Supplemental Security Income for People with Disabilities: Implications for Medicaid

The SSI Disability Determination Process

SSA uses a five-step process to determine whether an adult qualifies as disabled for purposes of receiving SSI (Figure 4).1 The first question is whether the person has earnings at a level of “substantial gainful activity” (SGA).2 The SGA amount in 2021 is $1,310 per month.3 If a person has earnings at or above the SGA amount, they are not eligible for SSI, regardless of any disability or health condition.4 The next question is whether the person has a “severe” impairment.5 Despite the term “severe,” this step is not a high bar as generally any medically determinable impairment will qualify at step two. The impairment also must have lasted or be expected to last for a continuous period of at least 12 months or to result in death.6

The third step in the SSI disability determination process for adults involves examining whether the person meets SSA’s strict rules that define disability (Figure 4). Specifically, the question at step three is whether the person’s impairment “meets or equals the listings,”7 and unlike the assessment of “severity” at step two, this is a much more rigorous inquiry. The listings are sets of criteria organized by body system that SSA has determined meet its definition of disability.8 Simply having a certain diagnosis is not enough to meet SSA’s definition of disability; instead evidence must establish that each of the specific criteria in the applicable listing is met.9 Alternatively, SSA can determine that a person’s impairment is “medically equivalent” to one of the listings.10 Additionally, in cases that involve medical evidence of drug addiction or alcoholism, SSA must determine that drug addiction or alcoholism is not a “contributing factor material to the determination of disability.”11 Essentially, this means that the person still would meet the criteria in the disability listings even if they stopped using drugs or alcohol.12 If a person is determined to satisfy a set of criteria in the listings, they qualify for SSI.13

If a person does not meet any of the listings, the final two steps in the adult disability determination process consider their ability to work (Figure 4). Step four asks whether the person has the “residual functional capacity” (what the person remains able to do despite limitations from any physical or mental impairments) to do any of their “past relevant work.”14 Past relevant work includes any work within the past 15 years that meets the definition of SGA (above) and lasted long enough for the person to learn to do it.15 If SSA determines that a person can still do their past relevant work, they are not eligible for SSI.16 If SSA determines that a person cannot return to their past relevant work, step five asks whether the person can do any work that exists in significant numbers in the national economy, considering their residual functional capacity, age, education, and work experience.17 So long as such work exists, either in the region where the person lives or in several other regions of the country, “[i]t does not matter whether [w]ork exists in the immediate area in which you live; [a] specific job vacancy exists for you; or [y]ou would be hired if you applied for work,” according to SSA’s regulations.18 If SSA determines that the person cannot do any work in the national economy, they qualify for SSI.19

SSA’s process to determine disability for purposes of SSI eligibility for children differs in some respects from the process used for adults. 20 The first two questions, whether the child has earnings at a substantial gainful level and whether the child has a “severe” impairment, are the same as those used in the adult process.21 Step three for children asks whether the child meets or equals a listing, again divided by body system but using different criteria for children than adults.22 If a child meets or medically equals one of SSA’s listings, they qualify for SSI.23 If a child does not meet a listing, the final consideration is whether the child “functionally equals” the listings.24 This requires a finding of “marked” limitation in two functional domains or “extreme” limitation in one domain, compared to other children of the same age without impairments.25 The functional domains are acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being.26

Appeals Process

If an initial application for SSI is denied, there are several levels of appeal available (Figure 8). State disability determination agencies generally make the eligibility decision on initial applications, using SSA’s rules.27 The first appeal level is a request for reconsideration, which generally involves a paper review for initial applications denied for medical reasons.28 The second appeal level is an administrative law judge (ALJ) hearing, which provides an opportunity to present testimony and written evidence.29 The third appeals level is review by the Appeals Council, which typically is based on the submission of written arguments.30 Appeals Council decisions can then be appealed to federal court.31 The appeals process can take a long time and can be difficult for individuals to navigate on their own without legal representation. For example, the average wait time between an ALJ hearing request and a hearing date ranged from five months to over 16 months, depending on the hearing office location, in March 2021.32

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Figure 8: SSI Application and Appeals Process

Continuing Disability Reviews

After the initial eligibility determination, SSI enrollees are subject to “continuing disability reviews.” The timeframes for these reviews are established based on whether and when SSA expects the person’s medical condition to improve. For cases in which medical improvement is expected, eligibility is reviewed at intervals from six to 18 months.33 Cases involving disabilities that are not considered permanent but for which medical improvement cannot be accurately predicted are reviewed at least every three years.34 Cases involving disabilities that are considered permanent are reviewed every five to seven years.35 Decisions terminating SSI eligibility also are subject to the multi-level appeals process described above.

Issue Brief

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