- Contact Information
- Eligibility for Retirement Benefits – Self and/or Family
- SSDI (Title II) Eligibility
- Disability Insurance Benefits
- SSI (Title XVI) Eligibility
- Resource Test
- Income Test and Benefit Amounts
- Social Security Work Incentive Programs
- Appeal Process
- Request for Reconsideration
- Request for Hearing Before an Administrative Law Judge
- Appeals Council
- Federal Court or Reapplication
The Federal Social Security Act (Public Law 74-2710) was passed in 1935, establishing retirement benefits for older individuals. Income supplements and disability-related benefits were attached to the law in subsequent years. Today, there are three basic types of Social Security benefits:
- Retirement Benefits (usually called "social security")
- Social Security Disability Insurance (SSDI) - added to the law in 1954 as Title II
- Supplemental Security Income (SSI) - added to the law in 1974 as Title XVI.
Social Security benefits provide limited monthly income from the federal government. The Social Security Administration (SSA) does not pay for AT directly, but entry into the system is an important first step in being able to access devices and services through other related programs. For example, in Delaware, anyone receiving SSI benefits is automatically eligible for Medicaid, and Medicaid pays for many AT devices as durable medical equipment. (Refer to the Medicaid section for more details.) Note, however, that while a person may be eligible for certain programs, enrollment is not automatic. It is necessary to submit an application in order to receive benefits. Once an adult begins receiving Social Security benefits, AT may also be accessed through Social Security Work Incentive programs. Those programs are discussed later in this section. Proceeds from Social Security retirement benefits can also be applied to the purchase of AT devices for the beneficiary or that person's family members with disabilities.
Call the Social Security Administration's national toll-free number, (800) 772-1213, to find out how to apply. Questions regarding eligibility for Social Security benefits may be directed to the Social Security Administration office in the consumer's county of residence. The locations and telephone numbers of the county offices are:
920 W. Basin Road
New Castle, DE 19720
(302) 323-0304 (voice)
300 South New St.
Dover, DE 19901
(302) 674-5162 (voice)
Suite 202, Professional Park
Georgetown, DE 19947
(302) 856-9620 (voice)
People using telecommunication devices for the deaf/text telephones
(800) 325-0778 (weekdays 7 a.m.-7 p.m.)
Social Security Retirement Benefits can be a source of AT funding for both the retiree and some members of that person's family. The retiree may utilize both financial and insurance benefit components. That person's family members who qualify can receive up to one half the amount of the retiree's full benefit (up to a certain overall family limit) without affecting the retiree's benefit amount. Family members who qualify include:
- Spouse age 62 or over
- Spouse of any age who is taking care of the retiree's child who is under age 16 or has a disability
- Former spouse, age 62 or over, if the marriage lasted for 10 or more years and the former spouse remains unmarried
- Children, stepchildren, adopted children, and sometimes grandchildren up to age 18 (age 18-19 if they are full-time students through grade 12)
- Children over age 18 who have disabilities that occurred prior to age 22. This category is an important one for certain adults with disabilities. These individuals are qualified to receive benefits under their parents' earning records.
Title II (the term the Social Security Administration uses for SSDI) is an insurance program that provides monthly cash benefits to those who are eligible. SSDI is not short-term or partial disability payment; rather, it is designed for those whose disability is expected to be long-term. Only people with one or more disabilities qualify, and the following additional requirements must be met:
- The disability must prevent the person from earning
above a certain income level called the Substantial Gainful Activity
A person with a disability who earns below the SGA level is
eligible for SSDI benefits. While the SGA levels are likely to
future years, the 2004 levels are as follows:
- $810 average gross income per month for persons with disabilities other than blindness
- $1,350 average gross monthly income for people who are blind
- SGA for self-employed individuals with disabilities is measured in hours rather than average monthly income.
- The person (or his/her deceased spouse or parent) must have achieved insured status by having paid into the Social Security system. Typically, such payments need to be for at least half of the quarters in the 10 years preceding the onset of the disability.* Most employers pay automatically when federal taxes, sometimes called FICA taxes, are deducted from payroll.
*Workers disabled before age 31 are not held to this standard. The minimum requirement is 1.5 years work in the 39 months before onset of the disability.
Certain family members of a person who is receiving SSDI also qualify for benefits; the same ones identified above in the retirement benefit category are included.
In addition, some family members of deceased wage earners are entitled to benefits called "survivors' benefits."
- The disabled son or daughter of a deceased worker may receive benefits indefinitely (or until the condition goes away) if: the adult child is unmarried, s/he was dependent on the parent, and the onset of the disability occurred prior to age 22. Those who are not disabled can receive similar benefits up to age 18. The deceased family member simply must have paid federal income taxes for the required number of years.
