SOCIAL SECURITY PROGRAMS &

DISABILITY CLAIMS PROCESS

Social Security Administration

Contact Social Security

Web site – www.socialsecurity.gov

Phone 1-800-772-1213

In person

Complete application, disability

reports, medical releases

WWW.SSA.GOV

If you receive benefits or have Medicare, you can: Get your benefit verification letter

Check your benefit and payment information Change your address and phone number

Start or change direct deposit of your benefit payment.

WWW.SSA.GOV

• Age 62 or older; based on earnings record

• Spouse age 62 or older; minor/disabled adult children; spouse under 62 caring for child

RETIREMENT INSURANCE – SOCIAL SECURITY

• Payment based on deceased worker’s earnings record

• Widow(er) [age 60]; disabled widow(er) [age 50]; minor/disabled adult children; widow(er) caring for child

SURVIVOR INSURANCE – SOCIAL SECURITY

• Based on earnings record and disability determination

• Spouse age 62 or older; minor/disabled adult children; spouse under 62 caring for child

DISABILITY INSURANCE – SOCIAL SECURITY

• Needs-based - must have limited income and resources to be eligible

• Must also be blind, disabled, or age 65 or older

• No benefits payable to spouses/dependents

SSI – SUPPLEMENTAL SECURITY INCOME

Social Security Disability

Benefit Programs

Title II SSDI

Social

Security

Disability

Insurance

Medicare

Title XVI SSI

Supplemental Security Income

Medicaid

Distinctive Features

SSDI FUNDED BY FICA TAXES

GENERALLY UNAFFECTED BY OTHER INCOME AND RESOURCES

SSI FUNDED BY GENERAL

TAX REVENUES

AFFECTED BY CHANGES IN INCOME, RESOURCES AND LIVING ARRANGEMENTS

Distinctive Features

SSDI • BE MEDICALLY DISABLED • HAVE WORKED LONG ENOUGH IN JOBS COVERED BY SOCIAL SECURITY • BE A WIDOW OR DISABLED ADULT CHILD

ssdi

SSI • BE MEDICALLY DISABLED • NEEDS BASED i.e.; LIMITED INCOME • RESOURCES BELOW:

$2000/INDIVIDUAL $3000/COUPLE

Distinctive Features

SSDI • BENEFIT AMOUNT IS

BASED UPON LEVEL OF EARNINGS OVER WORK YEARS

• MEDICARE COVERAGE STARTS AFTER 24 MONTHS OF ENTITLEMENT

SSI • BENEFIT AMOUNT IS

BASED ON INCOME AND LIVING ARRANGEMENT.

• IMMEDIATE MEDICAID

The Medical

Decision

Process

Social Security

Disability The Medical Decision Process

What Happens Next

Social Security will forward the application to the state Disability Determination Services (DDS) agency

In Michigan, there are four offices:

Detroit

Kalamazoo

Lansing

Traverse City

Social Security’s

Disability

SSA accepts disability claims for all allegations. However, there are some expedited claims.

: for applicants whose medical conditions are so severe that their conditions obviously meet Social Security's definition of disability.

Specific list of qualifying conditions online. http://www.ssa.gov/compassionateallowances/conditions.htm

: A case is designated critical when the claimant's illness is alleged or identified as terminal

: A case is designated critical when the claim involves any current or former member of a military service who:

Sustained an illness, injury, or wound; Is alleging a physical or mental impairment, regardless of how

the impairment occurred or where it occurred (i.e., United States or on foreign soil); and

Sustained the impairment while on active duty status on or after October 1, 2001.

Veterans who have a VA compensation rating of 100% permanent and total may receive expedited processing of applications for Social Security disability benefits.

www.socialsecurity.gov/people/veterans

What Happens Next

Disability Determination Services (DDS) Disability Claim Adjudicators, Licensed Physician and Psychologist work together to make the correct Decision!

The DDS will contact the medical providers to obtain medical records.

“All Allegations must be documented”

The DDS may ask for additional information about how the condition affects daily activities

Social Security’s

Definition of Disability

A medical condition or

combination of

impairments preventing

substantial gainful

activity for at least 12

months, or expected to

result in death. The

determination also

considers age,

education & work

experience.

What is Substantial Gainful Activity

(SGA)?

“Gainful” work activity is: Work performed for pay or profit; Non-Blind $1090 per month or Blind $1820 per month or Work of a nature generally performed for pay or profit; or Work intended for profit, whether or not a profit is realized.

Important Information

Does the claimant have a representative?

SSA-1696

What is the alleged onset date?

What is the filing date?

What is the claimants age, education and work history?

MDI – Medically Determinable Impairment

When obtaining Medical Evidence, typically DDS will request records 12 months prior to the claimants Filing Date or Alleged Onset Date aka “AOD.”

DDS may request much older records, typically in an attempt to obtain objective medical evidence that establishes the presence of a longstanding MDI. -Examples:

School Records IQ Scores PET Scans Pathology Reports Chromosomal Testing (Karyotype Analysis)

Function Report Form aka ADL (Activities of Daily Living) • Adult Form: SSA-3373 • Child Form • 3rd Party

Work History Report: SSA-3369 Other Forms:

• Asthma Form • Seizure Questionnaire • Teacher Questionnaire – Children • SLP Questionnaire – Children

*NOTE- Incomplete and missing forms are one of the most prevalent roadblocks DDS

encounters preventing

efficient claims adjudication.

