TN 34 (07-24)
SI 02302.320 Sample Notices - 1611(e)(1)(E) Extended Payment Provisions (Institutionalized Recipients)
Notice Number |
Manual or Automated |
Form |
Situation |
1 |
Manual |
SSA-L8166 |
SSI payment due recipient in public institution, 1619(a) eligible in month of move |
2 |
Manual |
SSA-L8166 |
Same as Situation #1, shows language modified due to income |
3 |
Manual |
SSA-L8166 |
SSI payment due recipient in LA-D, 1619(a) eligible in month of move |
4 |
Manual |
SSA-L8151 |
Recipient in LA-D, 1619(b) eligible in month of move |
5 |
Manual |
SSA-L8155 |
Same as Situation #1, OSS payment terminates |
6 |
Manual |
SSA-L8155 |
Same as Situation #1, reduction in OSS payment |
7 |
Manual |
SSA-L8166 |
Same as Situation #3, OSS payment terminates |
8 |
Manual |
SSA-L8166 |
Same as Situation #3, shows language modified due to income |
9 |
Manual |
SSA-L8155 |
Recipient in public institution, SSI payment terminates in 3rd month |
10 |
Manual |
SSA-L8155 |
Recipient in LA-D, SSI payment is reduced in the 3rd month |
11 |
Manual |
SSA-L8151 |
Recipient in LA-D, SSI payment increases in the 3rd month |
12 |
Manual |
SSA-L8155 |
Sample notice of living arrangement change discovered 3 months later |
Situation #1
An individual who moves into a public medical care institution is not normally eligible
for Supplemental Security Income (SSI) payments if Medicaid is not paying over half
of the cost of care. However, if the individual was eligible under 1619 for the month
of the move, checks would continue at the same rate (subject of changes in income)
for the first 2 full months at the new address.
(See Situation #3 for public medical care institution where Medicaid is paying over
half of the cost of case.)
Sample Case:
In this example, an individual moves into a Veterans Administration hospital on August
21, 1987. This is a public medical care institution, so normally they would not be
eligible for any SSI payments while living there. However, they were eligible under
1619 (a) for the month of August.
They will continue to receive checks for the first 2 full months they are in the hospital
(September and October). The payment rate will be calculated as if they were still
living alone in their apartment. Income for July and August will be used to calculatetheir
payments for September and October, respectively.
(In most of these examples, the payments calculation is based on a retrospective monthly
accounting cycle of 2 months. This means that the recipient's SSI payment is reduced
by income received 2 months in the past.)
Situation #1
Supplemental Security
Income Notice
Date: August 24, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
We are writing to you because you moved into the Memorial Veterans Hospital on August
21, 1987, you will still receive Supplemental Security Income (SSI) checks for the
first 2 full months you are there. For September you will receive $140.00 and for
October you will receive $160.00.
This letter also explains why your move may affect your SSI checks in the future.
Why We Can Still Pay You
We usually cannot pay you any SSI while you live in a public institution such a Memorial
Veterans Hospital. However, because you were working before you entered the hospital,
we can pay you SSI checks for the first 2 full months you live there.
We can do this by using special rules which help people who work while they receive
SSI. Because you qualify under these rules, you will receive a $140.00 SSI check in
September, and a $160.00 check in October.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
-
•
In July your earnings were $$$¢¢, and in August your earnings were $$$¢¢.
SEE NEXT PAGE
Enclosure
TURN THIS OVER IF YOU THINK WE ARE WRONG
Situation #1 (Back)
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, get
in touch with us. Please bring this notice with you if you come to a Social Security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days,
you must have a good excuse.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical condition. Then, the only appeal
you can have is a case review. The people in our offices can explain how these appeals
work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the two kinds of appeals:
-
1.
CASE REVIEW
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medical
condition.
-
2.
INFORMAL CONFERENCE
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless you do not agree with what we decided about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAL IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, Social Security number, and why you think we are wrong.
Also tell us what kind of appeal you want—CASE REVIEW OR INFORMAL CONFERENCE. If you cannot write to us, call our office or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if you want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program. There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.
Situation #1 (Page 2)
XXX-XX-XXX DI Page 2 of 2
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. In you case, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in Memorial Veterans Hospital throughout the months of September
and October, your SSI checks will stop beginning in November 1987. This will happen
because the law does not allow us to pay you any further money while you live in such
a public institution.
