by a physician, physician’s assistant (PA), advanced practice registered nurse (APRN), or psychologist which includes the printed name of the health professional, the specialty of the health professional, and the address and phone number of the health professional, and states:

A.   that the individual’s medical condition has increased in severity during the 12 months prior to the date the individual requested the administrative appeal; or

B.   that the medical condition for which the SSA based the decision to deny the individual’s SSA benefits is unrelated to the medical information upon which the Disability Determination Unit (DDU) based the decision to approve the individual for APTD benefits.

 

If the individual fails to provide the documentation above, or the documentation provided does not demonstrate that the requirements have been met, the individual is not eligible for continued receipt of APTD financial assistance pending the appeal.

 

·      Additionally, if the termination of APTD financial assistance is ultimately overturned at the appeals hearing due to the individual’s medical condition having increased in severity during the 12 months prior to the date the individual requested the administrative appeal, or because the medical condition for which the SSA denied SSA benefits is not the medical condition for which the individual was approved APTD cash assistance, the individual must provide, within 30 calendar days of the date the District Office is notified of the appeals decision, written notification from the federal agency that the individual has:

-     appealed the SSA denial, and that the appeal with the SSA includes the documentation that the medical condition for which the individual was denied has increased in severity during the past 12 months; or

-     reapplied for SSA benefits for the same medical condition for which the individual applied for APTD financial assistance.

 

If the individual fails to provide the documentation described above within the 30 calendar day time frame, APTD cash must be terminated and is not to be continued pending any appeals on this subsequent termination.

 

PREVIOUS POLICY

NEW POLICY

Individuals were ineligible for APTD cash assistance if the individual was denied SSA benefits due to not meeting the SSA medical criteria.

SSA denials will only impact APTD cash eligibility if the individual is denied SSA benefits due to not meeting the SSA medical criteria, if the denial occurred within 12 months prior to the individual’s application date for APTD cash assistance.

Applicants and recipients are required to provide information related to SSA denials within:

·      30 calendar days from the date of application for APTD cash assistance for any SSA denials received within 12 months prior to applying for APTD cash; and

·      10 calendar days of having received the denial for any SSA denials received after the APTD application has been filed.

If an APTD cash applicant or recipient appealed the termination of their APTD cash benefits because the individual was denied SSA benefits due to not meeting SSA medical criteria, the individual was not eligible for continued receipt of the APTD cash grant, even if within 10 days from the date on the notice of termination, the individual requested continued receipt of APTD cash assistance pending the appeal.

An APTD cash assistance recipient may receive continued receipt of APTD cash benefits while pending their appeal if the recipient filed the appeal because APTD cash assistance was terminated due to receipt of a denial of SSA benefits based on not meeting SSA medical criteria, only when all of the following conditions have been met:

·      the request for continued receipt of APTD cash assistance pending his or her appeal of the termination is received within 15 days from the date on the notice of the termination of APTD cash assistance; and

·      within that same 15-day time period, the individual provides documentation signed and dated by a physician, PA, APRN, or psychologist which includes the printed name of the health professional, the specialty of the health professional, and the address and phone number of the health professional, and states:

-     that the individual’s medical condition has increased in severity during the 12 months prior to the date the individual requested the administrative appeal; or

-     that the medical condition for which the SSA based the decision to deny the individual SSA benefits is unrelated to the medical information upon which the DDU based the decision to approve the individual for APTD benefits.

If the individual fails to provide the documentation above, or the documentation provided does not demonstrate that the requirements have been met, the individual is not eligible for continued receipt of APTD financial assistance pending the appeal.

Additionally, if the termination of APTD financial assistance is ultimately overturned at the appeals hearing due to the individual’s medical condition having increased in severity during the 12 months prior to the date the individual requested the administrative appeal, or because the medical condition for which the SSA denied SSA benefits is not the medical condition for which the individual was approved APTD cash assistance, the individual must provide, within 30 calendar days of the date the District Office is notified of the appeals decision, written notification from the federal agency that the individual has:

·      appealed the SSA denial, and that the appeal with the SSA includes the documentation that the medical condition for which the individual was denied has increased in severity during the past 12 months; or

·      reapplied for federal benefits for the same medical condition for which the individual applied for APTD financial assistance.

If the individual fails to provide the documentation described above within the 30 calendar day time frame, APTD cash must be terminated and is not to be continued pending any appeals on this subsequent termination.

Note: APTD cash received during pending appeals is subject to recoupment if the Administrative Appeals Unit (AAU) does not find in favor of the individual.

This policy only applies to eligibility for APTD cash assistance and does not apply when determining eligibility for APTD medical assistance.

