Introduction

The Social Security Administration (SSA) decides who is eligible for disability payments under rules established in the Social Security Act by the U.S. Congress. In this chapter we describe the two main SSA programs that administer disability payments. We briefly explain the requirements that any claimant must meet to receive benefits. We also provide a number of tips on how to deal with the SSA bureaucracy, and include answers to some of the most frequently asked questions about Social Security Disability.

Two Different Programs

Once you qualify as disabled under the Social Security Act, the SSA makes disability payments under one of two programs:

• Social Security Disability Insurance (SSDI), for workers who have paid into the Social Security trust fund (and their dependents), or
• Supplemental Security Income (SSI), for disabled individuals with limited incomes and assets (and their dependents).

SSDI claims are also referred to as Title 2 claims because they are authorized under Title 2 of the Social Security Act. SSI claims may be referred to as Title 16 claims because they are authorized under Title 16 of the Social Security Act. A person claiming a disability is called a claimant. Some claimants apply under both Title 2 and Title 16; these are known as concurrent claims.

When the SSA receives your application, it will determine whether you are eligible for disability benefits under SSDI or SSI , even if you have not specifically requested both. This means that if you apply only for SSDI benefits, the SSA will automatically process your claim for any SSI disability benefits to which you might be entitled. If your SSDI claim is turned down, you don’t have to file another claim for possible SSI benefits.

1. Social Security Disability Insurance

SSDI provides payments to workers who have made contributions to the Social Security trust fund through the Social Security tax on their earnings. SSDI is also available to certain dependents of workers. If you are found eligible for SSDI, you might be entitled to retroactive (past) benefits if you can show that you were disabled before the date of your application. (See Chapter 10 for more details on when benefits begin.)

a. Who Qualifies?

To qualify for SSDI, you must fall into one of the following categories:

i. You are a disabled insured worker under age 65

You must have worked both long enough and recently enough to qualify. It may not be sufficient that you worked for many years and paid Social Security taxes. When you worked is also important. The law requires that you earn a certain number of work credits in a specified time before you are eligible for benefits. You can earn up to four credits per year, each credit representing three months. The amount of earnings required for a credit increases each year as general wage levels rise.

The number of work credits needed for disability benefits depends on your age when you become disabled. Most people need at least 20 credits earned over ten years, ending with the year they become disabled. Younger workers may qualify with fewer credits.

In effect, you count backwards from the year that you became disabled to see whether you have the appropriate number of credits. That means that credits from many years before you became disabled are automatically wiped out, or expire. This can lead to a dangerous situation for people who haven’t worked for many years before becoming disabled. Their credits may dip below the required amount, and they can lose eligibility for SS DI. The date on which they lose their eligibility is called the "date last insured," or DLI —often a subject of dispute in Social Security cases. If you think your DLI is too far in the past to qualify you for SSDI, talk to your local SS A Field Office to make sure—in certain rare circumstances, you may still qualify.

The rules are as follows:

• Before age 24. You’ll need at least six credits earned in the three-year period ending when your disability started.
• Age 24 to 31. Credit for having worked half the time between age 21 and the time you become disabled. For example, if you become disabled at age 27, you would need credit for three years of work (12 credits) during the six years between ages 21 and 27.
• Age 31 or older. In general, you will need the number of work credits shown in the chart below. Unless you are blind (see CD Part 2 for definitions of legal blindness), at least 20 of the credits must have been earned in the ten years immediately before you became disabled.

You can find out how many credits you have by contacting your local SSA office or, if you have access to the Internet, by filling out a form at www.ssa .gov/mystatement.

ii. You are the family member of an eligible worker

The SSA pays auxiliary benefits to people who qualify based on certain family members’ entitlement to retirement or disability benefits. Benefits are paid based on the earnings records of the insured worker who paid enough Social Security taxes. If you qualify for auxiliary benefits, you do not necessarily have to be disabled; nor do you need the work credits described above.

