Disability Basics
An overview of America’s Disability Insurance Program
The Social Security Administration was formed on August 14, 1935, as part of Franklin D. Roosevelt’s post-Depression “New Deal.” It was designed to provide retirement benefits for American workers. The first Social Security office was opened in 1936 in Austin, Texas, and the number of offices has grown considerably to the current 1,230 Social Security field offices throughout the United States. In addition to geographical expansion, the Social Security Administration has expanded its programs. After 20 years of Congressional discussion and debate, the Social Security Disability Insurance (SSDI) program was signed into law in 1956. The SSDI program is an insurance program that protects American workers from financial ruin if they become medically disabled – that is, unable to work.
The Social Security Administration was formed on August 14, 1935, as part of Franklin D. Roosevelt’s post-Depression “New Deal.” It was designed to provide retirement benefits for American workers. The first Social Security office was opened in 1936 in Austin, Texas, and the number of offices has grown considerably to the current 1,230 Social Security field offices throughout the United States. In addition to geographical expansion, the Social Security Administration has expanded its programs. After 20 years of Congressional discussion and debate, the Social Security Disability Insurance (SSDI) program was signed into law in 1956. The SSDI program is an insurance program that protects American workers from financial ruin if they become medically disabled – that is, unable to work.
American workers pay into the Social Security Disability Insurance plan through mandatory wage withholdings via Federal Insurance Contributions Act taxes, more commonly referred to as FICA taxes. Both employees and employers currently pay 6.2% of gross wages into the FICA program, which funds two important trusts: the Old-Age and Survivors (OASI) Trust and the Disability Insurance (DI) Trust. These are separate accounts managed by the United States Treasury. Disability benefits are paid to eligible individuals from funds withdrawn from the Disability Insurance Trust. Collectively, the retirement and disability programs are officially called the Retirement, Survivors, and Disability Insurance (RSDI) programs.
Eligibility requirements and the definition of being “disabled” have changed considerably since the inception of the SSDI program. For example, at the beginning of the SSDI program, only individuals aged 50 or greater were eligible, and children of disabled workers were not eligible for any benefits. However, despite these changes, the basic “deal” remains the same: if you work, you are insured for disability benefits. These benefits include monthly financial payments as well as access to Medicare. The average monthly financial benefit is approximately $1,165 in 2015 and the maximum amount for an individual is $2,663.
Supplemental Security Income (SSI)
In 1974, an additional disability program was created. This program is called Supplemental Security Income (SSI). This program is a welfare program that provides benefits to (1) people aged 65 or greater who do not qualify for Social Security retirement benefits due to insufficient work history (they did not “pay in”); (2) disabled people who do not have enough work history (they did not “pay in”) the required work credits, and (3) blind people who do not qualify for the main Social Security Disability Insurance plan because they did not “pay in.” Because SSI recipients do not need a work history to qualify and it is a need-based program, they must meet specific resource and income limitations in order to establish and maintain eligibility. Eligible individuals qualify for monthly financial benefits as well as Medicaid insurance. The federal standard rate for SSI recipients in 2015 is $733.00. It is important to note that the SSI program utilizes the same process and definition to determine whether an individual is medically disabled. Effectively, the SSI program “piggybacks” off the Social Security Administration infrastructure that is in place to make non-medical and medical determinations regarding eligibility, as well as for general program administration. Currently, there are approximately 5.6 million SSI beneficiaries in the U.S.
Supplemental Security Income (SSI)
In 1974, an additional disability program was created. This program is called Supplemental Security Income (SSI). This program is a welfare program that provides benefits to (1) people aged 65 or greater who do not qualify for Social Security retirement benefits due to insufficient work history (they did not “pay in”); (2) disabled people who do not have enough work history (they did not “pay in”) the required work credits, and (3) blind people who do not qualify for the main Social Security Disability Insurance plan because they did not “pay in.” Because SSI recipients do not need a work history to qualify and it is a need-based program, they must meet specific resource and income limitations in order to establish and maintain eligibility. Eligible individuals qualify for monthly financial benefits as well as Medicaid insurance. The federal standard rate for SSI recipients in 2015 is $733.00. It is important to note that the SSI program utilizes the same process and definition to determine whether an individual is medically disabled. Effectively, the SSI program “piggybacks” off the Social Security Administration infrastructure that is in place to make non-medical and medical determinations regarding eligibility, as well as for general program administration. Currently, there are approximately 5.6 million SSI beneficiaries in the U.S.
