TN 34 (07-24)
SI 02302.310 List of Sample Notices - 1619 Benefits (Noninstitutional)
Notice Number
|
Manual or Automated
|
Form |
Situation |
1 |
Automated |
SSA-L8155 |
Notify recipient of potential 1619(b) when 1611 or 1619(a) payments cease |
2-A |
Automated |
SSA-L8166 |
1619(b) eligibility in State which used SSI criteria for Medicaid |
2-B |
Automated |
SSA-L8166 |
Same as #2-A, in State which uses more restrictive criteria for Medicaid |
2-C |
Automated |
SSA-L8025 |
Initial award, recipient already in 1619(b), meets Medicaid use test in State using
SSI criteria
|
2-D |
Automated |
SSA-L8025 |
Same as #2-C, in State using more restrictive criteria |
3 |
Automated |
SSA-L8165 |
Earnings stop cash payments, not eligible for 1619(b) under Medicaid use test |
4 |
Automated |
SSA-L8166 |
Same as 3, not eligible under threshold test |
5 |
Automated |
SSA-L8165 |
Informational notice about potential 1619 eligibility sent the first time gross earnings
reach $200 or more
|
6 |
Manual |
SSA-L8165 |
Informational notice about potential 1619 eligibility sent with manual award notice
as an enclosure
|
Situation #1
Social Security Administration
Supplemental Security Income
Notice of Planned Action
Date: October 20, 1987
Claim Number:
XXX-XX-XXXX DI
Recipient Name
Street Address
City/State/Zip code
*Type of Eligibility*
Individual — Disabled
We are writing to tell you about changes in your Supplemental Security Income payments.
The following chart shows the SSI money due you for the months we changed. As you
can see from the chart, we are changing your payments for both past and future months.
The rest of this letter will tell you more about this change.
Your Payments Will Be Changed As Follows:
From |
Through |
Amount Due Each Month |
September 01, 1987 |
Continuing |
$.00 |
We will stop your payment as show above beginning December 1987.
Why Your Payments Changed
Because of your income, you are not eligible to receive Supplemental Security Income
payments for September 1987 on.
Your SSI Is Based On These Facts
You have monthly income which must be considered in figuring your eligibility as follows:
-
•
Your Social Security benefits — before deductions for Medicare premiums, if any —
of $140.00 for September 1987 on.
-
•
Your wages of $530.00 for September 1987 on.
Situation #1 (Page 2)
SITUATION #1 (CONT.)
XXX-XX-XXXX
Page 2
10/20/87
Information About Medicaid
You may be getting Medicaid from your State. If you are, you may be able to keep your
Medicaid coverage, even though your SSI checks are stopping.
We will be in touch with you soon about your Medicaid coverage. In the meantime, your
Medicaid coverage should not change until we talk to you.
For information about any change in your Medicaid eligibility caused by this action,
you should get in touch with the local County Welfare Department.
Things To Remember
-
•
We may be in touch with you later about any payments we previously made.
-
•
This determination replaces all previous determinations for the above periods.
-
•
Even though you are not due payment, you are still considered to be eligible under
the Supplemental Security Income program. You should report any event that might affect
your eligibility or allow you to receive payments again.
Do You Think We're Wrong
If you thing we're wrong, you have the right to appeal. We'll correct mistakes. We'll
look at any new facts you have.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
Situation #1 (Page 3)
SITUATION #1 (CONT.)
XXX-XX-XXXX
Page 3
10/20/87
Appeal In 10 Days To Keep Getting Your Same Check
-
•
We won't change your check if you appeal within 10 days.
-
•
The 10 days start the day after you get this letter.
-
•
If you lost your appeal, you might have to pay back some or all of the money.
How To Appeal
There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
your case.
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case.
-
•
Informal conference. You'll meet with the person who decides your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can
bring other people to help explain your case.
-
•
Formal conference. This is a meeting like an informal conference. The difference is we can make people
come to prove you're right. We can make them bring important papers about your case,
even if they don't want to help you. You can question these people at your meeting.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyers. We can give you the names of
these groups.
Situation #1 (Page 4)
SITUATION #1 (CONT.)
