General Information

Program Description

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 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

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.

Social Security Field Offices

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 nonmedical 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.

State 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 consultative examination (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 II, Evidentiary Requirements, 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. The second appeal is processed by a Hearing Office within SSA's Office of Hearings and Appeals. 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 the Office of Hearings and Appeals 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 who 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.

Consultative Examiners for the DDS

In the absence of sufficient medical evidence from a claimant's own medical sources, SSA, through the State DDS, may request an additional examination(s). These CEs are performed by physicians (including osteopaths), psychologists or, in certain circumstances, other health professionals. All CE sources must be currently licensed in the State and have the training and experience to perform the type of examination or test SSA requests.

Fees for CEs are set by each State and may vary from State to State. Each State agency is responsible for comprehensive oversight management of its CE program.

Medical professionals who perform CEs must have a good understanding of SSA's disability programs and their evidentiary requirements. In addition, these medical professionals are made fully aware of their responsibilities and obligations regarding confidentiality and:

• CE scheduling intervals;
• CE report content;
• Elements of a complete CE;
• When a complete CE is not required; and
• Signature requirements.

Go to Part II - Evidentiary Requirements, for more information about CEs.

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.

Questions and Answers About Social Security Disability Programs

This information is designed to provide a more thorough understanding of the disability programs administered by SSA. Following are some of the most frequent questions asked about these programs.

Q. Who can get disability benefits under Social Security?

A. Under the Social Security disability insurance program (title II of the Act), there are three basic categories of individuals who can qualify for benefits on the basis of disability:

• A disabled insured worker under 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.
• A disabled widow or widower, age 50-60 if the deceased spouse was insured under Social Security.

Under title XVI, or SSI, there are two basic categories under which a financially needy person can get payments on the basis of disability:

• An adult age 18 or over who is disabled.
• A child (under age 18) who is disabled.

Q. How is the disability determination made?

A. SSA’s regulations provide for disability evaluation under a procedure known as the "sequential evaluation process." For adults, this process requires sequential review of the claimant's current work activity, the severity of his or her impairment(s), the claimant's residual functional capacity, his or her past work, and his or her age, education, and work experience. For children applying for SSI, the process requires sequential review of the child's current work activity (if any), the severity of his or her impairment(s), and an assessment of whether his or her impairment(s) results in marked and severe functional limitations. If an adult or child is found disabled or not disabled at any point in the evaluation, the evaluation does not continue.

Q. When do disability benefits start?

A. 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.

In addition, under the SSI disability program, an applicant may be found "presumptively disabled," and receive cash payments for up to 6 months while the formal disability determination is made. The presumptive payment is designed to allow a needy individual to meet his or her basic living expenses during the time it takes to process the application. If it is finally determined that the individual is not disabled, he or she is not required to refund the payments. There is no provision for a finding of presumptive disability under the title II program.

Q. What can an individual do if he or she disagrees with the determination?

A. If an individual disagrees with the initial determination in the case, he or she may appeal it.

The first administrative appeal is a reconsideration, which is generally a case review at the State level by an adjudicative team that was not involved in the original determination.

If dissatisfied with the reconsideration determination, the individual may request a hearing before an administrative law judge.

If he or she is dissatisfied with the hearing decision, the final administrative appeal is for review by the Appeals Council.

In general, a claimant has 60 days to appeal an unfavorable determination or decision. Appeals must be filed in writing and may be submitted by mail or in person to any Social Security office.

If the individual exhausts all administrative appeals, but wishes to continue pursuing the case, he or she may file a civil suit in Federal District Court and eventually appeal all the way to the United States Supreme Court.

Q. Can individuals receiving disability benefits or payments get Medicare or Medicaid coverage?

A. 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, 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.

Q. Can someone work and still receive disability benefits?

A. Social Security rules make it possible for people to test their ability to work without losing their rights 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.

For more information about work incentives, ask any Social Security office for the publication:

"A Summary Guide to Social Security and Supplemental Security Income Work Incentives for People with Disabilities"

Q. How can the individual receive vocational training services?

A. Applicants for disability payments may be referred to a State VR agency for rehabilitation services. The referral may be made by the DDS, Social Security, the treating source, or by personal request. The services may be medical or nonmedical and may include counseling, teaching of new employment skills, training in the use of prostheses, and job placement. In determining whether VR services would be beneficial in returning a person to employment, the medical evidence from the treating source may be very important.

Medical Evidence

Under both the title II and title XVI programs, medical evidence is the cornerstone for the determination of disability.

Each person who files a disability claim is responsible for providing medical evidence showing that he or she has an impairment(s) and how severe the impairment(s) is. However, SSA will help claimants get medical reports from their own medical sources when the claimants give SSA permission to do so. This medical evidence generally comes from sources who have treated or evaluated the claimant for his or her impairment(s).

