Study Guide
Lesson
Two
SSA Terms and Definitions
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In this lesson, we will introduce you to important Social Security terms
and definitions. For additional terms, see Social Security Disability Guide
terms index. Please note that our definitions may be slightly different
from those found in other materials. We consider our definitions to be
actionable definition. That is, our definitions are designed to guide you
in the execution or lack of execution of a give action within the disability
process.
Why Terms and Definitions?
As a practicing disability advocate, you will quickly discover that a sound
understanding of the Social Security disability process begins with an
awareness of those terms and definitions commonly used by Social Security.
This segment is designed to familiarize you with what we consider to be some
of the most important terms and procedures.
What is Social Security Disability?
Social Security Disability is a program administered both by the State and
Federal Government which provides monthly cash benefits and medical
assistance to individuals determined by Social Security to be totally
disabled and unable to perform any type of work activity.
The law defines disability under the Social Security program as the
inability to do any kind of substantial gainful activity SGA or work, due to
any physical or mental impairment, which is expected to last for at least
twelve months or result in death. To meet this definition, a person must
have a severe impairment which prevents that person from performing any type
of work in the national economy. Let's look more closely at some of the
terms within this critically important definition to disability.
What is Substantial Gainful Activity (SGA)?
Substantial Gainful Activity or SGA is defined as work on a full or
part-time basis in which an individual earns a preset amount of monthly
income which is determined by Social Security. The monthly income amount
changes from year to year and is calculated by Social Security. The Social
Security Administration sets the SGA earnings amount on an annual basis
taking into consideration inflation and other economic factors. Example:
If the SGA level is $750 per month, and a person earns less than $750 per
month, that person is below SGA and may be financially eligible to apply for
disability benefits.
What is a Severe Impairment?
A severe impairment is any disorder, physical or mental, that can be shown
by acceptable medical evidence to prevent a person from functioning normally
in an ordinary working environment. If the impairment does not interfere
with the claimant's ability to perform work activity, it is probably not a
severe impairment as defined by Social Security.
How long must the Impairment Last?
Unless the impairment is expected to result in death, it must last or be
expected to last for twelve consecutive months. This requirement is called
the duration requirement and is an important part of Social Security’s
definition of a total disability.
What is Sequential Analysis?
Sequential Analysis is a step-by-step process used in the evaluation of a
Social Security disability case. This process is the most important
sequence in the disability process because it guides you through the
required steps needed to determine if a person meets Social Security’s
criterion for a total disability.
Adjudication:
The term adjudication is an all inclusive term that defines the entire
Social Security disability process. A disability case is said to be in
adjudication when it is moving through the Social Security disability
process.
Allegations:
This term allegation refers to the medical impairments alleged by the
claimant. A claimant can allege one or more impairments in his/her quest to
receive disability benefits. However, an impairment alleged by the claimant
must be severe and supported by acceptable medical evidence. If impairment
significantly reduces a claimant’s physical or mental capability, it should
be alleged in a disability claim.
What is Acceptable Medical Evidence?
Acceptable medical evidence means that the evidence itself can be used by
SSA to make a final decision in a disability claim. Any evidence submitted
by a licensed physician, psychologist, psychiatrist, osteopath, optometrist,
or ophthalmologist, is considered to be acceptable evidence for
determination of a disability case. Authorized summaries of medical records
from hospitals, clinics, sanitariums and other medical institutions are also
acceptable for case analysis.
Chiropractic and non-medical holistic sources are not considered to be
acceptable medical sources for making a final determination of a disability
case. However, these sources are important and can give a fuller picture of
a claimant's real capabilities.
What is an
Alleged Onset Date
(AOD)?
An Alleged Onset Date (AOD) is the date alleged by the claimant as being the
beginning date of the impairment or the date his impairment forced him to
stop working. This date is used by both the advocate and Social Security to
determine the approximate date for requested medical evidence. That is, you
want to request medical evidence from at least the alleged onset date to the
present.
