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by Cheryl Stapley
Overview of SSDI and SSI Please note that the following information is provided for your information and reference. It is not legal advice. Please see your attorney.
Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) are programs that offer disability benefits administered by the Social Security Administration (SSA). Although both programs provide a disability benefit, the purpose, benefits, and eligibility requirements for the two programs are different. SSDI is an insurance program for people who become unable to work due to disability. It is funded by the FICA tax and helps replace income lost due to disability. It also keeps your earnings record current so that you can receive a larger Social Security benefit at retirement age. In order to qualify for SSDI, you must have worked and paid FICA taxes for a certain amount of time. Normally you must have worked 20 of the 40 quarters (5 of the 10 years) prior to the onset of your disability, but for younger workers this requirement is reduced. If you were self-employed, you will only be eligible for SSDI if you paid enough FICA tax to qualify for coverage. You are eligible for SSDI regardless of your financial situation - this is an insurance program that you have been paying for as long as you have been paying FICA taxes. However, if you are receiving benefits from Worker's Compensation Fund, or state disability, or a pension from a job in which you did not have to pay Social Security taxes, there may be a reduction in your SSDI benefits. The SSDI benefit is calculated on your past earnings. The benefit amount will therefore be different for different people. SSDI benefits cut off at age 65 when Social Security retirement (usually the same amount as the disability benefit) and Medicare benefits take over. Once you have been approved for SSDI, your benefits will not begin until the sixth full month from the date of disability onset. Additional "auxiliary" benefits may be payable to other family members (such as spouses, children, or parents) based on the earnings record of the person receiving SSDI. People who are approved for SSDI will qualify for Medicare benefits 24 months after receiving their first monthly check. Look into sick leave, Family Medical Leave, or COBRA to help fill in the gap until your Medicare benefits begin. For details on the SSDI program, refer to the following SSA information:
SSI is based on financial need rather than employment history. There are strict financial guidelines that a person must meet in order to qualify for SSI. Both earned and unearned income will be taken into account when determining your eligibility, as well as the income and resources of others who contribute to your support. Depending on your level of income, you may receive the maximum monthly benefit, a reduced monthly benefit, or you may not be eligible to receive benefits at all. To qualify for SSI, you must be at least 65 years of age, OR blind, OR disabled. In addition, you must have financial need. Certain citizenship and residency requirements also apply. SSI provides a standard monthly benefit (increased annually for cost-of-living), which may be reduced depending on your financial situation. In 1999, the benefit was $500 per month for individuals, $751 for couples who both qualify. Once you are approved for SSI, you will receive your benefits for the first full month after the date you filed your claim, or (if later), the date on which you became eligible for SSI. People who are approved for SSI will qualify for Medicaid benefits immediately. For details on the SSI program, see the following SSA publication:
It is possible for a person to qualify for BOTH SSI and SSDI. When you apply for either SSI or SSDI, the Social Security Administration should check to see if you are eligible for the other benefit as well. If you qualify for both benefits, and your SSDI benefit is less than the maximum SSI benefit, you may be eligible to receive an SSI payment in addition to SSDI, up to the maximum allowed for SSI. Both SSI and SSDI require that you meet SSA's definition of "disability". See the Disability Definition below for detail on what this means.
You can apply for SSI or SSDI at any Social Security Administration office. Contact the SSA (1-800-772-4222) and set up an appointment for an interview at the SSA office closest to you. Forms that should be completed prior to your interview will be mailed to you or you can pick them up from the SSA office . Expect the interview to last up to two hours. If you have brought all of the necessary information and have filled out the forms beforehand, it may be quicker. You can also go to the SSA office without making an appointment, as long as you are prepared to wait for an interview, possibly for a few hours. It is possible for you to apply over the telephone and have the information sent to you for signature. In fact, you may be encouraged to do this when you call for an appointment. Everything you give them should be in writing, and you should have copies of it. By applying in person, you will benefit from free advice and an examination of your papers for errors and omissions before they are filed. In some cases, special appointments may be made for applicants whose disability creates a problem for them to go through the normal appointment process. Even though SSA may encourage you to apply by telephone, you have the right to an in-person interview. If you are denied the right to an in-person interview, contact your U.S. Senator or State Representative. Some people have been told over the telephone that they do not appear to be eligible for benefits. If this happens, and you believe that you qualify, insist on filing an application anyway. Note: The Social Security clerk is required to take notes concerning your appearance any time that you go to the office in person. This may be either beneficial or harmful to your case, depending on whether you "appear" disabled. People with "invisible" disabilities may benefit from telephone correspondence rather than in-person interviews. Application for SSI benefits should be made as soon as possible, as they are usually only retroactive to the first day of the month after the application date. You may obtain a "protective filing date" by calling your local district office and making an appointment. The retroactive benefits will be based on the protective filing date rather than the appointment date. SSDI benefits will not begin until the sixth full month after the onset of your disability, regardless of the date of your application. This does not mean that you cannot apply immediately. If your application happens to be approved before the sixth month, you will not receive benefits until the sixth month. If it is approved after that time, you will receive a retroactive payment. There are three forms (available from Social Security District Offices) that should be completed by you prior to your appointment, the Disability Report, Function Report, and Work History. If you are unable to complete these forms prior to your appointment, be sure to bring all of the necessary information with you. It is critical to