Insurance and Finance Issues
Social Security Disability Insurance
By: Tom Stewart, JD, MS, PA-C
Disability is a scary topic. It is nevertheless an important one. It is important not only for people with multiple sclerosis (MS), but for everyone because unforeseeable accidents and other diseases may occur. The consequences of unemployment related to disability are numerous, and may include loss of income, lack of health care benefits, loss of professional identity, social isolation, and increased focus on pain and impairments.
At least two of these problems can be partially remedied by qualifying to receive Social Security Disability Insurance (SSDI) benefits. Qualifying to receive SSDI benefits will ensure an income stream and medical insurance. SSDI payments can replace a significant amount of income, up to 80% when payments to dependents are included. Importantly, SSDI recipients are also eligible to receive Medicare benefits although this is a delayed benefit and Medicare coverage will not begin for two years. Medicare coverage for SSDI beneficiaries is critical because many would not be able to obtain insurance in private markets. As of January 1, 2006, everyone receiving Medicare has access to prescription drug coverage.
Workers who pay social security taxes will be covered if they have a sufficient work history. Social security translates your work history into "credits." Most people who have worked most of their adult lives are covered by SSDI.
For those not covered by SSDI, Supplemental Security Income (SSI), which is also administered by the SSA, should be considered. This program is based on the amount of money someone has rather than their work history. SSA uses the same standard to determine disability for both SSI and SSDI.
To be eligible for SSDI benefits, you must have a medical impairment that has (or is expected) to last at least 12 months. Thus, having an MS exacerbation by itself will not entitle someone to receive SSDI benefits because exacerbations often resolve without permanent disability. (On the other hand, private short-term disability benefits are sometimes available; check with your employer.) Your physicians' records will be very important in determining whether you have a qualifying medical impairment.
The SSA has described impairments that are considered severe enough to find someone disabled. These are sometimes referred to as "the listings." The specific criteria that will qualify someone to receive benefits are complex. The SSA describes impairments related to the musculoskeletal, neurological and cardiovascular systems to mental disorders and skin disorders and everything in between. The Adult Listings of Impairments is available at http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm.
For those who do not meet the Listings, the state — through whichever department administers SSDI for that state — will determine an applicant's Residual Functional Capacity. This is complex assessment of an applicant's abilities in light of his or her medical condition, work history, education, age, and past work experience.
Some people will find the SSDI application process straight forward and will immediately succeed in their application. This group of people will generally have good access to medical care, have well-documented impairments (e.g., wheel chair use), and will have the energy and cognitive abilities to handle the complexities of the application process.
In other situations, people may experience significant difficulties obtaining the benefits to which they may be entitled. In particular, those whose disability is based primarily on cognitive problems and fatigue may face special challenges. People with chronic pain also face special challenges as pain is subjective and documenting the physical and biological changes that occur with chronic pain conditions can be difficult.
For example, when people who have MS and have cognitive problems and fatigue apply for SSDI, they encounter a typical neurological examination, which is not typically designed to assess these symptoms in detail in an objective way. Thus, many people with MS who are unable to work because of cognitive difficulties and fatigue may have a normal or near-normal neurological examination reflected in their medical records. This is a problem because their medical records may not support their application with objective evidence of their most significant impairments. In addition, applying for SSDI is a complex process and people with MS who have fatigue and cognitive problems may find the process of applying overwhelming and may leave out critical information in their application.
Another problem for potential SSDI applicants is deciding whether and when to apply for benefits, especially if the disease or condition is chronic. MS is chronic disease, and for many, slowly progressive, thus, there is rarely a single day when disability starts; rather, like the progression of the disease itself, an inability to work usually develops gradually. To successfully apply for disability benefits, an applicant must not be earning more than $860 per month. As a practical matter, this means that an applicant must quit his or her job prior to applying for disability benefits. Especially given that success is not guaranteed, this sometimes feels like an awful gamble, one that at least temporarily interrupts income and, possibly, medical coverage.
Not everyone who applies for SSDI qualifies with their initial application. Of those who apply for disability benefits, only 37% nationally and 29% regionally (including CO, ND, SD, Utah, and MT) are successful on their initial application. For those who apply with neurological problems in Colorado, the success rate is 39%. The percentage of successful claims increases when the appeals are considered, In addition, having a claim denied does not limit reapplying in the future, so although the initial success rate is low, it is much higher when appeals and reapplications are taken into account.
Although SSDI offers critical benefits, there is no guarantee that your application will be successful. However, you can take certain steps that will improve your understanding of the process and may improve your chances of success. Here are a few suggestions.
This article was adapted with permission from the Rocky Mountain MS Center, Summer 2006, InforMS newsletter. Visit www.mscenter.org for more information.
Tom Stewart, J.D., M.S., PA-C, is the Director of Programs & Services for the Rocky Mountain MS Center in Englewood, Colo.
At least two of these problems can be partially remedied by qualifying to receive Social Security Disability Insurance (SSDI) benefits. Qualifying to receive SSDI benefits will ensure an income stream and medical insurance. SSDI payments can replace a significant amount of income, up to 80% when payments to dependents are included. Importantly, SSDI recipients are also eligible to receive Medicare benefits although this is a delayed benefit and Medicare coverage will not begin for two years. Medicare coverage for SSDI beneficiaries is critical because many would not be able to obtain insurance in private markets. As of January 1, 2006, everyone receiving Medicare has access to prescription drug coverage.
Workers who pay social security taxes will be covered if they have a sufficient work history. Social security translates your work history into "credits." Most people who have worked most of their adult lives are covered by SSDI.
