Disabilities guidebook: social security disability benefits (2024)

Medical evidence documenting the child’s medical condition is essential.

In evaluating whether a child is disabled, SSA uses the following four-step analysis:

As with adults, SSA has determined that certain medical conditions are automatically disabling. It has identified them in the "Listing of Impairments for Children."

The medical condition must matchone of the adult or child Listings. SSA will then find the child to be disabled. SSA may find a child disabled if the condition is "medically equal" in severity.

If the child’s condition does not meet or is not medically equal to a Listing, proceed to step four.

Suppose the child's condition does not meet or is not medically equal to one of the conditions in the Listings. Then, SSA may find the child to be eligible if the child's condition is "functionally equal” to a Listing.

Functionally equalmeans the impairment causes "marked and severe" limitations in the level of functioning, in:

Medical evidence must show the child’s medical impairment. In examining the child’s ability to function, SSA will look at information from those who observe the child. Evaluations for special education services and early intervention programs are also very important.

In determining whether a child has a marked limitation, SSA considers the child’s level of functioning in:

You can call toll free (800) 772-1213 to make an appointment to apply at your local Social Security office. You may apply for SSDI benefitsonline. You can also start an SSI applicationonline. However, you will need to go into a Social Security office to complete the application.

When you apply, you will need to give SSA information about:

SSA will ask you to complete a “Disability Report” form. It is very important to complete the form providing all the information requested. Medical evidence is very important in a disability case. No matter how sick you are, you will need medical evidence of your condition to obtain benefits. Therefore, it is important to seek medical treatment if you are thinking about applying for either SSDI or SSI.

SSA’s disability determination process, for adults or children, can take quite a bit of time. SSA has a presumptive eligibility process for some serious situations. For example, a person who has suffered a stroke and after three months has a great deal of difficulty walking.

Persons who are presumptively eligible can receive up to 6 months of benefits while SSA evaluates their cases. SSA has developed a quick determination process for situations like a terminal illness. It has expanded the quick determination process in recent years. It identifiestypes of medical problems that are so serious anyone who has the diagnosis meets SSA’s disability criteria. Persons with these conditions should be flagged for the quick determination process. Alistof these conditions is on the SSA website.

When it makes a decision on your application, SSA will send you a notice. The notice will explain whether you will receive benefits, and if so, in what amount.

If you disagree with the decision made by Social Security, you can appeal. See the belowAppeals section.

If you want to try to go back to work while you are on SSDI or SSI, it is important to try to plan ahead. You will not automatically lose your disability benefits if you go back to work. SSA has special rules called work incentives. They allow you to keep all or part of your benefits while you try out your ability to work. SSA’s rules concerning work, however, are complex and can be confusing. There are agencies in Illinois that can help you plan and determine how work earnings may affect your benefits. For agencies that can help you, see thedirectory of agencieson SSA’s website.

Note:Be sure to let SSA know if you start a job or leave a job. For SSI you must also report any changes in your monthly income, your assets, or your living situation. Changes can affect the amount of your benefit. Reporting right away will help you avoid any overpayment problems with SSA.Keep a record of any change that you report. Then you can show that you made a timely report even if SSA later claims it never received it.

For SSDI, there is a “Trial Work Period.” During this period you can receive full benefits regardless of how much you earn. You must report your work activity and continue to have a disabling impairment.

The [no-lexicon]Trial[/no-lexicon] Work Period is a total of nine months, not consecutive, in a 5 year period. The term “Trial Work Period” can be confusing. SSA allows you to try out your ability to work in a total of nine months without affecting your benefits. The months can be in a row or they can be spread out during the 5 year period. A month counts toward the nine-month total if you earn more than $1,110.

If during this 36 month period, your average earnings have been at least per month on a sustained basis. Then, SSA will continue your benefits for three more months and then will cut off all benefits. SSA can reinstate your benefits anytime during the 36 month period if your earnings go down below the $1,550level. If your average earnings have been less than $1,550per month on a sustained basis, your SSDI benefits will be unaffected. You will continue to receive your full SSDI payment in addition to your earnings.