Spouse’s and divorced spouse’s benefits. To qualify for auxiliary benefits as a spouse or divorced spouse, one of the following must apply (42 U.S.C. § 402(b), (c), (e), (f); 20 CFR §§ 404.330–349):

• You are the divorced spouse of a retired or disabled worker who is entitled to benefits, you are 62 years old or older, and you were married to the worker for at least ten years.
• You are the divorced spouse of a worker insured under SSDI who has not filed a claim for benefits, you are age 62 or older, your former spouse is aged 62 or older, you were married for at least ten years, and you have been divorced for at least two years.
• You are a disabled widow or widower, at least 50 years of age but less than 60 years old, and you are the surviving spouse of a worker who received Social Security disability or retirement benefits.
• You are the surviving spouse (including a surviving divorced spouse) of a deceased insured worker, and you are age 60 or older.
• You are the surviving spouse (including a surviving divorced spouse) of a deceased insured worker, and you care for a child of the deceased entitled to benefits who either is under age 16 or has been disabled since before age 22. (These benefits are known as "mother’s or father’s benefits.")

Child’s benefits. A dependent, unmarried child is entitled to child’s insurance benefits on the Social Security record of an insured parent, or deceased parent who was insured at death, if any of the following apply (42 U.S.C. § 402(d); 20 CFR §§ 404.350–369):

• The child is under age 18.
• The child is age 18 or 19 and a full-time student.
• The child is an adult and has been disabled since before age 22. (See Chapter 3 for a more detailed discussion of benefits for children.)

Parent’s benefits. You may qualify for parent’s benefits if all of the following are true (42 U.S.C. § 402(h); 20 CFR §§ 404.370–374):

• Your child was an insured worker who died.
• You are at least 62 years old.
• You are divorced, widowed, or unmarried and have not married since your child’s death.
• You were receiving at least one-half of your support from your child at the time of death.
• You can provide evidence of this support within two years of the death (you may be exempt from providing evidence if unusual circumstances, such as extended illness, mental or physical incapacity, or language barrier, show that you could not have reasonably known of the two-year rule).

Lump-sum death benefits. A lump-sum death payment of several hundred dollars may be paid to the surviving spouse of an insured worker if the survivor was living in the same household as the deceased at the time of death. You must apply for this benefit within two years of the insured worker’s death. (42 U.S.C. § 402(i); 20 CFR §§ 404.390–395.)

b. Citizenship or Residency Requirements

If you qualify based on the criteria listed above, you may receive SSDI payments if you are a U.S. citizen or permanent resident, living in the United States or abroad. If you are neither a citizen nor a permanent resident, you still may be entitled to receive SSDI if you can show that you are lawfully present in the United States and meet certain other criteria. (8 U.S.C. § 1611(b)(2).)

If you are a citizen when you apply for SSDI, you will have to show proof of your citizenship. Acceptable forms of proof include a birth certificate showing birth within the United States (including Washington, D.C.), Puerto Rico after January 14, 1941, Guam, Virgin Islands of the U.S. after 1917, American Samoa, Swain’s Island, and Northern Mariana Islands. Any of the following documents will also satisfy the proof of citizenship requirement:

• Forms N-550 and N-570 (Certificate of Naturalization issued by U.S. Citizenship and Immigration Services (US CIS) or its predecessor, the Immigration and Naturalization Service (INS))
• U.S. passport issued by the U.S. State Department
• Form I-197 (U.S. Citizen Identification Card issued by US CIS or the INS)
• Form FS-240 (Report of Birth Abroad of a Citizen of the U.S. issued by the U.S. State Department)
• Form FS-545 (Certification of Birth issued by a foreign service post)
• Forms N-560 and N-561 (Certificate of Citizenship issued by US CIS or the INS)
• Form DS-1350 (Certification of Report of Birth issued by the U.S. State Department)
• American Indian Card I-872 (DHS for Kickapoo Indian Tribe), or
• Northern Mariana Card I-873 (INS card for birth in the N. Mariana islands before 1986, obsolete but still valid).

If you are a permanent resident or resident alien, you will have to show that you are lawfully in the United States under one of the following conditions:

• lawful admission for permanent residence
• admission as a refugee or conditional entrance as a refugee
• asylum status or pending application for political asylum
• parole status
• deportation withheld or pending application for withholding of deportation
• member of a class of aliens permitted to remain in the United States for humanitarian or other public policy reasons, or
• you have been battered or subjected to cruelty by a family member while in the United States.

