HeyMikey posted this extreemly helpful comment on the different programs run by SSA.
This requires a fairly geeky level of understanding of how the retirement and disability programs work. But as Ross Perot said, hang in here with me for a minute.
You might want to eyeball it by clicking on his name link above, before slipping through the "Infinity sign" a la kos...
KosAbility is a Sunday volunteer diarist com- munity of, by & for people living with disabilities, who love someone with a disability, or who want to know more about the issues. By disability we mean temporary and permanent health/medical conditions — from small, gnawing problems to major, life-threatening ones. Our use of love someone extends to cherished members of other species.
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From my point of view as a disability analyst, there are five basic steps I have to go through, overall, to decide if you qualify under the rules of Social Security — How we decide if you qualify for disability. This is the medical side. The financial qualifications are decided by the Field Office.
[Step 1.] Is the applicant engaging in SGA [Substantial Gainful Activity]? For 2014, the amount was an average of $1,070 a month. For 2015, it is 1,090.
This may be why so many complain they know "able" people collecting disability. You have to be able to work at a level of employment that exceeds this limit on a continual basis. Some people with a disability can handle a 20 hour work week, or two eight hour days a week. They just can't manage a 35-40 hour work week on a regular basis.
As to why a person with an MDI [Medically Determinable Impairment] might work at SGA, this is the best example I can give: I have a brother-in-law who is legally blind. He works full time. If he decided he couldn't keep it up tomorrow, he could file for SSDI, and qualify as a legally blind person immediately. People do not have to stop working, if legally disabled. The fact that they do, and then can stop and collect SSDI/SSD, is the safety net for the misfortune of being legally blind, deaf, wheel-chair bound, or similarly differently abled.
[Step 2.] Does the claimant have an MDI that is "severe"? Whether medical or psychiatric, the impairment must interfere with basic work-related activities to be judged a "severe" or "marked" MDI. They also must have an MDI that has, or can be expected to, last for a continual period of 12 months, or reasonably be expected to end in death. Therefore, a high risk pregnancy does not qualify.
NB: I have had claimants who were denied because their MDI was not expected to last a continual period of 12 months, called a Durational Denial. They filed again, around six months later, and the Barr-Epstein, or leg fracture, was still causing marked limitations in their ability to engage in SGA. Then they get a "Reopening," and will most likely qualify for back disability, from the earliest date disability can be established.
There are rules by which a family can collect after the death of the applicant, but I will skip that, unless someone specifically asks. Specific Physical RFC's and Psychiatric RFC's (Residual Functional Capacity) qualifications will be outlined below.
[Step 3.] For each of 14 major body systems, SS Disability maintains a Listings of medical conditions that are so severe they automatically mean one is disabled. Listings of Impairments-Adults. Liver cancer, and cardiac and respiratory diagnoses that meet medical guidelines, come to mind here. If the condition is not on the list, we have to decide if it is of equal severity to a medical condition that is on the list. If it is, we will find that you are disabled. And the Listings are different for people over and under 18. I will stick with adults for this diary. However, these are not the only ways to qualify. See the next two and a half steps.
[Step 4. Part 1.] Can the claimant return to previous work? Any work done in the 15 years prior to the allegation of becoming too disabled to work count. Then, any that meet the definition of SGA are winnowed out, meaning did you do them long enough, or earn enough money in a given time span, to count? SS breaks these down based on the physical strength required (sedentary, light, medium, heavy, or very heavy). Residual Functional Capacity, and the SVP (skill level). Skill levels break down to unskilled (1 month or short demo to master), semi-skilled (between three and six months to master), and skilled (six months and often many years to master). How Social Security Defines Skilled and Unskilled Work: SVPs (scroll down to #79 at this link).
