SOAR Fundamentals

Introductions

Local SOAR Leads

Program Participants

Please tell us: Your name and work location What are your plans/goals for using

SOAR in your work? What do you need to learn today to

get you there?

Logistics and Housekeeping

Take care of yourself Restrooms and breaks

Ground rules Cell phones Ouch, Stretch, ELMO Others?

Values and language Parking Lot

SOAR

SOAR stands for SSI/SSDI Outreach, Access and Recovery

Focus is on people who are homeless or at risk for homelessness

Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with SSA since 2005

All 50 states currently participate; no direct funding provided to states

Why is SSI/SSDI Important for Individuals?

SSA disability benefits can provide access to: Income Housing Health Insurance Treatment Other supportive services

For people with disabilities, SSI/SSDI can be a critical step towards ending homelessness and promoting recovery

Why is Access to SSI/SSDI Important for States & Localities?

People experiencing homelessness are frequent users of expensive uncompensated health care

Can recoup cost of this care from Medicaid for up to 90 days retroactive to date of SSI eligibility

States and localities can recoup from SSA the cost of public assistance provided during the application process

SSI, SSDI and Medicaid bring federal dollars into states, localities and community programs

Changing Lives Since 2005

19,008 persons experiencing or at risk for homelessness have been approved on initial application

65 percent approval rate overall

Compares to 10-15 percent for unassisted applications from people who are homeless and 29 percent for all applicants

Approvals were received in an average of 100 days in 2013

Appeals can take a year or more; many people give up and do not appeal

Top Eight States

Served more than 4,000 persons

89 percent approval rate on initial applications

Approval rates are highest in places where more SOAR critical components are implemented

SOAR Technical Assistance Center

SAMHSA funds the SOAR TA Center to support states and communities

Offers virtual and on-site technical assistance

SOAR TA Liaisons are responsible for SOAR in multiple states

Get to know your SOAR TA Liaison Reach out for help or answers to

questions about any aspect of SOAR

Online Course Experience

Wows Wishes

Activity: Reasons for the Work We Do

This program is about: Ending homelessness Promoting recovery Transforming lives

Discussion: What brought you to this work?

SOAR Fundamentals Agenda

The Basics Getting Started

Who is a SOAR applicant?

Engaging the applicant

State SOAR process

Forms

Medical Summary Report Refresher

Tracking Outcomes

Special Populations

Appeals Now What?

SOAR Fundamentals Materials

PowerPoint slide handouts

Sample SSA Forms

MSR Worksheet

Sample Medical Summary Reports

Your State’s SOAR Process

Sample Application Packet

Any other materials that you want participants to have!

SOAR Fundamentals: The Basics

SOAR Has Broader Goals

Housing

Access to treatment and other services

Employment

Opportunities

Community Investment

Decrease in adverse

outcomes (incarceration

& hospitalizatio

n)SOAR

SOAR Partners

Social Security Administration (SSA) Federal agency that administers SSI/SSDI Makes the non-medical decision

Disability Determination Services (DDS) State agency under contract to SSA Makes the medical/disability determination

Medical/treatment providers Assessments/evaluations Medical records

You!

SSI & SSDI: The Basics

SSI: Supplemental Security Income; needs based; federal benefit rate is $721 per month in 2014; provides Medicaid in most states

SSDI: Social Security Disability Insurance; amount depends on earnings put into SSA system; Medicare generally provided after 2 years of eligibility

The disability determination process for both programs is the same

Application Process

Application

Initiated at SSA

SSA Determines Non-Medical

Eligibility

SSA Transfers Claim to

DDS

DDS Determi

nes Medical

Eligibility

DDS Returns Record to SSA

SSA Notifies Applican

t

Criteria for Eligibility

1. Medically Determinable Physical or Mental impairment Illness must either meet or be equivalent to the

“listing” criteria used by DDS. Supporting information must be documented in medical records

2. Duration The impairment tied to the illness(es) must have

lasted OR be expected to last 12 months or more OR be expected to result in death

3. Functional Information Applicants must demonstrate that significant

functional impairment related to the illness(es) exists that impede their ability to work

Sequential Evaluation

Step 3 is Key!

