                            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.


