Most Americans know the term “Social Security” and expect they’ll receive some sort of retirement benefit in the distant future. Not everyone realizes that Social Security payroll deductions also pay for a disability insurance program that can help you and your family if you can’t work because of a medical condition.
Social Security Disability Insurance Program can be confusing, from the application process to making sure your work and earnings are correct to obtaining proper medical documentation, and then, what to do if your claim is denied? We’re going to answer your questions and, if you have questions that aren’t addressed by this article, please call Acadia Disability and we can have one of our experts help you with your Social Security Disability Benefits claim.
In this article, you’ll find information on the following topics:
- Social Security earnings and benefits
- SUPPLEMENTAL SECURITY INCOME
- AM I “DISABLED”?
- HOW TO APPLY FOR SOCIAL SECURITY DISABILITY
- HOW TO APPEAL A SOCIAL SECURITY DISABILITY DENIAL
- HOW CAN A REPRESENTATIVE HELP ME?
- SOCIAL SECURITY DISABILITY HEARING
- WHAT HAPPENS AT A SOCIAL SECURITY DISABILITY HEARING?
- FAVORABLE DECISIONS AND WHAT HAPPENS NEXT?
- UNFAVORABLE DECISIONS AND APPEALS
SOCIAL SECURITY EARNINGS AND BENEFITS
Nearly everyone who works pays into Social Security through FICA tax payroll deductions. FICA consists of two parts—Medicare taxes, which are 1.4% of wages, and Social Security, or “OASDI,”—Old-Age, Survivors, Disability Insurance—which is 12.4%, half paid by the employer and half by the employee. Social Security is similar to many private companies who require workers be “vested” to be eligible for retirement, and to be eligible for Social Security Benefits, workers must have enough earnings to be “fully insured.” Social Security requires you to earn 40 quarters of coverage between the year after you turn 21 and ending with the year before you reach age 62. That’s a total of 10 years of earnings. If you work before or after those ages, the amount of your Social Security Benefit will change to reflect your additional work, but the earnings won’t count toward Social Security insured status. Currently, “covered quarter” requires $1,320 in wages, so if you earn more than $5,280 yearly, you’ll earn 4 quarters of coverage.
Social Security Disability Insurance (SSDI) is like other insurance plans that require “premiums” be paid, only in this case, premiums are paid through your payroll deductions. For eligibility, you still have to be “fully insured,” but there are special rules for people under 31 years of age who haven’t had time to work 10 years. When your medical condition prevents you from going back to work, you’re still insured, but your coverage will expire, so don’t delay filing for your Social Security Disability Benefits. Also, Disability Benefits are only payable for one year prior to the date an application is filed, so filing your application timely is critical!
Besides being “fully insured,” SSDI has strict guidelines for a finding of “disabled.” Social Security Disability requires a medical impairment that prevents you from returning to work for at least 12 months or that is likely to result in death. Unlike other disability insurance programs, for SSDI, it’s 100% or nothing. You have to be completely unable to perform your past work or any other work in order to be found disabled by the Social Security Administration.
Here’s an illustration: You started your working career as a carpenter’s assistant and now you own a successful commercial construction company. You haven’t picked up a hammer in over eight years, but you’re responsible for hiring and firing, keeping the budget, and making sure all jobs get completed on time. Two years ago, you were injured in a car accident, hitting your head on the windshield and, since then, you have haven’t been able to keep track of projects or money or your truck keys, and it’s gotten to the point you’ve lost jobs and are selling your business. When the Social Security Administration decides if you meet the requirements to be disabled, they will look at the work duties of all the jobs you did in the past 15 years and determine if your medical condition would prevent you from doing any of those jobs, not just your last job.
SUPPLEMENTAL SECURITY INCOME
Some individuals don’t have the required earnings to be eligible for SSDI or have low overall earnings, and that’s where the Supplemental Security Income program can help. Supplemental Security Income (SSI) is a needs-based program that can add to your monthly income and provide you with Medicaid health benefits if the Social Security Administration finds that you’re disabled. The requirements for disability are the same as the SSDI program.
AM I “DISABLED”?
