Applying for Disability in Wisconsin
How to apply and qualify for SSD, SSI in Wisconsin (WI)
Note: If you have already filed a claim and been denied for disability, or are wondering what to do in the event of a Social Security denial, proceed to the reconsideration and hearing appeal sections below.
Level I: Disability Application - Individuals applying for disability benefits in Wisconsin will generally have between a 30 to 34 percent chance of being approved at the initial claim, or disability application, level. As two-thirds of initial claims are likely to be denied, a claimant should be prepared for the possibility of having to file one or more appeals before receiving a Social Security Disability Award or SSI disability Award.
Qualifications for disability benefits in Wisconsin, through either the Social Security Disability (SSD) or Supplemental Security Income (SSI) program are based on the following:
1) The existence of a medically determinable physical or mental impairment.
2) The impairment presenting a level of severity that interferes with the ability to engage in normal daily activities (which, for children, will translate to difficulty in engaging in age-appropriate activites and which, for adults, will translate to difficulty in performing work activity at a substantial and gainful activity level).
3) The medically diagnosed impairment exhibiting this level of severity for a period of not less than a full year.
Non-medical requirements for disability
Requirements for disability benefits are not confined to medical criteria, however. All cases are subject to non-medical criteria concerning income and, potentially, assets. To be eligible for Social Security Disability benefits, a person filing for disability cannot be engaged in work activity while earning what SSA considers to be a substantial and gainful income. This applies to eligibility for SSI disability as well.
However, eligibility for SSI also imposes a limit on the level of resources, or assets, that an individual may possess in order to qualify to receive disability benefits. The asset limit for SSI benefits is currently $2000. Note: There is no consideration of assets for SSD, or Social Security Disability, benefits.
Filing for disability in Wisconsin
The process of qualifying for disability benefits begins with filing a disability application. The application can be done online at the SSA website if the claim is for title II Social Security Disability benefits only.
However, SSI claims cannot be taken online at present. As many claims will be for SSI benefits, or may be concurrent (meaning in both the SSD and SSI categories), it is therefore advisable for a claimant to contact a local Social Security office through which an appointment can be set to have a disability application interview conducted.
The disability application interview may be conducted over the phone, or in person with a field office claims representative (CR) if the claimant has transportation or mobility issues. This may also be requested for claimants who simply prefer a phone interview.
Note: a claimant should be careful to provide as much information, at the time of filing for disability, regarding their work history. Likewise, this should be done for the medical treatment history as well. Tip: to ensure that useful information is not accidentally omitted from the disability application, it is advisable for a claimant to write down their medical and work histories prior to the application inteview.
The disability evaluation process
After the approved for disability. Not surprisingly, of course, most claims for disability are denied on the basis that the claimant retains the ability to engage in work activity.
Note: There are cases in which a claim may be approved without considering the claimant's work history. This is when the medical evidence indicates the claimant has a medical condition that satisfies a listing in the Social Security Disability list of impairments.
However, the majority of cases are not approved this way, mainly because the criteria for a listing is very specific and most medical records will not be adequate for this. Additionally, the majority of medical conditions are not given consideration in the listing manual.
Level II: Request for Reconsideration - When a disability application is denied, a claimant may choose to stop pursuing their claim, file a brand new application for disability, or file an appeal.
Giving up on the claim is seldom productive since individuals who do this will often file again months later, the result being months of lost time. Filing a new claim is also not productive since a new claim is very likely to be denied for the same reasons as the first claim, and the claimant may potentially lose a substantial amount of disability back pay.
The appeals process is ordinarily the best route to follow. The first appeal is the request for reconsideration, an appeal that is processed in an identical manner to the disability application.
Requesting the reconsideration appeal
The reconsideration is requested by contacting the Social Security office where the initial claim was taken. After the appeal is requested, SSA will mail out the appropriate paperwork (the disability appeal form, the disability appeal report form, and a medical release form).
Social Security will allow 60 days, plus an additional five days for the mailing of documents, to get the appeal submitted. This paperwork, however, should be returned as soon as possible to minimize processing delays on the case.
Note: Individuals who submit a reconsideration appeal should do the following: 1) Make a copy of all paperwork before submitting the appeal, 2) Do a followup call to the Social Security office within 2 weeks of sending in the appeal to verify that it was received. Appeals that are not received in a timely fashion will generally require the claimant to start over with a new claim, except in cases where a good cause reason applies.
