Disability benefits are for those who cannot work because they have a medical condition that is expected to last at least one year or result in death. Federal law requires that we use a strict definition of disability even though other programs are able to offer partial or short term disability. We pay benefits through two different programs: the Social Security Disability Insurance program (SSDI) and the Supplemental Security Income program (SSI).
Social Security Disability:
Because Social Security Disability (SSDI) is an insurance program, it requires enough overall work as well as enough recent work where the Social Security taxes were paid into the program. The number of credits required can vary from person to person based on their age when they became disabled. Social Security Disability applications can be filed online at www.socialsecurity.gov/pgm/disability.htm.
Supplemental Security Income:
Supplemental Security Income (SSI) is a program based on financial need and pays benefits to disabled adults and children who have limited income and resources. Whether your client can get SSI depends on their income and resources (the things they own). If someone receives SSI, then they may also be able to get other benefits, such as Medicaid and food stamps.
Disability Determination Services:
The decision about whether your client meets our definition of disability is made by a state organization called the Disability Determination Services (DDS) using our definition of disability. DDS considers a person’s medical condition as well as whether he or she is able to perform jobs previously held or any other kind of appropriate work based on age, education, and work experience.
Substantial Gainful Activity (SGA):
If your client is still working when they file, we will decide if they are able to do significant and productive physical or mental work. This is termed the ability to engage in substantial gainful activity (SGA). In 2013, monthly earnings of more than $1040 ($1,740 if they are blind) are considered substantial gainful activity. The SGA amount changes each year. For self-employed clients we use several complex criteria to determine if SGA is being performed. In making our decision about your client’s work, we also consider their impairment-related work expenses and subsidies provided by their employer.
Amount of Benefits:
When benefits are approved under the SSDI program, cash payments begin with the sixth full month after the date the disability began (with certain limitations on retroactivity). The amount of the monthly check is based on the applicant’s average lifetime earnings. The Social Security Statement that your client receives each year provides an estimate of how much he or she would receive if they became disabled.
Benefits for your client’s family:
If your client receives Social Security disability benefits, some of their family members may be able to receive benefits. Those members include
- Age 62 or older
- Spouses under 62 if they are taking care of a child (under age 16 or disabled) and the child is entitled on the client’s record
- Age 62 or older divorced spouses if the marriage lasted at least 10 years and they are unmarried
- If a divorced spouse wants information about benefits, have them contact us
- Up to age 18
- Age 19 if they are full-time students in secondary school
- Severely disabled children age 18 or older as long as they became disabled before
- Age 22
There is a limit to the amount of benefits that can be paid to your client and the family members. The client’s checks are not affected by family members drawing benefits.
Windfall Elimination Provision:
Pensions from work that was not covered by Social Security (federal civil service, some state or local government employment) may reduce your client’s Social Security benefit. This is called the Windfall Elimination Provision.
They can learn more online or by calling Social Security.
The family’s benefits can be affected by factors including their own work and receipt of a government pension. Social Security will provide them a complete list of reporting responsibilities when they file for benefits.
The process for filing for Social Security disability or Supplemental Security Income (SSI) disability is similar to filing for retirement benefits. The difference is in the added medical decision for the disability. Each state has a Disability Determination Service (DDS) that works with Social Security to make the medical decisions.
In preparation for the disability application, it will be helpful to gather some information ahead of time whether your client is filing online, at the Social Security office, or over the telephone.
Some of the information for adult applications includes:
- Medical information
Names, addresses, and phone numbers of all doctors, hospitals, and clinics Patient ID number(s)
- o Approximate dates seen n
- o Names of medications being taken
- o Medical records in the client’s possession
- An original or certified birth certificate (if we haven’t seen it recently)
- Military records such as the DD-214 if your client was in the military service
- W-2 or self-employment federal tax forms if your client worked last year
- Workers’ compensation information, including date of injury, claim number, and proof of payment amounts
- Social Security Number(s) for your client’s spouse and minor children
- Checking or savings account information for direct deposit
- Name, address, and phone number of a person who Social Security can contact if we are unable to get in touch with your client.
Help your client provide their work record for the last 15 years.
Childhood Disability Benefits:
If your client is applying for childhood disability benefits, Social Security will need to know:
- Any medical records your client already has, including the dates the child was seen or treated and the child’s patient ID number(s), if known.
