Individuals suffering from a physical or mental condition that keeps them from being able to work face many problems. Among these are the loss of income from a job and, frequently, loss of insurance. Thus, people needing access to health care the most are often the least able to get it. If a person who is unable to work is able to qualify for disability benefits under the Social Security Act, some household income can be provided and, in addition, access to Medicaid becomes available if benefits are allowed under the SSI program.
People seeking benefits under the Social Security Act will primarily be seeking benefits under either or both of the following programs: The first program is under Title II of the Social Security Act and provides Disability Insurance Benefits (DIB). This program provides payment to the person based upon the earnings paid into the Social Security system. The patient becomes eligible, if he qualifies, for an amount equal to 100% of his age 65 retirement benefits. This benefit is available based upon a showing that the individual is "disabled" within the meaning of the Social Security Act.
The second program that a patient may apply for is Supplemental Security Income (SSI). To qualify, the patient must be "disabled" and, in addition, household income must not be above a certain level. If an individual meets both of these criteria, he will be eligible for approximately $500.00 per month and, in addition, benefits under the Medicaid program. Generally, the access to the healthcare system available through Medicaid is even more important to the person than the monthly check. There is no requirement that a person have ever worked in order to establish eligibility for SSI.
Social Security Administration Procedure
It should be borne in mind that the Social Security Administration requires that fairly stringent criteria be met in order to qualify for Social Security benefits under either of these two programs. The definition of "disability" under both the DIB and SSI programs is the same.
To determine whether an individual is qualified for benefits, the Social Security Administration utilizes a five-step process commonly known as the sequential evaluation process.
Step One
First, it must be determined whether the individual is working. If the patient is working, and the work being done is "substantial gainful activity", the Social Security Administration is required to find that the patient is not disabled without regard to the patient's medical condition. "Substantial Gainful Activity", in general, means that the individual is earning less than $700.00 per month. If the individual earns more than $700.00 per month, a presumption arises that the individual is engaged in "substantial gainful activity" and thus is precluded from drawing benefits under the Social Security Act. It is important to note that "earnings" are different from "income". A person is not disqualified due to having, for example, dividend income or rental income in an amount which exceeds $700.00. The issue is whether the person has earnings.
The Social Security Regulations define "disability" as "the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve (12) months." In addition, the Regulations require that an individual have "a severe impairment which keeps the patient from being unable to engage in their previous work or any other substantial gainful activity which exists in the national economy."
If the patient is not engaged in "substantial gainful activity" (step 1 of the sequential evaluation process), the process goes to step 2.
Step Two
The second step is to determine whether the individual has a "severe impairment". A "severe impairment", for purposes of the Social Security Act, does not require that the impairment be severe in the sense that term is normally utilized. An impairment is severe if it "significantly limits" a person's physical or mental ability to do basic work activity.
It is important to note at this juncture that the Social Security disability program is not geared so much to the nature of the impairment as it is the impact that the medical condition has upon the individual's ability to engage in work related activity. Accordingly, if an individual suffers from a profound medical problem, but that medical problem does not significantly impact upon the individual's ability to engage in work related activity, the individual's claim for benefits will be denied based upon the impairment not being "severe".
If the physical or mental condition, or combination of these problems, limits the individual's ability to engage in basic work activities, then the inquiry continues to the third step of the sequential evaluation process. It is important to note that the Regulations require the Social Security Administration to consider the combined effect of all the person's impairments, without regard to whether any such impairment, if considered separately, would be a sufficient severity to qualify alone for benefits. Thus, if an individual suffers from depression, diabetes or other physical or mental impairments, these impairments must be considered and quantified in determining whether the individual is "disabled".
A determination that a disability claimant's medical impairment is not "severe" is only appropriate when a claimant's impairment or impairments, either singularly or in combination, is slight. "An impairment can be considered as not severe only if it is a slight abnormality which has such a minimal effect on the individual that it would not be expected to interfere with the individual's ability to work, irrespective of age, education, or work experience."
The severe impairment must, however, meet the duration requirement. The impairment must be of sufficient severity as to preclude substantial gainful activity for a period of not less than twelve (12) consecutive months or, in the alternative, be of such severity that it can be expected to result in death.
Step Three
At the third step of the sequential evaluation process, it must be determined whether the individual has an impairment or combination of impairments which meet or equal the Listings. If the patient has an impairment or impairments which meet the duration requirement, and meets the following criteria described, the Social Security Administration is required to find the person disabled without consideration of the person's age, education or work experience.
If the patient has a condition which meets or equals a Listing, a finding of "disabled" is required and the other two steps (steps four and five) described herein are inapplicable.
Step Four
At the fourth step of the sequential evaluation process, it must be determined whether the impairment or combination of medical impairments prevent the person from being able to engage in his past relevant work. If the person can do any of the work on a full time, 40 hour basis that he has done in the last fifteen (15) years, the Regulations require that the person be found "not disabled."
Step Five
If the person cannot do past relevant work, further inquiry is made (at the fifth step of the sequential evaluation process) to determine whether other jobs exist in significant numbers in the national economy that the person can perform. At this step, other factors are considered, including the person's age, education, and skills obtained through past work experience.