Public Law 104-193 requires that members of the Social Security Advisory Board be given an opportunity, either individually or jointly, to include their views in the Social Security Administration’s annual report to the President and Congress on the Supplemental Security Income (SSI) program. We have asked the Social Security Administration (SSA) to include in this year’s annual report the following statement of our views on third party assistance for SSI disability applicants that is provided by community-based non-profit organizations.
SSI is a federal public assistance program, based on need, for people who are age 65 or older, blind, or disabled. Although filing for SSI benefits requires the submission of a significant amount of information that makes it an intimidating process for anyone, the information is needed nonetheless to determine eligibility under the current statutes. Therefore, applying for SSI can be a confusing and stressful task. When claimants decide it is time to apply, they may already be at an advanced age, were born with a disabling condition, or have acquired a disability or serious health condition. In addition, these individuals may have family members depending on their income for financial support. By the time the individuals decide to apply, the application process may seem daunting. The SSI applicant may have additional stressors, such as homelessness or mental illness that make it difficult to navigate successfully through the steps of the application process.
While some claimants are able to independently navigate their way through both the federal application and any additional state medical application without assistance, others – particularly those individuals with limited personal resources or abilities – may seek help from community-based programs that are typically operated by non-profit organizations. During our recent study of claimant representation, we had an opportunity to learn about the kinds of supports and services offered by these organizations. In this statement, we provide a brief overview of non-profit third party organizations and review models of apparently successful third party initiatives.
In general, the non-profit organizations that provide assistance to individuals filing for SSA disability benefits are social service organizations, health care entities, or legal aid agencies. These social service agencies typically help individuals with low to moderate incomes access a wide variety of federal, state, and local benefits and services such as in-home support services, food stamps, and general relief. They may also assist clients with specific limitations, such as a mental illness or homelessness. The legal aid agencies provide a broad range of services related to civil actions or government regulations, and those services can include assistance with filing for government benefits. With regard to the disability programs administered by SSA, non-profit organizations may provide assistance to individuals at any point of the multi-stage disability application process, from filing the initial application through appealing an adverse decision. In addition, we should note that our research found that health care entities, such as hospitals and clinics, may contract with
for-profit third party providers to assist their patients, particularly the uninsured, with SSI and Medicaid applications.
The client base for these organizations frequently includes individuals who may be lacking in resources on several fronts, such as those who have little or no income, no usual source of medical care, or no effective support system for engaging a private attorney or other representative. All three types of organizations are usually funded by a combination of public or private grants, charitable donations, and possibly by state or federal funding. Non-profit organizations provide their services at either no cost or very little cost to the claimant, and may sometimes be contracted by other entities to provide their services to eligible clients.
During the filing process, representatives from these non-profit organizations help claimants filing for SSI benefits by completing the necessary forms, either through SSA’s online process
1 or via a paper application. As an important part of this application process, the representatives help the claimant to explain or describe the nature of the claimant’s impairment or impairments and the ensuing limitations in order to present a clear picture to decision makers. Some representatives add a narrative explanation to the standard application in which they record their own observations about the claimant’s abilities or level of functioning, or an overview of the supporting medical and other documentation they are submitting with the application.
In an effort to prevent unnecessary delays and reduce the time SSI claimants must wait for benefits, these third party representatives will often take additional steps to provide as much medical information as possible. The motivation for this is that the more complete the medical information, the less time it should take to make a decision on the case. They often obtain signed statements and copies of records from medical sources and include them with the initial application rather than waiting for the disability examiner to request the information. Further, the representatives may arrange for the claimant to see a physician or have medical testing done to obtain needed verification of the disabling impairment. This can eliminate the need for (and the cost of) examinations the disability examiner would request in order to obtain medical evidence. The need for such examinations is particularly high for certain segments of the SSI claimant population who may not have regular access to health care services and therefore have few medical or psychological sources of evidence.
After the claim is filed, the representatives will typically open a communication channel with the disability examiners handling their cases. The first step may be a call to the state agency (known generically as a Disability Determination Service, or DDS), which in most cases makes the disability decision on SSI applications. In this call, the representative will want assurance that the claim has been received, and then will want to identify the examiner who will be working the case. Assistance will continue throughout the DDS portion of process with the representative gathering any additional information and/or evidence the examiner needs to support the disability decision. This can include additional medical or psychological evidence, information about new medical sources, details about the claimant’s past work, and information surrounding the limitations in activities of daily living; i.e., any supporting information or evidence needed to make a determination.
