TN 11 (09-92)

SI 02302.310 List of Sample Notices - 1619 Benefits (Noninstitutional)

 

Notice
Number
Manual or
Automated
FormSituation
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.

  • The 60 days start the day after you get this letter.

Situation #4 (Page 2)

 

                            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 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 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 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

 

  • 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:

  • Your SSI checks will go down as the amount of money you earn goes up.

  • 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:

  • You have any questions.

  • 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:

  • You have any questions.

  • You want more information about his 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 Decid