Initial letter sent to inform claimant of: Examiner Contact Info All medical sources written The potential of a Consultative Exam 15 day time limit on returning forms To contact DDS with any changes/updates to:

Address/Telephone number New Doctors Hospitalizations New medical conditions Return to work Change of schools

http://ssa.gov/disability/professionals/bluebook/evidentiary.htm

• Licensed physicians (MD) • Licensed osteopaths (DO) • Licensed or certified • psychologists (PhD) • Independent general practice • School psychologists • Licensed optometrists • Licensed podiatrists • Hospitals, clinics, or other health facilities. • Qualified Speech Pathologist SLP (CCC)

http://ssa.gov/disability/professionals/bluebook/evidentiary.htm

• Mental Health Therapists -LMSW - LPC • Social Workers - Social Service agencies • Physician Assistants • Audiologists • Chiropractors • Nurse Practitioners • Vocational Counselors • Teachers and School professionals • Parents/relatives, neighbors, friends, clergy • Day Care Providers

Medical History,

Clinical findings,

Testing and Laboratory findings

Diagnosis

Treatment

Medical source statement

Nature, severity, and limiting effects of impairment

Probable duration

Remaining capacity to work.

1. Is the claimant engaging in Substantial Gainful Activity aka “SGA”?

2. Does claimant have a severe impairment?

3. Does claimant Meet or Equal a listing?

4. Can claimant perform Past Relevant Work aka “PRW”?

5. Can claimant perform Other Work?

http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR86-08-di-01.html

The treating source is not asked or expected to make a decision whether an individual is disabled. This is reserved for the SSA Commissioner.

The Medical Source Statement (MSS) is the opinion of the treating source, based on their own medical findings, about what the individual's ability to perform work-related activities on a sustained basis (8 hours a day,5 days a week), in spite of the impairment.

This statement describes the applicant’s ability to:

Stand

sit

lift

carry

walk

handle objects

hear

speak

travel

Acquiring and using information Attending and completing tasks Interacting and relating with others Moving about and manipulating objects Caring for self Health and physical well-being Understanding and memory Concentration and persistence Social Interaction Adaptation

DDS will order Consultative Examinations (CE) when there is insufficient medical evidence to make a decision with claimants own treatment records.

Most common CE’s: Internal Medicine Exam Psychological Exam

DDS examiner typically will not schedule a CE until Function Report and/or Work History Reports are received indicating claimant’s willingness to cooperate.

A medical condition

or combination of impairments preventing them from doing things that children the same age normally do - for at least 12 months, or expected to result in death.

6 areas of function considered:

1. Acquiring & Using Information

2. Attending & Completing Tasks

3. Interacting & Relating with Others

4. Moving About & Manipulating Objects

5. Caring for Self

6. Health & Physical Well-Being

Once child's function is determined, it is compared with age-appropriate activities for that child.

Documentation generally required for childhood claims:

School Records: Teacher Questionnaires

http://www.socialsecurity.gov/forms/ssa-5665.pdf

SLP Questionnaires

IEPs

IQ Testing

Medical Records: Hospital Visits

MD/DO Office Records

Psychological Office Records

Xrays, MRIs, CT/CAT Scans, Pulmonary Testing, etc.

http://www.socialsecurity.gov/disability/professionals/bluebook/index.htm

12.02 Organic mental disorders: 12.03 Schizophrenic, paranoid and other psychotic disorders: 12.04 Affective disorders: 12.05 Intellectual disability: 12.06 Anxiety-related disorders: 12.07 Somatoform disorders: 12.08 Personality disorders: 12.09 Substance addiction disorders: 12.10 Autistic disorder and other pervasive developmental disorders:

38

Intellectual disability:

A. Mental incapacity evidenced by dependence upon others for personal needs (e.g., toileting, eating, dressing, or bathing) and inability to follow directions, such that the use of standardized measures of intellectual functioning is precluded; OR

B. A valid verbal, performance, or full scale IQ of 59 or less; OR

C. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment imposing an additional and significant work-related limitation of function;

Complete & Return Forms- Function Report Work History Report (*Especially age 50+) Most examiners will not schedule Consultative Examinations (CE)

until these forms are received.

To avoid claim denial for Failure to Cooperate (FTC), submit these forms ASAP.

Most forms have 15 day turnaround requirement. **DDS views receipt

of these forms as claimant’s willingness to cooperate. Be sure someone is listed as a 3rd party contact on the claim.

Assist claimant in confirming and attending CE’s.

We send an award notice that explains:

When benefits start and monthly benefit amount

Reporting Responsibilities

(Examples: work activity, medical improvement)

When the case will be reviewed

What to do if questions

Frequency of the Review? We will review your case periodically to see if you are

still disabled. The frequency of the reviews depends on the expectation of recovery.

If medical improvement is: “expected” your case normally will be reviewed within

6 to 18 months. “possible” your case normally will be reviewed no

sooner than (3) three years. “not expected” your case normally will be reviewed no

sooner than (7) seven years.

We send a letter explaining our decision

The decision can be appealed within 60 days after the notice is received

At the appeal, if anything has changed the application can be updated

Detroit P.O. Box 345 Detroit, MI 48231 Shiba Sanders 1-800-383-7155, ext. 66866 Shiba.Sanders@ssa.gov Kalamazoo P.O. Box 4020 Kalamazoo, MI 49003 Jenna Shackelford 1-269 337-3519 Jenna.Shackelford@ssa.gov

Professional Relations Officers

Lansing P.O. Box 30011 Lansing, MI 48909 Brice Edmonds

1-517-702-5440

Brice.Edmonds@ssa.gov

Traverse City P.O. Box 1200 Traverse City, MI 49685 James V. Parrish

1-800-632-1097 ext. 6738#

James.Parrish@ssa.gov