QUESTIONS AND ANSWERS MOST FREQUENTLY ASKED QUESTIONS ABOUT SOCIAL SECURITY DISIBILITY BENEFITS
MOST FREQUENTLY ASKED QUESTIONS ABOUT SOCIAL SECURITY DISABILITY BENEFITS 1) What is the definition of disability? The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be e3xpected to last for a continuous period of not less than 12 months. 2) What is a Medically Determinable Impairment? Impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings not only by the individual s statement of symptoms. 3) What determines who may be eligible for disability benefits? Under the Social Security Administration s (SSA) disability insurance program (title II of the Act), there are three basic categories of individuals who may be able to qualify for benefits on the basis of disability: a disabled insured worker under the age of 65; a person disabled since childhood (before age 22) who is a dependent of a deceased insured parent or a parent entitled to title II disability or retirement benefits; and a disabled widow or widower age 50-60 if the deceased spouse was insured under Social Security. Under title XVI, or Supplemental Security Income (SSI), there are two basic categories under which a financially needy person can get payments on the basis of disability: 2
an adult age 18 or over who is disabled and a child (under age 18) who is disabled. 4) What is the difference between title II and title XVI? Title II provides for payment of disability benefits to individuals who are insured under the Act by virtue of their contributions to the Social Security Trust Fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides for SSI payments to individuals (including children under age 18) who are disabled and have limited income and resources. 5) How is the disability determination made and eligibility determined? A sequential review is made of the claimant s current work activity, severity of the impairment(s), age, impact of impairment on work related abilities, past and current work experience, age and education. A disability claims adjudicator obtains any existing medical evidence. If that evidence is unavailable or if further examination or testing is needed to make a determination, the Disability Determination Service (DDS) will, at its expense, arrange for a consultative examination. The claimant s treating source is usually the preferred source for performing the examination on his /her own patient. 6) When do disability benefits start? The law provides that, under the Social Security disability program, disability benefits for workers and widows usually cannot begin for 5 months after the established onset of the disability. The 5 month waiting period does not apply to individuals filing as children of workers. Under SSI, disability payments may begin as early as the date the individual files an application. 7) What is the definition of an onset date? An onset date is the date which the DDS determines that a claimant was eligible for disability benefits. 3
8) Can someone work and still receive disability benefits? Social Security rules make it possible for people to test their ability to work without losing their right to cash benefits and Medicare or Medicaid. These rules are called work incentives. The rules are different for title II and title XVI, but under both programs they may provide: continued cash benefits; continued help with medical bills; help with work expenses; or vocational training. 9) Is eligibility for benefits retroactive to the onset date? Yes; however, title II payments may only be made 12 months prior to the application date. For title XVI, payments may begin as early as the application date. 10) Who determines whether or not a claimant meets or equals a listing? The DDS agency has a staff of trained people, including disability examiners and doctors, who decide if Social Security s criteria for eligibility is met. 11) How does the filing process work? The following steps must be taken in order to file a claim: a claim may be filed by mail, telephone, or in person at any Federal Social Security District Office; the Federal Social Security Office initially screens claimants to determine whether they meet basic work and age requirements; the vast majority of claimants pass the initial screening and their applications are referred to DDS. 12) What if a claimant is denied benefits? If denied benefits, a claimant can proceed with the following steps: 4
the claimant may ask to be reconsidered. This is called the recon or reconsideration step. This process is similar to the initial filing except that a different adjudicator and a different doctor make the determination; if a claimant is denied a second time, he/she may appeal to a Federal Social Security Administrative Law Judge; if the Administrative Law Judge denies the case, the claimant may appeal to the Social Security Appeals Council; if the claimant exhausts all administrative appeals but wishes to continue pursuing the case, he/she may file a civil suit in Federal District Court and eventually appeal all the way to the United States Supreme Court. 13) How long does the entire process take? On an average, the entire process is broken down into the following categories: the interview with the Federal Social Security District Office and mailings take between 5 to 10 days; once the State DDS agency receives the claim, it takes an average of 67 days to process the case. (This is among the lowest processing times in the nation.); the reconsideration process takes an average of 52 days; the Administrative Law Judge process takes a average of 265 days to process; the Appeals Council process could take in excess of 1 year to complete. 14) What if the claimant s case is reversed during any of the appeal stages and he/she is determined to be disabled is the claimant only eligible to receive disability payments from the time of reversal? In most cases, the claimant will receive payment for all the time it has taken to reach a favorable decision. However, payment is based on the onset date and the filing date. The onset date is the date that the claimant is first found to be severe enough to meet SSA s criteria. For title XVI claimants, payments can begin as early as the application date. Title II claimants usually must serve a waiting period of 5 full months after the onset is established and can be paid retroactively up to 12 months from the application date. 15) How is payment received? 5