We will write to you again before we do anything to stop your checks.
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.
Manager's Name
Title
Situation #2
This example is only slightly different from Situation #1. The facts are the same
as in Situations #1, except that the individual received the same amount of money
in July and August 1987. Therefore the language in the first paragraph is modified
to account for the fact that the two special checks will be issued in the same amount
($140.00).
Situation #2
Supplemental Security
Income Notice
Date: August 24, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
We are writing to you because you moved into the Memorial Veterans Hospital on August
21, 1987, you will still receive Supplemental Security Income (SSI) checks for the
first 2 full months you are there. For September and October you will receive $140.00
per month.
This letter will also explain how your move may affect your SSI in the future.
Why We Can Still Pay You
We usually cannot pay you any SSI while you live in a public institution such as Memorial
Veterans Hospital. However, because you were working before you entered the hospital,
we can pay you SSI for the first 2 full months you live there. We can do this by using
special rules to help people who work while they receive SSI. Because you qualify
under these rules, you will receive checks for $140.00 for both September and October.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
-
•
In July and August your earnings were $$$¢¢ each month.
SEE NEXT PAGE
Enclosure
TURN THIS OVER IF YOU THINK WE ARE WRONG.
Situation #2 (Back)
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, get
in touch with us. Please bring this notice with you if you come to a Social Security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days,
you must have a good excuse.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical conditions. Then, the only appeal
you can have is a case review. The people in our offices can explain how these appeals
work. You can have a lawyers, friend, or someone else help you with your appeal.
Here are the two kinds of appeals:
-
1.
CASE REVIEW
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medical
condition.
-
2.
INFORMAL CONFERENCE
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless yo do not agree with what we decided about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAR IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, Social Security number, and why we are wrong. Also
tell us what kind of appeal you want—CASE REVIEW OR INFORMAL CONFERENCE. If you cannot write to us, call our office or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program. There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.
Situation #2 (Page 2)
XXX-XX-XXX DI Page 2 of 2
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. In your case, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in Memorial Veterans Hospital throughout the months of September
and October, your SSI checks will stop beginning in November 1987. This will happen
because the law does not allow us to pay you any further money while your live in
such a public institution.
We will write to you again before we do anything to stop your checks.
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. If will help us answer your questions.
Manager's Name
Title
Situation #3
If an individual moves into a public or private medical care institution, and Medicaid
pays for over half the cost of care, Supplemental Security Income (SSI) payment is
limited to a maximum of $25.00 (plus, in some cases, an optional State supplement).
However, if the individual was eligible under 1619 for the month of the move, the
checks for the first 2 months would not be subject to the $25.00 payment limit.
Sample Case:
In this example, an individual moves into a nursing home on August 21, 1987. Medicaid
pays for over half of their care, so they normally would only be eligible for $25.00
per month while living there. However, because they were eligible under 1619(a) for
August 1987, they will continue to receive their checks at the old rate for September
and October.
The payment rate will be calculated using the full Federal benefit rate rather than
the $25.00 limit. Income from July and August will be used to calculate their payments
for September and October, respectively.
Situation #3
Supplemental Security
Income Notice
Date: August 24, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
We are writing to you because you moved into the Shady Lane Nursing Home on August
21, 1987. You will receive Supplemental Security Income (SSI) payments of $71.50 each
month for September and October, the first 2 full months you are there.
This letter also explains how your move may affect your SSI in the future.
Why We Can Still Pay You
We usually cannot pay more than $25.00 in SSI money each month while you live in a
medical care center such as the Shady Lane Nursing Home and while Medicaid pays for
more than half of your expenses. However, because you were working before you entered
the nursing home, we can pay you more than $25.00 for the first 2 full months you
live there.
We can do this by using special rules which help people who work while they receive
SSI. Because you qualify under these rules, you will receive checks for $71.50 for
both September and October.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
-
•
In July and August your earnings were $$$cc each month.
SEE NEXT PAGE
Enclosure
TURN THIS OVER IF YOU THINK WE ARE WRONG.
Situation #3 (Back)
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, get
in touch with us. Please bring this notice with you if you come to a Social Security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days,
you must have a good excuse.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical condition. Then, the only appeal
you can have is a case review. The people in our offices can explain how these appeals
work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the two kinds of appeals:
-
1.
CASE REVIEW
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medical
condition.
-
2.
