MEDICARE: A Few Things You Should Know Before You Turn Age 65 It's no secret. Most people wait until the last minute to take care of something they could have done well ahead of time. Enrolling in the Federal Medicare Program is no exception. To help save you from a few last minute headaches, here are some things you should know about Medicare BEFORE you turn age 65. Quite simply, Medicare is a federal health insurance program for older Americans. Medicare covers you when you receive hospital or physician care in any of the 50 states including Washington DC, and U.S. commonwealth territories and possessions. Most Americans - working or retired - are eligible for Medicare upon their 65th birthday. Those who are not eligible include a limited number of public employees, people without U.S. citizenship, and people convicted of certain crimes. Disabled U.S. citizens under the age of 65 may also be eligible for Medicare coverage. Your local Social Security Office can provide further details. In order to sign up for Medicare, visit your local Social Security Office AT LEAST THREE MONTHS before you turn 65. You will be required to show your birth certificate or other proof of age. If you need to apply by mail, call the local office to make the appropriate arrangements. You'll find the address and phone number under "Social Security Administration" in your local phone book. Why it's important to enroll in Medicare on time: If you don't submit your Medicare enrollment application by your 65th birthday, you should do so as soon as possible after that date. Medicare's Part A hospital insurance coverage can be retroactive for up to one year after you apply; however, Medicare Part B coverage is not retroactive. There are also late enrollment premium penalties you should be aware of. These penalties apply to both Medicare Parts A and B. The first penalty can affect you if you are NOT eligible for premium-free Part A coverage and you enroll after your 65th year. Your Part A monthly premium becomes 10 percent higher for each 12 month period you fail to enroll. The Part B penalty takes effect if you do not enroll for this coverage when you turn age 65. Your Part B monthly premium will be 10 percent higher (than the basic premium most participants pay) for each year you could have had medical insurance but failed to do so. If you are covered by an employer's health plan, you may be able to delay your Part B enrollment and avoid the premium penalty. And finally, if you do not enroll for either Medicare Parts A or B during your 65th year, you will have to do so during the annual open enrollment period. Your local Social Security office can provide you with further details about the annual enrollment period. DISABILITY Who Should Read This? _______________________________________________________________________ You should, if you want to know more about the various kinds of disability benefits available from Social Security. This booklet will tell you who is eligible, how to apply, and what you need to know once benefits start. We pay disability benefits under two programs: the Social Security disability insurance program and the Supplemental Security Income (SSI) program. The medical requirements for disability payments are the same under both programs and a person's disability is determined by the same process. While eligibility for Social Security disability is based on prior work under Social Security, SSI disability payments are made on the basis of financial need. And there are other differences in the eligibility rules for the two programs. This booklet deals primarily with the Social Security disability program. For information on SSI disability payments, refer to the section, "A Word About Supplemental Security Income," at the end of this booklet, or ask for the booklets, "Supplemental Security Income" and "Working while Disabled...How Social Security Can Help" from the Social Security field office. Please Note: This file provides a general overview of the disability program. The information it contains is not intended to cover all provisions of the law. For specific information about your case, contact Social Security. _______________________________________________________________________ What's Included _______________ Part 1--Introduction to Disability And Social Security What We Mean By "Disability" Who Can Get Social Security Disability Benefits Disability Benefits For Children How Much Work YOu Need For Social Security Benefits Part 2--Signing Up For Disability How To Apply How We Determine Disability Rules For Blind Persons If Your Claim Is Denied Part 3--When Your Claim Is Approved Your First Check How Much You Will Get From Social Security How Other Payments Affect Benefits Benefits May Be Taxed You Can Get Medicare If You're Disabled Reviewing Your Disability What Can Cause Benefits To Stop Part 4--Going Back To Work Benefits While You Work A Word About Supplemental Security Income For More Information Other Booklets Available _______________________________________________________________________ PART 1--INTRODUCTION TO DISABILITY AND SOCIAL SECURITY Disability is something most people don't like to think about. But the chances of your becoming disabled are probably greater than you realize. In fact, studies show that one out of four young workers will become disabled some time during their lifetime. It's a fact that, while most people spend time working to succeed in their jobs and careers, few think about ensuring that they have a safety net to fall back on should the unthinkable happen. This is where Social Security comes in. We pay cash benefits to people who are unable to work