Over time, the Social Security Administration, based in Woodlawn, Maryland, has grown into a massive federal agency. It is the largest social program in the United States by far, consuming nearly 40% of United States federal government funds while providing income to 64 million individuals, 14 million of whom receive benefits under the Social Security Disability Insurance program.
What is Social Security’s Definition of Being “Disabled”?
Social Security uses a strict definition of what it means to be “disabled” under the SSDI and SSI programs
There are literally hundreds of disability insurance programs in the United States. There are private insurance plans, typically obtained through an employer, there are railroad insurance plans for railroad employees, the U.S. Postal Service has its own disability insurance plan, and the Veteran’s Administration covers military veterans through the VA disability insurance program. Each of these programs has the same fundamental objective: to provide income to people who can no longer work due to a medical condition. However, each of these programs has its own definition of what it means to be “disabled” under their rules. They also have their own process for determining whether you meet their definition of being disabled. And, of course, the benefits are very different between one program and the next. For example, Social Security disability does not have a short-term disability program, nor do they have a partial disability system, such as is used in the VA disability program (in which veterans can be found 30% or 70% or 100% disabled, etc.). In Social Security disability, you either meet the definition, or you do not. If you do meet the definition, you receive all benefits until such time as you no longer meet their definition of being disabled. This is why understanding the definition of being disabled under SSA rules is critical. The only definition of what it means to be “disabled” that matters to us and our clients is Social Security’s definition.
Social Security’s Definition of Being “Disabled”
Social Security defines disability as the inability to engage in a substantial gainful activity (SGA) due to a medically determinable physical or mental impairment(s) that has lasted or is expected to last for a continuous period of at least 12 months or result in death.
“You must not be able to engage in a substantial gainful activity (SGA).” This means you cannot have the ability to work above a specific income level. In 2015, the income level is $1,090 per month. This is a pre-tax (or gross) number. So if you are working above this SGA level, your claim will be denied automatically. It does not matter how sick you are, how strong your medical evidence is, or how difficult it is to pay your bills. You will be technically denied if you are earning wages above the SGA level. There are two exceptions to this SGA rule. First, if you incur medical expenses directly as a result of your work, these expenses can be deducted from your monthly wages to determine if you exceed SGA. Second, if your employer is making accommodations for you in the workplace such that the work you are actually performing is not competitive in nature, this can also impact whether you exceed the SGA income rule. But, in the vast majority of claims, if you are working above SGA, your claim will be denied. This SGA test is also utilized by SSA to determine if current beneficiaries (people who receive disability benefits) should have their benefits terminated if they return to work.
“Due to a medically-determinable physical or mental impairment.” This means your allegations must be supported by medical evidence that substantiates your allegations or, as Social Security puts it, your impairment must “result from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.” If someone complains of back pain, but he has no evidence demonstrating the underlying cause of the back pain, the claim will have very little chance of being approved because it is not medically determinable. It is important to note, as the term above suggests, that Social Security will review all physical and mental impairments as long as they are supported by medical evidence. Oftentimes, a claimant will suffer from heart problems and bipolar disorder, so SSA will take both into consideration when they evaluate your claim. Again, only if these are supported by relevant medical evidence.
“That has lasted or is expected to last for a continuous period of at least 12 months or result in death.” This is what Social Security calls the Duration Requirement. Basically, the symptoms must have lasted or be expected to last 12 full months. For example, if you have your hip replaced and you will be out of work for 6 months, but the prognosis is that you will be back to normal in 6 months, you would not meet Social Security’s definition of being disabled because the duration requirement of 12 months is not expected to be met. If, however, you have a hip replacement and you are not expected to walk again for two years, you would meet the duration requirement. If you have a medical condition that is expected to result in death, you meet the duration requirement, again assuming the medical condition is well-supported with medical evidence.
