1. Overview of Social Security Disability & Medicaid
Health Justice Clinic
2018

2. Disability Income Social Security Programs:
Social Security Disability Income (“SSDI” “Title II”)
Supplemental Security Income (“SSI” “Title XVI”
Private Disability Insurance
Short Term Disability
Long Term Disability

3. Social Security Disability Insurance (“SSDI”) (“Title II”)
Monthly cash benefit to disabled persons and dependents
Insurance – based on payroll taxes (FICA)
Must have worked long enough and recently enough (5 out of last 10 years)
Payment amount dependent on earnings history
No “partial” disability.

4. Supplemental Security Income (SSI) (“Title XVI”)
Monthly benefits to aged, blind or disabled persons
Needs-based program, considers income and assets
Payment amount supplements any other income up to a maximum
Year 2018 maximum payment: $753 per month
(This link has updated maximum benefit amounts.

5. Social Security: Comparisons
Both programs use the same rules to determine whether claimant is disabled
Different rules for financial eligibility
Both programs governed entirely by federal law
Statute
Regulations
Agency Rulings (“Social Security Rulings”)
POMS (Program Operating Procedures)
HALLEX (Hearing Office Rules)

6. Medicaid
Joint Federal and state health insurance for uninsured low-income/resource people
Administered by the stt
In non-expansion states, like NC, only select groups of people can qualify for Medicaid
Can qualify if disabled under the SSA rules for disability
Appeals heard by State hearing officers

7. Statutory Definition of Disability
Severe mental or physical impairment
Medically verifiable by lab tests, physical examination or other objective medical procedures
has lasted, or is expected to last, at least twelve consecutive months or result in death
renders claimant unable to engage in substantial gainful activity (“SGA”)

8. Three domains Medical Functional Capacity Vocational Impairments
Identifying them
Proving them with medical records, tests, labs, etc
Functional Capacity
Limitations that result from impairments and/or treatments
What causes them?
Vocational
Client’s vocational history
Job analysis
How the functional limitations affect work related activities

9. Disability application process
Initial application
Filed at local Social Security office or online
Disability evaluation done at State Agency (Disability Determination Service)
Should take a couple months – often takes much longer
About on third approved.
If denied: Request for Reconsideration
File within 60 days of denial (paper or online)
DDS again looks at whether claimant is disabled
This can take a couple months up to 4-6 months or more
About 10% approved

10. Further appeals
Administrative Hearing (after denial of reconsideration)
Hearing before Administrative Law Judge (Raleigh, Wilmington, Fayetteville, Greensboro, Charlotte, etc.)
Wait time for hearing months from time of request for hearing
Approval rate 52% in NC
Appeals Council (approved or remanded: 12%)
Federal Court (reversed or remanded: 49%)

11. Two important limitations
Substance Abuse:
Claimant may not received benefits if substance abuse “contributes materially” to the finding of disability (20 CFR )
Compliance with treatment:
No benefits if claimant fails to follow prescribed treatment that would restore ability to work. (20 CFR )
Acceptable excuses: treatment contrary to religion, very risky; considers physical, mental, educational, and linguistic limitations
§ How we will determine whether your drug addiction or alcoholism is a contributing factor material to the determination of disability.
(a) General. If we find that you are disabled and have medical evidence of your drug addiction or alcoholism, we must determine whether your drug addiction or alcoholism is a contributing factor material to the determination of disability.
(b) Process we will follow when we have medical evidence of your drug addiction or alcoholism. (1) The key factor we will examine in determining whether drug addiction or alcoholism is a contributing factor material to the determination of disability is whether we would still find you disabled if you stopped using drugs or alcohol.
(2) In making this determination, we will evaluate which of your current physical and mental limitations, upon which we based our current disability determination, would remain if you stopped using drugs or alcohol and then determine whether any or all of your remaining limitations would be disabling.
(i) If we determine that your remaining limitations would not be disabling, we will find that your drug addiction or alcoholism is a contributing factor material to the determination of disability.
(ii) If we determine that your remaining limitations are disabling, you are disabled independent of your drug addiction or alcoholism and we will find that your drug addiction or alcoholism is not a contributing factor material to the determination of disability.
§ Need to follow prescribed treatment.
(a) What treatment you must follow. In order to get benefits, you must follow treatment prescribed by your physician if this treatment can restore your ability to work.
(b) When you do not follow prescribed treatment. If you do not follow the prescribed treatment without a good reason, we will not find you disabled or, if you are already receiving benefits, we will stop paying you benefits.
(c) Acceptable reasons for failure to follow prescribed treatment. We will consider your physical, mental, educational, and linguistic limitations (including any lack of facility with the English language) when determining if you have an acceptable reason for failure to follow prescribed treatment. The following are examples of a good reason for not following treatment:
(1) The specific medical treatment is contrary to the established teaching and tenets of your religion.
(2) The prescribed treatment would be cataract surgery for one eye, when there is an impairment of the other eye resulting in a severe loss of vision and is not subject to improvement through treatment.
(3) Surgery was previously performed with unsuccessful results and the same surgery is again being recommended for the same impairment.
(4) The treatment because of its magnitude (e.g. open heart surgery), unusual nature (e.g., organ transplant), or other reason is very risky for you; or
(5) The treatment involves amputation of an extremity, or a major part of an extremity.

