Disability Evaluation Under Social Security
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Disability Evaluation Under Social Security
(Blue Book- September 2008)
Part I – General Information
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act)) and the supplemental security income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to individuals who are “insured” under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides for SSI payments to individuals (including children under age 18) who are disabled and have limited income and resources.
The Act and SSA’s implementing regulations prescribe rules for deciding if an individual is “disabled.” SSA’s criteria for deciding if someone is disabled are not necessarily the same as the criteria applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in 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.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
What is a “Medically Determinable Impairment”?
A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings-not only by the individual’s statement of symptoms.
The Disability Determination Process
Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called disability determination services, or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA’s Office of Disability Adjudication and Review.
Social Security Field Offices
SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, by mail, or via an online application process. The application and related forms ask for a description of the claimant’s impairment(s); names, addresses, and telephone numbers of treatment sources; and other information that relates to the alleged disability. (The “claimant” is the person who is requesting disability benefits.)
The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, citizenship/residency and Social Security coverage information, and additionally, for SSI eligibility, income, resources, and living arrangement information. The field office sends the case to a DDS for evaluation of disability.
State Disability Determination Services
The DDSs, which are fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law.
Usually, the DDS tries to obtain evidence from the claimant’s own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a consultative examination (CE) in order to obtain the additional information needed. The claimant’s treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part II, Evidentiary Requirements, for more information about CEs.)
After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source(s) and ask for supplemental information.
The DDS also makes a determination whether the claimant is a candidate for vocational rehabilitation (VR). If so, the DDS makes a referral to the State VR agency.
After the DDS makes the disability determination, it returns the case to the field office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, the appeal is usually handled much the same as the initial claim, except that the disability determination is made by a different adjudicative team in the DDS than the one that handled the original case.
Office of Disability Adjudication and Review
Claimants dissatisfied with the first appeal of a determination may file subsequent appeals. The second appeal is processed by a hearing office within ODAR. An administrative law judge makes the second appeal decision, usually after conducting a hearing and receiving any additional evidence from the claimant’s medical sources or other sources.
ODAR frequently conducts medical development through the DDS. However, hearing offices may also contact medical sources directly. In rare circumstances, an administrative law judge may issue a subpoena requiring production of evidence or testimony at a hearing.
The Role of the Health Professional
Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways:
- As treating sources or other medical sources who provide medical evidence on behalf of their patients;
- As CE sources to perform, for a fee, examinations and/or tests that are needed;
- As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA’s regional offices, or in SSA central office; or
- As medical experts who testify at administrative law judge hearings or respond to written interrogatories from the administrative law judge.
A treating source is a claimant’s own physician, psychologist, or other acceptable medical source who has provided the claimant with medical treatment or evaluation and has or has had an ongoing treatment relationship with the claimant. The treating source is usually the best source of medical evidence about the nature and severity of an individual’s impairment(s).
If an additional examination or testing is needed, SSA usually considers a treating source to be the preferred source for performing the examination or test for his or her own patient.
The treating source is neither asked nor expected to decide whether the claimant is disabled. However, a treating source will usually be asked to provide a statement about an adult claimant’s ability, despite his or her impairments, to do work‑related physical or mental activities or a child’s functional limitations compared to children the same age who do not have impairments.
Consultative Examiners for the DDS
In the absence of sufficient medical evidence from a claimant’s own medical sources, SSA, through the State DDS, may request an additional examination(s). These CEs are performed by licensed physicians (medical or osteopathic physicians), psychologists or, in certain circumstances, other health professionals such as optometrists, podiatrists, and speech-language pathologists. All CE sources must be currently licensed in the State and have the training and experience to perform the type of examination or test SSA requests.
Fees for CEs are set by each State and may vary from State to State. Each State agency is responsible for comprehensive oversight management of its CE program.
Medical professionals who perform CEs must have a good understanding of SSA’s disability programs and their evidentiary requirements. In addition, these medical professionals are made fully aware of their responsibilities and obligations regarding confidentiality and:
- CE scheduling intervals;
- CE report content;
- Elements of a complete CE;
- When a complete CE is not required; and
- Signature requirements.
See Part II of this guide for more information about CEs.
Program Medical Professionals
Physicians of virtually all specialties, psychologists and speech-language pathologists at the State, regional, or national levels review claims for disability benefits. The review work is performed in the State DDSs or SSA’s regional offices or headquarters. It is strictly a case review in which the program physician, psychologist or speech-language pathologist usually has no contact with the claimant.
Because there is no direct involvement of medical professionals in the disability decisions made by administrative law judges in ODAR, administrative law judges sometimes request expert testimony on complex medical issues. Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings or respond to written interrogatories. The experts are paid a fee for their services.
