Five Step Process

May 29, 2017

The five steps of adult sequential evaluation of disability. The decision on whether an adult is disabled is based on a five-step sequential evaluation process. All SSA adjudicators follow this process. If the claimant is not disabled at a given step, the sequential evaluation ends.

Step #1. Are you working?
To be eligible for disability benefits, a person must be unable to engage in substantial gainful activity (SGA). SGA is a monthly income amount that the SSA sets. This amount changes every year. For 2018, the SGA amount is $1,180.

If you are not working, we will send your application to the Disability Determination Services (DDS) office that will make the decision about your medical condition. The DDS uses Steps 2-5 below to make the decision.

Step #2. Is your condition “severe”?
Is to consider whether you suffer from a severe physical and/or mental condition? This threshold is fairly low, requiring a showing of more than a minimal impact upon your ability to work. In other words, the claimant must prove you suffer from a medical condition that poses an impact upon your working ability.

Step #3. Is your condition found in the list of disabling conditions?
For each of the major body systems, we maintain a list of medical conditions that we consider so severe that it prevents a person from completing substantial gainful activity. If your condition is not on the list, we have to decide if it is as severe as a medical condition that is on the list.

Compassionate Allowances plan. In addition, SSA has two fast-track processes, Quick Disability Determinations (QDD) and Compassionate Allowances (CAL). Given the applicant’s medical conditions, QDD use a computer-based program to screen initial applications where a disability determination is highly likely. Example includes acute leukemia, amyotrophic lateral sclerosis [ALS], and pancreatic cancer.  The model allows these high-likelihood claims to receive priority and be expedited in cases involving more serious impairments.

Step #4. Can you do the work you did previously?
An individual’s residual functional capacity (RFC) is the most they can physically or mentally do in spite of their medical condition. This is not the average they can do, but the absolute most they can do. To determine RFC, the SSA will review an individual’s medical records for a list of their conditions, treatment, symptoms, and limitations. The SSA will then take that information and determine your functional capacity, both physically and mentally. Once the SSA has determined what you are physically and mentally capable of, the organization will determine when your limitations prevented you from performing your past relevant work. Past relevant work is any work you have performed in the past fifteen years in which you earned SGA, while performing the job long enough to learn it. This can be very important to your claim depending upon your age and your RFC. This analysis is where things start to become very tricky, and where age becomes a huge factor.

Step #5. Can you do any other type of work?
If you can’t do the work you did in the past, we look to see if there is other work you could do despite your impairment(s). We consider your medical conditions, your age, education, past work experience, and any transferable skills you may have.

The general concept is that if you are age 50 to 54 and found to have a sedentary RFC, with an inability to perform the work you have done in the past fifteen years, you will be found disabled. This effectively means you can be found eligible for disability benefits, even though there are jobs available to you at the sit-down level. Once an individual reaches age of 50 it would be too difficult to retrain you to perform a sit-down type of position. And as one continues to age, the rules continue to become even more relaxed.

















(6) above chart prepared by

(1) Code of Federal Regulations (CFR) in appendix 1 to subpart P of part 404
(3) DI 22001.001
(4) 20 CFR 404.1520 and 416.920
(5) Physical Residual Functional Capacity Assessment (RFC), SSA-4734
(6) 5 step process chart:
(7) Disability Benefits, Publication No. 05-10029

Substantial Gainful Activity (SGA)

February 1, 2017

What is Substantial Gainful Activity (SGA) []

  • Work is “substantial” if it involves doing significant physical and/or mental activities.
  • “Gainful” work activity is: (1) Work performed for pay or profit; or (2) Work of a nature generally performed for pay or profit; or (3) Work intended for profit, whether or not a profit is realized.

Evaluate your Activity for SGA Purposes []

  • We generally use earnings guidelines to evaluate whether your work activity is SGA.
  • Earnings averaging over $1,180 a month (for the year 2018) generally demonstrate SGA.
  • If you are blind, earnings averaging over $1,970 a month (for the year 2018) generally demonstrate SGA.

Earnings Requirement – DLI

January 31, 2017

Note: There are two categories of disability, Title II, Disabled Insurance Benefit (SSDI) and Title XVI, Supplemental Security (SSIDI) claims. This article applies to coverage under SSDI, but is not applicable to SSIDI.

To obtain SSDI, the claimant generally need to meet two tests: the recent work test and the duration of work test.

Certain blind workers have to meet only the duration of work test.

