Where to Turn... Your Guide to Federal Disability Policies and Programs Authors Patrice Drew, Esq. Cathy Ficker Terrill Anne C. Parrette, Esq. Project Coordinator Janna Starr Editors Larry H. Hoffer Lisa Ward Monique Marino Brain Injury Association US Department of Health and Human Services HRSA Health Resources and Services Administration Maternal and Child Health Bureau Disclaimer The Brain Injury Association shall not be held liable for content changes made by unauthorized parties, including but not limited to: alterations of text, images or other information within Where to Turn: Your Guide to Federal Disability Policies and Programs (the Guide.) The Guide contains general information. It is not an authoritative legal document, nor shall it be construed as legal advice. The Guide shall not be relied upon as a legal authority for acting or refusing to act. The information contained in the Guide may change as Federal polices and programs are amended periodically. The Brain Injury Association is not responsible for notifying the Public of these changes. Disability Programs Under The Social Security Administration What are the two disability programs administered by the Social Security Administration? The Social Security Administration administers two disability programs: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. SSDI and SSI are the largest of several Federal programs that provide assistance to people with disabilities. People who have severe disabilities and meet strict medical rules may qualify for benefits under either program. What is the difference between the SSDI and SSI programs? Generally, the medical requirements for disability eligibility are the same under both programs. But, SSDI eligibility is based on your prior work experience, while SSI eligibility is based on your financial need. SSI may be considered the "low income" component of the Social Security Administration. Also, SSDI and SSI are funded differently. Where does the SSDI and SSI money come from? The SSDI program is funded by the Social Security taxes a working person pays. When a working person becomes disabled or retires, that person (and his or her family members) may collect monthly benefits from Social Security, based on the money the person paid in taxes. When that working person dies, his or her family may collect survivor's benefits. The SSI program is funded by general tax revenues. The SSI program pays benefits to people who have limited income and assets. How does the Social Security Administration define "disability"? Under the SSDI and SSI programs, the word "disability" does not mean "disability" in the way that most of us think of the word. It is important to understand how the Social Security Administration defines "disability," because it is a very strict definition. Other Federal programs have different definitions for disability. For example, some programs may pay for a person's partial disability or a person's short-term disability. Social Security does not recognize partial or short-term disability. The decision about a person's possible disability under the Social Security Administration is based strictly on that person's inability to work. This is because the Social Security Administration assumes that working families have access to other resources that will provide support during periods of short-term disabilities, including workers' compensation, insurance, savings and investments. The Social Security rules for disability don't seem very fair. The Worker's Compensation Commission says I am partially disabled, so why doesn't Social Security say the same thing? The ultimate decision on your disability status is a legal conclusion based on the Social Security regulations and related Federal court decisions. The findings from another government agency, such as the Worker's Compensation Commission, or from an insurance company, are not considered by Social Security. SSDI What does "disabled" mean under the SSDI rules? "Disabled" under the SSDI rules means that you have a physical or mental condition(s) that prevents you from working, and the condition(s) is expected to last at least a year, or result in death. Do I qualify for SSDI? To qualify for Social Security Disability Insurance (SSDI) benefits, you must be disabled under the Social Security Administration's definition, and you must have worked long enough and recently enough under the Social Security Administration's rules. To put it another way, SSDI benefits are based on how much money you have "paid into the system" by paying taxes. A working person who pays taxes earns what the Social Security Administration calls "work credits." To be eligible for SSDI benefits, a person must have earned a certain number of work credits. You qualify if... you have worked long enough and recently enough you have "paid into the system" by paying taxes How many work credits can I earn per year? You can earn no more than four work credits in one year. The amount of earnings required for one work credit increases each year as the general wage levels rise. How many work credits do I need to earn to be eligible for SSDI benefits? The number of work credits you need to be eligible for SSDI benefits depends partly on the age you were when you became disabled, and on how recently you earned these credits. Generally, you need to have earned 20 work credits in the last 10 years, ending with the year you became disabled. Your age makes the difference. For example, younger workers may qualify for SSDI benefits with fewer credits. The credit rules are very complicated. Most people are very confused by these rules. The Social Security Administration keeps track