Social Security’s definition of being “disabled” is specific. However, it is not detailed enough to understand whether you might meet the definition. In addition, to understanding SSA’s definition of being disabled, it is also important to understand the process they use to determine if you meet their definition, as well as understand the five-step sequential evaluation process they employ. While the definition of being disabled is fairly straightforward, in practice it is much more complex.
What process does social security use to evaluate disability claims?
Social Security uses a 5-Step sequential evaluation process to determine if your SSDI or SSI claim will be approved
At each phase of a disability claim, there is an adjudicator or decision-maker. At the Initial Application and Reconsideration phases, the decision-maker is a Disability Determination Service (DDS) Examiner who works in consultation with a DDS Physician. At the Hearing phase, the decision-maker is the Administrative Law Judge who often consults with a Medical Expert (ME). The following evaluation is employed by the adjudicator at each phase.
First and foremost, you cannot be working above what Social Security calls a Substantial, Gainful Activity (SGA) level. Basically, you cannot be earning more than $1,170 on a gross (pre-tax) monthly basis. The SGA rule is the most important non-medical criteria, but there are other non-medical criteria that also must be satisfied in order for the claim to progress to a complete medical review at Step 2. No matter how severe and debilitating your medical conditions may (even if well-supported by years of medical evidence) if you do not meet the non-medical eligibility requirements, your claim will not advance to Step 2 and your claim will be technically denied. You can appeal a technical denial, but generally speaking, if the facts are correct, the appeal will be unsuccessful.
The question at Step 2 is whether or not your impairments are severe. To determine whether your impairments are severe, all medical evidence is assembled. At any phase in the process, the adjudicator can request that you complete Activities of Daily Living and Vocational Questionnaires, which provide an opportunity to communicate how your symptoms have impacted your ability to function normally. The adjudicator may also schedule a Consultative Examination (CE) with a doctor who is contracted by DDS to perform medical evaluations on their behalf. Once all evidence has been assembled, the adjudicator reviews the information and decides whether or not your symptoms are severe. To be considered severe, the symptoms must limit your ability to perform basic work-like activities. Severity can take many forms, including physical limitations, such as limited ability to walk, stand, lift, push, carry things, etc. Severity can also encompass the inability to speak, hear, see, concentrate, follow basic instructions, get along with co-workers, etc. If your symptoms are determined to be severe, your claim progresses to Step 3, otherwise, it is denied at Step 2 and you have the opportunity to appeal.
At Step 3, the question is whether your impairment meets or equals a medical “Listing.” Social Security has broken down the human body and mind into 14 different Impairment categories, called the Listing of Impairments. The specific listing under which your claim will be evaluated is dependent upon which type of impairment you have. For example, if it is a breathing-related impairment, it would be evaluated under Listing 3.00 Respiratory System, but if it was an immunological impairment, it would be evaluated under Listing 14.00 Immune System Disorders. If the adjudicator reviews your medical records and determines you meet a medical listing, you are found to be Disabled at Step 3 and you are eligible to receive disability benefits. If, however, you do not meet a medical listing, the claim proceeds to Step 4.
The objective of Step 4 is to determine whether you have the ability to perform the work you have performed previously. To determine this, the adjudicator determines your Residual Functional Capacity (RFC). Your RFC identifies what your body and mind can still do after considering your medical symptoms. In developing your RFC, the adjudicator will consider all impairments and symptoms, including mental and physical, and including severe and non-severe impairments. The adjudicator will estimate your ability to perform such functions as sitting, standing, walking, lifting, carrying, pushing, pulling, reaching, handling, stooping, crouching, remembering, understanding, etc. Your RFC might contain some of the following limitations: inability to stand and walk for greater than 4 hours total out of an 8-hour workday, inability to sit for longer than 2 hours, inability to lift and carry more than 10 pounds, inability to climb ropes or ladders, inability to maintain concentration, persistence or pace, etc.