The representative often plays the role of expeditor, following up with physicians, clinics and hospitals to obtain evidence or ensure that files are sent to the examiner. Further, this kind of assistance is invaluable in tracking down hard-to-reach claimants, such as those who are homeless or mentally ill or who, due to financial circumstances, frequently move – often without providing notice or any forwarding address. The representative may also contact the claimant to make sure appointments for any scheduled examinations are kept, and may arrange transportation to those appointments.
Representatives from community-based non-profit agencies offer services to SSI claimants to assist in developing a claim that is as complete as possible when it is submitted to the disability examiner, and then to monitor that claim throughout the process to provide any information or evidence needed to make a decision. Their services have the potential to both speed up the process and ensure that the claimant receives the most informed determination possible. To be effective, the representative should ideally have a thorough knowledge of SSA policy, take a comprehensive approach to documenting the claimant’s disabling conditions, and establish good communication with both the claimant and SSA/DDS representatives.
During our study of claimant representation, we heard from representatives of several different non-profit organizations that represent SSI claimants, who described the elements of their programs that they believe led to their success. We present the following models as examples of third party assistance that emphasize timely, thorough, and collaborative assistance that can benefit the claimant and also support the goals of the disability program.
One third-party assistance model that shifts the collection of information and claims development away from SSA is the SOAR (SSI/SSDI Outreach, Access and Recovery) model. SOAR is a joint project of the Department of Housing and Urban Development (HUD) and the Substance Abuse and Mental Health Services Administration (SAMHSA) at the U.S. Department of Health and Human Services (DHHS). The project’s goal is to increase access for eligible claimants to disability benefits administered by Social Security, and thereby improve housing options, treatment opportunities, and other support services for long-term homeless populations. SOAR does this by providing strategic planning, training, and support to state and local organizations that serve these populations.
The SOAR model is based on case management specifically designed to assist a segment of the population that is hard to serve due to the transient nature of their daily lives. While many homeless individuals have both mental and physical disabilities, there is often little in the way of formal evidence to support their claims for disability benefits. The case manager’s primary responsibility is to gather any available information, and then supplement those records through examinations by physicians or psychologists. As part of the process, a comprehensive summary is developed that provides a complete narrative history of the individual’s impairments and medical/psychological treatment, along with observations and assessments of functional capacity and limitations. These summaries are reviewed and signed by the physicians and/or psychologists who have examined the individual applicant. The process is designed to provide as complete a record as possible for use by the DDS examiner in making a disability determination. Furthermore, once the case is assigned in the DDS, the case manager continues to develop the record as directed by the examiner.
From the FO and DDS perspectives, the staff at the SOAR project does much of the work of collecting necessary information. Perhaps equally as important, they also serve as a point of contact with this particular population, relaying any information needed to fill in the gaps, ensuring that the claimant attends consultative examinations if needed, and generally doing everything possible to ensure that all existing information is available to the decision-maker.
Since 2006, SOAR projects have assisted with nearly 15,000 disability applications with an average allowance rate of 71 percent.
2 This rate is worth noting when it is compared to the national allowance rate of only 35 percent,
3 or the allowance rate for SSA’s Homeless Outreach Projects & Evaluation (HOPE) grants,
4 which essentially serve the same population. In fiscal years 2005 through 2007, the HOPE project allowance rate was about 41 percent -- only slightly better than the national average.
5 As of 2011, the processing time for SOAR’s cases average 101 days as compared to national processing time of 113 days
6 for SSI initial disability claims. By the end of 2012, officials anticipate that there will be SOAR projects in all 50 states.
After more than five years, there are some indications that the third-party assistance provided by these projects is effective, at least for the segment of the population these projects serve. However, in terms of transference, the question is whether this kind of assistance can be used with other groups, and if so, what customization, if any, might be necessary. The protocol developed for the SOAR projects is already being tested with other groups such as veterans. For example, the SOAR project in Washington State is working in collaboration with the Washington Department of Veterans Affairs to assist returning military personnel. And case managers at the New London Homeless Hospitality Center for Veterans in Connecticut received specialized training using what they described as “a nationally tested and validated model (SOAR)” to assist veterans pursuing disability benefits.
