understanding your disability

Understanding Your Disability

As Defined by the Social Security Act

Nothing in this brochure is legal advice. By reading this brochure, you understand that there is no attorney-client relationship created between you and Caring Voice Coalition, Inc. or any of its advocates.

As Defined by the Social Security Act

Understanding Your Disability

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Table of Contents

About Caring Voice Coalition 5How We Help 5How Much Does CVC Charge? 6Commonly Used Acronyms 6How Does the SSA Define Disability? 6 The Five-Step Disability Determination ProcessWhat is Substantial Gainful Activity (SGA)? 8Social Security Disability vs. 8 Supplemental Security IncomeDisability Benefits and Medical Coverage 9Children and Disability Benefits 13The Appeals Process 15Tips for Applying for Disability 16Wellness Journal 18

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About Caring Voice CoalitionCaring Voice Coalition, Inc. is a national 501(c)(3) non-profit, charitable organization, established in 2003 to serve the comprehensive needs of individuals with serious, chronic disorders.

How We Help

Many persons impacted by a chronic illness reach a point when they can no longer work. In response, Caring Voice developed a Disability Program to help individuals understand the complicated issues involved with proving entitlement to disability benefits. By providing accurate information about Social Security programs and benefits for which you and your family may be eligible, CVC assists in determining whether applying for benefits is right for you.

CVC aims to obtain a favorable decision at the earliest possible stage because we understand the financial and medical needs associated with chronic illnesses. To do so, CVC collects your medical records and analyzes the technical issues in order to present a well-supported claim before the Social Security Administration.

A CVC advocate1 familiar with the Social Security Act will serve as your representative and assist you through every stage of your claim. CVC evaluates each case to determine the applicable ruling or guideline under which an individual should be found disabled. Your advocate then sets out to collect the necessary evidence to present a strong, well-supported claim.

In the event that your claim must be appealed to an Administrative Law Judge, a CVC advocate will prepare your case and represent you at the hearing. Caring Voice Coalition can assist with appeals through the initial hearing level.

1 Caring Voice Coalition’s advocates are not your attorneys and will not become your attorney at any point during your affiliation with CVC.

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How Much Does CVC Charge?

CVC provides disability assistance free of charge.

Commonly Used Acronyms

Administrative Law Judge (ALJ)Caring Voice Coalition (CVC)Continuing Disability Review (CDR)Date Last Insured (DLI)Disability Determination Services (DDS)Disabled Adult Child benefits (DAC)Social Security Administration (SSA)Social Security Disability Insurance (SSDI)Substantial Gainful Activity (SGA)Supplemental Security Income (SSI)

How Does the SSA Define Disability?

The Five-Step Disability Determination Process

To decide if you are disabled, Social Security uses a step-by-step process involving five questions:

1. Are you working? If you are working and your earnings average more than a certain limit, you cannot be considered disabled. See ssa.gov for the applicable SGA limit. If you are not earning above the applicable earnings limit, SSA goes to Step 2.

2. Is your condition “severe”? Your condition must interfere with basic work-related activities for your claim to be considered. If it does not, SSA will find that you are not disabled. If your condition does interfere with basic work-related activities, SSA goes to Step 3.

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3. Is your condition found in the list of disabling conditions? For each of the major body systems, SSA maintains a list of medical conditions that are so severe that they automatically mean you are disabled. If your condition is not on the list, SSA must decide if it is of equal severity to a medical condition that is on the list. If it is, SSA will find that you are disabled. If it is not, SSA goes to Step 4.

4. Can you do the work you did previously? If your condition is severe, but not at the same or equal level of severity as a medical condition on the list, then SSA must determine if it interferes with your ability to do the work you did previously. If it does not, your claim will be denied. If it does, SSA proceeds to Step 5.

5. Can you do any other type of work? If you cannot do the work you did in the past, SSA determines if you are able to adjust to other work. SSA considers medical conditions, age, education, past work experience and any transferable skills you may have. If you cannot adjust to other work, your claim will be approved. If you can adjust to other work, your claim will be denied.