of how many work credits a person has earned, so you don't need to know how to calculate work credits. These are the rules: Before age 24-you may qualify for SSDI benefits if you have earned six credits in the three-year period ending when your disability started. Age 24 to 31-you may qualify for SSDI benefits if you have earned credit for having worked half the time between age 21 and the time you became disabled. For example, if you became disabled at age 27, you would need credit for three years of work (12 credits) out of the past six years (between age 21 and age 27). Age 31 or older-In general, you will need to have the number of work credits shown in the chart below. Unless you are blind, at least 20 of the credits must have been earned in the 10 years immediately before you became disabled. Born After 1929, Become Disabled At Age 31 through 42 44 46 48 50 52 54 56 58 60 62 or older Credits You Need 20 22 24 26 28 30 32 34 36 38 40 How long can I receive SSDI benefits? You can receive SSDI benefits until age 65. When you reach age 65, the SSDI benefits automatically convert to Social Security retirement benefits, but the payment amount remains the same. Can my family members qualify for SSDI benefits? Certain family members may qualify for benefits. These family members include: A spouse who is age 62 or older, or a spouse who is any age if he or she is caring for your child under age 16 or a child with a disability who also is receiving disability payments. A widow or widower with a disability who is age 50 or older. The disability must have started before your death or within seven years after your death. (If your widow or widower caring for your children receives Social Security checks, he or she is eligible if he or she becomes disabled before those payments end, or within seven years after they end). An unmarried son or daughter, including an adopted child, or, in some cases, a stepchild or grandchild. The child must be under age 18 or, if in high school full-time, under age 19. Your unmarried son or daughter, age 18 or older, if he or she has a disability that started before age 22. He/she must meet the adult definition of disability. (If a child with a disability under age 18 is receiving benefits as the dependent of a worker who is retired, deceased or disabled, someone should contact Social Security to have his or her checks continued at age 18 on the basis of disability). SSI How do I qualify for SSI benefits? Supplemental Security Income (SSI) is for people who don't own many assets or have a low income. People who receive SSI benefits usually receive food stamps and Medicaid as well. SSI is for people who are 65 or older, blind or who have a disability (including children who are blind or who have a disability). It is important to know that SSI benefits are intended only as a supplement. The amount of SSI money can increase every year based on cost-of-living adjustments. The level varies from one state to another, so check with your local Social Security office to find out more about SSI benefit levels in your state. People receiving SSI benefits must have limited income and assets. Generally, people with assets worth less than $2,000, or couples with assets worth less than $3,000, can qualify for SSI benefits. The Social Security Administration usually does not count items like your home or car (unless it's an expensive one) as an "asset." What does "disabled" mean under the SSI rules? "Disabled" means that you have a physical or mental condition(s) that prevents you from working and is expected to last at least one year or result in death. How does the Social Security Administration decide if I am "disabled" under the SSDI or SSI programs? The Social Security Administration applies a five-step test to determine if you are disabled, as follows: 1. Are you working (conducting substantial gainful activity)? If you are working, and your earnings average more than $700 a month, you will not be considered disabled. If you are working, and your earnings are less than $700 a month, your ability to do work may make your case more difficult to prove. The Social Security Administration calls work "substantial gainful activity," or "SGA." Social Security defines SGA as: any significant and productive physical or mental activity that is done or intended for pay or profit. If you are not engaged in SGA, go to step #2. 2. Do you have a "severe impairment" or "combination of impairments" that is expected to last for at least 12 months or result in death? Your physical or mental condition(s) must be "severe" so that it interferes with basic work-related activities. It also must be expected to last for at least 12 months, or result in death. If not, you will not be considered to have a disability. If you think your condition meets these requirements, go to step #3. 3. Is your condition found on the Social Security Administration's list of disabling impairments? The Social Security Administration maintains a list of physical and mental impairments covering each of the major body systems. This list is known as "the medical listings." The impairments on this list are considered to be so severe that they automatically entitle a person to a finding of disability. If your impairment is not a "listed impairment," you must prove that your impairment is of equal severity to an impairment on the list. Therefore, the test is whether your impairment "meets or equals a listing." If your impairment is on the list, you will be found to have a disability. If your condition equals a listed impairment, go to step #4. 