- Medication(s) the child is taking.
- Child’s medical assistance number, if any
- Names, addresses and phone numbers of any schools the child attended in the past 12 months, including the names of teachers, psychologists, counselors, speech and other therapists who have seen or treated the child.
- The child’s Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP), if the child has one; and any other school records that are available.
- Names, addresses and phone numbers of any social services programs and the name of caseworkers that have information about the child.
- Name, address, and phone number of another adult who helps care for the child and can help us get information, if necessary
- Names, addresses, and phone numbers of any employers the child has worked for.
- An original or certified copy of the child’s birth certificate if Social Security hasn’t seen it recently.
- Names and Social Security Number(s) for all the children and adults who live in the household.
- For SSI childhood disability cases, Social Security will also need:
- o Proof of current income for the child and family members living in the household (for example, pay stubs, self-employment tax returns, unemployment or other program benefits, child support).
- o Proof of resources for the child and parents living in the household (for example, bank account statements, life insurance policies, certificates of deposit, stocks or bonds).
And SSI Process
Disability Benefits Evaluation:
When the application is submitted to Social Security, it is sent to the Disability Determination Service to evaluate your client’s medical condition. DDS reviews the case to determine whether the medical condition is severe enough to prevent any substantial work and whether the medical condition has lasted, or is expected to last, at least one year, or be expected to result in death. In a childhood disability determination, the case is evaluated based upon whether it causes marked or severe functional limitations.
Often, DDS sends additional forms for completion to the client or others who know about the client’s disability. Encourage the client to return the information as quickly as possible. Sometimes, DDS schedules a consultative examination to determine if the client is disabled. The exam is paid for by Social Security. If your client does not go to the examination, their claim may be denied.
After the DDS makes a decision, the case is returned to the Social Security office for processing. From beginning to end, this process usually takes about 100 days. Of course, some cases are processed more quickly and some take longer, especially those involving consultative examinations.
If your client is filing an application for SSI, Social Security may need to update their record after the medical decision has been made to determine whether there have been any changes to income, resources, and/or living arrangements since the application was filed. If the application was for SSI disabled child benefits, Social Security may also ask about parental living arrangements, income, and resources.
Military service members can receive expedited processing of disability claims from Social Security. Benefits available through Social Security are different than those from the Department of Veterans Affairs and require a separate application.
The expedited process is used for military service members who become disabled while on active military duty on or after October 1, 2001, regardless of where the disability occurs.
The Social Security Administration and the Department of Defense (DoD) are working together to improve the electronic medical records collection process. Please refer to the press release at http://www.socialsecurity.gov/pressoffice/pr/ssa-dod-hit-pr.html for more information.
Below are the answers to the questions most people ask about applying for disability benefits. Knowing the answers to these questions will help you understand the process.
What types of benefits can individuals receive?
Social Security pays disability benefits through two programs: the Social Security disability insurance program, which pays benefits to your clients and certain members of their family if they are “insured,” meaning that they worked long enough and paid Social Security taxes; and the Supplemental Security Income (SSI) program, which pays benefits based on financial need.
For more helpful information on Wounded Warriors, please visit www.socialsecurity.gov/woundedwarriors.
What is Social Security’s definition of disability?
By law, Social Security has a very strict definition. To be found disabled:
- Individuals must be unable to do substantial work because of their medical condition(s); and
- Individuals’ medical condition(s) must have lasted, or be expected to last, at least one year or to result in death.
While some programs give money to people with partial disability or short-term disability, Social Security does not.
Can individuals receive benefits for a past disability if their health has improved?
That depends. If we find that a client is disabled under our rules and their application was filed within a specified time frame, we will consider whether they qualify for a closed period of disability. There are specific requirements for a closed period of disability:
The medical evidence must establish that they were unable to engage in substantial work for a continuous period of 12 months, but by the time the disability decision is made, their condition has improved to the point where we find they are no longer disabled.
Your client must also must file an application within 14 months after the disability ended.
If your client meets the requirements for disability benefits, there is a five-month waiting period before their first monthly benefit can be paid. They can receive up to 12 months of retroactive benefits from the date they file an application with Social Security.
