SSDI Eligibility & Appeals

Overview

Social Security Disability Insurance (SSDI) is a monthly cash benefit paid by the United States government. It is paid to individuals with disabilities who meet requirements based on employment history. In certain cases, an individual who is disabled can receive SSDI based on a spouse’s or parent’s employment history.

Who Is Eligible for SSDI?

SSDI is for adults ages 18 and up who have worked and paid enough in FICA “payroll” taxes. Due to the Federal Insurance Contributions Act, employers remove this tax from employee wages and send the money to the Social Security trust fund. Self-employed individuals pay directly. If a person has paid enough FICA tax at the right times, they have insured status.

In addition to having insured status, a person must have a severe medical condition that interferes with their ability to work and that is expected to last at least 12 months. (This disability standard also applies to adults in the SSI program.)

Note: The SSDI payment amount depends on how much the worker has paid in FICA taxes.

Understanding Ability to Work—Substantial Gainful Activity

Substantial Gainful Activity, abbreviated as SGA, refers to an ability to work and earn above a certain amount in a month. This amount is set each year by the Social Security Administration (SSA). If an individual’s SSDI countable income is more than the SGA amount, the person meets the Social Security disability definition regarding ability to work and earn. In 2024, the SGA amount is $1,550 for individuals who are not blind and $2,590 for individuals who are blind. (For more about SSDI countable income, see Tool 4.)

Proving Disability

To prove disability, an applicant should submit medical evidence, vocational rehabilitation records, recent education records, and information about past work activity.

Tip: When applying for SSDI, be sure to submit medical and other relevant evidence to SSA.

Who Has Insured Status?

As a person works and pays FICA taxes into the Social Security trust fund through payroll deductions (or self-employment taxes), they earn credits toward qualifying for SSDI “on their own record.” They can earn up to four credits in a calendar year. (A credit is sometimes called a quarter of coverage.)

In 2024, gross earnings of $1,730 earn one credit. This credit may be earned in a short time period or over several months. Some people with full-time employment earn the maximum four credits for a calendar year after working only a few months. Once an individual has $6,920in gross earnings during the 2024 calendar year, they have earned the maximum of four credits for the year. The amount needed to earn a credit is adjusted each year.

The number of credits needed to establish insured status for SSDI depends on age:

• Age 31 or older: 20 credits must have been earned during the last 10 years. For example, to establish disability at age 45, an individual must have earned 20 credits of coverage between ages 35 and 45.
• Ages 24 through 30: An individual must have earned credits for working roughly half the time between age 21 and the time they became disabled. For example, an individual who becomes disabled at age 27 must have earned 12 credits between ages 21 and 27. Those credits could be spread over the 6-year period or could occur within a shorter period.
• Before age 24: An individual must have earned six credits in the 3-year period ending when their disability starts. (If a young adult has even a modest recent work history, they should consider applying for SSDI benefits.)

Note: Unlike SSI, which is for individuals with limited income and resources, the SSDI program has no income or resources test. The SSDI payment amount is never reduced based on the amount of earned income. Most unearned income will not result in a reduced SSDI payment. Also, SSDI does not have a resource limit.

Benefits for Disabled Family Members

A person’s insured status can allow a family member to qualify for SSDI:

• Childhood Disability Benefits (CDB): CDB is for adults whose disability started before age 22 if one of their insured parents has become disabled or retired, or has died.
• Disabled Widow(er)’s Benefits (DWB): DWB is for surviving spouses who are at least age 50 but not yet age 60 if their late spouse was insured.

Many of the rules for CDB and DWB are the same as SSDI. All the work incentives described in Tool 4 apply to CDB and DWB in the same way as SSDI. For individuals who get SSDI and CDB, or SSDI and DWB, work incentives apply to each benefit individually.

More about CDB

The amount of a CDB payment can be:

• If the parent receives SSDI, up to 50% of the parent’s Social Security benefit (the primary insurance amount or PIA)
• If the parent receives retirement benefits or is deceased, up to 75% of the parent PIA.
• If more than one dependent is paid from a parent’s Social Security record, they all share 50 or 75% (or a lower amount) with the others.

Medicaid When SSI Ends Due to CDB or DWB Payments

If a person receiving Supplemental Security Income (SSI) becomes eligible for CDB or DWB then the increase in their unearned income from their CDB or DWB payment could cause them to be ineligible for SSI. They could lose not only their SSI monthly payment but also their Medicaid eligibility. This could also happen later, if their CDB payment increases. However, in most states, they will remain eligible for Medicaid, thanks to a provision of the Social Security Act in Section 1634(c).

