Benefit Development Resource Toolkit: SSA

Throughout the following section, links to various web pages are provided for reference. Please note that web page addresses change frequently and while the addresses provided were accurate as of the issuance of this Toolkit, if you are unable to access any of the web pages through the links, please refer to the main Social Security website at  www.socialsecurity.gov and navigate to the information you are seeking.

Definition

Social Security benefits are payments made to covered individuals based on contributions a worker has made to the Social Security trust fund. The Federal Insurance Contributions Act (FICA) mandates withholding Social Security contributions from a worker’s paycheck. The Social Security Administration (SSA) is responsible for administering Social Security benefits.

Difference between SSI and Social Security Benefits

Supplemental Security Income (SSI) differs from the Social Security benefits discussed below. Unlike SSI, Social Security benefits are not needs-based. Social Security benefits are entitlements based on a worker’s contributions; therefore, there are no income or resource eligibility factors associated with collecting Social Security benefits. The amount that a recipient is paid is based on the earnings of the specific worker. Information on SSI can be found elsewhere in the Tool Kit.

Types of Social Security Benefits

The types of Social Security benefits that a worker or certain members of the worker’s family may receive are:

• Social Security Disability Insurance (SSDI)
• Social Security Retirement
• Social Security Survivors

Filing for Social Security Benefits

An individual should file for Social Security benefits as soon as it is believed that they are eligible (see SSA Benefit Eligibility Chart), for SSA benefits eligibility information). There is no waiting period to file for benefits; however, there is a five-month waiting period for a disabled worker to begin receiving Social Security Disability Insurance (SSDI) benefits.  SSDI benefits are sometimes referred to as SSD or SSA.

Eligibility for Social Security Benefits

An individual may be entitled to Social Security benefits based on their own work record or based on a spouse’s or parent’s work record. The benefit amounts will vary depending on a worker’s contributions and there is a maximum amount of benefits payable on a worker’s record.

Note: Disabled adult children may be eligible for Social Security benefits on a parent’s work record; therefore, it is important to determine whether the person’s parents are working, retired, disabled or deceased, and to apply for benefits as soon as possible after the parent(s) stop(s) working.

Social Security Retirement Benefits

A person may qualify for Social Security Retirement benefits upon retiring from work. They can choose to retire at full retirement age and receive full Social Security Retirement benefits or retire as early as age 62 and receive reduced benefits. The full retirement age will gradually increase to 67. Delaying application until full retirement age based on the year of the applicant’s birth allows him or her to collect full benefits. Information about benefit levels and ages for collecting Social Security retirement benefits can be found on the SSA website at https://www.ssa.gov/benefits/retirement/.

The amount of an insured worker’s retirement benefits is based on their lifetime earnings. The worker’s actual earnings are indexed to reflect changes in average wages over the years the insured person worked.

Social Security Survivor Benefits

Social Security Survivors benefits are available to certain family members of a deceased worker who earned enough credits while working to be insured.

Social Security Survivors benefits can be paid to:

• A widow or widower - full benefits at full retirement age, or reduced benefits as early as age 60
• A disabled widow or widower - as early as age 50
• A widow or widower of any age if they care for the deceased's child who is under age 16 or disabled and receiving Social Security benefits
• Unmarried children under 18 or up to age 19 if they are attending high school full time (under certain circumstances, benefits can be paid to stepchildren, grandchildren, or adopted children)
• Children of any age who were disabled before age 22 and remain disabled
• Dependent parents age 62 or older

Further information about survivor benefits can be found at: https://www.ssa.gov/benefits/survivors/

Social Security Disability Insurance

OPWDD individuals are most likely to receive payments under Social Security Disability Insurance (SSDI). This program provides income benefits to disabled or blind individuals who meet all the following criteria:

• The person has worked and paid Social Security taxes long enough to be covered under Social Security insurance (the number of credits needed for disability benefits depends on the individual’s age at the time they became disabled)
• They have paid Social Security taxes in recent years
• They are considered medically disabled or blind
• They are either not working or is working and earning less than the Substantial Gainful Activity (SGA) level

Definition of Disability

A person is generally considered disabled if they cannot do work done before becoming disabled or blind and cannot adjust to other work due to their medical condition. The SSA defines disability as the inability to engage in any substantial gainful activity because of a medically determinable physical or mental impairment that either:

• Has lasted, or is expected to last, at least one year; or
• Is expected to result in death

Substantial Gainful Activity

SSA evaluates the work activity of the person claiming or receiving disability benefits under SSDI. SSA uses earnings guidelines to determine whether the individual’s work activity is considered Substantial Gainful Activity (SGA) and whether the individual is disabled.