XXX-XX-XXXX
Page 4
10/20/87
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office please bring this letter. It will help us answer your questions.
Herbert R. Doggette, Jr.
Deputy commissioner
for Operations
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
Fill-ins:
Under the caption “ Information About Medicaid ” the 3rd paragraph is underlined in the example to show that it is a fill-in. It is
existing paragraph 1152, and will be used only if a State makes it own Medicaid determinations.
The agency to contact will be the name of the agency designated by the Sate (the existing
fill-ins to paragraph 1152).
In States with Federal Medicaid determinations, paragraph 1152 will not be sent. This
caption will be followed by only the first 2 paragraphs shown.
Situation #2-A
Social Security Administration
Supplemental Security Income SITUATION #2-A
Important Information
Date: November 23, 1987
Claim Number:
XXX-XX-XXXX DI
Recipient Name
Street Address
City/State/Zip Code
*Type of Eligibility*
Individual — Disabled
Information about Medicaid
You will still get Medicaid even though your SSI checks have stopped. Your coverage
will continue because you qualify for Medicaid under special SSI rules.
Please Remember This
Even though you are not getting SSI checks now, you should report any change that
might let us start your checks again. You also need to report any change that might
affect your Medicaid coverage. This is a list of some change you should report.
-
•
If your income changes, by going up or down , you should let us know.
-
•
If the money, property and other things you own increases, please let us know.
-
•
If your address changes, or if other people move either into or out of your household, you should let us know.
We Will Review your Case
Since you qualify for Medicaid based on SSI rules, we will review your case within 12 months to see if you are still disabled under our rules.
When we do this, we will only look to see if your health has improved. We will not
consider the amount of your earnings when we decide if your are still disabled .
Situation #2-A (Page 2)
SITUATION #2-A (CONT.)
XXX-XX-XXXX
Page 2
11/23/87
Do You Think We're Wrong
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one your want. If you meet with us in person, it may help us decide
your case .
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This is the only kind of appeal you can have to appeal a medical
decision.
-
•
Informal conference. You'll meet the person who decides your cases. You can tell that person why you think
you're right. You can give us more facts to help prove you're right. You can bring
other people to help explain your case.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
Situation #2-A (Page 3)
SITUATION #2-A (CONT.)
XXX-XX-XXXX
Page 3
11/23/87
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office please bring this letter. It will help us answer your questions.
Herbert R. Doggette, Jr.
Deputy commissioner
for Operations
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
Fill-ins Under the Cation “ We Will Review Your Case ”
-
1.
The underlined “within 12 months” will be used when 1611 payments covert to 1619(b) status.
When 1619(a) status is replaced by 1619(b) status, the fill-in is “soon”.
-
2.
When the recipient is blind, the word “blind” will be used instead of the word “disabled”.
Situation #2-B
Social Security Administration
Supplemental Security Income SITUATION #2-B
Important Information
Date: January 18, 1988
Claim Number:
XXX-XX-XXXX DI
Recipient Name
Street Address
City/State/Zip code
*Type of Eligibility*
Individual — Disabled
Information about Medicaid
You may be able to qualify for Medicaid based on SSI rules, even though your SSI checks
have stopped. Your State will make the final decision, and they should be doing this
soon.
The people in your State have to look to see if you had Medicaid coverage when your
were last due SSI checks. If you did, then your Medicaid coverage will continue, even
though your SSI checks have stopped.
Please Remember This
Even though you are not getting SSI checks now, you should report any change that
might let us start your checks again. You also need to report any change that might
affect your Medicaid coverage. This is a list of some changes you should report.
-
•
If your income changes, by going up or down , you should let us know.
-
•
If the money, property and other things you own increases, please let us know.
-
•
If your address changes, or if other people move either into or our of your household, you should let us know.
Situation #2-B (Page 2)
SITUATION #2-B (CONT.)
XXX-XX-XXXX
Page 2
01/18/88
We Will Review your Case
Since you may qualify for Medicaid based on SSI rules, we will review your case soon to see if you are still disabled under our rules.
When we do this, we will only look to see if your health has improved. We will not
considered the amount of your earnings when we decide if you are still disabled .
