Medical/Professional Relations

Answers for Doctors & Other Health Professionals

Doctors and other health professionals play a major role in ensuring that their patients are aware of the provisions of the Social Security disability programs. This booklet answers the questions most frequently asked by doctors and other health professionals; e.g., who is eligible; how is disability determined under Social Security law; and how does work affect benefits?

1. What are Social Security's Disability Programs?

The Social Security Administration (SSA) manages two programs which pay monthly disability benefits to people under age 65 who cannot work for at least a year because of a severe disability: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Medical requirements are the same for both programs.

SSDI benefits are paid to people who have worked long enough and recently enough under the program. Those who have been receiving benefits for at least 24 months also qualify for Medicare coverage. SSI disability payments are made to adults and children with limited income and resources. No prior work is needed. SSI recipients generally qualify for Medicaid, a State-run health assistance program.

2. What exactly is SSA's definition of disability?

For adults, the Social Security law defines disability as the "inability to engage in any substantial gainful activity (SGA) 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 12 months."

A child is considered to be disabled under Social Security law if the child has any medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

3. Why is SSA's definition of disability so strict?

The disability programs are designed to provide long-term protection to individuals who are totally disabled, using Social Security criteria, and unable to do any kind of work in the national economy (or, for children, if their impairment or combination of impairments does result in marked and severe functional limitations). This is the most difficult type of disability to protect against, and most people and their employers cannot afford to protect against this risk through other means. Short-term disability can be provided for through other means; e.g., workers' compensation, insurance, family, savings and investments.

Thus, as you can see, the disability program is meant to provide benefits for only those with the most serious impairments. In that respect, it may be considered very "strict."

4. Who gets disability benefits?

Social Security disability benefits can be paid to:

• Disabled workers under 65 and their families;

• Individuals who become disabled before 22, if a parent (or in certain
  cases, a grandparent) who is covered under Social Security retires,
  becomes disabled, or dies;

• Disabled widows or widowers, age 50 or over, if the deceased spouse
  worked long enough under Social Security. This also applies to certain
  disabled surviving divorced spouses over 50;

• Blind workers.

5. Who can receive SSI?

Supplemental Security Income disability payments can be made to:

• Disabled persons under 65 who have very limited income and resources;

• Disabled children under 18;

• Blind adults or children.

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6. Who determines whether a person is disabled?

A determination as to whether a claimant is disabled as defined in the law is made for SSA by a team, composed of a physician/psychologist and a disability examiner, working in the disability determination services (DDS) of the State in which the claimant lives. Typically, the physician or psychologist in the DDS maintains a private practice in addition to serving as a member of the team responsible for making the disability determination.

7. Why are patients, who, in my opinion, have severe disabilities
    denied disability benefits by Social Security?

The disability team in the DDS must evaluate all of the elements involved in a disability determination, some of which may not be apparent to the treating physician/psychologist. These would include, when appropriate, age, vocational and educational factors that may contribute to the patient's ability to work.

8. Is it likely that a person considered "disabled" under another
    program will be found disabled by Social Security?

Not necessarily. The rules in the Social Security law for determining disability differ from those in other Government and private programs.
A person eligible for disability payments under one program may not be eligible under Social Security. However, a decision made by another agency and medical reports it obtained will be considered in determining whether a person is disabled for Social Security purposes.

9. Does the DDS team also examine the applicant?

No. It relies entirely on the evidence in the claims folder reported by you and others who have examined or treated the claimant. The DDS examiner or physician/psychologist may contact you to clarify information you submitted, or for additional information.

10. Do all State DDSs use the same medical criteria?

Yes. There is one set of medical criteria used by every DDS. This ensures uniform and consistent adjudication of a claim no matter where the claimant lives.

11. How are Social Security's disability evaluation criteria developed
      and why does it take so long to update or revise them?

These criteria are developed by Social Security medical consultants and other program and medical experts. Any change in the medical evaluation criteria for Social Security disability must reflect the latest approved, established medical practices and procedures. This necessarily requires careful and complete consideration of proposed revisions, a process that involves public review and comment.

12. How do I get a copy of the medical evaluation criteria?

The medical evaluation criteria (commonly referred to as the "Listing of Impairments" or the "Listings") is available online at Disability Evaluation Under Social Security.