Test1: Recent Work Test. Must have worked approximately five out of the 10 years before your disability totally removed you from the workforce. This rule recognizes that workers who became disabled while still young obviously did not have the opportunity to acquire lengthy work records.

How is the recent work test performed? SSA computes the “date last insured” (DLI) is the last date that an individual is eligible to receive Social Security Disability Insurance (SSDI). Your DLI depends on when you last worked. In order to receive SSDI, you must pass the “recent work test“, which means you must have worked five of the past ten years (technically, 20 of the last 40 quarters). The rules are different if you are under 30. See section following for further discussions.

Recent Work Test

  • age 24 <= 21 worked 1.5y out of 3y before disability
  • age 24-31 >24 to <31 worked 50+% since turning 21 e.g. age 29, then 29-21 = 8 or worked at least 4y out of 8y
  • age 31 => 31 worked 5 or 10yrs before disabled

Test2: The duration test is based on your age at the time you become disabled. The test basically requires you worked and paid into the Social Security fund through the payment of Social Security taxes for a long enough time to be covered by SSDI.

The following table integrates these two test.










Case 1: The claimant, age 27 (DOB 12/31/20×1), had worked for three years (age 22, 23, 27) and became disabled in quarter 4, age 27 (onset date). The claimant have met the recent work test (3 years out of 6 years before onset date). The claimant, before age 28 has 6 quarters (or 1.5 years) of work, consequently the claimant have met the duration test.

Case 2: The claimant, age 50 (DOB 12/31/19×1), had worked for five years (age 40 to 45) and became disabled in quarter 4, age 50 (onset date). The claimant have met the recent work test (5 years out of 10 years before onset date (20/40 insured test)). The claimant, before age 50 has 30 quarters (or 7.5 years) of work, consequently the claimant have met the duration test.


DLI, Date Last Insured

An individual’s “date last insured” establishes the period of coverage during which an individual must prove that they became disabled. The taxes paid to Social Security act like a “premium” paid for any other insurance. Once paid in and credited, each quarter of coverage establishes a certain amount of time during which an individual can establish that they became disabled. Just as with an expired policy for car insurance or medical insurance, if a person becomes unable to work after a date last insured, there is no recourse for Title II Worker’s benefits under Social Security law.

As mentioned above, an individual earns “coverage” for Social Security Title II Disability benefits by working at a sufficient earnings level and paying FICA taxes, which stands for the “Federal Insurance Contributions Act.” FICA taxes are comprised of two separate taxes, Social Security and Medicare taxes. If a worker earns enough in wages in a given quarter, those wages go towards the worker’s eligibility for Title II benefits. In 2015, to qualify for a “quarter of coverage,” an individual must have earned $1,220 in the respective quarter.

Based on how many quarters of coverage you earn over your working life, and when you stopped working, the Administration will then calculate an individual’s date last insured. The most common method for calculating this date is called the “20/40 Insured Test”. Social Security will look at your earnings record, and generally count back 20 covered quarters, and will then count forward by 40 quarters (both covered and uncovered, see glossary). Typically, this means that if an individual has worked full time for five years in the last ten years, they are still “insured” for Title II benefits.

Date last insured (DLI) refers to the last date you are eligible to receive Social Security disability insurance (SSDI). In order to receive SSDI you must pass the “recent work test.” This means that you need to have worked the past 5 out of 10 years. More specifically, you must have worked 20 of the last 40 quarters.

Case: “ . . . your disability benefits will not start August, 20×7. The reason is that your earnings record did not pass our 20/40 Insured Test.”


Online Filing; Status of Claim

January 29, 2017

Check Your Application or Appeal Status

The service provides important information about your claim or appeal, including, as appropriate:

  • Date of filing;
  • Current claim location;
  • Scheduled hearing date and time;
  • Re-entry numbers for incomplete applications;
  • Servicing office location; and
  • Claim or appeal decision.



January 29, 2017

If You Do Not Receive Benefits, You Can:

  • Request a replacement Social Security card if you meet certain requirements;
  • Check the status of your application or appeal;
  • Get your Social Security Statement, to:
  • Estimates of your future benefits;
  • Verify your earnings; and
  • View the estimated Social Security and Medicare taxes you’ve paid; and
  • Get a benefit verification letter

If You Receive Benefits Or Have Medicare, You Can:

  • Request a replacement Social Security card if you meet certain requirements;
  • Report your wages if you work and receive Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) benefits;
  • Get your benefit verification letter;
  • Check your benefit and payment information;
  • Change your address and phone number;
  • Start or change direct deposit of your benefit payment;
  • Request a replacement Medicare card; and
  • Get a replacement SSA-1099 or SSA-1042S for tax season.

