Disability Evaluation Under Social
Part I - General Information
The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (Act)) and the Supplemental Security Income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to disabled individuals who are "insured" under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides SSI payments to disabled individuals (including children under age 18) who have limited income and resources.
The Act and SSA's implementing regulations prescribe rules for deciding if an individual is "disabled." SSA's criteria for deciding disability may differ from the criteria applied in other government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) 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.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a 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.
What is a "Medically Determinable Impairment"?
A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. The medical evidence must establish that an individual has a physical or mental impairment; a statement about the individual's symptoms is not enough.
The Disability Determination Process
Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called Disability Determination Services, or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA's Office of Disability Adjudication and Review (ODAR).
Social Security Field Offices
When an individual applies for disability benefits, whether online, in person, by telephone, or by mail, the application is initially processed at an SSA field office. The completed application and related forms provide information about the claimant's impairment(s); names, addresses, and telephone numbers of medical sources; and other information that relates to the alleged disability. (The "claimant" is the person who is requesting disability benefits.)
The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, citizenship and residency, and Social Security coverage information. For SSI eligibility, the field office verifies income, resources, and living arrangement information. The field office sends the case to a DDS for disability evaluation.
State Disability Determination Services
The DDSs are State agencies responsible for developing medical evidence and making the initial determination about whether the claimant is or is not disabled or blind under the law. These State agencies are fully funded by the Federal Government.
Usually, the DDS obtains evidence from the claimant's own medical sources first. When the evidence is unavailable or insufficient to make a determination, the DDS may arrange a consultative examination (CE) to obtain additional evidence. The individual's own medical source(s) is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part II, Evidentiary Requirements, for more information about CEs.)
After completing its development, the DDS makes the disability determination. An adjudicative team consisting of a medical or psychological consultant and a disability examiner usually makes the determination. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source and ask for additional information.
The DDS will refer the case to the State vocational rehabilitation (VR) agency if the claimant is a candidate for VR.
The DDS returns the case to the field office after making a disability determination. The field office takes appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant to be disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found to be not disabled, the file is retained in the field office in case he or she decides to appeal the determination.
If the claimant appeals an initial determination, the appeal is usually handled much the same as the initial claim with the exception that a different adjudicative team in the DDS than the one that handled the original case makes the reconsideration determination.
Office of Disability Adjudication and Review
Claimants who are dissatisfied with the reconsideration determination may request a hearing before an administrative law judge (ALJ) in ODAR. The claimant may submit additional information and evidence to the ALJ, and the ALJ will issue a decision based on all the evidence of record, including evidence obtained at the hearing.
When an ALJ needs additional evidence, the hearing office frequently coordinates with the DDS to obtain the evidence. However, hearing offices may also contact medical sources directly. In some circumstances, an ALJ may issue a subpoena requiring production of evidence or testimony at a hearing.
The Role of the Health Professional
Health professionals play a vital role in the disability determination process and participate in the process in a variety of ways:
- As medical sources who provide medical evidence on behalf of their patients;
- As CE sources who perform, for a fee, examinations or tests that are needed;
- As full-time or part-time medical or psychological consultants reviewing claims in a DDS, in one of SSA's regional offices, or in SSA’s central office; or
- As medical experts who testify at ALJ hearings or respond to written interrogatories from the ALJ.
Claimant’s Own Medical Sources
A medical source who has evaluated, examined, or treated a claimant is usually the best source of medical evidence about the nature and severity of a claimant's impairment(s).
If an additional examination or testing is needed, SSA usually considers a claimant’s own medical source to be the preferred source for performing a CE.
Consultative Examiners for the DDS
In the absence of sufficient medical evidence from a claimant’s own medical sources, SSA, through the State DDS, may request an additional CE(s) to be performed by licensed medical sources (such as physicians and psychologists). All CE sources must be currently licensed in the State and have the training and experience to perform the type of examination or test SSA requests.
Each State establishes the set fee for CEs, and fees may vary from State to State. Each State agency is responsible for comprehensive oversight of its CE program.
Medical professionals who perform CEs must have a good understanding of SSA's disability programs and their evidentiary requirements. In addition, these medical professionals are made fully aware of their responsibilities and obligations regarding confidentiality and:
- CE scheduling intervals;
- CE report content;
- Elements of a complete CE;
- When a complete CE is not required; and
- Signature requirements.
See Part II of this guide for more information about CEs.
Program Medical Consultants and Psychological Consultants
Medical consultants, who are physicians, and psychological consultants, who are psychiatrists and psychologists, review disability claims at the State, regional, or national levels. During a case review, a medical or psychological consultant usually has no contact with the claimant.
Administrative law judges may request medical expert testimony on complex medical issues. Each hearing office maintains a roster of medical experts who are called to testify as expert witnesses at hearings or to respond to written interrogatories. The experts are paid a fee for their services.
