Elder Law Medicaid Assistance

Social Security and Social Security Disability Insurance Medical Qualifications

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) both require medical determination. Still, there are some differences in the eligibility requirements and how each program evaluates medical evidence. To be eligible for these benefits, individuals must have a medical condition that meets the definition of disability according to the Social Security Administration (SSA).

Supplemental Security Income

Individuals must have a disability that prevents them from engaging in any substantial gainful activity and must meet certain financial eligibility criteria. Typically, the medical evidence that determines disability focuses on the individual’s overall functional limitations, including activities of daily living, social abilities, and concentration.

Social Security Disability Insurance

Individuals must have a disability that is expected to last at least 12 months or result in death, and they must have worked and paid Social Security taxes for a certain length of time and in recent years. The medical evidence used to determine disability typically focuses on the individual’s ability to perform work-related activities.

Determination Process

Medical evidence from treating physicians and other healthcare providers is the primary source of information used to make medical determinations. The Disability Determination Services (DDS), a state agency that works with the SSA, is responsible for reviewing medical evidence and determining an individual’s eligibility for disability benefits.

The Five-Step Process

The SSA uses a five-step sequential evaluation process to determine if an individual has a disability. This process considers many factors, such as:

  1. Substantial Gainful Activity (SGA) – The SSA first determines if the applicant is currently working and earning more than a certain amount of money each month, known as SGA. If the applicant’s income is near the SGA level, the SSA will generally not consider them disabled.
  2. Severity of Impairment – If the applicant is not engaging in SGA, the SSA then evaluates the severity of the medical condition to determine if it significantly limits their ability to perform basic work-related activities. The SSA will deny the claim if the condition is not severe enough.
  3. Listing of Impairments – The SSA maintains a list of medical conditions and impairments that are so severe they automatically qualify an applicant for disability benefits. If the applicant’s medical condition is on the list, the SSA will generally approve their claim.
  4. Ability to Perform Past Work – If the applicant’s condition is not on the list, the SSA will assess their ability to perform any of the jobs they have held in the past. The SSA will deny the claim if the applicant can perform any of their past work.
  5. Ability to Perform Other Work – If the applicant can’t perform their past work, the SSA will assess their ability to perform other work that exists in significant numbers in the national economy, considering the applicant’s age, education, work experience, and functional limitations. The SSA will generally approve their claim if the applicant can’t perform other work.

Disability Determination Services and the Social Security Administration

The DDS is a state agency that works closely with the SSA to determine claim validity. The SSA refers disability claims to DDS, which then evaluates the medical and vocational evidence to determine whether the claimant meets the criteria for disability benefits. Once the DDS makes a decision, it sends the case back to the SSA, which notifies the claimant of the decision and, if approved, begins to process the payment of benefits. If the claimant receives a denial, the claimant has the right to appeal the decision within a certain timeframe.

Why is the SSA’s Definition of Disability so Strict?

SSI and SSDI programs are designed to provide long-term protection to those who are fully disabled, using the Social Security Administration’s criteria. These individuals can’t do any meaningful work in the national economy. Disabilities that prevent workforce participation are the most difficult type of disability to protect. Most individuals, families, and employers can’t afford to protect against this risk through other means.

In contrast, short-term disability can provide for individuals through other means, such as:

  • Family
  • Insurance
  • Worker’s Compensation
  • Savings
  • Investments

SSI and SSDI disability programs can benefit those with the most serious impairments. That is why the determinations are very strict.

How a Disability Attorney Can Help

A disability attorney can be an invaluable resource when seeking SSI and SSDI benefits. Here are some ways a disability attorney can help with the determination process:

  • Evaluation of Your Case – An experienced disability attorney can evaluate your case and determine if you meet the criteria for disability under the SSA’s guidelines. They can help you determine which disability program (or both) is the best for you.
  • Gathering and Organizing Medical Evidence – To qualify for disability benefits, you must provide medical evidence showing the severity of your condition and how it limits your ability to work. A disability attorney can help you gather and organize the medical evidence required to support your claim.
  • Filing the Application – A disability attorney can assist with completing and submitting the application for disability benefits to the SSA. They will include all necessary information and submit the application on time.
  • Representing Your Case at Hearings – If your initial claim for benefits receives a denial, you have the right to appeal the decision and have a hearing in front of an Administrative Law Judge (ALJ). A disability attorney can represent you at the hearing and advocate on your behalf.
  • Legal Advice and Support – A disability attorney can provide legal advice and support throughout the disability determination process. They can answer your questions, address your concerns, and help you navigate the system’s complexities.

Overall a disability attorney can help increase your chances of receiving approval for disability benefits by ensuring your application is complete and accurate and providing legal representation and advocacy at every stage of the process. They understand the intricacies of medical determinations and how to present your claim best to receive approval.

Please contact our Spokane office today or schedule a consultation to discuss your legal matters. We would be happy to help you and welcome your call.

No Legal Advice Intended. This blog includes general information about legal issues and developments in the law. Such materials are for informational purposes only and may not reflect the most current legal developments. These informational materials are not intended, and must not be taken, as legal advice on any particular set of facts or circumstances. You need to contact a lawyer licensed in your jurisdiction for advice on specific legal issues or problems.