[Step 4. Part 2.] Per the DOT Dictionary of Occupational Titles, for example, the job as a child monitor (AKA "babysitter") is medium. If you performed the job as light, doing less heavy lifting, and it was SGA, SSDI will decide you can RTPW (Return to Prior Work) as you performed it. Conversely, the job as a floor supervisor is light per the DOT, but medium as the claimant performed it. Then the claimant who has an RFC of light can RTPW as performed in the general economy, and will be found not disabled.
[Step 5.] Can the claimant adjust to other work? This takes into consideration the medical condition(s), age, education, past work experience and any transferable skills the claimant may have. If they cannot adjust to other work, the claim will be approved. People over age 50-55 are generally not expected to go back to school and learn a whole new career skills set. People between 18-44 generally are. If the claimant can RTOW (Return to Other Work) the claim will be denied.
If you are allowed at steps 4 or 5, it is a Med/Voc allowance, sometimes called "qualifying on the grid" - The SS Grid Rules — scroll halfway down that page 'til you see an obvious grid or chart entitled Table No. 1—Residual Functional Capacity...Limited to Sedentary Work....
Examples:
Table No. 1—Residual Functional Capacity: Maximum Sustained Work Capability Limited to Sedentary Work as a Result of Severe Medically Determinable Impairment(s)
Rule Age Education PRW Decision
201.01 Advanced age Limited or less Unskilled or none Disabled
201.02 ditto ditto Skilled or semiskilled—skills not transferable Disabled
201.03 ditto ditto Skilled or semiskilled—skills transferable Not disabled
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In these examples, based on the claimant's age (advanced), education level (High school or more, limited or less, illiterate/less literate in English), previous work experience (skilled, unskilled, or none), and the transferability of said skills (another whole can of worms), two different claimants with only one variable between them makes the difference between an allowance or a denial.
Age Categories
* Younger person. If you are a younger person (under age 50), we generally do not consider that your age will seriously affect your ability to adjust to other work. However, in some circumstances, we consider that persons age 45-49 are more limited in their ability to adjust to other work than persons who have not attained age 45.
* Person closely approaching advanced age. If you are closely approaching advanced age (age 50-54), we will consider that your age along with a severe impairment(s) and limited work experience may seriously affect your ability to adjust to other work.
* Person of advanced age. We consider that at advanced age (age 55 or older), age significantly affects a person's ability to adjust to other work. We have special rules for persons of advanced age and for persons in this category who are closely approaching retirement age (age 60 or older).
Special Adverse Profiles — somewhat arcane.
Compassionate Allowances "to expedite the processing of SSDI and SSI disability claims for applicants whose medical conditions are so severe that their conditions obviously meet Social Security's definition of disability."[ Compassionate Allowances FAQs ]
PRFC (Physical Residual Functional Capacity)
1.) Exertional limits: Ability to lift, carry, push, pull, sit, stand, or walk.
2.) Non-exertional limits:
Postural limits: Ability to climb, balance, stooping, kneel, crouch, or crawl.
Manipulative (hands)
Communications
Vision
Hearing
Environmental
MRFC (Mental Residual Functional Capacity)
There are four core psych areas. If you are found "markedly" impaired in any of the four core areas, you may be found disabled.
1.) Ability to understand and follow simple directions or instructions.
2.) Ability to maintain attention and concentration for a sustained period of time.
3.) Ability to react appropriately to other people.
4.) Ability to adjust to stress or change in a normal competitive work environment.
"WHAT DO YOU GUYS WANT?"
Personally, I focus initially on age, education, past work, and allegations. [Allegations = assertions of illness yet to be substantiated]. That gives me a ballpark on the chances. At the initial level, it is about 30-40% chance of being allowed. I go over the body systems in which the claimant alleges limitations, assess what I need to allow them, and proceed to send for the medical records. Anything the claimant can bring to the Field Office to have scanned into the file can possibly help qualify you immediately. It's a case by case basis, however, always.