4. Can you do the work you did previously? If your condition is severe, but not one of the listed impairments, then you must show that your condition interferes with your ability to do the work you did previously (i.e., the work you have performed in previous jobs). If your condition does not interfere with your ability to do the work you did previously, your claim will be denied. If it does, go to step #5. 5. Can you do any other type of work? If you cannot do the work you did in the past, the Social Security examiners will look to see if you can perform any other work "that exists in the national economy." The examiners might determine that you are able to adjust to other work. In making this determination, the Social Security examiners will consider the following factors: Your medical condition(s) Your age Your education Your prior job training Your daily activities before and after you became disabled Your attempts to work or do work activities (e.g., doing the laundry, caring for young children) since you became disabled Your ability to perform certain job-related activities, including: standing, stooping, carrying, lifting, pushing/pulling, hand manipulation, memory, judgment, seeing and hearing What if the Social Security Administration decides that I can do work that I don't want to do (because it is below my training level, boring, not enjoyable, pays less money than I used to earn etc.)? Unfortunately, these factors are irrelevant under the Social Security rules. If there is a job available in the national economy that you can perform, then you will not be considered disabled. For example, a heart surgeon may be able to work as a cashier, or do some other type of "sitting" job. If so, the heart surgeon will not be found disabled. What is "Substantial Medical Proof" and why do I need it? Substantial medical proof is the evidence Social Security requires from your treating doctors or hospitals to prove that you are disabled. It includes your medical records, doctor reports, laboratory test results, signs and symptoms of a disability. It is crucial that you get treatment from your own doctor(s). Your own doctor(s) can support and document your disability before you apply for disability benefits. Your own doctor(s) also can examine and treat you over time. This will allow your doctor(s) to gain a better understanding of your physical/mental condition(s). My doctor is willing to write a letter saying that I am totally and permanently disabled; is this enough substantial medical proof? No. Social Security is looking for a complete medical report. This report should include such things as your medical history, clinical findings, laboratory findings, diagnoses, treatment, medical assessment, prescription medications, etc. It is up to the Social Security Administration to determine if you are disabled. It is not up to your doctor to make this decision. Social Security sent me to one of their doctors. Is this enough for substantial medical proof? Not really. When you apply for disability benefits, Social Security may send you to a doctor for a medical examination (sometimes called a "consultative exam"). These doctors have been hired by Social Security. They will examine you once, and they will not provide you any treatment or medications. Also, they will not be able to discuss the history of your disability, nor your history of treatment and medications. What if I can't afford a doctor? If you can't afford a doctor, you should contact your local Department of Health and Human Services office to obtain medical assistance. Ideally, you should have been getting treatment from your own doctor before you apply for disability benefits. Are there special rules for people who are blind? Yes. You will be considered "blind" under the Social Security rules if your vision cannot be corrected to better than 20/200 in your better eye, or if your visual field is 20 degrees or less, even with a corrective lens. There are a number of special rules for persons who are blind. The rules recognize the severe impact of blindness on a person's ability to work. For example, the earnings limit for people who are blind generally is higher than the $700 limit that applies to workers who are not blind, but who are workers with other disabilities. This amount changes each year. You can contact the Social Security Administration for the current figures and other information on special rules for persons who are blind. Ask for the leaflet entitled: If You Are Blind...How We Can Help (Publication No. 05-10052). Are there special rules for children who have a disability? Yes. There are three ways a child may be eligible for benefits from the Social Security Administration: SSI Benefits For Children -These are benefits payable to children with disabilities under age 18 who have limited income and resources, or come from homes with limited income and resources. Social Security Dependents -These are benefits payable to children under the age of 18 who are on the record of a parent who is collecting retirement or disability benefits from Social Security, or survivors benefits payable to children under the age of 18 on the record of a parent who has died. Although children under age 18 who are eligible for these benefits might have a disability, the Social Security Administration does not need to consider their disability to qualify them for benefits, since these children are getting benefits in a different way. Note: A child can continue receiving dependents or survivors benefits until age 19 if he or she is a full-time student in elementary or high school. Social Security Benefits for Adults Disabled Since Childhood-Childhood disability benefits normally stop when a child reaches age 18 (or 19 if the child is a full-time