- The disabled surviving spouse (or ex-spouse if the
marriage lasted 10 or more years) qualifies if:
- The surviving person is age 50 or above (one who is not disabled must be age 60 or above).
- The disability of the surviving spouse started before the original beneficiary died, or within seven years after death.
- The surviving spouse caring for the deceased's children who receive benefit payments becomes disabled before those payments end (for example, when the child turns 18) or within seven years after they end.
There is a five month waiting period for receipt of SSDI benefits after the person becomes disabled.
Only persons with disabilities who have received SSDI cash benefits for 24 months may be eligible for the medical insurance portion of SSDI, which is actually disability-related Medicare. The exception to this rule is that persons under age 65 with Amyotrophic Lateral Sclerosis (ALS/ Lou Gehrig's disease) can receive Medicare coverage during the first month in which they receive SSDI benefits.
SSI is a small monthly income supplement for qualified people with disabilities of all ages and for anyone who is age 65 or older. In contrast to SSDI, Title XVI eligibility depends on a person's income and resources. SSI, unlike SSDI, does not require a work history. The picture is a bit complex because some income and resources are counted in eligibility determinations while others are not. The following is a basic overview of how it works.
A single person can have no more than $2,000 in assets (bank accounts, stocks, bonds, or other types of securities). For couples, the asset cut-off is $3,000. Individuals are allowed up to $1,500 for burial expenses, and an additional $1,500 for a spouse's burial expenses. The first family car usually does not count as a resource. Life insurance policies with a total face value of $1,500 or less per person and personal belongings may also be exempt. Finally, the home in which a person lives and the land that the house is on are not counted as resources. However, owned real estate other than a person's residence may be counted unless the property is essential to an individual's self support (such as rental property or land used to produce food for personal/private consumption).
Under the SSI program, the initial determination of eligibility also includes consideration of whether the applicant's income is less than the appropriate SGA amount income listed above. SGA is not applied under SSI to people who are blind. Income is divided into two categories: earned and unearned. Earned income includes wages, net earnings from self-employment, and income received from sheltered workshops. Unearned income includes all income that is not earned, such as Social Security benefits, workers' or veterans compensation, pensions, support and maintenance in kind, annuities, rent, and interest.
Generally, a person who has an unearned monthly income of less than $810 for 2004 will qualify for federal SSI payment. In order to determine SSI eligibility and the amount that will be awarded, the Social Security Administration must consider an individual's income level. However, not all income is counted. The first $20 of unearned income, the first $65 of earned income, and half of the person's wages over $65 are not counted in determining the benefit amount. The formula starts with subtracting the first $20 of unearned income [called the General Income Exclusion (GIE)] and the first $65 of wages [called the Earned Income Exclusion (EIE)] from total income. Then, half of what remains after subtracting that $85 is subtracted from the SSI monthly maximum income level of $564 to arrive at the SSI benefit amount.
To illustrate, let's perform the calculation for a person who receives a monthly income of $885
|Gross Monthly Income||
|Then, dividing the remainder in half||
|We get countable income||
The countable income figure is then subtracted from the $564 SSI maximum monthly income level to determine the benefit amount:
|SSI Max Income Level||
|SSI Benefit Amount||
The $164 would be the amount of the SSI beneficiary's monthly check. So the person's total monthly income is $885 + $164 = $1,049.
The current (2004) maximum federal SSI monthly payment is $564 for an eligible individual, and $864 for an eligible couple. However, the law gives states the option of supplementing that figure and varying the payment amounts based on living arrangements and geographical area. Delaware provides a modest supplement only to those who are in protective care arrangements.
As with SSDI, there are ways of setting aside income under SSI for the purchase of AT devices and services. Setting the money aside reduces reported income and increases the benefit award by the same amount, so the money spent on the device or service is replaced. Related information is contained in the section on Work Incentive Programs.
Anyone receiving SSI or SSDI benefits can purchase AT through one of the work incentive programs if the equipment is in some way related to getting or keeping a job. Note that self-employed SSI or SSDI recipients may also qualify for these programs. There are now several types of work incentive programs for people with disabilities other than blindness: the Impairment Related Work Expense (IRWE), the Plan to Achieve Self Support (PASS), and the "Ticket to Work" program. The IWRE and the "Ticket to Work" are available to both SSI and SSDI recipients; the PASS program is usually limited to SSI recipients. Persons who are blind may utilize the Blind Work Expense (BWE) program, which is also limited to SSI recipients. A blind or visually impaired consumer may also have access to PASS and IRWE programs if the BWE option is not available.
