Archive for the ‘Health And Safety’ Category
What Types of Social Security Benefits are Available?
Greeman & Toomey asked:
Types of Social Security Disability Benefits
The Social Security Administration has established a number of different types of disability programs. Although the medical rules are similar under each program, the technical rules on eligibility set each program apart. What program you may be eligible for depends on a number of factors, including your work history, age, household income and marital status. You may be eligible for more than one type of benefits, but generally SSA will pay you the higher benefit amount of any one program you may be entitled to.
Disability Insurance Benefits: This program, also known as “DIB” or Title II benefits, awards benefits to individuals who, because of a physical or mental impairment, are unable to work at a “substantial” gainful level, and their condition has existed or is expected to exist for at least a 12 month period. By “substantial,” SSA means the claimant would be unable to earn over $900.00 per month because of their disability. This dollar amount increases slightly every year. To be eligible for DIB, a claimant must have worked long enough and paid enough into Social Security through their FICA taxes to be “insured.” As a general rule, if a claimant worked at least five of the last 10 years, he would be “insured” for purposes of DIB. How much a claimant receives each month if found disabled and entitled to DIB is based on how much he “paid into” the system during his working life. Generally, the longer someone has worked and the higher his earnings, the more he would be paid if found disabled. Individuals found disabled and entitled to DIB benefits may be awarded retroactive benefits. Retroactive benefits can only go back one year from the date of the initial application. There is a five-month waiting period from the date the claimant is determined to be disabled until entitlement to DIB benefits begin. To illustrate this, if a claimant files a claim for DIB on January 1, 2006 alleging disability as of February 2005, and SSA determines he is disabled and his disability began February 1, 2005, he would be eligible for retroactive benefits starting in July 2005. In addition to receiving individual DIB benefits, your minor children may also qualify for auxiliary benefits based on your disability. These benefits are granted in addition to any benefit you receive. To ensure any minor children are awarded any benefits they may be entitled to, it is important you furnish the names and Social Security numbers of any minor children you have to SSA. The children do not have to live in the same household to be eligible for auxiliary benefits.
Supplemental Security Income: This program, also known as SSI or Title 16 benefits, is a “needs-based” program in which individuals with little or no resources or assets may receive disability benefits. The medical criteria for SSI eligibility is the same as that used for DIB — a physical or mental impairment which prevents you from working at a “substantial” gainful level, and the condition has existed or is expected to exist for at least a 12 month period. Effective January 2007 the SSI payment for an eligible individual is $623 per month and $934 per month for an eligible couple. There is no retroactive eligibility for SSI benefits: benefits can go back only to the month in which your claim was filed. Unlike DIB, there is no five-month waiting period for entitlement to SSI, so your eligibility would begin the month in which you filed your claim or were determined to be disabled, whichever is later. A claim for SSI benefits can also be filed on behalf of any minor children with a disability; however, as with Adult SSI claims, to be entitled to SSI benefits the household income must be below certain limits.
Disabled Adult Child: This program provides disability benefits to adult children of deceased or disabled parents. In addition to the medical requirement that you have a physical or mental impairment which prevents you from working at a “substantial” gainful level, and the condition has existed or is expected to exist for at least a 12 month period, you must also show that your condition has existed and has been disabling since before your 22nd birth date. In addition, you must be the adult child of a parent who is currently receiving DIB benefits, or the Adult child of a parent who is deceased and was “insured” for purposes of eligibility for DIB benefits. It is not necessary that the adult child ever worked because benefits are paid on the parent’s earnings record. The adult child must not have worked and earned “substantial earnings” for an extended period at any point after turning 22; however, certain expenses the adult child incurs in order to work may be excluded from these earnings. An adult child already receiving SSI benefits should check to see if benefits may be payable on a parent’s earnings record. Higher benefits might be payable and entitlement to Medicare may be possible.