Confidentiality of Records
Two separate laws, the Freedom of Information Act and the Privacy Act, have special significance for Federal agencies. Under the Freedom of Information Act, Federal agencies are required to provide the public with access to their files and records. This means the public has the right, with certain exceptions, to examine records pertaining to the functions, procedures, final opinions, and policy of these Federal agencies.
The Privacy Act permits an individual or his or her authorized representative to examine records pertaining to him or her in a Federal agency. For disability applicants, this means that an individual may request to see the medical or other evidence used to evaluate his or her application for disability benefits under the Social Security or the SSI programs. (This evidence, however, is not available to the general public.)
SSA screens all requests to see medical evidence in a claim file to determine if release of the evidence directly to the individual might have an adverse effect on that individual. If so, the report will be released only to an authorized representative designated by the individual.
Questions and Answers about Social Security Disability Programs
This information is designed to provide a more thorough understanding of the disability programs that SSA administers. Following are some of the most frequently asked questions about these programs.
Q. Who can get disability benefits under Social Security?
A. Under the Social Security disability insurance program (title II of the Act), there are three basic categories of individuals who can qualify for benefits on the basis of disability:
- A disabled insured worker under full retirement age.
- An individual disabled since childhood (before age 22) who is a dependent of a parent entitled to title II disability or retirement benefits or was a dependent of a deceased insured parent.
- A disabled widow or widower, age 50-60 if the deceased spouse was insured under Social Security.
Under title XVI, or SSI, adults and children under age 18 who have limited income and resources can receive payments based on disability or blindness.
Q. How is the disability determination made?
A. SSA’s regulations provide a procedure known as the "sequential evaluation process" for disability evaluation. For adults, this is a five-step process that requires sequential review of:
- the claimant's current work activity (if any),
- the severity of his or her impairment(s),
- a determination of whether his or her impairment(s) meets or medically equals a listing (see Part III of this guide),
- the claimant's ability to perform his or her past relevant work, and
- his or her ability to do other work based on age, education, and work experience.
For children applying for SSI, the process requires sequential review of:
- the child's current work activity (if any),
- the severity of his or her impairment(s), and
- an assessment of whether his or her impairment(s) meets, medically equals, or functionally equals a listing.
If SSA can find an adult or child either disabled or not disabled at any step, the evaluation is complete.
Q. When do disability benefits start?
A. Disability benefits for workers and widows usually cannot begin for 5 months after the established onset of the disability. Therefore, Social Security disability benefits will be paid for the sixth full month after the date the disability began. The 5-month waiting period does not apply to individuals filing as children of workers. Under SSI, disability payments may begin as early as the first full month after the individual applied or became eligible for SSI.
In addition, under the SSI disability program, an applicant may be found "presumptively disabled or blind," and receive cash payments for up to 6 months while the formal disability determination is made. The presumptive payment is designed to allow an individual with limited income and resources to meet his or her basic living expenses during the time it takes to process the application. If it is finally determined that the individual is not disabled, he or she is not required to refund the payments. There is no provision for a finding of presumptive disability or blindness under the Title II program.
Q. What can an individual do if he or she disagrees with the determination?
A. If an individual disagrees with the initial determination in the case, he or she may appeal it. Usually, the first administrative appeal is a reconsideration. At the reconsideration appeal level, generally the case is reviewed at the State level by an adjudicative team that was not involved in the original determination. If dissatisfied with the reconsideration determination, the individual may request a hearing before an administrative law judge. If the individual is dissatisfied with the hearing decision, he or she may request review by the Appeals Council. In general, a claimant has 60 days to appeal an unfavorable determination or decision. Appeals must be filed in writing and may be submitted by mail, in person to any Social Security office, or online where available.
After an individual has completed the administrative appeals process, he or she may seek judicial review by filing a civil action in Federal district court.
Q. Can individuals receiving disability benefits or payments get Medicare or Medicaid coverage?
A. Medicare helps pay hospital and doctor bills of disabled or retired people who have worked long enough under Social Security to be insured for Social Security benefits. It generally covers people who are 65 and over; people who have been determined to be disabled and have been receiving benefits for at least 24 months or have amyotrophic lateral sclerosis; and people who need long‑term dialysis treatment for chronic kidney disease or require a kidney transplant. In general, Medicare pays 80 percent of reasonable charges.
In most States, individuals who qualify for SSI disability payments also qualify for Medicaid. States may refer to the Medicaid program by different names. The program covers all of the approved charges of the Medicaid patient. Medicaid is financed by Federal and State matching funds, but eligibility rules may vary from State to State.
Q. Can someone work and still receive disability benefits?
A. Social Security’s “work incentive” rules make it possible for people to test their ability to work without losing their eligibility for cash benefits and Medicare or Medicaid. The rules are different for title II and title XVI, but under both programs they may provide:
- continued cash benefits;
- continued help with medical bills;
- help with work expenses or;
- vocational training.
For more information about work incentives, ask any Social Security Office for the publication entitled the "Red Book," A Summary Guide to Employment Supports for Persons with Disabilities under the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) Programs. You can access the Red Book online at: