EDPNA EXAM PRACTICE QUESTIONS WITH ANSWERS | COMPLETE GUIDE 2023/2024 (GRADED)

Examples of good cause are described in 404.911: - ANSWER • You were seriously ill and were prevented from contacting us in person, by phone, in writing, or through a friend, relative, or other person; • There was a death or serious illness in your immediate family; • Important records were destroyed or damaged by fire or other accidental cause; • You were making serious efforts to find necessary information to support the claim but had not been able to obtain it within the stated time periods; • You requested additional information from us explaining this action within the time limit. Within 60 days of receiving the explanation you requested reconsideration or a hearing, or within 30 days of receiving the explanation you requested Appeals Council review or filed a civil suit; • We gave you misleading, incorrect or incomplete information about when and how to request administrative review or to file a civil suit; • You did not receive notice of the determination or decision; • You sent the request to another government agency in good faith within the time limit and the request did not reach us until after the time period had expired; or • Unusual or unavoidable circumstances exist, which show that you could not have known of the need to file timely, or which prevented you from filing timely. SSA will consider the following for deciding whether a claimant had good cause - ANSWER • What circumstances kept the claimant from making the request on time; • Whether SSA's action mislead the claimant; • Whether the claimant did not understand the requirements; • Whether the claimant had any physical, mental, educational, or linguistic limitations which prevented them from making a timely request or from understanding or knowing about the need to file a timely request for review. Social Security Disability Insurance SSDI - ANSWER Title XVI SSDI Eligibility - ANSWER 1. Is the applicant under full retirement age (66)? 2. Is the applicant fully insured? 3. Is the applicant insured for disability? Auxiliary Benefits - ANSWER Benefits can be paid to the disabled worker's family in some cases. Benefits can be paid to dependent children under the age of 18 or a spouse (or divorced spouse if married for 10 years) under the age of 62 who has joint care of the children. Supplemental Security Insurance SSI - ANSWER Title II Supplemental Security Insurance SSI Citation - ANSWER CFR 20 Section 416 SSI - ANSWER No work requirement Children can qualify as disabled No retroactive benefits earlier than filing date Strict income and resource provisions Definition of Disability - ANSWER Citations: 404.1505, 416.905 The inability to do any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months. Insured Status - ANSWER 1. An individual must be fully insured 2. as a general rule they must meet to 20/40 requirement. (5 of last 10 years) Insured status - ANSWER Quarters of Coverage at least 6 Quarters One of Four For every year beginning with the year after attainment of age 21 up until the age you turn 62 or you die Rules of Disability Insured Status (SSDI Only) - ANSWER Citations: 404.130, 404.131, and 404.140 Rule 1 - 20/40:You have to have 20 quarters of coverage in the 40-quarter period ending with the quarter that you became disabled. This is called the 20/40 rule. Or essentially, you have worked five years out of the last ten years, before you became disabled. Rule 2 - Special Insured Status: Rule 3: You had a period of disability before age 31.You are insured in a quarter for purposes of establishing a period of disability or becoming entitled to disability insurance benefits if in that quarter- (1) You are disabled again at age 31 or later after having had a prior period of disability established which began before age 31 and for which you were only insured under paragraph (c) of this section; and (2) You are fully insured and have QCs in at least one-half the calendar quarters in the period beginning with the quarter after the quarter you became age 21 and through the quarter in which the later period of disability begins, up to a maximum of 20 QCs out of 40 calendar quarters; however- (i) If the number of quarters during this period is an odd number, we reduce the number by one; (ii) If the period has less than 12 quarters, you must have at least 6 QCs in the 12-quarter period ending with that quarter; and (iii) No monthly benefits may be paid or increased under Rule Ill before May 1983. Rule 4: You are statutorily blind. (1) You are disabled by blindness as defined in § 404.1581; and (2) You are fully insured. Special Insured Status (SSDI Only) - ANSWER Disable before the age of 31 20 CFR 404.130: You are insured in a quarter for purposes of establishing a period of disability or becoming entitled to disability insurance benefits if in that quarter- (1) You have not become (or would not become) age 31; (2) You are fully insured (next chapter); and (3) You have Quarters of Coverage (QCs) in at least one-half of the quarters during the period ending with that quarter after the quarter you became age 21; however- (i) If the number of quarters during this period is an odd number, we reduce the number by one; and (ii) If the period has less than 12 quarters, you must have at least 6 QCs in the 12- quarter period