Confidentiality of Records
Two separate laws, the Freedom of Information Act and the Privacy Act, have special significance for Federal agencies. Under the Freedom of Information Act, Federal agencies are required to provide the public with access to their files and records. This means the public has the right, with certain exceptions, to examine records pertaining to the functions, procedures, final opinions, and policy of these Federal agencies.
The Privacy Act permits an individual or his or her authorized representative to examine records pertaining to him or her in a Federal agency. For disability applicants, this means that an individual may request to see the medical or other evidence used to evaluate his or her application for disability benefits under the Social Security or the SSI programs. (This evidence, however, is not available to the general public.)
SSA screens all requests to see medical evidence in a claim file to determine if release of the evidence directly to the individual might have an adverse effect on that individual. If so, the report will be released only to an authorized representative designated by the individual.
Questions and Answers About Social Security Disability Programs
This information is designed to provide a more thorough understanding of the disability programs administered by SSA. Following are some of the most frequent questions asked about these programs.
Q. Who can get disability benefits under Social Security?
A. Under the Social Security disability insurance program (title II of the Act), there are three basic categories of individuals who can qualify for benefits on the basis of disability:
- A disabled insured worker under full retirement age.
- An individual disabled since childhood (before age 22) who is a dependent of a parent entitled to title II disability or retirement benefits or was a dependent of a deceased insured parent.
- disabled widow or widower, age 50-60 if the deceased spouse was insured under Social Security.
Under title XVI, or SSI, there are two basic categories under which a financially needy person can get payments based on disability:
- An adult age 18 or over who is disabled.
- child (under age 18) who is disabled.
Q. How is the disability determination made?
A. SSA’s regulations provide for disability evaluation under a procedure known as the “sequential evaluation process.” For adults, this process requires sequential review of the claimant’s current work activity, the severity of his or her impairment(s), a determination of whether his or her impairment(s) meets or medically equals a listing (see Part III of this guide), the claimant’s residual functional capacity, his or her past work, and his or her age, education, and work experience. For children applying for SSI, the process requires sequential review of the child’s current work activity (if any), the severity of his or her impairment(s), and an assessment of whether his or her impairment(s) results in marked and severe functional limitations. If an adult or child is found disabled or not disabled at any point in the evaluation, the evaluation does not continue.
Q. When do disability benefits start?
A. Disability benefits for workers and widows usually cannot begin for 5 months after the established onset of the disability. Therefore, Social Security disability benefits will be paid for the sixth full month after the date the disability began. The 5-month waiting period does not apply to individuals filing as children of workers. Under SSI, disability payments may begin as early as the first full month after the individual applied or became eligible for SSI.
In addition, under the SSI disability program, an applicant may be found “presumptively disabled or blind,” and receive cash payments for up to 6 months while the formal disability determination is made. The presumptive payment is designed to allow a needy individual to meet his or her basic living expenses during the time it takes to process the application. If it is finally determined that the individual is not disabled, he or she is not required to refund the payments. There is no provision for a finding of presumptive disability or blindness under the Title II program.
Q. What can an individual do if he or she disagrees with the determination?
A. If an individual disagrees with the initial determination in the case, he or she may appeal it. The first administrative appeal is a reconsideration, which is generally a case review at the State level by an adjudicative team that was not involved in the original determination. If dissatisfied with the reconsideration determination, the individual may request a hearing before an administrative law judge. If he or she is dissatisfied with the hearing decision, the final administrative appeal is for review by the Appeals Council. In general, a claimant has 60 days to appeal an unfavorable determination or decision. Appeals must be filed in writing and may be submitted by mail or in person to any Social Security office.
If the individual exhausts all administrative appeals, but wishes to continue pursuing the case, he or she may file a civil suit in Federal District Court and eventually appeal all the way to the United States Supreme Court.
Q. Can individuals receiving disability benefits or payments get Medicare or Medicaid coverage?
A.Medicare helps pay hospital and doctor bills of disabled or retired people who have worked long enough under Social Security to be insured for Social Security benefits. It generally covers people who are 65 and over; people who have been determined to be disabled and have been receiving benefits for at least 24 months or have amyotrophic lateral sclerosis; and people who need long‑term dialysis treatment for chronic kidney disease or require a kidney transplant. In general, Medicare pays 80 percent of reasonable charges.
In most States, individuals who qualify for SSI disability payments also qualify for Medicaid. The Medicaid program is referred to by different names depending on the State. The program covers all of the approved charges of the Medicaid patient. Medicaid is financed by Federal and State matching funds, but eligibility rules may vary from State to State.
Q. Can someone work and still receive disability benefits?
A. Social Security rules make it possible for people to test their ability to work without losing their rights to cash benefits and Medicare or Medicaid. These rules are called “work incentives.” The rules are different for title II and title XVI, but under both programs they may provide:
- continued cash benefits
- continued help with medical bills
- help with work expenses or
- vocational training
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