INFORMAL CONFERENCE
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless you do not agree with what we decide about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAR IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, Social Security number, and why you think we are wrong.
Also tell us what kind of appeal you want —CASE REVIEW OR INFORMAL CONFERENCE. If you cannot write to us, call our office or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if you want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program. There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.
Situation #3 (Page 2)
XXX-XX-XXX DI Page 2 of 2
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. In your case, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in the Shady Lane Nursing Home throughout the months of September
and October, we will have to lower your SSI check for November to no more than $25.00.
This will happen because the law does not allow us to pay you more than $25.00 while
you live in such a nursing home. If you have other income, you may receive less than
this.
We will write to you again before we make any changes to your SSI check.
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.
Manager's Name
Title
Situation #4:
The new legislation affects individuals who were eligible under 1619(b) as well as
1619(a) for the month of the move to the institution. Most of the language in the
preceding samples can be used for 1619 (b) cases. However, certain modifications are
necessary because these individuals were not receiving Supplemental Security Income
(SSI) checks before they moved. In some cases, they may not have been receiving checks
for several years.
Sample Case:
In this example, an individual moves into a nursing home on August 4, 1987. Medicaid
pays for over half of their care, so they normally would only be eligible for $25.00
per month while living there. However, because they were eligible under 1619(b) for
August 1987, they will receive checks at the full rate for September and October.
Because they were not eligible for checks in July or August, their payment for September
and October is based on their income for the month of September under the retrospective
monthly accounting rules. Since they had no countable income in September, they will
therefore receive checks at the full Federal benefit rate ($340.00) for the 2 months.
The field office will suppress the computer-generated notice, and issue a manual notice,
which will explain that two checks will be issued in each of the months affected by
the special rules. This is because the computer system recognizes that the individual
is due $25.00 each month, and will send them a check in that amount. The field office
will then pay the balance by issuing automated one-time payments.
Situation #4:
Supplemental Security Income
Notice of Change
Date: August 7, 1987
Claim Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
We have received information that affects your payments (or those of the individual named above, on whose behalf you applied to receive payments). Based on this information, we are taking the following action:
We are writing to you because you moved into the Shady Lane Nursing Home on August
4, 1987. You will receive Supplemental Security Income (SSI) checks for the first
2 full months you are there. We will pay you $340.00 in SSI money for September and
for October. We will send you two checks each month, one for $315.00 and one for $25.00
This letter also explains how your move may affect your SSI in the future.
Why We Can Still Pay You
We usually cannot pay more than $25.00 in SSI money each month while you live in a
medical care center such as the Shady Lane Nursing Home, and while Medicaid pays for
more than half of your expenses. However, because you were working before you entered
the nursing home, we can pay you more than $25.00 for the first 2 full months you
live there.
We can do this by using special rules which help people who work while they receive
SSI. Because you qualify under these rules, we will send you $340.00 for both September
and October.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that the are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
Enclosure:
SEE NEXT PAGE
TURN THIS OVER IF YOU THINK WE ARE WRONG
Situation #4 (Back)
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, get
in touch with us. Please bring this notice with you if you come to a Social Security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days,
you must have a good excuse.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical condition. Then, the only appeal
you can have is a case review. The people in our offices can explain how these appeals
work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the two kinds of appeals:
-
1.
CASE REVIEW
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medical
condition.
-
2.
INFORMAL CONFERENCE
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless you do not agree with what we decided about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAR IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, social security number, and why you think we are wrong.
Also tell us what kind of appeal you want—CASE REVIEW OR INFORMAL CONFERENCE. If you cannot write to us, call our office or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if you want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.
Situation #4 (Page 2)
XXX-XX-XXX DI Page 2 of 2
-
•
You have no income for September and October other than your SSI checks of $340.00
Things To Remember
If you continue to live in the Shady Lane Nursing Home throughout the months of September
and October, we will have to lower your SSI check for November to no more than $25.00.
This will happen because the law does not allow us to pay you more than $25.00 while
you live in such a nursing home. If you have other income, you may receive less than
this.
We will write to you again before we make any changes to your SSI check.
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.
Manager's Name
Title
Situation #5
As explained under Situation #1, when an individual moves into a public medical care
institution, payment can continue for 2 months. However, the State where the individual
lives may choose not to make optional supplemental payments under the new provision.
If so, the supplemental payment is stopped even though Federal payment will continue
for 2 months.