Acceptable Medical Sources

Documentation of the existence of a claimant's impairment must come from medical professionals defined by SSA regulations as "acceptable medical sources." Once the existence of an impairment is established, all the medical and nonmedical evidence is considered in assessing impairment severity.

"Acceptable medical sources" generally include licensed physicians (including licensed osteopaths), licensed or certified psychologists, and licensed optometrists (for measurement of visual acuity and visual fields). Social Security also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.

Medical Evidence from Treating Sources

Currently, many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant's impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.

Other Evidence

Information from other sources may also help show the extent to which a person's impairment(s) affects his or her ability to function. Other sources include public and private social welfare agencies, non-medical sources such as teachers, day care providers, social workers and employers, and other practitioners such as naturopaths, chiropractors, audiologists, and speech and language pathologists.

Medical Reports

Physicians, psychologists, and other health professionals are frequently asked by SSA to submit reports about an individual's impairment. Therefore, it is important to know what evidence SSA needs. Medical reports should include:

• medical history;
• clinical findings (such as the results of physical or mental status examinations);
• laboratory findings (such as blood pressure, x-rays);
• diagnosis;
• treatment prescribed with response and prognosis;
• a statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source's findings on the above factors. This statement should describe, but is not limited to, the individual's ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling. In cases involving mental impairments, it should describe the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe his or her functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if a child is a newborn or young infant from birth to age 1, responsiveness to stimuli).

Consultative Examinations

If the evidence provided by the claimant's own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by recontacting the treating source for additional information or clarification, or by arranging for a CE. The treating source is the preferred source for a CE if he or she is qualified, equipped, and willing to perform the examination for the authorized fee. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

• the treating source prefers not to perform the examination;
• the treating source does not have the equipment to provide the specific data needed;
• there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source;
• the claimant prefers another source and has good reason for doing so; or
• prior experience indicates that the treating source may not be a productive source.

Consultative Examination Report Content

A complete CE is one which involves all the elements of a standard examination in the applicable medical specialty. A complete consultative examination t report should include the following elements:

• the claimant's major or chief complaint(s);
• a detailed description, within the area of specialty of the examination, of the history of the major complaint(s);
• a description, and disposition, of pertinent "positive" and "negative" detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing;
• results of laboratory and other tests (e.g., X-rays) performed according to the requirements stated in the Listing of Impairments;
• the diagnosis and prognosis for the claimant's impairment(s);
• a statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should describe the opinion of the consulting physician or psychologist about the claimant's ability, despite his or her impairment(s), to do work-related activities such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling; and, in cases of mental impairment(s), the opinion of the physician or psychologist about the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe the child's functional limitations in learning, motor functioning, performing self care activities, communicating, socializing, and completing tasks (and, if the child is a newborn or young infant from birth to age 1, responsiveness to stimuli); and
• the consultative physician or psychologist will consider, and provide some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation of laboratory test results, and the conclusions will represent the information provided by the physician or psychologist who signs the report.

Evidence Relating to Symptoms

In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding:

• the claimant's daily activities;
• the location, duration, frequency, and intensity of the pain or other symptom;
• precipitating and aggravating factors;
• the type, dosage, effectiveness, and side effects of any medication;
• treatments, other than medications, for the relief of pain or other symptoms;
• any measures the claimant uses or has used to relieve pain or other symptoms; and
• other factors concerning the claimant's functional limitations due to pain or other symptoms.

In assessing the claimant's pain or other symptoms, the decisionmaker(s) must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.

Listing of Impairments

The Listing of Impairments describes, for each major body system, impairments that are considered severe enough to prevent a person from doing any gainful activity. Most of the listed impairments are permanent or expected to result in death, or a specific statement of duration is made. For all others, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. The criteria in the Listing of Impairments are applicable to evaluation of claims for disability benefits or payments under both the Social Security disability insurance and SSI programs.

Part A of the Listing of Impairments contains medical criteria that apply to adults age 18 and over. The medical criteria in part A may also be applied in evaluating impairments in persons under age 18 if the disease processes have a similar effect on adults and younger persons.

The criteria in the Listing of Impairments apply only to one step of the multi-step sequential evaluation process. At that step, the presence of an impairment that meets the criteria in the Listing of Impairments (or that is of equal severity) is usually sufficient to establish that an individual who is not working is disabled. However, the absence of a listing-level impairment does not mean the individual is not disabled. Rather, it merely requires the adjudicator to move on to the next step of the process and apply other rules in order to resolve the issue of disability.