Overview of Social Security Disability Programs
Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance Benefits (DIB, or sometimes SSDI), and the Supplemental Security Income (SSI) program. (Within Social Security, Disability Insurance Benefits are commonly referred to as Title II, and SSI as Title XVI, from their chapter titles within the Social Security Act).
Disability Insurance Benefits (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. These benefits are paid out of the Social Security Trust, which is funded by wage earners’ FICA withholdings. SSI (Title XVI) provides for cash assistance to individuals who are disabled and have limited income and resources. SSI benefits are paid out of the federal government’s general revenue fund.
Definition of Disability:
The definition of disability used by Social Security is established by law, and is the same whether one is applying for Disability Insurance Benefits or SSI. Disability is “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.”
It is worth noting that this definition is not the same definition used by other government disability programs such as VA Disability, state disability programs, or workers’ compensation claims (L&I in Washington).
What constitutes a “Medically Determinable Impairment:
A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities that 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:
Disability claims are initially processed through an individual’s local Social Security offices and a state agency called Disability Determination Services (DDS). Subsequent appeals of unfavorable determinations are decided at the reconsideration level by DDS, then at hearing by an administrative law judge in Social Security’s Office of Disability Adjudication and Review (ODAR).
Social Security Field Offices:
Applications for disability benefits may be filed three ways: in person, at the claimant’s local Social Security office; by telephone, using Social Security’s toll-free number, (800) 772-1213; or online, through Social Security’s website, www.ssa.gov. 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 local Social Security office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. Once the application is complete, the local office then sends the case to DDS for evaluation of disability.
State Disability Determination Services (DDS):
DDS offices, 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 under the law.
Usually, 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 to complete the CE, however, DDS may also obtain the CE from an independent source. When the claimant alleges a mental impairment, DDS will generally require a consultative psychological examination (a Psych CE).
After completing its initial development, DDS makes a 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 re-contact a medical source(s) and ask for supplemental information.
After 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 DDS finds the claimant disabled, Social Security will complete any outstanding non-disability development, compute the benefit amount, and begin the steps needed to pay benefits. If the claimant is found not disabled, the file is retained in the field office and the claimant is given 60 days to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, the first level of appeal in most states is known as Reconsideration (or, simply Recon). Ten states have been designated as “Prototype” states, and have done away with Reconsideration completely. At Recon, the review is usually handled in much the same way as the initial claim. Upon the filing of a Request for Reconsideration, the file is returned to DDS, where a new adjudicative team, consisting of different personnel, makes a determination of disability.
Office of Disability Adjudication and Review:
If the finding after Reconsideration remains unfavorable to the claimant, they are entitled to request a hearing before an impartial judge. The claimant or their representative files a Request for Hearing with the local field office, and the case is transferred to Social Security’s Office of Disability Adjudication and Review (ODAR). After receiving any additional evidence from the claimant’s medical sources, a hearing in the case is conducted by an administrative law judge (ALJ). Further medical development deemed necessary by the ALJ may be conducted through DDS. However, judges may also request testimony at the hearing by non-examining medical experts (ME’s) or vocational experts (VE’s). In rare circumstances, an ALJ may contact medical sources directly and/or issue a subpoena requiring production of evidence or testimony at a hearing.
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