ending with that quarter. Insured Status - Statutorily Blind - ANSWER Citation: 404.130(e) Statutorily blind individuals must only meet the fully disability insured status. Statutorily Blindness - ANSWER Defined in the law as central visual acuity of 20/200 or less in the better eye with the use of correcting lens. An eye which has a limitation in the field of vision so that the widest diameter of the visual field subtends an angle no greater than 20 degrees is considered to have a central acuity of 20/200 or less. (404.1581) Fully Insured Status (SSDI Only) - ANSWER 404.110 You need at least one QC (Quarter of Coverage) for each calendar year after you turned 21 and the earliest of the following: • The year before you attain age 62, • The year before you die, or • The year before you become disabled. The minimum number of QCs needed is 6. The maximum number needed is 40. Any year (all or part of a year) that was included in a period of disability is not included in determining the number of QCs you need. Waiting Period (SSDI Only) - ANSWER There is a 5-month period in which a claimant must have been disabled for 5 full consecutive months, beginning with the month that they were both insured and disabled, before cash benefits can begin. Your waiting period can begin no earlier than the 17th month before the month you apply-no matter how long you were disabled before then. Medicare Waiting Period - ANSWER Test Tip: Include the 5-month waiting period in your calculation and count 29 months forward from established onset date to get the date the Medicare eligibility would begin. To become eligible for Medicare a claimant has to have 24 months of disability eligibility, meaning they have been paid 24 months of cash benefits. 24 months after SSDI payments begin, the claimant will be automatically eligible for Medicare. Disabled Adult Child (DAC) (SSDI Only) - ANSWER An adult who was disabled before age 22 may be eligible for child's benefits if a parent is deceased, or receiving Social Security retirement, or receiving Social Security disability benefits. SSA considers this Disabled Adult Child claim a "child's" benefit because it is paid on the parent's earnings record. To meet requirements, the adult child -- including an adopted child, or, in some cases, a stepchild, grandchild, or step grandchild - must 1. be unmarried; 2. be age 18 or older; 3. have a disability that started before age 22; 4. meet the SSA definition of disability for adults, and 5. not have substantial earnings to be insured for Title 2 on their own record. Disabled Widow Benefits (DWB) - ANSWER Citation: 404.335 A widow or widower may be eligible for Disabled Widow(er)'s benefits if these requirements are met: 1. The widow(er) is between 50 and 60 years old; 2. The widow(er) meets the SSA definition of disability for adults; 3. The widow(er)'s disability began before or within seven years after the spouse's death. 4. The deceased spouse must have been on Title 2 disability or had Title 2 insured status at death. Substitution Of Party (SSDI) - ANSWER POMS DI 23510.035 Substitution of Party is limited to a surviving spouse who was living with the decedent at the time of death or within six months immediately preceding death, or to the parent or parents of a disabled or blind child who was living with the parent or parents at the time of death or within six months immediately preceding the month of death. Title XVI may also be pursued on a deceased claimant if Medicaid benefits had been paid on the claimant's behalf. Substitution Of Party (SSI) - ANSWER 1. Surviving spouse living with claimant or entitled to benefits on the claimant's account in the month of death; 2. Any child entitled to monthly benefits on the claimant's SSN for the month in which the claimant died; 3. Parent(s) of the claimant entitled to monthly benefits on the claimant's SSN for the month in which the claimant died; 4. Surviving spouse of the claimant; 5. Child(ren) of the claimant; 6. Parent(s) of the claimant; 7. Legal representative of the estate of the claimant. Appeal Deadlines - ANSWER Test Tip: 60 days +5 days for mailing= 65 days to appeal! Levels of Appeal - ANSWER The three levels of appeal relevant to non-attorney representatives are: · Reconsideration · Administrative Hearing · Appeals Council Timely Appeals - ANSWER Important to file because administrative finality. A determination or decision becomes final and binding if it is not appealed timely. Trial Work Period (SSDI Only) - ANSWER Citation: 404.1592, (no equivalent in 416) The worker does have a period of time during which they can work without risk of losing their benefits. The trial work period is 9 months and it can be 9 different months so it doesn't have to be consecutive. A beneficiary can work in January and then again in May and then again in September and that's only three months of their trial work period (TWP) the trial work period cannot begin in a month that cannot be considered TWP month if the work occurred during the waiting period. There are dollar amounts that Social Security applies to decide if you use one of your TWP months. In 2017 that was $840.00 in 2018 it is $850.00. If a person works and earns $500, they have not used one of their 9 trial work period months but if they work and earn $900 in a month then 1 of their 9 TWP months has been used. Rules: 9 months within a 60 month rolling period Income (SSI Only) - ANSWER test tip: Income does not have to be cash to be counted against a claimant. Income is defined in the regulations at 20 CFR 416.1104. You will find that income is anything that you received during a calendar month, that can be used to meet your needs for food or shelter. It may be cash or non-cash. Non-cash items they consider "in-kind" income. "In-kind" income is an item of food or shelter or something that you can use to get food or shelter. Additionally, Social Security breaks all income down into two categories; either earned income or unearned income. Earned Income (SSI Only) - ANSWER Citations: 416.1112 "Earned Income We Do Not Count" Test Tip: Remember the two disregards are $20.00 no matter what, and $65.00 additionally, if the income is considered "earned income." Wages OR net profit from self-employment are both considered under this provision. Wages are counted when they are received and credited to the claimant or recipient. Self-employment net earnings are counted by a taxable year, where they take the net profit, divided by 12 months - 1 /12th of the net profit is counted as income in each of those twelve months. The first deduction is a twenty-dollar disregard, which is taken from all the income received in a month. If the income is considered earned income, SSA will additionally take a second deduction of $65.00 disregard. The computation continues by SSA counting half of the remaining earned income, after these deductions. Unearned Income (SSI Only) - ANSWER One important example is cash, Other examples of unearned income include, but are not limited to: annuities, pensions, SSDI benefits, or other periodic payments like alimony, support payments, dividends, interest, some royalties, rental income, prizes, awards, gifts, inheritances, etc. Support and maintenance in-kind, can also be considered unearned income In Kind Support (SSI Only) - ANSWER Citations: 416.1102, 416.1130 -416.1148 anything that you received used to meet your needs for food or shelter. Almost always unearned income There are special rules as to how the value of this food or shelter is treated and received in a month. You should really be familiar with 20 CFR 416.1130 through 1148 for the detailed information about those rules. One Third Reduction Rule (VTR) - ANSWER Test Tip: If the claimant is not receiving both food AND shelter, the 1/3 reduction rule does not apply. Instead SSA uses the presumed value rule as described in 416.1140. Applies when a claimant is living with someone else who is providing them with food and shelter. Social Security reduces the SSI monthly amount in that situation by one third. There is also a provision where any other income in the household, or that the recipient receives, is additionally subtracted from that 113rd lower SSI payment amount. Presumed Max Value (SSI) - ANSWER Citation: 416.1140 This is similar to the 1/3 reduction rule, but it is applied in a situation where claimant normally lives in their own home but still gets help in the form of food and shelter or from another individual. In that situation Social Security deducts the current market value of the item from the monthly benefit subject to a maximum 1/3 of the FBR. The presumed maximum value rule is rebuttable and if the recipient feels that the help that they are getting is not worth 1/3 of $841 (for 2022), then they can submit evidence to establish that the help they receive is worth less. Income Deeming - ANSWER Citation: 416.1160 Income deeming is the process of considering another person's income and/or resources to be available for meeting the basic needs of a disabled SSI claimant or recipient. Deemed income is a major class of income where the actual disabled individual is not receiving the income, but another person's income is deemed to be used for the individual's benefit. To understand deeming, you must first understand the term "ineligible individual" which is a person who is ineligible for SSI benefits due to income and/or resources. Deeming relationship include: • Parent-to-Child Deeming: Parent-to-child deeming only applies to deeming of income and resources from ineligible parent(s) to an SSI eligible child under the age of 18. Once the child reaches age 18, deeming of income and resources from the parent(s) no longer applies. Generally, for parent-to-child deeming to apply, the child needs to be living with the parent(s). However, there are certain instances when a child who lives away from the parental home is still subject to parent to-child deeming. A common example of this would be when a child under age 18 is away at school, but is still under parental control. There are also several very limited situations in which SSA may waive deeming of parental income and/or resources. • Spouse-to-Spouse Deeming: Spouse-to-spouse deeming only applies when an SSI eligible individual is married to an ineligible spouse. If both members of a married couple are SSI eligible, another set of rules will apply. Generally, spouse-to-spouse deeming applies only when the two spouses live together in the same household, but there are some exceptions. In addition, there are certain circumstances under which SSA may treat individuals who are not legally married as a married couple for the purposes of