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Lindsey Holden, EBS in Portage County, assisted a client in obtaining QMB. The client's spouse received an inheritance that caused her to lose SSI, Medicaid, and QMB. However, the main portion of the inheritance was real property in the spouse's name, only. This meant that the client could be eligible for MAPP, but because she did not qualify for premium-free Part A, she would be responsible for Part A and Part B premiums without QMB. The client's spouse intended to sell the property eventually, but was hesitant to do so that quickly. When Lindsey explained that she could become QMB eligible if the property was listed for sale, they contacted a realtor (a relative) who listed the property for them. Lindsey was able to show IM that the property was unavailable under MEH 16.2.2 , and with assertive follow-through, the client's QMB was processed.
11/30/2023
Story #128
Jennie Bowers in St. Croix County helped a client with a successful appeal following the denial of a medical procedure. Her client had had prostate cancer and had developed some severe and unpleasant side effects from the medications used to treat the condition. The client worked with his doctor for over a year to try and come up with alternate, non-surgical ways of treating the problems, but was unsuccessful. He had excess skin that had swelled up near his prostate area causing painful urination, difficulty maintaining cleanliness, and painful walking (due to rubbing). Ultimately, his doctors determined surgery was necessary to correct the problem. Medicare initially denied part of the surgical procedure as being “cosmetic." However, by obtaining medical records showing the client's many trips to the doctor regarding the problem as well as his many unsuccessful attempts at treating the issue using less invasive techniques, Jennie was able to demonstrate to Medicare that this surgery was entirely medically necessary for treatment of his pain and condition. The client agreed to let Jennie send in pictures of the condition (taken by his doctor) along with the appeal so that the reviewers could see the scope of the problems that the client had been dealing with. As they say, a picture is worth a thousand words! Upon seeing the pictures and reading the appeal, Medicare agreed that the surgery was not cosmetic, and approved coverage for the remaining $5,000 balance.
Monetary Impact = $5,000
10/31/2023
Story #127
Jessica Smith, EBS in Eau Claire County, helped a client successfully appeal the denial of her gastrointestinal testing. The client was 76 years old and experiencing symptoms initially diagnosed as mild food poisoning and expected to pass within a day or so. However, when her symptoms did not improve after a couple of days and actually worsened, she returned to her doctor's office and insisted on additional testing. Good thing the client was persistent because she actually tested positive for C difficile toxin, commonly known as “C-diff." The client received a phone call from an epidemiologist at Mayo Hospital in Rochester, Minnesota with instructions about starting a strong antibiotic regimen immediately due to the serious implications of the infection. Medicare denied the test as unnecessary; however, upon investigating the facts, Jessica found out that the client had met three of the five conditions in the Medicare Local Coverage Determination (LCD), even though it was only necessary to have met one of those five conditions in order for Medicare to cover the test. Jessica obtained a copy of the patient's medical records regarding the need for the test and sent in the appeal. Medicare agreed that the test was warranted and paid for the $816 claim. And since the client also had a supplement, she did not owe anything for the test after it was covered by Medicare.
Monetary Impact = $816
10/31/2023
Story #126
Ellen Venne, EBS of Adams County, helped a client get an SSI Overpayment waived. The client, who suffered from mental health issues and confusion related to medication side effects, did not understand when SSA called him and told him he needed to start paying $200 per month. SSA had made a mistake when paying him SSI benefits (they failed to consider his wife's Social Security Retirement Income), and then assessed an overpayment of nearly $14,000. Ellen helped the client request a waiver, and in less than two months, the entire overpayment was waived.
Monetary Impact = $14,000
9/29/2023
Story #111
Terri Esselman, EBS of Clark County, helped a client negotiate a $10 per month repayment plan with SSA for an SSI overpayment. The client was incarcerated, and had incurred an SSI overpayment totaling over $2,000. The client did not deny that he was overpaid, and did not want to request a reconsideration or waiver. Instead, he just wanted to reduce his monthly repayment amount so SSA would not take his full checks. At first, SSA told the client the lowest amount they could accept was what could be repaid over 12 months, then they said 36 months. However, Terri was able to use the POMS rule that a person receiving LIS (Part D Low Income Subsidy) qualifies for a repayment amount as low as $10 per month. After educating SSA about this policy, he was granted this repayment amount and can now pay it off slowly over time as he re-enters the community post-incarceration.