13. How is the Listing of Impairments used in deciding cases?

In general, the Listing of Impairments is used as the standard by which the severity of the impairment is evaluated. If a claimant has a severe impairment or combination of impairments that meets the duration requirement and is included in the Listings ("meets"), or is medically equivalent in severity to a listed impairment ("equals")--and is not working--he or she generally would be considered disabled. If the claimant is doing substantial gainful work, he or she ordinarily would not be considered disabled under the law, despite the severity of the impairment.

Many findings of disability can be made based only on medical considerations. But, as mentioned earlier, if a claim cannot be decided on medical factors alone, then the person's age, education, and work experience are considered.

14. What type of information should be included in the medical report
      for a patient?

Your report should include the history and clinical and laboratory findings, as well as the diagnosis and treatment prescribed and the response to treatment--as much objective information from the patient's chart as possible. You also should include a statement about what work activities the patient can still do despite his/her impairment.

15. How important is my statement about what my patient can still do?

Your statement about what work activities the patient can still do despite his/her impairment, based on the history and clinical and laboratory findings that you provide, can be very important to the decision on whether your patient is disabled as defined by the law. Generally, we will consider the opinion of a physician or other medical source who is treating the patient on a continuing basis more persuasive when it is well supported by the clinical and laboratory findings and consistent with other evidence in the patient's record. Therefore, it may occasionally be necessary for the State DDS to recontact you for additional information if they do not have sufficient information to make a decision.

Since it is our responsibility under the law to decide whether a claimant is "disabled" or "unable to work", we cannot consider your opinion on these issues or your opinion that a patient has an impairment or combination of impairment that meets or equals those described in the Listings of Impairments. However, we will consider the medical findings that support your opinion when the decision is made on whether your patient is disabled.

16. Who pays for the report?

Social Security can pay a reasonable amount for reports of existing medical evidence it requests from physicians/psychologists, hospitals and other non-Federal providers of medical services. Contact your DDS for its payment information.

17. Is the initial report from the treating physician/psychologist all the
      medical information that the DDS team needs to decide a case?

In many cases, yes. Frequently, reports from other treatment sources, such as hospitals and clinics, also are used. If the DDS requires certain clinical or laboratory data that was not reported, the DDS may call or write you to find out if you have the needed information in your records.

18. Suppose I do not have the information requested?

Then the DDS may ask if you wish to provide the information by performing tests or an examination for a fee paid by the DDS; or the DDS may send the claimant to an independent medical source for an examination and the required information--if you prefer not to do the examination or do not have the equipment to provide the specific data needed. These are called "consultative examinations (CEs)."

19. Who are these "independent medical sources"?

Generally, they are physicians and psychologists in private practice in all specialties. If you are interested in performing CEs, contact the DDS in the State where you practice.

20. How are the fees for consultative examinations set?

Each State determines the rate of payment to be used for purchasing medical or other services necessary to make determinations of disability, and fees vary from State to State. Federal regulations require that the rates may not exceed the highest rate paid by Federal or other public agencies in the State for the same or similar type services.

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21. It takes a lot of time to write up medical reports on my
      consultative examinations. Can I phone them in?

Yes. Many State agencies (generally referred to as the "Disability Determination Services") may employ a teledictation service which enables the consultative physician/psychologist to do just that. The service can be used at any time, including nights and weekends. You receive a typed transcript of your telephoned report to review, sign, and return to the State agency.

22. If I perform consultative examinations, are there any legal
      considerations of which I should be aware?

Yes. When the DDS contracts with you to do consultative examinations (CEs), you are an independent contractor, and are responsible for conducting the examination in a proper manner, just as you do with your own patients. The DDS does not offer you protection in this situation. We do point out, however, that since you will be conducting an examination only, and performing only those tests that the DDS authorizes, not prescribing treatment, there is little chance of any legal action being filed against you. (Additionally, the DDSs do not order invasive tests.) The claimant is advised beforehand that the consultative physician/psychologist does not make the disability determination and that the "CE" evidence is evaluated along with all other evidence in the claim.

23. Can a person appeal a medical determination that he or she is not

Yes. There are several levels of appeal. They are explained in the fact sheet, "The Appeals Process", which is available at any Social Security office.

24. Do benefits stop when a disabled worker who has not recovered
      goes back to work?

Generally, not right away. A continuing disability review (CDR) is scheduled periodically to determine if there has been any medical improvement sufficient to permit the person to work again. The evidence on which a determination is based includes evidence from the person's own medical source, including a statement about the person's ability, despite his or her impairments, to do work-related physical or mental activities. Additional medical/psychological examinations or tests may be required.

