An exception

There is, however, an exception when an individual draws less than a full monthly retirement benefit for a period and is approved for disability benefits; Social Security will make up the difference between the early retirement amount and the full disability amount for those months the individual was disabled but receiving early retirement benefits (retroactively).

Compassionate allowances

Social Security has developed a list of more than 225 compassionate allowances currently, which, if the insured person has one of these conditions, shortens the time frame for being approved for disability benefits to approximately two weeks.

The allowances can be found at http://ssa.gov/compassionateallowances/conditions.htm

Denial of claims

If an individual’s application for SSD is denied (we can see from the following table that most initial applications are), he or she can appeal the decision. A denied applicant must request a review of the denial within 60 days from the date of the denial letter. The first step of the appeal process in most states is the request for reconsideration, a review of the claimant’s file by another claims examiner. If the applicant is denied again, he or she may appeal to the next level by requesting a hearing with an administrative law judge who works for the SSA.

The SSA recently met its goal to increase the number of administrative law judges to more than 1,500. With more than 255,000 hearing requests in 2017, individuals should consider legal representation when preparing for their disability appeals.

Reducing benefits due to payments by other government type disability payments

If someone is entitled to receive disability benefits from private long-term disability insurance benefits, these benefits will have no impact on the insured’s SSDI benefits. However, if someone is claiming SSDI benefits and simultaneously receives government-regulated disability benefits, such as workers’ comp benefits or temporary state disability benefits, they can end up reducing SSDI benefits. The rule is that a disabled SSDI recipient may not receive more than 80% of the average amount earned before the disability ensued in combined SSDI and other disability benefits. If that occurs, the SSDI benefit will be reduced. SSI and Veterans Benefits Administration (VA) benefits (not disability benefits) will not reduce an individual’s SSDI benefit.

No disability payments at full retirement age and older

If one is still receiving disability insurance by the time of his or her full retirement age, the payments morph into retirement benefits. The amount of the retirement payments remains the same.

Back pay for delayed benefit approval

Because initial denial of claims for SSDI occur in roughly 60% of situations, when approval finally happens, retroactive benefits—back pay—is not uncommon. The amount available in back pay, of course, depends on the applicant’s SSDI monthly amount. The number of months of back payments one gets will be determined by the months between the application date and the established date of onset (when the applicant’s disability started). If an individual previously applied for disability benefits, he or she may be able to get back pay going back to the original application date.

Generally no benefit for disabled children

Generally, children cannot qualify for SSDI because such benefits are available only to disabled workers having sufficient FICA credits or quarters. (However, if a disabled child’s parent is eligible for Social Security retirement or disability, the child may be able to receive a dependent’s benefit called the disabled adult child benefit after turning 18.)

If a worker’s adult child is disabled before the age of 22, he or she can qualify for benefits based on a parent’s earnings record. Anyone who becomes disabled after turning 22 needs to pass the recent work test, a measure of how many years of work the disabled individual has performed depending on his or her age.

The Medicare or Medicaid piece

After collecting disability benefits for 24 months, a beneficiary will become eligible for Medicare, regardless of that beneficiary’s age. In the interim, if the disabled individual’s income and assets fall less than certain benchmarks, that person may qualify for Medicaid benefits.

Working while collecting disability benefits

Trial work period—The trial work period allows a patient to test his or her ability to work for at least nine months. During the trial work period, the patient will receive full Social Security benefits regardless of how much is being earned as long as he or she reports the work and continues to have a disability. In 2019, a trial work month is any month during which total earnings are more than $880. If the patient is self-employed, he or she has a trial work month when he or she can earn more than $880 (after expenses) or work more than 80 hours in his or her own business. The trial work period continues until the patient has worked nine months within a 60-month period.

Extended period of eligibility—After the trial work period, the patient has 36 months during which he or she can work and still receive benefits for any month that earnings aren’t substantial. During a trial work period, neither a new application nor disability decision is necessary to get the Social Security disability benefit.

Expedited reinstatement—If benefits stop because of substantial earnings, the patient has five years to ask the SSA to restart the benefits if the patient is unable to keep working because of the condition. The patient won’t have to file a new application or wait for benefits to restart while the medical condition is being reviewed.

Continuation of Medicare—If Social Security disability benefits stop because of earnings, but the patient is still disabled, free Medicare Part A coverage will continue for at least 93 months after the 9-month trial work period.

CDRs for adults

Most claims are set for review every three or seven years, depending on the likelihood that a benefit recipient’s condition will improve. If a claimant has a condition that is expected to medically improve, a CDR may be conducted even sooner than three years. In contrast, Social Security beneficiaries whose condition is not expected to improve or are disabled due to a permanent condition (such as a lost limb or impaired intellectual functioning) may have their claim reviewed even less than every seven years.

However, even those with permanent disability conditions may be eventually subject to CDRs. Further, CDRs are also more frequently conducted for beneficiaries who are age 50.

CDRs for children receiving disability benefits under SSI

Children who are receiving (needs based, not regular Social Security) SSI disability benefits will automatically have their claims reviewed when they turn 18. The standards that must be met for an adult to be considered disabled are different from those for a child. Therefore, at age 18, the child will be evaluated under the adult standards. Newborns who receive SSI due to a low-birth weight will have their claim reviewed prior to the one-year mark.

