Evaluation Process for SSIPosted on:3/20/2012
|Whether an adult is eligible for disability benefits is determined through a five-step evaluation process. A child's eligibility is determined on the basis of the first three steps. |
Steps 1 and 2 require a determination of (1) whether the adult or older child is presently working or the younger child is engaged in age-appropriate substantial gainful activity (an affirmative answer disqualifies the individual) and, if not, (2) whether the applicant's impairment(s) is severe enough to limit significantly the ability to perform basic work-related or school-related activities (if not, the applicant is disqualified).
At step 3, evidence in an applicant's medical file describing symptoms, signs of illness, and laboratory findings is compared with disability listings compiled by the Social Security Administration for a direct match or for a finding of medical or functional “equivalency.”
Medical equivalence exists when the applicant has the signs, symptoms, and laboratory findings associated with a listed condition, but does not have a diagnosis that matches directly a listed condition. Functional equivalence means that the applicant's ability to function is limited as if his or her condition were medically equivalent.
If the applicant has certain conditions, such as Acquired Immune Deficiency Syndrome (AIDS) or symptoms of equal severity to those of a person diagnosed with AIDS, the applicant is considered likely to receive benefits and will be categorized as “presumptively” eligible, meaning that benefits may be paid for up to six months before the full application process is complete. In addition, the law permits an emergency payment to a presumptively eligible person that is paid in advance of a final determination of eligibility. An emergency payment is repaid through proportional deductions from benefit checks. In March 1996, the rules for eligibility for SSI were changed to disqualify from coverage individuals whose alcohol or drug use was the “contributing factor” material to their disability.
For the adult whose eligibility cannot be finalized at step 3, the inquiry continues. In Step 4, applicants are asked whether they are able to do work that they have done in the past and, if not, Step 5 asks whether applicants are able to engage in any other substantial gainful activity considering their age, work experience and education. Benefits will be denied if the answer to either inquiry is affirmative.