Example: Your client files an application for Social Security disability benefits in December 2010. After reviewing the claim, we find that their disability started on April 15, 2009, and that the condition improved to the point that they were no longer considered disabled as of September 2010. We refer to this as a closed period of disability.
Their five-month waiting period begins May 2009, the first full month they are disabled. The months in their waiting period are May, June, July, August, and September. Thus, the first month for which your client is entitled to disability benefits is October 2009.
Your client could potentially receive benefits for October 2009 until September 2010, the month their disability ended. Based on the application they filed in December 2010, they would receive 10 months of retroactive benefits for December 2009 through September 2010.
How does military pay affect eligibility for disability benefits?Active duty status and receipt of military pay does not, in itself, necessarily prevent payment of Social Security disability benefits. Receipt of military payments should never
stop your clients from applying for disability benefits from Social Security. If they are receiving treatment at a military medical facility and working in a designated therapy program or on limited duty, we will evaluate their work activity to determine their eligibility for benefits.
Your clients cannot receive Social Security disability benefits if they engage in substantial work for pay or profit. However, the actual work activity is the controlling factor and not the amount of pay they receive or your military duty status.
How do individuals apply?
They may apply for disability benefits at any time while in military status or after discharge, whether they are still hospitalized, in a rehabilitation program, or undergoing out-patient treatment in a military or civilian medical facility. They may apply online at www.socialsecurity.gov/woundedwarriors, in person at the nearest Social Security office, by mail, or by telephone. They may call 1-800-772-1213 to schedule an appointment. If they are deaf or hard of hearing, they may call our TTY number, 1-800-325-0778. We also have a “disability starter kit” available online to help individuals complete their application.
What information does an individual need to provide?
To apply for benefits, an individual or his/her representative must provide information and documentation about their age, employment, proof of citizenship, and information regarding all impairments and related treatment. Social Security will make every reasonable effort to help them get the necessary medical evidence.
Important: Individuals should file the application for disability benefits as soon as possible with any documents readily available. Do not delay filing, even if they do not have all the documents mentioned below.
- Original or certified copy of your birth certificate or proof of U.S. citizenship or
- legal residency if foreign born;
- Form DD 214, if discharged from military service; W-2 form or income tax return from last year; Proof of military pay or workers’ compensation; Social Security numbers of his/her spouse and minor children;
- Checking or savings account number, if they have one;
- Name, address, and phone number of a contact person, in case they are unavailable; and
- Medical records that they have or that they can easily obtain from all military and civilian sources.
How does Social Security make the decision?
Disability claims are sent to a State Disability Determination Services (DDS) office that makes disability decisions. The State has medical and vocational experts who will contact your clients’ doctors and other places where they received treatment to get their medical records.
The State agency may ask them to have an examination or medical test. They will not have to pay the costs of any additional exams or tests they are asked to take. If the State does request an examination, make sure they keep the appointment.
How long does it take?
The length of time it takes to receive a decision on a disability claim can vary, depending on several factors, but primarily on:
The nature of the disability;
How quickly we obtain medical evidence from doctors or other medical source; and
Whether it is necessary to send your client for a medical examination in order to obtain evidence to support his/her claim.
What can individuals do to speed the decision?
- They can speed the decision on their application for benefits by being prepared for their interview. We can take prompt action on their claim if they:
- Let us know right away that their disability occurred while on active military duty;
- Have information available regarding all the doctors they have seen and the address of the military site where their records are kept;
- Notify us of any address changes they have while we are working on their claim; and
- Inform us about any changes in doctors, hospitals, or outpatient clinics where they are receiving treatment.
After we receive your client’s application for Social Security disability benefits, we will identify it as a military service member claim and expedite it through all phases of processing, both at Social Security and the DDS. We also expedite disability claims filed online.
Can family members get benefits?
Certain members of your client’s family may qualify for benefits based on their work. They include:
- The spouse, if he or she is age 62 or older;
- The spouse, at any age, if he or she is caring for a child of your client’s who is younger than age 16 or disabled;
- An unmarried child, including an adopted child, or, in some cases, a stepchild or grandchild. The child must be younger than age 18 or younger than age 19 if in elementary or secondary school full time; and
- An unmarried child, age 18 or older, if he or she has a disability that started before age 22. (The child’s disability also must meet the definition of disability for adults.)