Sample Case:
In this example, an individual moved into a Veterans Administration hospital on August
4, 1987. This is a public medical care institution, and Medicaid is not paying for
over half of the cost of care. Therefore, their checks would normally be stopped effective
September 1987 (the first full month at the new address). However, since they were
eligible under 1619(a) for August 1987, their payments for September and October will
still be computed using the full Federal benefit rate.
The individual was also receiving an optional State supplemental payment. Since they
live in a State which chooses not to supplement recipients who live in an institution
under the new provision, the supplemental payment is stopped for September and October
even though Federal payment continues. Therefore the notice must explain why payment
can continue and why it will be decreased.
Situation #5
Supplemental Security Income
Notice of Planned Action
Date: August 7, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are reducing your Supplemental Security Income
(SSI) check from $148.91 to $88.00 starting in September 1987. We plan to reduce the
amount of your check because you moved into the Memorial Veterans Hospital on August
4, 1984.
Why Your Payments Changed
We usually cannot make any SSI payments while you live in a public institution such
as the Memorial Veterans Hospital. However, because you were working before you entered
the hospital, we can pay you for the first 2 full months you live there.
We can do this by using special rules which help people who work while they receive
SSI. Because you qualify under these rules, you will receive $88.00 for both September
and October.
You will receive less money than we paid you before you entered the hospital, because
you cannot receive money from your State while you are in the hospital. Since your
old SSI payment included $60.91 that came from your State, your check has been reduced
by that amount. As a result, your next SSI check will be for $88.00.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #5 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lost your appeal, you might have to a pay some or all of this money
back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decided your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #5 (Page 2)
XXX-XX-XXX DI Page 2 of 2
-
•
You are living in the State of (State Name).
-
•
In July and August your earnings were $$$¢¢ each month.
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. In your case, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in Memorial Veterans Hospital throughout the months of September
and October, we will have to stop your SSI checks beginning November 1987. This will
happen because the law does not allow us to pay you any further money while you live
in such a public institution.
We will write to you again before we do anything to stop your checks.
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.
Manager's Name
Title
Situation #6
This example is only slightly different from Situation #5. The facts are the same
as in Situation #5, except that the State is still making an optional supplement to
the Federal payment, though at a reduced rate. Therefore, the language has to show
that the State supplement is being reduced (though not stopped altogether).
Situation #6
Supplemental Security Income
Notice of Planned Action
Date: August 7, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are reducing your Supplemental Security Income
(SSI) check to $148.91 to $128.91 starting in September 1987. We plan to reduce the
amount of your check because you moved into the Memorial Veterans Hospital on August
4, 1987.
Why Your Payments Changed
We usually cannot make any SSI payments while you live in a public institution such
as the Memorial Veterans Hospital. However, because you were working before you entered
the hospital, we can pay you for the first 2 full months you live there. We can do
this by using special rules which help people who work while they receive SSI.
You will receive less money than you did before you entered the hospital, because
you are due less money from your State. The SSI money that you receive from (State
Name) is being reduced from $60.91 to $40.91. As a result, your next SSI check will
be for $128.91.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #6 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review out decision. We'll change mistakes. Do you have other questions? If so, get
in tough with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #6 (Page 2)
XXX-XX-XXX DI Page 2 of 2
-
•
You are living in the State of (State Name).
-
•
In July and August your earnings were $$$¢¢ each month.
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. For example, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in Memorial Veterans Hospital throughout the months September
and October, we will have to stop your SSI checks beginning in November 1987. This
will happen because the law does to allow us to pay you any further money while you
live in such a public institution.
We will write to you again before we do anything to stop your checks.
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.
Manager's Name
Title
Situation #7:
As explained under Situation #3, when an individual moves into a medical care institution,
and Medicaid is paying for over half of the cost of care, payment can continue at
the old Federal rate for the first 2 months at the new address. However, the State
where the individual lives may choose not to make optional supplemental payments under
the new provision. If so, the supplemental payment is stopped even though Federal
payment continues at the old rate.
Sample Case:
In this example, an individual moved into a nursing home on August 4, 1987. Medicaid
paid for over half of their care, so their checks normally would be reduced to $25.00
in September. However, because they were eligible under 1619(a) during August, their
payments for September and October will be computed using the full Federal rate.
However, their State has chosen not to supplement institutionalized recipients under
the new provision (and does not supplement the $25.00 rate). Therefore the notice
explains that the Federal rate continues for 2 months, but the checks will be reduced
because there will be no optional State supplementation.