Objective medical evidence is crucial. The MD or PhD can write all the progress notes or letters they like stating you are disabled. I need evidence: MRI's, EMG/NCS, x-rays, pathology reports, consistent treatment [as evidenced by long term psych progress notes], what medications you may have already tried and their effectiveness or lack there of, PT notes, lab tests, and 3rd party Function Forms all help greatly.
Credibility of claimant statements are another big plus. If the claimant only limps when they believe someone is watching, or claims they need a cane or walker, but no one has ever seen them use it, that's not good. Claims to be so disabled "I can't do anything" are also looked upon with a jaundiced eye. Be specific. If you can do laundry or shopping, but only with help for heavy lifting and carrying, be specific that way. If you can tolerate being among people but only certain ones, or for a short while, quantify who, how many people, for how long, and any other details specific to your situation. It's a tad disconcerting to read "I can't stand to be around other people, period," then find the claimant or their significant other is four months pregnant. Something isn't right, there.
Ask the analyst what s/he needs. They want to close the claim, believe me, and hopefully, in your favor. If something changes, call them ASAP. They should send you a letter with their 800 number within two days of receiving the claim in the analyst's office, which isn't necessarily the day after the claimant applies. Call and ask if they have all your treating source information. Field Offices are busy. They make mistakes. So do we. Touching base with us keeps us on our toes, too.
Do you need a lawyer? My first impulse is to say "No." There are Non Attorney Disability Reps —[ note that's a page at a dot com site, not a dot gov - see also this professional association]— and some counties have advocates in their DSS [Department of Social Services] offices. [NB: Whether to have an advocate on DSS staff is a decision made at the county level, and mainly serves to help get people off "welfare," and on to SSD, if they qualify.] Field Office Locator by Zipcode have links to other agencies that can assist you with your welfare, housing, meal assistance and other support services, including some links to legal aide or other services for the disabled. Attorneys can charge up to 25% of $600 or more in the preceding calendar year. You won't be getting so much that you can throw that kind of money away. However, we have so many wonderful SSD/SSDI lawyers and non-legal representatives posting in dk, I will never say never. And if the claimant needs help, due to inability to comprehend and navigate the system, then of course they should get help, paid or pro bono.
Generally, paid Attorney Reps tend to get involved after the claimant is denied at the initial level, and applies for a hearing. (I have seen them there from day one, though.)
Always Apply for a Hearing If Your Claim/Application is Denied.
Chances for an allowance at the Hearing (or ALJ - Administrative Law Judge) Level are more like 60%. [Remember: at the initial level, it averages 30-40%.] Also, ALJ's have greater leeway for judging the credibility of the claim, if the allegations didn't come off as quite that disabled on paper. (There is also a such thing as video hearings, now, if needed.) I have worked on re-certifications that were turned down at the initial level, and appeared properly so. Then I read the ALJ's decision, and the ALJ can take the same evidence, and turn it to an acceptable allowance. It's called due process, and the claimant is entitled to this. The information for filing an appeal is right in the denial letter.
Obviously, I am not a lawyer. I'm an AS/RN with going on 10 years working in a specific office in a specific state with specific medical, technical, and quality review people, and even we do not always agree. The purpose of this diary is to guide you through the process, and link you to places where you can gain more information that may pertain to your specific MDI. Feel free to ask questions, and send private messages, if shy about sharing with the general community. Please bear in mind the limitations I just outlined, and tailor your expectations accordingly.
Special thanks to postmodernista for the kick in the pants, and for having the courage to coordinate this group ~ HeyMikey for his particular contribution, leading me to consider writing this ~ Joan McCarter for the original diary, Social Security chief: Disability cut would be a 'death sentence' ~ xxdr zombiexx for being so supportive in all diaries on this and similar subjects. Anyone else I may have missed in my brief research, if the lightbulb comes on, I will add additional thanks as they occur. Because it takes a Community.
And my own personal, unexpected, and much needed Guardian Angel through this, mettle fatigue.
Solidarity!