Important Notice- (1) SSI Will Stop

Earlier we told you that we were reviewing (2) case to see if (3) disabled under the definition of disability for adults. After reviewing all the information carefully, we have decided that (4) no longer (5) for Supplemental Security Income (SSI).

We urge you to read this entire letter. It includes important information about appeal rights and Medicaid eligibility. It also explains how you can continue to receive benefits if you appeal.

Fill-ins

1. (1) 

   Choice 1: Your

   Choice 2: Recipient's Name (possessive)

2. (2) 

   Choice 1: your

   Choice 2: recipient's name (possessive)

3. (3) 

   Choice 1: you are

   Choice 2: Claimant's full name is

   Choice 3: Claimant's full name is

4. (4) 

   Choice 1: you

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

5. (5) 

   Choice 1: qualify

   Choice 2: qualifies

The Decision On (1) Case

[Insert required Personalized Case Language (“PDN”) or reference to the personalized attachment. See DI 26530.010.]

Fill-in:

1. (1) 

   Choice 1: Your

   Choice 2: Recipient's Name (possessive)

When Payments Will Stop

Under the disability rules for adults (1) no longer disabled as of (2). (3) will get SSI for that month and the next 2 months. (4) last SSI payment will be for (5) as long as (6) to meet all other eligibility requirements until then.

Fill-ins

1. (1) 

   Choice 1: you are

   Choice 2: Claimant's full name is

   Choice 3: Claimant's full name is

2. (2) 

   Month/day/year (in the format, “January 12, 1998”)

3. (3) 

   Choice 1: You

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

4. (4) 

   Choice 1:Your

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

5. (5) 

   Month/year (in the format, “January 1998”)

6. (6) 

   Choice 1: you continue

   Choice 2: Claimant's full name continues

   Choice 3: Claimant's full name continues

Information About Your Medicaid

For information about any change in your Medicaid eligibility caused by this action, you should get in touch with (1).

Fill-in:

1. (1) 

   See NL 00804.110 paragraph 1144 for the fill–in language.

   NOTE: Do NOT use the language in paragraph 1144 — only the fill-in.

You Have Important Appeal Rights

If you disagree with the decision, you have the right to appeal. We will review the case and consider any new facts you have. A person who did not make the first decision will decide the case.

• •

  You can ask for an appeal anytime within 60 days. But if you want to keep getting payments while we decide the case, you must ask for an appeal within the first 10 days.

• •

  The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  You must have a good reason for waiting more than 60 days to ask for an appeal.

• •

  You have to ask for an appeal in writing. We will ask you to sign a form SSA-789-U4, called “Request for Reconsideration-Disability Cessation.” To get this form, contact one of our offices. Address(es) and phone number(s) are shown on the last page of this letter. We can help you fill out the form.

Please read the enclosed pamphlet, “Your Right To Question The Decision Made on Your Claim.” It contains more information about the appeal.

Appeal In 10 Days To Keep Getting Your Payment

• •

  The 10 days also start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

• •

  If you lose the appeal, you might have to pay back some or all of this money. However, we may decide that you do not have to pay the money back.

How An Appeal Works

A Disability Hearing Officer will decide (1) SSI appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on the appeal. The meeting works like this.

• •

  The DHO will mail you a letter at least 20 days before the meeting to tell you its date, time and place.

• •

  You can look at (2) file before the meeting.

• •

  You can tell the DHO the reasons you think (3) still disabled. You should give the DHO any information you think is missing from (4) file. You can bring someone to represent you at the meeting. And you can bring people to explain the reasons (5) disabled.

• •

  You can have the DHO ask people to come to the meeting to speak about (6) disability and bring important papers. You can question these people at the meeting.

• •

  You do not have to go to the meeting in person. If you do not want to go, you can still give the DHO more facts you may have. The DHO will decide the case using these facts, and what is now in the file. But if you go to the meeting, it may help the DHO decide the case.

Fill-ins:

1. (1) 

   Choice 1: your

   Choice 2: (recipient's name, possessive)

2. (2) 

   Choice 1: your

   Choice 2: (recipient's name, possessive)

3. (3) 

   Choice 1: you are

   Choice 2: (recipient's name) is

4. (4) 

   Choice 1: your

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

5. (5) 

   Choice 1: you are

   Choice 2: Claimant's full name is

   Choice 3: Claimant's full name is

6. (6) 

   Choice 1: your

   Choice 2: (recipient's name, possessive)

If You Want Help With Your Appeal

You can have a lawyer, friend, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. The local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before they can collect it.

If (1) Health Gets Worse

If (2) health gets worse, please get in touch with us. (3) may be able to get SSI again. We can help you file a new application for SSI.

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. So, if you disagree with this decision, you should ask for an appeal within 60 days.

Fill-ins:

1. (1) 

   Choice 1: Your

   Choice 2: (Recipient's Name, possessive)

2. (2) 

   Choice 1: your

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

3. (3) 

   Choice 1: You

   Choice 2: Claimant's full name

   Choice 3: Claimant's full name

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at (1). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

(2)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Fill-ins:

1. (1) 

   FO Phone Number from DOORS

2. (2) 

   FO Street Address from DOORS

Follow NL 00601.003.