Situation #7
Supplemental Security Income
Notice of Planned Action
Date: August 7, 1987
Social Security Number:
Beneficiary Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are reducing your Supplemental Security Income
(SSI) check from $150.91 to $90.00 starting in September 1987. We plan to reduce the
amount of your check because you moved into the Shady Lane Nursing Home on August
24, 1987.
Why Your Payment Changed
We usually cannot pay more than $25.00 each month while you live in a medical care
center such as the Shady Lane Nursing Home and while Medicaid pays for more than half
of your expenses. However, because you were working before you entered the nursing
home, we can pay you the higher amount of $90.00 for the first 2 full months you live
there. We can do this by using special rules which help people who work while they
receive SSI.
You will receive less money than you did before you entered the Shady Lane Nursing
Home, because you cannot receive money from your State while you are in the nursing
home. Since your old SSI payment amount included $60.91 that came from your State,
your check has been reduced by this amount. As a result, your next SSI check will
be for $90.00.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please call us.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #7 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to a add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We give your names of these groups.
Situation #7 (Page 2)
XXX-XX-XXX DI Page 2 of 2
-
•
You live in the State of (State Name).
-
•
In July and August your earnings were $$$¢¢ each month.
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. In your case, we used income from July to figure your payment for
September, and your income from August to figure your payment for October.
Think To Remember
If you continue to live in the Shady Lane Nursing Home throughout the months of September
and October, we will have to reduce your check again. This will happen because the
law does not allow us to pay more than $25.00 while you live in such a nursing home.
We will write to you again before we do anything to reduce your check.
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.
Manager's Name
Title
Situation #8
For this example, the basic facts are similar to Situations #7. The individual moved
into a nursing home on August 4, 1987, and is eligible under the special rules for
September and October. The State supplement is stopping. The difference is that the
amount of the wages for August was less than for July. The effect is that the September
payment (based on the July income) will be less than the August payment, and the October
payment will be greater than the September payment.
This example also illustrates how the notice must account for the way in which the
computer system processes these cases. It is possible that for one of the months affected
by the new rules the individual can get one check, and then for the second month they
can get two checks.
In this situation, the system computed that the individual was due the money for September
because of their July income. However, the field office recognized that under the
special rules they were due $19.00. The office therefore suppressed the notice generated
by the computed system, and issued an automated one-time payment of $19.00 for September.
Because the individual's wages were lower in August, they were due more money for
October. Because the system will compute that they are due $25.00 in October, it will
send them a check for $25.00 on October 1. However, the field office recognizes that
the actual payment due for October under the special rules will be $66.00. The office
will therefore issue a second automated one-time payment of $41.00 in October.
This notice therefore must contain all the following information:
-
•
An explanation of the special rules.
-
•
An explanation of why payment is reduced (because of the termination of the State
supplement).
-
•
The effect on SSI payments of the earnings for July and August.
-
•
The fact that payment for October will be made in two checks instead of one.
Situation #8
Supplemental Security Income
Notice of Planned Action
Date: August 7, 1987
Social Security Number:
Beneficiary Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are reducing your Supplemental Security Income
(SSI) from $150.91 to $19.00 in September 1987. We plan to reduce the amount of your
check because you moved into the Shady Lane Nursing Home on August 4, 1987. We will
increase your check to $66.00 in October. We will send you two checks for October,
one for $25.00 and one for $41.00.
Why Your Payment Changed
We usually cannot pay more than $25.00 each month while you live in a medical care
center such as the Shady Lance Nursing Home and while Medicaid pays for more than
half of your expenses. And because of money you made while you were working, we normally
could not pay you any money for the month of September.
However, because you were working before you entered the nursing home, we can pay
you some money for September and October. We can do this by using special rules which
help people who work while they receive SSI. Because you qualify under these rules,
we will send you a check for $19.00 in September, and two checks for a total of $66.00
in October.
We will be paying you less money than we did before you entered the Shady Lane Nursing
Home, because you cannot receive money from your State while you are in the nursing
home. Since your old SSI payment amount included $60.91 from you State, your check
has been reduced by this amount. As a result of this change, and because of the money
you made while you were working, your next SSI check will be for $19.00.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #8 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision.We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice.
You'll keep getting your same check until we decide your appeal. If you lose your
appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #8 (Page 2)
XXX-XX-XXX DI Page 2 of 2
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for September and October.
