Transcript Social Security Disability Benefits

Disability:
Social Security and SSI
AIDS Clinic
January 30, 2004
Social Security Disability Benefits

Monthly cash benefit to disabled persons or their
dependents

Not a needs-based program: eligibility is based on
payment of sufficient Social Security taxes

Must have worked long enough and recently enough
(5 out of last 10 years)

Payment amount dependent on wage history
Supplemental Security Income

Monthly benefits to aged, blind or disabled
persons

Eligibility based on financial need, considers
income and assets

Payment amount supplements any other
income up to a maximum

Year 2004 maximum payment: $564 per
month ($846 for eligible couple)
Associated Medical Programs

SSDI: Medicare




Available after two years of SSDI eligibility (29
months after “onset date”)
Part A – Hospitalization
Part B – Outpatient, tests, etc. ($66 annual
premium and $100 annual deductible)
Prescription drug coverage will be weak
Associated Medical Programs

SSI: Medicaid



Income based program – health care for
the poor
Automatically available to SSI recipients
Pays doctors, prescriptions, but low
reimbursement rate to providers
Administrative Process

Initial application

Reconsideration

Administrative Hearing

Appeals Council Review

Judicial Review (U.S. District Court)
DI and SSI DISABILITY
Determinations and Appeals
Fiscal Year 2000
Initial Level
1,988,425
Reconsiderations
584,540
ALJ Dispositions
433,584
Appeals Council
122,780
Federal Court
Decisions
12,011
Allow
38%
Allow
16%
Allow
59%
Allow
2%
Allow
6%
Deny
62%
Deny
84%
Dismiss
12%
Deny
29%
Dismiss
2%
Remand
22%
Deny
74%
Remand
48%
Deny
39%
Dismiss
6%
Definition of Disability

Severe mental or physical impairment

Medically verifiable by lab tests, physical examination
or other objective medical procedures

has lasted, or is expected to last, at least twelve
consecutive months or result in death
renders claimant unable to engage in substantial
gainful activity (“SGA”)

Five-Step
Sequential Evaluation
1.
Is the claimant doing Substantial Gainful Activity (SGA)?
2.
Does the claimant have a “severe” impairment?
3.
Does the impairment meet or equal a listed impairment?
4.
Can the claimant do past relevant work?
5.
Can the claimant do any work existing in significant numbers?
Yes
Gainfully
Employed?
No
No
Severe
Impairment?
Yes
Yes
Meets or equals
listing?
No
Yes
Able to do past
relevant work?
No
Yes
Able to perform any work
existing in significant numbers?
No
Not disabled
Disabled according to
vocational factors
Disabled under
listings
Two important limitations

Substance Abuse:


Claimant may not received benefits if substance abuse
“contributes materially” to the finding of disability (20 CFR
404.1535)
Compliance with treatment:



No benefits if claimant fails to follow prescribed treatment
that would restore ability to work. (20 CFR 404.1530)
Acceptable excuses: treatment contrary to religion, very
risky; considers physical, mental, educational, and linguistic
limitations
For HIV infected, common problem is medication adherence.
Sequential Evaluation
Step 1: Work

Is the claimant engaged in substantial gainful
activity?


“Substantial” means work activity that involves
significant physical or mental activities
For 2004, “gainful” means resulting in income of
$810/month (gross income minus impairment
related work expenses)
Sequential Evaluation
Step 2: Severity

Does the claimant have a severe
impairment?

A severe impairment significantly limits physical or
mental ability to do work activities, such as






physical functions-walking, lifting, carrying
seeing,hearing, speaking
understanding and carrying out instructions
use of judgment
responding appropriately to supervision
dealing with changes in work setting
Sequential Evaluation
Step 3: Listings

Does the impairment, or combination of
impairments, meet or equal a “listed
impairment”?




Organized by body systems
Impairments presumed to prevent the ability to
engage in SGA
Each listing includes a diagnosis as well as certain
findings which must be included in medical
records
many listings include durational requirements and
severity levels
Step 3: HIV Listing



Part of “Immune System Listing -- 14.00 series
Specifically begins at 14.08, but includes introductory material –
which is very important
Requires a positive HIV test PLUS an “AIDS-defining” condition


Common examples: mycobacterial infection, candidiasis,
cytomegalovirus disease, Kaposi’s sarcoma, HIV wasting syndrome,
severe diarrhea, pneumocystis carinii pneumonia
At 14.08N, allows for disability finding with combination of less
severe symptoms resulting in



marked restrictions of activities of daily living,
marked difficulties in maintaining social functioning, or
marked difficulties in completing tasks in a timely manner due to
deficiencies in concentration, persistence or pace
Step 3: Other Important Listings

12.00 -- Mental Disorders

12.04 -- Affective Disorders


Includes depression, a very common problem with persons with
HIV
12.05 – Mental Retardation

significantly subaverage general intellectual functioning with deficits
in adaptive functioning initially manifested before age 22



IQ of 59 or less;
IQ between 60 and 70, combined with another physical or mental
impairment that imposes work-related limitations;
or IQ between 60 and 70 and restriction in activities of daily living’
social functioning; concentration, persistence or pace; or repeated
episodes of decompensation
Sequential Evaluation, Step 3:
Equivalence &Multiple Impairments

Medical equivalence (20 CFR §404.1526)





medical findings equivalent in severity and duration to
the listed condition
useful when the claimant’s condition doesn’t match any
listed condition
must be confirmed by a doctor, preferably a treating
physician
must be based on medical evidence
Combination of Impairments can also be
considered for medical equivalence
(20 CFR
§404.1523)
Sequential Evaluation
Step 4 – Past Work

Can the claimant perform past relevant work?

This step evaluates functional ability



“residual functional capacity” -- what a person can do
despite his/her limitations
takes into account all limitations, physical and
mental, including those not considered “severe”
Any work done in the last 15 years is considered
“relevant”
Sequential Evaluation
Step 5 – Other Work

If a claimant cannot perform past relevant work,
can he/she do other work?
 This step assesses physical/mental residual
functional capacity, PLUS age, education
and work experience, transferability of skills
 burden of proof shifts to the SSA
Sequential Evaluation
Step 5 - determination

Two ways to answer this question:

1. Vocational expert:


expert testifies at hearing about specific jobs claimant could
do
jobs proposed must exist in “significant numbers” in the
region in which the claimant lives
Disability Haiku
“Disability”
You have been denied
Malingerer, whiner, bum...
Egg-candle, mister
Hannah Demeritt
Sequential Evaluation
Step 5 - “Grids”

Medical-Vocational Guidelines (the “grids”)




Guidelines are made up of four charts, one for each
exertional limitation (e.g. claimant limited to sedentary,
light, medium or heavy work)
Claimant is plotted based on age, education and skill
level
Result of disabled/not disabled is dictated by the chart
Grids are inappropriate if the claimant has nonexertional impairments (e.g., fatigue, diarrhea,
mental impairments, pain)
Example Grids:
“residual functional
capacity” limited to
sedentary work