 

POLICY

 

SSA denials will only impact APTD cash eligibility if the individual received the denial due to not meeting the SSA medical criteria, and the denial occurred within 12 months prior to the individual’s application date for APTD cash assistance. Applicants and recipients are required to provide information related to SSA denials within:

·      30 calendar days from the date of application for APTD cash assistance for any SSA denials received within 12 months prior to applying for APTD cash; and

·      10 calendar days of having received the denial for any SSA denials received after the APTD application has been filed.

 

Per DFA SR 11-27, this policy will continue to be applied differently based on the individual’s APTD cash recipient status as of June 30, 2011, but now incorporates the policy change stated above, as follows:

 

·      Individuals who were not recipients of APTD cash assistance on June 30, 2011 are ineligible for APTD cash assistance upon the first denial of SSA benefits, if that denial occurred within 12-months prior to the individual’s application for APTD cash assistance, or any time after the individual’s application date for APTD cash.

·      Individuals who were recipients of APTD cash assistance on June 30, 2011 are ineligible for APTD cash assistance upon the second denial of SSA benefits when:

-     one denial may be made prior to July 1, 2011, as long as the denial was determined within 12-months prior to the individual’s application for APTD cash assistance; and

-     at least one denial must be made any time after July 1, 2011.

 

NOTE: As of May 2013, around 70 cases exist that include an individual who was an APTD recipient on June 30, 2011. The policy released in this SR regarding individuals who were recipients of APTD cash assistance on June 30, 2011 must be applied to those 70 cases.

 

An APTD cash assistance recipient may receive continued receipt of the APTD cash benefit pending their appeal if the recipient filed the appeal because APTD cash assistance was terminated due to receipt of a denial of SSA benefits based on not meeting SSA medical criteria, when all of the following criteria are met:

 

·      The request for continued receipt of APTD cash assistance pending the appeal is received within 15 days from the date on the notice of the termination of APTD cash assistance; and

·      Within that same 15-day time period, the individual provides documentation signed and dated by a physician, physician’s assistant (PA), advanced practice registered nurse (APRN), or psychologist which includes the printed name of the health professional, the specialty of the health professional, and the address and phone number of the health professional, and states:

-     that the individual’s medical condition has increased in severity during the 12 months prior to the date the individual requested the administrative appeal; or

-     that the medical condition for which the SSA based the decision to deny the individual’s SSA benefits is unrelated to the medical information upon which the Disability Determination Unit (DDU) based the decision to approve the individual for APTD benefits.

 

If the individual fails to provide the documentation above, or the documentation provided does not demonstrate that the requirements have been met, the individual is not eligible for continued receipt of APTD financial assistance pending the appeal.

 

If the termination of APTD financial assistance is ultimately overturned at the appeals hearing due to the individual’s medical condition having increased in severity during the 12 months prior to the date the individual requested the administrative appeal, or because the medical condition for which the SSA denied SSA benefits is not the medical condition for which the individual was approved APTD cash assistance, the individual must provide, within 30 calendar days of the date the District Office is notified of the appeals decision, written notification from the federal agency that the individual has:

·      appealed the SSA denial, and that the appeal with the SSA includes the documentation that the medical condition for which the individual was denied has increased in severity during the past 12 months; or

·      reapplied for SSA benefits for the same medical condition for which the individual applied for APTD financial assistance.

 

If the individual fails to provide the documentation described above within the 30 calendar day time frame, APTD cash must be terminated and is not to be continued pending any appeals on this subsequent termination.

 

Note: APTD cash received during pending appeals is subject to recoupment if the AAU does not find in favor of the individual.

 

NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION

 

District Offices must continue to follow current developing potential sources of income policy, preventing the confirmation of any cash assistance case that does not have verified proof of application for other potential sources of income, and entering pertinent information, as it is provided by the applicant or recipient, into the “Benefits Applied For Outside New HEIGHTS” screen in New HEIGHTS.

 

New HEIGHTS is unable to make any changes related to this SR due to conflicting demands related to the imminent implementation of Care Management and the Affordable Care Act (ACA) Medicaid-related changes. Pending New HEIGHTS ability to make further changes, Family Services Specialists (FSS) must do the following to implement this policy:

 

For Individuals Who Provide SSA Denials and Were Not Receiving APTD Cash Assistance on June 30, 2011

 

·      Upon receipt of all pages of the SSA denial, the FSS reviews the SSA denial to determine the following information:

-     The date the denial was issued; and

-     The reason for the denial, which is located on the “Explanation of Determination” page.