Disabled Widow’s/Widower’s Benefits: If you are a disabled widow or widower age 50 or older you may be able to receive benefits off your spouse’s (or former spouse’s) Social Security record. If you are a widow or widower from a spouse you were divorced from, to be eligible for benefits you need to have been married to your spouse for 10 years or longer and your disability must have started before age 60 and within seven years of the date in which the worker died. If you were married to your spouse when they passed away, Social Security does not require that you were married for 10 years. In either case, you will need to provide proof of relationship in the form of your marriage certificate or divorce decree, along with your spouse’s death certificate when you file for benefits. If you file a claim for Disabled Widows/Widower’s benefits and DIB or SSI benefits, you will receive only the higher monthly benefit amount of the two programs.
Medical Insurance: Once you are found disabled and entitled to Social Security disability benefits, you will also be eligible for medical insurance though Medicare or Medicaid. If you filed a claim for DIB, Disabled Adult Child or Disabled Widow’s/Widower’s benefits, you may be eligible for Medicare. However, eligibility for Medicare does not start until you have been disabled for 25 months. If you are approved for Social Security benefits under any of the above-listed programs, SSA will contact you approximately two months before your eligibility for Medicare begins. If you have already been disabled for 25 months, be sure to keep a record of all medical bills as you may be reimbursed by Medicare for these expenses. There is no waiting period for Medicaid; however, your income and resources must be very low to qualify. If you have applied for and have been approved for SSI you probably qualify for Medicaid. You may think that Medicaid and Medicare are the same, but actually they are two different programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact Social Security or your local social services or welfare office.
This article has been written to give you a general overview of the Social Security disability programs and the disability process. As this article may not address all questions you might have, please contact us for further information.
Marc
Types of Social Security Disability Benefits
The Social Security Administration has established a number of different types of disability programs. Although the medical rules are similar under each program, the technical rules on eligibility set each program apart. What program you may be eligible for depends on a number of factors, including your work history, age, household income and marital status. You may be eligible for more than one type of benefits, but generally SSA will pay you the higher benefit amount of any one program you may be entitled to.
Disability Insurance Benefits: This program, also known as “DIB” or Title II benefits, awards benefits to individuals who, because of a physical or mental impairment, are unable to work at a “substantial” gainful level, and their condition has existed or is expected to exist for at least a 12 month period. By “substantial,” SSA means the claimant would be unable to earn over $900.00 per month because of their disability. This dollar amount increases slightly every year. To be eligible for DIB, a claimant must have worked long enough and paid enough into Social Security through their FICA taxes to be “insured.” As a general rule, if a claimant worked at least five of the last 10 years, he would be “insured” for purposes of DIB. How much a claimant receives each month if found disabled and entitled to DIB is based on how much he “paid into” the system during his working life. Generally, the longer someone has worked and the higher his earnings, the more he would be paid if found disabled. Individuals found disabled and entitled to DIB benefits may be awarded retroactive benefits. Retroactive benefits can only go back one year from the date of the initial application. There is a five-month waiting period from the date the claimant is determined to be disabled until entitlement to DIB benefits begin. To illustrate this, if a claimant files a claim for DIB on January 1, 2006 alleging disability as of February 2005, and SSA determines he is disabled and his disability began February 1, 2005, he would be eligible for retroactive benefits starting in July 2005. In addition to receiving individual DIB benefits, your minor children may also qualify for auxiliary benefits based on your disability. These benefits are granted in addition to any benefit you receive. To ensure any minor children are awarded any benefits they may be entitled to, it is important you furnish the names and Social Security numbers of any minor children you have to SSA. The children do not have to live in the same household to be eligible for auxiliary benefits.