SGA is the performance of significant and productive physical or mental work for pay or profit. A dollar amount is designated as the SGA level. Individuals whose monthly earnings average more than the SGA level are deemed to be engaged in substantial gainful activity in the absence of evidence to the contrary. A person whose monthly earnings average below the SGA level is presumed not to be engaged in SGA. The SGA level is higher for people who are blind. Current SGA levels can be found at: https://www.ssa.gov/OACT/COLA/sga.html. 

Social Security Benefits for Children

Minor children may qualify to receive benefits on a parent’s work record when the parent retires, is disabled, or dies. An eligible child can be a biological child, adopted child or stepchild.  A dependent grandchild may also qualify.

To receive benefits, the child must:

• Be unmarried
• Be under age 18
• Be 18-19 years old and a full-time student (no higher than grade 12)
• Be 18 or older and disabled from a disability that started before age 22 (see below for information regarding Social Security benefits for a Disabled Adult Child)

If a child works while receiving benefits, the same earnings limits apply to him or her as apply to the worker. A child's earnings affect only their own benefits. They do not affect the worker’s benefits or those of any other beneficiaries on the worker’s record. If the worker works while receiving their benefits, their earnings may impact the benefits of all beneficiaries receiving on the worker’s record.

Benefits paid to a minor child are “derivative” benefits based on a parent’s work record. While the child may be disabled, benefits paid to children who are under the age limits listed above are not disability benefits. Normally, benefits stop when children reach age 18, however, if the child is still a full-time student at a secondary (or elementary) school at age 18, benefits will continue until the child graduates or until two months after the child becomes age 19, whichever is first. If a child is disabled and turns 18 (or 19 if they are still in elementary or secondary school), a disability determination is required in order to qualify him or her for Disabled Adult Child benefits.

Social Security Benefits for a Disabled Adult Child

An unmarried child at least 18 years old with a disability that started before age 22 may be eligible to receive Social Security benefits on a parent’s work record when that parent begins receiving SSDI or Retirement benefits or dies. These are Disabled Adult Child (DAC) benefits. If an individual is already receiving Social Security benefits when they turn 18, a disability determination by SSA is required for him or her to collect benefits as a DAC.

The marriage of a DAC beneficiary to someone who is not receiving Social Security disability benefits causes termination of DAC benefits. If the DAC beneficiary marries someone who is receiving Social Security disability benefits at the time of the marriage, the individual’s DAC benefits will not terminate because of the marriage.

A person who loses a DAC benefit when they marry may be re-entitled to the DAC benefit if the marriage is annulled or voided. An annulled or voided marriage is legally nonexistent under state law, with or without a judicial decree. The parties to a void or annulled marriage are considered never to have been husband and wife. A person who loses a DAC benefit when they marry would not be re-entitled to the DAC benefit if the marriage were to end by death or divorce.

An individual’s DAC benefit is independent of any SSDI or DAC benefits received by their spouse. Therefore, Social Security benefits paid to a DAC beneficiary do not end if/when their spouse’s SSDI or DAC benefits end.

DAC benefits end if the individual if Social Security determines that the individual is no longer disabled.

Questions about an individual’s eligibility for continued DAC benefits or for re- entitlement should be directed to the local Social Security office.

Further information about Social Security Disability is at: https://www.ssa.gov/benefits/disability/

There are four ways to apply for Social Security benefits:

1.  Online at www.ssa.gov or www.socialsecurity.gov

2.  By phone at 1-800-772-1213

3. By mail (the specific local office can be located by zip code at www.ssa.gov or www.socialsecurity.gov

4. In person (the specific local office can be located by zip code at www.ssa.gov or www.socialsecurity.gov

About the Interview Process

In order to begin the application process if not applying online, it is necessary to make an appointment for a disability claims interview by calling SSA’s toll free number (1-800- 772-1213) to make an appointment. Application for DAC benefits cannot be made online.

The disability claims interview lasts about one hour. When an interview is scheduled, SSA will mail a Disability Starter Kit to the applicant. The Disability Starter Kit will help the applicant prepare for the disability claims interview. The Disability Starter Kit is also available online at www.ssa.gov or www.socialsecurity.gov.

To prepare for the interview, the Disability Report, Medical and Job Worksheet, and the Disability Checklist included in the kit should be completed in advance. Copies of these forms can be found on the Social Security website.