Do You Think We're Wrong
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form call “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
your case .
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This is the only kind of appeal you can have to appeal a medical
decision.
-
•
Informal conference. You'll meet with the person who decides your cases. You can tell that person why
you think you're right. You can give us more facts to help prove you're right. You
can bring other people to help explain your case.
Situation #2-B (Page 3)
SITUATION #2-B (CONT.)
XXX-XX-XXXX
Page 3
01/18/88
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Securiy office.
If you visit an office please bring this letter. It will help us answer your questions.
Herbert R. Doggette, Jr.
Deputy commissioner
for Operations
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
Fill-ins Under the Caption “ We Will Review Your Case ”
-
1.
The underlined “soon” will be sued when 1619(a) status is replaced by 1619(b) status.
When 1611 status is converted to 1619(b) status, the fill-in is “within 12 months” is used.
-
2.
When the recipient is blind, the word “blind” will be used instead of the word “disabled”.
Situation #2-C
Social Security Administration
Supplemental Security Income SITUATION #2-C
Notice of Award
Date: October 10, 1987
Claim Number:
XXX-XX-XXXX DI
Claimant Name
Street Address
City/State/Zip code
*Application Filed*
March 1, 1987
*Type of Eligibility*
Individual — Disabled
This is to notify you that you are eligible to receive Supplemental Security Income
payments under the provisions of Title XVI of the Social Security Act. The rest of
this letter will tell you more about our decision.
How Much We'll Pay
Beginning |
Through |
Monthly Amount Payable |
March 1, 1987 |
August 31, 1987 |
$340.00 |
September 1, 1987 |
Continuing |
$ .00 |
Information About Your Payments
We may be in touch with you about money that may be due for earlier months.
Your SSI Is Based On These Facts
-
•
You were disabled in March 1987 on.
-
•
You were living in the State of Maryland for March 1987 on.
-
•
Your have monthly income which must be considered in figuring your payment as follows:
— Your wages of $885 for September 1987 on.
-
•
Because of your income, you are not eligible to receive Supplemental Security Income
payments for September 1987 on.
Situation #2-C (Page 2)
SITUATION #2-C (CONT.)
XXX-XX-XXXX
Page 2
10/10/87
Things to Remember
-
•
Payments may change if you circumstances change. Therefore, you are required to report
any changes in your situations that may affect your Supplemental Security Income payment.
For example, you should tell us if you move, if anyone else moves from or into your
household, if your martial status changes, if income or resources for you or members
of your household, if your marital status changes, if income or resources for you
or members of your household change, if your medical condition improves or if you
go to work. Read the booklet — What You Have to Know About SSI — carefully for additional
information about this requirement.
-
•
The doctors and other trained personnel who decided that you are disable expect your
health to improve. Therefore, we will review your case in August 1988. We will send
you a letter before we start the review. Based on the review, your SSI will continue
if you are still disabled. But it will end if you are not longer disabled.
Information About Medicaid
Even though you are not getting SSI checks now, you do qualify for Medicaid based
on SSI rules. For that reason, you need to report any change that might affect your
Medicaid coverage. You should also report any changes that might let us start your
checks again. This is a list of some changes you should report.
-
•
If your income changes, by going up or down , you should let us know.
-
•
If the money, property and other things you own increases, please let us know.
-
•
If your address changes, or if other people move either into or out of your household, you should let us know.
We Will Review Your Case
Since you qualify for Medicaid based on SSI rules, we will review your case within 12 months to see if you are still disabled under our rules.
Situation #2-C (Page 3)
SITUATION #2-C (CONT.)
XXX-XX-XXXX
Page 3
10/10/87
When we do this, we will only look to see if your health has improved. We will not
consider to amount of your earnings when we decide if you are still disabled .
Do You Think We're Wrong
If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll
look at any new facts you have.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
your case .
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This is the only kind of appeal you can have to appeal a medical
decision.
-
•
Informal conference. You'll meet with the person who decides your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can
bring other people to help explain your case.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
Situation #2-C (Page 4)
SITUATION #2-C (CONT.)
