E.Other Health Care Concerns

CHAPTER 3  |  DISABILITY BENEFITS FOR CHILDREN  |  109



by a federal, state, or local government

agency, and housing 17 or more residents.

There are exceptions to this rule. If a

child lives for an entire month in a public

institution or private medical care facility

where more than 50% of the costs are

covered by private insurance, Medicaid, or

a combination of the two, the child may be

eligible for a $30 monthly SSI payment. (20

CFR § 416.211 (b)(1)(i)(ii).) This exception

also applies if a child spends part of a

month in a public institution and part in

a private medical facility where more than

50% of the costs are covered by private

insurance, Medicaid, or a combination of

the two. (Examples of medical facilities

are hospitals, skilled nursing facilities, and

intermediate care facilities. However, any

medical facility can qualify.) There is no

limitation on the SSI payment if the child is

in a private facility and does not receive or

expect to receive more than 50% of the cost

of the child’s care from private insurance

or Medicaid. (Program Operations Manual

System (POMS) SI 00520.001.)

EXAMPLE: Matthew, a disabled child, was

born at Tall Oaks Multi-Care Center on

October 4. He remained in the hospital

until January 5, when he was released to

live with his parents at home. Private health

insurance paid for more than 50% of the

cost of Matthew’s care for the months of

October and November. For December



and January, more than 50% of the cost of

his care was paid for by a combination of

private insurance and Medicaid. Matthew is

eligible for the $30 per month benefit.



Because of the complexity of laws

involving SSI for children living in

institutions, call your local Social Security

Field Office if your disabled child who

receives SSI is going to be in a facility. In

fact, the SSA requires that you report if

your child is admitted or discharged from a

medical facility or another institution. (See

Chapter 13 for details.)



4.Medicare

Medicare is a federal health insurance

program for people 65 or older or those who

have received SSDI benefits for at least two

years. Because children do not qualify for

SSDI benefits on their own until they turn

18 (if they qualify at a younger age they are

receiving auxiliary dependents’ or survivors’

benefits through their parents), no child can

get Medicare coverage until he or she is 20

years old. The only exception is for children

with chronic renal disease who need a

kidney transplant or maintenance dialysis.

Those children will be eligible for Medicare

only if a parent receives SSDI or has worked

enough to be insured by Social Security.



l



C H A P T E R



Getting Benefits During the

Application Process (SSI)

A. Applying for Presumptive Disability......................................................................................113

B. Impairments Qualifying for Presumptive Disability by Field Office..................114

1.Observation......................................................................................................................................114

2. Statement by the Claimant or Guardian..........................................................................114

3. Disorders Requiring Confirmation From Another Source......................................115

C. Qualifying for Presumptive Disability Through the DDS..........................................116

1. High Potential for Presumptive Disability........................................................................117

2. Caution in Granting Presumptive Disability...................................................................117

3. Low Potential for Presumptive Disability.........................................................................117



4



112  |  NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY



P



resumptive disability (PD) payments

are made to a person who is initially

applying for SSI benefits, and whose

medical condition is such that there’s a strong

likelihood the person will be found eligible

for disability payments. The person must

meet all nonmedical factors of eligibility—

such as having low income and few assets. If

you are an SSDI claimant—a worker who

has paid Social Security taxes—you are not

entitled to presumptive disability. If you

apply simultaneously for SSI and SSDI, any

presumptive disability you might qualify for

will be based on the SSI claim only.



SKIP AHEAD

If you are only applying for SSDI

benefits, you do not need to read this chapter.

You may proceed to Chapter 5.



If the SSA agrees that you are presump­

tively disabled, you may receive payments

for up to six months while your application

for disability benefits is pending. Payments

begin in the month in which the SSA

made the presumptive disability finding. If,

after six months of presumptive dis­ability

payments, the SSA has not made a formal

determination on your disability application,

the presumptive disability payments end

until this formal determination is made.

People applying for SSI based on a dis­

ability are commonly awarded presumptive

disability cash payments. It never hurts to



request them. If you are granted presump­

tive disability, you can also receive free

health care under Medicaid earlier than

would otherwise be possible. But being

granted presumptive disability does not

necessarily mean that the SSA will make

a favorable final determination on your

disability application. And if the SSA denies

your request for benefits before you have

received a full six months of presumptive

disability benefits, you will not receive the

balance.

You will not have to pay back any of

the presumptive disability payments you

were given before your claim was denied,

except in some unusual situations (20 CFR

Đ416.537(b)1):

The SSA later determines that you

did not qualify under the nonmedical

eligibility requirements—this

exception primarily targets those

people who commit fraud to obtain

benefits.