Regardless of the type of Social Security benefit applied for, the applicant should be prepared to provide the following information about him or herself:

• Name, gender, Social Security number
• Date and place of birth
• Relationship to the worker on whose work record the applicant is applying
• Birth or baptismal certificate
• Marital status
• Citizenship status
• Whether the applicant has a legal guardian
• Whether they have earned social security credits under another country’s social security system
• Whether they have had earnings in all years since 1978
• A summary of where they have worked and the kind of work done
• The name(s) of their employer(s) or information about their self- employment and the amount of earning for the current year and last year
• A copy of the most recent W-2 Form (Wage and Tax Statement) or, if self- employed, their federal tax return for the past year
• Whether they received or expect to receive any money from an employer since the date they became unable to work
• Whether they have ever worked for the railroad industry
• Dates of service for any active military service prior to 1968 and any benefits they have ever been eligible to receive from a military or civilian agency
• Whether they qualify for or expect to receive a pension or annuity based on their own employment with the federal government of the United States or one of its states or local subdivisions
• Whether the applicant has ever been convicted of a felony
• Whether the applicant, age 13 or older, has any unsatisfied felony warrants for arrest or unsatisfied federal or state warrants for arrest for violations of conditions of parole or probation

In addition, for disability benefits, the applicant must supply the following:

• Names, addresses and phone numbers of the doctors, caseworkers, hospitals and clinics that have provided treatment and dates of the visits
• Name(s) and dosage(s) of all medicine they take
• The date they became unable to work because of illnesses, injuries or conditions
• Whether they are still unable to work
• Medical records already in their possession from doctors, therapists, hospitals, clinics and caseworkers
• Laboratory and test results
• Whether they have filed or intend to file for worker’s compensation or any public disability benefits
• For disability benefits for adult children disabled before age 22, forms SSA-3368 and SSA-827 that describe medical condition and authorize disclosure of
• information to SSA (see Disability Report – Adult (SSA-3368) and Authorization to Disclose Information to the Social Security Administration (SSA) (SSA-827)

In addition to demographic and medical information where applicable, an applicant for Social Security benefits should also be prepared to provide information about their parent(s) and/or spouse (current and any former) and their work record or that of the worker on whose record the applicant is applying. The following are examples of information SSA may ask for:

Parental Information

• Parents’ names, dates of birth and social security numbers
• Whether the applicant has a parent who was dependent on the worker for half of their support at the time the applicant became disabled (if applicable)
• If the applicant is the worker’s stepchild, the date the worker and the applicant’s parents were married
• Whether the worker is the applicant’s natural or adoptive parent
• Date of adoption if adopted by the worker
• Whether the applicant has been adopted by someone other than the worker

Spousal Information

• Spouse’s name, date of birth (or age), and social security number (if known) of current and any former spouses
• Dates and places of all marriages and, for marriages that have ended, how and when they ended
• Whether the applicant’s spouse has ever worked for the railroad industry

Information about an Applicant’s Children

• Names of any unmarried children under 18, ages 18-19 and in secondary school, or disabled before age 22
• Whether the applicant has or had a child under age three living with him or her during a calendar year when they had no earnings

Information about a Deceased Worker:

• The worker's date and place of death
• The state or foreign country of the worker's fixed permanent residence at the time of death
• Whether the worker was unable to work because of illnesses, injuries or conditions at any time during the 14 months before their death (if "Yes",
• SSA will also ask for the date they became unable to work)
• Whether the worker was in the active military service before 1968 or ever worked for the railroad industry (if so, SSA will ask for the dates of service and whether they ever received a pension from a military, federal or civilian agency)
• Whether the worker earned Social Security credits under another country's social security system
• Whether the worker was employed or self-employed in all years from 1978 through last year
• How much the worker earned in the year of death and the year before death
• Whether the worker ever filed for Social Security benefits, Medicare or Supplemental Security Income (if so, SSA will also ask on whose Social Security record they applied)
• Whether the applicant was living with the worker at the time of death

SSA accepts photocopies of W-2 forms, self-employment tax returns or medical documents, but must see the original of most other documents, such as a birth certificate (SSA will return original documents to the applicant).

When SSA makes a decision on an application, they send a letter to the beneficiary indicating whether the application has been approved or denied. If it is approved, SSA will include a claim number, which is the Social Security number of the worker with one of the following suffixes:

A = Self

B = Spouse

C = Child (includes DAC)

D = Widow/Widower

It can take three to five months to process an application for disability benefits. When a decision is reached on the case, SSA will send the applicant a letter. If the application is approved, the letter will indicate the amount of the benefit and when the payments will start. If the application is not approved, the letter will explain why and tell the applicant how to appeal the decision if they do not agree with it.

When Benefits are Paid

Social Security benefits are paid to either the person or their representative payee by check or direct deposit.  SSA strongly encourages direct deposit.

