General Assistance Denial for Medical Reasons
by: Northwest Justice Project
When may I get General Assistance?
The General Assistance (GA, formerly GAU) program provides income and medical coverage if you are a citizen or eligible immigrant, you have income and resources within Department of Social and Health Services (DSHS) rules, and you are "incapacitated." Incapacitated means you are unable to work due to physical or mental conditions (or both) that are expected to last at least 90 days.
If your spouse receives Supplemental Security Income (SSI) and receives a supplemental payment for you, you cannot receive GA and you will have to meet the stricter Social Security "disability" standard to obtain public cash or medical assistance. See our publications How to Fight Your Denial of Denial of SSI or SSD; How Can I Get Medical Coverage or Help with Medical Bills; and Medicaid for Adults 65 and Older or Disabled Who Don't Get SSI.
If DSHS denies you GA because they say you have too much income or resources, or they say they have another reason other than your medical condition, see our publication How to Fight a Denial of DSHS Public Assistance.
If you need help to get or keep DSHS benefits, DSHS may be required to offer you extra services and protections before they deny your application. This could be because you have a physical or mental disability; problems reading or writing; problems speaking or understanding English; problems from drug or alcohol use; or other problems. If you think you need extra help, see our publication Necessary Supplemental Accommodations (NSA).
What can I do if DSHS denies me GA?
You may do any of the following, or all three:
- Ask for a fair hearing.
- Ask a DSHS supervisor to review and explain the decision.
- Reapply.
1. Fair Hearing
You have 90 days from the date of the denial notice to request a hearing. Generally, DSHS has 45 days to decide if you can get GA. If they do not send you a letter within 45 days of your application, you can ask for a fair hearing to get a decision about whether you can receive GA.
You can ask for a fair hearing by writing or calling the Office of Administrative Hearings (OAH) at P.O. Box 42489, Olympia, WA 98504, phone: 1-800-583-8261. Or you may ask for one by calling or writing your DSHS office. If it is an emergency, call the OAH and ask to have your hearing held as soon as possible. This is called an "expedited" hearing. Otherwise, your hearing will probably be 20 days, or more, after the date you request it.
An Administrative Law Judge (ALJ) who does not work for DSHS will hold the hearing and write a decision. If you win your hearing the ALJ usually will order the benefits paid effective the day that DSHS denied them.
Note: If you are representing yourself, get our publication titled, Representing Yourself at a Fair Hearing.
2. Ask for an explanation and review.
Before or after you request a hearing, you can ask your DSHS worker to explain more about the decision. You may learn that DSHS had the wrong information or was missing some information. If so, try to provide the information and ask the worker for any help you need to get it. If it will cost you money to get the information, ask DSHS to pay for it or if there is some other proof they will accept.
You may also ask the worker's supervisor for a meeting to review the termination. If you write to the supervisor, he or she must write back within 10 days. If that doesn't change the decision, you can write the head administrator of the local DSHS office, who also must write back in 10 days.
If you disagree with what the worker, supervisor, and administrator decide, there is no more appeal unless you also request a fair hearing.
3. Reapply
You can reapply for benefits at any time, even if you have requested a fair hearing. Reasons to reapply include:
-
You think DSHS was correct to deny you before but your circumstances have changed.
-
You have more information that might change the decision, but your DSHS worker or supervisor refuses to consider it unless you apply again. You can reapply while also trying to use the new information in your fair hearing. However, the approval of a new application probably won't go back to the date you first applied, or to the date DSHS first denied you GA.
What should I do after I request a hearing?
Contact the Fair Hearing Coordinator (FHC) at the local DSHS office. The FHC will represent DSHS in the hearing. Many cases can be settled before the hearing by pointing out that DSHS made a mistake, or by getting more complete medical information.
Before the hearing, the FHC must prepare and give you a fair hearing packet that gives details about their case and includes all of the documents that DSHS will present as evidence. You can better prepare for your hearing if you get started before you receive the packet.
Phone the FHC and ask for an appointment to look at your file and discuss your case. Obtain copies of all the medical reports and other documents in your file that DSHS used or created in making and explaining its decision. There may be medical information favorable to you that DSHS doesn't include in the packet.
The DSHS letter that denied you GA should provide at least one Washington Administrative Code (WAC) rule that is put there to support DSHS's decision. Ask the FHC for any other rules that DSHS relied on in denying your application. The GA rules are in WAC Chapter 388-448. You may read the rules at the DSHS office or your public library or online at http://www.leg.wa.gov/wac/.
