SSDI and SSI, and how the decision is actually made

The firm represents claimants in Social Security disability matters — SSDI, SSI and concurrent claims — at the application stage and through reconsideration, hearings and appeals, for people in Suffolk and Nassau County.

The single most useful thing to understand before you start is that this is not a medical question the way a patient experiences it. It is an administrative test with a fixed structure, and a claim wins or loses on how well the record answers that structure — not on how sick you are. Most of this page describes that structure, because knowing it changes what you and your doctors put in the file.

SSDI, SSI, and filing for both

The medical standard is identical. Only the non-medical requirements differ, which is why a person can be found disabled and still be denied — on insured status, on resources, or on the waiting period.

Where an SSDI benefit computed from a thin earnings record falls below the SSI threshold, a person may be eligible for both. The agency calls these concurrent claims, and they are common. The income and resource limits and the federal benefit rate are set by statute and adjusted annually; the agency publishes the current figures.

What “disabled” means here

The definition is narrower than the ordinary meaning of the word, and it has three parts, any one of which can end a claim on its own:

1. A medically determinable physical or mental impairment — established by objective medical evidence from an acceptable medical source. Symptoms alone, however real, do not establish one.
2. Duration — the impairment has lasted or can be expected to last a continuous period set by statute, or to result in death.
3. Inability to do substantial gainful activity — not merely your old job. You must be unable to do your past relevant work and, considering age, education and work experience, unable to adjust to other work existing in significant numbers in the national economy.

Substantial gainful activity

Substantial means work involving significant physical or mental activities — and work can be substantial even if it is part-time, pays less, carries less responsibility, or is easier than what you did before. Gainful means work done for pay or profit, or of a kind usually done for pay or profit, whether or not you actually make a profit. Expressly excluded: self care, household tasks, hobbies, therapy, school attendance, club activities and social programs.

For an employee it is measured in countable earnings — gross pay less any subsidy and less impairment-related work expenses. The monthly figure is set by the agency and adjusted for national wage growth, with a separate, higher figure for statutory blindness. It is published on the agency’s own pages and in its annual guide, which is where it should be read.

The five-step sequential evaluation

This is the whole architecture of a disability claim. The agency works through it in order and stops as soon as it can decide.

Steps one through four are the claimant’s burden. Step five is the agency’s. That shift is the most consequential structural fact in the whole system, and it is why the quality of the residual functional capacity finding — which is where the record either supports you or does not — usually decides the case.

The listings, and residual functional capacity

The Listing of Impairments

Published by the agency and universally called the Blue Book, the listings describe impairments considered severe enough to prevent any gainful activity regardless of age, education or work history, organized by body system. One part applies to adults, another to claimants under 18.

To meet a listing you must satisfy all of its criteria, including any introductory criteria, and the duration requirement. The regulation is explicit that an impairment cannot meet a listing on the basis of a diagnosis alone. The specified clinical and laboratory findings must actually be documented. Expecting a diagnosis to win a case is probably the single most common misunderstanding claimants bring.

To medically equal a listing, the impairment must be at least equal in severity and duration to the criteria. That can happen three ways: the impairment is listed but you lack one finding, and have other findings of equal medical significance; the impairment is not listed at all and is compared to the closest analogous one; or a combination of impairments, none sufficient alone, together carries equal medical significance.

The listings are revised body system by body system on a rolling basis, which is why no criteria appear on this page. The agency’s own publication is the version-controlled source.

Residual functional capacity

Residual functional capacity is the most you can still do despite your limitations, assessed on all the relevant evidence. It is not a medical opinion — it is an administrative finding reserved to the Commissioner, which is why a doctor’s letter cannot supply it directly.

It covers physical abilities (sitting, standing, walking, lifting, carrying, pushing, pulling, reaching, handling, stooping, crouching), mental abilities (understanding and carrying out instructions, responding to supervision, coworkers and work pressure, concentrating and persisting), and other limits including vision, hearing, communication and tolerance of environmental conditions. The evidence includes medical records, medical source statements about what you can still do, consultative examinations the agency may purchase at its own expense, and non-medical observations from you, your family and people who know you.

The appeals ladder

1. Initial determination. Made by the state disability determination agency under federal standards. In New York that function sits within the state’s Office of Temporary and Disability Assistance; the Social Security field office handles the non-medical side.
2. Reconsideration. A written request. New York reinstated this step at the start of 2019 after having been a test state without it — older material saying New York claimants go straight to a hearing is wrong.
3. Hearing before an administrative law judge. Testimony, often a vocational expert and sometimes a medical expert, and a decision. This is where the largest share of successful claims are won.
4. Appeals Council. May decline review, leaving the judge’s decision as the final decision of the agency, or grant review and decide.
5. Federal district court. A civil action in the district where you live — for Nassau and Suffolk, the Eastern District of New York. The court reviews legal error fully, but the agency’s factual findings are conclusive if supported by substantial evidence. It may affirm, modify or reverse, with or without sending the case back.