NOTE: In some situations, a divorced spouse may qualify for benefits based on your client’s earnings if he or she was married to your client for at least 10 years, is not currently married, and is at least age 62. The money paid to a divorced spouse does not reduce your client’s benefit or any benefits due to his or her current spouse or children.
When do individuals get Medicare coverage?
Individuals will get Medicare coverage automatically after they have received disability benefits for 24 months.
How does Medicare affect service members’ TRICARE?
For service members who are entitled to Medicare Part A (hospital insurance) and Part B (Medical insurance), TRICARE provides Medicare “wraparound” coverage. Medicare is the primary payer for these beneficiaries, and TRICARE serves as a supplement, paying the Medicare deductible and patient cost share.
If a service member entitled to Medicare Part A based on disability or permanent kidney failure, contact the Department of Defense to find out how this may affect their TRICARE benefits. They may need to be enrolled in Medicare Part B to keep their TRICARE coverage. For general information about TRICARE, please visit www.tricare.mil/mybenefit/ ProfileFilter.do.
Individuals who are awarded retroactive Social Security disability benefits also may become entitled to Medicare Part A for months before they receive the disability award notice. Effective October 2009, TRICARE beneficiaries who are awarded retroactive benefits based on disability or permanent kidney failure do not have to enroll in Part B for those months in the past and can keep their TRICARE coverage as long as they enroll in Part B currently. Service members should contact the Department of Defense to find out whether they need to enroll in Medicare Part B so they can keep their TRICARE.
The Patient Protection and Affordable Care Act of 2010 provides for a 12-month Medicare Part B special enrollment period for TRICARE beneficiaries who are entitled to Medicare Part A, but did not enroll in Medicare Part B during their initial enrollment period. The Department of Defense will notify eligible individuals about this period.
For more information about TRICARE and recent changes in the law, please visit www.socialsecurity.gov/legislation/tricareinfo.html.
What if service members remain on active duty?
They may receive Social Security disability benefits and remain on active duty. It is important that they immediately contact Social Security if there is a change in their:
- Military Occupational Specialty code (MOS);
- Air Force Specialty Codes (AFSC); or
- Navy Enlisted Classification (NEC).
A permanent change of station (PCS) move from one duty station to another is also a potential indicator that they may be going back to work and should contact Social Security.
Changes in their work status may affect their Social Security benefits. Tell us right away about any changes in their work or active duty status.
If they are planning to change their PCS, MOS, AFSC, or NEC, they can request a Benefits Planning Query from Social Security. This query contains information about the status of their disability benefits, work history and current work status, health insurance, scheduled medical reviews, and representative payee data.
They can use the Benefits Planning Query as a tool to help you plan your return to work. Request your query by calling 1-800-772-1213 or visiting your local field office.
What should I know about working?
Social Security has special rules called work incentives that allow your clients to test their ability to return to work and still receive monthly Social Security disability benefits.
They also can get help with the education, training, and rehabilitation they need in order to work. Starting on page 17, you will find a description of the work incentives and other programs that can help your clients return to the work force. For more information, ask us for “Working While Disabled— How We Can Help” (Publication No. 05-10095) or visit www. socialsecurity.gov/work.
Do individuals need to report their work activity?
Yes. If your client takes a job, it is important that they let us know about it as soon as possible. They should tell us:
- When they start or stop work; and
- If there is a change in their job duties, hours of work, or rate of pay.
Even if they are receiving full pay, they still may qualify for Social Security disability benefits.
They may visit their local field office to report their current work activity. They can find the closest office on our website at www.socialsecurity.gov.
Ask the Social Security representative to give your client a receipt showing that they reported their work activity. The work report receipt is for their records and serves as proof that they told us about your current work situation.
What happens next?
When we receive notification that your client has returned to work, we perform a work continuing disability review (CDR). During this review, we look to see whether they are doing substantial work. For 2013, we consider your client to be doing substantial work if their monthly earnings are over $1,040 ($1,740 if they are blind).
That amount may change each year. When we conduct a work CDR, we ask your client to complete an SSA-821- BK (Work Activity Report-Employee). Your client should complete the form and provide as much detail as possible about their job duties.