If You Are a Representative Payee, You Can:

  • Complete and submit Representative Payee Accounting Reports;
  • See the status of any completed Representative Payee Accounting Report; and
  • Receive a receipt for any report you submit.

Disability Determination Services (DDS)

January 29, 2017

Disability Determination Services (DDS), fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering the initial determination on whether or not a claimant is disabled or blind.

DDS will obtain evidence from the claimant’s own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a consultative examination (CE) to obtain the additional information needed.

Consent for Release of Information, SSA-3288.

Payment Centers

January 29, 2017

DI 13010.215 Procedure for Extended Period of Eligibility (EPE):

  • PC 1- NEPSC 877-385-0640
  • PC 2- MATPSC 877-385-0644
  • PC 3- SEPSC 877-310-6767
  • PC 4- GLPSC 877-311-5797
  • PC 5- WNPSC 877-310-7807
  • PC 6- MAMPSC 877-311-8738
  • PC 7- OCO 877-385-0643
  • PC 8- OIO 877-385-0645


Overview: The Process

January 28, 2017


  1. CSR initial claims with caller/beneficiary, set up appt
  2. At the appt, the Claims Representative set up claims via (a) MCS and (b) eView
  3. DDS exams the claimant and make medical determination as to disability or not; sends letter.
  4. If deemed medically approved, the FO will review non-medical qualifications.
  5. If deemed “NOT” disabled, the beneficiary can appeal: recon, ALJ, ODAR. A new entries are setup in eView.

Redbook Example









  • Stopped working, alleged onset date (AOD)
  • Filed for concurrent benefits, both T2/SSDI and T16/SSIDI
  • Received award letter with onset date of 2/14/2017
  • SSIDI commence at $750/mo (Federal benefit rate, FBR, in 2018); Medicaid starts.
  • SSDI benefits start (Entitlement date = Onset date + 5 months). Total benefits $770 = $300 in SSDI and $470 in SSIDI. SSIDI: 750 – (300 SSDI + 20 general income exclusion)
  • Medicare starts (Entitlement date + 24 months). Part A is free. Part B is 134/mo.  Since CLMT is eligible for SSI, the state pays for Part B (state buy-in)










  • Returns to work, earns $2,000/mo (1,800 value and 200 employer subsidy).
    • TWP begins for SSDI
    • SSI stops due to earnings
  • TWP ends (9 months: J- F-M-A-M-J-J-A-S)
  • Extended Period of Eligibility (EPE) begins after TWP ends. For the next 36 months (EPE= 10/2022 + 36 months = 9/2025). Work at SGA continues.

SSDI benefits cease, (3 months) grace months for payment are 10/2022-12/2022.

SGA?  CLMT pays for his work transportation of $350/mo. There is a medical need for him to take a taxi. SSA deducts the cost of his transportation expenses as impairment-related work expenses (IRWE). SGA = 2000 – 200 -350 = 1,450, which is over the SGA level of 1,180 for 2018.

  • Grace months for payment are 10/2022-12/2022 or 3mos






  • SSDI benefits stop
  • EPE ends (starts 10/2022 + 36 months = 9/2025)
  • Extended Medicare begins
  • SSDI termination month. Medicaid ends if earnings are over state threshold amount. Entitlement may stop earlier than October 2025 if he no longer meets our disability requirements.
  • Extended Medicare stops = TWP + 93mos = 9/2022 + 93mos = 07/2030. May be able to purchase Premium HI and/or buy into Medicaid
  • Last month to file for EXR if no longer working and still disabled


  • Alleged onset date (AOD)
  • Blind Work Expenses (BWE, vs IRWE)
  • Concurrent: filing for both T2/SSDI and T16/SSIDI
  • Extended Period of Eligibility (EPE) = TWP + 36mos = Sept 2022 + 36mos = Sept 2025
  • EPE consists of 36mos during which a beneficiary may receive a full cash benefit for any
  • month the person does not perform Substantial Gainful Activity (SGA). As long as the individual continues is disability, their entitlement to benefits doesn’t fully terminate until EPE ends. [DI 13010.215]
  • Expedited reinstatement (EXR): see discussion follows.
  • Extended Medicare = TWP + 93mos = Sept 2022 + 93mos = July 2030. 93 mos = 7 years, 9 months
  • Grace period = TWP + 3mos = Sept 2022 + 3 mos = Dec 2022
  • Substantial gainful activity (SGA)
  • Impairment-related work expenses (IRWE vs BWE)
  • SSDI
  • Trial Work Period (TWP) = 9 months. Ends Sept 2022

– – – –
Given: SGA in 2018 is $1,180

NOTE. How does the claimant’s work activity affect his SSI benefit (Title XVI)?
SGA rules are different for SSI. For SSI disability benefits, we only consider SGA when the initial claim is filed (unless the disability is blindness, then we do not consider SGA at all). We do not consider SGA after a person becomes eligible for SSI. However, we must determine whether the person continues to meet the non-disability requirements, including income and resources. We determine the effect of the claimant’s earnings on his SSI eligibility and payment amount on a month-by-month basis.

