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How does the Social Security Administration determine eligibility for SSDI and SSI?

How does the Social Security Administration define "disabled"? How do they determine whether an individual is disabled? Am I eligible for disability payments?

You have come to the right place. The Moss Disability Group provides guidance throughout the disability application process, from the Initial Application through all levels of appeal.

How does the Social Security Administration define "disabled" and how do they determine whether an individual is disabled?

The Social Security Administration defines disability as "the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months."

In order to determine whether an individual is disabled, the Social Security Administration engages in what is called the Sequential Evaluation Process (SEP).

What is the Sequential Evaluation Process?

The SEP consists of a five-step evaluation to determine whether an individual is entitled to disability payments (please note: the SEP in applications for child disability benefits varies somewhat from the standard SEP evaluation).

Step 1: Are You Currently Working At Substantial Gainful Activity (SGA) Levels?

The first step in the SEP is to determine whether one is working and, if so, at what level of earnings. If an individual has monthly income above SGA levels, then they are not disabled and the SEP stops after the first step of the evaluation.

SGA amounts change yearly, but one can have a maximum of $1,310 in monthly earnings in 2021 without being considered SGA. Earnings of $1,310 and above are considered SGA. It is important to note that "earnings," for the purposes of step 1 in the SEP, do not include any private disability payments, a severance package provided by an employer, or payment for unused sick or personal leave accrued while being employed prior to one's disability.

If you are not engaging in SGA, then the Social Security Administration will proceed to step 2 of the SEP.

Step 2: Do You Have A Medically Determinable Impairment?

A medically determinable impairment is defined as a physical or mental impairment that results from anatomical, physiological or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. The medical evidence must establish that an individual has a physical or mental impairment. A statement about the individual's symptoms is not enough.

In short, your impairment must be diagnosed by an acceptable medical source (for example, a doctor, a nurse practitioner, or a psychologist) based upon objective findings. Complaints of symptoms are not enough to constitute a medically determinable impairment.

If you do not have any medically determinable impairment, then the SEP ends and you will be found to not be disabled. If you do have a medically determinable impairment, then the Social Security Administration will proceed to step 3 of the SEP.

Step 3: Does Your Medically Determinable Impairment Meet Or Equal A Listing?

The Social Security Administration provides a list of specific criteria for various impairments. If an individual meets or equals the criteria for any listing, they will be found to be disabled. You may have seen the listings criteria referred to as the "Social Security Administration's Blue Book." It is not easy to meet or equal the requirements for a listing, and the criteria are often complex and difficult to understand.

If an individual is found to meet or equal one of the listings, the SEP will end after step 3 and the individual will be found to be disabled.

If an individual does not meet or equal one of the listings, the Social Security Administration proceeds to "step 3.5" of the SEP.

Step 3.5: The Residual Functional Capacity (RFC).

Although technically part of "step 3" of the SEP, determination of the RFC is also known unofficially as "step 3.5" of the SEP. During this step, the Social Security Administration determines a claimant's RFC. This is a function-by-function assessment by the Social Security Administration as to your maximum ability to perform sustained work-related activities on a regular and continuing basis (i.e. 8 hours a day for 5 days a week).

The RFC determination plays an extremely significant role at steps 4 and 5 of the SEP.

Step 4: Can You Perform Your Past Relevant Work (PRW)?

At step 4 of the SEP, the Social Security Administration determines whether an individual is capable of performing PRW. PRW is work that was: 1) performed at SGA levels; 2) within the last 15 years; and 3) for a long enough period of time to have reached average performance in that job.

At the hearing level, for the step 4 evaluation, an independent vocational expert (VE) will determine what job titles constitute the claimant's past work. The VE will generally base this determination upon your testimony and work history report provided to the SSA, as well as information contained in the Dictionary of Occupational Titles (DOT) and its companion publication, the Selected Characteristics of Occupations (SCO).

The DOT and SCO are publications from the United States Department of Labor that define the general duties and functional requirements necessary to perform jobs in the national economy.

The DOT identifies the exertional level at which jobs are performed. The possibilities include: sedentary, light, medium, heavy or very heavy. The DOT also identifies the Specific Vocational Preparation (SVP) number for each job. The SVP essentially is a finding regarding how long it takes one to obtain average performance in a given job. SVP numbers range from 1 (learning a job after a short demonstration) to 9 (requiring over 10 years performing a job to have reached average job performance).

During the hearing, the VE will identify the DOT number for your past work, the exertional level it was performed at (both as generally performed in the national economy and as actually performed by yourself), and the SVP level for this job. The VE's testimony in this matter will be based upon the DOT.

Based upon the testimony of the VE, the ALJ will then determine whether your past work meets the requirements to be considered PRW. If an ALJ determines that your past work is considered PRW, an assessment will then be made whether you are capable of performing your PRW.

In order to determine whether one is capable of performing PRW, the Social Security Administration will determine whether an individual with the claimant's RFC (determined at step 3.5 of the SEP) can perform the physical and mental demands of one's PRW. At the Hearing Stage, this determination is usually based upon the testimony of the VE.

If the Social Security Administration finds that you are capable of performing PRW, you are not disabled. If you are determined to be unable to perform PRW, the Social Security Administration will then proceed to step 5 of the SEP.

Step 5: Are There Jobs That Exist In Significant Numbers In The National Economy For You?

At step 5 of the SEP, the Social Security Administration will determine whether jobs exist in significant numbers in the national economy for an individual with your age, education, work experience and RFC. As with step 4, at the Hearing Stage, this determination is usually based upon the testimony of a VE.

If there are such jobs that exist in significant numbers in the national economy, the Social Security Administration will find that you are not disabled. However, if no such jobs exist, you are determined to be disabled.

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