Once SSA has determined that an applicant meets non-medical criteria, the application is sent to the State Disability Determination Services (DDS) for an evaluation of the applicant’s disability.This chapter explains the process that the DDS uses to make that determination and outlines some of the special factors that affect applicants with mental illnesses and substance use disorders.
Under SSA rules, an adult is disabled if he or she is unable to do any “substantial gainful activity 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.”[1] This definition includes several specific points:
While every person has the right to apply for SSA disability benefits, some applicants may not meet SSI/SSDI eligibility requirements. In these instances, case managers should explain the requirements and assist the person in finding more appropriate and available sources of support.
Once an SSA field office determines an applicant meets income and resource guidelines, the application is sent to the State Disability Determination Services (DDS) for processing. SSA has agreements with each state and the District of Columbia to undertake disability evaluations. Every state has its own DDS, which may be located in the State’s Department of Labor, Social Services, or another agency.
The process of determining whether an individual is disabled entails a five–step test, or sequential evaluationprocess. At each step, the DDS asks and answers a specific question regarding the applicant, ensuring that different aspects of disability are considered before an application is either approved or denied.
To determine whether an individual meets disability criteria, SSA and DDS staff use the sequential evaluation process to consider different kinds of information, ensuring that the person’s disability is completely reviewed. Since the steps are sequential, the process may stop at a step if specified criteria are met. The specific steps are shown in Figure 2 and described in further detail below.
This step evaluates whether an applicant is engaging in substantial gainful activity or SGA. If an applicant is engaging in SGA, he or she is ineligible for either SSI or SSDI. The amount of gross earnings considered changes annually. In 2004, the amount was $810 per month; in 2005, the amount is $830 per month. Individuals who earn these sums but who have special conditions or expenses related to their disabling condition may not be considered to be earning SGA by SSA. If an applicant is not working at all, or he or she is not earning at the level of SGA, the case moves to the next step.
A severe impairment is defined as an impairment or combination of impairments that “significantly limit … physical or mental ability to do basic work activities.”[3] Under Social Security regulations and guidelines, the threshold for this test is not particularly demanding. The critical issue for case managers is to ensure that information sent to the DDS demonstrates that a person’s functioning has been severely impaired. If the information shows the presence of a severe impairment, the process moves to the next step.
Disability Evaluation under Social Security (also known as the Blue Book), a publication distributed by SSA, provides criteria under which SSA automatically will find an applicant disabled in the Adult and Childhood programs. These criteria take the form of a Listings of Impairments, commonly referred to as “the listings.”[4] Disability determinations at this step are made without regard to age, education, and work experience.[5] The nature of an individual’s physical or mental impairment is compared against the criteria that must be met or equaled for that impairment to be considered disabling. If medical evidence shows the applicant meets these criteria or has impairments equivalent in severity to them, the applicant will be found disabled—as long as the criteria have been met, or are expected to be met, for at least 12 months, or if the impairment can be expected to result in death
Case managers should note that even if a person doesn’t qualify under the listing for a single diagnosis, he or she may qualify, at a later step of the sequential evaluation process, as a result of multiple impairments. For example, a person might have diagnoses of depression, diabetes, congestive heart failure, and hypertension. While any one of these chronic illnesses might not rise to the level of a disability under SSA rules, the combination of these illnesses might do so.[6] Therefore, case managers are advised to refer all potential applicants to SSA for evaluation.
If an individual does not meet or equal the requirements of the listings, the sequential evaluation process continues.
In this step of the sequential evaluation, SSA determines whether the applicant has the ability to perform the same work he or she did in the past. If the answer is yes, the applicant will be found not to be disabled. If the answer is no, the analysis moves to Step 5 of the sequential evaluation that examines whether the applicant can perform other work.
In determining whether an individual has the ability to perform past relevant work, SSA will review:
At Step 5 of the sequential evaluation, SSA determines if the applicant can do any other work that exists in significant numbers in the national economy. It does not matter whether a specific job is available where the applicant lives, whether a specific vacancy exists, or whether the applicant would be hired if he or she applied for the job. Thus, an applicant might be found capable of being a gardener even if no gardening positions are available in his or her area and even if the applicant wouldn’t be hired for such a job if one were available. In making this decision, SSA once again will use the applicant’s RFC but will now take into account the applicant’s age, education, and work experience. To help make this evaluation, SSA relies on Medical–Vocational Guidelines, also known as “the grids.”[7]
The grids are designed to make observations about a large number of people. For example, one of these observations is that a person under age 50 with a high school education can do many different jobs. Older, uneducated applicants are more likely to be found disabled than younger applicants, even when their disabilities are the same.