Physical Residual Functional Capacity Assessment, SSA-4734

January 28, 2017

The RFC form (SSA-4734) is the Physical Residual Functional Capacity Assessment form that helps the Social Security Administration rate the functional capacity of a Social Security Disability claimant after considering one’s mental or physical disability into account, including:

  • Range of motion
  • Physical strength
  • Lifting ability
  • Flexibility
  • Stamina and ability to carry objects
  • Other abilities required for their job

Application Process

December 29, 2016

There are three primary methods for applying:

  1. Online. The applicant must setup to check on the status of an application,
  2. Call the national wide call center and to set up a telephone appointment or an office appointment, or
  3. Visit your local office (field office (FO)).  If you live abroad, one can usually go to the U.S. Embassy/consulate (

Required information and proofs.

  1. Information About the Applicant.
    • Your name, SSN, date of birth, and place of birth.
    • Maritial status (single, married, divorced, widow(er)). The name, SSN, date of birth of your current spouse and any former spouse.
    • Your minor children (before age 18): Their names, SSN, and dates of birth. Publication: EN-05-10085
    • Disabled adult child (onset date before age 22): Their names, SSN, and dates of birth.
    • Direct deposit information: (1) Financial institution’s Routing Transit Number (RTN) and the account number or (2) Request Direct Express debit card
  2. Detailed information about your medical illnesses, injuries or conditions:
    • Your name, SSN, date of birth, and place of birth.
    • Maritial status (single, married, divorced, widow(er)). The name, SSN, date of birth of your current spouse and any
    • Names, addresses, phone numbers, patient ID numbers and dates of treatment for all doctors, hospitals and clinics;
    • Names of medicines you are taking and who prescribed them; and
    • Names and dates of medical tests you have had and who sent you for them.
  3. Your Work as an Employee or Self-Employed.
    • Your gross earnings (net earnings if self-employed) for last year and this year
    • The name and address of your employer(s) for this year and last year
    • A copy of your Social Security Statement (applicant “must” verified)
    • The beginning and ending dates of any active U.S. military service you had before 1968 (submit DD-214).
    • A list of the jobs (up to 5) that you had in the 15 years before you became unable to work and the dates you worked at those jobs
      • Information about any workers’ compensation, black lung, and/or similar benefits you filed, or intend to file for. These benefits can:
      • Be temporary or permanent in nature;
      • Include annuities and lump sum payments that you received in the past;
      • Be paid by your employer or your employer’s insurance carrier, private agencies, or Federal, State or other government or public agencies; and
        Be referred to as:
        Workers’ Compensation;
        Black Lung Benefits;
        Longshore and Harbor Workers’ Compensation;
        Civil Service (Disability) Retirement;
        Federal Employees’ Retirement;
        Federal Employees’ Compensation;
        State or local government disability insurance benefits; or
        Disability benefits from the military (This includes military retirement pensions based on disability but not Veterans’ Administration (VA) benefits.)
  4. Proofs, “orignial” documents only; photo copies are not acceptable. Should be mailed or delivery to local Social Security office.
    • Birth certificate or other proof of birth;
    • Proof of U.S. citizenship or lawful alien status if you were not born in the United States;
    • U.S. military discharge paper(DD-214) if you had military service before 1968;
    • W-2 forms(s) and/or self-employment tax returns for last year;
    • Medical evidence already in your possession. This includes medical records, doctors’ reports, and recent test results; and
    • Award letters, pay stubs, settlement agreements or other proof of any temporary or permanent workers’ compensation-type benefits you received.

IMPORTANT: If lost certain documents could be difficult or may be impossible to replace. You or your representative should bring such documents to a Social Security office where we will examine them and return them to you immediately.

Workers’ compensation (WC) or certain public disability benefits (PDB) paid by federal, state, or local governments (example: California SSDI) – see separate discussion.
Publication: EN-05-10018. Form SSA-546