How does the Social Security Administration decide that you’re disabled? Once SSA determines you’re “fully insured,” like we talked about above, a finding of “disabled” is like a decision tree, if “yes,” go here, if “no,” go there. First, your medical impairment, or the combination of your medical impairments, has to be “severe,” which means they limit your ability to perform basic work-related activities. Those activities can be physical, like walking, lifting and carrying heavy objects, sitting, or climbing stairs, or they can be mental, like remembering, being able to understand and carry out instructions, or getting along with co-workers and supervisors.
Once it’s established you have a “severe” impairment, SSA compares the “Listings of Impairments” found in Social Security Regulations with the information contained in your medical records. If you have one of the serious medical conditions contained in the Social Security list of impairments, your medical impairment should be found to be disabling without considering any vocational factors. While the Regulations aren’t the easiest to navigate, you can find the Social Security Disability Listings in Appendix 1 to Subpart P, Part 404. The descriptions are fairly detailed, but our expert staff at Acadia Disability has the experience to help you understand the Social Security Disability requirements.
If your medical impairments don’t exactly match any of those listed in Appendix 1, the Social Security Administration goes onto Appendix 2, which is where vocational factors come into play. This a little more confusing. Now SSA looks at your age, education, and past “relevant” work, that is the work you performed over the past 15 years. The SSDI process includes evaluating the limitations imposed by your medical condition and determining whether there is work that you can perform despite those limitations.
HOW TO APPLY FOR SOCIAL SECURITY DISABILITY BENEFITS
Social Security Disability Application forms are located at Social Security’s website– www.ssa.gov/benefits/disability.
We recommend checking your Social Security Benefits Earnings Record to make sure all of your past work and wages are correct. You can register for a MySocialSecurity account at www.SSA.Gov/myaccount or go to your local Social Security Office. This is also a good time to update name changes on your Social Security Card. Take your paperwork to the Social Security Office, including photo identification (which you’ll need to enter the office) along with any documentation like marriage certificates, divorce decrees, and court orders, as well as any W2s for work that is not included on your earnings record. Check your SSA Earnings Record carefully to make sure that someone else isn’t using your SSN. If someone else is using your Social Security Number, that will be obvious, and getting it straightened out is imperative. Once that’s all done, it’s time to fill out the application for Social Security Disability Insurance.
Social Security Regulations state that, even if a person is eligible for Social Security Benefits, they can’t receive those benefits until they file an application. Make sure all your information is correct, including your full name, SSN, address, alternate contact information, and whether someone else can discuss your claim with Social Security Staff members. You’ll need the date you stopped working, or the date you started missing work regularly because of your medical impairment. If you stopped working but received short-term disability insurance payments or were on sick leave and received payments that might appear as wages from your employer, enter that information on the application as well. You’ll also need your banking information so future payments may be deposited directly into your checking or savings account.
One of the forms included in the Disability Benefits Application packet is an Adult Disability Report, which requires information about your past work, including the dates of your employment, employers’ names, and types of duties you performed. You’ll also need to explain what your medical conditions are and how they limit your ability to work. Be specific and straightforward in your explanations because people who don’t know you or your situation will be reviewing your paperwork. It’s important to explain clearly why you can’t go back to work.
The Adult Disability Report will also ask you about your doctors’ office visits, any hospitalizations, physical and occupational therapy, and counseling sessions you may have had immediately before and since you stopped working. You don’t have to collect all these medical records—the Social Security Administration will request the records for you. If you’re filing for a child or you have an impairment that was well-documented in school records, do try to get those while school’s in session. Summer breaks can cause delays when SSA tries to request school records.
One of the forms available on Social Security’s website is a Function Report – Adult (SSA-3373BK). This form is no longer required, but downloading and reviewing the form will show you exactly what areas Social Security Administration considers when determining whether a disability exists.
That’s it. Just sign your forms and submit them to the Agency, either online or in person at your local Social Security Office.
It is a universal truth that waiting on a decision seems to take forever and may be the hardest part of the application process. From time to time the news reports on the backlog of disability claims and how long it takes to receive a decision. There are hundreds of thousands of disability claims pending at Social Security and each case is considered on its own merits. So, while you’re waiting, be sure to keep your scheduled doctor’s appointments and attend all physical or occupational therapy or counseling sessions. Take your medications as prescribed and let your doctor know if you’re experiencing side effects.