12. Five-Step Sequential Evaluation
Is the claimant doing Substantial Gainful Activity (SGA)?
Does the claimant have a “severe” impairment?
Does the impairment meet or equal a listed impairment?
Can the claimant do past relevant work?
Can the claimant do any work existing in significant numbers in the national economy?

13. Sequential Evaluation Step 1: Work
Is the claimant engaged in substantial gainful activity (“SGA”)?
“Substantial” means work activity that involves significant physical or mental activities
For 2013, “gainful” means resulting in income of $1040/month (gross income minus impairment related work expenses)
Good source for financial data (if this URL works)
Also: SSA FAQ’s: (can link to tax, benefit, earnings amounts)
The mere fact that the claimant is not working is not sufficient to disqualify.
have to assess whether the work is a real job --
substantial AND
gainful -gainful generally considers earnings, but definition is broad:
-”Work activity is gainful if it is the kind of work usually done for pay or profit, whether or not a profit is realized. 20 CFR s (b)
-special rules for self-employment

14. Sequential Evaluation Step 3: Listings
Does the impairment, or combination of impairments, meet or equal a “listed impairment”?
Organized by body systems
Impairments presumed to prevent the ability to engage in SGA
Each listing includes a diagnosis as well as certain findings which must be included in medical records
many listings include durational requirements and severity levels

15. Important Listings 14.11 – HIV Listings 12.00 -- Mental Disorders
Affective Disorders (e.g. depression)
12.06 – Anxiety Disorders
Cancer listings

16. Steps 4 & 5 Residual functional capacity (“RFC”)
What can the claimant do in spite of her/his impairments?
Assess physical, mental
Strength, manipulative limitations, environmental restrictions, etc.
Ability to sit, stand, walk, lift, carry, etc.
Strength classifications
Heavy, Medium, Light, Sedentary
RFC is what the claimant can sustain on a full-time basis, 5 days/week, 8 hrs/day or equivalent

17. Step 4 Step 4: Past RELEVANT Work
Work done at the SGA level within the past 15 years, long enough to have learned the job
You have to find out about all the client’s past jobs
Job title, tasks performed, physical demands, skills/tools used
Full time/part time
Pay rate

18. Step 5 Step 5: Any work Consideration of vocational factors Jobs
Client’s age, education, work experience
Claimants over age 50 considered to have less ability to adjust to new work, so easier to be approved
Jobs
Jobs considered are those listed in the Department of Labor’s Dictionary of Occupational Titles
Doesn’t matter whether there are available jobs or whether claimant could get the job
Must be able to work on a full-time and sustained basis

19. Step 5
Considers combined impact of all impairments, including “non-exertional” limitations, e.g., need for frequent breaks, difficulty getting along in workplace, absenteeism
Medical-vocational guidelines – (“Grids”)
Direct an outcome based on client’s profile
Strength: heavy, medium, light, sedentary
Age
Education
Skill level of past work
Grids don’t take non-exertional limitations into consideration

20. Proving Disability Medical Records Affidavits/statements from
Doctors & other health care providers
Social Workers, Case Managers
Employers, friends, family who are aware of limitations, other relevant facts
Other records, e.g.
School Records
Work records