March 6, 2025 by Aimee VonBokel
Lone Star Legal Aid’s Jeff Larsen Helps Man Keep Disability and Medicare Benefits
Topic
Story of Justice
After a serious surgery in 2019, Donald qualified for Social Security Disability Insurance (SSDI). But then, five years later, in January 2024, Donald received a letter saying he no longer qualified for SSDI. He called Lone Star Legal Aid for help.
SSDI is a payroll tax-funded federal insurance program of the United States federal government. Managed by the Social Security Administration, the program is designed to provide monthly stipends to people who cannot work as a result of a physical disability.
After his surgery, Donald began receiving a monthly check for about $1,000. It’s not enough to live well, but it’s enough to help contribute food and cover utilities at a family member’s house, where he now lives. The letter said he could appeal the decision, so he requested a hearing. The Social Security Administration scheduled a hearing for a month later, at the end of February.
Finding the Right Attorney At Lone Star Legal Aid
When Donald explained his situation to an intake worker at Lone Star Legal Aid (LSLA), they connected him with attorney Jeff Larsen. After several conversations with Larsen – and after Larsen consulted with his team of legal specialists – LSLA determined that Donald could benefit from legal assistance. After reviewing his income and expenses, staff determined that Donald qualified for free legal assistance. Most people on SSDI qualify for free legal representation from Lone Star Legal Aid.
Donald was scheduled for a hearing before an Administrative Law Judge (ALJ), an employee of the federal Social Security Administration. In preparation for the hearing, Larsen requested Donald’s medical records. Larsen learned that, in addition to the surgery, Donald experienced sudden hearing loss, apparently caused by antibiotics and also severe diabetic neuropathy. Despite multiple requests to Harris Health, the full medical records were not available in time for the February hearing. Luckily, Larsen requested a hearing reset, which was granted.
It’s important to get a copy of the medical records, Larsen says, because the ALJ might only have records up to the date the hearing was scheduled. A lot of times, medical situations develop or worsen in the meantime. ALJ’s can’t always keep up with the latest chart updates.
The new hearing date would be in November, almost a year later. Because Donald appealed his case within 10 days of getting his initial letter, he would continue to receive his SSDI check until the November hearing.
When Larsen prepared for Donald’s hearing, he looked into other aspects of his case. “I try to do what I call a benefits checkup with all my clients,” Larsen says. “Did he qualify for food stamps, also known as SNAP (Supplementary Nutritional Assistance Program)? Did he have medical insurance of some kind? Was he getting evicted? We have attorneys that do bankruptcy, IRS, family law… I try to get clients connected if they need other kinds of help.”
Considering the Whole Picture
As Larsen discussed these details with his client, Larsen realized there was another thing he could do to help. The Social Security Administration was reducing Donald’s Title II or disability insurance benefits. “After two years of disability insurance, you become eligible for Medicare,” Larsen explains. “People get hurt with that gap. In Harris County, you can somewhat cover it with the Harris County Hospital District by using Harris Health,” he notes.
For disabled people, Medicare coverage works almost like it does for retired people: Part A is automatic. It’s free, but it only pays for 80% of hospital visits. Part B covers the other 20%, plus co-payments, but you have to pay a $175 Part B premium. Because Larsen has worked on complex disability cases for decades, he immediately recognized that Donald would probably be eligible for a different program that covers the Part B Medicare Premium, called QMB. Qualified Medicare Beneficiary is a Medicaid program that pays the Medicare premium and other costs and QMB recipients have to renew their eligibility every three years.
None of this mattered, however, unless Donald continued to get his disability insurance, because he was only eligible for Medicare if he was eligible for SSDI.
Initial Hearing Before an Administrative Law Judge
Finally, the date of the appeal hearing came. It was early November and the hearing was online. Attorney Larsen appeared on the video conference from his office. Donald logged in from his home. Larsen had already submitted the medical records and a pre-hearing memo explaining why LSLA thought Donald should continue receiving SSDI. “Most judges don’t demand a pre-hearing memo, but they appreciate it,” Larsen says, “so most attorneys submit one.”
