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In Pain, Out of Work and Can't Pay the
Bills
A Resource Directory for People with CRPS
Government Assistance Programs
Social Security
The Social Security Adminsitration (SSA) offers disability benefits
under two programs: the Social Securty Disability Insurance
program, for people who are "insured" (you worked
long enough and paid Social Security taxes), and the Supplemental
Security Income (SSI), which is based on financial need. Both
programs require medical and other informaiton in order to decide
if you meet the SSA's defnintion of disability. The SSA approved
a Social Security Ruling (SSR) on CRPS (click
here to read the ruling).
CRPS, when documented by appropriate medical signs, is a medically
determinable impairment that can last for 12 or more months
and be the basis for finding of "disability." Disability may
not be established on the basis of an individual’s statement
of symptoms alone.
Requirements for a Medically Determinable Impairment
- The inability to engage in any substantial gainful activity
(SGA) by reason of a medically determinable physical or
mental impairment that can be expected to result in death
or has lasted or can be expected to last for a period of
not less than 12 months
- The impairment must result from anatomical, physiological,
or psychological abnormalities that can be shown by medically
acceptable clinical and laboratory diagnostic techniques
- An impairment must be established by medical evidence
that consists of signs, symptoms, and laboratory findings
- CRPS can be established in the presence of chronic complaints
of severe pain disproportionate to the degree of documented
soft tissue injury and one or more of the following signs
in the affected region:
- Swelling
- Autonomic instability (In the affected regions there
may be color, temperature or trophic changes in skin
as well as changes in sweating or in the amount of goose
flesh?also called increased pilomotor erection)
- Abnormal hair or nail growth
- Dystrophic nails
- Osteoporosis
- Abnormal movement
The documentation of objective medical findings is critical
in establishing the presence of CRPS as a medically determinable
impairment. Your clinical records reflecting ongoing medical
assessment and treatment from your physician and other healthcare
professionals are extremely helpful in documenting the clinical
findings. Make every reasonable effort to secure all relevant
evidence to ensure appropriate and thorough disability evaluation.
Generally, you must have the evidence for the 12-month period
before you apply.
Where to Apply
You can go to your local Social Security Office, apply online or call the office and apply over the phone.
Make sure to ask for extra copies of all documents you sign.
The Role of the Healthcare Provider
The Treating Source is your own physician or other
medical professional who can provide the most complete documentation
of the nature and severity of your impairment. This physician
is not asked or expected to decide if you are disabled. However,
he or she will be asked to provide a statement about your
ability, despite your impairments, to do work-related physical
or mental activities.
Consultative Examiners (CE) are licensed medical professionals
hired by SSA to perform an additional examination. CEs have
a clear understanding of SSA disability programs and their
evidentiary requirements as well as responsibilities and obligations
regarding confidentiality.
Program Medical Professionals are physicians in all
specialties who perform paper reviews of claims in the State
DDS or SSA regional office.
Medical Experts are healthcare professionals who are
paid for their testimony when administrative law judges request
expert testimony on complex medical issues.
Evaluations of the Claim
Once a medically determinable impairment has been found, the
severity of your impairment must be established. If the claim
adjudicator finds that the RSD symptoms cause a limitation
or restriction having more than a minimal effect on your ability
to do basic work activities, the adjudicator must find that
the impairment is severe and proceed to the next step-determining
your residual functional capacity (RFC).
Just because you can’t do your present job doesn’t mean
you can’t do any job.
SSA will look at your age, education, and past work experience,
including any skills you have acquired during your work history.
It will look at your duties at your old jobs to see if you
learned any skills you might be able to use in another, easier
kind of job and then decide whether you can physically and
mentally do that kind of work. The younger and more educated
you are, the easier SSA thinks it will be for you to adjust
to a new job.
Social Security will pay benefits if there is a medical reason
why you cannot do any work for which you might quality. Whether
you can actually get a job doesn’t count.
For any claim, remember that documentation is the
key to success. It is essential that your medical treatment
records substantiate your claim. For example, if you tell
a judge that chronic pain is making you depressed, make sure
that you are being treated for depression or your credibility
will fly right out the window.
Ticket to Work Program Resources
One strategy while applying for Social Security Disability benefits might be to request an evaluation by your state’s Department of Vocational Rehabilitation which might provide written documentation that you are unable to work outside the home and no home-based employment is available in your locale. If your case is closed, a letter (like the one here) can be included with an appeal.
Kinds of Benefits
Disability Insurance Benefits (DIB)
In order to qualify, you must have paid enough Social Security
tax to be covered (generally pay five years out of the previous
10 before disability begins). The monthly benefit is set
by your income, with the maximum currently at $1,300 per
month. In some cases, your dependent children may also qualify.
Supplemental Security Income (SSI)
This program doesn’t require you to have paid social security
tax. It is a needs-based federal welfare program providing
benefits to those with little income and resources. The
initial application can take between three and six months
to process. In order to qualify, you must have:
- A physical
or mental impairment that prevents you from working for
at least 12 months
- Little or no income and less than $2,000
in resources ($3,000 if a couple), not including your home
and car
- If your claim is denied, a notice of appeal rights
will accompany the denial notice. You must file an appeal
within 60 days of the notice. Then SSA will reconsider your
application and consider new and updated medical evidence.