Section 1634(c) excludes the DWB amount, CDB amount, or any CDB increase amount from SSI countable income in the 42 states where Medicaid is automatic for SSI beneficiaries. In the nine 209(b) states (Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Oklahoma, and Virginia), the state may or may not follow SSI rules, including this rule, to determine countable income. If you reside in a 209(b) state, you should ask your Medicaid agency if this special rule applies in your state.

What Happens after Applying for SSDI

After submitting an SSDI application, the applicant (and their representative payee, if any) will get a written notice of approval or denial. This notice usually arrives within 6–9 months.

• If the application is denied, the applicant has a right to appeal (see below).
• If the application is approved, several dates and details become important: the 5-month waiting period, retroactive benefits, and the 24-month Medicare waiting period.

The 5-Month Waiting Period

If the application is approved, the applicant must wait 5 months after the disability onset date before SSDI payments start. For example, if the disability onset date is March 23, the applicant must wait during April, May, June, July, and August. The first SSDI payment will be in September. Because of the delay in getting decisions from SSA, some applicants have already completed the 5-month waiting period before receiving their approval decision. Their payments can start right away.

Retroactive Benefits

SSA can pay up to 12 months of benefits before the date of the application. Because of the delay in getting decisions from SSA, many applicants receive a lump-sum retroactive SSDI payment when their application is approved. They then get monthly SSDI payments after the retroactive payment.

The 24-Month Medicare Waiting Period

After SSDI payments start, the beneficiary must wait 24 months for Medicare coverage. Because of the delay in getting decisions from SSA, the actual wait time for Medicare can be much shorter by the time the application is approved.

After the 24-month waiting period, the SSDI beneficiary is automatically eligible for premium-free Medicare Part A (hospital insurance) and may enroll in Part B (medical insurance) and Part D (Prescription Drug Plan). The optional Part B and Part D each have monthly premiums and potential out-of-pocket expenses. Special programs can help with these expenses, such as the Medicare Savings Programs for Part B and the Extra Help program for Part D. (For more about Medicare, see Tool 6.)

Tip: If you are a counselor, be sure to advise a new SSDI beneficiary about when Medicare might start and deciding whether to enroll in the optional Medicare Part B and Part D.

SSDI and Medical Continuing Disability Reviews (CDRs)

All SSDI beneficiaries experience periodic medical reviews. These are called medical Continuing Disability Reviews or medical CDRs. The review checks if the beneficiary’s condition has medically improved enough that the person can work at the SGA level.

A medical CDR has one of two outcomes:

• SSDI benefits continue: This happens if there is no medical improvement, or there has been some improvement, but the individual still cannot work at the SGA level.
• SSDI benefits end: This occurs if there has been medical improvement and the person can work at the SGA level. However, beneficiaries have the right to appeal that decision (see below), and some may be able to use the Section 301 work incentive, which allows for continued SSDI payments if the person is in an approved vocational rehabilitation program.

SSA’s rules and process for SSDI medical CDRs and those for adult SSI medical CDRs are the same. For more information, see SSI at Work, Tool 2.

Appealing SSDI Decisions

The SSDI program allows an applicant or beneficiary to appeal any decision concerning eligibility or payment amount. Here we focus on appealing SSA decisions based on a finding that the individual no longer meets the disability criteria.

If SSA decides to terminate benefits following a medical CDR, it must send a written notice to the beneficiary and their representative payee, if any. That notice must explain all the following:

• That SSDI benefits are being terminated based on a determination that the beneficiary no longer meets the disability criteria
• The effective date of the termination
• Steps that can be taken to request an appeal and the time limit for doing so
• That the right to request that SSDI benefits continue during the appeal and the time limit for doing so

How to Appeal an SSDI Decision

An appeal can be filed online or by sending a letter to the address in the notice. It can also be appealed or by going to an SSA office with the notice in hand and explaining you want to appeal that decision.

The notice will include the method for appealing and the time limit (generally 60 days from receipt of the notice). Also, the notice will explain how to request that SSDI continue during the appeal and the time limit for requesting that (generally 10 days from receipt of the notice).

Getting an Attorney or Advocate to Assist with Your Appeal

When appealing, you would be wise to find an attorney or advocate who has experience with SSDI appeals to represent you. Here are some tips for locating one:

• Try the Legal Services or Legal Aid program for your state or region. To find one, see the Our Grantees page on the federal Legal Services Corporation website.
• Ask the Protection and Advocacy Program for your state (many have the “Disability Rights” in their program name). To find your program, visit the National Disability Rights Network website.
• Seek a private attorney in your area who may—for a fee paid through back benefits—agree to handle the appeal. A search for the bar association in your county or region of the state may be the best way to find one.

Tip: If you are a professional assisting an SSDI applicant or beneficiary, always refer them to an attorney or advocate for representation as soon as you learn that they have received a notice denying their SSDI application or terminating their right to continue receiving SSDI.