Person can be found disabled at Step 3 and begin receiving benefits

If adequate evidence is presented that impairment meets the Listings and the applicant is unable to work

Connecting functional limitations to their inability to work with appropriate medical documentation is key

Documenting the Disability

Case managers need to collect medical records from all treatment sources Applicant report Collateral sources (friends, family, other service

providers) Common treatment providers

Two releases (agency and SSA-827) for each treatment source are signed so that the case manager can share these records with SSA and DDS

Used to meet the Listings

Organize your search!

Documenting the Disability

If medical records are not current, case managers may need to arrange for assessments to be done

Mental status exams must be done within 90 days of submitting application

DDS requires that the applicant has a diagnosis from a doctor (MD/PhD/EdD)

Make the Link to Work

The question DDS must answer is: “Can the person work and earn SGA?”

Disability must meet the criteria in the “Listings”

Must make the link between a person’s illness, his/her inability to function in a work setting

Functional Information

For mental illnesses, the applicant must demonstrate functional impairments that meet the Listings

Document all four areas Activities of daily living Social functioning Concentration, persistence and pace Repeated episodes of decompensation

Must demonstrate marked functional impairments in at least two areas

Functional Information

For physical impairments, the application must demonstrate significant limitations in meeting physical, mental, sensory and other requirements of work

A limited ability to perform certain physical demands of work activity (e.g. sitting, standing, walking, lifting, carrying, etc.) may reduce a person's ability to do past work and other work

Using the Blue Book Listings

http://www.ssa.gov/disability/professionals/bluebook/ AdultListings.htm

For each category of mental impairment: General description of disorder Section A – types of symptoms and impairments

(diagnosis) Section B – required “level of severity” (limitations

in functioning) Section C – medically documented history (longer

period of documentation)

To qualify, an individual must: Meet A + B Or C

Criteria “A” – Blue Book Listings

Psychiatric evaluations

Physical health evaluations

Specialty physical health evaluations

Neurological reports Laboratory results

Diagnostic tests Neuropsychological

tests Psychological tests Admission

summaries Discharge

summaries

Criteria “B” – Blue Book Listing

Bio-psychosocial evaluation reports

Occupational therapy evaluation reports

Vocational evaluation reports

Psychiatric Rehabilitation Day Program notes

Supported housing progress notes

Functional descriptions

Medical Summary Report

Remember to Make the Link

Diagnosis Part “A” of the Listing

Functional Limitations Part “B” of the Listing

Why the applicant is unable to work.The MSR helps illustrate the connection between A and B

The Secret to Approvals?

A + B = Approval

Co-Occurring Disorders

If substance use is deemed "material" to a person's disability, benefits will be denied

Substance use is "material" when: If a person were clean and sober, the

functional impairment would not exist and the person would not be disabled

The determination does NOT require sobriety

Use past periods of sobriety (hospital, jail, treatment) to document symptoms that persisted

Medical Summary Report (MSR)

The MSR is a letter which describes the individual and his/her functional limitations and struggles Supports medical records submitted Helps DDS “see” the person you are working with Illustrates the connection between the applicant’s

functional limitations and the impairment Answers the question: “Why can’t the applicant

work?”

The MSR worksheet guides the case manager through the sections of the written report

The letter, not the worksheet, is submitted to DDS

Medical Summary Report

Medical Summary Reports are considered medical evidence if signed by a treating physician or psychologist

Even without a physician’s signature it is important for DDS’s determination of the applicant’s ability to work

Getting Started

The Challenge

Limited resources

Limited time

A lot of people need our help

Applications involving mental illness and co-occurring substance use disorders are complicated

The SOAR Applicant

Who can be helped by SOAR? Adults who are experiencing, or at risk for, homelessness And who have mental illness, co-occurring disorders or

other physical disabilities or conditions

Who is considered “homeless”? Moving from place to place throughout the month Living “doubled-up” Living in uninhabitable housing, outside or in shelters Living in unstable or non-permanent housing Exiting jails or prisons and who have no stable place to

live 

Identifying SOAR Applicants

Using the Tool

Identify individuals who most need your assistance

Do not discourage anyone from applying for SSA benefits

Plan for alternative service or referral

Make the Tool Work For You

Consider adding your program acceptance criteria

Use in conjunction with other assessment tools

Consult with colleagues or the SOAR TA Center

Engaging Applicants

Create and maintain a safe space for you and the applicant

Keep your promises: Under promise and over deliver

Find out where the person spends his/her time Develop ways to maintain contact, including

someone to contact should you need to reach the applicant

Ask open-ended questions Be mindful of non-verbal communication

Our State or Local SOAR Process

Attention Local/State Leads! The next few slides cover the standard SOAR

process; adapt these slides if your process differs from this

Add information about your local/state SOAR process here How to set protective filings dates When to contact SSA How to communicate with DDS Where to access records and assessments