8/31/2023
Story #104
Gail Sauerman also achieved a favorable result for a client with an SSI overpayment that went all the way to an ALJ hearing. The client had a large SSI overpayment that was mainly due to real property that she shared with her ex-husband. We were able to prove that because he refused to sell the property, then it should not be counted as an available resource. However, SSA still assessed an overpayment for three months due to being over resources from multiple vehicles. Gail worked meticulously with the client to provide a timeline of when the vehicles were owned, sold, inoperable, and junked. She obtained pictures of the vehicles and ledgers from the scrap dealer. The ALJ accepted the additional information Gail gathered and issued a favorable decision, which eliminated the remaining $1,119 of the overpayment.
Monetary Impact = $1,119
8/30/2023
Story #103
Kenton Zink, EBS for Dane County, helped a client reduce an SSI overpayment of more than $12,000 to around $900 by demonstrating to the Social Security Administration (SSA) that the client was over the SSI asset limit due to COVID-19 stimulus payments. He then helped the client understand options for spending down assets and provided SSA with updated bank statements and a receipt showing that she had used her remaining assets to prepay rent. He got the issue resolved within a week, and the client's benefit payments resumed without missing a month. With SSI being her only source of income, the client was greatly relieved to have that problem resolved so quickly.
Monetary Impact = $11,100
6/29/2023
Story #93
Kris Schiek, EBS in Oneida County, helped a client successfully appeal an SSI overpayment of over $14,000. Kris helped the client obtain bank statements dating back to 2020 to show that SSA incorrectly counted his COVID-19 stimulus payments as available resources. Kris's supervising attorney created a table to show how the stimulus checks kept accumulating and, because they are excluded resources, he should not have been assessed an overpayment for not spending them down. SSA agreed, and issued a favorable decision in less than two months.
Monetary Impact = $14,000
6/29/2023
Story #91
Pam Fuchs, EBS in Sauk County, helped a client successfully appeal an SSDI overpayment in a case that took nearly two years to resolve. The client was injured while working in another state many years ago and received worker's compensation (WC) after that. She later moved to Wisconsin and applied for SSDI benefits after her WC payments had ended. SSA sent a letter to her representative payee asking for information about the WC payments, but the representative payee had significant medical issues and was unable to respond to that letter. As a result, SSA assumed the client was receiving WC payments and SSDI benefits at the same time without any offset calculated. Because the overpayment notice was so vague, Pam helped the client request reconsideration because SSA had not provided enough information for us to evaluate whether an overpayment had actually occurred. SSA responded by asking for records of the client's WC payments. Pam tried to track down the records, but the client's former employer, medical providers, and WC attorney no longer had any records. She was finally able to obtain records from the state where the work injury occurred, which showed that the client had not been receiving any WC payments at the time she applied for SSDI. SSA agreed, and not only did the client no longer have an overpayment issue, but SSA actually owed her some money!
6/29/2023
Story #89
Melissa Chase, EBS in Fond du Lac County, recently helped a 72-year-old client with an SSI termination and pending overpayment. SSA continued to count this client's COVID-19 stimulus payments as a resource, and they also counted an extra vehicle that the client did not actually own. Melissa worked with the client and SSA for months to try to get this issue resolved. Finally, Melissa helped the client appeal and send in a statement regarding these issues. One week later, the client received backpay of almost $3,500 and her SSI payments resumed.
Monetary Impact = $3,500
6/29/2023
Story #86
Amanda Runge, EBS in Winnebago County, recently received a fully favorable decision for a client with an SSDI overpayment of over $114,000. The client, a 61-year-old man, had worked for many years for a friend. SSA alleged that this client had gone over the monthly substantial gainful activity (SGA) amount with his earnings for several years. However, this client's friend/boss had provided him with a lot of extra accommodations and even paid him for days in which he did not work. Amanda helped the client gather evidence of this, along with paystubs and a letter from his former boss, to send in with the appeal. The appeal was fully favorable, and the client no longer owes an SSDI overpayment.