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What is Substantial Gainful Activity (SGA)?

SSA generally uses earnings guidelines to evaluate whether work activity is SGA. Earnings averaging more than a certain limit demonstrate SGA. See ssa.gov for the applicable SGA limit.

The Difference Between Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)

Social Security Disability (SSDI)

SSDI is a federal disability insurance program designed for individuals who have worked enough to earn sufficient “work credits.” Under this program, monthly payments are based on the individual’s earning record. SSDI provides monthly cash benefits and Medicare entitlement to those who are disabled. If you do not have enough work credits to qualify for SSDI, then you may be eligible for SSI. Those who receive SSDI approval will begin receiving monthly cash benefits after five full months of waiting.

Work Credits

How Much Work Do You Need?In addition to meeting Social Security’s definition of disability, you must have worked long enough and recently enough under Social Security to qualify for disability benefits. Social Security work credits are based on your total yearly wages or self-employment income. You can earn up to four credits each year. The amount needed for a credit varies from year to year. In 2014, you earn one credit for each $1,200 of wages or self-employment income. For example, if Tom earns $6,000 in the year 2014, he will earn all four credits for 2014.

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The number of work credits you need to qualify for disability benefits depends on the age at which you became disabled. Generally, you need 40 credits, 20 of which were earned in the last 10 years ending with the year you became disabled. However, younger workers may qualify with fewer credits. I M P O R TA N T: Your insured status affects whether you are eligible for benefits. If you wish to pursue a claim for benefits, you should do so while your Social Security coverage is in effect.

Supplemental Security Income (SSI)

SSI is a combined state and federal financial assistance program that provides monthly payments to individuals who either never worked or have insufficient credits on their earnings record to qualify for SSDI. An individual with little or no income receives the federal benefit amount, which generally changes yearly. See ssa.gov for the current federal benefit rate.Both SSI and SSDI programs are administered by the Social Security Administration, and the disability criteria are the same for both. Each individual who applies for SSI is also screened for SSDI benefits. SSI payments may be available during the usual five-month waiting period before SSDI case benefits begin. Benefits become payable the month after the application is filed, regardless of when the disability began.

Disability Benefits and Medical Coverage

Two years after entitlement to SSDI benefits, an individual becomes eligible for Medicare. Once eligible, an SSDI recipient is automatically enrolled in Medicare, unless he or she affirmatively opts out. In addition, all Medicare beneficiaries may enroll in a prescription drug plan (Part D Plan) which can help pay part of their medication costs, for an additional premium. It is important for an individual to sign up for medical or drug coverage when he or she first becomes eligible for Medicare. If you wait too long to sign up, you may be subject

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to higher premiums and have to wait for the next open enrollment period to sign up. People with limited income and resources may qualify for “Extra Help” with medical and drug costs. To see whether you qualify for Extra Help, visit www.socialsecurity.gov/extrahelp or call 1-800-772-1213.Most people who qualify for SSI will also become entitled to Medicaid in the state in which they live.

How will returning to work affect my benefits?

The SSA has created special rules that make it possible for people receiving SSDI or SSI to work and still receive monthly payments until they can work on a regular basis. Additionally, if an individual cannot continue working because of his or her medical condition, the person may resume receiving his or her benefits.

Work incentives include:

• Continued cash benefits for a time while you work

• Continued Medicare or Medicaid while you work• Help with education, training and rehabilitation to start

a new line of work

While the rules are different under Social Security and SSI, it is important to let the SSA know promptly when an individual starts or stops working.

Understanding Supplemental Security Income

While there is no work history requirement to be eligible for SSI, you must:

• Be at least 65 years of age, blind or disabled• Meet citizenship requirements• Meet the financial requirements for SSI

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What are the financial requirements for SSI?

SSI recipients are typically required to have:

1. Financial resources that do not exceed $2,000 for one person and $3,000 for a couple; and

2. Income below a certain limit

What resources are counted for SSI eligibility?