your application that you fill out these forms as accurately and completely as possible. If you have questions concerning the application forms, you can call the SSA office. Keep copies of all forms, medical records, documents, and correspondence to and from SSA, including the envelopes of any mailings received from SSA (showing the postmark date). It is also a good idea to have your application, or any requests for appeals, hand-delivered (by yourself or someone else), and obtain a receipt showing that it was filed. You may wish to consider obtaining representation to assist you in your application. There are attorneys who specialize in SSA Disability representation, or you can check with your local Legal Aid society, which may be able to provide you with assistance at little or no cost--especially if you are applying for SSI. You can obtain a representative at any step of the process, however, it is not usually recommended you obtain one for the initial application. Some representatives may be willing to answer basic questions or help you determine whether you have a good case without any fee. Even if you aren't sure that you want to hire an advocate or attorney, you may want to find out what help might be available to you at no cost. The National Organization of Social Security Claimants' Representatives (NOSSCR) can help you find a representative in your area.
The Disability Report documents your disability. It will indicate when and where you received medical treatment, and what types of treatments you received. It is very important to provide clear, accurate, and complete information, or your claim may be delayed or denied. You will be asked to list your physical or mental disabilities or impairments. Be sure to list everything you can in detail, including non-obvious impairments such as depression, pain, anxiety, bladder problems, dizziness, fatigue, or pain. When listing information on your doctors and treatments, be sure to indicate the names, addresses, and phone numbers of all medical service providers, as well as the dates of service. The Disability Determination Service will need to confirm each of these medical service providers and obtain the appropriate medical records. This is the information that is used to determine whether you are disabled, so you need to be sure it is as detailed as possible. If you can provide copies of the medical records from your hospitals, doctors, and other medical providers, as well as laboratory and test results, your claim decision can be made much more quickly, often months earlier. The disability analyst must obtain copies of these records, and this is usually where the long delay in processing your claim comes from. Until the analyst receives all of your medical records and information, he or she cannot make a decision on your case. Medical care providers are often very slow at providing this information, and you are the one who suffers. If you can provide them yourself, your claim will not be held up because of waiting to receive this information. You must be sure to include all relevant information. SSA will not investigate for any other medical information concerning your disability that is not in your file, so if you don't include it, don't expect them to know about it. The Work History ReportThe Work History Report documents information your job history for the past 15 years. Describe your work experience in detail, including the mental and physical tasks required to perform each job -- especially if you are no longer able to perform those tasks. For example, if your job required you to stand for many hours or lift heavy objects, and you are no longer able to do that, be sure to indicate that. Be sure to list whether your job required any walking, standing, lifting, or carrying, even if it was on rare occasion. Document any failed work attempts, as this will help show that you are unable to perform your prior job. Age is often a factor in determining whether or not you are capable of performing prior work. If you are over age 50, and are unsuited for sedentary work due to lack of education or skills, you are more likely to be approved than if you are under age 50 and have a history of sedentary work. The Function ReportThis report helps document how your disability affects your daily life. Be sure to include specific examples of basic daily living or employment activities that you can no longer do. It is important to be very detailed. Do not gloss over things that you find difficult - you are trying to prove that you have a disability! If you are unable to shop or drive, or take care of your yard, or if you need help to perform certain functions, be sure to note those things. Some examples of things that might be included in this report would be how long you can sit, stand, or walk; how much you can lift or carry; whether you can use your hands for fine motor skills, grasping, or pulling; whether you can use your feet to manipulate leg controls; whether you can crawl, climb, squat, or reach; your sleep patterns; whether you can drive, go shopping, or perform housework; or whether your memory or concentration are impaired. Indicate how your daily routine has changed since you became disabled - what could you do before that you can't do now? Indicate circumstances that aggravate your condition, such as activity or environmental conditions. You may include statements by friends, family, or acquaintances concerning how your daily life has been affected. You should provide at least one recent doctor's report that diagnoses the disability, explains the impairments to your work capacity, gives specific examples of what you can and cannot do, and indicates the expected amount of time that the disability is expected to last. Try to get your doctor to submit a written report in addition to filling out a Residual Functional Capacity (RFC) questionnaire. An opinion by a doctor (especially a specialist) who has treated you numerous times over a period of time and has given you tests for impairment will be given more weight than a single exam (other than a referral to a specialist), or an opinion by an SSA appointed examiner. The Daily Activities Worksheet from PDS can help you gather information about your impairment and help you (and your doctor) file an accurate and detailed report. Additional Information to Include Be sure to indicate exactly how your disability caused a problem with your work, such as inability to perform certain duties. Again, it is very important to be detailed, and give specific examples. Create a list of all medicines that you are taking, both prescription and over-the-counter. Indicate the purpose of the medication, dosage and side effects. If prescribed, list the prescribing physician. Obtain informational sheets about your specific disability or medical condition, including symptoms and prognosis, especially if your disorder is rare. It is up to you to prove your disability. According to the Social Security Act, "An individual shall not be considered to be under a disability unless he furnishes such medical and other evidence of the existence thereof as the Commissioner of Social Security may require." Social Security Act, Section 223(d)(5)(A).