Monetary Impact = $114,000
6/29/2023
Story #85
Jennifer Trasser, EBS in Outagamie County, recently helped a 64-year-old client get an SSI overpayment waived. The client had received annual rental payments in January every year, and he used this income to pay his property taxes. He thought that SSA understood that this was a recurring payment every January, so he didn't need to report it each year. However, he was still issued SSI benefits and was determined to have had an overpayment for the month of January spanning four years. Jennifer helped the client submit a waiver request. She then attended the personal conference with the client to provide support and assistance. A few weeks later, the client received notice that his overpayment was waived.
6/29/2023
Story #81
Pam Fuchs, EBS in Sauk County, recently helped a client with an administrative waiver of an SSI overpayment. SSA had actually stopped the client's benefits because they believed she was over the resource limit, but Pam helped the client send up-to-date bank statements to SSA showing that she was under the resource limit, and SSA reinstated her benefits. Although the client had overpayments waived in the past, her medical conditions made it difficult for her to manage her finances, and she no longer had the same support network helping her as she had in the past. Pam helped the client fill out the paperwork to request a waiver, and SSA agreed to waive the overpayment.
5/31/2023
Story #76
Mindy Shrader, EBS in Sauk County, helped a client with a successful reconsideration of an SSI overpayment. The client received an overpayment notice in April 2023 alleging that she had been overpaid in an earlier month and in May 2023, which stopped her benefits as of May 1. Mindy determined that the earlier month's overpayment was due to the fact that the client's MCO had not deducted that month's CBRF room and board payment from her account. Mindy obtained a letter explaining the situation from the MCO and argued to SSA that this was similar to a situation where a beneficiary is only over the resource limit because the landlord did not cash a rent check before the first of the following month. SSA agreed with this and determined the client had not been overpaid in that month. Mindy also provided bank statements to show that the client had remained under the resource limit but was obviously unable to obtain a May bank statement in April when the reconsideration was filed. Unfortunately, SSA continued to insist that the client was ineligible for benefits in May. Thankfully, Mindy was able to obtain a bank statement with the client's May 1 balance after May 1, and SSA finally agreed to reinstate the client's benefits.
5/3/2023
Story #75
Emily Reuter, EBS in Grant County, recently helped a client with a successful reconsideration of an SSI overpayment. SSA believed that the client was over the SSI resource limit because she and her spouse owned a number of tools that had previously been exempt business assets when the spouse was working. Emily worked with the client to figure out an approximate resale value for the tools, which turned out to be less than SSA's estimate of the value. More importantly, Emily argued that the tools should be considered household goods, as the client and her spouse planned to use them to make repairs to their home in the near future. SSA agreed, and the client was thrilled!
5/31/2023
Story #73
Jamie Ausloos, EBS in Forest County, helped a client eliminate an SSI overpayment totaling over $13,000. SSA incorrectly counted the client's income for more than five years. Jamie helped the client submit a Request for Reconsideration form and bank statements for the months at issue. SSA not only eliminated the entire overpayment, but it also determined the client was due back payment of over $500. Most impressively, SSA made its decision in just three weeks (reconsiderations often take years!)
Monetary Impact = $13,500
4/28/2023
Story #66
Amanda Higgins, EBS in Dodge County, helped a client clear up an issue related to the amount she was contributing to her household's food and shelter expenses. The client was living with her daughter's family, and when she applied for SSI, she told SSA that she was unsure how much she contributed to household expenses. Instead of explaining to the client why this information was needed and giving her an opportunity to follow up with the agency, SSA assumed that she was not paying for her own food and shelter expenses and reduced her SSI benefit amount by 1/3. Amanda helped the client submit information showing that the client was paying her fair share of household expenses in July 2022, but SSA did not act on that information for many months. After a number of unsuccessful attempts to work with the local field office, Amanda and the client were finally able to speak with someone at SSA in January of 2023. That worker was able to update SSA's records showing that the client had been paying for her food and shelter expenses, and the client is now receiving the full federal SSI benefit amount. In addition, the client will be receiving a significant amount of backpay for the months her benefits were incorrectly reduced!
