Collected and printed by CFIDS - Albuquerque "News of the Month."
From the CFIDS Foundation of San Francisco "Treatment News"
Downloaded from CompuServe Good Health Forum 16 (now Chronic Illness Forum)
Dr. Karen Erzine (Chief, Medical Evaluation Branch/Internal Medicine, Office of Disability, Social Security Administration, Baltimore, Maryland) gave a presentation designed to demystify the Federal disability process, especially for those treating or suffering from CFIDS.
Note from Frank Albrecht, Novembeer 1999. This is
an old text but the basic process has not changed. There are new
determinations making it easier for people with fatiguing illnesses to
get disability. For these and much other useful information, see
the CFIDS Association of America Disability
and Health Insurance page.
The Social Security Administration (SSA) administers two disability programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) .
SSDI, a social insurance program funded through contributions paid by workers and their employers, covers disabled workers, their dependents, their widows, and their disabled adult children. Eligibility for SSDI benefits is based on an individual's work history, and the amount of the benefit is based on the individual's earnings. SSDI requires a 5-month waiting period for cash benefits and provides Medicare coverage after 24 months.
SSI is paid to disabled or blind adults and children on the basis of financial need, and the monthly Federal payment is a fixed amount, although some states supplement the Federal payment. Also, in most states, Medicaid benefits are linked to SSI entitlement. There is no mandatory waiting period for SSI or Medicaid.
The definition of disability is the same for both programs, i.e., to be considered disabled under the Social Security Act, an individual must be unable "to engage in any substantial gainful activity by reason of any medically-determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months."
Children (applying for SSI benefits) must have an impairment of comparable severity to that which would disable an adult. However, instead of evaluating ability to work, an individual functional assessment is made of how the children's impairment affects his or her ability to perform normal daily activities that healthy children of a similar age can do.
The disability determination for each claimant is made by an agency in each state called the Disability Determination Services (DDS). The DDSs are fully funded by the Federal government and are responsible for developing medical evidence to determine whether a claimant is disabled under the law and when disability began and/or ended.
The DDS requests medical evidence of record -- specifically, infor- mation about the claimant's impairment(s) from the treating sources (those physicians, psychologists, hospitals, clinics, etc.), identified by the claimant on the disability application. This evidence is the most important evidence in the process because it provides a longitudinal picture of the claimant's impair- ments(s). However, if that evidence is insufficient to make a determination, the DDS will purchase a consultative examination from the treatment source or from an independent source.
The individual's impairment must result from anatomical, physio- logical, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings. The impairment may not be established on the basis of symptoms alone, but symptoms are considered in evaluating the impairment.
A 5-step sequential process is used to evaluate the evidence in order to determine if the individual is disabled:
If YES, disability denied; if NO then proceed to step 2.
2) Is there a severe impairment? A severe impairment signifi- cantly limits the physical or mental ability to do basic work activities.
If NO, disability denied; if YES, then proceed to step 3.
3) Does the impairment meet or equal the severity of an impairment in the medical listings?* The listings describe medical conditions that are so severe that if they are "met," an individual is deemed unable to do any work.
If YES, allow disability benefits; if NO, then proceed to step 4.
4) Does the impairment prevent the individual from doing his or her past relevant work? SSA assesses the individual's residual functional capacity and compares it to the physical and mental demands of work done in the past.
If NO, disability denied; if YES, then proceed to step 5.
5) Does the impairment prevent the individual from doing any other work? SSA considers the individual's residual functional capacity, age, education, and past work experience.
If NO, disability denied; if YES, disability allowed.
Physicians can help in this process by providing complete longitudinal evidence that thoroughly describes the clinical condition(s) and treatment rendered. It is also helpful to indicate response to treatment, toxicity of medications, and/or other factors that contribute to the impairment. Because state agencies and field offices are experiencing extremely high workloads, the benefit application process can take several months. In some states, with some cases, the decision can be reached relatively quickly, such as within 2 months; in other circumstances the process can take as long as 6 months.
have general questions or would like to apply for benefits, call your local
Social Security office or call toll free 800-772-1213 (or 800-325-0078
for TDD services for those with hearing impairments). If readers have additional
questions about this article or would like to request a copy of SSA's listing
of impairments or any other publications on the disability program, please
write to: SSA, Office of Disability, Professional Relations Branch, 3-A-10
Operations, 6401 Security Boulevard, Baltimore, Maryland 21235.
* There is no medical listing for CFS/CDIDS, but individuals may have a documented impairment or a combination of impairments that are disabling.