Social Security Disability (SSDI/SSI) and Medicare

The Federal Government provides benefits to people who are unable to work due to physical and/or medical problems through two programs.

Social Security Disability Insurance (SSDI)

You may qualify for SSDI payments if you have a medical condition that prevents you or is likely to prevent you from engaging in substantial gainful employment for a year or more. Substantial gainful employment is not as easily definable term.

To be considered precluded from substantial gainful employment a claimant must be able to prove one or more of the following:

1. Not be gainfully employed.
2. Have a severe impairment.
3. Impairment will last 12 months or more or result in death.
4. Satisfy the requirements of a medical listing from the Code of Federal Regulations
5. Prove that you are unable to perform any of the jobs you held during your last 15 years of working. This is known as past relevant work.
6. Prove that you are unable to perform any other job that is available in national or local economy in reasonable numbers based on your transferable skills and educational level.
7. If you are age 50-54, a limitation to sedentary work may be sufficient to qualify.
8. If you are 55 or older, a limitation to light work may be sufficient to qualify.
9. If you are unable to speak English, the age categories in d and e shift down five years.
10. Have a sufficient amount of quarters paid into the social security system within the last five years.
11. If you are younger than age 50 and are unable to meet a medical listing, your chances of getting SSDI will be difficult absent a showing of significant impairment.

Supplementary Security Income (SSI)

SSI is a poverty program for people who do not qualify for SSDI.

If you are age close to age 62 and you qualify for SSDI, you should apply for SSDI benefits instead of taking early retirement at age 62. By receiving SSDI until age 65, you will avoid most of the decrease in regular social security retirement benefits that results from early retirement.

In most cases where SSDI benefits are awarded, you will be eligible for Medicare coverage within 36 months from the date you were found to be disabled by the Social Security Administration (SSA).

It is important that if Medicare/MediCal pays for medical treatment that is part of your workers’ compensation clam, that these governmental agencies be notified that this treatment is for a workers compensation claim. Under the Medicare Secondary Payer (MSP) rules, failure to take Medicare’s interest into account or failure to reimburse Medicare can result in Medicare seek reimbursement for their costs from you or denying you future medical care under the Medicare program.

In most cases SSA will deny your application for SSDI. Your application will also most likely be denied at the reconsideration level. At that point, you will have to request a hearing before an administrative law judge (ALJ) at the Office of Disability Adjudication Review (ODAR).

My office has significant experience in representing claimants before the ODAR. If you have a serious medical condition or combination of conditions that your doctor(s) tell you are likely to prevent you from engaging in substantial gainful employment for a year or more or you have been off work for a year or more, please contact my office so that we can determine if you should apply for SSDI.