for a year or more because of a disability. Benefits continue until a person is able to work again on a regular basis and a number of work incentives are available to ease the transition back to work. ____________________ What We Mean By "Disability" It's important that you understand how Social Security defines "disability." That's because different programs have different bases for determining disability. As a result, some programs may pay for partial disability or for short-term disability. Social Security does NOT. Disability under Social Security is based on your inability to work. You will be considered disabled if you are unable to do any kind of work for which you are suited, and if your inability to work is expected to last for at least a year or to result in death. Some consider this a strict definition of disability, and it is. The program assumes that working families have access to other resources to provide support during periods of short-term disabilities, including workers compensation, insurance, savings, and investments. It is designed to provide a continuing income to you and your family when you are unable to do so. Benefits continue as long as you remain disabled. ____________________ Who Can Get Social Security Disability Benefits You can receive Social Security disability benefits at any age. If you are receiving disability benefits at age 65, they become retirement benefits, although the amount remains the same. Certain members of your family may also qualify for benefits on your record. They include: *Your unmarried son or daughter, including a step-child, adopted child, or, in some cases, a grandchild. The child must be under 18 or under 19 if in high school full time. *Your unmarried son or daughter, 18 or older, if he or she has a disability that started before 22. (If a disabled child under 18 is receiving benefits as a dependent of a retired, deceased, or disabled worker, someone should contact Social Security to have his or her checks continued at 18 and later on the basis of disability.) *Your spouse who is 62 or older. *Your spouse at any age if he or she is caring for a child of yours who is under 16 or disabled and also receiving checks. Certain family members may qualify for disability benefits if you should die. They include: *Your disabled widow or widower 50 or older. The disability must have started before your death or within 7 years after your death. (If your widow or widower caring for your children receives Social Security checks, she or he is eligible if she or he becomes disabled before those payments end or within 7 years after they end.) *Your disabled ex-wife or husband who is 50 or older if the marriage lasted 10 years or longer. ____________________ Disability Benefits For Children In recent years, there has been a growing concern about whether parents are aware of the disability benefits that are available for their disabled children. More than 475,000 children under 18 who have disabilities currently receive such benefits; most suffer some form of mental retardation, others from various childhood conditions. Social Security disability benefits may also be paid to children 18 or older who were disabled before age 22. These benefits will continue into their adult years as long as they remain disabled. Many children qualify for disability benefits under the SSI program. For more information, ask Social Security for the booklet, "Supplemental Security Income". A recent court order changed the way we decide if a child is disabled, generally making it easier for children to qualify for Social Security and SSI disability benefits. ____________________ How Much Work You Need For Social Security Benefits To qualify for Social Security disability benefits, you must have worked long enough and recently enough under Social Security. In 1991, you ear 1 credit of coverage for each $540 in earnings, up to a maximum of 4 credits per year. The amount of earnings required for a credit increases each year as general wage levels rise. Family members who qualify for benefits on your work record do not need work credits. The number of work credits needed for disability benefits depends on your age when you become disabled. *Before age 24--You need 6 credits in the 3-year period ending when your disability starts. *Age 24 to 31--You need credit for having worked half the time between 21 and the time you become disabled. For example, if you became disabled at age 27, you would need credit for 3 years of work (out of 6 years). *Age 31 or older--You need to have the same number of work credits as you would need for retirement, as shown in the following chart. Also, you generally must have earned at least 20 of the credits in the 10 years immediately before you became disabled. _______________________________________________________________________ Born After Born Before 1929, Become 1930, Become Credits Disabled At Age Disabled Before 62 You Need _______________________________________________________________________ 31 through 42 20 44 22 46 24 48 26 50 28 52 30 53 31 54 32 55 33 56 34 57 1986 35 58 1987 36 59 1988 37 60 1989 38 62 or older 1991 or later 40 _______________________________________________________________________ PART 2--SIGNING UP FOR DISABILITY How To Apply You should apply at any social Security office as soon as you become disabled. (You may file by phone, mail, or by visiting the nearest office.) However, social Security disability benefits will not begin UNTIL THE 6TH FULL MONTH OF DISABILITY. This "waiting period" begins with the first full month after the onset of your disability. The claims process for disability benefits is