The ALJ’s job is to determine whether Donald could possibly work to earn his income. If a person is physically unable to work, he or she is entitled to SSDI. The amount of their monthly SSDI stipend is based on how many years they have worked and what wages they earned.
The ALJ determined that Donald could only do sedentary work. His medical condition would require him to miss work often and he would need additional breaks and so forth. When the ALJ listed all the requirements, she offered the scenario to a Vocational Expert (VE). ALJ’s sometimes invite a VE to participate in the hearing. The VE said no jobs were available for someone in Donald’s situation. The ALJ asked a few more questions and adjourned the hearing. Donald was approved!
A Second Hearing with Texas HHSC: Medicaid and the Medicare Part B premium
As often happens at Lone Star Legal Aid, Donald came in with one problem, and in the process of solving that problem, attorney Larsen learned of a second problem that needed solving. After securing the SSDI benefits, Larsen proceeded to review Donald’s Medicare situation.
Donald was paying a $175 premium for Medicare Part B. The amount was deducted from his $1,258 SSDI check before Donald ever received it. Donald qualified for SSDI benefits of $1,258 a month, but he was only receiving $1,083 because the Medicare Part B premium of $175 was deducted. Larsen believed Donald qualified to have the $175 covered by a different program called QMB. $175 can make a big difference when you’re living on such a tiny stipend.
While the SSDI benefits are administered by the federal government, Medicaid’s QMB program is administered by the state. To review Donald’s eligibility for QMB, Larsen filed a request for appeal with the Texas Health and Human Services Commission (HHSC). Then, at a hearing about a month later, Larsen unraveled a series of mistakes made by HHSC when they reviewed Donald’s eligibility for Medicaid QMB.
Anyone can see that Donald lives on a very small income, but these programs have strict eligibility guidelines. HHSC had used the SSI definition of income, which includes something they call “in-kind support income or maintenance, or IKSM.” Basically, HHSC said Donald was entitled to less support because he was living in his father’s house. What HHSC hadn’t considered, however, was that Donald was paying the equivalent of rent by covering the utility bills for the entire household. Once Larsen explained the situation to HHSC, they had to re-calculate his eligibility.
When HHSC looked at Donald’s situation the way Larsen did, they saw that he did indeed qualify for QMB. What’s more, they conceded they’d made a mistake in their initial calculations. Donald was owed a refund for the months he paid the $175 premium for Part B Medicare.
Donald first called Lone Star Legal Aid in early 2024. He was in danger of losing the monthly disability check that provided him just enough money to survive. It took about a year for attorney Jeff Larsen to help Donald through a series of hearings with both the Social Security Administration and the Texas Department of Health and Human Services. In the end, Donald not only retained the necessary disability stipend, but he was enrolled in QMB, which meant he’d get another $175 per month – instead of having that amount deducted for the Part B Medicare premium. Furthermore, as a result of the Part B coverage, he would no longer need to pay co-pays at medical visits. Finally, because Larsen uncovered an error in the HHSC evaluation, Donald received a refund for the money HHSC had mistakenly charged him for the Medicare Part B premium for several months. “He got the benefits he actually needed to live on,” Larsen summarized. “It’s my favorite thing to do,” says Larsen. “QMB is a terrific program. It really helps people like Donald. But he didn’t know he was eligible. I had him fill out a 3-page form and now, he’s got his Medicare Part B premiums for as long as he needs them!”
Lone Star Legal Aid (LSLA) is a 501(c)(3) nonprofit law firm focused on advocacy for low-income and underserved populations by providing free legal education, advice, and representation. LSLA serves millions of people at 125% of federal poverty guidelines, who live in 72 counties in the eastern and Gulf Coast regions of Texas, and 4 counties in Southwest Arkansas. LSLA focuses its resources on maintaining, enhancing, and protecting income and economic stability; preserving housing; improving outcomes for children; establishing and sustaining family safety, stability, health, and wellbeing; and assisting populations with special vulnerabilities, like those with disabilities, the aging, survivors of crime and disasters, the unemployed and underemployed, the unhoused, those with limited English language skills, and the LGBTQIA+ community. To learn more about Lone Star Legal Aid, visit our website at www.LoneStarLegal.org.
Media contact: media@lonestarlegal.org