Getting Started: Completing an Initial SSI/SSDI Application

Getting Started: Days 2 – 3

Complete and have applicant sign the SSA-1696 Appointment of Representative form

SSA-1696: Appointment of Representative

Permits communication with SSA and DDS about the applicant’s file

Case manager receives copies of all applicant communication from SSA and DDS

The most important tool for working with someone who is experiencing homelessness

“The Key to the City”

Neither the agency or the case manager is liable for the decision made by DDS

It is NOT the same as the representative payee

SOAR providers should check “waiving fees from all sources”

Getting Started: Days 2 – 3

Request Letter

SSA-827

Agency Release

SSA-827: Authorization to Disclose Information to SSA

Allows SSA and DDS to gather medical records and information from medical records departments

SOAR providers - use along with Agency Release Form when requesting medical records from every source (HIPAA Compliant)

All forms should be signed by the applicant

Available online

Getting Started: Weeks 1 – 2

SSA-3368: Disability Report Adult

SSA 3368: Adult Disability Report

Gathers basic information about the applicant’s work history, medical treatment and education

Helps DDS know which providers will have medical evidence for the application DDS will request records from the medical sources

listed SOAR case managers can indicate in Remarks

which records they will submit with the application

Complete online, use the paper version as a worksheet

Getting Started: Weeks 3 – 4

SSA-8000: Application for SSI

SSA-8000: SSI Application

Title XVI

Needs based so income and resources are counted

Longer application

The amount of pages may seem overwhelming but for many, resources are so limited that many of the pages will be blank

Don’t assume that the applicant does or does not have resources

Can be completed in person, by phone or submitted hard copy

Getting Started: Weeks 3-4

SSA-16: SSDI Application

SSA-16: SSDI Application

Title II

SSDI eligibility is based on work history

No resources and assets counted Not necessary to establish need

Explores eligibility for other benefit programs (Worker’s Compensation, VA benefits, etc.)

SSA prefers online submissions

Establishes protective filing date for SSI applications

Remember the ‘Remarks’ Section

Found on the SSA-8000, SSA-16 and SSA-3368

Indicate that this is a “SOAR” claim if the person is experiencing or at risk of homelessness

Provide additional information that will clarify responses to questions on the forms

Reference the question number in the comments section along with the explanation

Getting Started: Weeks 5 – 8

Medical Summary Report (first and last pages)

Submitting the Application

Call the SSA SOAR Contact at least 1-2 weeks before the 60-day deadline, or earlier, to request an appointment to submit the completed application

24-48 hours before the SSA appointment, submit the combined Disability Application (SSA-16) and Disability Report (SSA-3368) online

Submit the completed application package using the SOAR Checklist for Initial Claims as a cover sheet

Submitting the Application

http://www.ssa.gov/applyfordisability/

SOAR Application Checklist

Reminder! A Complete SOAR Packet Includes:

1. SOAR Checklist as a cover sheet for the completed application package

2. SSA-1696 Appointment of Representative form

3. SSA-827 Authorization to Disclose Information to SSA

4. SSA-8000 signed and dated by applicant

5. MSR signed by the SOAR provider as well as the applicant’s physician or psychologist

6. Copies of all medical records in chronological order

7. SSA-3368 and SSA-16 submitted on-line 24-48 hours before turning in completed application package (Items 1-6)

Organizing Your Effort

Make a file for each applicant Consider a folder with sections Include a cover sheet Section for medical records Section for SSA/DDS Correspondence Have files prepared in advance

Create a contact list for SSA reps, DDS adjudicators and medical records providers