generally longer than for other types of Social Security benefits--from 60 to 90 days. It takes longer to obtain medical information and to assess the nature of the disability in terms of your ability to work. However, you can help shorten the process by bringing certain documents with you when you apply. These include: *The Social Security number and proof of age for each person applying for payments. This includes your spouse and children, if they are applying for benefits. *Names, addresses, and phone numbers of doctors, hospitals, clinics, and institutions that treated you and dates of treatment. *A summary of where you worked in the past 15 years and the kind of work you did. *A copy of your W-2 Form (Wage and Tax Statement), or if you are self-employed, your Federal tax return for the past year. *Dates of any prior marriages if your spouse is applying. Do not delay filing for benefits just because you do not have all of the information you need. The Social Security office will be glad to help you. ____________________ How We Determine Disability You should be familiar with the process we use to determine if you are disabled. It's a step-by-step process involving five questions. They are: 1. Are you working? If you are and you are earning $500 or more a month, you generally cannot be considered disabled. 2. Is your condition "severe"? Your impairments must interfere with basic work-related activities for your claim to be considered further. 3. Is your condition found in the list of disabling impairments? We maintain a list of impairments for each of the major body systems that are so severe they automatically mean you are disabled. If your condition is not on the list, we have to determine if it is of equal severity to an impairment on the list. If it is, your claim is approved. If it is not, we go to the next step. 4. Can you do the work you did previously? If your condition is severe, but not at the same or equal severity as an impairment on the list, then we must determine if it interferes with your ability to do the work you did in the last 15 years. If it does not, your claim will be denied. If it does, your claim will be considered further. 5. Can you do any other type of work? If you cannot do the work you did in the last 15 years, we then look to see if you can do any other type of work. We consider your age, education, past work experience, and transferable skills, and we review the job demands of occupations as determined by the Department of Labor. If you cannot do any other kind of work, your claim will be approved. If you can, your claim will be denied. ____________________ Rules For Blind Persons The Social Security disability program has special rules for blind persons. If you qualify, you may receive benefits either on the basis of blindness or on the basis of disability. You are considered blind under Social Security rules if your vision cannot be corrected to better than 20/200 in your better eye, or if your visual field is 20 degrees or less, even with a corrective lens. If you are blind, you can earn up to $810 a month in 1991 before your earnings are considered "substantial gainful work". If you are blind, you should file for disability even if you are working regularly and your earnings are too high to receive disability benefits. That's because you might be eligible for a disability "freeze." This means that your future benefits, which are figured on your average earnings over your working life, will not be reduced because of relatively lower earnings in those years when you are blind. ____________________ If Your Claim Is Denied If your claim is denied, or if you disagree with any other decision we make, you may appeal the decision. The Social Security office will help you complete the paperwork. There are four levels of appeal. If you disagree with the decision at one level, you may appeal to the next level. You have 60 days from the time you receive the decision to file an appeal to the next level. We assume that you receive the decision 5 days after the date on it, unless you can show us that you received it later. *Reconsideration Your file is reviewed by persons other than those who made the original decision. *Hearing If the reconsideration decision is still unfavorable, you may apply for a hearing before a judge. If you are appealing a decision that you are no longer medically disabled, you may also request that we continue your benefits while you wait for a decision. *Appeals Council The appeals Council will review your case if it feels that there is an issue that the judge did not address. If it denies your review, or you otherwise disagree with its decision, you may appeal to a Federal Civil Court. *United States District Court Again, you have 60 days from the day you received the notice of the decision to appeal to a Federal Court. _______________________________________________________________________ PART 3--WHEN YOUR CLAIM IS APPROVED Your First Check Once a decision is made that you are disabled, you will receive your first Social Security disability check dating back to the 6th full month from the onset of your disability. You also will receive a booklet describing your responsibilities as a Social Security beneficiary: "When You Get Social Security Disability Benefits--What You Need To Know." You should read this booklet carefully and keep it in a safe place with your other valuable papers in order to refer to it whenever questions arise. ____________________ How Much You Will Get From Social Security The amount of your monthly disability benefits is based on your lifetime average earnings covered by Social Security. The average monthly