Most foreign workers in the United States are covered under the U.S. Social Security program and can potentially qualify for disability benefits. If, however, you are neither a citizen nor a permanent resident, you still may be covered under Social Security Disability. Federal law generally requires that all workers should pay Social Security taxes, and therefore be covered under SSDI for services performed in the United States. This is true even if they are nonresident aliens or employees who work here for short periods.

There are a few exceptions, however. Some non-immigrant foreign students and exchange visitors temporarily working in the United States may be exempt from paying Social Security taxes and therefore would not qualify for disability benefits under SSDI if they became disabled.

Noncitizen or permanent residents of the United States who are entitled to SSDI may be paid benefits while they reside abroad, depending upon their citizenship status and the countries in which they live. However, with some exceptions, an alien beneficiary who leaves the United States must either return to the U.S. at least every 30 days or for 30 consecutive days during each six-month period in order to continue to draw benefits. One exception is made for alien beneficiaries who are on active military duty for the United States. Another exception exists for alien beneficiaries who live in and are citizens of Germany, Greece, Ireland, Israel, Italy, or Japan. (The United States has treaty obligations with these nations to continue paying benefits regardless of how long beneficiaries are outside the United States.) Citizens of the Netherlands may receive partial benefits. (See Chapter 13 for more information about receiving benefits outside of the United States.)

Be aware of restricted countries. There are a few countries where residents cannot receive benefits even if they otherwise qualify. These include Cuba, North Korea, and Vietnam.

2. Supplemental Security Income (SSI)

The SSI program provides payments to an adult or child who is disabled and has limited income and resources. If your income and resources are too high, you will be turned down for benefits no matter how severe your medical disorders. You will be turned down even if you have not paid enough in Social Security taxes to qualify for SSDI.

The SSI limits on income and resources is one of the most complicated areas handled by the SSA. Although important points are covered here, only SSA representatives can accurately determine your income and resources for purposes of qualifying for SSI.

a. Income Limits

To qualify for SSI, your monthly income (as counted by the SSA) cannot exceed something called the federal benefit rate (FBR). The FBR for a married couple is approximately 33% more than for an individual. If only one member of a couple is eligible, both spouses’ income is still considered. If a child under age 18 is living with parents, then the parents’ income is considered. The FBR is set by law. It increases annually as dictated by cost-of-living adjustments. In 2008, a cost of living adjustment (COLA) of 2.3% raised the FBR to $637 per month for individuals and $956 for couples.

The federal benefit rate sets both the SSI income limit and the maximum federal SSI payment. The FBR payment is supplemented in every state except Arkansas, Georgia, Kansas, Mississippi, Tennessee, Texas, and West Virginia. In all other states, the allowed income level and the SSI payments are higher than the federal maximums. In California, Iowa, Massachusetts, and Nevada, the state supplements are higher for blind recipients than for others. Also, the amount of the state supplement depends on whether you are single or married and on your particular living arrangements. Although the amount of the state supplement varies widely, it can be as much as several hundred dollars.

The SSA does not count the followingincome and benefits when calculating your income level:

• $20 per month of most income, except wages
• $65 per month of wages and one-half of wages over $65
• food stamps, and
• home energy or housing assistance. (See Chapter 13 for more detailed information on income limitations.)

b. Resource Limits

To qualify for SSI , your resources must also not exceed certain limits. A "resource" is cash or another asset that can be converted to cash and used for support. If you or your spouse have the right, authority, or power to sell property and keep the proceeds, it will be considered a resource.

Resources are categorized as either liquid or nonliquid. Liquid resources include cash and other assets that could be converted to cash within 20 working days. The most common types of liquid resources are savings and checking accounts, stocks, bonds, mutual funds, promissory notes, and certain types of life insurance. Nonliquid resources cannot be converted to cash within 20 working days. They include both real property (land) and personal property. The SSA may consider some resources to be both liquid and nonliquid (such as an automobile or life insurance policy).

The resource limits are set by law. They are not subject to regular cost-of-living adjustments, but they have increased slowly over the years. For 2008, you will not be eligible for SSI disability payments if your assets exceed:

• $2,000 for a single person, or
• $3,000 for a married couple (even if only one member is eligible for SSI).