Medical Summary Report Refresher

Critical Components

Serving as the appointed representative

Collecting and submitting medical records

Electronically submitting applications and medical evidence whenever possible

Collaborating with physicians for assessments and medical information

Collaborating with SSA and DDS

Submitting a Medical Summary Report

The Importance of the Medical Summary Report

Critical component of the SOAR model

Provides a vivid picture of the individual for the DDS examiner who never sees them

Provides a clear link to the functional impairment

Often takes place of the SSA-3373 Function Report

Helps to avoid the limited space and check-boxes of these forms

Is medical evidence when co-signed by a physician or psychologist

Can be sent directly to the DDS examiner or hand delivered to SSA

Receives positive feedback from DDS examiners around the country

Tips for Writing

Collect medical records after Releases of Information are signed

Go through medical records and organize in chronological order

Set aside several hours at a time to begin writing the report with no interruptions

Sit down with all information -- medical records, intake packet, completed MSR worksheet (personal, medical, employment and substance use history) and any current mental status exams

Components of the MSR

Reference Section Introduction Personal History Diagnostic and Treatment Information Link to Functional Impairment Summary Contact Information

Introduction Section

Demographics

Physical description – hygiene, grooming, dress, make-up, any unique characteristics

Include diagnoses and impairment information

Help the DDS examiner “see” the individual as you do!

Diagnoses and Treatment

Psychiatric and physical

Chronological treatment history

Specific quotes from the applicant or record that illustrate diagnosis

Observations of behavior

Durational issues

Current mental status exam

Link to Functional Impairment

Critical to connect symptoms/effects of illness with marked functional impairments

To the extent possible in all four functional areas

Demonstrate impact of illness(es) on ability to work

Medication – effects and side effects Support and effect of support Compare with lack of support

Make the Link

The MSR is the link that connects the diagnosis to the limitations that the applicant experiences

Being able to document this link is very important in order to demonstrate the applicant’s inability to engage in substantial gainful activityDiagnosis

Limitations in

Functioning

Why can’t the applicant

work?

Medical Summary Report Worksheet

Tool for gathering information needed to write the MSR

Open-ended questions Tell me about …

How often …

When was the last time …

Functional questions Context of questions – SGA Distinguish between access and ability

Do not turn the worksheet in to DDS!

Summary and Contact Information

Ties all information together for a concise picture of the individual

Contact – names and numbers

Co-signed by case manager, treating physician/psychologist

MSR Samples & Support

Visit the SOAR website for MSR samples and abbreviated versions

The SOAR TA Center will review redacted MSR letters and provide feedback upon request

Worth the Effort

The overall process of applying for benefits is time-consuming

Putting forth the initial effort for an earlier, more successful outcome may seem difficult, but it is worth the effort!

Programs with higher outcomes submit medical summary reports

Tracking Outcomes

Online Application Tracking (OAT)

https://soartrack.prainc.com A web-based program that allows case

managers to keep track of their outcomes Free Easy to use Accessible from any web browser Nothing to download

On a secure server HIPAA compliant

No personal identifying information is collected

Registration

Outcomes in OAT

Outcomes for initial applications & appeals Approval rates Time to decision Critical components

Optional outcomes Housing Employment Medicaid and other public benefit

reimbursements

Applicant Identification (ID)

No personally identifiable information Alpha-numeric ID

First 2 letters of first name Last 2 digits of the birth year First 2 letters of last name Last 4 digits of the Social Security Number

Case workers should record Applicant ID in the case file for cross reference

Example: Summary Report

Special Populations

Special Populations

Veterans

Children

Justice-Involved Persons

Veterans and SSA Benefits

The definition of disability and application process is different for VA and SSA benefits Discharge status is not a factor in SSI/SSDI determination Those denied for VA benefits may still be eligible for

SSI/SSDI Veterans can access SSA benefits while they are waiting

for VA benefits Veterans who receive a partial disability rating and

limited VA benefits may also receive supplemental SSA benefits

Health insurance associated with SSA benefits can be important for Veterans without VA health care

SSA has special provisions for expediting disability applications for Wounded Warriors, that also apply to appeals

VA Staff and SOAR

Staff are encouraged to participate in SOAR training and assist with SSI/SSDI applications

May disclose VA records to SSA if Veteran signs the appropriate release (SSA-827)

Can assist in gathering documentation, completing the SSI/SSDI application forms, and referring the Veteran to a SOAR representative, if needed

May not serve as Authorized Representative (SSA-1696) or Representative Payee (SSA-11), but can be listed as a contact who knows the Veteran

How Do Children Qualify for SSI?