benefit for a disabled worker in 1991 is $587, and the average payment to a disabled worker with a family is $1,022. The following chart gives examples of disability benefits that may be payable to you and your family. _______________________________________________________________________ Approximate Monthly Benefits If You Become Disabled in 1991 And Had Steady Earnings _______________________________________________________________________ Your Earnings in 1990 Your $51,300 Age Your Family $10,000 $20,000 $30,000 $40,000 $50,000 Or More+ __________________________________________________________________________ 25 You $473 $ 732 $ 958 $1,079 $1,196 $1,202 You, spouse, child* 687 1,098 1,437 1,619 1,795 1,803 35 You 468 722 950 1,069 1,174 1,177 You, spouse, child* 674 1,083 1,426 1,604 1,762 1,766 45 You 467 720 947 1,040 1,103 1,105 You, spouse, child* 672 1.081 1,421 1,560 1,655 1,657 55 You 469 724 934 997 1,040 1,041 You, spouse, child* 676 1,086 1,402 1,496 1,561 1,562 64 You 476 736 942 997 1,035 1,036 You, spouse, child* 690 1,104 1,414 1,496 1,553 1,554 __________________________________________________________________________ + Use this column if you earn more than the maximum Social Security earnings base. * Equals the maximum family benefit. Note: The accuracy of these estimates depends on the pattern of your actual past earnings. ____________________ How Other Payments Affect Benefits Eligibility for other government benefits can affect the amount of your Social Security disability benefits. *Other Disability Benefits Social Security benefits may be affected if you are also eligible for workers' compensation (including black lung) or for disability benefits from certain Federal, State, Civil Service, or military disability programs. Total combined payments to you and your family from Social Security and any of these other programs generally cannot exceed 80 percent of your average current earnings before becoming disabled. *Government Pension Offset If you are a disabled widow or widower or the spouse of a disabled worker, a "government pension offset" may reduce your Social Security payment. The offset applies if you become eligible for a Federal, State, or local government pension based on your own work not covered by social Security. The amount of your Social Security spouse's benefit may be reduced by two-thirds of the amount of your government pension. There are some exceptions when the offset would not apply. For more information, call or visit Social Security to ask for a free copy of the fact sheet, "Government Pension Offset." *Pension From Work Not Covered By Social Security If you become disabled and entitled to a Social Security disability benefit and you also receive a monthly pension based on work not covered by social Security, your disability payment will be smaller than normal. That's because we use a different formula to figure the Social Security benefit of people who get other public pensions. For more information, call or visit Social Security to ask for a free copy of the fact sheet, "A Pension From Work Not Covered By Social Security." ____________________ Benefits May Be Taxed A relatively small number of people may have to pay Federal income taxes on their Social Security benefits. This usually happens only if your total income is high. At the end of the year, you will receive a Social Security Benefit Statement (Form SSA-1099) showing the amount of benefits you received. The statement is to be used for completing your Federal income tax return if any of your benefits are subject to tax. You may use the Internal Revenue Service Publication 915 for additional information on the tax. ____________________ You Can Get Medicare If You're Disabled You will be automatically enrolled in Medicare after you have been getting disability benefits for 2 years. There are two parts to Medicare--hospital insurance and medical insurance. Hospital insurance helps pay hospital bills and some follow-up care. The taxes you paid while you were working financed this coverage, so it's free if you're eligible. The other part of Medicare, medical insurance, helps pay doctors' bills and other services. You pay a monthly premium for this coverage if you want it. Almost everybody has both parts of Medicare. ____________________ Reviewing Your Disability Your benefits will continue as long as you are disabled. However, your case will be reviewed periodically to see if you are still disabled. The frequency of the reviews depends on the expectation of recovery. *If medical improvement is "expected," your case will be reviewed within 6 to 18 months. *If medical improvement is "possible," your case will be reviewed no sooner than 3 years. *If medical improvement is "not expected," your case may be reviewed no sooner than 7 years. ____________________ What Can Cause Benefits To Stop There are two things that can cause us to decide that you are no longer disabled and to stop your benefits. The basic yardstick used to determine if you are still disabled is whether your work is "substantial." Usually, earnings of $500 or more a month are considered substantial. This level of work is referred to as "substantial gainful activity." Your disability benefits would also stop if it is determined that your medical condition has improved to the point that you are no longer disabled. You must promptly report any improvement in your condition, your return to work, and certain other events as long as you are receiving benefits. These responsibilities are explained in the booklet you will receive when benefits start. _______________________________________________________________________ PART 