What is an Established Onset Date (EOD)?
The Established Onset Date (EOD) is the date
of onset of an impairment established by the Social Security office.
Often the AOD and the EOD are the same, but they can be very different.
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Example: A client
injures himself and is no longer able to perform his customary work from
that date forward. The date of injury or the day he stopped working is the
same date. However, if the claimant was injured and returned to work for
several months at full pay, then stopped working as a result of his
impairment, the earlier AOD would not be the same as the later EOD. SSA
will use the EOD as the official onset date in the case. The claimant’s
benefits would be calculated from the EOD in this case, not the AOD.
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What is the 20/40 Rule?
In order for a person to be determined eligible to apply for SSDI benefits,
that person must not only be currently earning less than SGA, he must also
meet the 20/40 rule. The 20/40 rule refers to the total number of quarters a
person must have worked in the past ten years in order to be insured under
the Social Security Disability Insurance program. If the applicant meets the
20/40 rule, he can then proceed with his application.
What is a Concurrent Case?
A concurrent case is a Social Security disability claim that involves a
single individual applying for both SSI and SSDI benefits. The claimant
must have the proper amount of work history and meet the SSI income criteria
in order to be eligible to apply concurrently.
Consultative Examination:
A consultative examination is a physical or mental examination of a claimant
at the request and expense of the Social Security Administration. A
representative should request a consultative examination if you feel that
the available evidence is not enough to show the full extent of the
claimant's conditions.
What is a Diary Date?
This term has two meanings:
a The interval of time until a claim is re-evaluated after benefits are
allowed.
b. The interval of time a State agency holds a claim to determine the
outcome of some medical problem or treatment, before a final decision is
made. This situation usually occurs in conditions like an acute heart
attack where Social Security will wait to see if the claimant rapidly
improves with treatment. This date or event is also referred to has a
medical hold.
What is a Date Last Insured (DLI)?
The Date Last Insured (DLI) refers to an SSDI case where a person has worked
enough quarters to be eligible to apply for current disability benefits. If
the applicant has not worked in approximately five of the last seven years
at SGA level, that person may have a DLI in the past. The claimant with a
DLI in the past may not be eligible for current benefits unless he is found
disabled prior to his DLI in the past.
If a person has a DLI in the past, he may apply for benefits from the
original onset date to the DLI date whether he is currently disabled or not.
If this is the case in an SSDI case, the client must be found disabled on
or before his/her DLI date in order to receive benefits. If the claimant is
found disabled prior to his DLI, he can then apply for current benefits.
If as a representative you find yourself doing a case with a DLI in the
past, you need only be concerned with medical evidence dated on or before
that DLI date. The date last insured, like case types, is determined by
Social Security.
Meets the Medical Listing:
A case is said to meet the medical listing if the impairment is of such
severity that it meets Social Security’s defined definition of that
disease. Social Security’s defined definitions of disease states can be
found in Social Security’s listing manual. See instructional syllabus for
link to medical listings.
Equals the Medical Listings:
A case is said to equal the medical listing if the impairment is of such
severity that it equals Social Security’s defined definition of that
disease. Social Security’s defined definitions of disease states can be
found in Social Security’s listing manual. See instructional syllabus for
link to medical listings.
Presumptive Disability (PD):
A presumptive disability is an opinion by Social Security that allows
disability benefits to be paid even while the client is applying for
benefits. In these cases, there is a presumption of disability. That is,
Social Security believes that the case will result in an allowance
determination so it begins making payments during the application process.
A PD is only used in SSI claims.
Who can apply for benefits?
Any American citizen one month of age to sixty-four and one half years of
age may apply for SSA disability benefits if they are suffering from a
severe physical or mental impairment. With the exception of child cases,
the impairment must prevent the applicant from performing SGA level work.
In child cases, the impairment must prevent the child from performing age
related or age appropriate activities.