The day of the month that an individual receives their benefit check is dependent on the date of birth of the person (worker) on whose work record the benefit is paid. The following chart details what day each month a check or the direct deposit is made will be received:

Social Security benefits prior to May 1997; or if receiving both Social Security and SSI, Social Security is paid on the third of the month.

A person can replace their Social Security card if it is lost or stolen. There is a limit of three replacement cards issued to an individual in one year and a total of ten during a lifetime. Legal name changes and changes in immigration status that require card updates may not count toward these limits. Limits may also not apply if the individual can prove that the card is needed to prevent a significant hardship. Please see https://faq.ssa.gov/en-US/Topic/article/KA-02017 for further information.

If an individual disagrees with an initial Social Security or SSI determination or decision, they may request an appeal. The appeal consists of several levels of administrative review as noted below. 

Reconsideration

Complete review of a claim by SSA staff who did not take part in the first decision. A case review or an informal or formal conference may be requested. In a case review, SSA will look at the case without meeting with the individual. In informal and formal conferences, the individual and their representative may participate and present witnesses. A formal conference also gives the individual the opportunity to question witnesses and gives SSA the opportunity to require witnesses to appear.

Note: SSA currently does not use the Reconsideration step for disability determinations made in New York State, however, Reconsideration may be requested in other adverse post- eligibility issues. Disability appeals may be started online at: https://secure.ssa.gov/iApplsRe/start.

Administrative Law Judge Hearing

If the applicant disagrees with an initial determination or a reconsideration decision (if applicable), a hearing may be requested. An administrative law judge who had no part in the initial decision or the reconsideration of the case will conduct the hearing.

Appeals Council Review

If the applicant disagrees with a hearing decision, they may ask for a review by Social Security’s Appeals Council. The Appeals Council considers all requests for review, but it may deny a request if it believes the hearing decision was correct. If the Appeals Council decides to review the case, it will either decide the case itself or return it to an administrative law judge for further review.

Federal Court Review

If the individual disagrees with the Appeals Council’s decision or if the Appeals Council decides not to review the case, the individual may file a lawsuit in a federal district court. The letter SSA sends the individual about the Appeals Council’s action also will tell him or her how to ask a court to look at the case.

Timeframe for Requesting an Appeal

An individual has 60 days from the date they receive a Social Security or SSI decision letter to request an appeal. If the last day of the 60-day window falls on a Saturday, Sunday, or national holiday, the next business day is considered the last day of the window.  SSA will assume the individual received the decision letter within five

days after the date on the letter, unless the individual can prove that they received it later.

Format for Requesting an Appeal

A request for an appeal must be in writing, either by using an SSA appeal form (available by request from SSA) or by sending SSA a signed letter stating that the individual wishes to appeal the decision and including their Social Security number. If the individual does not appeal within 60 days, they may lose the right to do so. In that case, the last SSA decision is final. If the person has good reason for not appealing within the time limit, they may request more time. The individual must request more time from the SSA in writing and must state the reason for the delay.

Requesting Continued Benefits during the Appeal Process

An individual may request that SSA continue to pay their benefits while SSA is making a decision on an appeal if the individual is appealing a decision that they can no longer get Social Security disability benefits because their medical condition is not disabling. For the benefits to continue, the request must be made within ten days of the date of receipt of the letter from SSA informing the individual of the decision. If the individual’s appeal is denied, they may have to pay back any money that they were not eligible to receive.

Repayment Process if an Appeal to the Administrative Law Judge is Denied

If an appeal is denied, the individual and their Representative Payee (if applicable) will receive a notice of the Administrative Law Judge decision. If repayment of SSA benefits is required, individuals may repay in a lump sum or arrange with SSA to repay in installments (at least $10 per week) over a 12-month period. If repayment within 12 months is not possible, repayment may be spread over 36 months. Alternatively, if the individual is receiving other benefits from SSA, they may choose to have their benefits reduced by the amount of the repayment obligation until the funds are repaid.

Information regarding the duties of a representative payee can be found at the Social Security website: www.ssa.gov or www.socialsecurity.gov.

Individuals moving into or living in OPWDD certified settings may need a representative payee. The residential agency must determine whether a person needs a representative payee. This evaluation must be completed within 10 days upon admission, when a person moves, if there is a change in their circumstances or ability to manage funds, and if the person or someone else requests a review on their behalf. If the agency determines a person needs a representative payee, and they did not have one before, a healthcare professional must conduct an evaluation and submit their findings to SSA. For additional information about OPWDD residential providers responsibility to assist an individual in managing benefits see the OPWDD Personal Allowance Manual.

Additional information about Social Security benefits is available on the SSA website:

www.ssa.gov or www.socialsecurity.gov.