Module #1

Understanding the Basics of SSI and Appeals

This module focuses on helping you to understand the basics of the SSI program, how it works and is administered, how disability is determined, and processes to appeal SSI program decisions.

Orientation to Supplemental Security Income (SSI)

Supplemental Security Income (SSI) is a means-tested program providing monthly cash payments to children and adults with disabilities.  It is administered by the Social Security Administration (SSA).  For calendar year 2019, the SSI program pays a maximum monthly federal benefit rate (FBR) of $771.  At their option, 32 states pay an additional SSI state supplement.

In 41 states and the District of Columbia, an individual who receives SSI is automatically eligible for Medicaid.  In the remaining nine states, known as section 209(b) states, Medicaid for SSI recipients is subject to state-specific eligibility criteria.  The nine 209(b) states are:  Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Oklahoma, and Virginia.

 

SSI Eligibility for Youth and Adults

Establishing Disability.  An adult SSI applicant, age 18 or older, must show through medical evidence that he or she is unable to perform substantial gainful activity.   Evidence from VR agencies, evidence of how well the individual performs in employment settings, and even the applicant’s ability to do a range of activities of daily living may also be relevant to meeting the SSI disability standard.  The SSI program has a separate disability standard for children under 18.  The child applicant must show, through a combination of medical evidence and educational records, several substantial deficits in the ability to function in both school and non-school settings compared to his or her non-disabled peers.  Statements from parents, other family members, and even neighbors could also be relevant to the childhood disability determination.

The SSI applicant and those helping with the application must take steps to make sure medical and other relevant evidence is submitted to SSA.

Establishing Financial Eligibility.  The SSI applicant must also establish that both their countable income and countable resources are within the program’s limits.  For example, if the child or adult receives Social Security benefits, $20 of that income will be excluded and what remains will be subtracted from the maximum SSI payment otherwise due.  Also, for the child under 18, a part of their parent(s)’ income could be counted as income to the child to reduce the SSI payment that is due or, if that “deemed” income is high enough, eliminate the child’s eligibility for an SSI payment. At age 18, the SSI program will no longer count the income and resources of the parents no matter how high the income or resources are.

Middle class families of youth with severe disabilities should be prepared to have their child apply for SSI at age 18 as parental income and resources will no longer count against the child at age 18.

In the case of both adults and children, countable resources must not exceed $2,000.  For example, $2,200 in a bank account would make either the adult or the child ineligible for SSI.  In some cases, the resources of the parent(s) could count toward the child’s $2,000 resource limit. For more detailed information about SSI’s income and resource rules, see our Toolkit, How Income and Resources Impact SSI Eligibility and/or Payment Amount

SSI and Medical Reviews

All SSI recipients, both children and adults, will be subject to a medical continuing disability review (CDR) from time-to-time, to determine if they continue to meet the disability criteria of the SSI program.  For most recipients, the medical CDR will occur every three to five years.  The purpose of the medical review is to determine if the recipiant’s condition has medically improved and, if it has, to determine if that medical improvement is such that it renders the recipient no longer disabled under SSI criteria.  If there is no medical improvement, or if there has been medical improvement but the individual still meets the SSI disability criteria, SSI benefits will continue.  If there has been medical improvement and the individual’s disability no longer meets the SSI disability criteria, the SSI benefits will be terminated subject to the right to appeal that decision.

All children who receive SSI based on the childhood disability criteria will be subject to an Age 18 Redetermination when they reach age 18.  The purpose of this medical review will be to determine whether the recipient meets the separate SSI disability standard for adults.  Unlike the medical CDR, which looks for evidence of medical improvement, the Age 18 Redetermination is a new, initial determination and follows the same review process used for any new adult application for SSI.  If SSA determines that the recipient's condition meets the SSI disability standard for adults, benefits will continue.  If SSA determines that the condition does not meet the disability standard for adults, SSI benefits will be terminated subject to the right to appeal the decision.

See our separate Toolkit, Medical Continuing Disability Reviews and the Age 18 Redetermination for more in depth information on this topic.

Appealing Decisions Regarding SSI

The SSI program allows an applicant or beneficiary to appeal any decision concerning SSI eligibility or SSI payment amount.  Our focus, in this Toolkit, is SSA decisions that either deny an SSI application or terminate eligibility based on a find that the individual does not meet the disability criteria for the program or no longer meets that criteria. 

The written notice explains how to appeal.  If SSA decides to terminate benefits,  following a medical CDR or an Age 18 Redetermination, it must send a written notice to the beneficiary and his or her representative payee, if any. That notice must explain: 

  • that SSI benefits are being terminated based on a determination that the beneficiary no longer meets the SSI disability criteria (following a medical CDR) or is not considered disabled under adult criteria (following an Age 18 Redetermination);  

  • the effective date of the termination;  

  • steps that can be taken to request an appeal and the time limit for doing so; and  

  • the right to request that SSI benefits continue during the appeal and the time limit for doing so.   

An appeal can typically be filed by sending a letter to the address referenced in the notice or by going to an SSA office, with the notice in hand, and explaining you want to appeal that decision. 

Applicants and their families must carefully read the SSI denial or termination notice, as the method for appealing and the time limit for doing so (generally 60 days from receipt of the notice) will appear on the notice.  Also, the notice will explain how to request that SSI continue during the appeal and the time limit for requesting that (generally 10 days from receipt of the notice).

Referring to an attorney or advocate for representation on the appeal.  An SSI applicant or beneficiary who appeals an SSA decision finding the individuals is not disabled or no longer disabled would be wise to find an attorney or advocate, with experience on SSI appeals, to represent them on the appeal.  See our section on “Web-Based Resources” for tips and links that may help you find a representative from a Legal Services or Legal Aid office, from a Protection and Advocacy office, or through the bar association covering your state or region of the state. 

You should always look to refer a consumer to an attorney or advocate for representation as soon as you are aware the individual has received a notice denying their SSI application or terminating their right to continue getting SSI.