Disability: Social Security and SSI

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Disability Social Security and SSI

• AIDS Clinic
• January 30, 2004

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Social Security Disability Benefits

• Monthly cash benefit to disabled persons or their
  dependents
• Not a needs-based program eligibility is based
  on payment of sufficient Social Security taxes
• Must have worked long enough and recently enough
  (5 out of last 10 years)
• Payment amount dependent on wage history

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Supplemental Security Income

• Monthly benefits to aged, blind or disabled
  persons
• Eligibility based on financial need, considers
  income and assets
• Payment amount supplements any other income up to
  a maximum
• Year 2004 maximum payment 564 per month (846
  for eligible couple)

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Associated Medical Programs

• SSDI Medicare
• Available after two years of SSDI eligibility (29
  months after onset date)
• Part A Hospitalization
• Part B Outpatient, tests, etc. (66 annual
  premium and 100 annual deductible)
• Prescription drug coverage will be weak

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Associated Medical Programs

• SSI Medicaid
• Income based program health care for the poor
• Automatically available to SSI recipients
• Pays doctors, prescriptions, but low
  reimbursement rate to providers

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Administrative Process

• Initial application
• Reconsideration
• Administrative Hearing
• Appeals Council Review
• Judicial Review (U.S. District Court)

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DI and SSI DISABILITY Determinations and
Appeals Fiscal Year 2000
Allow 38
Deny 62
Initial Level 1,988,425 Reconsiderations 584,540
ALJ Dispositions 433,584 Appeals
Council 122,780 Federal Court Decisions 12,011
Allow 16
Deny 84
Allow 59
Dismiss 12
Deny 29
Allow 2
Dismiss 2
Remand 22
Deny 74
Allow 6
Dismiss 6
Remand 48
Deny 39
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Definition of Disability

• Severe mental or physical impairment
• Medically verifiable by lab tests, physical
  examination or other objective medical procedures
• has lasted, or is expected to last, at least
  twelve consecutive months or result in death
• renders claimant unable to engage in substantial
  gainful activity (SGA)

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Five-Step Sequential Evaluation

• Is the claimant doing Substantial Gainful
  Activity (SGA)?
• Does the claimant have a severe impairment?
• Does the impairment meet or equal a listed
  impairment?
• Can the claimant do past relevant work?
• Can the claimant do any work existing in
  significant numbers?

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Yes
Gainfully Employed?
No
No
Severe Impairment?
Yes
Yes
Meets or equals listing?
No
Yes
Able to do past relevant work?
No
Yes
Able to perform any work existing in significant
numbers?
No
Disabled under listings
Disabled according to vocational factors
Not disabled
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Two important limitations

• Substance Abuse
• Claimant may not received benefits if substance
  abuse contributes materially to the finding of
  disability (20 CFR 404.1535)
• Compliance with treatment
• No benefits if claimant fails to follow
  prescribed treatment that would restore ability
  to work. (20 CFR 404.1530)
• Acceptable excuses treatment contrary to
  religion, very risky considers physical, mental,
  educational, and linguistic limitations
• For HIV infected, common problem is medication
  adherence.

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Sequential EvaluationStep 1 Work

• Is the claimant engaged in substantial gainful
  activity?
• Substantial means work activity that involves
  significant physical or mental activities
• For 2004, gainful means resulting in income of
  810/month (gross income minus impairment related
  work expenses)

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Sequential EvaluationStep 2 Severity

• Does the claimant have a severe impairment?
• A severe impairment significantly limits physical
  or mental ability to do work activities, such as
• physical functions-walking, lifting, carrying
• seeing,hearing, speaking
• understanding and carrying out instructions
• use of judgment
• responding appropriately to supervision
• dealing with changes in work setting

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Sequential EvaluationStep 3 Listings

• Does the impairment, or combination of
  impairments, meet or equal a listed impairment?
  
• Organized by body systems
• Impairments presumed to prevent the ability to
  engage in SGA
• Each listing includes a diagnosis as well as
  certain findings which must be included in
  medical records
• many listings include durational requirements and
  severity levels

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Step 3 HIV Listing

• Part of Immune System Listing -- 14.00 series
• Specifically begins at 14.08, but includes
  introductory material which is very important
• Requires a positive HIV test PLUS an
  AIDS-defining condition
• Common examples mycobacterial infection,
  candidiasis, cytomegalovirus disease, Kaposis
  sarcoma, HIV wasting syndrome, severe diarrhea,
  pneumocystis carinii pneumonia
• At 14.08N, allows for disability finding with
  combination of less severe symptoms resulting in
• marked restrictions of activities of daily
  living,
• marked difficulties in maintaining social
  functioning, or
• marked difficulties in completing tasks in a
  timely manner due to deficiencies in
  concentration, persistence or pace

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Step 3 Other Important Listings

• 12.00 -- Mental Disorders
• 12.04 -- Affective Disorders
• Includes depression, a very common problem with
  persons with HIV
• 12.05 Mental Retardation
• significantly subaverage general intellectual
  functioning with deficits in adaptive functioning
  initially manifested before age 22
• IQ of 59 or less
• IQ between 60 and 70, combined with another
  physical or mental impairment that imposes
  work-related limitations
• or IQ between 60 and 70 and restriction in
  activities of daily living social functioning
  concentration, persistence or pace or repeated
  episodes of decompensation

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Sequential Evaluation, Step 3Equivalence
Multiple Impairments

• Medical equivalence (20 CFR 404.1526)
• medical findings equivalent in severity and
  duration to the listed condition
• useful when the claimants condition doesnt
  match any listed condition
• must be confirmed by a doctor, preferably a
  treating physician
• must be based on medical evidence
• Combination of Impairments can also be considered
  for medical equivalence (20 CFR 404.1523)

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Sequential EvaluationStep 4 Past Work

• Can the claimant perform past relevant work?
• This step evaluates functional ability
• residual functional capacity -- what a person
  can do despite his/her limitations
• takes into account all limitations, physical and
  mental, including those not considered severe
• Any work done in the last 15 years is considered
  relevant

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Sequential EvaluationStep 5 Other Work

• If a claimant cannot perform past relevant work,
  can he/she do other work?
• This step assesses physical/mental residual
  functional capacity, PLUS age, education and work
  experience, transferability of skills
• burden of proof shifts to the SSA

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Sequential EvaluationStep 5 - determination

• Two ways to answer this question
• 1. Vocational expert
• expert testifies at hearing about specific jobs
  claimant could do
• jobs proposed must exist in significant numbers
  in the region in which the claimant lives

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Disability Haiku

• Disability
• You have been denied
• Malingerer, whiner, bum...
• Egg-candle, mister
• Hannah Demeritt

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Sequential EvaluationStep 5 - Grids

• Medical-Vocational Guidelines (the grids)
• Guidelines are made up of four charts, one for
  each exertional limitation (e.g. claimant limited
  to sedentary, light, medium or heavy work)
• Claimant is plotted based on age, education and
  skill level
• Result of disabled/not disabled is dictated by
  the chart
• Grids are inappropriate if the claimant has
  non-exertional impairments (e.g., fatigue,
  diarrhea, mental impairments, pain)

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Example Grids residual functional capacity
limited to sedentary work