deeming. • Sponsor-to-Alien Deeming: Sponsor-to-alien deeming only applies to deeming the income and/or resources of an ineligible individual (and the individual's ineligible spouse if the individual is married) who sponsors an alien's legal entry into the United States. Deeming applies whether or not the alien lives with the sponsor. The process for deeming under all three provisions is complicated and it is different for each provision. There is a deeming chart that is published each year and the 2023 chart is attached via a link. You will not be expected to calculate actual deeming by yourself. You can use this chart to get good idea of whether a potential claimant or potential client could reasonably be eligible for SSI. Resources - ANSWER Citation: 416.1201 (Subpart L - Resources & Exclusions) Part 2 of benefit eligibility Resources are things you own such as: • cash; • bank accounts, stocks, U.S. savings bonds; • land; • life insurance; • personal property; • vehicles; • anything else you own which could be changed to cash and used for food or shelter; and • deemed resources. The following things generally do not count toward the resource limit, no matter how much they are worth: • the house you live in; • one vehicle, if it is used for transportation for the claimant or a member of the claimant's household (in practice, the most expensive vehicle in your name); • life insurance policies the claimant owns with a face value of $1,500 or less per person; • burial plots or spaces for the claimant or the claimant's immediate family; • a burial fund of up to $1,500 each for the claimant and the claimant's spouse's burial expenses; • household goods and personal effects; • property the claimant or the claimant's spouse uses in a trade or business, or on their job if they work for someone else; and • if the claimant is disabled or blind, money or property set aside under a Plan to Achieve Self-Support (PASS). Resources - ANSWER Citation: 416.1201 (Subpart L - Resources & Exclusions) divided into two categories: • Liquid resources can be converted into cash within 20 days. The 20 days excludes certain non-workdays as described in 20 CFR 416.120(d); • Non-liquid assets cannot be turned into cash within 20 days (ex. Loan agreements, vehicles, machinery, livestock, buildings, and land that the claimant does not live on). Non-liquid resources are evaluated according to their equity value except as otherwise provided. 20 CFR 416.1218 Remember: Income is anything that comes in during the month that you can use to provide food or shelter. Resources anything that you already had before a month began that you can use to provide food and shelter. Fee Approval - ANSWER Citation: 404.1720, 404.1730** A representative may not charge a fee for any work performed on behalf of a claimant for Social Security benefits unless the fee is specifically approved by the SSA.** Fee Agreement - ANSWER Citation: 404.1720, 404.1730 Fees are limited to 25% of past-due benefits limited to a regulatory cap (not to exceed $7200 as of November 30, 2022). Past-due benefits has very specific definitions which are a little different for Title 2 and for Title XVI claims Fee Petition - ANSWER Citation: 404.1720, 404.1730 Another way that you can request and be approved to receive a fee is by fee petition. Under fee petition you have to show exactly what you did and ask the adjudicator to approve an amount that you request based on the work and the amount of time you spent on the case. There is no technical limit to the amount Social Security could approve under a fee petition. Administrative Finality - ANSWER Citation 404.987 and 416.1487 Once the Commissioner (DDS/ALJ/AC) decides about whether or not the claimant is disabled, and the claimant does not request review within the time period (usually 60 days +5 for mailing) or SSA does not notify the claimant of its intent to revise the determination or decision, it becomes final and the claimant loses his or her right for further review. Reopening - ANSWER Citations 404.988 and 416.1488 A final determination or decision can be reopened under the following conditions: • Within 12 months of the date of the initial determination for any reason. • In SSI claims, within 2 years of the date of the initial determination if SSA finds there is good cause. • In SSDI claims, within 4 years of the date of the initial determination if SSA finds there is good cause. Once a decision is final, it cannot be changed unless SSA reopens it. Either SSA or the claimant can request reopening. When a claimant requests that a prior claim be reopened, the decision as to reopen is at the discretion of SSA/DDS and there are very specific conditions "good cause" for reopening - ANSWER Citations 404.988 and 416.1488 • New and material evidence is furnished. • A clerical error in benefit computation was made. • The evidence that was considered clearly shows on its face that an error was made. Res Judicata - ANSWER SSA has previously decided based on the same facts, same issues, same parties and same adjudicative period. If a claim is filed for the same facts and issues as a previous denied claim and if for the same time period as the previous claim, it will be dismissed. For SSDI cases, applies when both of the following factors occur: • A subsequent claim has been filed. • The last determination