XXX-XX-XXXX
Page 4
10/10/87
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office, please bring this letter. It will help us answer your questions.
We are sending you a pamphlet which contains important information you should know.
The pamphlet is call “What You Have To Know About SSI”.
Dorcas R. Hardy
Commissioner
of Social Security
ENCLOSURE
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
Fill-ins Under the Caption “ We Will Review Your Case ”
-
1.
The underlined “within 12 months” will be used when 1611 payments convert to either 1619(a) or 1619(b) status.
When 1619(a) status is replaced by 1619(b) status, the fill-in is “soon”.
-
2.
When the recipient is blind, the word "blind" will be used instead of the word “disabled”.
Situation #2-D
Social Security Administration
Supplemental Security Income SITUATION #2-D
Notice of Award
Date: October 10, 1987
Claim Number:
XXX-XX-XXXX DI
Claimant Name
Street Address
City/State/Zip Code
*Application Filed*
March 1, 1987
*Type of Eligibility*
Individual — Disabled
This is to notify you that you are eligible to receive Supplemental Security Income
payments under the provisions of Title XVI of Social Security Act. The rest of this
letter will tell you more about our decision.
How Much We'll Pay
Beginning |
Through |
Monthly Amount Payable |
March 1, 1987 |
August 31, 1987 |
$340.00 |
September 1, 1987 |
Continuing |
$.00 |
Information About Your Payments
We may be in touch with you about money that may be due for earlier months.
Your SSI Is Based On These Facts
-
•
You were disabled in March 1987 on.
-
•
You were living in the State of Connecticut for March 1987 on.
-
•
Your have monthly income which must be considered in figuring your payment as follows:
— Your wages of $885 for September 1987 on.
-
•
Because of your income, you are not eligible to receive Supplemental Security Income
payments for September 1987 on.
Situation #2-D (Page 2)
SITUATION #2-D (CONT.)
XXX-XX-XXXX
Page 2
10/10/87
Things to Remember
-
•
Payments may change if your circumstances change. Therefore, you are required to report
any changes in your situation that may affect your Supplemental Security Income payment.
For example, you should tell us if you move, if anyone else moves from or into your
household, if your marital status changes, if income or resources for you or members
of your household change, if your medical condition improves or if you go to work.
Read the booklet — What You Have to Know About SSI — carefully for additional information
about this requirement.
-
•
The doctors and other trained personnel who decided that you are disabled expect your
health to improve. Therefore, we will review your case in August 1988. We will send
you a letter before we start the review. Based on that review, your SSI will continue
if you are still disabled. But it will end if you are no longer disabled.
Information About Medicaid
Even though you are not getting SSI checks now, you may qualify for Medicaid based
on SSI rules. The people in your State will make the final decision, and they should
be doing this soon.
They have to check to see if you had Medicaid coverage when you were last due SSI
checks. If you did, then your Medicaid coverage will continue, even though your SSI
checks have stopped because of your work.
Because you qualify for Medicaid based on SSI rules, you need to report any change
that might affect your Medicaid coverage. You should also report any changes that
might let us start your checks again. This is a list of some changes you should report.
-
•
If your income changes, by going up or down , you should let us know.
-
•
If the money, property and other things you own increases, please let us know.
-
•
If your address changes, or if other people move either into or out of your household, you should let us know.
Situation #2-D (Page 3)
SITUATION #2-C (CONT.)
XXX-XX-XXXX
Page 3
10/10/87
We Will Review Your Case
Since you qualify for Medicaid based on SSI rules, we will review your case within 12 months to see if you are still disabled under our rules.
When we do this, we will only look to see if your health has improved. We will considered
the amount of your earnings when we decide if you are still disabled.
Do You Think We're Wrong
If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll
look at any new facts you have.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form call “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
your case .
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This is the only kind of appeal you can have to appeal a medical
decision.
-
•
Informal conference. You'll meet with the person who decides your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can
bring other people to help explain your case.
Situation #2-D (Page 4)
SITUATION #2-D (CONT.)
XXX-XX-XXXX
Page 4
10/10/87
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office, please bring this letter. It will help us answer your questions.
We are sending you a pamphlet which contains important information you should know.