• Cash and bank accounts• Land and buildings (other than the home

in which you reside)• Personal property such as jewelry and household goods• Life insurance• Stocks, bonds, or other investments• Vehicles (other than the one used for transportation for

yourself or someone in your household)

What assets are exempt?

SSA excludes the following when considering the value of your resources:

• Home in which you live• Equipment required due to your physical condition

• Household goods and property worth less than $2,000• One wedding ring and one engagement ring• Burial space for you and your family• Burial funds for you and your spouse, each valued at

$1,500 or less• Life insurance policies with a combined face value of

$1,500 or less. However, you and your spouse may each have life insurance policies totaling no more than $1,500

• Retroactive SSI or SSDI checks for up to nine months after you receive them

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• One vehicle, if it is used for transportation purposes for yourself or someone in your household

• Property set up in a trust according to certain states’ laws, as long as the SSI beneficiary has no direct access to trust funds

What income is counted for SSI eligibility?

If your income is over the allowable limit, you cannot collect SSI. This limit is adjusted annually according to the cost of living. If your income is below the limit, your SSI benefit will be reduced according to the amount of income. SSI counts several kinds of income:

• Earned income: money received for wages or earnings from self-employment

• Unearned income: money received from other sources, such as SSDI benefits, unemployment insurance, workers’ compensation, interest income, and cash from friends or relatives

• In-kind income: free food, clothing, or shelter

Deemed income: If you live with a spouse, parent or sponsor, then SSA will consider part of this person’s income to compute your potential SSI benefit amount.

How will returning to work affect my SSI benefits?

The amount of SSI payments is based on how much other income an individual has. When other income increases, SSI payments typically decrease. When an individual earns more than the SSI limit, the payments will stop. However, payments will automatically start again for any month income drops to less than the SSI limits.

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Children and Disability BenefitsChildren’s Benefits

Children under age 18, whether disabled or not, may be eligible to draw benefits on a parent’s Social Security earnings record if the parent is receiving disability or retirement benefits from Social Security or the parent is deceased and has met insured status requirements.

Disabled Adult Children’s Benefits

A disabled child of an insured parent who is receiving disability or retirement benefits, or has died, may be eligible for a Disabled Adult Child (DAC) benefit. If the child is age 18 or older, unmarried (although marriage to another DAC beneficiary is allowable), and the disability began prior to age 22, he or she may be eligible for DAC. This benefit may continue for the child’s lifetime, as long as the child remains disabled, unmarried, does not engage in substantial gainful activity resulting in benefit cessation, and does not become entitled to a higher benefit amount on

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another Social Security program. DAC benefits will result in Medicare eligibility after being entitled to cash benefits for 24 months.

SSI Disabled Child’s Benefits

A child younger than age 18 can qualify for SSI benefits if he or she meets Social Security’s definition of disability for children, and his or her income and resources fall within the eligibility limits. The income and resource guidelines are adjusted according to the number of parents and other children living in the household.

However, once a child turns 18, only his or her income and resources are included for SSI eligibility purposes, even if he or she continues living at home. It is important to note that any person who is found eligible for SSI benefits under the rules for children will automatically be subject to a review upon attaining age 18 to determine if he or she remains disabled under the adult rules.

Criteria

Social Security evaluates a child’s condition under a special set of rules for determining disability in children.If a child’s condition is not listed and is not medically as serious as a listed condition, a child will be considered disabled if he or she has severe limitations in his or her activities. Social Security will look at all your child’s activities, such as playing and attending school, and compare your child’s functioning with other children the same age who do not have disabilities. Important factors in this decision can include the side effects of medications and treatments required by the child’s condition and how much help the child needs to function in daily activities compared to other children.

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The Appeals Process

Level One - ReconsiderationThe Reconsideration process occurs when an appeal is made on the initial denial. The Disability Determination Services for each state reviews the previously considered information, along with any new information that becomes available. You must file the Request for Reconsideration within 60 days of receipt of the denial.