4--GOING BACK TO WORK Benefits While You Work If you're like most people, you would rather work than try to live on disability benefits. There are a number of special rules that provide cash benefits and Medicare while you attempt to work. We call these rules "work incentives." You should be familiar with these disability work incentives so that you can use them to your advantage. If you are receiving Social Security disability benefits, the following rules are among the work incentives that apply: *Trial Work Period--For 9 months (not necessarily consecutive), you may earn as much as you can without affecting your benefits. (The 9 months of work must be in a 5-year period to be considered a trial work period.) A trial work month is any month in which you earn more than $200. After 9 months of trial work, your work is evaluated to see if it is "substantial." If your earnings are $500 or less a month, benefits will generally continue. If earnings average more than $500 a month, benefits will continue for a 3-month grace period before they stop. *Extended Period of Eligibility--For 36 months after a successful trial work period, if you are still disabled, you will be eligible to receive a monthly benefit without a new application for any month your earnings drop below $500. *Deductions for Impairment-Related Expenses--Work expenses related to your disability will be discounted in figuring whether your earnings constitute substantial work. *Medicare Continuation--Your Medicare coverage will continue for 39 months beyond the trial work period. If your Medicare coverage stops because of your work, you may purchase it for a monthly premium. For more information about Social Security's work incentives, ask for a copy of the booklet, "Working While Disabled...How Social Security Can Help. _______________________________________________________________________ A Word About Supplemental Security Income As we stated earlier, the medical requirements for disability payments are the same for Social Security and SSI, and a person's disability is determined by the same process for both programs. But there are some differences between Social Security and SSI that you should know about. These include: *No disability waiting period is required under SSI. Since SSI payments are based on financial need, the presumption that a person has resources to handle short-term health problems does not exist. *Under SSI, you may qualify for an immediate disability payment if your condition is obviously disabling and you meet the SSI income and resource limits. *Different work incentive rules apply to SSI recipients. The major difference is that cash benefits and Medicaid continue as long as the SSI income limits are not exceeded (the substantial gainful activity level does not apply). Another important rule permits money to be set aside for up to 48 months for a work goal. Other special rules apply to blind persons, disabled students, and people with disabilities who work in sheltered workshops. Some work incentive rules are the same for Social Security disability and SSI. These include the work expenses exclusion and the continuation of benefits while in a vocational rehabilitation program. For more information about SSI disability payments, ask for the publications, "Supplemental Security Income" and "Working While Disabled...How Social Security Can Help." ____________________ For More Information For more information or to apply for benefits, call or visit Social Security. It's easiest to call Social Security's toll free telephone number. The number is 1-800-2345-SSA (1-800-234-5772). You can speak to a representative 7 a.m. to 7 p.m. each business day. The Social Security Administration treats each call confidentially. We also want to ensure that you receive accurate and courteous service. That is why we have a second Social Security representative listen to some telephone calls. ____________________ Other Booklets Available Social Security has a number of publications that contain information about other Social Security programs. Contact Social Security to get a free copy of any of these publications. They include: *Understanding Social Security-- A comprehensive explanation of all the Social Security programs. *Retirement-- Explains Social Security retirement benefits. *Survivors-- Explains Social Security survivors benefits. *Medicare-- Explains Medicare hospital insurance and medical insurance. *Supplemental Security Income-- Explains this program which provides a basic income to people 65 or older, disabled, or blind who have limited income and resources. THE DISABILITY PROCESS UNDER SOCIAL SECURITY The social Security Administration has the responsibility to administer two disability programs, The Disability Insurance (DI) program (under Title II of the Social Security Act) and the Supplemental Security Income (SSI) program (under Title XVI). Under Title II, monthly benefits are payable to people under 65 who have worked long and recently enough under Social Security. Every person who pays into Social Security contributes to the Social Security Disability Trust Fund. After a certain period of time working in employment covered under Social Security, a person gains insured status and is entitled to a disability benefit if he/she becomes severely impaired an cannot work. Medicare coverage is available to those who have received disability benefits for 24 months. SSI disability payments are made to needy people who are under 65 and have limited income and few resources. These payments are made from General Revenue funds. Most SSI recipients qualify for Medicaid, a State-run medical assistance program. Each