Claimants who have disability representation provided by a disability attorney or a non-attorney disability representative will have their appeals submitted by their representative. Nonetheless, it is always a good idea to contact the representative once the letter of denial has been received. This ensures that both parties are aware of the status of the case and may help to avoid a missed appeal deadline.
Decisions at the reconsideration level
The requirements for disability and the qualifications process at the reconsideration level are unchanged from the application level. Once again, a disability examiner (a different examiner) will review the evidence to determine the claimant's functional limitations, and whether or not these limitations will bar the claimant from engaging in substantial and gainful work activity.
Not surprisingly, most reconsideration appeals are denied. This should not be surprising considering the fact that the process is the same. It is seldom the case that a reconsideration is approved unless the prior disability examiner made a noticable error on the case, or unless strong new medical evidence is brought into the case.
Decisions at the reconsideration level are also generally quicker and it is not unusual to receive a decision within 60 days. Again, this is because most of the processing has been completed at the application level.
Claimants who are denied on their reconsideration should immediately file a request for a hearing before an administrative law judge. While reconsiderations have a high rate of denial, hearing appeals offer claimants their best opportunity for receiving a Social Security Disability award or SSI award.
Level III: Request for Hearing before an Administrative Law Judge - The disability hearing is the second Social Security appeal available to claimants and may be requested only after a reconsideration appeal has been denied.
Like all appeals, the hearing must be requested within 60 days of the date of the prior denial, but, ideally, should be requested immediately after receiving notification of the denial of the reconsideration appeal to avoid unnecessary case processing delays, as well as the possibility of a missed appeal deadline.
Individuals who are denied at the disability application level will find that their best opportunity for receiving a disability award will come at a hearing where the decision is not made by a disability examiner at a state DDS (disability determination services) agency, but, instead, by a federal administrative law judge.
ALJs render decisions at ODAR, the office of disability adjudication and review, more simply referred to as the hearing office. ODAR is where a case is transferred after a request for hearing has been submitted to a local Social Security office (by an unrepresented claimant or, if the claimant has representation, by their disability attorney or non-attorney disability representative.
After a case has been transferred to a hearing office, it will usually remain there for an indeterminate number of months until A) it is assigned to an ALJ and later B) a hearing date is set.
Medical evidence and case preparation at the hearing level
Because there will ordinarily be a space of several months between the time that the hearing request has been submitted and the hearing date has actually been set, whatever medical records are in the file will be considered by SSA to be out of date.
What do we mean by "out of date"? For the Social Security Administration to make an approval on a claim for ongoing benefits, the decision-maker (a disability examiner or judge) must have access to recent medical records. SSA defines recent as not older than 90 days.
Older records that are in the file will be used to establish the onset for a claimant's case (i.e. when they became disabled, which is important for determining how much in back pay they may be eligible to receive and whether or not they will have a waiting period before receiving medicare coverage, assuming their claim is for SSD benefits, versus SSI disability benefits which do not come with medicare, but medicaid). However, older records cannot establish that the individual is "currently" disabled and, therefore, eligible to receive continuing monthly disability benefits.
While many or most claimants will intuitively recognize the importance of medical records, and even the significance of recent medical record evidence, most will be unaware of this fact: while at the disability application and reconsideration appeal levels, SSA will gather a claimant's medical records, at the disability hearing level, the Social Security Administration does not perform this task.
Many claimants who arrive at their disability hearing unrepresented may be surprised to learn that everything that there is no evidence in their file that may allow for an approval to be made. This is in addition to the fact that the majority of unrepresented claimants will be unable to decipher the information that is in their file, including previously gathered records, prior decisions, and the basis for which prior decisions were made.
For this reason, claimants who are unrepresented at the time that their reconsideration appeal is denied may wish to consult with a disability lawyer or non-attorney disability representative (because the next step in the process will be to request a hearing).
As with the first two levels of the system, the approval rate at the hearing level varies by state. Nationally, however, it has been fairly consistent that roughly half of all disability hearings are won by claimants. This greatly exceeds the rate of approval at the initial claim or application level. Typically, claimants who appear at hearings unrepresented will receive a disability award in 40 percent of cases heard, while represented claimants will receive a disability award in 62 percent of cases heard.
Note: Hearings in Wisconsin are more likely to be denied than approved and trail the national average. On average, 39.8 percent of hearings are denied by Administrative law judges in Wisconsin.
At the individual hearing offices, however, the statistics are slightly different. The Madison WI hearing office has a disability award rate of 41.9 percent and the Milwaukee WI hearing office has a disability award rate of 38.5.
About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.
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