One of our claimants—let’s call her Kathleen – was confused and concerned when she got a letter from the Social Security Administration (SSA) that stated she had met the medical requirements for disability benefits, but the non-medical requirements of her claim still needed to be reviewed before a decision could be made. SSA asked her to contact them, and she wondered what they wanted. After all, they had a whole file on her, and they had agreed she was disabled. What were the non-medical requirements and why couldn’t SSA just pay her claim? What more could they possibly need to know about her?
I can understand why Kathleen felt anxious. She had already been waiting several months for a decision on her initial claim. What I needed to explain to her was that a determination of disability is the medical part of that decision. There are also non-medical eligibility issues SSA must review and decide before benefits can be calculated and a claim can be paid. This is true whether the claim is a Social Security Disability Insurance claim (SSDI), a Supplemental Security Income claim (SSI), or a claim for both types of benefits (what we call a concurrent claim). These issues are what SSA refers to as non-medical requirements.
If SSA Agrees that I’m Disabled, Why Wouldn’t I Be Eligible for Benefits?
You would think that proving a medical disability would be enough to get benefits. This is what Kathleen thought. Even so, there are other issues that affect eligibility for benefits. The most basic ones are:
Social Security coverage (credits):
SSDI: You have to be insured for SSDI benefits. This means you must have paid into Social Security and earned enough work credits. How many credits you need depends on how old you are. How many credits you have depends on how many quarters you worked to earn them. If you don’t have enough work credits, you aren’t eligible for SSDI.
SSI: To get SSI benefits, work credits aren’t required.
SSDI: Not only must you have earned enough work credits, the onset of your disability must have occurred on or before your work credits expired, which is usually about five years after you last worked full time. This is called your “date last insured” or DLI.
It works something like car insurance. When you pay for car insurance, you pay in advance for coverage. At some point, your car insurance expires. If you get into a car accident after the policy expires, you’re not covered, and any claim you make won’t be paid. Similarly, you pay into Social Security and accrue work credits. But, if you stop working and are no longer paying into Social Security, your work credits eventually expire. If SSA determines that your disability occurred after the date your credits expired, you will not be approved for SSDI no matter how disabled you may become after your date last insured.
SSI: Your eligibility for SSI is based on income and assets, not on work credits. So, the “date last insured” issue does not apply for SSI.
Income and Assets: SSA may ask for proof of your income to be sure you’re not earning too much to qualify for benefits. And they may also look at your assets to determine your eligibility for SSI.
SSDI: To get SSDI benefits, you can’t be engaging in Substantial Gainful Activity (SGA), which means you can’t be making more than a certain amount of money set by SSA. Right now, that amount is $1,000 per month. But this amount can change from year to year. SSA looks at whether you’re working now, or if you worked at any time from when you became disabled to the present. SSA may want proof of your work activity as well as documentation on how much you earned, especially if you were self-employed or an independent contractor.
SSI: You must meet strict income and asset limitations in order to qualify for SSI. So, SSA will ask you for proof of any income or assets you may have, not only for you, but also for anyone in your household. (Yes, this is legal!) Income can include cash or other things that someone provides for you. For example, if someone pays part of your rent, SSA may consider reducing your SSI benefit. If you’re married and live with your spouse, your spouse’s income could affect the amount of your benefit.
Disabled – Yes! Eligible – Yes! So what’s the Holdup?
Once SSA determines that you are eligible to receive a benefit, they may want additional information to determine how much you should be paid, or whether benefits should be held until some other matter is resolved. You’ll be expected to provide documentation and your benefit amount may be affected if any of the following apply to you:
Workers Compensation or public disability benefits: If you are receiving Workers Compensation for a work-related injury, or disability benefits from your state, SSA will most likely reduce your government benefit. In some cases (more frequently with SSI) the receipt of Workers Compensation or other public disability benefits can zero out your benefit from SSA.
(Note: The situation is usually reversed when you receive private disability benefit payments, such as Long Term Disability benefits from a group policy with your employer. In this case, SSA won’t offset your SSDI benefits, but your private disability-benefit carrier may offset for benefits you receive from SSA.)
Defaults on student loans, taxes, or other government obligations: The government wants its money. So if you’ve fallen behind on debts or obligations to the government, SSA will offset your benefits to pay back the government before SSA pays you.
Outstanding overpayments of prior Social Security benefits: If you were previously on disability and somehow incurred an overpayment, SSA wants you to pay it back. You may have an overpayment if SSA continued to pay you even though you returned to work, or if SSA miscalculated a current or retroactive benefit. SSA will usually try to work out overpayment issues with you, of course, but having an overpayment of past benefits could delay the payment of your current disability payments.
Defaults on alimony or child support: Federal law may require the government to deduct and pay alimony or child support before you get your benefits.
Outstanding felony warrants: SSA wants to know if you were arrested, escaped from custody, or avoided prosecution. If so, you must clear up the warrants before your benefits can be paid.
Appointment of a representative payee: SSA can require that someone be appointed to handle your disability benefits on your behalf If SSA feels that you’re incapable of managing your finances. The person appointed is called a representative payee and has obligations to account to SSA for benefits managed on your behalf. If SSA requires a representative payee in your case, payment of benefits will be delayed until the appropriate documentation is signed and the representative payee is in place.
Lumped all together, these are called non-medical requirements for eligibility of disability benefits. There are others, but these are the most common things that affect eligibility or hold up benefit calculation or payment.
Did Kathleen Get Her Benefits?
After I explained to Kathleen what was going on, she called SSA as they had requested. She knew Freedom Disability had already collected and submitted most of the information SSA needed. They just needed a few more dates and financial information with supportive documentation. Because I had told her that providing the information requested as soon as possible was the best way to determine her eligibility and get her benefits calculated and paid, that’s what she did.
Within a couple of weeks, Kathleen received her Notice of Award. I’m happy to report that since then she has also received a deposit for her back pay and her first monthly benefit.