student). But those benefits can continue to be paid into adulthood if the child has a disability. To qualify for these benefits, you must be eligible as the child of someone who is getting Social Security retirement or disability benefits, or of someone who has died. Also, the child must have a disability that began prior to age 22. Although most of the people getting these benefits are in their 20s and 30s (some are even older), the benefit is called a "child's" benefit because of the eligibility rules. What are the rules for children under 18? Most children do not have their own income and do not have many assets. However, when children under age 18 live at home (or are away at school but return home occasionally and are subject to parental control), Social Security considers the parents' income and assets when deciding if the child qualifies. Social Security calls this process "deeming" of income and assets. You should check with your local Social Security office for information about your child's specific situation and for a full explanation of the "deeming" process. What are the rules for children 18 and older? When a child turns 18, Social Security will no longer consider a parent's income and assets when deciding if the child can get SSI. A child who was not eligible for SSI before his or her 18th birthday because a parent's income or assets were too high may become eligible at 18. On the other hand, if a child with a disability who is getting SSI turns 18 and continues to live with his or her parent(s), but does not pay for food or shelter, that child may qualify for less money. How does Social Security decide if a child is disabled? This is what the law says: A child will be considered disabled if he or she has a physical or mental condition (or a combination of conditions) that results in "marked and severe functional limitations." The condition must last or be expected to last at least 12 months or result in the child's death. Also, the child must not be working. Just like with adult disability, Social Security first will check to see if the child's disability can be found in a special "list of impairments," or if the condition is equal to an impairment on the list. The list includes symptoms, signs or laboratory findings of more than 100 physical and mental problems, such as cerebral palsy, mental retardation or muscular dystrophy, that are severe enough to disable a child (Social Security calls these symptoms, signs or laboratory findings "objective evidence"). The child will be considered disabled if his or her resulting difficulties (Social Security calls these "functional limitations") are the same as the functional limitations of any impairment on the list. Social Security also says that the child's difficulties must be "marked and severe." I think I have a disability. How do I apply? You should apply as soon as you have a disability. It is important, however, to know that your Social Security disability benefits will not begin until the sixth full month of disability. This waiting period begins with the first full month after the date Social Security decides that your disability began. You can apply for benefits by calling a toll-free number: 1-800-772-1213, between 7:00 a.m. and 7:00 p.m., Monday through Friday. People who are deaf or hard of hearing may call a toll-free TTY number, 1-800-325-0778, between 7:00 a.m. and 7:00 p.m., Monday through Friday. When you call Social Security, a representative can make an appointment for you to apply by telephone. You also may visit your nearest Social Security Office to file for disability benefits. The Social Security representatives can tell you over the phone where your nearest Social Security Office is, if you tell them your zip code. How long will it take for Social Security to make a decision about my disability? The claims process for disability benefits generally takes a long time. Often, the decision process can last from 60 to 90 days. Can I make the decision process go faster? You can help shorten the process by bringing certain documents with you when you apply for benefits. These documents include: Social Security number Birth certificate or other evidence of your date of birth Military discharge papers, if you were in the military service Spouse's birth certificate and Social Security number if he or she is applying for benefits Children's birth certificates and Social Security numbers if they are applying for benefits Checking or savings account information, so your benefits can be deposited directly Names, addresses and phone numbers of doctors, hospitals, clinics and institutions that treated you and dates of treatment Names of all medications you are taking Medical records from your doctors, therapists, hospitals, clinics and caseworkers Laboratory and test results Work summary: a list of where you have worked in the past 15 years and the kind of work you did Copy of your W-2 Form (Wage and Tax Statement), or if you are self-employed, your federal tax return for the past year Dates of prior marriages if your spouse is applying * If you are applying for SSI benefits you also need to provide Social Security with the following documents: Information about the home where you live, such as your mortgage and lease information, and your landlord's name Payroll slips, bank books, insurance policies, car registration, burial fund records and other information about your income and the things you own * The documents you submit must be originals or certified copies from the issuing agency. The Social Security office will not accept uncertified photocopies as evidence. Should I wait until I have all the necessary documents before