Please check these facts carefully to make sure that they are right. If we have the
facts right, then your checks will be in the right amount. If there is a mistake,
please contact us.
-
•
You live in the State of (State Name).
-
•
In July your earnings were $$$¢¢ and in August your earnings were $$$¢¢.
We use the amount of your income from 2 months earlier when we figure your SSI payment
for a given month. For example, we used your income from July to figure your payment
for September, and your income from August to figure your payment for October.
Things To Remember
If you continue to live in the Shady Lane Nursing Home throughout the months of September
and October, we will have to reduce your check again. This will happen because the
law does not allow us to pay you any more than $25.00 while you live in such a nursing
home.
We will write to you again before we do anything to reduce your check.
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.
Manager's Name
Title
Situation #9
After an individual moves to a public medical care institution, and receives payment
at the old rate for 2 months because of 1619, payment will stop in the third full
month at the new address. A Notice of Planned Action will explain this determination.
In this example, a recipient moved into a Veterans Administration hospital on July
15, 1987. After they received checks for August and September under the new provision,
payment was stopped in October. The notice explains why the checks are being stopped
and why they were not stopped at an earlier date.
Situation #9
Supplemental Security Income
Notice of Planned Action
Date: Septebmer 7, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we plan to stop your Supplemental Security Income
(SSI) in October 1987. We plan to stop your checks because you can no longer receive
SSI while you live in the Memorial Veterans Hospital. Your last SSI check will be
the one you received on September 1, 1987.
Why We Are Stopping Your Check
As we told you in an earlier letter, we have paid you while your live in Memorial
Veterans Hospital under special SSI rules. These special rules apply only for the
first 2 full months you live there.
Regular SSI rules now apply. Under the regular SSI rules we cannot pay people who
live in a public institution for an entire month. This means we have to stop your
SSI checks. There are two reasons for this.
-
•
You are living in Memorial Veterans Hospital, which is a public institution.
AND
-
•
Medicaid pays for half or less than half of the cost of your care.
Things To Remember
In the future you may qualify again for SSI payments. If you think you meet the rules
for receiving SSI checks again, 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.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #9
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lose your appeal, you might have to pay some of all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can question these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #9 (Page 2)
XXX-XX-XXX DI Page 2 of 2
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.
Manager's Name
Title
Situation #10
After an individual moves to a medical care facility, and receives payment at the
old rate for 2 full months because of 1619, payment will be reduced in the third month
if Medicaid still pays for over half the cost of care. A Notice of Planned Action
will explain this determination.
In this example, a recipient moved into a nursing home on July 15, 1987. After they
received checks for August and September under the new provision, payment was reduced
to $25.00 in October. The notice explains why the checks are being reduced, and why
they were not reduced at an earlier date.
Situation #10
Supplemental Security Income
Notice of Planned Action
Date: September 7, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are reducing your Supplemental Security Income
(SSI) from $90.00 to $25.00 starting in October 1987. We plan to reduce your check
because you are still living in the Shady Lane Nursing Home.
Why Your Payments Changed
As we told you in an earlier letter, for 2 months we have paid you a higher amount
of SSI under special SSI rules. But these special rules can apply only for the first
2 full months you live there.
The regular SSI rules now apply to you. Under the regular SSI rules we can only pay
people up to $25.00 if they live in a medical care facility and Medicaid pays more
than half the cost of their care. This means we have to reduce your SI checks to $25.00
starting in October. There are two reasons for this.
-
•
First, you are living in a medical care facility.
AND
-
•
Second, Medicaid pays for more than half the cost of your care.
SEE NEXT PAGE
We won't change your check if you appeal within 10 days after getting this notice.
TURN THIS OVER if you think we're wrong
Situation #10 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong? If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in tough with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice. You'll keep getting your same check until we decide your
appeal. If you lose your appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people to come to
help prove you're right. We can make them bring important papers about your case.
We can do this even if they don't want to help you. You can question these people
at your meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #10 (Page 2 of 2)
XXX-XX-XXX DI Page 2 of 2
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.
Manager's Name
Title
Situation #11
The preceding situation explained how an individual's checks could be reduced in the
third full month of living in a nursing home, where Medicaid provides over half of
the care. However, in some situations a recipients payment might increase rather than
decrease in the third month.