1/31/2023
Story #54
Ashley Greene, EBS in Crawford County, recently helped a client regain access to her online bank account so that the client could continue to receive her SSI benefits. The client lost her debit card several months before, and when she tried to request a replacement card online, she accidentally created a second account. Thinking that this could be fraud, the bank put a hold on her account and asked her to send copies of a state ID card and Social Security card so they could verify her identity. Unfortunately, the client had also lost her Social Security card. To make matters worse, SSA sent the client a letter saying that they stopped her SSI benefits because her most recent benefit check had been returned. This left her with no income and no access to any of the money in her bank account. The client set up a new account at a local bank, but SSA could not change her direct deposit information without confirmation of her old bank account routing number. Ashley helped the client set up a MySSA account so that she could request a new Social Security card. That card arrived within a week, and Ashley helped the client send a copy to the online bank. Although customer service said they would reset her account, that still wasn't resolved a month later. Ashley helped the client send additional documentation to prove her identity, and after meeting with the client four times in one week in order to work on this, the client finally regained access to her account. This meant that the client could change her direct deposit information with SSA, and SSA deposited over $3,000 in SSI backpay the following week. Ashley also helped the client file complaints about the online bank with the Consumer Financial Protection Bureau and the Wisconsin Department of Financial Institutions.
Monetary Impact = $3,000
11/30/2022
Story #40
Tiffany Scully, EBS in Dane County, also assisted a 63-year-old client with a good cause late appeal for an SSDI appeal. (Note: EBS typically do not help with SSDI appeals, but Tiffany got permission from her BSSA to assist in this narrow circumstance). The client was referred to the EBS Program by a nurse practitioner at a local cancer treatment clinic who tried to assist him with a phone appointment to apply for disability, but they were unable to get through to the claims rep due to phone issues and missed their scheduled appointment. When Tiffany and the client contacted the Madison SSA FO to reschedule, the claims rep informed them that the record showed the client already applied for SSDI in August 2021, based on a history of seizures. His claim was denied in March 2022. The client did not recall ever applying for SSDI, even though the forms had been signed by him, and he never received the denial notice. Tiffany explained that while the original claim was still pending, in November 2021, the client had been diagnosed with metastatic melanoma. During the call with SSA, the claims rep consulted with the FO manager who recommended submitting a good cause late appeal rather than a new disability application. With the client's permission, Tiffany consulted with the nurse practitioner at the cancer clinic who confirmed that the client met and exceeded the criteria under the compassionate allowance listing for skin malignant melanoma with metastases. After consulting with her program attorney, Tiffany met with the client and completed the necessary forms to request the good cause appeal, then faxed everything to the Madison FO and indicated that it was a TERI case. After making numerous calls to the FO over the course of two months requesting an update on when the claim would be sent to the DDB, Tiffany utilized the escalation process, and the area work incentives coordinator ensured that this process was completed. Within a few days of receiving the claim, the DDB issued a favorable decision which the area work incentives coordinator communicated to the EBS. The client is very pleased as his monthly Social Security benefit increased significantly under SSDI. Prior to the appeal, he had been receiving early retirement benefits, and, after paying his rent each month, he had less than $200 remaining for his other living expenses, making it difficult to make ends meet.
10/30/2022
Story #38
Leda Judd successfully helped a consumer receive SSI and SSRE with a backdate.
The consumer called our office because he hasto pay $1.35 per med and wants to go back
to using his Foward card since he had $0 co-pays. A referral was made to me on June 2, 2022.
