Answers for
Doctors & Other Health Professionals
Doctors and other health professionals play a major
role in ensuring that their patients are aware of the provisions of the
Social Security disability programs. This booklet answers the questions
most frequently asked by doctors and other health professionals; e.g.,
who is eligible; how is disability determined under Social Security law;
and how does work affect benefits?
1. What are Social Security's Disability Programs?
The Social
Security Administration (SSA) manages two programs which pay monthly disability
benefits to people under age 65 who cannot work for at least a year because
of a severe disability: Social Security Disability Insurance (SSDI) and
Supplemental Security Income (SSI). Medical requirements are the same
for both programs.
SSDI benefits are paid to people who have worked
long enough and recently enough under the program. Those who have been
receiving benefits for at least 24 months also qualify for Medicare coverage.
SSI disability payments are made to adults and children with limited income
and resources. No prior work is needed. SSI recipients generally qualify
for Medicaid, a State-run health assistance program.
2. What exactly is SSA's definition of disability?
For adults, the Social Security law defines disability
as the "inability to engage in any substantial gainful activity (SGA)
by reason of any medically determinable physical or mental impairment
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."
A
child is considered to be disabled under Social Security law if the child
has any 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.
3.
Why is SSA's definition of disability so strict?
The disability
programs are designed to provide long-term protection to individuals who
are totally disabled, using Social Security criteria, and unable to do
any kind of work in the national economy (or, for children, if their impairment
or combination of impairments does result in marked and severe functional
limitations). This is the most difficult type of disability to protect
against, and most people and their employers cannot afford to protect
against this risk through other means. Short-term disability can be provided
for through other means; e.g., workers' compensation, insurance, family,
savings and investments.
Thus,
as you can see, the disability program is meant to provide benefits for
only those with the most serious impairments. In that respect, it may
be considered very "strict."
4.
Who gets disability benefits?
Social
Security disability benefits can be paid to:
Disabled workers under 65 and their families;
Individuals who become disabled before 22, if a parent (or in certain
cases, a grandparent) who is covered under Social Security retires,
becomes disabled, or dies;
Disabled widows or widowers, age 50 or over, if the deceased spouse
worked long enough under Social Security. This also applies to
certain
disabled surviving divorced spouses over 50;
Blind workers.
5.
Who can receive SSI?
Supplemental
Security Income disability payments can be made to:
Disabled persons under 65 who have very limited income and resources;
Disabled children under 18;
Blind adults or children.
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6.
Who determines whether a person is disabled?
A determination
as to whether a claimant is disabled as defined in the law is made for
SSA by a team, composed of a physician/psychologist and a disability examiner,
working in the disability determination services (DDS) of the State in
which the claimant lives. Typically, the physician or psychologist in
the DDS maintains a private practice in addition to serving as a member
of the team responsible for making the disability determination.
7.
Why are patients, who, in my opinion, have severe disabilities
denied disability benefits by Social Security?
The disability
team in the DDS must evaluate all of the elements involved in a disability
determination, some of which may not be apparent to the treating physician/psychologist.
These would include, when appropriate, age, vocational and educational
factors that may contribute to the patient's ability to work.
8.
Is it likely that a person considered "disabled" under another
program will be found disabled by Social Security?
Not necessarily.
The rules in the Social Security law for determining disability differ
from those in other Government and private programs.
A person eligible for disability payments under one program may not be
eligible under Social Security. However, a decision made by another agency
and medical reports it obtained will be considered in determining whether
a person is disabled for Social Security purposes.
9.
Does the DDS team also examine the applicant?
No. It
relies entirely on the evidence in the claims folder reported by you and
others who have examined or treated the claimant. The DDS examiner or
physician/psychologist may contact you to clarify information you submitted,
or for additional information.
10.
Do all State DDSs use the same medical criteria?
Yes.
There is one set of medical criteria used by every DDS. This ensures uniform
and consistent adjudication of a claim no matter where the claimant lives.
11.
How are Social Security's disability evaluation criteria developed
and why does it take so long to update
or revise them?
These
criteria are developed by Social Security medical consultants and other
program and medical experts. Any change in the medical evaluation criteria
for Social Security disability must reflect the latest approved, established
medical practices and procedures. This necessarily requires careful and
complete consideration of proposed revisions, a process that involves
public review and comment.
12.
How do I get a copy of the medical evaluation criteria?
The medical
evaluation criteria (commonly referred to as the "Listing of Impairments"
or the "Listings") are contained in a handbook entitled, Disability
Evaluation Under Social Security, SSA Pub. No. 64-039. If you would like
a copy, call or write the DDS.
13.
How is the Listing of Impairments used in deciding cases?