After the 36 months end, if your earnings exceed the SGA threshold, your benefits will end. You will not be entitled to receive benefits in months in which your earnings drop below SGA. However, you may be entitled to expedited reinstatement if you become unable to work again.

Be sure to report all work. Unreported earnings are one of the most common reasons for overpayment. Do not assume that SSA will know you are working just because you are paying FICA taxes. Your earnings record will eventually reach SSA; in fact, this is how SSA spots overpayments. However, the information will not reach SSA in time to adjust your monthly benefits when they are paid. You must report your earnings to SSA.

SSA may review your eligibility and decide that you are no longer disabled because you can work.

If you lose your job or your wages are reduced, SSA can increase your SSI because of your reduced income. Suppose. SSA stops your SSI checks because of your earnings, but then you lose your job You can ask to start your benefits without a new application if it has been less than 12 months since you received your last SSI check. If it has been more than 12 months since your SSI stopped, you will need to file a new application for SSI.You may need to prove that you still meet the disability criteria.

In figuring your work earnings, SSA will deduct any work expenses related to your disability. These deductions include any items or services that you need to work, even if it is usefuldaily. Be sure to keep receipts or other records of these expenses and report them to SSA.

Examples of disability-related expenses:

Using this classification, SSA marks the case to determine whether you continue to be disabled.

SSA will plan to review your case in six months to 18 months if SSA expects your condition to improve. It will let you know that the case is scheduled for review in the same notice as the benefit approval. For example, medical improvement is expected where disability is based on a serious bone fracture. However, surgery is planned and could result in a return to work.

In other cases, SSA will review the case at some point between three years and seven years. It depends on the type of condition you have, and whether medical improvement is possible. SSA can also begin a disability review for other reasons, including that you return to work.

If SSA is reviewing your case to decide if you still are disabled, SSA will send you a letter about your review. You will have a chance to submit medical evidence to show that you still are disabled.

When SSA reviews your case, it starts by evaluating whether your condition has medically improved. The fact that you have done some work will not automatically mean you are no longer disabled. On the other hand, SSA may consider your work and the tasks you perform in deciding whether you are still disabled.

A Plan for Achieving Self Support (PASS) is a special program.It allows SSI recipients to set aside income and assets needed to achieve a specific work goal. The money and assets set aside will not act to reduce your SSI payment. The goal of your plan may be to start a business or get a job.

To develop a plan, you first set a work goal. Figure out what you need to reach that goal, such as training, materials, car, tools, etc., and determine the cost of these items or services. Your plan to achieve your work goal may require vocational training or college education. If so, be sure to include expenses for such training and education. When you have your plan and the expenses, you can complete the PASS application. See the SSA website for theform application.

You can get help with setting up the PASS plan from:

You submit the completed application to the local Social Security office.

An SSA representative trained in developing PASS plans will review to determine if it is reasonable. SSA’s representative should work with you, discussing the plan and making changes if necessary. The completed plan must:

If your plan is not approved, you can appeal that decision, or you can submit a new plan.

If your plan is approved, you can then set aside some of your income to be used toward meeting your PASS goals. The funds set aside will not affect your eligibility for benefits. You should place the money in a separate bank account so that you will be able to easily account for the funds. You should always keep a receipt when you use the money for expenses allowed under your PASS plan. SSA may contact you to make sure that you are doing what the PASS plan says and that you are on track to reach your goal. You must tell the SSA office in writing about the changes and the reasons and receive approval.

You should contact your local SSA office if you would like more information about creating a PASS plan.

HBWD provides the broad health coverage offered under the Medicaid program. Workers with countable income of up to 350% of the federal poverty guidelines may qualify for the program.

Unlike other Medicaid programs, under HBWD you can have up to $25,000 in assets. You will need to pay a monthly premium. The amount depends on your income.

HBWD is often used by persons with disabilities to avoid a Medicaid spend-down. If you are working and have Medicaid spend-down, you should explore applying for HBWD. In most cases, the premium you would pay for HBWD will be less than your spend-down amount.

