September 2012 Archives

Medicare Entitlement based on Disability

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"I have an odd situation in which I was disabled from a surgery gone bad...

The surgery was April 2011, and I have been out of work since then. I have been covered under a private-insurance disability through my employer since then and only recently applied with SSA. I have been approved through SSA, but they changed my disability date to January 2012.

I know I have the right to appeal, however, is it wise? I am thinking more along the lines of Medicare, since my disabilities are quite severe and more than anything else I need help with the medical bills since I'm only 25 and my SSA income is very low.

Thank you so much for your time, and I'm sorry if you have answered a question like this before."




You are right to be concerned about Medicare entitlement. Medicare entitlement based upon disability begins two years from the date you first become entitled to receive a monthly Social Security disability benefit. You are able to appeal the Social Security disability onset date. By my calculations, if you appeal based upon the an 04/11 date of disability you would have become eligible for your monthly Social Security disability benefit 10/11 rather than 01/12, which would mean you would be entitled to receive Medicare 10/13.

It appears that they established your disability date as of 01/12 and that your entitlement month would be 07/12 or 06/12 depending on the day in 01/12. This would mean that your entitlement to Medicare would be 07/14 rather than 10/13, so it is beneficial to have the earliest date of onset possible.

Generally, you have sixty five days from the date of your award letter to file an appeal of your disability onset unless you have a good reason for being late. If you are considering an appeal, try to do so timely.







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My own opinion is that the real problem is disability examiners and the system they work in. The social security disability and SSI disability system is federal, but every DDS operates independently. And decision-making is not uniform, not even between units in a DDS. I think the real problem is that DDS examiners have a disinclination to approve too many cases. This is because external quality control (in the Atlanta region, this was known as DQB, or disability quality branch) tended to send back as "returns" (cases for which DQB found errors in decision-making on the part of disability examiners) cases that had been marked for approval by disability examiners. Very seldom was a return a case that had been denied by an examiner. The effect was that approvals were suppressed.

I remember one case in which a person suffered second and third degree burns to 25 percent of their body. They had been discharged at one point by UNC hospital but had been readmitted because of renal failure subsequent to their injuries. Our unit manager forced the case to be denied. The unit medical consultant went along with the unit supervisor (how independent does this make the unit medical consultant then?) and the rationalization was that the level of stricture from the burns was not significant enough that it couldn't resolve within 12 months.

Completely wrong. That was a good example of unit supervisors exercising their influence on decision-making simply because they want to suppress approvals and reduce the potential for returns from external quality control, which makes them look bad to upper DDS agency management. In other words, state government employees subverting the system for their perceived career goals.

Given this, it is not surprising that judges reverse so many of these bad decisions. Judges do not answer to management. They are autonomous. And in being so, they re-introduce a level of fairness into the system since the state-run DDS agencies have the opposite effect. Which is why it is so disheartening to see attempts to paint all judges as being too lenient.







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