It is important that they tell us whether they are in a designated work therapy program or whether they are assigned limited duty because of their disability. They may be receiving full military pay, but not performing work duties. Without this information, we cannot properly evaluate their work, and their Social Security benefits may be suspended or terminated.
Trial Work Period (TWP) The TWP allows your client to test their ability to work for at least nine months. The months do not need to be consecutive. During the TWP, your client will receive their full Social Security benefits, regardless of how much they earn, as long as they report their work activity and they continue to have a disabling impairment.
In 2013, a trial work month is any month in which your client’s total earnings are more than $750, or, if they are self-employed, they earn more than $750 (after expenses) or spend more than 80 hours in their own business. The TWP continues until they have worked nine trial work months within a 60-month period.
Extended Period of Eligibility (EPE)After the TWP ends, they have 36 months during which they can work and still receive
benefits for any month that their earnings are not “substantial.”
During the EPE, their benefits are suspended for any month that they have substantial earnings. However, they will receive a benefit for any month their earnings fall below the substantial level. They do not need a new application or disability determination to receive a Social Security disability benefit during the EPE.
More information on work incentives is available at www.socialsecurity.gov/redbook.
Ticket to Work Program
Social Security’s Ticket to Work program offers many supports that can help your client return to work. Under the Ticket program, your client can obtain vocational rehabilitation, training, job referrals, and other employment support services free of charge. These services are provided by Employment Networks, which are private organizations or government agencies (state or local) that have contracts with Social Security to provide employment services and other supports to beneficiaries with disabilities.
If your clients are interested in using the Ticket program to go to work or get vocational se1`rvices, please call 1-866-968-7842, toll-free.
Work Incentives Planning and Assistance (WIPA) program
The WIPA program is a nationwide network of community-based organizations with experts who can answer questions about Social Security’s work incentives and help your client make a decision about working.
WIPA experts, called Community Work Incentive Coordinators, provide information and work incentives planning and assistance to people who are receiving Social Security disability benefits and who are currently working or considering work. They can help your client understand how work affects their disability benefits and explain what other federal, state, and local supports there are for people with disabilities who want to work.
To locate the WIPA project nearest your client, call 1-866-968-7842, toll free.046720
Q and A
Q. How long does it take to get notified of a decision about disability?
A. The length of time that it takes to receive a disability decision is from three to five months or longer. It can vary depending on the nature of the disability, how quickly we obtain medical evidence, whether or not we need to request a consultative exam, and whether the claim is randomly selected for a quality assurance review of the decision.
Q. What is the difference between the SSDI program and the SSI program?
A. SSDI is financed by Social Security taxes paid by workers, employers and self-employed people. SSDI requires the worker to have a required amount of taxable work to be insured for benefits. Disability benefits are payable to blind or disabled workers, widow(er)s, or adults disabled since childhood who meet the definition of disability. The amount of the monthly benefit is based on the average lifetime earnings of the insured worker.
SSI is financed through federal general revenues. Benefits are payable to adults or children who are disabled or blind and have limited income and resources. The monthly payment varies up to the maximum federal benefit rate and can be increased by the State in which the client lives or decreased by your client’s countable income and resources.
Q. Why is there a five-month waiting period for SSDI benefits?
A. The five-month waiting period ensures that Social Security is meeting our legal requirement to pay only long-term disability payments to people.
Q. If individuals receive SSDI benefits and their condition worsens, can their benefits be increased?
A. No. The Social Security disability benefit is based on the amount of the client’s lifetime earnings before the disability began and not the severity of the disability.
Q. Will individuals automatically get Medicare?
A. We will automatically enroll a beneficiary in Medicare after he or she has been entitled to disability benefits for two years. We start counting the 24 months from the month your client became entitled to benefits (this includes any months that back-pay benefits).
A. In addition, people with Amyotrophic Lateral Sclerosis, ALS (or commonly known as Lou Gehrig’s disease) get Medicare beginning with the month they become entitled to disability benefits. People with end-stage chronic renal disease (ESRD) get Medicare based on when they begin dialysis or receive a transplant. If your client or their family member is working and has a group health plan based on their work since the time they were first eligible for Medicare, then they will qualify for a Special Enrollment Period.