The hearing, and your right to object to its format

A Long Island claimant’s case is assigned to the hearing office in Central Islip, though the agency may use a remote hearing site. Four manners of appearance exist — in person, telephone, agency video, and online video with your agreement — and you have a written right to object, within a short window, described in the questions below.

Onset, insured status, and building the record

Date last insured

For SSDI, you must be insured at the time the disability begins. Coverage is based on recent covered work, with relaxed rules for workers disabled young and for statutory blindness. After you stop working, insured status eventually lapses on the date last insured, and you must prove you became disabled on or before it. A claim filed years after work stopped becomes a problem of proving a past condition from past records. SSI has no date last insured.

Onset date

Three dates matter. The alleged onset date is when you say you became disabled. The potential onset date is the earliest date you met the non-medical requirements. The established onset date is the earliest date you met both the definition of disability and the non-medical requirements — and that is what the agency is looking for.

For a traumatic injury the date of the event is the starting point, even if you worked that day. For progressive conditions the agency reviews the medical evidence — severity, treatment history, progression — to find the first date the definition was met, considering all impairments together. Whether to call a medical expert to infer an onset date is now discretionary with the judge; material asserting the judge must do so reflects a ruling that has been rescinded.

The waiting period

SSDI entitlement requires being disabled throughout a waiting period of a set number of consecutive full months, which cannot begin more than a fixed number of months before the month of application — which is what caps retroactive benefits however long you were actually disabled. No waiting period applies where there was a prior period of disability within a set number of years, or for a claimant diagnosed with ALS whose application was approved on or after July 23, 2020. SSI has no waiting period.

What actually persuades

The agency must develop your medical history, but the burden of proving disability is yours, and you must tell the agency about all your sources and submit the related evidence on an ongoing basis. Three things do more than anything else:

• Consistent treatment. Gaps read as periods of improvement, whatever the reason for them.
• Objective findings. Imaging, testing, clinical observation — the things that make an opinion supportable.
• Function-specific documentation. Not “unable to work,” but how long you can sit, how much you can lift, how often you would be off task or absent, and why.

The most common credibility problem at hearing is a mismatch between the limitations described and the daily activities reported. Both overstating and understating cause it.

Working after benefits start

The system is built so that trying to work is not a trap.

The trial work period

Lets you test working while still being considered disabled. A fixed number of service months, which need not be consecutive, counted within a rolling sixty-month window. During those months the full benefit is paid regardless of how much you earn — the substantial gainful activity figure is irrelevant during the trial work period. The monthly amount that triggers a service month is lower than the substantial gainful activity figure and is adjusted annually by the agency; a self-employment alternative based on hours worked also exists.

The extended period of eligibility

After the trial work period ends, a thirty-six month reentitlement period runs. Within it, benefits are payable for any month your earnings fall below substantial gainful activity. When substantial work first occurs after the trial work period there is a grace period — that month and the two following are paid. After that, benefits are suspended rather than terminated for months over the limit, and can restart without a new application or a new disability determination if the work stops during the period.

Other supports

• Continued Medicare for an extended period after the trial work period ends, even if cash benefits stop because of work, with a buy-in available afterward.
• Expedited reinstatement — if benefits ended because of work, they may be restarted within a set number of years without a full new application, where the same or a related impairment again prevents substantial work.
• Impairment-related work expenses and subsidies, deducted from gross earnings in determining what counts.

SSI has its own, different set of incentives, and the two should not be assumed to work alike. Every threshold in this section changes annually and is published by the agency.

Documents to bring

The first meeting goes faster and produces better advice if you bring whatever you have of the following. Missing items are normal — bring what exists.

• Every notice and decision you have received, with the envelope or the date you received it
• The names, addresses and treatment dates of every doctor, hospital, clinic and therapist
• A list of your medications, with dosages and side effects
• Your work history for the last fifteen years, with job titles and what the work physically involved
• The date you last worked, and why you stopped
• Any employer accommodation, reduced schedule or help from coworkers you received before stopping
• Any workers’ compensation, private disability, veterans or state disability claim or award
• Your most recent Social Security earnings statement, if you have one
• Anything already written about what you can and cannot do physically or mentally
• For a child’s claim: school records, individualized education program, and any evaluations

Frequently asked questions