A significant proportion of individuals who are homeless have physical health problems as well as mental health problems. All of these difficulties need to be reported and documented to be considered during the sequential evaluation process. The presence of physical ailments in combination with mental disorders may lead to the stronger possibility of a finding of disability by the DDS. For example, a person who is homeless may have skin, feet, breathing, or infectious disease problems from living outdoors. Case managers should ensure that all physical and mental health problems are documented and reported.
Alcohol or drug addiction alone does not constitute a disability for the purposes of SSI and SSDI. It is possible, however, for applicants using drugs and/or alcohol at the time of application to be found disabled and receive SSI. The test for determining eligibility is whether “drug addiction or alcoholism is a contributing factor material to the determination of disability.”[8] Thus, SSA determines whether an applicant would still be disabled if he or she were sober and abstinent from drugs or alcohol. If SSA's determination is positive, the applicant will be found disabled, providing that income and resource criteria are met.
Although SSA has considered drug and alcohol addiction materiality since the SSI program began in 1974, the definition of disability as it is affected by addictions has evolved. Before 1996, a person with a substance use disorder could obtain benefits if he or she could show the presence of a disabling condition, whether or not the condition was related to a substance use disorder. SSA required that he or she adhere to certain restrictions (e.g., a requirement to have a representative payee). Since 1996, however, if a person has a substance use disorder that is determined to be material to his or her disability, he or she will not receive SSI.
When assisting individuals who are using drugs and/or alcohol, case managers should: • Make sure that the medical records submitted to SSA contain evidence of
Once a case manager has a better sense of a person’s life history, he or she should find out more about the individual’s level of functional impairments, if any, and the source of these impairment(s). Drugs may be used by a person with mental illness to address or to mask feelings and behaviors related to his or her mental health status. Therefore, the case manager should inquire whether reported problems occur when a person is sober or only when the person is using drugs or alcohol.
For example, if a person stated that he or she takes substances to dull the fear and discomfort created by hallucinations, the case manager could conclude that the mental disorder is the problem and that the symptoms are likely to remain, even in the context of abstinence from drugs. Conversely, if an individual reported that he or she manages activities of daily living fairly well when sober, but avoids these tasks when using or withdrawing from substances, this person might be found not disabled.
The determination of disability is complicated when substance use is involved. At the same time, it is possible for the DDS to make a correct determination when given thorough, accurate, and complete medical and functional information. By gathering this information, a case manager can understand better what is affecting the person’s symptoms and functioning and can share the information with the DDS examiner.
The critical question regarding substance abuse is: “Would this person be disabled if in recovery?” Case managers must make sure that the DDS receives all medical information to help to answer this question to foster an accurate determination.
While the criteria for determining disability are stringent, the process ensures that a range of issues related to disability are considered before an application is approved or denied. This chapter detailed the steps in the disability determination process to give case managers familiarity with each stage of the process.
Sometimes issues such as substance abuse can complicate a disability determination. While individuals who are disabled solely on the basis of their addictions are not eligible for SSI, persons whose addictions exist in combination with other illnesses may be eligible. It is important for case managers to encourage these individuals to apply. Case managers can play a critical role in developing and providing the documentation to promote appropriate disability determinations. Additional information about how to provide medical documentation to SSA is discussed in the next chapter.
120 C.F.R. 404.1505(a) and 416.905(a).
2Evidence to establish a "medically determinable impairment" must be provided by "acceptable medical sources." Acceptable medical sources are licensed physicians, psychologists (including school psychologists), optometrists, podiatrists, and licensed or certified speech-language pathologists. See 20 C.F.R. 404.1513 and 416.913.
320 C.F.R. 416.920(c).
4The listings can be viewed at the Web site www.socialsecurity.gov/disability/professionals/bluebook/index.htm and at 20 C.F.R. 404, Supart P, Appendix 1. Also, see 20 C.F.R. 416.925-926.
520 C.F.R. 416.920(d).
6This is a particularly important consideration for individuals with substance use disorders. More information about substance use appears later in this chapter.
7The grids are available at www.socialsecurity.gov/OP_Home/cfr20/404/404-ap10.htm. Note that the grid rules were recently revised. See the final rules amended at www.socialsecurity.gov/regulations/articles/rin0960_af37f.htm.
820 C.F.R. 416.935(a).