Things you should bring with you for your appointment
If you are applying for SSI, you should also bring the following:
If you are unable to provide some of the information listed above, you can still apply and have your interview. SSA may be able to help you obtain the additional information. If you have not already filed your completed forms (you can file the forms prior to your appointment if desired), you will need to turn them in or fill them out when you arrive at the district office. The Social Security claims representative will review your Disability, Work, and Function Reports for completeness, and will complete a Claim Form (or Initial Application Form). If necessary, the representative may also need to verify residency or immigration status at this time. Your work history will be verified to determine whether you meet the work requirements for SSDI and/or SSI. If you qualify for both benefits, you may apply for both. After your appointment, your file will be forwarded to your state's Disability Determination Services (DDS). It is this department that actually makes the initial approval or denial of your claim. Get the name and phone number of the person handling your case so that you can follow up on it and make sure that he or she has all of the information necessary to handle the case. Volunteer to provide any additional information on your impairment. Depending on the backlog of claims, the completeness of your forms and documentation, and the amount of time required for the analyst to receive all of the information from your doctors, you will usually receive a decision in 60 to 120 days. If you are applying for SSI: In some cases where there is a severe and obvious disability, and it is highly likely that your application will be approved, the Social Security office may consider you to have a "presumptive disability" and issue benefits to you for a number of months (maximum of six months) while your case is being processed. It is important to understand that even though you may begin receiving benefits under these conditions, it does not mean that you have been approved for SSI. If for some reason your claim is eventually denied, your benefits will be terminated. If this occurs, however, you will note have to repay the benefits that you received under presumptive disability. For more about presumptive disabilities, refer to the following SSA documents:
You may be able to achieve a priority standing and have your case assigned to a Disability Analyst more quickly under certain circumstances, such as homelessness, terminal illness, AIDS, or if all of the medical documentation for your case has already been collected.
Disability Determination Services (DDS) will review the claim file and return an initial determination of approval or denial. Because of the backlog of cases, and the amount of medical review that is necessary, there is often a wait of several months before your claim is approved or denied. Once your case has been assigned to a disability analyst, he or she will review the medical evidence. This involves contacting all of the relevant medical sources that you listed on the Disability Report in the twelve months prior to your application date, plus older ones if appropriate. Copies of all medical reports and test results must be obtained, if you did not provide them. This is where the long delay often comes from in reaching a decision on your case. It may take months for the analyst to get all of the necessary information from your medical care suppliers, which is why it is so important to provide the medical reports and test results yourself if you can. The analyst has no control over the medical care suppliers - if the suppliers are slow in providing the requested information, the analyst has no choice but to wait. Depending on the medical evidence provided, the analyst may arrange for you to be evaluated by a physician associated with SSA, and which will be paid for by SSA. This will often be done if your medical information is not recent. If you miss three scheduled appointments, your claim will probably be denied. The analyst, along with staff doctors, will then determine whether you meet the required criteria for disability according to the SSA disability requirements. The SSA requirement states that an adult must be:
For children, they may additionally be considered disabled if the impairment "causes marked and severe functional limitations". If you are statutorily blind (central visual acuity of 20/200 or less in the better eye with the use of a correcting lens, or an eye in which the widest diameter of the visual field subtends an angle no greater than 20 degrees), it is not necessary that your blindness meets the duration requirement, or that you be unable to engage in substantial gainful activity. There are 5 steps in determining whether you meet the disability requirements. The following applies to non-blind adults - requirements for children and the blind are slightly different: 1. Are you engaging in "substantial gainful activity"?"
