Social Security Disability: How SSDI and SSI Claims Are Decided
The five steps in the disability determination for SSDI or SSI benefit claims.
When you apply for Social Security disability benefits, the Social Security Administration (SSA) wants to know whether your medical disorder is severe enough for you to qualify for benefits. To determine this, the SSA will send your file to the Disability Determination Service (DDS) agency in your state for a medical review. Either a claims examiner and/or a medical consultant (M.D. or D.O.) will determine your medical eligibility, depending on your state. DDS is concerned only with determining your medical eligibility for disability benefits (not your legal or financial eligibility).
Any time your claim for disability is evaluated -- whether at DDS or when you appeal a DDS decision -- Social Security procedures require that specific issues be addressed, in a specific order. This is done to make sure that everyone gets the same consideration. If at any point in the SSA's five-step analysis, the evaluating agency or court determines that your impairments justify a grant of disability benefits, the evaluation ends. This article explains what happens at every step in the disability determination process.
Step 1. Are You Engaged in Substantial Gainful Activity?
First Social Security checks to see if you're currently working or if you've worked since you applied for benefits. If you are working and making a certain amount of money ($1,130 per month or more in 2016), you are probably doing what's called "substantial gainful activity" (SGA, or work). If you earn more than the allowed level for SGA, you won't qualify for Social Security disability benefits, even if you have an impairment that meets the requirements for disability. If you have no earnings or your earnings fall under the SGA limit, the analysis proceeds to Step 2.
Step 2. How Severe Are Your Impairments?
The second step involves a determination of the severity of your impairments. If the DDS medical consultant or claims examiner who is assigned your case finds that your impairments do not (or should not) significantly limit the work you could do, your impairment will be considered not severe (or non-severe, mild, or slight). Your claim will be denied if none of your impairments (individually or combined) are considered severe. Medical conditions cover the range of severity from "not severe" to "incapacitating."
The effect of your impairments on your ability to function mentally or physically is what matters, not just the presence of the impairments. For example, if you have severe hypertension (high blood pressure) that might limit the amount of physical work you can safely do, but is controlled with drugs so that your blood pressure is normal, your impairment would be considered "not severe." Similarly, a seriously nearsighted person whose vision can be made clear with glasses does not have a severe impairment.
On the other hand, if you have retinal disease that blurs your vision and your condition can't be corrected with glasses, your impairment would be more than "not severe." This same is true for painful arthritis in your spine that cannot be improved surgically.
If your impairments are determined to be significant -- that is, they are more than "not severe" -- the analysis proceeds to Step 3 for further analysis of the level of severity.
Step 3. Do You Meet the Listing of Impairments?
At the third step of the review, the DDS medical consultant or claims examiner will compare your disability to an official list -- called the Listing of Impairments -- to see if your impairments are severe enough to meet or equal the SSA requirements in the listings. The listings come from federal regulations (they can be found at 20 C.F.R. Part 404). The listings differ for adults and for children.
Each impairment listing specifies a degree of medical severity that's required for you to be found disabled. If your condition meets or exceeds the required severity, DDS will presume that you can't do any type of substantial work.
The listings cover most common, severe impairments. If any of your impairments exactly match the criteria of a listing, you will be considered disabled and granted disability benefits regardless of your age, education, or work experience.
If none of your impairments match an impairment listing, the reviewer must determine if you have an impairment that is equivalent to a similar impairment in terms of medical severity (this is called "equaling a listing"). Allowing benefits based on the "equal" standard recognizes that it is impossible for the SSA to include all impairments in the listings. If the SSA says your impairments are equally as severe as those in the listings, you will be granted disability benefits.
For your impairments to be considered equal to a listing, the reviewer must find one of the following to be true.
- Your impairment is not listed, but it is of the same medical severity as a listed impairment.
- You don't meet the criteria of a listing, but your medical findings have the same meaning as the listing criteria. For example, you might have a laboratory test that, while not specifically mentioned in the listing, shows the same results as a test that is included in the listing.
- You have a combination of impairments where none alone is severe enough to meet a listing, but together they are equal to the severity of a listed impairment. For example, you have heart disease and lung disease, which together cause much greater medical severity than either would alone.
- For a child applying for SSI, the impairment is considered a "functional equal" of the listings. The "functional equal" standard gives benefits to children whose impairments cause the same amount of functional loss as any of the listings. Relatively few children have impairments that qualify as functional equals.
If your impairments or combination of impairments do not meet or equal any listing -- or combination of listings -- the analysis proceeds to Step 4.
Step 4. Can You Do Your Prior Job?
If your impairments do not meet or equal any listing, the DDS medical consultant or claims examiner will consider whether, despite your not meeting a listing, the impairments are severe enough to prevent you from doing the kind of work (if any) you've done in the past. If your impairments are not severe enough to prevent you from doing work you've done in the past, your claim will be denied with the rationale that you can return to your prior line of work. The DDS medical consultant or claims examiner makes this assessment by evaluating your "residual functional capacity" -- that is, how much ability you still have despite your medical condition.
If DDS finds you cannot perform your prior work, the analysis proceeds to Step 5.
Step 5. Can You Do Any Other Job?
If the DDS medical consultant or claims examiner agrees that your impairments prevent you from doing your prior work, the agency will consider whether or not there are other jobs in country that you can do despite your limitations. If DDS believes there is other less physically or mentally demanding work you can do, your claim will be denied on the basis that there are jobs that you can perform. But be clear about this: Social Security does not have to find you a particular job, or a job with pay equal to what you used to make, or a job of equal skill, or a job near where you live, in order to deny your claim. It just needs to determine that there is work out there in sufficient numbers that you could be doing.
There is an exception to this rule that applies mainly to those over 50 or 55. If you are are of a certain age, Social Security regulations may not expect you to be able to adjust to other work -- as long as you don't have recent job education or training, or skills you learned from past work, that you could easily put to use at other jobs. If you fit into one of these "grid rules," DDS may not deny you benefits in Step 5.
For More Information
If you are denied benefits, see Nolo's articles Social Security Disability: Eight Reasons You Could Be Denied Benefits and Social Security Disability: Deciding Whether to Appeal a Denied Claim.
For more information about Social Security disability in general -- including tips on applying for benefits and understanding medical listings -- see Nolo's Guide to Social Security Disability: Getting & Keeping Your Benefits, by David A. Morton III, M.D. (Nolo).