Disability Criteria - Eligibility For Social Security and SSI Disability

Social Security administers two disability programs that have different non-disability criteria but use the same disability medical evaluation process.

Title II benefits, otherwise known as SSD, or Social Security Disability, is based upon an insured status that is earned through work activity. A person essentially becomes insured for SSD through work credits earned by years of working.

This insured status can lapse, however, particularly if a person has been not been able to work for a considerable length of time due to a disabling condition.

For individuals who have never become insured for SSD (such as children and stay-at-home spouses), or who have lost their insured status for SSD, there is the title 16 SSI program.

SSI, otherwise referred to as Supplemental Security Income is based upon need, in addition to being disabled. This means that eligibility for SSI hinges upon meeting certain resource limits.

Translation: you cannot have more than $2000 in countable assets to receive SSI. This is true even if you are found to be medically disabled following a review of your claim.

The medical criteria for SSI and Social Security Disability

Just as ALJs (administrative law judges) do so at the disability hearing level, Social Security Administration disability examiners use medical criteria outlined in the Social Security Disability guide book, "Disability Evaluation Under Social Security". The guidebook, also known as the listings, or the blue book (because, in printed form, the cover is blue) focuses on a number of medical condition for which SSA lists very specific approval criteria.

The disability handbook contains medical impairment listings that cover several body systems (such as the endocrine system for which diabetes would be evaluated and the neurological system for which epilepsy would be evaluated). It also contains the medical criteria needed to meet or equal the severity of an impairment listing, which can then result in an approval of benefits.

Getting approved on the basis of a listing in the Social Security list of impairments is fairly difficult. To complicate matters, most medical conditions--physical or mental--are not given a separate listing. Perhaps only 15-20 percent of cases that are awarded benefits are approved on the basis of a listing.

What if I cannot win disability by satisfying a listing?

Although all medical decisions are based upon the medical criteria set forth in the disability impairment listings, some disability applicants will be approved for disability even if they do not meet or equal the impairment listings. This happens when a review of the claimant's medical treatment history and work history allows the Social Ssecurity Administration to conclude that a claimant is not capable of doing their past work or doing some type of other work.

This type of decision makes use of several things:

1. A review of the claimant's medical records.

2. An analysis of the claimant's work history (the types of jobs that were performed, the physical and mental requirements of each job, and the skill levels involved.

3. The application of a set of medical-vocational rules known as the vocational grid. Grid rules allow a disability examiner or judge to "plug in" a claimant's age, skills, education level, and current RFC, or residual functional capacity, and then arrive at a specific rule that finds the claimant "disabled" or "not disabled".

Note: to use an example of RFC, a claimant's medical condition may be examined and it may be determined that they have an RFC of light. This would mean they cannot do more than light exertional work which would limit them to lifting 20 lbs at the most, and only occasionally. The result would be that if their past work required more than light exertion, they could not be expected to return to that past work, or do any other type of work that was rated more than light (e.g. medium or heavy). This is a very simply example, of course, and is only used to illustrate the meaning of RFC, or residual functional capacity.

Will I qualify for SSD or SSI disability?

All individuals who file for disability with Social Security will be evaluated for both programs. If they are eligible for both, their disability claim will be sent to the state disability agency as a concurrent disability claim. If not, their will be approved for disability even if they do not meet or equal the listing criteria for a specific impairment, such as depression or degenerative disc disease. These individuals may receive their approvals based upon residual functional capacity (what a person is capable of doing despite the limitations of their disabling condition), age, education, past work, and their ability to perform or be trained for other types of work.

If an individual's residual function capacity makes it impossible to do all substantial work activity including jobs they have done before as well as other types of work, they may be approved for disability on the basis of a medical vocational approval. Basically, all Social Security Disability decisions involve medical criteria whether the disability claims are for SSI disability or Social Security Disability.

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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