• The SSA made an error in computing

your monthly presumptive disability

payment—in this situation, you need

only repay the amount of money

that went over the amount you were

supposed to receive. Even in this

situation, the SSA can waive the

requirement that you repay the money

if both of the following are true:

You were not at fault.

Repayment would defeat the purpose

of the SSI law, would be unfair, or

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CHAPTER 4  |  GETTING BENEFITS DURING THE APPLICATION PROCESS  |  113



would interfere with administration

of SSI law due to the small amount

of money involved.

NOTE: The sponsor of an immigrant

who is denied disability may be responsible

for repaying the immigrant’s presumptive

disability payments. (20 CFR § 416.550.)



Emergency Payments

In cases of extreme hardship, the law

permits a one-time emergency cash

advance payment to people who appear

to qualify for presumptive disability

through SSI. (42 U.S.C.A. § 1383(a)(4)(A);

20 CFR 416.520.) Extreme hardship means

that without the payment, you risk an

immediate threat to your health or safety,

such as the lack of food, clothing, shelter,

or medical care.

This advance payment is not extra

benefit money. The SSA eventually gets

the money back, by deducting it from

your presumptive disability checks, usually

spread out over a period of six months.

If you think you need an emergency

advance payment, tell the Social Security

Field Office when you are applying for

SSI benefits. If you are eligible, you will

receive an emergency payment, which

will take seven to ten days to process. The

amount of the payment for one person

cannot exceed $750 (the federal benefit

rate in 2018), plus any applicable state

supplementary amount.



Emergency Versus

Immediate Payments

Do not confuse emergency payments

with immediate payments. The SSA will

issue immediate payments through a Field

Office in critical cases within 24 hours.

(You must already be receiving SSI or SSDI

payments to collect an immediate payment,

so immediate payments do not apply to

presumptive disability.)

Immediate payments can be made to both

SSI and SSDI claimants who qualify. To qualify,

you must have a financial emergency or

present a potential public relations problem

for the SSA. Critical cases are those involving

delayed or interrupted benefit payments.

Examples might include the loss of a benefit

check in the mail or a natural disaster like

a hurricane or tornado wiping out parts of

a town and interfering with normal benefit

check delivery to a number of people.

For immediate payments, the maximum

amount payable for either SSI or SSDI is

$999. The exact amounts vary, and must be

calculated by the SSA Field Office.



A. Applying for Presumptive

Disability

You apply for presumptive disability at

your local SSA Field Office when you apply

for SSI. The SSA Field Office can grant

presumptive disability at that time if you

have any of a limited number of impairments



114  |  NOLO’S GUIDE TO SOCIAL SECURITY DISABILITY



(see Section B, below). Most applications,

however, are forwarded to the state Disability

Determination Services (DDS) without

an award of presumptive disability. But

the DDS also has wide discretion to grant

presumptive disability. So even if your

condition isn’t listed below, once your file

is forwarded to the DDS, be sure to ask

the examiner handling your claim about

presumptive disability (see Section C, below).



B. Impairments Qualifying

for Presumptive Disability

by Field Office

An SSA Field Office representative has the

power to grant six months of presumptive disability payments when you apply for benefits,

if there is a reasonable basis for believing that

you have a disabling impairment. Of course,

Field Office representatives are not doctors,

but they can award presumptive disability to

claimants who are obviously disabled. This is

one way the SSA is trying to speed up providing low-income disabled people with financial

assistance.

The Field Office may grant presumptive

disability in three ways: based on the

representative’s observations, based on the

claimant’s statements, or after requesting

confirmation from another source. The

sections below cover each method.



1.Observation

Under federal regulations, the Field Office

representative can award presumptive



disability upon seeing that a claimant has

one of the following disabling conditions:

• amputation of two limbs, or

• amputation of a leg at the hip.



2. Statement by the Claimant

or Guardian

The Field Office representative can award

presumptive disability payments based on

the word of the claimant (or the claimant’s

parent or guardian, in the case of a

child) that he or she has certain disabling

impairments. The disabling impairments

must be very severe, because the Field Office

personnel are not doctors and are screening

only for obvious cases. Note that the actual

medical severity needed to ultimately qualify

for disability benefits based on one of these

disorders may be less than what is required

to receive presumptive disability payments.

The disabling impairments are as follows:

• total blindness

• total deafness

• bed confinement or immobility without

a wheelchair, walker, or crutches due to

a long-standing condition—such as a

chronic condition that is not likely to

improve with further treatment and has

been present for a year or more

• a stroke more than three months in the

past with continued marked difficulty

in walking or using a hand or an arm—

marked means more than moderate, but

less than extreme, but does not require

an inability to walk or total paralysis in

an arm