Ask the FHC to explain anything about DSHS's decision that you do not understand, and ask what evidence would convince DSHS to change its decision. Then, if you can, get that evidence. This may convince DSHS to change its decision and give you GA without needing a hearing.
If you cannot reach the FHC, or if you believe he or she is unreasonable, ask to speak to the supervisor or the administrator of the DSHS office. If DSHS still does not agree with you, present your case to the ALJ at the fair hearing.
How do I prove that I am unable to work?
After you apply for GA, DSHS reviews your medical and vocational information. This information is usually on DSHS physical or psychiatric/psychological evaluation forms from one or more doctors who examined you. DSHS will use a seven step "Progressive Evaluation Process" (PEP) form that follows the WAC rules. You need to figure out what parts of the evaluations, and what step of PEP, show DSHS's reason for denying your benefits. You can find out more about how DSHS incapacity specialists use PEP by looking at their Social Service Manual, on line at http://www1.dshs.wa.gov/esa/socialservices/Sections/Top.
When you first contact the FHC, ask why the medical information does not prove that you are unable to work, and what it would need to say to prove the opposite. If you think any doctor, who did an evaluation for DSHS, may support you on any point that DSHS has told you is important to their denial, ask him or her for a letter of support. If you have a regular treating doctor, psychologist, nurse practitioner, or mental health worker, you may be able to get the proof DSHS says it needs from her or him. The law requires DSHS to give great weight to the opinion of your treating physician. If you are a client of the Department of Vocational Rehabilitation (DVR), ask your DVR counselor for copies of all the medical or vocational information in your DVR file that may be helpful.
If you believe you need more medical evaluation to prove your case, ask DSHS to set this up and to pay the necessary costs. You will have to give a good reason why the evaluation is needed to completely review your ability to work. Some examples are:
-
If DSHS made their decision without getting evaluations of all your medical problems that they know about.
-
If you have a history of a medical problem which you still believe prevents you from working, but which was not evaluated.
-
If any doctor's DSHS evaluation form mentions medical problems outside that doctor's expertise, or recommends more evaluation that DSHS did not get.
-
If you have some other reason to believe that the doctors who did DSHS reports did not completely evaluate your medical condition, or did not fill out the DSHS form completely (for example, if they did not fill in the blank for how long you are expected to be unable to work or left out one or more of your medical conditions).
-
If DSHS says there is no objective medical evidence supporting what a doctor has said about your condition, or how it limits your ability to work, ask them to follow up with the doctor or tell you what specific testing is needed. If further tests are required, ask DSHS to pay for them.
If DSHS refuses to pay for more evaluation before your hearing, you may phone the OAH (the number is listed on your Notice of Hearing) and ask to speak with an ALJ. If the ALJ does not order DSHS to pay for a second evaluation, try to get an evaluation from another doctor yourself. You may want to try seeing a doctor you saw in the past. Even if DSHS is not paying for the evaluation, you can ask your own doctor to use DSHS's physical or psychological/psychiatric evaluation form, which is the format that makes it easiest to apply DSHS's criteria to your doctor's opinions. You can ask DSHS for copies of the forms to hand-carry to your doctors or download and print them yourself at http://www1.dshs.wa.gov/dshsforms/forms/eforms.html. (Look for forms 13-021 and 13-021A.) Any further evaluations you get may persuade the FHC to settle the case or persuade the ALJ at the hearing. Finally, you may ask the ALJ at the hearing itself to order DSHS to pay for more evaluation.
If you cannot settle your case before the hearing, you should testify at the hearing about how your medical problems limit what you are able to do. The WAC rules, the DSHS evaluation forms, the PEP form, and the fair hearing packet will help you understand what issues to focus on. If there is information the FHC has not included in the packet which you think supports your case, be sure to make a copy for the ALJ before the hearing. If you give a copy to the FHC before the hearing, the FHC should be able to get it to the ALJ for you. At the hearing, give examples from throughout your daily life, especially in situations where you worked or tried to. It may also help to have one or more people, who know you well, to testify to the things you are able and unable to do.
How can I get legal help?
You can get assistance in preparing for your hearing by calling CLEAR, a toll-free intake, advice, and referral service run by the Northwest Justice Project. To contact CLEAR, call toll free 1-888-201-1014 between 9:30 a.m. and 12:30 p.m., Monday through Friday, or on Tuesdays, from 3:30 p.m. to 6:15 p.m.
7111EN
This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of the date of its printing, August 2006.
© 2006 Northwest Justice Project.
1-888-201-1014, TTY 1-888-201-9737
(Permission for copying and distribution granted to the Alliance for Equal Justice and individuals for non-commercial use only.)
|