An increase is possible because of the accounting cycle using in Supplemental Security
Income (SSI) to determine a recipient's benefits. This cycle is know as retrospective
monthly accounting, or RMA. Under RMA, current benefits are based on the income received
2 months in the past. Thus, for the first 2 months of residence in the institution,
the recipient's SSI payment was being reduced by income earned 2 months in the past
(e.g., August's SSI was based on June's income, etc.).
With the third month of residence in the institution, income received prior to the
change of address no longer counts against the SSI check. If the recipient receives
no income while in the institution, the full benefit (usually $25.00) is payable in
the third month.
The advantage offered by the new 1619 rule is that some benefit, even if less than
$25.00, may be payable for the first 2 months of residence in the institution. Under
old rules, the results of RMA frequently meant that no benefit could be paid for the
these months, even though the recipient's earnings stopped upon entering the institution.
Sample Case:
An individual was working in July 1987, and eligible under 1619(a). They entered a
nursing home on July 15, and stopped work. Under RMA, their earnings for June and
July were used to compute their payments for August and September, respectively. Because
of the earnings, they would normally have been due no checks for August and September
while in the nursing home living arrangement. However, because of the special rules
we were able to pay them $11.50.
Since they had no income in August, no deduction due to income was made from the October
check. Therefore, the individual is due the full $25.00 for October. Since this check
is larger than the $11.50 per month they got for August and September the notice must
explain the increase.
Situation #11
Supplemental Security Income
Notice of Change
Date: September 9, 1987
Claim Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
We have received information that affects your payments (or those of the individual named above, on whose behalf you applied to receive payments). Based on this information, we are taking the following action:
Starting in October 1987, we will increase your Supplemental Security Income (SSI)
check from $11.50 to $25.00. Your check is being increased because you no longer have
other income that counts against your SSI. The rest of this letter will tell you more
about this.
Information About Your Payment
-
•
Your regular monthly check of $25.00 will be sent to you about the first day of October
1987.
-
•
This is the first check you will receive that is at your newly increase rate.
Your Payment Is Based On These Facts
We used the following facts to figure the amount of your SSI for October. Please check
these facts carefully to make sure that they are right. If we have the facts right,
then your checks will be in the right amount. If there is a mistake, please contact
us.
-
•
Your earnings stopped in July 1987.
-
•
You are living in the Shady Lane Nursing Home.
-
•
Medicaid pays for more than half the cost of your care.
SEE NEXT PAGE
Enclosure:
TURN THIS OVER IF YOU THINK WE ARE WRONG
Situation #11 (Back)
YOUR RIGHT TO APPEAL
If you think we are wrong, you have the right to appeal. If you appeal, we will review
our decision. If we made a mistake, we will fix it. If you have any questions, get
in touch with us. Please bring this notice with you if you come to a Social Security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
HOW TO APPEAL
There are two different kinds of appeals. You can pick the one you want unless you
do not agree with what we decided about your medical condition. Then, the only appeal
you can have is a case review. The people in our offices can explain how these appeals
work. You can have a lawyer, friend, or someone else help you with your appeal.
Here are the two kinds of appeals:
-
1.
CASE REVIEW
You can give us more facts to add to your file. Then, we will decide your case again.
You will not meet with the person who will decide your case. This is the only kind
of appeal you can have if you do not agree with what we decided about your medial
condition.
-
2.
INFORMAL CONFERENCE
You will meet with the person who will decide your case. You can tell that person
why you think you are right. You can also give us more facts to help prove you are
right. You can bring other people to help explain your case. You can pick this kind
of appeal unless you do not agree with what we decided about your medical condition.
REMEMBER, YOU PICK THE KIND OF APPEAL YOU WANT. BUT, IF YOU APPEAL IN PERSON, IT MAY
HELP US TO DECIDE YOUR CASE.
TO APPEAL, YOU MUST MAKE A REQUEST IN WRITING. Be sure to tell us your name, social security number, and why you think we are wrong.
Also tell us what kind of appeal you want—CASE REVIEW OR INFORMAL CONFERENCE. If you
cannot write to us, call our office or come in and someone will help you.
There are groups that can help you with your appeal. Some groups may be able to give
you the name of a lawyer who will help you for free. Let us know if you want the names
of these groups.
You have other rights because you are eligible under the supplemental security income
program. There are also some things you must do. The enclosed booklet tells you what
you should know. Please read this booklet and keep it in case you have questions later.