A person who attempts to work may continue to receive up to 4 years of support and services involving cash payments and/or health care coverage. These include:

. Nine months of trial work, called a "trial work period" (TWP)
  (not necessarily consecutive) during which a person may continue to
   receive benefits regardless of amount of earnings;

. A 36-month extended period of eligibility following the end of the 9-month
  TWP during which benefits may be paid for any month earnings fall below
   the SGA level (up to $500);

. Continuation of Medicare for at least 39 months after the trial work period;

. Deduction from gross earnings of impairment-related work expenses in
  deciding if earnings constitute SGA. (These include wheelchairs and
  seeing-eye dogs.)

. Continuation of monthly payments and Medicare or Medicaid for a person
   whose impairment has shown medical improvement related to the ability
   to work, if the person is participating in an approved vocational
   rehabilitation program which is expected to result in allowing the individual
   to work and become self-supporting.

Additional information about these and other work incentive provisions is contained in the pamphlet, "Working While Disabled: How Social Security Can Help"; in the leaflet, "Benefits for Disabled People Who Return to Work"; and in SSA Publication No. 64-030, Red Book on Work Incentives: A Summary Guide to Social Security and Supplemental Security Income Work Incentives for People with Disabilities, which are available at any Social Security office.

25. What are "continuing disability reviews" (CDRs)?

The Social Security law requires that all disability cases be reviewed periodically to make sure that individuals are still disabled. The frequency of reviews depends on the nature and severity of the impairment, the likelihood of improvement and other factors. Reviews may range from 6 months for cases where medical improvement is expected, up to 7 years where medical improvement is not expected.

A person's disability benefits generally will continue unless there is strong evidence of both medical improvement and ability to work. There are some exceptions which apply in relatively few instances.

During a review, you may be asked to provide current medical evidence. If an additional examination or test is needed, the DDS team may request you to conduct it; or the individual may be sent to an independent medical source.

A person who gets a notice that he or she is no longer disabled under the definition in the law, may appeal the determination; he/she has special rights not available to those denied upon initial application for disability benefits. The individual may meet face-to-face with the decisionmaker during the first level of appeal (reconsideration). Benefits may be continued through the first two levels of appeal if this is requested within 10 days after a determination notice is received.

26. How does Social Security identify cases where a disabled
      person's condition improves?

Because disabled people are required to inform us if their conditions improve or if they return to work, we may learn of the improvement through such self-reporting, or the improvement may be determined as a result of a review of such persons' cases.

27. What happens if the individual becomes disabled again?

If a worker becomes disabled again within 5 years after a previous period of disability, he or she will not have to serve a new 5-month waiting period before disability benefits may resume. In addition, if the person was previously entitled to Medicare, that protection will resume immediately. (This provision also applies to disabled widows and widowers and adults disabled before age 22 whose benefits start again within 7 years.)

28. Can a person receive disability checks from both Social Security
      and another government agency?

Yes. However, Social Security benefits to a disabled worker and family may be affected if the worker is also eligible for Workers' Compensation (including black lung) or for disability benefits from certain Federal, State or local government programs.

Total combined payments to the worker and family from Social Security and any of these other programs generally cannot exceed 80 percent of the worker's average current earnings before the disability began. The monthly Social Security benefit is reduced when necessary to keep within this limitation. All of the worker's earnings covered by Social Security, including amounts above the maximum taxable by Social Security, may be considered when figuring average earnings.

29. I understand that there are special provisions for blind persons.
      What are they?

A person who, in the better eye, with the use of corrective lenses, has either a visual acuity of 20/200 or less or a visual field restricted to 20 degrees or less, is eligible for disability benefits if he or she has worked long enough under Social Security. A blind person who is eligible for SSI needs no Social Security work credits.

A blind person is eligible under Social Security for a disability "freeze" even though working. This means that future benefit amounts, which are figured on average earnings, will not be reduced because of low earnings or no earnings in some years because of blindness.

Even if a blind person is now employed or self-employed, he or she may benefit from one of several special provisions for blind people who work. For additional information, see the SSA Fact Sheet, "Benefits for Disabled Social Security Beneficiaries/Recipients who Work" or contact any Social Security office.

30. How can I get more information for my patients?

You may contact any Social Security office for more information on any of the facts reported in this booklet. The toll-free number is 1-800-772-1213.

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