year, more than two million persons apply for Social Security disability insurance (SSDI) benefits and/or Supplemental Security Income (SSI) disability payments, nationwide. Social Security and SSI disability payments currently are made to more than four million disabled individuals and their families. These programs provide cash payments and health care coverage when a worker or eligible needy individual is unable to work for at least a year due to a physical or mental impairment--payments which continue as long as the person is unable to work due to his/her impairment(s). The Social Security Administration also has a number of work incentives which provide continued benefits and health care coverage for disabled persons who want to work. The process of determining disability begins when a person applies for SSDI benefits or SSI disability payments at a Social Security Administration (SSSA) field office, either in person or by phone. It involves a network of Federal, State and local agencies and services and input from many segments of the health community. It also involves substantial input from beneficiary support groups, particularly in expanding opportunities for disabled beneficiaries to work. The purpose of this booklet is to provide an overview of the disability process for participants at all levels. It is designed to acquaint health professionals (including physicians, psychologists, mental health workers, and advocacy groups) with how the process works and how they can assist those persons who apply for disability payments under Social Security. DEFINITION OF DISABILITY The statutory definition of disability is the same for both the SSDI and SSI programs and is as follows: 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." The term "SGA" generally is defined in terms of the amount of a person's earnings. As of January 1991, a person can earn $500 a month ($810 a month for the blind) without those earnings being considered SGA. "Medically determinable" conditions are established through appropriate evidence from treating sources, hospitals, clinics, and in some cases, consultative examinations (CEs). THE APPLICATION PROCESS Disability claims are processed through a network of some 1,300 Social Security field offices the central office, and 54 State agencies, generically known as Disability Determination Services (DDS). The case flow is as follows: Social Security Field Office An application for disability benefits is obtained by an SSA representative, either in person, by telephone or by mail. The application includes a description of impairment(s), names and addresses of the claimant's medical sources(s), dates of treatment and other information that relates to the alleged disability. The SSA field office then verifies non-medical eligibility requirements, which include earnings and coverage information. The field office assists the applicant to obtain evidence to substantiate information information related to age, employment, and marital status, if spouse's/children's benefits are involved. The field office may also assist the applicant to develop medical or lay evidence in support of his/her claim. When the field office verifies that the non-medical eligibility criteria are met, the case is forwarded to the State agency. State Disability Determination Services (DDS) The DDSs, which are fully funded by the Federal Government, are the State agencies responsible for developing medical evidence sufficient to render an equitable determination on whether the claimant is or is not disabled or blind under the law, and determine when disability began and/or ended. The DDs obtains, if possible, medical evidence from the claimant's medical sources. If that evidence is insufficient to render a determination, the DDSs will purchase a consultative examination from the treating source, or from an independent source. The medical evidence is then reviewed by a team composed of a physician (in the case of mental impairments, a clinical psychologist may be used) and a disability examiner, and a disability determination is made. The State agency sends a determination notice to the claimant. A determination is also made as to whether the applicant is a candidate for vocational rehabilitation (VR). If so, a referral to the State VR agency is made. After the disability determination is made, the case is forwarded to one of SSA's field offices for further action. APPEALS PROCESS A determination that a person is not disabled may be appealed. There are four levels of appeal: a reconsideration, which, in initial cases, is generally a case review by someone other than the original decision maker, at the State level. (In cases where an individual is receiving benefits because of a disability, and SSA decided that he or she has medically improved, the individual may meet with a disability hearings officer); a hearing before a federal administrative law judge; a federal review by the Appeals Council; and a civil action can be filed in the Federal District Court where he or she resides, if the individual still is not satisfied. In general, a claimant has 60 days from receipt of the notice of the decision to file an appeal. Appeals must be filed in writing and may be submitted by mail or in person to any Social Security office. (For further information, see the SSA Fact Sheet, "The Appeals Process.") THE DISABILITY DETERMINATION PROCESS SSA's disability determination process is designed to achieve the highest degree of accuracy, uniformity, consistency, and timeliness. It relies on he participation of the medical community, both in providing the medical evidence used in determining disability, and