The pamphlet is called “What You Have To Know About SSI”.
Dorcas R. Hardy
Commissioner
of Social Security
ENCLOSURE
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
Fill-ins Under the Caption “ We Will Review Your Case ”
-
1.
The underlined “within 12 moths” will be sued when 1611 payments convert to 1619(b) status.
When 1619(a) status is replaced by 1619(b) status, the fill-in is “soon”.
-
2.
When the recipient is blind, the word “blind” will be used instead of the word “disabled”.
Situation #3
Social Security Administration SITUATION #3
Supplemental Security Income
Important Information
Date: October 10, 1987
Recipient Name Claim Number:
Street Address XXX-XX-XXXX DI
City/State/Zip Code
*Type of Eligibility*
Individual — Blind
Information About Medicaid
We have decided that you are not eligible for Medicaid based on SSI rules. This decision
is based on facts you gave us about how often you expect in us Medicaid.
Your State may be able to help you with other kinds of medical assistance. You can
contact the local County Welfare Department at any time to see if the people there
can help you with your medical expenses.
Please Remember This
In the future you may qualify again for SSI or for Medicaid based on SSI rules. This
could happen if one of the following is true.
-
•
You meet the rules for getting SSI checks again.
OR
-
•
You need more help in paying for your medical expenses.
If either or both of these things is true, please contact us right away . This is important, because if we can start your SSI checks by September 1988 , you will not have to file a new claim.
Do You Think We're Wrong
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter.
Situation #3 (Page 2)
SITUATION #3 (CONT.)
XXX-XX-XXXX
Page 2
10/10/87
-
•
You'll have to have a good reason for waiting more than 60 days.
-
•
To appeal, you must fill out a form called “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide
your case .
-
•
Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This is the only kind of appeal you can have to appeal a medical
decision.
-
•
Informal conference. You'll meet with the person who decides your case. You can tell that person why you
think you're right. You can give us more facts to help prove you're right. You can
bring other people to help explain your case.
If You Want Help With Your Appeal
You may want help from a friend, lawyer or someone else. There are groups that can
find a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
If You Have Any Questions
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office please bring this letter. It will help us answer your questions.
Herbert R. Doggette, Jr.
Deputy Commissioner
for Operations
-
NOTE: The bracketed language is the newly cleared notice language for section 1619.
The Month/Year (“ March 1988 ” in the sample notice) is a fill-in. It is the 12th month following the last month
an SSI payment is due.
Situation #4
Social Security Administration
Supplemental Security Income SITUTATION#4
Important Information
Date: October 10, 1987
Recipient Name Claim Number:
Street Address XXX-XX-XXXX DI
City/State/Zip Code
*Type of Eligibility*
Individual — Disabled
Information About Medicaid
We have decided that you are not eligible for Medicaid based on SSI rules. You are
not eligible because you are able to pay for your medical expenses with your income.
This decision is based on facts you gave us about your earnings,health problems, and
medical expenses.
Your State may be able to help you with other kinds of medial assistance. You can
contact the local County Welfare Department at any time to see if the people there
can help you with your medical expenses.
Please Remember This
In the future you may think you qualify again for SSI or for Medicaid based on SSI
rules. This could happen if one of the following is true.
-
•
You meet the rules for getting SSI checks again.
OR
-
•
You need more help in paying for your medical expenses.
If either or both of these things is true, please contact us right away . This is important, because if we can start your SSI checks by September 1988 , you will not have to file a new claim.
Do You Think We're Wrong
-
•
You have 60 days to ask for an appeal.
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The 60 days start the day after you get this letter.
Situation #4 (Page 2)
XXX-XX-XXXX
Page 2
10/10/87
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You'll have to have a good reason for waiting more than 60 days.
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To appeal, you must fill out a form called “Request for Reconsideration.” The form is SSA-561. To get this form, contact one of our offices. We can help you
fill out the form.
How To Appeal
There are two ways to appeal. You can pick the one your want. If you meet with us in person, it may help us decide
your case .
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Case review. You have the right to review the facts in your file. You can give us more facts to
add to your file. Then, we'll decide your case again. You won't meet with the person
who decides your case. This the only kind of appeal you can have to appeal a medical
decision.
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Informal conference. You'll meet with the person who decides your case. You can tell that person why you
think you're right. You give us more facts to help prove you're right. You can bring
other people to help explain your case.
If You Want Help With Your Appeal
You may want from a friend, lawyer or someone else. There are groups that can find
you a lawyer. Some can give you a free lawyer. We can give you the names of these
groups.
If You Have Any Question
If you have any questions, you should call, write or visit any Social Security office.
If you visit an office please bring this letter. It will help us answer your questions.
Herbert R. Doggette, Jr.
Deputy commissioner
for Operations
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NOTE: The Month/Year (“ September 1988 ” in the sample notice) is a fill-in. It is the 12th month following the last month
an SSI payment is due.
Situation #5
Supplemental Security Income
Notice of Decision
Date: August 21, 1986
Social Security Numer:
XXX-XX-XXXX DI
Recipient Name
Street Address
City/State/Zip Code
We are writing to tell you about some special rules that can help you while you are
working.
These special rules can help you keep some SSI payment and Medicaid while you are
working or if you start earning more money than you are now.
The rules work this way:
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Your SSI checks will go down as the amount of money you earn goes up.
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If your income gets too high and we have to stop your SSI checks, you may be able
to keep your Medicaid as long as you need it. If your income goes down later, we can
send you checks. You may not have tofile a new SSI application to get Medicaid started again.
If you qualify for these special rules, we will review your case to see if you are
still disabled or blind under our rules. When we do this, we will only look to see
if your health problems have improved. We will not considered the amount of money you earn in deciding if you are still disabled or blind.
Remember . . . if you are disabled or blind and are thinking about working or earning
more than you do now, the SSI rules can help you. The rules let you keep your SSI and Medicaid while you try to become independent
.
See other side for important information
Situation #5 (Back)
GET IN TOUCH WITH SOCIAL SECURITY IF:
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You want more information about this case.
Call or write to our office if you have questions or need more information. If you
like, come to our office and someone will help you. Please bring this notice with
you if you come to a Social Security office.
Situation #6
Supplemental Security Income
Notice of Decision
Date:
Social Security Numer:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
If you are blind or disabled and are receiving supplemental security income (SSI),
there are some special rules you should know about. There special rules make it possible
for you to work and still receive SSI payments and Medicaid coverage.
I have listed below some of the questions you might ask about this and the answers
to those questions. If you have any additional questions, please call your local Social
Security office for assistance.
What Are The Special Rules About?
They are about going to work. The special rules mean that you can earn a certain amount
of money and still receive your SSI payments and Medicaid coverage.
How Much Can I Earn?
This amount is different for everyone. But generally, as the money you earn goes up,
the amount of your SSI payment will go down. You may earn enough from your work to
cause your SSI checks to stop. By then your total income for working will be higher
than if you were only receiving SSI.
What About Medicaid? Will It Stop Too?
That depends on how much you earn. But generally, your Medicaid coverage will continue
while you are working. You may want to check with your local Social Security office
to find out how much you can earn and still qualify for Medicaid.
See other side for important information
Situation #6(Back)
GET IN TOUCH WITH SOCIAL SECURITY IF:
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You want more information about their case.
Call or write to our office if you have questions or need more information. If you
like, come to our office and someone will help you. Please bring this notice with
you if you come to a Social Security office.
Situation #6 (Page 2)
Date
Page 2 of 2
Recipient Name
XXX-XX-XXXX
What Happens If I Lose My Job, Or If I Start Earning Less?
Let us know right away. We can increase the amount of your SSI payments, or start
your SSI and Medicaid again if they have stopped. You may not even have to file a
new application.
Will You Still Consider Me To Be Disabled If I Go To Work?
Yes. The only time we would say you are not longer disabled is if your health has
improved. The special rules allow us to disregard the fact that you are working when
we look to see if you are still disabled.
What Should I Do If I Decide To Go To Work?
Again, let us know right away. We will need to make sure the special rules are applied
in your case. Also, we will need to check to see if your health has improved.
Dorcas R. Hardy
Commissioner
of Social Security