The IRWE is money that is set aside from income to pay for equipment or services a person may need in order to work. Some examples are transportation (including vehicle purchases), medication, medical equipment and other adaptive devices, and home modifications (including ramps). The basic requirements of IRWE are as follows:
- Items or services must be purchased directly by the beneficiary (remember to keep all receipts/records of purchase).
- Items/services should not be reimbursable by other funding sources such as public or private insurance.
- The items/services must be needed to enable the person to work.
- Items/services must be related specifically to the individual's impairment.
IRWEs can cover a very broad range of devices and services. Examples include: any equipment or service a person needs to prepare for work before leaving home, such as ramps or medical equipment; transportation to and from work (including the purchase of a car or van); ostomy or incontinence supplies (including diapers and catheters); and even personal assistance in the home for a short time before or after work. The IRWE program is available to both SSI and SSDI beneficiaries.
The "Ticket to Work and Work Incentives Improvement Act of 1999" was enacted by Congress to increase beneficiary choice in obtaining rehabilitation and vocational services and to remove barriers forcing people with disabilities to choose between health care coverage and work. Beginning in 2001, Delaware was one of 13 states chosen for the first phase of the "Ticket to Work." In early February 2002, the SSA began distributing "tickets" to all SSDI and SSI recipientsin Delaware age 18 or over, which can be used to obtain vocational rehabilitation and other employment support services (including AT) from an approved provider of the recipient's choice. There will be a limit of one "ticket" per period of disability but people may receive multiple "tickets" during their lifetime. The "Ticket to Work" program is voluntary. Those with disabling conditions classified as "medical improvement expected" (MIE) will have to wait until long after their initial eligibility determination—after their first "continuing disability review" (CDR)—to receive their "tickets." This legislation also expanded Medicaid coverage so that persons with disabilities who work and have incomes up to 250% of the federal poverty level can purchase Medicaid coverage.
Available only to SSI recipients, the PASS is another way of setting income aside to purchase equipment or services. The set-aside can be done in a way that keeps income, as well as resources considered for SSI eligibility, below the qualifying cutoff so that there is no reduction in benefits. Therefore, when the Social Security Administration calculates a beneficiary's SSI payment amount, income set aside under a PASS is not counted. A PASS does not affect SGA determination for the initial eligibility decision. Set-aside money may be used for AT devices and services, education, or even business start-up. In other words, it might include any items or services that would make a person vocationally self-sufficient. Although somewhat similar to the IRWE, the PASS is different in several respects:
- The PASS must be in writing and approved by the Social Security Administration before it can be implemented; the IRWE does not carry this requirement. The SSA prefers that beneficiaries use its PASS form (SSA-545-BK). The PASS plan should describe a specific work goal that the beneficiary is capable of performing and a specific time frame for reaching that goal.
- A separate account needs to be established for PASS set-aside money, and payments into the account must be made according to the schedule stated in the PASS. It is not just a question of saving receipts for reimbursement.
- The PASS's time frame cannot exceed 48 months.
A note of caution: Once money has been set aside for a PASS, spending it for something else can result in loss of SSI benefits.
The Blind Work Expense functions in much the same way as the IRWE. It covers every expense that the IRWE covers and more. However, it is distinct from the IRWE in several important respects:
- The BWE program is only available to SSI recipients who are blind, while IRWEs are available to both SSI and SSDI recipients.
- BWEs need not be "impairment-related." For example, regular transportation expenses such as cab or bus fare or other expenses that a non-disabled person might routinely incur would not be deductible as an IRWE, but would be as a BWE. Expenses such as lunch and childcare, federal, state and local income taxes, are all legitimate BWEs.
- BWE requests must be made in writing, but unlike the PASS, they need not be approved before making the actual purchase. Nonetheless, it may be safer to check with the SSA before making such purchases.
Once an SSDI recipient is ready to return to work, s/he may be entitled to a nine month trial work period.
The rules and features of the TWP are as follows:
- The person must earn over $580 in a given month in order for that month to be considered part of the trial work period. If the person is self-employed, the requirement is 80 or more hours of work in a month.
- The nine months do not have to be consecutive, but
the TWP ends after the ninth month in which the person earns
over the limit.
- SSDI and Medicare benefits continue during the TWP, no matter how high the person's earnings are, as long as the disability continues.
- One is not eligible for disability benefits or a TWP if s/he works at SGA level within 12 months of the start of the impairment and before the Social Security Administration approves the claim for disability benefits.
- If a person has a medical recovery prior to the end of the TWP, benefits may stop.
- A new SGA determination is made after the TWP.