Continuing disability review process

If a disability income benefit recipient’s Social Security claim is up for review, the SSA will notify that individual by mail. The SSA will send either a copy of the short form, Disability Update Report (SSA-455-OCR-SM) or the long form, Continuing Disability Review Report (SSA-454-BK), announcing a CDR. The short form is generally for those whose condition is not expected to improve, and is only two pages long.

If a benefit recipient’s condition could improve, or if his or her answers on the short form concern the SSA, the agency will respond by sending the benefit recipient the long form. The long form is similar to the initial disability application at 10 pages long. The form will question whether the benefit recipient saw a doctor, was hospitalized in the past year, whether the recipient underwent medical tests in the past year, such as electrocardiograms, blood tests, or x-rays, and, whether that disability income benefit recipient was working.

A benefit recipient is encouraged to submit any updated medical evidence to the SSA, although the SSA may also obtain such information on their own. In general, the SSA will be reviewing the period of 12 months prior to the notice, although the agency can examine evidence from any time after a recipient was initially granted benefits.

Medical improvement review standard

Assuming that an SSDI benefit recipient has not returned to work, the SSA will first determine whether there has been medical improvement in that claimant’s condition. If improvement is not substantiated then the CDR process is complete, and the disabled individual’s benefits (and auxiliary benefits) will not be affected.

In contrast, if the answer is yes, the SSA will then decide if the medical improvement affects the benefit recipient’s ability (or inability) to work. Assuming it does not, the disability benefits would continue. But if the SSA comes to the conclusion that the benefit recipient’s condition has improved to the point where he or she can return to work, that person will be notified that benefit payments will stop and will be given the chance to appeal the decision.

If the SSA feels that the evidence is insufficient to decide, or if there are inconsistencies between what the benefit recipient reports and medical evidence, the benefit recipient may be required to participate in for a consultative examination, which is an examination by a doctor that is paid for by Social Security.

Request for reconsideration

If benefits were stopped because of medical improvement, the individual who claims to continue to meet Social Security’s definition of disability can request a face-to-face hearing with a disability-hearing officer, even at the reconsideration stage.

Request for hearing

If the claimant’s request for reconsideration is denied, the claimant must file a request for hearing, and a request for continuing benefits, within 10 days after receiving the notice of adverse action. One may elect continuing benefits along with a hearing request even if he or she did not elect continuing benefits when filing the initial request for reconsideration. To continue receiving benefits, one must file a request for reconsideration (appeal) within 10 days of receiving the notice of cessation along with a request for continuing cash benefits, Medicare, or both. Note that this time limit is much shorter than the 60 days for the appeal itself.

If the claimant files the request for continuing benefits later than 10 days after receiving the notice of cessation or reconsideration, Social Security will deny the request for continuing benefits, unless the person making the request can show good cause for the late filing.

Further appeals

If one’s appeal is denied at the hearing level and that individual still wishes to appeal to the Appeals Council, he or she will no longer continue to receive disability benefits. However, if the Appeals Council remands the appellee’s case for a new hearing, benefits will continue with no action on the appellee’s part. One can also choose to continue benefits for others (such as children) receiving benefits based on the covered worker’s earnings record.

Completing the benefit election request form

The benefit election request form, Form SSA-795, Statement of Claimant or Other Person, can be downloaded from the Social Security website (SSA.gov). The form has a simple checkbox format, but an accompanying letter should also explain briefly, but specifically, why benefits should continue.

Continuing disability benefits for others

When a claimant requests to have one’s own benefits continued while appealing the cessation of his or her benefits, that appealing party should also request to continue benefits for others that were based on the appellee’s earnings record. However, the other persons receiving benefits based upon the appellee’s earnings record must also make their own election to receive continuing benefits: Each beneficiary must also make his or her own election to receive continuing benefits during the appeal period.

After the appellee requests continuing benefits for others receiving benefits on his or her earnings record, Social Security will advise those people of their right to elect to receive continuing benefits, and they then can respond with their own elections to receive (or not receive) continuing benefits.

Continuing SSI and Medicaid benefits

If one elects continuing SSI benefits and was eligible for Medicaid before receiving a cessation notice, Medicaid benefits will continue automatically. One’s needs-based SSI benefits may be suspended or changed while his or her appeal is pending if the appellee’s living circumstances change (typically changes in income, excess resources, or different living arrangements).

Working while appealing

If an individual received SSDI and worked at what would be considered substantially gainful employment during a trial work period while waiting for an appeal, that person’s SSDI benefits may be suspended.

Waiver opportunity

Social Security will consider waiving the recovery of disability benefits paid while an appeal is pending as long as the person who had received the benefits before the denial had appealed the cessation of benefits in good faith. An appeal is presumed to be made in good faith unless the individual filing the appeal failed to cooperate with Social Security during the appeal. Not cooperating generally means failing without good reason to provide medical or other information requested by Social Security or failing without good reason to attend a physical or mental examination.