Supplemental Security Income: This program, also known as SSI or Title 16 benefits, is a “needs-based” program in which individuals with little or no resources or assets may receive disability benefits. The medical criteria for SSI eligibility is the same as that used for DIB — a physical or mental impairment which prevents you from working at a “substantial” gainful level, and the condition has existed or is expected to exist for at least a 12 month period. Effective January 2007 the SSI payment for an eligible individual is $623 per month and $934 per month for an eligible couple. There is no retroactive eligibility for SSI benefits: benefits can go back only to the month in which your claim was filed. Unlike DIB, there is no five-month waiting period for entitlement to SSI, so your eligibility would begin the month in which you filed your claim or were determined to be disabled, whichever is later. A claim for SSI benefits can also be filed on behalf of any minor children with a disability; however, as with Adult SSI claims, to be entitled to SSI benefits the household income must be below certain limits.
Disabled Adult Child: This program provides disability benefits to adult children of deceased or disabled parents. In addition to the medical requirement that you have a physical or mental impairment which prevents you from working at a “substantial” gainful level, and the condition has existed or is expected to exist for at least a 12 month period, you must also show that your condition has existed and has been disabling since before your 22nd birth date. In addition, you must be the adult child of a parent who is currently receiving DIB benefits, or the Adult child of a parent who is deceased and was “insured” for purposes of eligibility for DIB benefits. It is not necessary that the adult child ever worked because benefits are paid on the parent’s earnings record. The adult child must not have worked and earned “substantial earnings” for an extended period at any point after turning 22; however, certain expenses the adult child incurs in order to work may be excluded from these earnings. An adult child already receiving SSI benefits should check to see if benefits may be payable on a parent’s earnings record. Higher benefits might be payable and entitlement to Medicare may be possible.
Disabled Widow’s/Widower’s Benefits: If you are a disabled widow or widower age 50 or older you may be able to receive benefits off your spouse’s (or former spouse’s) Social Security record. If you are a widow or widower from a spouse you were divorced from, to be eligible for benefits you need to have been married to your spouse for 10 years or longer and your disability must have started before age 60 and within seven years of the date in which the worker died. If you were married to your spouse when they passed away, Social Security does not require that you were married for 10 years. In either case, you will need to provide proof of relationship in the form of your marriage certificate or divorce decree, along with your spouse’s death certificate when you file for benefits. If you file a claim for Disabled Widows/Widower’s benefits and DIB or SSI benefits, you will receive only the higher monthly benefit amount of the two programs.
Medical Insurance: Once you are found disabled and entitled to Social Security disability benefits, you will also be eligible for medical insurance though Medicare or Medicaid. If you filed a claim for DIB, Disabled Adult Child or Disabled Widow’s/Widower’s benefits, you may be eligible for Medicare. However, eligibility for Medicare does not start until you have been disabled for 25 months. If you are approved for Social Security benefits under any of the above-listed programs, SSA will contact you approximately two months before your eligibility for Medicare begins. If you have already been disabled for 25 months, be sure to keep a record of all medical bills as you may be reimbursed by Medicare for these expenses. There is no waiting period for Medicaid; however, your income and resources must be very low to qualify. If you have applied for and have been approved for SSI you probably qualify for Medicaid. You may think that Medicaid and Medicare are the same, but actually they are two different programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact Social Security or your local social services or welfare office.
This article has been written to give you a general overview of the Social Security disability programs and the disability process. As this article may not address all questions you might have, please contact us for further information.
Marc
How are Medical Experts Used in Social Security Disabilty (ssdi) Cases?
Greeman & Toomey asked:
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act) and the supplemental security income (SSI) program (title XVI of the Act).
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.
The Act and SSA’s implementing regulations prescribe rules for deciding if an individual is “disabled.” SSA’s criteria for deciding if someone is disabled are not necessarily the same as the criteria applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
What is a “Medically Determinable Impairment”A medically determinable physical or mental impairment is an 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.
The Disability Determination Process
Social Security Field Offices
Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called disability determination services or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA’s Office of Hearings and Appeals (OHA).
SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, or by mail. The application and related forms ask for a description of the claimant’s impairment(s), names, addresses, and telephone numbers of treatment sources, and other information that relates to the alleged disability. (The “claimant” is the person who is requesting disability benefits.)
The field office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. The field office sends the case to a DDS for evaluation of disability.
Disability Determination Services
The DDSs, which are fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law.
Usually, the DDS tries to obtain evidence from the claimant’s own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a CE in order to obtain the additional information needed. The claimant’s treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part III for more information about CEs.)
After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant (who is a physician or psychologist) and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source (s) and ask for supplemental information.
The DDS also makes a determination whether the claimant is a candidate for vocational rehabilitation (VR). If so, the DDS makes a referral to the State VR agency.
After the DDS makes the disability determination, it returns the case to the field office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, the appeal is usually handled much the same as the initial claim, except that the disability determination is made by a different adjudicative team in the DDS than the one that handled the original case.
Office of Hearings and Appeals
Claimants dissatisfied with the first appeal of a determination may file subsequent appeals. A hearing office within the Office of Hearings and Appeals (OHA) processes the second appeal. An administrative law judge makes the second appeal decision, usually after conducting a hearing and receiving any additional evidence from the claimant’s medical sources or other sources.
Medical development by OHA is frequently conducted through the DDS. However, hearing offices may also contact medical sources directly. In rare circumstances, an administrative law judge may issue a subpoena requiring production of evidence or testimony at a hearing.
The Role of the Health Professional
Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways:
As treating sources or other medical sources who provide medical evidence on behalf of their patients;
As CE sources to perform, for a fee, examinations and/or tests that are needed;
As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA’s regional offices, or in SSA central office; or
As medical experts who testify at administrative law judge hearings.
Treating Sources
A treating source is a claimant’s own physician, psychologist, or other acceptable medical source that has provided the claimant with medical treatment or evaluation and has or has had an ongoing treatment relationship with the claimant. The treating source is usually the best source of medical evidence about the nature and severity of an individual’s impairment (s).
If an additional examination or testing is needed, SSA usually considers a treating source to be the preferred source for performing the examination or test for his or her own patient.
The treating source is neither asked nor expected to make a decision whether the claimant is disabled. However, a treating source will usually be asked to provide a statement about the claimant’s ability, despite his or her impairments, to do work-related physical or mental activities.
Program Medical Professionals
Physicians of virtually all specialties and psychologists at the State, regional or national levels review claims for disability benefits. The review work is performed in the State DDSs or SSA’s regional office or headquarters. It is strictly a paper review in which the program physician or psychologist usually has no contact with the claimant.
Medical Experts
Because there is no direct involvement of medical professionals in the disability decisions made by administrative law judges in the Office of Hearings and Appeals, administrative law judges sometimes request expert testimony on complex medical issues. Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings. The experts are paid a fee for their services.
Confidentiality of Records
Two separate laws, the Freedom of Information Act and the Privacy Act, have special significance for Federal agencies. Under the Freedom of Information Act, Federal agencies are required to provide the public with access to their files and records. This means the public has the right, with certain exceptions, to examine records pertaining to the functions, procedures, final opinions, and policy of these Federal agencies.
The Privacy Act permits an individual or his or her authorized representative to examine records pertaining to him or her in a Federal agency. For disability applicants, this means that an individual may request to see the medical or other evidence used to evaluate his or her application for disability benefits under the Social Security or the SSI programs. (This evidence, however, is not available to the general public.)
SSA screens all requests to see medical evidence in a claim file to determine if release of the evidence directly to the individual might have an adverse effect on that individual. If so, the report will be released only to an authorized representative designated by the individual.
Lance
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act) and the supplemental security income (SSI) program (title XVI of the Act).
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.
The Act and SSA’s implementing regulations prescribe rules for deciding if an individual is “disabled.” SSA’s criteria for deciding if someone is disabled are not necessarily the same as the criteria applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
What is a “Medically Determinable Impairment”A medically determinable physical or mental impairment is an 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.