- Up to 36 months after the trial work period ends, a person can still receive an SSDI benefit check for any month in which earnings fall below the SGA level. This is called the Extended Period of Eligibility (EPE). This will be true provided that the person is still disabled at the time and has proof of sub-SGA earnings. If earnings fall below SGA in the final months of the EPE and beyond, or if the person discontinues work before the 36th month and remains disabled, benefits could continue indefinitely. However, if the person's earnings are at or above SGA during the final month of the extended period of eligibility (even if they were below SGA for several months beforehand), benefits will cease. If, after benefits have been discontinued, earnings fall below the SGA level, it is possible to obtain (through a new application) another trial work period, but the disability may have to be proven again before any additional benefits are awarded.
- Since January 2001, the SSA has permitted expedited benefits for those whose SSDI or SSI disability benefits have ended because of earnings from work. The beneficiary can request reinstatement of benefits, including Medicare and Medicaid, without filing a new application when s/he has become unable to work because of a medical condition. Requests for reinstatement must be filed within 60 months from the month when benefits were terminated. In addition, temporary benefits, including Medicare and Medicaid, may be paid for up to six months while the case is being reviewed.
If a claim for benefits is denied for any reason, the applicant has the right to appeal that decision. Submission timeframes are similar to those of public insurance carriers such as Medicaid and Medicare, but the process itself is somewhat different.
Review requests must be submitted in writing within 60 days of the denial. The claimant has the right to review his/her own claim file (upon request) and to submit new information that may have a bearing on the eligibility decision. Such information should be included in the letter requesting a review. If the SSA requires the claimant to be examined by an independent doctor, the claimant must comply. At the reconsideration stage, personnel at the SSA who did not participate in the initial decision to deny benefits review the claim.
Most reconsiderations are based upon a file review without the claimant being present. However, in the case of benefits termination due to the claimant's improved medical condition, the claimant has the option of meeting with a disability hearing officer. At that meeting, the claimant will need to explain why the disability continues to qualify him/her for benefits.
The reconsideration process typically lasts approximately three months. Most requests for reconsideration are unsuccessful, but it is important to not get discouraged. Instead, one should persevere and consider requesting a hearing before an Administrative Law Judge.
If the claim is denied at the review stage, the claimant may file for a hearing before an Administrative Law Judge (ALJ). The request must be made within 60 days of the review decision. The claimant has a right to be accompanied by a representative (attorney or non-attorney) at the hearing. According to the SSA, approximately 80 percent of claimants have representatives assist them at these hearings. Again, any new and relevant information should be submitted at the time of the request.
The hearing before the ALJ is particularly important because it is, typically, the first time a decision-maker meets face-to-face with a claimant. The ALJ can take into account a claimant's subjective complaints of pain, though these complaints must be supported by evidence. At the hearing, the claimant and other witnesses testify under oath or affirmation, and the testimony is recorded verbatim. The ALJ listens to witnesses' testimony, receives documentary evidence, and considers arguments made by the claimant and/or his/her representative. If the ALJ believes it necessary, the ALJ may arrange for consultative examinations to be performed at a later date and may obtain additional medical evidence from those who have treated the claimant.
At a later date, the ALJ will issue a written decision and a copy of this decision will be mailed to the claimant and his/her representative. If the ALJ denies the claimant's appeal, the next step is an appeal to the Appeals Council.
The ALJ hearing process can take approximately 12 to 18 months before a decision is made.* However, since it often provides the best chance of success for a claimant compared to the other administrative steps in this process, claimants should take advantage of this opportunity. Claimants who need an attorney can contact Community Legal Aid Society, Inc.’s Disabilities Law Program at (302) 575-0660, 575-0696 (TTY/TDD) in New Castle County, (302) 674-8500 (voice and TTY/TDD) in Kent County, and (302) 856-0038 (voice and TTY/TDD) in Sussex County to inquire about the possibility of free representation.
*(February 2002)“Social Security Disability: Disappointing Results from SSA's Efforts to Improve The Disability Claims Process Warrant Immediate Attention” (GAO-02-322) Washington, D.C.: U.S. General Accounting Office.)
An appeal to the Appeals Council must also be filed within 60 days of the ALJ's decision. The Appeals Council represents the final step in the administrative appeals process. If the Appeals Council grants a request to review the ALJ's denial, it will review all of the evidence in the claimant's file as well as the ALJ's decision. However, the claimant does not have an opportunity for a hearing before the Appeals Council. The Appeals Council can: 1) decide in the claimant's favor; 2) send the case back to the ALJ for another hearing or the gathering of additional evidence; or 3) deny the claimant's request for review of the ALJ's decision. The Appeals Council process typically takes approximately 15 months, after which written notice of its decision is sent to the claimant.
If the Appeals Council sustains the denial, a claimant has 60 days from the date of that denial to file a civil suit in Federal District Court. Another option, which can be pursued at the same time as a suit in federal court, is to file a reapplication for benefits with the SSA.