·      When the date of the denial is more than 12 months prior to the individual’s application date for APTD cash assistance, regardless of the reason for the denial, the FSS must document the date of and reason for the denial in the Case Comments section of New HEIGHTS, but not deny/terminate APTD cash benefits.

·      When the date of the denial is less than 12 months prior to, or after, the individual’s application date for APTD cash assistance, and the reason for the SSA denial is medical, the FSS must deny/terminate APTD cash assistance on the Program of Assistance (POA) screen by selecting the reason message “Did Not Meet SSA Medical Criteria for SSA-Related Benefits.”

 

For Individuals Who Provide SSA Denials and Were Receiving APTD Cash Assistance on June 30, 2011

 

·      Upon receipt of all pages of the SSA denial, the FSS reviews the SSA denial to determine the following information:

-     The date the denial was issued; and

-     The reason for the denial, which is located on the “Explanation of Determination” page.

·      When the date of the denial is more than 12 months prior to the individual’s application date for APTD cash assistance, regardless of the reason for the denial, the FSS must document the date of and reason for the denial in the Case Comments section of New HEIGHTS, but not deny/terminate APTD cash benefits.

·      When the date of the denial is less than 12 months prior to, or after, the individual’s application date for APTD cash assistance, and the reason for the SSA denial is medical, the FSS must review the case to determine if the SSA denial is the individual’s first or second SSA denial, and:

-     if the SSA denial is the individual’s first denial, the FSS must document the denial in Case Comments, but not deny/terminate APTD cash benefits.

-     if the SSA denial is the second denial, but was received prior to July 1, 2011, the FSS must document the denial in Case Comments, but not deny/terminate APTD cash benefits.

-     if the SSA denial is the second denial, and was received after July 1, 2011, the FSS must deny/terminate APTD cash assistance on the POA screen by selecting the reason message “Did Not Meet SSA Medical Criteria for SSA-Related Benefits.”

 

The following text will be inserted onto the Notice of Decision (NOD) generated when the APTD cash benefits are denied or terminated on the POA screen, which has been updated to incorporate the new policy regarding appeals:

 

You were denied benefits by social security for medical reasons. We too cannot give you cash benefits for this same reason. If you already started to get APTD cash benefits AND you ask for an administrative appeal you can ask to keep getting the same APTD cash benefits while you wait for your administrative appeal decision. TO DO SO YOU MUST provide a statement signed by a physician, physician’s assistant, advanced practice registered nurse, or psychologist indicating that your medical condition has increased in severity in the last 12 months or is unrelated to the medical condition for which you were denied Social Security. This signed statement must also include the health professional’s printed name, specialty, address, phone number, and signature date. The signed statement must be given to us within 15 days of the date of this notice for you to keep getting the same APTD cash benefits while you wait for your administrative appeal decision. Otherwise, state law changes do not allow you to keep getting your APTD cash benefits. You must pay back all APTD cash you receive while you wait for your administrative appeal decision if the administrative appeal decision is against you.

 

Upon receipt of an individual’s request for an administrative appeal, the FSS continues APTD cash benefits while the individual is waiting for the administrative appeal decision when:

 

·      The individual had been approved for APTD by DDU and was receiving the APTD cash benefits (new applicants who were not receiving APTD cash cannot “continue” benefits pending the appeal when they were not yet receiving benefits);

·      The request for the administrative appeal is received in the District Office within 15 days of the date on the notice of the APTD termination; and

·      The individual provides documentation signed and dated by a physician, physician’s assistant (PA), advanced practice registered nurse (APRN), or psychologist which includes the printed name of the health professional, the specialty of the health professional, and the address and phone number of the health professional, and states:

-     that the individual’s medical condition has increased in severity during the 12 months prior to the date the individual requested the administrative appeal; or

-     that the medical condition for which the SSA based the decision to deny the individual SSA benefits is unrelated to the medical information upon which the Disability Determination Unit (DDU) based the decision to approve the individual for APTD benefits.

 

NOTE: The statement from the physician, PA, APRN, or psychologist regarding a medical condition increasing in severity must specify the increase happened at some point within the last 12 months prior to the date the individual requested an administrative appeal. If the increasing severity of the medical condition happened over a period of time longer than 12 months, or at some point prior to 12 months, the individual cannot receive continued benefits while pending the appeal.

 

EXAMPLES: A physician, PA, APRN, or psychologist’s statement indicates that an individual’s medical condition has increased in severity:

 

·      due to an incident which happened 13 months prior to the date the individual filed the administrative appeal. This individual would not be eligible for continued receipt of APTD cash benefits while the individual is waiting for the administrative appeal decision because the incident happened more than 12 months prior to the date the individual filed the administrative appeal.