The Disability Determination Process
Social Security Field Offices
Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called disability determination services or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA’s Office of Hearings and Appeals (OHA).
SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, or by mail. The application and related forms ask for a description of the claimant’s impairment(s), names, addresses, and telephone numbers of treatment sources, and other information that relates to the alleged disability. (The “claimant” is the person who is requesting disability benefits.)
The field office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. The field office sends the case to a DDS for evaluation of disability.
Disability Determination Services
The DDSs, which are fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law.
Usually, the DDS tries to obtain evidence from the claimant’s own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a CE in order to obtain the additional information needed. The claimant’s treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part III for more information about CEs.)
After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant (who is a physician or psychologist) and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source (s) and ask for supplemental information.
The DDS also makes a determination whether the claimant is a candidate for vocational rehabilitation (VR). If so, the DDS makes a referral to the State VR agency.
After the DDS makes the disability determination, it returns the case to the field office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, the appeal is usually handled much the same as the initial claim, except that the disability determination is made by a different adjudicative team in the DDS than the one that handled the original case.
Office of Hearings and Appeals
Claimants dissatisfied with the first appeal of a determination may file subsequent appeals. A hearing office within the Office of Hearings and Appeals (OHA) processes the second appeal. An administrative law judge makes the second appeal decision, usually after conducting a hearing and receiving any additional evidence from the claimant’s medical sources or other sources.
Medical development by OHA is frequently conducted through the DDS. However, hearing offices may also contact medical sources directly. In rare circumstances, an administrative law judge may issue a subpoena requiring production of evidence or testimony at a hearing.
The Role of the Health Professional
Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways:
As treating sources or other medical sources who provide medical evidence on behalf of their patients;
As CE sources to perform, for a fee, examinations and/or tests that are needed;
As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA’s regional offices, or in SSA central office; or
As medical experts who testify at administrative law judge hearings.
Treating Sources
A treating source is a claimant’s own physician, psychologist, or other acceptable medical source that has provided the claimant with medical treatment or evaluation and has or has had an ongoing treatment relationship with the claimant. The treating source is usually the best source of medical evidence about the nature and severity of an individual’s impairment (s).
If an additional examination or testing is needed, SSA usually considers a treating source to be the preferred source for performing the examination or test for his or her own patient.
The treating source is neither asked nor expected to make a decision whether the claimant is disabled. However, a treating source will usually be asked to provide a statement about the claimant’s ability, despite his or her impairments, to do work-related physical or mental activities.
Program Medical Professionals
Physicians of virtually all specialties and psychologists at the State, regional or national levels review claims for disability benefits. The review work is performed in the State DDSs or SSA’s regional office or headquarters. It is strictly a paper review in which the program physician or psychologist usually has no contact with the claimant.
Medical Experts
Because there is no direct involvement of medical professionals in the disability decisions made by administrative law judges in the Office of Hearings and Appeals, administrative law judges sometimes request expert testimony on complex medical issues. Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings. The experts are paid a fee for their services.
Confidentiality of Records
Two separate laws, the Freedom of Information Act and the Privacy Act, have special significance for Federal agencies. Under the Freedom of Information Act, Federal agencies are required to provide the public with access to their files and records. This means the public has the right, with certain exceptions, to examine records pertaining to the functions, procedures, final opinions, and policy of these Federal agencies.
The Privacy Act permits an individual or his or her authorized representative to examine records pertaining to him or her in a Federal agency. For disability applicants, this means that an individual may request to see the medical or other evidence used to evaluate his or her application for disability benefits under the Social Security or the SSI programs. (This evidence, however, is not available to the general public.)
SSA screens all requests to see medical evidence in a claim file to determine if release of the evidence directly to the individual might have an adverse effect on that individual. If so, the report will be released only to an authorized representative designated by the individual.
Lance