If you have been eligible for SSDI benefits for 24 months or more, you may also be eligible for Medicare . For more information about the Medicare program, see "The Medicare Program."

After the initial waiting period, you will remain eligible for Medicare while you receive an SSDI check. If you work and never earn enough money to stop receiving an SSDI check, your Medicare will also continue . Even if you return to work and earn enough to stop your SSDI checks, Medicare will continue for several years. You will remain eligible for Medicare during the 9 month Trial Work Period. Also, during your 36 months Extended Period of Eligibility. After the Extended Period, even if you lose SSDI, you will be eligible for Medicare. This is true for at least a total of 93 months after the completion of the Trial Work Period. This is called “Extended Medicare.” The local SSA office can tell you the exact time period of your “Extended Medicare” coverage.

After the Extended period ends, if you are "disabled" but not 65, you may buy Medicare Part A and B. This will cost the same as the amount paid by uninsured, eligible, retired beneficiaries.

If the benefit payments exceed your needs, the payee is required to save the extra money in a safe manner. For example, savings bonds or a savings account, separate from the payee’s own funds. SSA requires payees to file periodic reports explaining how the money has been spent or invested. They can require receipts or other proof.

A payee must notify SSA about facts that may affect your eligibility or amount of benefits This includes such things as:

If you are under age 18: For a child with a disability, the parent or legal guardian caring for the child is the preferred payee. SSA may consider a parent who is not living with the child but supporting them or is otherwise strongly involved . SSA may also consider another relative or stepparent. If no such person is available, SSA may appoint a social agency or institution as payee.

If you are over age 18: You have the right to request your representative payee. Although there are no specific qualifications, the payee cannot have been convicted of a felony. The payee should be someone who sees you on a regular basis. Someone you can easily contact if you need something. SSA has guidelines ranking the potential payees. They generally prefer a spouse or other relative who has a strong concern for the person's welfare. If no such person is available, SSA will consider making a close friend the payee. If no such person is available, SSA may appoint an agency or institution as payee.

It is sometimes difficult for SSI or SSDI recipients to find someone who is able to be their payee. When that happens, a social service agency may be available to be the payee. In order to encourage these agencies, the SSA will allow them to charge a fee of up to $25 per month. The agency must get written approval from the SSA before the agency can collect any fee.

The SSA rules do not allow any payee other than an approved social service agency to collect a fee.

When a child's claim is approved, SSA must determine whether the child is eligible for retroactive SSI benefits. Those are benefits for the time from the application for SSI to the time the claim is approved. If the child is entitled to a lump sum back benefit award that equals 6 times the maximum benefit amount. Those benefits must be placed into a special separate bank account. This special account is called a "dedicated account." Any interest earned must remain in the account.

The payee may use the money only for items directly related to the child's disability. This includes:

It is not a good idea for the payee to deposit other money, like their own money, into the account. Any money in the account is subject to SSA’s limits on use.

A payee should get pre-approval from SSA before taking any money for an item other than those listed. The payee must repay money used from a child’s account that is not related to the disability.

It is common for recipients to receive a notice that they have received benefits to which they were not entitled. This is called an "overpayment." Usually, SSA will require you to pay back any overpaid benefits. SSA will reduce your current benefits until the money is paid back. SSA has other ways to collect overpayments too. For example, if you file taxes and expect a refund, the government may take that refund. Overpayments occur when recipients have new sources of income and their benefits are not promptly reduced. If you don’t promptly report changes in your case that affect your benefits, you may also receive an overpayment.

If you receive a notice of overpayment, you have the right to appeal. You should file an appeal if you believe that SSA is wrong in saying that you received an overpayment. Also, if you believe that the amount of the overpayment is less than SSA claims. The deadline for filing an appeal is 65 days from the date on the notice of overpayment. See the belowAppeals section.

Even if you agree that you received an overpayment, you can ask that you not be required to pay the money back. This is called a "Request for Waiver of Recovery of Overpayment," commonly called a "waiver." You may request a waiver atany time, by completing a written form available at your local SSA office.