in the actual decision making process. The process is described in the following sections. Listing of Impairments To ensure uniformity and consistency in the way disability determinations are made, Social Security has developed a set of medical evaluation criteria for all body systems, called the "Listing of Impairments." The "Listing" describes over 100 of the most common diseases and disorders which are so serious or life-threatening that if the claimant "meets" one of them and is not engaging in SGA, he or she is deemed to be disabled. If an individual has an impairment that does not meet the specific criteria described in the "Listing" but has an impairment(s) of equal severity to a listed impairment, and is not working at the SGA level, he or she is also presumed to meet the definition of disability. This concept of "meeting" or "equaling" the Listing also is intended as a means of screening in (i.e., allowing) claims at the earliest stage of the disability evaluation process. This speeds benefits/payments to the most severely disabled individuals in the shortest period of time while saving the Federal government the cost of adjudicating the claim through the full sequential evaluation process (described below). The Listing is divided into two parts: Part A contains medical criteria that apply to adult persons age 18 and over. The medical criteria in Part A may also be applied in evaluating impairments in persons under age 18 if the disease processes have a similar effect on adults and younger persons. Part B contains additional medical criteria that apply only to the evaluation of impairments of persons under age 18. Certain criteria in Part A do not give appropriate consideration to the particular effects of the disease processes in childhood; i.e., when the disease process is generally found only in children or when the disease process is different in its effect on children than on adults. In evaluating disability for a person under age 18, Part B will be used first. If the medical criteria in Part B do not apply, then the medical criteria in Part A will be used. The medical criteria in the Listing describe impairments in terms of specific signs, symptoms and laboratory findings that are presumed severe enough to keep an individual from working a year or longer or in the case of a child, performing age-appropriate activities. The criteria are monitored and updated to reflect established procedures and practices in medicine. (For a detailed description of the Listing, see "Disability Evaluation Under Social Security." Sequential Evaluation There is a sequence in evaluating claims for disability under Social Security which directly reflects the requirements of the Social Security law. This step-by-step procedure is known as the "sequential evaluation process." It asks, in logical order, five questions. This process ensures that the definition of disability is applied consistently nationwide and results in a claim being decided as early in the process as possible. (For disabled widows/widowers and SSI children, a slightly different process is used.) For workers and adult SSI recipients, the five steps follow: *Step One. Is the claimant engaging in substantial gainful activity (SGA)? If a claimant is working and earning over $500 per month after applicable deductions, he or she is considered to be engaging in SGA and is generally found not to be disabled no matter how serious the medical condition. This is because disability under Social Security means the inability to work. The process stops here. If the claimant is not engaging in SGA, we go to step 2. *Step Two. Is the claimant's impairment(s) severe? A severe impairment is one that has more than a minimal effect on the claimant's ability to do basic work activities. (Basic work activities include walking, standing, lifting, carrying, seeing, speaking, etc.) Impairments which are not severe include those which are well controlled by diet, medication, or other therapies. If the medical condition is not severe, the disability claim is denied at this step. If the impairment is severe, we go on to stop 3. *Step Three. Does the claimant's impairment(s) meet or equal any listing in the Listing of Impairments? The Listing of Impairments is a compilation of medical criteria describing the most common impairments which are so serious that, if the claimant "meets" one of them and is not engaging in SGA, he or she is deemed to be disabled. If the impairment is severe but does not meet a listing, we determine whether the individual has an impairment or combination of impairments that are equivalent in severity to any listed impairment. We compare the signs, symptoms and laboratory findings associated with the impairment, including any functional limitations resulting from the impairment, with the corresponding criteria shown in the listing. If a claimant does not meet or equal a listing, we go to step 4 and, if necessary, step 5, where we consider both medical and vocational factors. *Step Four. Does the claimant's impairment(s) preclude the ability to perform past relevant work? At this stage in the process, we determine the claimant's residual functional capacity (RFC) to do his or her past work despite the impairment(s). If the past work was such that the impairment would prevent performing that work, we go on to the next step. *Step Five. Does the claimant's impairment(s) preclude the ability to perform other work? At this final step of the sequential evaluation process, we determine if the claimant can do other work. We consider the claimant's remaining ability to perform work-related activities despite his or her impairment