HOW TO APPEAL A SOCIAL SECURITY DENIAL
Of all applications that are filed for Social Security Disability Benefits, about 50% are approved. That seems harsh, after all that waiting. Don’t take “no” for an answer! File an appeal. In some areas of the country, that would mean filing a Request for Reconsideration. You’ll have to update the forms you completed with your initial application, including any new doctors you’ve seen, recent medical appointments, and hospitalizations. Also, if your condition has worsened since your application, add that information as well. Only 60 days are allowed to file a Request for Reconsideration, and that time flies by, so don’t delay filing an appeal.
If your Reconsideration claim is denied, or if you’re not required to file a Request for Reconsideration for a Social Security Disability Appeal, it’s time to file a Request for Hearing Before an Administrative Law Judge. Again, you only have 60 days to file your Request for Hearing, so file your appeal right away!
HOW CAN A REPRESENTATIVE HELP ME?
An experienced claimants’ representative understands the Social Security Regulations and the requirements of the Social Security Disability Insurance program. Here at Acadia Disability, we have a team of expert Social Security Disability Attorneys who understand the rules and regulations and we can answer your questions. Our experienced attorneys are familiar with the Social Security Disability requirements, have attended many hearings before Administrative Law Judges, and are well-versed in what the Judge will expect before, during, and after your hearing. Our staff will order updated medical records, submit briefs explaining your disability and why you can’t return to work, and will attend the hearing with you.
Most professional representatives will have you sign a fee agreement which, along with an Appointment of Representative form, is a contract allowing the Social Security Administration to discuss your case with him or her. Social Security Regulations state that the Administrative must approve payment of a fee to a claimant’s representative. The fee agreement allows the Administration to pay your representative from your past-due benefits (the time from your onset date until you begin receiving benefit payments). If your representative requests medical records to submit to your claim file and the doctor’s office or hospital requires payment, it’s likely going to be your responsibility to pay for those records.
SOCIAL SECURITY DISABILITY HEARINGS
When your Request for Hearing is received by the Office of Disability Adjudication and Review (ODAR), you’ll receive an acknowledgment letter, letting you know that your hearing will be scheduled and you’ll get at least 20 days’ notice of the hearing date. When you get a Notice of Hearing in the mail, contact your representative right away to make sure they received a copy of the Notice and to let them know if you have a conflict. You’ve waited a long time for this hearing—years, in fact—so, you should adjust your schedule. Having your hearing rescheduled may result in more months of waiting. Be sure to return the Acknowledgement of Notice of Hearing, showing that you’ll attend the scheduled hearing. Also, double check the location of the hearing, just to make sure you know where to go.
The Notice of Hearing will also explain who will attend the hearing. You and your representative, of course, the Administrative Law Judge, and a court reporter, and the ALJ may request testimony from a Vocational Expert (VE) witness as well. A Vocational Expert’s resume will be made part of your claim file, and you’ll be able to see that their “regular job” is finding work for people with injuries. Some VEs work with employers and workers compensation insurers to find jobs for individuals with on-the-job injuries. The VE is considered an impartial witness and does not testify about you specifically. If you’ve had contact with the VE through a worker’s comp claim or your employer, let your representative know immediately so the ALJ can arrange an appearance by a different expert.
WHAT HAPPENS AT A SOCIAL SECURITY DISABILITY HEARING?
There will be a lot of questions at your Social Security Disability Hearing. There’s no reason to be nervous because you know the answers to these questions. Also, it’s your day in court—you’ve waited a long time to speak to someone face-to-face and tell your story.
Whether the ALJ does the questioning or allows your representative to question you, he or she will want to know about your medical impairments, why you stopped working, and how your impairments limit your day-to-day functioning, even though you’re no longer working. Can you shop for groceries? Make the bed and do housework? Drive yourself to doctors’ appointments? These are all questions asked at hearings, along with many others. The Judge will ask about your interactions with co-workers and supervisors while you were working and how you get along with family members now. Be concise and clear, but don’t minimize your pain and limitations. Now’s not the time for a stiff upper lip. Tell your story.