What is a Waiting Period?
The actual starting date for cash benefits is the onset date minus six
months. The six months is called the waiting period. I guess Social
Security invented this period hoping most people would return to work or at
least medically improve within six months, saving taxpayer’s dollars. In
any event, if the onset is 1/1/05, the representative’s fee will be based on
the 1/1/05 onset date minus the six month waiting period. The actual amount
owed to the representative is determined by Social Security using factors
such as the claimant’s EOD and his/her income history.
What is an SSDI case?
Few people realize
that when they pay into Social Security retirement each month, they are also
paying into the SSDI program known as Social Security Disability Insurance.
This program is also referred to as the Title Two Program. The most common
disability case of an adult who has worked above the SGA level is the SSDI
case. Case types are determined by SSA.
What is an SSI case?
The second most common disability case type is called the Supplemental
Security Income program or Title Sixteen program. Any person who is claiming
a disability, child or adult, may apply for benefits under this program if
they meet Social Security’s income and resource criterion. The applicant
must be, as in all disability cases, impaired and unable to work or perform
age appropriate activities. However, in an SSI case an applicant must also
be without income or resources. As previously mentioned, case types and
income requirements are determined by the Social Security Administration.
Incidentally, SSI and SSDI cases are medically evaluated in exactly the
same way using the same basic adjudicative criteria.
Disability Hearing Officer DHO:
The office of Hearings and Appeals is nothing more than an office or
separate building used for hearings and appeals. An experienced disability
examiner who interviews claimants during the reconsideration process may be
located at the District Office or at an Office of Hearings and Appeals. The
Adjudicative Law Judge hearing will most likely occur at a Hearings and
Appeal office.
What is Vocational Analysis?
Vocational analysis is a process by which the claimant's ability to perform
work is determined. This is done by comparing the claimant’s remaining
ability to work, Residual Functional Capacity (RFC), with the availability
of work at his activity level in the national economy.
Residual Functional Capacity:
A Residual Functional Capacity (RFC) is the amount of functional capacity a
claimant has left after consideration of his impairments. The lower the RFC,
the more likely the client will be found disabled.
Residual Functional Capacity
will be discussed at great length in lesson 5 of this Study Guide.
What is a Case Assessment?
A case assessment is a process whereby the strength of a potential client's
case is determined prior to accepting the case. This is done by weighing a number of case
characteristics to determine the approximate percent chance of winning the
case.
What is Case Development?
Case development is a process where by the claimant's medical and vocational
evidence is collected and placed into a single location or folder. This
information is then used by the disability advocate to determine the extent
of the claimant's disability.
What is a Case Evaluation?
A case evaluation is a process where by all available medical evidence is
reviewed for the purpose of creating an argument on behalf of a
client. Within the case evaluation process, a representative will follow an
internal Social Security process called sequential analysis and vocational analysis.
Sequential and vocational analysis, along with the claimant's medical
documentation, enables an advocate to create a formal argument on behalf of
a client.
The Trial Work Period (TWP):
After a claimant has been found eligible for disability benefits, that
claimant is also entitled to receive a trial work period at any time during
his period of disability. The trial work period provision allows the
claimant to work up to nine months above SGA and still collect disability
benefits. The Trial Work Period provision is very important from a
vocational rehabilitation standpoint, because it encourages a claimant to
attempt work.
If the claimant completes the full nine months of the trial work period
without problems, his/her benefits will be discontinued after two additional
months of benefits. In many cases, this early financial support will allow a
claimant to get back on his feet and re-enter the work force. The TWP,
Ticket-to-Work and other work provisions are fantastic because they allow a
claimant who wants to work, the opportunity to get back on his feet. I
personally like these provisions because it saves taxpayer dollars.
Lesson Three Preview:
Lesson three will
introduce you to the concept of Sequential Analysis and how this procedure
is used in the evaluation of a Social Security disability case.
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