together with the individual's age, education, and work experience (including any transferable skills) in determining if he or she can do "other work." If the individual is denied at any step of the process, he/she may appeal. The sequential evaluation process is used for initial cases (new applications) and reconsideration of initial cases only. Different procedures are required in evaluating, at a later time, whether disability continues. Since children ordinarily cannot be evaluated based on their work ability, they are evaluated based on their ability to perform age-appropriate activities. SSA is presently developing new rules to improve our evaluation of children's impairments. Continuing Disability Reviews 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 in cases 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, a treating physician/psychologist may be asked to provide current medical evidence. If an additional examination or test is needed, the DDS team may request that the treating physician/psychologist 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 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 decision maker 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 decision notice is received. THE ROLE OF THE HEALTH PROFESSIONAL You are the key to an effective disability program, whose goal is to award benefits promptly and accurately to people who meet the definition of disability under Social Security. Therefore, the SSa believes that it is important for the medical community to be aware of its role and the role of the medical evidence that health professionals provide, in the disability process. Members of the medical community participate in the disability process in a variety of ways. Treating Sources Evidence from treating sources is extremely important to the Social Security disability determination process. In fact, nearly two-thirds of disability determinations are made based solely on medical evidence of record received from the claimant's medical sources. SSA guidelines emphasize the importance of the treating sources evidence in the decision making process. SSA also considers the treating physician/psychologist as a potential source for a consultative examination. As part of the medical evidence of record requested from the treating source, SSA also requests a medical assessment of the patient. Specifically, the treating source is asked to provide a statement (called a medical source statement) of what the person can still do despite his/her impairment(s). Consultative Examiners (CEs) Approximately one-third of disability claims requires use of CEs. In such cases, the individual is requested to have specific tests or examinations performed by the treating or other medical source. When needed, a physical and/or mental examination or test is purchased at Federal government expense. CEs may be necessary to (1) obtain more detailed medical findings about the claimant's impairment(s); (2) obtain technical or specialized medical evidence which is not available in the claimant's current medical file. The medical report submitted as a result of the CE should include a medical assessment (called a medical source statement) by the physician/psychologist of the individual's capability to function despite his/her impairment(s). Program Physicians/Psychologists SSA employs a number of health professionals in the disability program at the national, regional and State levels. At the SSA national headquarters, physicians and psychologists help formulate and evaluate medical policies and procedures throughout the agency, assessing the short and long term medical and operational research needs. Additionally, these professionals perform a nationwide quality assurance check. In the DDS, each disability determination is made by a team consisting of a physician or psychologist and a disability examiner. The physician's or psychologist's primary role is to make a judgment as to the severity of the impairment based on his or her review, analysis and interpretation of the significant clinical and laboratory findings and other tests and pathological studies. The examiner member of the team is trained in the medical, legal, administrative, and other program requirements. All disability determinations must be signed by both the physician or, in cases involving a mental impairment, the psychologist and the examiner who reviewed the claim. Program physicians and psychologists in the regional offices serve as an important link between headquarters and the various States. They perform a quality assurance review of the determinations made by the State agencies, answer questions on case-related issues, and consult with central office on medical policy issues. BENEFITS FOR DISABLED BENEFICIARIES WHO WORK The Social Security disability program contains a number of work incentives designed to help beneficiaries who attempt to work. SSA recognizes that a successful return to work is a progression of events beginning with the initial work attempt and ending with working on a full-time, regular basis. Work incentive provisions make it possible for beneficiaries to test their ability to work without losing entitlement to cash payments and/or Medicare or Medicaid protection, until they can reasonably be expected to pay their own way and buy their own health insurance protection. Additional information about these and other work incentive provisions is contained in the leaflets, "Benefits for Disabled People who Work" and "A Summary Guide to Social Security and Supplemental Security Income Work Incentives for the Disabled and Blind" which are available at any Social Security office.