In general,
the Listing of Impairments is used as the standard by which the severity
of the impairment is evaluated. If a claimant has a severe impairment
or combination of impairments that meets the duration requirement and
is included in the Listings ("meets"), or is medically equivalent
in severity to a listed impairment ("equals")--and is not working--he
or she generally would be considered disabled. If the claimant is doing
substantial gainful work, he or she ordinarily would not be considered
disabled under the law, despite the severity of the impairment.
Many
findings of disability can be made based only on medical considerations.
But, as mentioned earlier, if a worker's claim cannot be decided on medical
factors alone, then the person's age, education, and work experience are
considered.
14.
What type of information should be included in the medical report
for a patient?
Your
report should include the history and clinical and laboratory findings,
as well as the diagnosis and treatment prescribed and the response to
treatment--as much objective information from the patient's chart as possible.
You also should include a statement about what work activities the patient
can still do despite his/her impairment.
15.
How important is my statement about what my patient can still do?
Your
statement about what work activities the patient can still do despite
his/her impairment, based on the history and clinical and laboratory findings
that you provide, can be very important to the decision on whether your
patient is disabled as defined by the law. We will generally give much
more weight to the opinion of a physician or other medical source who
is treating the patient on a continuing basis, and we will give controlling
weight to such an opinion if it is well supported by the clinical and
laboratory findings and is not inconsistent with any other evidence in
the patient's record. Therefore, it may occasionally be necessary for
the State DDS to recontact you for additional information if they do not
have sufficient information to make a decision.
Since
it is our responsibility under the law to decide whether a claimant is
"disabled" or "unable to work," we cannot give controlling
weight to your opinion on these issues or to your opinion that a patient
has an impairment or combination of impairments that meets or equals those
described in the Listing of Impairments. However, we will consider any
opinion that you give us on these issues, and the medical findings that
support your opinion, when the decision is made on whether your patient
is disabled.
16.
Who pays for the report?
Social
Security can pay a reasonable amount for reports of existing medical evidence
it requests from physicians/psychologists, hospitals and other non-Federal
providers of medical services. Contact your DDS for its payment information.
17.
Is the initial report from the treating physician/psychologist all the
medical information that the DDS team needs
to decide a case?
In many
cases, yes. Frequently, reports from other treatment sources, such as
hospitals and clinics, also are used. If the DDS requires certain clinical
or laboratory data that was not reported, the DDS may call or write you
to find out if you have the needed information in your records.
18.
Suppose I do not have the information requested?
Then
the DDS may ask if you wish to provide the information by performing tests
or an examination for a fee paid by the DDS; or the DDS may send the claimant
to an independent medical source for an examination and the required information--if
you prefer not to do the examination or do not have the equipment to provide
the specific data needed. These are called "consultative examinations
(CEs)."
19.
Who are these "independent medical sources"?
Generally,
they are physicians and psychologists in private practice in all specialties.
If you are interested in performing CEs, contact the DDS in the State
where you practice.
20.
How are the fees for consultative examinations set?
Each
State determines the rate of payment to be used for purchasing medical
or other services necessary to make determinations of disability, and
fees vary from State to State. Federal regulations require that the rates
may not exceed the highest rate paid by Federal or other public agencies
in the State for the same or similar type services.
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21. It takes a lot of time to write up medical reports on my
consultative examinations. Can I phone
them in?
Yes.
Many State agencies (generally referred to as the "Disability Determination
Services") may employ a teledictation service which enables the
consultative physician/psychologist to do just that. The service can
be used at any time, including nights and weekends. You receive a typed
transcript of your telephoned report to review, sign, and return to
the State agency.
22.
If I perform consultative examinations, are there any legal
considerations of which I should be aware?
Yes.
When the DDS contracts with you to do consultative examinations (CEs),
you are an independent contractor, and are responsible for conducting
the examination in a proper manner, just as you do with your own patients.
The DDS does not offer you protection in this situation. We do point out,
however, that since you will be conducting an examination only, and performing
only those tests that the DDS authorizes, not prescribing treatment, there
is little chance of any legal action being filed against you. (Additionally,
the DDSs do not order invasive tests.) The claimant is advised beforehand
that the consultative physician/psychologist does not make the disability
determination and that the "CE" evidence is evaluated along
with all other evidence in the claim.
23.
Can a person appeal a medical determination that he or she is not
disabled?
Yes.
There are several levels of appeal. They are explained in the fact sheet,
"The Appeals Process," which is available at any Social Security
office.
24.
Do benefits stop when a disabled worker who has not recovered
goes back to work?
Generally,
not right away. A continuing disability review (CDR) is scheduled periodically
to determine if there has been any medical improvement sufficient to permit
the person to work again. The evidence on which a determination is based
includes evidence from the treating source, including a statement as to
the person's work capabilities. Additional medical/psychological examinations
or tests may be required.
