answers

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 page 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?

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.

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.

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; and Blind workers.

Who can receive SSI? Supplemental Security Income disability payments can be made to: Disabled persons under 65 who have very limited income and resources; and Disabled children under 18, if the household income and resources are below certain levels.

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.

Why are patients, who, in my opinion, have severe disabilities denied disability benefits by Social Security? The disability team in the DDS evaluates all of the elements involved in a disability determination, including age, vocational and educational factors that may contribute to the patient's ability to work. However, as most claims for disability benefits are denied at the initial and reconsideration levels, it is important that you stress to your patient the need to file an appeal and obtain legal representation. Most claims that go on to the hearing level before an administrative law judge ultimately prevail.

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.

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.

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.

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. SSA 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 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.

Can a person appeal a medical determination that he or she is not disabled? Yes. There are several levels of appeal, which are explained on this web site under Filing for Social Security Disability. As mentioned earlier in this article, as most cases (75 to 80%) of claims are denued at the inital and reconsideration level, it is important that your patient is aware of the appeals process, files an appeal on their denial, and contact an attorney regarding representation on their appeal.

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.