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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 Hearings and Appeals.
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 (who is a physician or
psychologist) 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 Hearings and Appeals
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 Hearings and Appeals. 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.
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 the claimant's ability, despite his or her
impairments, to do work- related physical or mental activities.
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 and psychologists 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 office or headquarters.
It is strictly a paper review in which the program physician or psychologist
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 Hearings
and Appeals, 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.
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 65.
- A person disabled since childhood (before age 22) who is a dependent of a
deceased insured parent or a parent entitled to title II disability or
retirement benefits.
- A 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 on the basis of disability:
- An adult age 18 or over who is disabled.
- A 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), 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. 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 date the individual files an
application.
In addition, under the SSI disability program, an applicant may be found
"presumptively disabled," 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 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; 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: "A Summary Guide to Social Security and Supplemental Security
Income Work Incentives for People with Disabilities"
Q. How can the individual receive vocational training services?
A. Applicants for disability payments may be referred to a State VR agency
for rehabilitation services. The referral may be made by the DDS, Social
Security, the treating source, or by personal request. The services may be
medical or nonmedical and may include counseling, teaching of new employment
skills, training in the use of prostheses, and job placement. In determining
whether VR services would be beneficial in returning a person to employment, the
medical evidence from the treating source may be very important.
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