Disability Evaluation Under Social
Security
(Blue Book- June 2006)
Part I - General Information
Program Description
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 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,
or by mail. 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,
or Social Security coverage 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 SSA's Office of Disability Adjudication and Review. 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.
Medical development by the Office of Hearings and
Appeals is frequently conducted 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.
Back
to Top
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.
Treating
Sources
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 make a decision 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 child’s 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 physicians (medical
or osteopathic physicians), psychologists or, in certain circumstances,
other health professionals. 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.
Go to Part II - Evidentiary Requirements, 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.
Medical Experts
Because there is no direct involvement of medical
professionals in the disability decisions made by administrative law judges
in the Office of Disability Adjudication and Review, 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. 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.
Back
to Top
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:
Under title XVI, or SSI, there are two basic
categories under which a financially needy person can get payments on
the basis of disability:
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),
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. The law provides that, under the Social Security
disability program, 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 name varies in some
States-the term "Medicaid" is not used everywhere.) 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.
For more information about work incentives,
ask any Social Security Office for the publication:
The Red Book — A Guide to Work Incentives
SSA
Pub. No. 64-039
ICN 468600
June 2006
Back to Top
|
www.socialsecurity.gov