I file for disability? No. You should not delay filing for benefits just because you do not have all the information you need. You can turn in necessary documents as you receive them. What do I do if I have been denied disability benefits? First, you should know that the majority of people filing for disability benefits will have their initial application denied. There are a series of appeals that you may file so that the Social Security Administration is required to take a closer look at your case. The entire appeals process can take a long time, from several months to a year or more. This is normal. There is a large backlog of pending disability cases at the Social Security Administration. As you go through the appeals process, try not to become discouraged. Also, make sure that you follow the proper appeals process when you get denied. The biggest mistake people make when they receive a denial letter is either to give up, or reapply for benefits, instead of appealing the denial. You should think of your first denial as the BEGINNING of the disability claim process, not the end. How do I appeal a denial of benefits from my first application? When you receive a denial letter in the mail, you should file your first appeal immediately. This is called a Request for Reconsideration. You have 60 days to file the Request from Reconsideration from the date you receive the denial letter. Just as you did to apply for benefits, you can call Social Security to file a Request for Reconsideration, or you can file it at your local Social Security office. If you do not file your Request for Reconsideration within 60 days, your case may be dismissed. If your case is dismissed, you will have to start the process over again. What do I do if my Request for Reconsideration (first appeal) is denied? Some cases are approved at the Reconsideration level but many of them are denied. When you receive your denial letter in the mail, you should file your second appeal immediately. This second appeal is called a Request for Hearing. You have 60 days to file a Request for Hearing from the date you receive the denial letter in the mail. If you do not file your Request for Hearing within 60 days, your case may be dismissed. If your case is dismissed, you will have to start the process over again. What happens at a disability hearing? The hearing will be held in front of an Administrative Law Judge. The hearing is closed and private. Although the hearing is held in a courtroom, it is an informal proceeding. Your success at the hearing depends partly on any new or additional evidence you bring to the judge. You have a better chance of getting your disability benefits approved at this level than you do at the "paper" level. Do I need to be represented by an attorney at the disability hearing? The administrative process surrounding the application for disability benefits is complicated, but there is no requirement that you hire an attorney to represent you. You are allowed to represent yourself at the hearing, to "appear pro se." In fact, you may choose any person to represent you, such as a family member, friend or social worker. Most people choose to hire an attorney once they have been denied disability benefits. How can an attorney help me? Often, a disability claim is denied because of procedural or administrative problems (i.e., reasons not even related to your disability). Some disability claims become lost due to the huge backlog of cases at the Social Security Administration. In many cases, your disability claim may not be adequate or complete, resulting in the ongoing denial of your claim no matter how many times you apply. It often is difficult for a person to understand why a claim is denied continually. A qualified attorney or practitioner can help you prepare and present clear, concise and complete factual and legal arguments that address relevant regulations and rulings in your case. What if I can't afford an attorney? How can I avoid being overcharged by an attorney? The Social Security Administration regulates attorney fees, so you will know ahead of time how much your attorney will be paid. The fees are awarded on a "contingency fee" basis. That means that the attorney only will be paid if you are approved for disability benefits. You will not have to pay the attorney if you are not approved for disability benefits. Some attorneys may charge you for certain out-of-pocket costs such as the cost for copying medical records. You should talk to your attorney about these costs at your first meeting and ask him or her for a cost estimate. In most cases, these costs should be minimal. If you are a successful SSDI applicant, the Social Security Administration will pay your attorney directly with a government-issued check. If you are a successful SSI applicant, you will be responsible for paying your attorney out of the funds you are awarded. Where can I find a Social Security Disability attorney? Most states have a "lawyer referral" number serviced by the local bar association. You also may contact the National Organization of Social Security Claimants' Representatives (NOSSCR) at 1-800-431-2804, or online, at www.nosscr.org. How can I locate my local Social Security Office? There are three ways to locate your local Social Security Office: 1. Use Social Security's Field Office Locator at: https://s3abaca.ssa.gov/pro/fol-home.html 2. Call 1-800-772-1213 and ask for the office nearest you 3. Check your phone book; look in blue pages under U.S. Government Resources National Organization of Social Security Claimants' Representatives (NOSSCR) www.nosscr.org 1-800-431-2804 Endnotes Social Security Administration www.ssa.gov