When counting up your assets, the SSA must exclude certain assets, including the following:

• your home (including adjacent land and related buildings), regardless of value. The home must be owned by you or your spouse and used as your principal residence.
• restricted allotted Indian lands
• household goods and personal effects up to $2,000 in value
• one wedding ring and one engagement ring of any value
• necessary health aids, such as a wheelchair or prosthetic device
• one automobile, regardless of value, if used to provide necessary transportation; if not used for that purpose, then one automobile up to $4,500 in value
• grants, scholarships, fellowships, or gifts used to pay tuition, fees, or other necessary educational expenses at an educational institution (including vocational or technical institution) for nine months beginning the month after the month the educational assistance was received
• nonbusiness property needed for support, up to a reasonable value
• resources of a blind or disabled person needed to fulfill an approved plan for achieving self- support (called a PASS plan). (See Chapter 13 for more information.)
• life insurance with a face value of $1,500 or less
• burial plots and certain burial funds up to $1,500
• disaster relief, and
• housing assistance paid under the U.S. Housing Act, the National Housing Act, or the Housing and Urban Development Act.

Exceptions to the residence requirements often involve complex legal issues, and you are probably best off consulting an attorney if you think an exception might apply to you.

c. Citizenship and Residency Requirements

SSI disability payments are usually available only to U.S. citizens. There are several exceptions, however, under which noncitizens might be eligible, including the following:

• During the first seven years after you were admitted, you are either legally residing in the United States as a refugee, have been granted asylum, satisfy certain conditions of withheld deportation, have been granted status as a Cuban or Haitian entrant or, under some conditions, entered as an Amerasian immigrant. (8 U.S.C. § 1612(a)(2)(A)(i)(I-V).)
• You legally entered the United States for permanent residence and have worked 40 qualifying quarters under the Social Security Act (see Section A1a, above). In some situations, you may be able to count the qualifying quarters of a parent (for the time you were under age 18) or a current spouse or deceased spouse. (8 U.S.C. § 1612(a)(2)(B).)
• You were honorably discharged from the U.S. military, you are on active duty in the U.S. military, or you are the spouse of a veteran or person on active duty, the unmarried dependent child of a veteran or person on active duty, or the surviving spouse of a deceased veteran or person on active duty and you have not remarried. (8 U.S.C. § 1612(a)(2)(C)(i-iii).)
• You were lawfully residing in the United States and receiving SSI benefits on August 22, 1996. (8 U.S.C. § 1612(a)(2)(E).)
• You were lawfully residing in the United States on August 22, 1996, and you are blind or otherwise became disabled at any time. (8 U.S.C. § 1612(a)(2)(F).)
• You are lawfully residing in the United States and are an American Indian born in Canada. (8 U.S.C. § 1612(a)(2)(G).)
• You have been battered or subjected to cruelty in the United States by a family member. (See Public Law 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, as amended by P.L.104- 208, the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, and P.L. 105-33, the Balanced Budget Act of 1997.)

d. Receiving Benefits When Outside of the U.S.

SSI payments are generally only available to people residing in the 50 states, District of Columbia, or Northern Mariana Islands. If you receive SSI disability benefits and move, for example, to Mexico or Puerto Rico, you will lose those benefits. There are a few exceptions for some U.S. citizen children and students:

• A blind or disabled child may be eligible for SSI benefits while outside the United States if the child is a U.S. citizen, lives with a parent who is a member of the U.S. Armed Forces assigned to permanent duty outside the United States, and was eligible to receive SSI benefits in the month before the parent reported for duty abroad.
• A student of any age may be eligible for SSI benefits while temporarily outside the United States for the purpose of engaging in studies not available in the United States, sponsored by an educational institution in the United States, and designed to enhance the student’s ability to engage in gainful employment. The student must have been eligible to receive SSI benefits in the month preceding the first full month abroad.

Defining Disabled

For adults and children applying for SSDI and for adults applying for SSI , being disabled means that you are unable to engage in any substantial gainful activity because of a medically determinable physical or mental impairment. The disability must have lasted or be expected to last for a continuous period of at least 12 months, or be expected to result in death.

For children applying for SSI , being disabled means the child has a medically determinable physical or mental impairment that causes marked and severe functional limitations. The limitations must have lasted or be expected to last for a continuous period of at least 12 months, or be expected to result in death.

Let’s break these concepts down further.