Four main criteria considered: Disability

A medically determinable physical or mental impairment, which results in marked and severe functional limitations and which can be expected to result in death or which has lasted for a continuous period of not less than 12 months

How does the child’s functional abilities compare to the functional abilities of a child of the same age who does not have the physical and/or mental impairments?

Income Parent/household income

Resources Parent/household resources

Citizenship/Immigration status

Justice – Involved Persons

Warrants (other than escape) should not hinder a person from applying or receiving payment

A person can apply for benefits while incarcerated

Prior history of incarceration alone does not make someone eligible for benefits

Engagement Tips for People in Correctional Settings

Jails and prisons have distinct cultures

Anticipate how this culture or “code” affects behavior and functioning in prison

Expand skills to engage individuals in this culture

Life experience affects engagement

Engagement involves creating a safe space

SSA Appeals Process

SSA Appeals Process

1. Initial determination2. Reconsideration3. Administrative

Hearing4. Appeals Council

Review5. Federal Court Review

Federal Court Review

Appeals Council Review

Administrative Hearing

Reconsideration

Initial Determination

Appeal Online

http://www.socialsecurity.gov/pgm/appeal.html

Reconsideration

First level of appeal in most states, except for these areas: Alabama, Alaska, California (Los Angeles North & WB),

Colorado, Louisiana, Michigan,  Missouri, New Hampshire, New York, & Pennsylvania

Request for Reconsideration needed to initiate the appeals process

Must be filed within 60 days of the date of the denial notice, plus an extra 5 days for mailing

Three forms to file: Request for Reconsideration Disability Report - Appeal Authorization to Disclose Information

All may be obtained and filed online at www.ssa.gov

Reconsideration

DDS takes an entirely new look at the case and makes a new determination on a person’s disability

New disability examiner/analyst and new reviewing physician

Many ways to support a claim at this stage:

Complete more detailed Disability Report - Appeal

Revisit the steps in the SOAR model to develop the claim for Reconsideration

What To Do If the Deadline Has Passed?

The applicant can appeal if he/she has “Good Cause” for missing the deadline

Ask SSA to accept late filing by giving “good cause” or reason for the delay Related to applicant’s disability Limited English proficiency and/or education Failure to understand the requirements Failure to receive denial notice within 5 days of

the date on the notice Unusual or unavoidable circumstances such as

hospitalization

Appeal vs. New Application

Starting a new application results in: The loss of the earlier protective filing date

and potential loss of months of back benefits

Requesting reconsideration: Preserves the protective filing date and

potential eligibility for months of back benefits

Be sure the applicant knows the difference and is making an informed choice!

Know the Reason(s) for Denial

Request the electronic folder (CD) from SSA or the Office of Disability Adjudication and Review (ODAR)

Review the CD to ascertain evidence on file and rationale for denial

Review earnings record to make sure there are no SGA earnings

Make note of errors, omissions and plan your strategy

Administrative Hearing

Administrative Law Judge (ALJ) Hearing If denied at Reconsideration or you are in

a prototype state File appeal online within 60 days of

decision Review the claim, including the evidence

used to deny the claim Submit new evidence if applicable Plan to attend the hearing

On the Record (OTR) Review

A written request asking that the ALJ make a favorable decision based on the evidence in the case record A favorable decision is the only decision possible through

an OTR review Otherwise there is no decision and the hearing process

goes forward as though the OTR never happened

You are requesting a decision based on new evidence that has become available since the DDS denial Can be as big as a catastrophic worsening of the

claimant’s condition, or as small as an onset date that was entered incorrectly

Can be requested by the claimant or SOAR representative but is often done through a screening process by the ODAR Attorney Adjudicators in an effort to clear hearing backlogs

Now What?

Next Steps

Get started on your first application Reach out to your colleagues, local leads

and the SAMHSA SOAR TA Center for assistance

Keep in close communication with your SSA and DDS representatives

Attend local SOAR steering committee meetings

Track your outcomes in OAT

Your State SOAR Team

Attention Local Leads!

Add your information below:

State Team Lead contact information

Local Lead(s) contact information