In order to qualify for a waiver, you must prove that you were not responsible for causing the overpayment. You must show that:

SSA denies many applications for disability benefits. Denials often occur because there was not enough medical evidence to prove a disabling problem. More than 50% of appeals are successful. If SSA denies your claim, strongly consider filing an appeal. Many people give up, wait a period of time, and reapply. In most cases, it is a better decision to file an appeal rather than to wait and to reapply.

You should also consider appeals in other cases. You can appeal if you believe that SSA wrongly reduced or terminated your benefits. Also, if SSA takes wrongful actions, such as finding an overpayment or requiring a representative payee.

Suppose you are already receiving benefits, and SSA sends you a notice to reduce or terminate. In that case, you may be able to keep your benefits while you appeal. You will need to act quickly to appeal, usually within ten days of receipt of the notice. Indicate on the appeal form that you wish to continue to receive your benefits during the appeal. For example, if SSA decides you are no longer disabled and sends you a notice, you may choose to keep your benefits until a judge issues a decision.

There levels of the Appeal Process are as follows:

If you are denied after Reconsideration, SSA will send you another notice.You have 65 days from the date on that notice to make a written request for a hearing before an ALJ.ALJs are administrative judges hired by SSA to conduct hearings.

If you request an ALJ hearing, you can appear with witnesses and testify about your problems and how they affect you. The ALJ may arrange for a medical or vocational expert to attend the hearing and testify. After the hearing, the ALJ will notify you in writing of the decision and explain the reasons. You may not receive the decision for several months.

Establishing disability under SSA’s rules is a complex process. It is important to give the ALJ all the medical information that shows you meet the criteria. You do not need to have a lawyer. However, it can be very helpful to have a lawyer represent you to show how you meet the criteria.

A large percentage of cases are approved at the ALJ hearing stage of the appeal process.

If the ALJ decision is not favorable, you can appeal again to the Appeals Council.You have 65 days from the date of the ALJ's notice to make a written request for review by the Council.

At this level, a review is somewhat limited. The Appeals Council will review the ALJ hearing record and the ALJ decision to see if:

You can explain all the reasons you want the Appeals Council to consider when you submit your request for review. In your request, you can ask the Appeals Council for additional time to submit a written argument. You may also submit new evidence for the period up to the date of the ALJ's decision. You will need to explain that the evidence was not available to you earlier.

The Appeals Council can:

If the Appeals Council upholds the ALJ's denial of your claim, you have 60 days to file a lawsuit.You may file a civil action in U.S. District Court where you live within 60 days after you receive notice of the Appeals Council's decision. Filing a federal lawsuit is a big task, and consulting an attorney is highly recommended. Some courts have programs to provide information to persons who want to file a lawsuit but don’t have a lawyer.

This level of appeal is also very limited. The judge will review to see if the Appeals Council fairly considered all evidence and properly applied the law. In general, you cannot introduce new evidence at this point. You may file a written argument in support of the case.

To file a request for reconsideration, request an ALJ hearing or request review by the Appeals Council, you can call SSA’s toll-free number, (800) 772-1213, or go to your local SSA office. Tell the representative you want to appeal the decision made on your case, and explain what the decision was. Have the decision in front of you when you call. If you go to the SSA office, take the notice of decision you are appealing with you.

SSA also offers an option to appeal a disability denial online. That includes a request for reconsideration or a request for a hearing before an ALJonline. Currently, you cannot request Appeals Council Review online.

At each stage of the appeal process described above, there is a time limit within which you must file an appeal. If you miss that deadline, SSA will consider your appeal only if you show that you had "good cause" for the delay.

Good cause includes:

The federal statute relating to the SSDI program can be found at 42 USC § §405,423. The federal regulations for that program can be found at20 CFR Part 404.

The federal statute relating to the Supplemental Security Income (SSI) program can be found at42 USC § 1381. The federal regulations for that program can be found at 20 CFR Part 416.

To apply for benefits or to file an appeal, contact your local Social Security office, or call (800) 772-1213(v) or (800) 335-0778 (TTY) for information and assistance.

More information can be found at the Social Security Administration'swebsite.