·      over the course of the individuals illness, which they have been suffering from over the past 5 years. This individual would not be eligible for continued receipt of APTD cash benefits while the individual is waiting for the administrative appeal decision because the increase in severity happened over a period of time longer than 12 months prior to the date the individual filed the administrative appeal.

·      2 days prior to the individual’s submission of the request for an administrative appeal. This individual would be eligible for continued receipt of APTD cash benefits while the individual is waiting for the administrative appeal decision because the incident happened less than 12 months prior to the date the individual filed the administrative appeal.

 

On the date the District Office receives an appeals decision that overturns the termination of APTD financial assistance due to the individual’s medical condition having increased in severity during the 12 months prior to the date the individual requested the administrative appeal, enter the following text on the “Required Verifications” screen:

 

Please ignore the above “DEADLINE” date. You have 30 days from the date of this notice to give us proof that you filed an appeal for SSA benefits (SSI or SSDI). You must include proof that the appeal you filed with the SSA includes the documentation that your medical condition has increased in severity during the past 12 months in the information you give us. Your APTD cash grant will stop if you do not give us this proof by [enter date].

 

On the date the District Office receives an appeals decision that overturns the termination of APTD financial assistance because the medical condition for which the SSA denied SSA benefits is not the medical condition for which the individual was approved APTD cash assistance, enter the following text on the “Required Verifications” screen:

 

Please ignore the above “DEADLINE” date. You have 30 days from the date of this notice to give us proof that you filed a new application for SSA benefits (SSI or SSDI), for the same medical condition for which you applied for APTD cash assistance. Your APTD cash grant will stop if you do not give us this proof by [enter date].

 

This text will appear on the New HEIGHTS-generated AE0055, Proof Needed to Determine Your Assistance. The AE0055 autopopluates a deadline date that is 10 days from the date the notice is generated, hence the statement “Please ignore the above “DEADLINE” date” included in the above text.

 

Set an expected change for 30 calendar days out from the date on the AE0055. If by the 30th day, the individual fails to provide the documentation described above, terminate APTD cash. If the individual appeals this termination, do not continue APTD cash while this appeal is pending.

 

Due to the complexity of the policy, the Regional Supervisors and the Training Unit may be contacted for any questions regarding implementation. The Facilitated Social Security Unit (FSSU) at State Office continues to track clients pursuing SSA benefits as it pertains to this policy and is available to review cases in regards to an APTD applicant or recipient’s Social Security requirements.

 

POLICY MANUAL REVISIONS

 

Revised Adult Assistance Manual Topics

 

Section 135.01  Administrative Appeal Requests and the ANP

Section 315.09  APTD Verification Requirements for SSA Denial

Section 315.11  Denial or Termination of Assistance

 

IMPLEMENTATION

 

The policy released in this SR is effective upon release.

 

CLIENT NOTIFICATION

 

Notification of the change in the APTD cash assistance policy was published in the NH Rulemaking Register, Office of Legislative Services, on January 17, 2013, and again on April 11, 2013. A public hearing on the amended Administrative Rules was held on February 7, 2013.

 

Text changes were made to the special message in the “Explanations” section of the New HEIGHTS-generated Notice of Decision for applicants and recipients whose APTD cash assistance is denied or terminated due to receipt of a medical denial form the Social Security Administration. These text changes reflect the revised policy released in this SR, as follows:

 

You were denied benefits by social security for medical reasons. We too cannot give you cash benefits for this same reason. If you already started to get APTD cash benefits AND you ask for an administrative appeal you can ask to keep getting the same APTD cash benefits while you wait for your administrative appeal decision. TO DO SO YOU MUST provide a statement signed by a physician, physician’s assistant, advanced practice registered nurse, or psychologist indicating that your medical condition has increased in severity in the last 12 months or is unrelated to the medical condition for which you were denied Social Security. This signed statement must also include the health professional’s printed name, specialty, address, phone number, and signature date. The signed statement must be given to us within 15 days of the date of this notice for you to keep getting the same APTD cash benefits while you wait for your administrative appeal decision. Otherwise, state law changes do not allow you to keep getting your APTD cash benefits. You must pay back all APTD cash you receive while you wait for your administrative appeal decision if the administrative appeal decision is against you.

 

No other client notification is planned.

 

TRAINING

 

No special training is planned or needed.

 

DISPOSITION

 

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

 

DISTRIBUTION

 

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective September 30, 2013. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance Manual.

 

DFA/LRB:s