- You may be asked to see a physician for an evaluation. If
the reconsideration application is denied, you may request
a hearing within 60 days of the denial.
Disabled Widow/Widower Benefit (DWB)
If you are a widow or widower who is currently disabled
but your spouse was covered under Social Security at the
time of death, you might be eligible for benefits. You must
be between the ages of 50 and 60 and have been married for
at least 10 years to the person covered. You must be able
to prove your disability was severe enough to meet the requirements
within seven years of your spouse’s death.
The Consolidated Omnibus Reconciliation Act (COBRA)
Social Security provides two types of disability benefits: 1) Social Security Disability Insurance (SSDI) and
2) Supplemental Security Income (SSI).
To be eligible for SSDI benefits, a claimant must have contributed to the Social Security Trust Fund (through payroll deductions) long enough and sufficiently enough. If approved, claimants receive monthly income immediately andMedicare after a 24-month waiting period. In the case of SSDI, award letters would not advise claimants to notify COBRA within 60 days, because claimants would need to keep their COBRA insurance during the waiting period until Medicare coverage begins. In some cases, benefits are awarded retroactively. Since the waiting period for Medicare starts as of the award date, a retroactive award date effectively reduces the wait for Medicare coverage but usually not by more than six months, so claimants would still need to keep their COBRA coverage until Medicare coverage takes effect.
SSI is for very low income/almost no assets/indigent elderly and disabled Americans, regardless of their contribution to the Social Security Trust Fund. If approved, claimants are immediately eligible for monthly income benefits and Medicaid insurance. Once Medicaid coverage is established (the claimant should verify that coverage is in effect) and the claimant wants to discontinue COBRA coverage, he/she should notify COBRA.
COBRA premiums are payable on a month-to-month basis and can be terminated at any time by notifying COBRA.
Special rules for disabled individuals and certain family members may extend the maximum periods of coverage. If a qualified beneficiary is deteremined to be disabled under the Social Security Act within the first 60 days of COBRA coverage, then the qualified beneficiary and all of the qualified beneficiaries in his or her family may be able to extend COBRA coverge for an additional 11 months. However, you may lose all rights to the additional COBRA coverage, if the Notice of the Determination is not provided to the COBRA carrier within 60 days of the date of the determination and before the expiration of the 18 month COBRA period. The qualified beneficiary who is disabled or any qualified beneficiaries in his or her family may notify the plan administrator of the Social Security Determination.
More Information
The Office of Management and Budget and the Department of
Labor recently added 25 citizen-focused benefit programs to
the Government Benefits website.
Do You Need a Lawyer?
For any of the federal programs, a lawyer isn’t necessary,
but can do the following:
- Know what medical proof is necessary and how to get it
- Counsel you before the hearing
- Explain the government’s decisions and how to appeal
Most lawyers work on a contingency fee, meaning they will
take a certain percentage (25% is common) of any back pay
the government owes you by the time you finally win the case. Go
to the National Organization of Social Security Claimants' Representatives for attorneys experienced in Social Security. Make sure fees
are established and understood before you begin the process.
For a comprehensive discussion on working with a lawyer, go
to How to Lose Your Case
in 12 Steps by Steven Schisler, Esq.
If your claim is approved, your benefits cannot begin before
the sixth full month of disability. Your social security benefit
may be reduced if you receive worker’s compensation or other
public disability payments or a pension from a job where you
did not have to pay Social Security taxes. Some benefits are
taxable. This health insurance program serves everyone over
65 years of age and people with disabilities under 65 years
of age who: have been entitled to receive Social Security
disability benefits for a total of 24 months, or need dialysis
treatments or a kidney transplant because of permanent kidney
failure. The program is available regardless of financial
need.
Medicare Part A covers hospitalization. Certain deductibles
and coinsurance amounts apply. Medicare Part B is voluntary
medical insurance with a monthly premium that helps pay doctor
bills and other approved medical services.
Medicaid
Medicaid is a joint federal/state program to provide physical
and related healthcare services to persons with low incomes.
People with disabilities may be eligible for Medicaid on the
basis of their income. Medicaid services are available in
all states. However, each state establishes its own eligibility
requirements for Medicaid based on federal guidelines.
That means that there are geographic differences between eligibility
requirements and types of services covered. In general, persons
may be eligible for Medicaid if they are receiving public
assistance benefits or Supplemental Security Income, or are
blind or disabled. Individuals with higher incomes may be
eligible for Medicaid, Supplemental Medical Care Assistance,
or their children may be eligible if medical expenses exceed
a given percentage of their annual income.
Medicare Part D Appeals: An advocate's manual to navigating the Medicare private drug plan appeals process (PDF)
From the Medicare Rights Center
Rent Assistance
Low income families may be eligible for housing assistance
payments from the US Department of Housing and Urban Development
(HUD). HUD payments are made directly to landlords to make
up the difference between a HUD-approved rental amount and
what the tenant is required to pay.