For those not covered by SSDI, Supplemental Security Income (SSI), which is also administered by the SSA, should be considered. This program is based on the amount of money someone has rather than their work history. SSA uses the same standard to determine disability for both SSI and SSDI.
Determining Disability
To be eligible for SSDI benefits, you must have a medical impairment that has (or is expected) to last at least 12 months. Thus, having an MS exacerbation by itself will not entitle someone to receive SSDI benefits because exacerbations often resolve without permanent disability. (On the other hand, private short-term disability benefits are sometimes available; check with your employer.) Your physicians' records will be very important in determining whether you have a qualifying medical impairment.
The SSA has described impairments that are considered severe enough to find someone disabled. These are sometimes referred to as "the listings." The specific criteria that will qualify someone to receive benefits are complex. The SSA describes impairments related to the musculoskeletal, neurological and cardiovascular systems to mental disorders and skin disorders and everything in between. The Adult Listings of Impairments is available at http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm.
For those who do not meet the Listings, the state — through whichever department administers SSDI for that state — will determine an applicant's Residual Functional Capacity. This is complex assessment of an applicant's abilities in light of his or her medical condition, work history, education, age, and past work experience.
Potential Problems for People Applying for SSDI
Some people will find the SSDI application process straight forward and will immediately succeed in their application. This group of people will generally have good access to medical care, have well-documented impairments (e.g., wheel chair use), and will have the energy and cognitive abilities to handle the complexities of the application process.
In other situations, people may experience significant difficulties obtaining the benefits to which they may be entitled. In particular, those whose disability is based primarily on cognitive problems and fatigue may face special challenges. People with chronic pain also face special challenges as pain is subjective and documenting the physical and biological changes that occur with chronic pain conditions can be difficult.
For example, when people who have MS and have cognitive problems and fatigue apply for SSDI, they encounter a typical neurological examination, which is not typically designed to assess these symptoms in detail in an objective way. Thus, many people with MS who are unable to work because of cognitive difficulties and fatigue may have a normal or near-normal neurological examination reflected in their medical records. This is a problem because their medical records may not support their application with objective evidence of their most significant impairments. In addition, applying for SSDI is a complex process and people with MS who have fatigue and cognitive problems may find the process of applying overwhelming and may leave out critical information in their application.
Another problem for potential SSDI applicants is deciding whether and when to apply for benefits, especially if the disease or condition is chronic. MS is chronic disease, and for many, slowly progressive, thus, there is rarely a single day when disability starts; rather, like the progression of the disease itself, an inability to work usually develops gradually. To successfully apply for disability benefits, an applicant must not be earning more than $860 per month. As a practical matter, this means that an applicant must quit his or her job prior to applying for disability benefits. Especially given that success is not guaranteed, this sometimes feels like an awful gamble, one that at least temporarily interrupts income and, possibly, medical coverage.
Success Rates
Not everyone who applies for SSDI qualifies with their initial application. Of those who apply for disability benefits, only 37% nationally and 29% regionally (including CO, ND, SD, Utah, and MT) are successful on their initial application. For those who apply with neurological problems in Colorado, the success rate is 39%. The percentage of successful claims increases when the appeals are considered, In addition, having a claim denied does not limit reapplying in the future, so although the initial success rate is low, it is much higher when appeals and reapplications are taken into account.
Practical Suggestions
Although SSDI offers critical benefits, there is no guarantee that your application will be successful. However, you can take certain steps that will improve your understanding of the process and may improve your chances of success. Here are a few suggestions.
- Anticipate the Need – If you have a chronic condition or disease, anticipate that you will need to apply for disability benefits at some time in the future. There is a good chance that you will never need to apply, but it is better to be safe than sorry. If possible, keep any private disability insurance you have, because you may not be able to purchase it again due to your diagnoses. Check to see if you are eligible for SSDI. If not, identify what steps, such as accepting part-time employment, may make you eligible.
- Understand the Benefits – Understand the details of the specific benefits that you may be entitled to if you become disabled. Every year the SSA sends out a statement describing these. Your dependents may be able to qualify to receive benefits if you become disabled.
- Take an Active Role with your Medical Record – Ask your health care provider to record any work-related difficulties in your medical record even while you are thriving in your work role. Your application will be stronger if there is a long pattern (longitudinal history) of symptoms rather than a sudden emergence immediately prior to your application. This is especially important if your primary symptoms are fatigue or cognitive dysfunction, which are not as likely to be well-documented in your medical record.
- Anticipate a Gap – Anticipate a gap in your medical coverage if you are awarded SSDI benefits. You are not entitled to insurance through Medicare for two years after receiving SSDI payments. For those with a working spouse who has employer-provided medical insurance, this may not be a big problem. For others, this gap in coverage may create significant problems.
- Consult your Medical Provider – Talk with your health care provider before applying for SSDI. Review whether your symptoms are reflected in your medical record. Anticipate that you may need to be referred for additional testing, such as neuropsychological testing or speech-language testing (if you have cognitive problems) or occupational therapy (if you have fatigue problems). Remember, your neurologist's record is likely to be critical in determining whether you are disabled.
- Detail all Symptoms – When describing your symptoms to Social Security, provide as much detail as possible and do not merely describe your abilities on your best days. Include the difficult days and any other factors that may make work impossible.
- Seek Legal Assistance – If your initial claim is denied, consider hiring an attorney to help advocate for you. In this context, attorneys usually receive a percentage of the amount received if you are ultimately successful.
This article was adapted with permission from the Rocky Mountain MS Center, Summer 2006, InforMS newsletter. Visit www.mscenter.org for more information.
Tom Stewart, J.D., M.S., PA-C, is the Director of Programs & Services for the Rocky Mountain MS Center in Englewood, Colo.