2. Is your condition "severe"?
3. Is your condition on the pre-determined list of disabling impairments?
4. Can you perform your previous work?
5. Can you do any other type of work?
Once a decision has been made to approve or deny a claim, the file will be returned to the Social Security District Office and you will be notified of the results. If your claim is approved, you will be asked to return to the office and verify the non-medical eligibility requirements, such as income, living arrangements, and any other items not already verified. If your claim is denied, you will receive a notice from Social Security indicating that your claim was not approved, the reasons for the decision, and that you have the right to file for reconsideration. The majority of claims are initially denied. Only about a third of cases are approved in the initial determination stage. In some cases, of course, the applicant truly does not meet the requirements. But in many other cases, the applicant may meet the conditions, but simply did not provide enough information for the analyst and doctor to justify approval according to the steps outlined above. You can greatly increase your odds of being approved at the initial stage by understanding how the determination process works, understanding what information needs to be included with your application, and providing complete, detailed, and accurate information. For an "inside" look at the Disability Determination process, see How Disability Determination Services Works.
Request an appeal as soon as possible after you receive a notice of denial. You can obtain and fill out the proper form and submit it, or you can send a simple letter to SSA indicating that you want to appeal the decision, then fill out the appropriate forms details and explanations later. The appeals process consists of the following steps, which must be taken in order:
Reconsideration The first step is requesting reconsideration by filing a "Request for Reconsideration". This is not the same as reapplying. If you reapply, you will be starting over from scratch, and will lose your original application date, which is important if you are applying for SSI. You must request reconsideration within 60 days of the date on the denial notice (see note*). You will also be expected to complete a "Reconsideration Disability Report", and provide any necessary additional Medical Release Authorizations. These do NOT need to be filed by the filing deadline. This form will ask for any new information about doctors, hospitalizations, or changes in your medical condition. The more information that is provided at this time, the better your chances for reversing the decision. Your file will then be sent back to the DDS office for reconsideration by a different analyst than the one who reviewed your initial claim. Unfortunately, most claims that are appealed at this level are denied again, unless you provide strong evidence that was not present in your original claim. If your claim is denied at the reconsideration stage, you must determine whether you want to appeal the denial and proceed to an Administrative Hearing. This is usually worthwhile since over half of the claims that are appealed to an Administrative Hearing are approved. Administrative Hearing At this point, you can personally meet with the people making decisions about your claim. This is when you will be able to present facts that may not be obvious from your medical records, and provide witnesses (including family or acquaintances) who can testify to your disability, or your inability to work. Slightly more than half of the applications appealed at this level are approved. It is highly recommended that you obtain assistance from an attorney who specializes in SSA disability claims, or a legal aid or disabilities organization to represent you at the hearing. Attorneys will generally take a case on a contingency fee based on a percentage of your retroactive benefits (you only pay a fee if you win). The fee is usually 25% of the retroactive benefit, up to a maximum that is set by Federal law ($4000 at the time of this writing). Although you can represent yourself at the hearing, your chances of being approved are significantly increased if you have the assistance of an attorney. For information about legal representation, contact the National Organization of Social Security Claimants' Representatives. If you wish to request a hearing, you must file a "Request for Hearing" form. Your request must be received by the SSA office within 60 days of the reconsideration denial (see note*). Once you have filed for a hearing, your file will be sent to the Office of Hearings and Appeals (OHA), and assigned to an Administrative Law Judge (ALJ). You should be notified at least 20 days before your hearing date. Because of the backlog of cases, a hearing date may not be set for many months. You and your representative(s) may examine your case file prior to the hearing. At the hearing itself, you may offer additional evidence, provide witnesses, and present oral or written statements. The process is somewhat like a trial in court, but is much less formal. Normally a decision will be made within 90 days of the receipt of all of the evidence, but in some cases, the decision may take longer. If you receive an unfavorable decision at this point, you have the right to a further appeal to the Appeals Council. At this point, the likelihood of having your claim approved in further appeals is dramatically reduced, and the process will probably drag on for a very long time. Nonetheless, if you feel that you have a good case, you may wish to continue with the appeal process. Note: it is possible that the Appeals Council will decide on it's own to review an ALJ decision, but in practice this rarely happens. Appeals Council You have 60 days from the date of the notice of denial by the OHA in which to file a review before the Appeals Council (see note*). To request a review, you must fill out and submit the "Request for Review of Hearing Decision" form. The Appeals Council will then review the hearing record, and make a decision to uphold, reverse, or modify the ALJ's decision. They may also choose to send the case back to the ALJ for a new hearing. It is unusual for the Appeals Council to reverse an Administrative Law Judge's decision and order payment for the claim, as they are usually mostly concerned with legal and procedural errors. If you receive an unfavorable decision from the Appeals Council, you can then appeal to Federal district court. Again, your appeal must be filed within 60 days of the notice (see note*). Further appeals can be made in Federal court, according to normal procedures. *Note: The deadline for requesting appeals is 60 days from the date of the denial notice received at the previous level. Because an additional 5 days is provided for mailing time, your reconsideration request must be received by SSA within 65 days of the date on the denial notice. Under certain circumstances, SSA may accept an appeal after the deadline if they determine that there was "good cause" for missing the filing deadline. It is recommended that your request be delivered by hand to the SSA District Office, getting a receipt to prove that you filed on time.