The Vocational Expert (VE) will be called to testify about your past work and the physical and mental exertion required in the jobs, as well as the skill level involved. Then, the ALJ will pose questions regarding a “hypothetical worker.” Remember, the Vocational Expert is an impartial witness and does not testify about you specifically. The “hypothetical worker” does resemble you, though, in that he or she is the same age, has the same education, and past work background. The ALJ will then describe work-related limitations on the worker caused by medical impairments (your medical impairments) based on records in the claim file and your testimony at the hearing. The Vocational Expert will offer an opinion about types of work available that, despite the limitations imposed by medical impairments, the hypothetical worker would be capable of performing. Your representative will point out any limitations that the ALJ did not consider and the VE may amend his opinion.
That’s the end of hearing. New information may have come out at the hearing, and the ALJ may decide to arrange a medical examination. If this is the case, you’ll be notified about your appointment. Again, be sure to attend the examination, because the ALJ may look unfavorably on your failure to do so and not have the appointment rescheduled. Also, additional medical records may be available after the hearing, and the ALJ will wait for those before he or she makes a decision.
Again, the hardest part—waiting for a decision. Once all the information is received, your representative can give you an idea about how long it will be before the decision is issued.
FAVORABLE DECISIONS AND WHAT HAPPENS NEXT?
Hurray! You received your decision in the mail, and it says you’re disabled. Your local Social Security Office also receives a copy of the decision, along with your representative. You’ll likely have more paperwork to complete before your SSDI Benefits payments can start. Your monthly income from SSDI will be considered, and you may be eligible for SSI payments as well. For SSDI, there is a five-month waiting period after your established onset date for payments to begin. This means that, if you stopped working in January and the ALJ decision states your established onset date is January, your payments will be calculated as of June. So, about four weeks after you receive the favorable ALJ decision you’ll get an SSA Notice informing you when your payments will start and the amount. There will also be information about the amount of your representative’s payment. Trying to sort out the payment amounts, onset dates, and past-due benefits can be confusing, and your representative can help you sort through these matters.
One important thing often overlooked is that Social Security Disability Beneficiaries are entitled to Medicare coverage after they’ve been disabled for 24 months. So, you can get the medical care you need to take care of yourself. Also, if you receive Supplemental Security Income payments, you may be eligible for immediate Medicaid coverage.
UNFAVORABLE DECISIONS AND APPEALS
If you receive a decision that you are not disabled and can return to work, read it carefully. The ALJ will explain why your condition did not meet the requirements to be “disabled” according to the Social Security Regulations. The unfavorable decision can be appealed to the Appeals Council, who will review your explanation about how the ALJ’s decision was incorrect. Do not send a rant about the ALJ and the Agency. Be specific and concise. Again, this is where a professional representative is extremely helpful. They have the skills and experience to read and understand the ALJ’s decision and to point out objective reasons why the ALJ got it wrong. They can explain why the combination of your medical impairments and vocational factors render you disabled.
Once your appeal is received by the Appeals Council, they can take different actions. First, they can find there was no error in the ALJ decision. Second, they can find there was an error and send the case back to the ALJ for another hearing and decision, also called a “remand.” The Remand Order will contain specific errors and the actions the ALJ has to take to correct the errors. In that case, you’ll likely be scheduled for another hearing and have another decision issued. Third, they can find that the evidence supports a finding of disability, vacate the ALJ decision, and issue a new decision finding you’re disabled.
There is another appeal level, and it’s filing a lawsuit in Federal Court against the Social Security Administration. The Court of Appeals can agree with the ALJ decision and the Appeals Council’s finding of no error, or the Court can remand the case back to the Social Security Administration for more action.
The requirements to be “disabled” according to Social Security Laws is strict, but if you’re not able to work because of a medical or mental impairment, you should begin the application process immediately! Acadia Disability and our experienced Social Security Disability Attorneys can help you navigate complex Social Security Regulations. We can answer your questions about filing a claim and we can help you with an application that you’ve already filed.
Social Security Disability Insurance can help you and your family with SSDI benefits and payments. Let us help you.