Social Security Disability:

An OverviewKelly Blad, MA, EDPNATraumatic Brain Injury and the Social Security Disability ProcessI added Eligible for Direct Payment Non Attorney 1Social Security Disability ProgramsRetirement, Survivors, and Disability Insurance (RSDI, Title II)Work based disability programMust prove disability prior to Date Last Insured Supplemental Security Income (SSI, Title XVI)Federal welfare program for the disabled, blind, and elderlyMust meet income and asset requirementsWhat are the two different benefit programs2

Retirement, Survivors, and Disability InsuranceMonthly benefit amount based on earnings recordMust be disabled and insured5 month waiting period for eligibilityAuxiliary benefits availableMedicare coverage after 24 months of eligibilityNot reduced by income or assetsSupplemental Security Income$721 for an individual and $1,081 for a couple and may be reduced depending onLiving situationIncome

Medical assistance coverageSubsidized housing, group residential housing reduces benefit typeIncome reduces benefit first $20 free, every $2 after reduces by $1Medical assistance coverage is eligible for each month they are eligible for $1 of SSI4Income/Asset limits for 2014

Concurrent ClaimsBoth SSI and RSDI

Need the amount....is it $730 ($20 in income is excluded?) and in 2014 end up being $741?DisabilityInability to engage in substantial gainful activity by reason of a medically determinable impairment that has lasted or is expected to last at least 12 months or result in death.

Sequential Evaluation ProcessStep 1: Is the claimant engaged in SGA?Substantial Gainful ActivityWork done for pay or profit

$1,070 gross per monthThere are different rules for self employment and higher amounts for blind individualsIRWEs may be deducted from gross incomeIf engaged in SGA, claimant is denied. If not, SSA moves to step 2.9Substantial Gainful Activity

Sequential Evaluation ProcessStep 1: Is the claimant engaged in SGA?

Step 2: Does the claimant have a severe impairment? Severe ImpairmentMore than a minimal limitation on ones ability to workIf SSA determines the claimant has no medically determinable severe impairments, the claim is denied. Otherwise, they move to step 3.12Sequential Evaluation ProcessStep 1: Is the claimant engaged in SGA?Step 2: Does the claimant have a severe impairment? work?

Step 3: Does the impairment meet or equal a medical listing?Medical ListingsSocial Security Website, Blue Book

Organized by body system

Separate listings for children and adults

First step in which someone may be approvedIf claimant meets a medical listing they are approved. If not, SSA moves to step 4.

14Blue Book Listings - Adult

Blue Book Listings - Child

Step 3.5 Residual Functional CapacityMaximum ability to do work related activities on a sustained basisSSA classifies physical RFC into Sedentary, Light, Medium, Heavy and Very Heavy. Mental RFC is more complicated but takes into consideration ones social functioning, ability to tolerate stress and changes in the workplace, and pace and persistence.Before moving to step 4, SSA must determine RFCTakes into consideration both mental and physical impairments

17Sequential Evaluation ProcessStep 1: Is the claimant engaged in SGA?Step 2: Does the claimant have a severe impairment? work?Step 3: Does the impairment meet or equal a medical listing?Step 4: Can the claimant perform his or her past relevant work?Past Relevant workWork performed gainfully within the last 15 years and performed long enough to be learnedIf SSA determines a claimant can perform his or her PRW, he or she is denied. If not, SSA moves to Step 5.

19Sequential Evaluation ProcessStep 1: Is the claimant engaged in SGA?Step 2: Does the claimant have a severe impairment? work?Step 3: Does the impairment meet or equal a medical listing?Step 4: Can the claimant perform his or her past relevant work?Step 5: Can the claimant perform any other work?Other WorkWork in the national economy

Age affects this step

Last step in which someone may be approvedSSA looks at all work in the national economy, not in the local areaFor a claimant aged 18-49, they must be unable to perform any work. Rules are relaxed for ages 50-54 and 55+ and more emphasis is placed on PRW

21Grid RulingsSpecial rules for older workers

Take into account RFC, age, education, and transferable skillsThere are hidden grid rules for illiterate and/or unable to communicate in English22Sedentary RFC, Advanced Age

Here is an example of the grid rules for someone who has been assigned a sedentary RFC and is of advanced age23Application ProcessInitial Application Online or in person application taken by district officeState agency collects medical records and makes determinationClear medical records, no red flagsMany people are denied at initialMost people approved at Initial meet or equal a listing or are over the age of 50 with heavier past relevant work24Confirm stats for this slide through the hearing sideFirst Appeal: Reconsideration60 deadline

State agency takes into account new evidenceIf denied initially, the claimant has 60 days to request reconsiderationMost claimants who are denied initially are again denied at reconsideration25Second Appeal: Request for Hearing60 day deadline

Claimant/claimants representative is responsible for providing medical records

Testimony and medical records are used to make determinationIf denied at recon, a claimant has 60 days to request a hearing with an Administrative Law JudgeMuch higher approval rate at this level as the ALJ can use his or her personal judgment in making a decision, however certain laws and procedures must be followed for consistency

26Third Appeal: Appeals Council60 day deadline

Not a new determinationIf denied at a hearing, a claimant has 60 days to request review by the Appeals CouncilThe ALJ has the right to use his or her judgment regarding credibility and weight of evidence, so the Appeals Council determines if the decision was made properly according to law and procedure, not necessarily whether or not the claimant is disabledIf the AC determines there was legal error, they will remand or reverse the decision. If they determine there is no legal error, then they will deny the claim

27Fourth Appeal: Federal District Court60 day deadline

Civil suit against Social Security

Must be represented by an attorneyIf denied by the Appeals Council, a claimant has 60 days to appeal to Federal District Court

28Potential Claim IssuesChemical Dependency

Lack of medical treatment

Noncompliance with treatment

Criminal backgroundProviders Role in SSAs DeterminationSSA uses medical, education, and rehabilitation records in the determination

Providers record diagnoses and symptoms

Providers can provide medial opinions

SSR 96-2p, but the final decision still lies with Social SecurityIf no medical records or inconsistent w/medical records, opinion will likely be thrown out

30ScreeningIs the individual unable to work full time?

Is it due to a medically determinable impairment?

Ultimate decision is with Social SecurityA wonderful service to your clients is screening and suggesting Social Security Disability application to those who may qualify. If you think someone would not be able to work full time because of their medical conditions, an application may be appropriate31Social Security Disability: An OverviewKelly Blad, MA, EDPNA