Other Disability Resources
Disability Resources by State
The Office of Management and Budget and the Department of
Labor has a full listing of over 100 programs
at the Benefits.gov website.
Local Resources
If you are seriously ill or disabled, in many states the utility
companies will continue your service and let you pay when
you are able. Each state utility system has different regulations,
but generally you must enlist the aid of your physician’s
office to verify your condition.
Phone
If you are unable to pay your phone bill, your physician must
call the service representative and follow up with written
verification of your illness within seven days. Phone companies
will extend your service for 30 days. If the illness continues,
you must repeat this process. Check the phone book for the
number of your local representative. Note: You
will be responsible for all overdue charges once you are no
longer ill.
Heat and Electricity
Your gas and/or electric company cannot shut off your power
if you or a member of your household has a serious illness
and financial hardship. Each state has different requirements,
but your physician must certify the illness in writing. If
the utility company refuses to protect your accounts from
shut off, contact your Department of Telecommunications and
Energy Consumer Division immediately.
Emergency Food and Shelter Programs (EFS)
Applicants to Emergency Food and Shelter Programs must show
evidence of a precipitating event that caused the emergency.
These programs provide assistance to any needy individual
who has received a notice of foreclosure, eviction, or termination
of utility services if the ability to pay is compromised because
of a sudden reduction in income. EFS can provide rent/mortgage
assistance and supplemental utility assistance, but this is
a one-time-only offer. These programs do not supplement SSI,
Aid to Family with Dependent Children (AFDC), or other public
assistance programs. Although criteria differ from state to
state, some of the common items are:
- You must provide the basic proof of economic situation
and family composition
- The agency will give you the amount which is required
and appropriate to the case
- You must have had a verifiable economic or personal crisis
- The agency will not pay if you are paying more than 75%
of your income on rent and have no prospects for increased
income
- The agency will not pay rent if you do not have a regular
income or prospect for one
- The agency does not assist people who are in a chronic
situation
Student Loans
If you are completely and permanently disabled, you may obtain a conditional discharge by the U.S. Department of Education by filling out the Disability Discharge Form (PDF) and submitting it to your loan holder. After three years, the Department will review the disability discharge and make a final determination on the discharge status of the applicable conditionally-discharged loans.
If you wish to regain student loan eligibility after having discharged your loans through permanent disability, will need to fill out the Physician's Certification of Borrower's Ability to Engage in Substantial Activity Form and submit it to the current loan holder. If you have had loans discharged through disability previously, you may be required to reinstate previously discharged loans.
Discharging Student Loans Due to Disability
Scholarship Resources for Students with Chronic Illness
Other Resources
In recent years, states have made significant investments
in home and community-based service (HCBS) systems for persons
with long-term support needs. The Federal government has been
a partner in this expansion, largely through policy changes
that have expanded financing options under the Medicaid program.
However, the development and management of cost-effective,
high-quality, home- and community-based service systems remains
a significant policy challenge for both states and the Federal
government. Many people that use HCBS services are dissatisfied
with the level of access, responsiveness to individualized
needs, and the quality of services provided in state HCBS
service systems.
The Resource Network on Home and Community-Based Services
is a partnership between the Assistant Secretary for Planning
and Evaluation (ASPE)*, CMS - Centers for Medicare & Medicaid
Services (formerly HCFA)*, state agencies that purchase and
manage HCBS services, and consumers. The mission of the Resource
Network is to work with states, the disability and aging communities,
and others who are committed to high quality consumer-directed
services in integrated settings through cost-effective delivery
models.
Home-based Care for the Disabled
Attendant care of home-based care programs have been developed
to allow physically disabled people to get the care they need
in their own homes, rather than having to become a resident
in a nursing home. To quality for this program, a person must
need physical assistance to achieve some of their life skills
(bathing, cooking, wound care, etc.). Each state has its own
program and the client pays a portion of the cost of this
care. The federal government has established a Medicaid Waiver
program to help all states provide these services to those
with a low income.
The National Association for Home Care and Hospice (NAHC)
NAHC is the nation's largest trade association representing
the interests and concerns of home care agencies, hospices,
home care aide organizations, and medical equipment suppliers.
NAHC believes that Americans should receive health care and
social services in their own homes, so far as this is possible.
Senior citizens and other vulnerable groups should be able
to live in independence through the assistance of home care
services, making institutionalization a last resort. NAHC
seeks to reverse the current bias that places hundreds of
thousands, possibly millions, of fragile children and chronically
ill seniors in nursing homes or retained in hospitals when
they could receive equal or better care at home. Here is a list
of NAHC organizations in each state.
Contact:
National Association for Home Care
228 Seventh Street, SE
Washington, DC 20003
Tel: 202.547.7424
Fax: 202.547.3540
Introduction
Assistive Devices
Caregiver Resources
Clinical Trials
Disability Resources
Government Assistance
Programs
Health Services/Insurance
Independent Living
Centers
Legal Aid
Living Expenses
Patient Assistance
Programs
Service, Faith-based,
and Private Organizations
Transportation
Veterans
Workers Compensation
Appendices:
Federal
Poverty Guidelines
Finding Free Clinics
Updated
December 1, 2010
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