I checked Cares prior to calling him and he had no income. He is 66 years old and turning
67 in the fall. During our conversation, he said he lived with his sister and in return
for rent he helped with their mother who had Alzheimer's. I asked him why he did not have
any income and he said he wanted to maximize his social security retirement benefit and
wait until his full retirement age to take SSRE. He said, according to SSA letters he
received, if he took it now it would be $337/m . If he waited until he was 70, it
would be $537. He had wanted to decline Medicare and stay on Medicaid only. I explained
he could not do that because he is entitled to Medicare at age 65. He was auto-enrolled in
to an LIS Part D plan because he had been on BC+. He said he can't ask his sister for any
more money, not even $1.35 for medications. I felt if he had income, he would be able to pay
for his medications and help out with household expenses. He agreed. We then discussed calling
the Social Security office to schedule an appointment to collect his SSRE AND apply for SSI so
he could receive his maximum benefit. When I did the math, I felt he would receive a total of
$861, which includes SSRE of $337 + $524 SSI. Plus the SSI state supp of $83.78. He would need
to claim shelter costs to get the state supp of $83.78. He said he would pay his sister rent if
he had money to pay her. We called SSA on 6/2/2022 and scheduled his appointment to apply for
SSRE and SSI. A phone apt was scheduled for June 24, 2022. I received an email from the
consumer that he was approved for SSI on July 5, 2022. "Great news! My SSI application was
accepted. I received payment already of $3400 today." He also stated that he will get his
SSRE and there will be a backpay but he was not given an amount.
Since this time, he has received several letters which are confusing and have conflicting
information. We called SSA to help us with understanding the letters. I explained he received a
letter reducing his SSI amount to $64/m for September. The rep at SSA assured us it will be all
straightned out by October. He then received a letter dated August 23, which states he has an
overpayment for SSI in the amount of $531. He did not want to file for a waiver or appeal due
to his mental health issues. I will continue to monitor this case and help him if he changes
his mind and wants to request a waiver or appeal.
I feel this story was important to point out because of the impact our program has. A person
may call for one issue and after we ask a few questions, realize there is a larger issue that
we can help with. Monetary impact is confusing because of the recent overpayment. I should
record $861 x 12 = $10,332 x 4 (years) = $41,328. If he had not called our office, he would
have most likely waited until he was 70 to draw on his SSRE benefit of $537. This is one of
the largest monetary impacts I have recorded. I have not closed this case because of the
overpayment but the person was approved for SSRE and SSI with backdates on 7/5/22.
Leda
Monetary Impact = $41,328
7/5/2022
Story #23
Kayli Williamson, EBS in Polk County, helped a client successfully appeal a $5,500 SSI overpayment notice which occurred between 2019 - 2021. The client had been alleged to have been over the $2,000 resource limit due to having too much money in his bank accounts and for owning a camper. Kayli wasted no time in digging into this case, and upon investigation discovered that the camper had recently been assessed by a professional who worked in the camper buying and selling industry. This professional had estimated the camper to be worth $0 due to its extensive roof and structural damage, bad tires, and irreparable fifth wheel due. The estimate indicated that at best the camper would only be worth money for metal scrapping if brought into a recycling center. Furthermore, the EBS found out that the camper was supposed to be an asset owned by his ex-wife given that the terms of their divorce judgment said the camper would belong solely to the ex-wife after the divorce was final in 2006. Therefore, the client had no legal right to sell or transfer the camper as doing so would be in violation of the divorce court order. Finally, Kayli discovered that the reason that the client's bank account was over the limit was due to stimulus money he had recently received. The stimulus money should have been an exempt resource for SSI for 12 months after the date it was received. Shortly after sending in the appeal, Kayli and the client were informed that their reconsideration request had been fully successful. The client was thrilled.
Monetary Impact = $5,500
6/30/2022
Story #17
Joanne Welsh, EBS in Richland County, helped a client successfully appeal an SSI overpayment. The client had received an inheritance many years ago, which caused her to lose SSI eligibility at that time. Over time, the client gradually spent the inheritance on her living expenses. When that money was gone, she reapplied for SSI. Although she began receiving benefits, SSA later decided that she still had the money from the inheritance, which put her over the asset limit. Joanne helped the client prepare a summary of how she had spent the money over several years and request reconsideration. SSA agreed that the client had not been over the asset limit when she reapplied for SSI, reinstated her benefits, and determined that she was owed over $1,600 in backpay for the months her benefits were stopped after she received the overpayment notice.
Monetary Impact = $1,600
6/30/2022
Story #15