Checks are mailed from a federal payment center on a monthly basis. Once a claimant s case is approved he/she will receive a lump sum check for any retroactive eligibility, and monthly disability payments will follow. The State Disability Determination agency is not involved in the issuance or mailing of Social Security disability payments. Payments are made by the federal Social Security Administration. 16) How long can an individual stay on disability? While there is no specified time-frame for how long a claimant can remain on disability, individuals who have been on disability for several years are subject to what is called a continuing disability review (CDR). Most individuals remain on disability until their physical or mental impairment has had sufficient improvement to allow them to re-enter the work force. 17) How does an individual cease to be eligible for disability? A claimant ceases to be eligible for disability when one or more of the following criteria apply: the claimant reaches the age of 65 or retires at age 62 with regular social security benefits; the claimant s physical or mental condition improves to a level that allows them to begin working again; the claimant dies; or if it is determined that the claimant committed fraud or similar fault. 18) Does the Arkansas Disability Determination agency have a fraud unit? Yes; an aggressive fraud department is fully staffed and uses state-of-the-art surveillance techniques and trained investigators to detect fraud or similar fault. 19) What are the consequences if it is determined that a claimant committed fraud or similar fault? If it is determined that a claimant has committed fraud or similar fault, the following action(s) may be taken: disability benefits may be stopped; 6
the claimant may be referred to the Prosecuting Attorney, the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI) and/or the United States Attorneys Office; or if found guilty, the claimant may be expected to repay benefits deemed fraudulent and may be incarcerated. 20) What is fraud? The term fraud describes the actions of a person who has the intent to fraudulently secure payment either in a greater amount than is due or when no payment is authorized. These actions constitute a felony. Title 18, U.S.C. provides for a fine or imprisonment for not more than five years, or both, upon conviction thereof. 21) What is similar fault? Sections 205 and 1631 of the Social Security Act (the Act) define similar fault as follows: an incorrect or incomplete statement that is material to the determination is knowingly made; or information that is material to the determination is knowingly concealed. 22) If a claimant has received disability payments for several years, are they subject to re-evaluation? Yes; the Federal Social Security Administration sends cases to the DDS to be reviewed by an adjudicator who is experienced at reviewing continuing disability reviews. If the adjudicator determines that the claimant is still disabled, the claimant remains on disability. If it is determined that the claimant is no longer disabled, the claimant is notified and is given the opportunity of a face-to-face hearing with the DDS hearing unit. 23) Can a claimant hire a lawyer? Absolutely; some claimants decide to hire personal lawyers when they first apply. Many claimants hire a lawyer when their claim is denied during the first two stages and they decide to appeal to a Federal Administrative Law Judge. Still there are many claimants who never hire a lawyer. There are no statistics to show whether hiring a lawyer significantly increases the likelihood of a claimant s case being allowed. 7
24) How many Social Security disability claims are processed each year in the State of Arkansas? Nearly 55,000 claims are processed each year in Arkansas in a timely manner (one of the fastest in the nation) with one of the highest accuracy rates in the nation at 97%. 25) Does Arkansas get its fair share of benefits for its population compared to other states? Arkansas has the 4 th highest percentage of its population on Social Security disability. Nearly two-hundred thousand claimants in the State of Arkansas currently are awarded social security disability benefits. The federal government spends $77,000,000 each month in disability benefits within the State of Arkansas. 26) Can individuals receiving disability benefits or payments get Medicare or Medicaid coverage? Yes; Medicare helps pay hospital and doctor bills of disabled or retired people who have worked long enough under Social Security to be insured for social security benefits. It generally covers people who are 65 and over; people who have been determined to be disabled and have been receiving benefits for at least 24 months; and people who need long-term dialysis treatment for chronic kidney disease or require a kidney transplant. In general, Medicare pays 80 percent of reasonable charges. In most states and in Arkansas, individuals who qualify for SSI disability payments also qualify for Medicaid. (The name varies in some states the term Medicaid is not used everywhere.) The program covers all of the approved charges of the medicaid patient. Medicaid is financed by federal and state matching funds, but eligibility rules may vary from state to state. 27) Where does the money come from to pay for these benefits? Supplemental Security Income (SSI) is the first federally administered cash assistance program in this country available to the general public. It is designed to provide a floor of income for the aged, blind or disabled who have little or no income and 8
resources. The program establishes that payment may be received as a right by those U.S. Citizens or legally admitted aliens residing in this country who qualify as aged, blind, or disabled and who meet income and resource criteria. No work credits are necessary for entitlement under this program. SSI is not the same as Social Security, even though the program is run by the SSA. The money for SSI checks comes from general funds of the United States Treasury Social Security benefits are paid from contributions of workers, employers, and selfemployed people. Social Security funds are not used for SSI checks. People who get Social Security checks may get SSI checks too, if they are eligible for both; however, a person does not have to be eligible for Social Security to get SSI. People getting federal SSI checks or state supplemental checks may also be eligible for social services provided by a state. These services help people meet problems in daily living or special problems related to age or a handicapping condition. Every SSI case is reviewed once a year to make sure that people getting checks are still eligible and that they are being paid the correct amount. These reviews are required by law. Sometimes a person getting SSI checks loses the mental or physical ability to manage the money. When this happens, the person who takes care of the recipient notifies the SSA. Arrangements are made to issue the checks to a relative or other person who can act for the recipient. The relative or other person is call a representative payee. 9