has become final and the claimant has a DLI in the past. Collateral Estoppel - ANSWER Citations 404.950(f) and 416.1450(f) "issue already decided" when a subsequent claim is filed alleging the same issues as a previous claim that was decided under a different program. Unlike Res Judicata, the concept of Collateral Estoppel can be the basis of an allowance or denial. Receiving SSI and also filing for DAC Common Law Marriage - ANSWER Citation: 404.726 SSA does recognize common-law marriage if the state (note - there are only a few states that still recognize it) where the couple lived does, but needs the following "preferred evidence" as proof: 1. If both spouses are alive, their signed statements and those of two blood relatives; 2. If either spouse is dead, the signed statement of the one who is alive and those of two blood relatives of the deceased person; or 3. If both the spouses are dead, the signed statements of one blood relative of each; in addition: • A deed listing both spouses • Any legal document showing one spouse has assumed the married surname • Employment records listing the common-law spouse as a immediate family member • Insurance policies naming the other party as a beneficiary • Bank statements showing joint ownership of an account Unsuccessful Work Attempt (UWA) - ANSWER Citation 404.1574c An effort to do work in employment or self-employment that discontinues or reduces to the non-Substantial Gainful Activity (SGA) level after a short time (no more than 6 months) because of the impairment or the removal of special conditions related to the impairment that are essential to the further performance of work. Income Exclusions - ANSWER 416.1112 Certain earned or unearned income situations include Impairment Related Work Expenses (IRWE) and earnings under a Plan to Achieve Self Support (PASS) Impairment-Related Work Expenses (IRWE) - ANSWER Income Exclusion: items and services needed or used to enable the claimant to work such as attendant care expenses; medical devices such as wheelchairs, canes, crutches; pacemakers; residential modifications; necessary medications; medical services; special transportation needs. It does not matter if the claimant also uses these items and services for non-work activities. IRWE will be deducted for SGA purposes when: • The item(s) or service(s) enables the claimant to work; • The claimant needs the item(s) or service(s) because of a physical or mental impairment; • The claimant pays for the item(s) or service(s) and are not reimbursed by another source such as Medicare, Medicaid, or a private insurance carrier; and • The cost is "reasonable", that is, it represents the standard charge for the item or service in the claimant's community. Plan to Achieve Self Support (PASS) - ANSWER Allows claimants to set aside income and/or resources for a specified period of time so that they can pursue a work goal that will reduce or eliminate the SSI or Social Security Disability Insurance benefits they are currently receiving. Income and resources set aside under PASS are not counted as income or resources for SSI eligibility. The criteria for PASS are very specific and experts are available to help claimants with setting up a pass account. Can include supplies to start a business, school expenses, equipment and tools, transportation, uniforms and other items or services you need to reach your employment goal. SVP 1-2 - ANSWER unskilled work SVP 3-4 - ANSWER Semi-Skilled Work SVP 5-10 - ANSWER Skilled work non-transferable skills - ANSWER unskilled worker SVP 1-2 Ocassional - ANSWER At least once and up to 1/3 of an 8 hr workday or 2.67 hours or less in an 8 hr workday Frequently - ANSWER 1/3 to 2/3 of an 8 hr day or 2.67 to 5.33 hr of a workday Constantly - ANSWER 2/3 or more of an 8hr work day or 5.33 or more hours of a workday illiteracy - ANSWER 404.1564 The inability to read or write. We consider someone illiterate if the person cannot read or write a simple message such as instructions or inventory lists even though the person can sign his or her name. Generally, an illiterate person has had little or no formal schooling. Marginal - ANSWER 404.1564 Ability in reasoning, arithmetic, and language skills which are needed to do simple, unskilled types of jobs. We generally consider that formal schooling at a 6th grade level or less is a marginal education. Limited - ANSWER 404.1564 Ability in reasoning, arithmetic, and language skills, but not enough to allow a person with these educational qualifications to do most of the more complex job duties needed in semi-skilled or skilled jobs. We generally consider that a 7th grade through the 11th grade level of formal education is a limited education. High School and above - ANSWER 404.1564 Abilities in reasoning, arithmetic, and language skills acquired through formal schooling at a 12th grade level or above. We generally consider that someone with these educational abilities can do semi-skilled through skilled work. External Limitations - ANSWER Strength demands of a job are affected such as sitting,standing,walking,lifting, carrying, push and pull Non-External Limitations (edit) - ANSWER side effects of some medications may reduce your general alertness, concentration, or physical stamina, affecting your residual functional capacity for non-exertional or exertional work activities.