Questions and Answers About the Disability Program

Q. What is meant by “Disability”

A. The definition of disability under Social Security is different than other programs. Social Security pays only for total disability. No benefits are payable for partial disability or for short-term disability.

Disability under Social Security is based on the inability to work. You are considered disabled under Social Security rules if you cannot do work that you did before and we decide that you cannot adjust to other work because of your medical condition(s). Your disability must also last or be expected to last for at least one year or to result in death.

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.