Once the adjudicator has developed your RFC, they will then list your Past Relevant Work (PRW), which is any job you performed during the 15 year period immediately preceding the Alleged Onset Date (AOD) of your disability. In general, if there is a job that you performed within 15 years of your AOD in which you worked close to full-time for a period of at least a few months, that job will likely be considered Past Relevant Work.
After finalizing your list of Past Relevant Work, the adjudicator must now classify it. The type of work you have done in the past will be classified by both exertional levels and by skill levels. For example, a Nurse works at the Medium exertional level and the position is considered Skilled, while a Security Guard works at the Light exertional level and the position is considered Semi-Skilled. Once all of your PRW has been classified, the adjudicator must then determine whether you have the functional ability to perform any of your past work. For example, if the Security Guard’s impairments prevent him or her from being able to stand and walk as is required for jobs at the Light exertional level, he or she would be unable to perform Security Guard work due to the limitations found in the RFC and the claim would advance to Step 5. If, on the other hand, the adjudicator determines you can still perform the functions required in your past work, you will be found Not Disabled and denied. You would then have the opportunity to appeal this denial.
Step 5 considers whether you can perform any other type of work, even if you have not performed it in the past. The adjudicator utilizes the same Residual Functional Capacity (RFC) developed in Step 4, and also considers your Age, Education, and Work Experience.
To start, Social Security classifies your Education level as follows:
• Illiterate (or unable to communicate in English)
• Marginal (generally 6th grade or less)
• Limited (generally 7th through 11th grades)
• High school (and above)
The Education level is important as it affects the skill level of different jobs that you might be able to perform. For example, if you have a Marginal education, then you would be limited to performing Unskilled jobs, but if you have a High school education then you would be expected to be able to perform both Semi-Skilled and Skilled jobs.
The adjudicator will then consider the next factor, Work Experience. Work Experience means any skills and abilities that you acquired from your past work. The fact that you are now at Step 5 means that the adjudicator determined at Step 4 that you can no longer perform your past work. However, the adjudicator will consider whether any of the skills and abilities you learned from your past work would transfer to a different job. For example, a Nurse who performed her job at the Medium exertional level and who can no longer perform her past work might have acquired skills that would transfer to a position as a Medical Assistant, a job which she could perform at the Light exertional level.
Finally, the adjudicator will consider the last factor, Age. Social Security evaluates adults in several Age categories:
• Younger (ages 18-49)
• Closely approaching advanced age (ages 50-54)
• Advanced age (ages 55-59)
• Closely approaching retirement age (ages 60+)
While Younger individuals have the burden of proving they are unable to perform any type of work, the burden is lessened in the more advanced age categories. Social Security refers to this premise as the Medical-Vocational Guidelines, or the “Grid Rules” because the key factors are laid out in a grid with the final column being a determination of either Disabled or Not Disabled. Basically, the older, less educated, and the fewer transferable skills you acquired in your past work, the more likely you are to be found Disabled.
If the adjudicator determines you can perform some other type of work, based on your age, education, and prior work experience, you would be found Not Disabled and denied. You would have the opportunity to appeal this denial. If, however, the adjudicator determines you cannot perform any other type of work, you would be found Disabled and approved for disability benefits at Step 5.
All Adjudicators Use the Same 5-Step Sequential Evaluation
Whether your claim is at the Initial Application phase, the Reconsideration phase, or the Hearing phase, the person who is making the determination regarding whether you are disabled will use the same 5-step sequential evaluation listed above. The key is presenting your claim in a manner that allows them to approve it at either step 3, 4, or 5 of the evaluation. If you would like assistance getting your claim approved, please contact us now to get started.
References
SSA HOME
The Social Security Administration Home Page.
SSA POMS
This section of the SSA Program Policy Information Site contains the public version of the Program Operations Manual System (POMS). The POMS is a primary source of information used by Social Security employees to process claims for Social Security benefits. The public version of POMS is identical to the version used by Social Security employees except that it does not include internal data entry and sensitive content instructions.
SSA HALLEX
The Social Security Administrations Hearings, Appeals, and Litigation Law Manual.
SSA CFR
Code of Federal Regulations Title 20 – Employees’ Benefits Chapter III- Social Security Administration
Social Security is the largest social program in the United States