Once you have been approved for disability benefits, you should be sure to read the following SSA booklets:
These publications describe your benefits and how they may be reduced or terminated, what changes need to be reported to SSA, outline policies regarding work incentives and SSA case reviews, and provide other miscellaneous information. It is important to continue to see your doctor regularly, and to keep copies of all records of medical care or tests. Ask your doctor on at least an annual basis whether or not you are capable of working on a sustained basis. If you are on SSI, keep bank account statements and paycheck stubs if you are working. This is documentation that you may need for future reviews. If You Work Both SSI and SSDI are paid on the assumption that your disability prevents you from being gainfully employed. If you work and receive payments that are over a certain limit per month, or if you are on SSI and have other income or resources that exceed the SSA limits, your benefits may be reduced, suspended, or terminated. Disability Reviews SSA will review all disability cases from time to time, to insure that people who are receiving benefits still meet the disability, financial, and other requirements. If your impairment has ceased, or is no longer disabling, your benefits will be terminated. Your review will usually be one of two kinds. You should consult with your doctor before replying to a review. The first kind is a Mailer Review. You will receive a Disability Update Report in the mail, which you are asked to fill out and return. This type of review is usually done for people who are unlikely to have a change to their disability status. The other kind is a Full Medical Review. You will receive a letter from SSA, and will be contacted by someone in the Social Security office. You will need to provide information about your medical visits in the past 12 months, including copies of records, and may be asked to have a government-paid exam if your tests and records are not current. Often the SSA gives you very short notice. If you need it, ask for an extension of time in order to get the appropriate records or to have a medical examination. Have your doctor examine you and determine your current medical status. You should have your doctor write a report for the SSA if they ask for a full medical review. If your benefits are terminated (only a small percentage are), you should appeal the decision if you and your doctor believe that you are still disabled. Approximately half of the people who appeal termination are reinstated. The appeals process follows the same steps as the process for the initial claim. However, you have two additional rights of appeal if SSA determines that you are no longer disabled: 1. A disability hearing that is part of the reconsideration process. You may meet the person who is reconsidering your case in person, and explain why you feel you are still disabled. This hearing is separate from your right to have a hearing before an Administrative Law Judge. 2. Continuation of Benefits. If you apply for continuation of benefits within 10 days of your termination notice, your benefits will continue until a decision is made by an ALJ. If you are denied, you may have to repay the benefits received. If you do not apply for continuation of benefits, your benefits will be terminated until your claim is re-approved. Overpayments If you receive an amount for any period of time that exceeds the amount you should have been paid, it will be considered an "overpayment". If SSA determines that you have received an overpayment, it will send you a "Notice of Overpayment". Unless you file an appeal, future payments will be reduced to recover the overpayment amount. You have two methods of appeal: If you feel that the overpayment is inaccurate, you may file an appeal by filing a "Request for Reconsideration" form. It is important to file immediately. If your request for reconsideration is made within 10 days from the date of the notice, your benefits will be unchanged until a decision is made. If you file after 10 days, your benefit will be reduced for overpayment, pending the final decision. Your request must be made within 60 days. You will have the choice of a formal hearing, informal hearing, or case review. An informal hearing is often the best choice, as it will give you the opportunity to discuss the problem. If you agree that there was an overpayment, but believe that you have good reason to be excused from repaying it, you may request a "Waver of Overpayment". This request can be filed at any time, but if it is requested within 10 days of the date on the notice of overpayment, your benefits will not be reduced to cover the overpayment until a decision has been made. SSA will waive the overpayment if is determined that there you were not at fault in the overpayment, if recovery would deprive you of income needed for ordinary and necessary living expenses, or if recovery would be against equity and good conscience.
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