1. Inability to Engage in Substantial Gainful Activity

Inability to engage in substantial gainful activity (referred to as the SGA requirement) means that if you work, you do not earn more than a certain amount of money. For nonblind people, the 2008 amount is $940 per month. For blind people, the amount is $1,570 per month in 2008 and is adjusted annually. If you ever need to find out the SG A income limit for a given year, simply call a local SSA office. (See Section C, below.)

Even if you have an impairment that meets the requirements for disability, you won’t qualify for SSDI or SSI if you earn more than the SGA level. In this situation, if you stop working and apply for disability payments, you must be able to show that your medical condition became worse or that special help you required to do your job was no longer available. The SSA is very lenient in this regard, if you make it clear that you had to stop working because of your medical problems. If you say you stopped working without a medical reason, you might not qualify to receive benefits.

SGA refers only to money you obtain from working, not money you obtain from other sources, such as investments or gifts.

2. Medically Determinable Impairment

A medically determinable physical or mental impairment is a disorder (abnormal condition) that results from anatomical (body structure), physiological (body function), or psychological (mental) abnormalities that can be proved by medically acceptable clinical and laboratory diagnostic techniques. The Social Security Act requires that a physical or mental impairment be established by medical evidence consisting of signs (objective findings by a medical provider), symptoms (subjective complaints by you), and laboratory findings.

In other words, the SSA must be able to determine that you have something wrong with you, either physically or mentally. To make such a decision, the government can ask to examine your treating doctor’s records and your hospital records, order x-rays or other tests as needed, or have you examined by a doctor of its choosing if your records are incomplete or too old. Symptoms such as pain are important, but alone cannot get you benefits. They must be linked to some physical or mental problem. In addition, your statement alone that you have symptoms is not sufficient. A doctor must show that you have a physical or mental condition that could cause the symptoms you say you have.

Remember: The medical listings are on the CD-ROM. CD Parts 1 through 14 contain the Listing of Impairments, which is the medical information the SSA uses to determine whether your impairment meets the requirements to obtain disability benefits.

3. Duration of Disability

Your impairment must be severe enough to disable you (according to the SSA’s medical criteria) for at least 12 continuous months or to result in your death. The 12-month duration requirement does not mean that you must have been severely ill for a year before applying for benefits. The SSA often presumes that an impairment will last a year when it has not improved after three months. If an impairment is obviously long-lasting and very severe, the SSA can make an immediate determination. For example, if your spinal cord was cut in half in an automobile accident, you will, at the very least, be unable to walk for the rest of your life. There would no reason for the SSA to wait before approving your claim, assuming you otherwise qualify.

The SSA includes the possibility of death in the definition of disability because death is the most extreme disability possible. Nothing in the Social Security Act specifies how to measure the possibility of death. But the SSA does provide some guidance. If you meet the criteria of any of the cancer listings, the SSA presumes you cannot work, based more on a poor prognosis than on an inability to do work. These cancer prognoses include a median life expectancy of 36 months. (See CD Part 13 on the CD-ROM for more on cancer listings and the definition of median life expectancy.) Sometimes, the SSA uses the same survival probabilities in deciding noncancer disabilities that might result in death. These estimates can be difficult to make and require medical knowledge.

Many people apply for disability after acute injuries or impairments that won’t produce any long-term effect severe enough to qualify for benefits. If you have any question in your mind about how long your impairment will last, apply for benefits. This is especially true if you are over 50 years old. Older people do not need as severe an impairment as people under 50 to be allowed benefits. You can also ask your doctor’s opinion about how long your illness will last. But it will be up to the SSA to decide whether you meet the minimum duration requirement of 12 months. In some cases, the SSA might think your impairment will last long enough, even if your doctor does not.

There is one exception to the duration of disability requirement: SSI claims based on blindness have no duration requirement.

Contacting the Social Security Administration

The SSA is headed by a commissioner. The commissioner, administrative offices, and computer operations are located in Baltimore. The SSA discourages visits to this central office regarding individual claims because service can be provided by local offices.

Local Social Security offices are where you can apply for:

• Social Security benefits
• SSI, black lung benefits and hospital insurance protection, and
• a Social Security number.

You can also:

• check on your earnings record
• enroll for medical insurance
• receive assistance in applying for food stamps
• get information about your rights and obligations under the law, and
• obtain forms you need to apply for or maintain benefits or appeal SSA decisions.

