Presumptive Disability: Eligibility and Filing

Applying for Social Security disability benefits can be a long and frustrating process. Fortunately, the Social Security Administration (SSA) recognizes that waiting months for a decision can cause extreme financial hardship. So, the SSA has a process for making immediate payments to applicants likely to qualify for SSI (Supplemental Security Income).

If you qualify, Social Security will pay you presumptive disability benefits before your SSI claim is decided. If Social Security later finds you aren't disabled and denies your SSI claim, you won't have to repay any presumptive disability payments you received (unless the SSA finds that you were never financially eligible for SSI).

But not everyone who qualifies for SSI is eligible for presumptive disability benefits. Read on to learn who can get these immediate benefit payments and how to apply for presumptive disability.

Qualifying for Presumptive Disability Benefits

To qualify for immediate SSI benefits, you must have a medical condition that's severe enough for Social Security to presume you'll meet the SSA's definition of disabled. You must also meet all the non-medical eligibility requirements for SSI.

SSI Non-Medical Eligibility Requirements

Before your request for presumptive disability can be considered, you must first meet the non-medical (legal and financial) requirements for SSI. Because it's a needs-based program, your income and resources must fall below the SSI limits. If you're applying for presumptive SSI benefits for your child, Social Security will determine financial eligibility based on your family's income and assets.

Presumptive Disability List of Conditions

Social Security generally considers the following conditions severe enough to qualify you for presumptive disability:

• amputation of two limbs
• amputation of a leg at the hip
• total blindness
• total deafness
• bed confinement and immobility without a wheelchair, walker, or crutches due to longstanding condition
• stroke more than three months ago, with difficulty walking or using a hand or arm
• cerebral palsy, muscular dystrophy, or muscular atrophy, with significant difficulty walking, speaking, or using your hands or arms
• Down syndrome
• severe intellectual disorder (must be at least seven years old)
• symptomatic HIV infection or AIDS
• terminal illness with hospice services or six months or less to live
• spinal cord injury with the inability to walk without a walker or similar device
• end-stage renal (kidney) disease (ESRD) requiring chronic dialysis
• amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, and
• low birth weight (see below).

If your medical condition isn't likely to meet the requirements of one of the impairments listed in Social Security's Blue Book, you probably won't qualify for presumptive disability. But you might still qualify for SSI if you can prove your impairments prevent you from working.

Presumptive SSI Disability Benefits for Low Birth Weight Babies

Babies born at a significantly low birth weight are eligible for presumptive disability benefits (whether or not the baby was premature) up to their first birthdays. Your baby can qualify for presumptive disability benefits while awaiting approval for SSI if the child was born at or below the following birth weights and corresponding gestational ages:

• 4 pounds, 6 ounces (2,000 grams) if born at 37 weeks or later
• 4 pounds, 2 ounces (1,875 grams) if born at 36 weeks
• 3 pounds, 12 ounces (1,700 grams) if born at 35 weeks
• 3 pounds, 5 ounces (1,500 grams) if born at 34 weeks
• 2 pounds, 15 ounces (1,325 grams) if born at 33 weeks, or
• 2 pounds, 10 ounces (1,200 grams) if born at any gestational age.

If your baby meets the above low birth weight requirements, you'll receive SSI payments for up to six months while your child's case is decided. Your baby will also qualify for free medical care through Medicaid.

But to qualify, you'll need a birth certificate or other medical record of your child's low birth weight. And your Social Security representative might contact the hospital or doctor to confirm your child's birth weight.

Who Decides If You Qualify for Presumptive Disability?

Your local Social Security field office can make presumptive disability determinations in many cases. For some conditions, the field office must get confirmation from a reliable source of information, such as:

• a doctor
• a social worker, or
• school personnel.

If the Social Security field office denies your request for immediate disability benefits, you might still qualify for presumptive disability benefits when your file moves to Disability Determination Services (DDS)—the state office that determines whether you qualify for regular disability benefits. DDS has more leeway in granting presumptive disability and may be able to grant these benefits to applicants with illnesses and conditions not included on the above list.

When Do Presumptive Benefits Start and Stop?

If approved, you could begin receiving presumptive disability benefits in as little as a few days up to a few weeks. Presumptive benefits last up to six months or until your SSI claim is approved (whichever is sooner).

At the end of the six months, your presumptive benefits will end—even if Social Security hasn't made an initial disability determination in your case. If that happens, you won't get SSI benefits until your claim is approved.

Applying for Presumptive Disability Benefits

You can request presumptive disability benefits when you file your SSI application. To do so, you must apply for SSI by phone (call 800-772-1213) or in person at your local SSA field office.

You'll need to supply proof that you qualify for presumptive disability, including a document signed by your doctor or an appropriate health care provider that verifies your condition. You might also need to provide diagnostic test results (like X-rays and lab tests).

SSI applicants with certain conditions must submit specific forms. For instance, if you're asking for presumptive disability benefits based on HIV, you must submit either:

• Form SSA-4814 (for an adult applicant), or
• Form SSA-4815 (for a child applicant).

If you've applied for SSI and presumptive disability based on ESRD, Social Security will need a copy of Form CMS-2728-U3 (End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration). This form is completed and signed at the facility that diagnosed your ERDS.

Other Fast-Track Programs

If Social Security doesn't approve your request for presumptive benefits, or they run out, you might qualify for interim assistance (IA) from your state government. These are cash payments to tide you over while you wait for SSI approval, but they need to be paid back with your SSI back pay. Learn more about how interim assistance works and which states offer IA.

In addition, disability applicants with certain medical conditions can qualify for Social Security's other expedited claims processing programs:

• the Compassionate Allowances program, and
• the Terminal Illness (TERI) program.

These programs are available for both SSI and SSDI (Social Security disability insurance) applicants.

The SSA also has two other programs that might provide immediate assistance: emergency payments and immediate payments, and veterans may be able to get fast-tracked decisions through the wounded warrior program.