Situation #11 (Page 2)
XXX-XX-XXX DI Page 2 of 2
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.
Manager's Name
Title
Situation #12
This situation provides an illustration of how a notice would look when information
about an individual's living arrangement is discovered after the fact. The language
must be modified to show that the new rules under 1619 were applicable in the past,
but not any longer.
Sample Case:
In this example, an individual moved to the Veterans Memorial Hospital on July 23,
1987. Because they were eligible under 1619 in July, they were due checks for August
and September. Payment should have stopped in October.
The field office was not notified of the change of address when it occurred. On November
1, the hospital told the office about the change. On November 2, a notice was prepared
to explain how the change affected payment.
The checks issued for August and September were correct because under the special
rules the change of address did not affect payment. However, the October and November
checks constituted an overpayment. A more detailed explanation of the overpayment
would be provided in a separate notice. Finally, no payment will be issued in December
because the individual still lives in the hospital.
Situation #12
Supplemental Security Income
Notice of Planned Action
Date: November 2, 1987
Social Security Number:
Recipient Name XXX-XX-XXXX DI
Street Address
City/State/Zip Code
Your payments (or those of the individual named above) will be changed as follows:
We are writing to tell you that we are stopping your Supplemental Security Income
(SSI) checks in December 1987. In additional, you were not due the SSI checks you
received for $295.00 in October and November. We will send you another letter about
the money you were not due.
We plan to stop your checks because you can no longer receive SSI money while you
live in Memorial Veterans Hospital.
Why Your Payments Changed
Usually we cannot pay you any SSI while you live in a medical facility such as Memorial
Veterans Hospital. However, because you were working before you entered the hospital,
you were due checks for the first 2 full months you were there. These checks were
due under special rules which help people who work while they receive SSI. You qualified
under these special rules because you were working in July 1987.
Beginning in October, however, the regular SSI rules applied to you. Under these rules,
we cannot pay people who live in a public institution for an entire month. This means
we have to stop your checks. There are two reasons for this.
-
•
First, you are living in Memorial Veterans Hospital, which is a public institution.
AND
-
•
Second, Medicaid pays for half or less than half of the cost of your care.
SEE NEXT PAGE
We won't change your check if you appeal wihtin 10 days after getting this notice.
TURN THIS OVER if you think we're wrong.
Situation #12 (Back)
YOUR RIGHT TO APPEAL
Do you think we're wrong. If so, you have the right to appeal. If you appeal, we'll
review our decision. We'll change mistakes. Do you have other questions? If so, get
in touch with us. Please bring this notice with you if you come to a social security
office.
You have 60 DAYS TO APPEAL after you get this notice. If you wait more than 60 days, you must have a good excuse.
APPEAL IN 10 DAYS TO KEEP GETTING YOUR SAME CHECK
We won't change your check if you appeal within 10 days after getting this notice.
You'll keep getting your same check until we decide your appeal. If you lose your
appeal, you might have to pay some or all of this money back.
HOW TO APPEAL
There are three different ways to appeal. You can pick the one you want. The people
in our offices can explain how these appeals work. You can have a lawyer, friend,
or someone else help you with your appeal.
Here are the three ways to appeal:
-
1.
CASE REVIEW:
You can give us more facts to add to your file. Then we'll decide your case again.
You don't meet with the person who decides your case.
-
2.
INFORMAL CONFERENCE:
You'll meet with the person who will decide 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.
-
3.
FORMAL CONFERENCE:
This is a meeting like an informal conference. Plus, we can make people come to help
prove you're right. We can make them bring important papers about your case. We can
do this even if they don't want to help you. You can questions these people at your
meeting.
To appeal, you must fill out a form at one of our offices. It is called a Request
for Reconsideration, SSA-561. On the form, YOU PICK THE KIND OF APPEAL YOU WANT. We'll help you fill it out.
There are groups that can help you with your appeal. Some can give you a free lawyer.
We can give you names of these groups.
Situation #12 (Page 2)
XXX-XX-XXX DI Page 2 of 2
As a result, September was the last month we could pay you any SSI. We will be in
touch with you later about the payments we sent you for October and November.
Things To Remember
In the future you may qualify again for SSI payments. If you think you meet the rules
for receiving SSI checks again, please contact us right away. This is important, because
if we can start your SSI checks by November 1988, you will not have to file a new
claim.
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.
Manager's Name
Title