There is no charge for these services. Employees of the SSA are public servants paid by your tax dollars. They are obligated to be helpful and courteous. If you encounter someone who is not helpful and courteous, ask to talk to a supervisor. Usually, this will cause an immediate change in attitude, because complaints might affect the employee’s job performance ratings and ultimately his or her promotions or income. If it is necessary, insist on speaking to the supervisor. Supervisors are usually very interested in working out problems. A request to talk to the supervisor’s supervisor is rarely necessary. If you feel you have been treated really badly, you can contact your local U.S. congressperson or senator. They will send a "Congressional inquiry" to the SSA. The SSA is very sensitive to public relations, and inquiries by Congress often get results if the complaint has merit.

Local Social Security offices exist in large cities of every state, and in bureaucratic language are known as Field Offices. Social Security office staff make regular visits to outlying areas to serve people who live a distance from the city in which the local office is situated.

These visits are made to locations called contact stations. You can obtain a schedule of these visits from your local Social Security office. Some contact stations are visited twice a week, while others may be visited only once or twice a month.

If you are denied SSDI or SSI , you can appeal that decision. (Appealing is discussed in Chapter 12.) The Office of Hearings and Appeals administers the entire hearings and appeals program for the SSA. Administrative law judges, located in or traveling to major cities throughout the United States and its territories, hold hearings and issue decisions when a claimant appeals a determination. The Appeals Council, located in Falls Church, Virginia, can review hearing decisions.

You can reach a live service representative by calling the SSA hotline at 800-772-1213, Monday through Friday (except holidays), from 7 a.m. to 7 p.m. If you are deaf or hard of hearing, TTY service representatives are available at the same times at 800-325-0778. All calls are confidential. After hours, you can obtain prerecorded information on a variety of topics.

SSA representatives can direct you to the Social Security office nearest you, as well as answer numerous other questions. Once you have made contact with your local SSA Field Office, you will deal with them rather than using the hotline. On the Internet, information about Social Security is at www.ssa.gov.

The SSA’s phone lines are busiest early in the week and early in the month; if your business can wait, call at other times.

Have the following items handy when you call:

• your Social Security number
• a list of questions you want to ask
• any recent correspondence you received from the SSA, and
• a pencil and paper to write down information and answers to your questions. Always write down the date you called.

Frequently Asked Questions About Social Security Disability

Following are some frequently asked questions about SSDI and SSI.

1. How is the disability determination made?

The SSA disability evaluation is made under a procedure known as the sequential evaluation process. For adults, this process requires step-by-step review of your current work activity, the severity of your impairment, your remaining physical and mental abilities, your past work, and your 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, and an assessment of whether the impairment results in marked and severe functional limitations. (The sequential evaluation process is discussed in Chapter 7.)

2. When do disability benefits start?

SSDI claimants may be entitled to retroactive (past) benefits, if the SS A finds they were disabled before their application date. Actual payments, however, cannot be made until five months after the date of the onset of disability. Cash benefit payments cannot be paid retroactively to cover more than 12 months before the application date— no matter how severe your disability.

There are exceptions to the five month waiting period requirement. These exceptions, along with more detailed information about onset, can be found in Chapter 10.

Under SSI, disability payments may begin as early as the first day of the month after an individual files an application, but no earlier. In addition, under the SSI program, you may be found "presumptively disabled" and receive cash payments for up to six months while the formal disability determination is made. The presumptive payment is designed to allow a needy person to meet his or her basic living expenses during the time it takes to process the application. If a claimant is denied SSI benefits, he or she is not required to refund the payments.

3. What if I disagree with the determination?

If you disagree with the initial determination, you can appeal. Under the old rules, the first appeal of a denial was called a reconsideration, which was generally a review of your case by a DDS team that was not involved in the original determination. Under the new Disability Service Improvement Process (DSIP ) that the SSA is implementing, your first appeal would be to a Federal Reviewing Official (FRO). If your case is denied by the FRO, you can request a hearing before an administrative law judge. If you are dissatisfied with that decision and wish to continue pursuing the case, you can file a civil lawsuit in federal district court and eventually appeal all the way to the U.S. Supreme Court. (Appeals are covered in Chapter 12.)