A person
who attempts to work may continue to receive up to 4 years of support
and services involving cash payments and/or health care coverage. These
include:
. Nine
months of trial work, called a "trial work period" (TWP)
(not necessarily consecutive) during which a person may continue
to
receive benefits regardless of amount of earnings;
. A 36-month
extended period of eligibility following the end of the 9-month
TWP during which benefits may be paid for any month earnings fall
below
the SGA level (up to $500);
. Continuation
of Medicare for at least 39 months after the trial work period;
. Deduction
from gross earnings of impairment-related work expenses in
deciding if earnings constitute SGA. (These include wheelchairs
and
seeing-eye dogs.)
. Continuation
of monthly payments and Medicare or Medicaid for a person
whose impairment has shown medical improvement related to
the ability
to work, if the person is participating in an approved vocational
rehabilitation program which is expected to result in allowing
the individual
to work and become self-supporting.
Additional
information about these and other work incentive provisions is contained
in the pamphlet, "Working While Disabled: How Social Security Can
Help"; in the leaflet, "Benefits for Disabled People Who Return
to Work"; and in SSA Publication No. 64-030, Red Book on Work Incentives:
A Summary Guide to Social Security and Supplemental Security Income Work
Incentives for People with Disabilities, which are available at any Social
Security office.
25.
What are "continuing disability reviews" (CDRs)?
The Social
Security law requires that all disability cases be reviewed periodically
to make sure that individuals are still disabled. The frequency of reviews
depends on the nature and severity of the impairment, the likelihood of
improvement and other factors. Reviews may range from 6 months for cases
where medical improvement is expected, up to 7 years where medical improvement
is not expected.
A person's
disability benefits generally will continue unless there is strong evidence
of both medical improvement and ability to work. There are some exceptions
which apply in relatively few instances.
During
a review, you may be asked to provide current medical evidence. If an
additional examination or test is needed, the DDS team may request you
to conduct it; or the individual may be sent to an independent medical
source.
A person
who gets a notice that he or she is no longer disabled under the definition
in the law, may appeal the determination; he/she has special rights not
available to those denied upon initial application for disability benefits.
The individual may meet face-to-face with the decisionmaker during the
first level of appeal (reconsideration). Benefits may be continued through
the first two levels of appeal if this is requested within 10 days after
a determination notice is received.
26.
How does Social Security identify cases where a disabled
person's condition improves?
Because
disabled people are required to inform us if their conditions improve
or if they return to work, we may learn of the improvement through such
self-reporting, or the improvement may be determined as a result of a
review of such persons' cases.
27.
What happens if the individual becomes disabled again?
If a
worker becomes disabled again within 5 years after a previous period of
disability, he or she will not have to serve a new 5-month waiting period
before disability benefits may resume. In addition, if the person was
previously entitled to Medicare, that protection will resume immediately.
(This provision also applies to disabled widows and widowers and adults
disabled before age 22 whose benefits start again within 7 years.)
28.
Can a person receive disability checks from both Social Security
and another government agency?
Yes.
However, Social Security benefits to a disabled worker and family may
be affected if the worker is also eligible for Workers' Compensation (including
black lung) or for disability benefits from certain Federal, State or
local government programs.
Total
combined payments to the worker and family from Social Security and any
of these other programs generally cannot exceed 80 percent of the worker's
average current earnings before the disability began. The monthly Social
Security benefit is reduced when necessary to keep within this limitation.
All of the worker's earnings covered by Social Security, including amounts
above the maximum taxable by Social Security, may be considered when figuring
average earnings.
29.
I understand that there are special provisions for blind persons.
What are they?
A person
who, in the better eye, with the use of corrective lenses, has either
a visual acuity of 20/200 or less or a visual field restricted to 20 degrees
or less, is eligible for disability benefits if he or she has worked long
enough under Social Security. A blind person who is eligible for SSI needs
no Social Security work credits.
A blind
person is eligible under Social Security for a disability "freeze"
even though working. This means that future benefit amounts, which are
figured on average earnings, will not be reduced because of low earnings
or no earnings in some years because of blindness.
Even
if a blind person is now employed or self-employed, he or she may benefit
from one of several special provisions for blind people who work. For
additional information, see the SSA Fact Sheet, "Benefits for Disabled
Social Security Beneficiaries/Recipients who Work" or contact any
Social Security office.
30.
How can I get more information for my patients?
You may
contact any Social Security office for more information on any of the
facts reported in this booklet. The toll-free number is 1-800-772-1213.
31.
How can I learn more about participating in the disability
programs?
You may
contact the Professional Relations Branch at the Social Security Administration's
Headquarters. The address is:
Social
Security Administration
Office of Disability Programs
Professional Relations Branch
4670 Annex Building
6401 Security Boulevard
Baltimore, Maryland 21235
SSA Publication No. 64-042
ICN 953635
September 1998
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