I M P O R TA N T: Some states do not have a Reconsideration stage; rather, the appeal goes directly to the hearing level. Visit https://secure.ssa.gov/poms.nsf/lnx/0412015100 to see whether your state skips the reconsideration stage. The states that skip the reconsideration stage are the first 10 listed under C. Test States.

Level Two - HearingIf you disagree with the Reconsideration decision, you may ask for a hearing. An Administrative Law Judge will conduct an informal hearing, in which you will have a chance to personally present your claim. The ALJ takes a fresh look at all of the evidence and issues an independent decision based on the merits of the claim.

I M P O R TA N T: CVC assistance generally ends at this stage.

Level Three - Appeals CouncilAppeals Council Review most often occurs when the claimant appeals an unfavorable decision by the ALJ. The Appeals Council may take no action on the claim, affirm the ALJ’s decision, reverse the ALJ’s decision or remand the case back to the ALJ with specific instruction on how to proceed.

Level Four - Federal CourtIf you disagree with the Appeals Council’s decision, or if the Appeals Council decides not to review your claim, you may file a lawsuit in a federal court. You may request an appeal all the way up to the United States Supreme Court, which the Supreme Court has discretion to hear.

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Continuing Disability Review

Depending on the severity of your condition, the SSA will periodically review whether your disability has improved. If the SSA determines you are no longer disabled, it will stop your benefits.

Social Security also reviews your income, resources, and living arrangement to ensure that non-medical requirements are met. This periodic review is called a redetermination.

Tips for Applying for Disability

Proof from Doctors

Medical EvidenceAccording to SSA, if your medical condition is severe enough to keep you from working, then it would be evidenced in doctor visits, tests, diagnosis and treatment. The records should support your symptoms.

Keep Good RecordsWithout records, you are unlikely to remember the date of every doctor visit, lab test, medicine taken and therapy received. Obtain the business cards of every doctor you see, save your medication lists and keep notes of your good days and bad days and other medical events. We recommend maintaining a diary that will allow you to keep track of this information. In order to assist you in this effort, we have developed a Wellness Journal for your use.

Evidence from You

Symptoms vs. DiagnosisSSA does not expect you to be an expert on medical conditions; SSA would rather learn about your impairment from your doctor and medical records. What SSA wants to receive from you are details about your symptoms. For example, how severe is your fatigue, shortness of breath, cognitive impairment, etc.?

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Is it constant or intermittent? What aggravates your symptoms? What reduces them? No one knows your symptoms better than you. Do your best to explain them in great detail without exaggerating or minimizing.

Do not omit or gloss over any lesser conditions just because you have one severe condition and several minor ones. Again, maintaining a Wellness Journal will help you keep track of these important details and may be very compelling in the SSA’s decision.

Physical RestrictionsWhat can’t you do? Sit for lengthy periods? Stand and walk? Lift and carry? Bend, twist, kneel and stoop? Manipulate objects with your hands? SSA will focus on your limitations rather than your diagnosis. Be specific in your descriptions. For example, “I am unable to sit for more than thirty minutes at a time.”

Effect of Symptoms and RestrictionsHow does your medical condition affect your daily activities? Tell SSA about the impact on your personal care (hygiene, dressing, bathing), errands and housework (driving, shopping, cleaning), and social functioning (hobbies, sports, interaction with friends and family).

Final Point

Consistency, Accuracy and Honesty Contradictions, errors, memory lapses and discrepancies all work to erode your credibility, and nothing will sink your claim faster than questions about your truthfulness.

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Wellness JournalWhich medications are you currently taking?

MEDICATION DURATION (Weeks) RESULT

Please visit caringvoice.org for more blank, printable Wellness Journal pages.

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Wellness JournalWhich medications are you currently taking?

MEDICATION DURATION (Weeks) RESULT


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Contact Caring Voice Coalition8249 Meadowbridge RoadMechanicsville, VA 23116Phone: (804) 427-6468Toll-free: (888) [email protected]

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