4. Can I receive disability benefits or payments while getting Medicare or Medicaid coverage?

Yes. Medicaid and Medicare are our country’s two major government-run health insurance programs. Generally, people on SSI and other people with low incomes qualify for Medicaid, while Medicare coverage is earned by working in jobs covered by Social Security, the Railroad Retirement Act, or for the federal government. Many people qualify for both. If you receive Medicare or Medicaid along with your disability benefits, you do not have to do anything special or additional to obtain such coverage once you have qualified for disability. You don’t have to write any letters or fill out any more forms. If and when you qualify for such coverage, the federal government will send you what you need.

SSDI claimants granted disability benefits qualify for Medicare coverage. The coverage doesn’t start for two years from the onset of disability—and that means two years starting after the initial five-month waiting period. Therefore, you may be left without medical insurance coverage for several years if you don’t have some other type of coverage or are not poor enough to qualify for SSI Medicaid coverage. There are three exceptions to the two-year rule:

• If you have end-stage renal disease with kidney failure and you require dialysis or a kidney transplant, coverage by Medicare can begin the third month after the month in which dialysis began.
• If you are terminally ill with a life expectancy of six months or less and receive hospice care, coverage by Medicare can begin immediately.
• Individuals with amyotrophic lateral sclerosis (ALS) qualify for Medicare as soon as they qualify for benefits.

If you get Medicare and have low income and few resources, your state may pay your Medicare premiums and, in some cases, other out-of-pocket Medicare expenses such as deductibles and coinsurance. Only your state can decide if you qualify. Contact your local welfare office or Medicaid agency. For more general information about Medicare, contact a local SSA office or look for Medicare Savings for Qualified Beneficiaries on the SSA’s website, www.ssa.gov.

SSI claimants granted disability qualify for Medicaid coverage in most states. Where available, Medicaid coverage starts immediately. Only 16 states have no medically needy programs for their aged, blind and disabled. The 16 states are Alabama, Alaska, Arizona, Colorado, Delaware, Idaho, Indiana, Mississippi, Missouri, Nevada, New Mexico, Ohio, South Carolina, South Dakota, Texas, and Wyoming.

5. Can I work and still receive disability benefits?

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 are called work incentives. The rules are different for SSDI and SSI , but under both programs, you can receive:

• continued cash benefits
• continued help with medical bills
• help with work expenses, or
• vocational training.

For more information about work incentives, contact a local SSA office or look for A Summary Guide to Social Security and Supplemental Security Income Work Incentives for People With Disabilities on the SSA’s website, www.ssa.gov. (Work incentives are discussed in Chapter 13.)

6. How can I receive vocational training services?

Claimants for SSDI or SSI may be referred to a state vocational rehabilitation agency for rehabilitation services. The referral may be made by the DDS (see Chapter 6), the SSA, a treating source, or 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 vocational rehabilitation services would benefit you in returning to work, medical evidence from your treating source may be very important.

7. I understand that to get disability benefits, my disability must be expected to last at least a year. Does this mean that I must wait a year before I can get benefits?

You do not have to wait a year after the onset of the disability before you can get benefits. File as soon as you can after becoming disabled.

8. I have been receiving Social Security disability benefits for the past four years and my condition has not improved. Is there a time limit on Social Security disability benefits?

No. You will continue to receive a disability benefit as long as your condition keeps you from working. But, your case will be reviewed periodically to see if there has been any improvement in your condition and whether you are still eligible for benefits (see Chapter 14). If you are still eligible when you reach 65, your disability benefits will be automatically converted to retirement benefits.

9. I had a serious back injury four years ago and received disability benefits for about 18 months, until I could return to work. Unfortunately, my back problems have recurred and I don’t know how much longer I will continue working. When I initially applied for benefits, I waited several months before I received my first check. If I reapply for benefits, will my wait be as long as it was the first time?

Maybe not. It depends on what the new medical reports say and whether additional evidence is required. A worker who becomes disabled a second time within five years after benefits stop can have his or her checks start again, beginning with the first full month of disability if the new claim is approved.

10. My brother had an accident at work last year and is now receiving SSDI disability benefits for himself, his wife and daughter. Before his accident, he helped support another daughter by a woman to whom he has never been married. Is the second child entitled to some benefits as well?

Yes. Even though your brother was not married to the second child’s mother, Social Security pays benefits to all of his children. Each child is entitled to equal benefits.