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While not involved in SOAR projects per se, there are other groups adopting similar procedures. In July 2009, Solutions for Progress, Inc., a company that assists low- and moderate-income individuals to apply for government benefits and services, developed a web-based application tool (the Benefit Bank) using many elements of the SOAR model. As of March 2012, the Benefits Bank’s project in Ohio maintains a 50-53% percent allowance rate for their homeless and at-risk-of-homelessness population as compared to the allowance rate of 29 percent
8 for all SSI cases processed in Ohio.
With at least some indication that these models can be used with a variety of populations to assist in the SSI application process, the next question is how do these non-profit agencies and organizations obtain funding to support the services they provide? The technical support teams that provide the planning, training, and support for SOAR projects are jointly funded by SAMHSA and HUD; but there is no direct funding to the state and local organizations that sponsor these projects. Therefore, funding must come from the community.
While local mental health and social services agencies provide much of the funding, there are a number of other funding strategies also being employed.
9 For example, the B.E.S.T. program in Portland, Oregon is funded through a combination of public money (from the city of Portland), and two hospital foundations (Kaiser Permanente and Providence Health Systems). A little over $600,000 financed the project for its first two years.
In Nashville, Tennessee, SOAR has joined forces with the AmeriCorps VISTA program to provide much needed staffing. Through this collaboration, the project receives at no cost a full-time VISTA volunteer who receives a monthly living allowance, health coverage, travel costs, and tuition support. In this community alone, over 220 individuals have received SSI/SSDI disability benefits through the services of volunteers who have collectively put in over 1,800 hours in little over a year
11. In Wilmington, NC, a SOAR case worker reported assisting 45 applicants who were awarded benefits. When these 45 applicants became eligible for SSI, they also became eligible for Medicaid. Their Medicaid allowed the community hospital to be reimbursed by Medicaid for approximately $123,000 it had spent on medical care for these 45 people. As a result of this success, the New Hanover Regional Medical Center agreed to continue to fund the project with a portion of future Medicaid reimbursement
12s. In Minnesota, the State is able to use state general assistance funds recouped from SSI retroactive benefits to enable continued funding of 14 SOAR projects in their state.
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Having found ways to fund these projects, the next challenge for these state and local organizations is assessing the cost benefit. With no universal funding mechanism for these projects, it would be difficult to assess the cost benefit for this kind of third party assistance at a national level. However at the local level, there are some examples of how organizations or communities have assessed the financial impact. The marketing for the B.E.S.T. program mentioned earlier emphasizes that it is not just the recipient but also the whole community that benefits from such projects; the project demonstrated that by announcing that community health care providers received over $230,000 in retroactive Medicaid payments from just seven cases.
While a variety of funding strategies have made these projects apparently successful on a relatively small scale for certain segments of the population, the challenge now is how to make some form of third-party assistance available to greater numbers of potential SSI claimants across a broader spectrum of disabilities. With over 3 million initial claims expected to be filed this year alone, resources needed to provide this type of assistance would be significant. However, a number of significant efficiencies could emerge from assisting with and enhancing the initial evidence collection process and case development, including: 1) stabilized economic conditions for individuals; 2) needed medical care received timely, resulting in better health outcomes and less dependence on emergency services; and 3) more streamlined and cost-effective process of determining eligibility to SSI benefits.
Given that SSA today has over 65,000 employees, why might third party assistance provided by non-profit organizations using evidence-based models be recommended? First of all, SSA’s workforce has decreased from approximately 71,000 in 2010 because the agency has been under a hiring freeze for the last few years. With the hiring limitations remaining in effect, SSA projects a net loss of 2,500 – 3,000 SSA and DDS employees due to attrition in the current fiscal year.
16 At the same time, baby boomers are reaching their disability prone years and moving into retirement, resulting in claims workloads – both retirement and disability – that are only going to continue to increase. The probability of SSA having sufficient staff to do the kind of case management described in the SOA R model above for every disability claim is very slim. One solution is to look outside the agency to organizations that have a mission-driven interest in making sure that disabled individuals – and particularly those with little or no resources – receive the benefits for which they are eligible.
During our study of third party representation, we heard how representation has the potential to improve the disability application process for SSI claimants and free up resources for the agency. In order to strengthen this public/private model, there are improvements to the process that we believe would benefit the claimant and SSA. We are currently finalizing a comprehensive report on third-party assistance based on our study of all types of representation and will include in that publication our specific recommendations for improvement. Nonetheless, as community-based non-profit organizations described in this statement serve - and will continue to serve - SSI claimants, we believe that increasing the effectiveness of the collaboration between SSA, DDSs, and these private organizations should be an important goal for all parties.
