Eligibility For Social Security Disability With Fibromyalgia

Fibromyalgia is a complex medical condition characterized by widespread pain. Fibromyalgia syndrome affects the joints, muscles and soft tissue. Symptoms include chronic muscle pain, fatigue, sleep problems, and painful tender points or trigger points, which can be relieved through medications, lifestyle changes and stress management.

A recent Social Security Ruling, SSR 12-2p, issued in 2012, addresses when fibromyalgia should be found as a medically determinable impairment.  This ruling provides guidance on how SSA develops evidence to establish that a person has a medically determinable impairment. A claimant for disabilty benefits will be found eligible if they satisfy either of two sets of criteria set forth in SSR 12-2p:

The 1990 ACR Criteria for the Classification of Fibromyalgia

A claimant may be found to have a medically determinable impairment of fibromyalgia if he or she has all three of the following:

  1. A history of widespread pain – pain in all quadrants of the body (the right and left sides of the body, both above and below the waist) and axial skeletal pain (the cervical spine, anterior chest, thoracic spine, or low back) – that has persisted (or that persisted) for at least 3 months.
  2. At least 11 positive tender points on physical examination (of 18 tender point sites).  A tender point is positive if the person experiences any pain when applying pressure.  The positive tender points must be found bilaterally (on the left and right sides of the body) and both above and below the waist.

The 18 tender point sites are located on each side of the body at the:

  • Occiput (base of the skull);
  • Low cervical spine;
  • Trapezius muscle (shoulder);
  • Supraspinatus muscle (near shoulder blade);
  • Second rib (top of rib cage);
  • Lateral epicondyle (outer aspect of the elbow);
  • Gluteal (top of the buttock);
  • Greater trochanter (below the hip); and
  • Inner aspects of the knee.

3.   Evidence that other disorders that could cause the symptoms or signs were excluded.

The 2010 ACR Preliminary Diagnostic Criteria

  1. A history of widespread pain;
  2. Repeated manifestations of six or more Fibromyalgia symptoms, signs, or co-occurring conditions, especially manifestations of fatigue, cognitive or memory problems (“fibro fog”), waking unrefreshed, depression, anxiety disorder, or irritable bowel syndrome;
  3. Evidence that other disorders that could cause these repeated manifestations of symptoms, signs, or co-occurring conditions were excluded.

Once it is established that a person has a medically determinable impairment, SSA will evaluate the case under the sequential evaluation process to determine whether the person is disabled.  SSA will consider the severity of the impairment, whether the impairment medically equals the requirements of a listed impairment, and whether the impairment prevents the person from doing his or her past relevant work or other work that exists in significant numbers in the national economy.  For more information on the 5-step sequential evaluation process for Social Security Disability, please click here for our post.

Increase In Social Security Disability Benefits For 2014

Social Security Administration (SSA) has announced a cost of living adjustment of 1.5% for 2014.  As a result, monthly benefits for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) beneficiaries will rise next year.

With the increase, the maximum federal benefit for an individual receiving SSI will rise from $710 per month to $721. The benefit for a couple on SSI will grow from $1,066 per month to $1,082. Many states add to SSI benefits for their residents meaning that actual payments could exceed these caps.  Massachusetts is one of the States that adds a supplemental benefit.

How Will the Affordable Care Act Affect Individuals With Disabilities?

As we are now entering the implementation of the Affordable Care Act (“Obamacare”, “ACA”), it will be interesting to see how each State decides coverage for their residents.  Although the Act has several mandates, it appears that each State has some latitude in how the Act is implemented.  The Affordable Care Act requires that health insurance plans sold to individuals and small businesses provide a minimum package of services in 10 categories called “essential health benefits.” These categories include hospitalization, maternity and newborn care, ambulatory care, and prescription drugs, to name a few.  But rather than establishing a national standard for these benefits, the Department of Health and Human Services (HHS) decided to allow each state to choose from a set of plans to serve as the benchmark plan in their state. Whatever benefits that plan covers in the 10 categories will be deemed the essential benefits for plans in the state.  Although flexibility and State by State choice according to local issues sounds reasonable on the surface, a federal benchmark definition of “essential health benefits” may have been a better choice given the complexity and magnitude of regulation this Act may require. [Read more…]

Can I Qualify For Disability Benefits With Anxiety?

Generalized Anxiety Disorder (GAD) is a disorder characterized by feelings of stress, tension, worry and apprehension.  To qualify for disability benefits based on anxiety, your condition must be more than general worrying over specific events.  Your condition must be so severe and overwhelming that it affects your activities of daily living and prevents you from working.

Symptoms associated with anxiety often include:

  • Restlessness
  • Fatigue
  • Difficulty concentrating
  • Irritability or explosive anger
  • Muscle tension
  • Sleep disturbances
  • Personality changes, such as becoming less social

[Read more…]

Qualifying For SSI and SSDI Disability

If you are disabled and can’t work, there are numerous programs and assistance to help you.  Two of those programs at the federal level are Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).  Although there are several differences between the SSI and SSDI disability programs, there is one similarity.  The definition of disability is the same and medical disability is assessed the same way under both programs.

Supplemental Security Income (SSI)

Supplemental Security Income (SSI) is the disability program for those individuals that have not worked or have not worked enough recently to be insured for benefits. It pays monthly cash benefits to people who are age 65 or older, those who are blind, or those who have a disability and have $2,000 or less in assets and have no or limited income. Both adults and children can apply for SSI.

[Read more…]

New Bill Would Expedite Disability Benefits For The Terminally Ill

Congress introduced a bill recently that would expedite SSDI benefits for the terminally ill.  SSDI benefits provide cash assistance for individuals that have paid FICA taxes and found disabled by the Social Security Administration.  This bill would ensure that those individuals with a short life expectancy receive the benefit that they deserve when they need it.  Under existing law, there is a five-month waiting period before and individual can receive SSDI benefits.  The “Expedited Disability Insurance Payments for Terminally Ill Individuals Act of 2013” would allow people whose medical condition results in a life expectancy of six months or less to receive:

  • 50% of SSDI benefits within the first month of diagnosis
  • 75% of monthly benefits for the second month
  • Full benefits for the third and all following months up to one year

[Read more…]

Qualifying For Disability Benefits With ADHD

A diagnosis for ADHD, like other conditions and injuries, does not mean a child will automatically qualify for disability benefits.  Children under 18 diagnosed with ADHD will be granted benefits if the severity of their condition meets the Social Security Administrations (SSA) impairment listing, or functionally equals the listing.   The applicable listing for ADHD can be found at 112.11 of the children’s listings.

To meet listing 112.11, your child must have all three (3) symptoms of ADHD:  marked inattention, marked impulsiveness and marked hyperactivity.  For children 3-18, the claimant must have severe difficulty in at least two (2) of the following four (4) areas:

[Read more…]

Disability Benefits For Children With Congenital Heart Defects

Congenital heart defects (CHD) are Americas #1 birth defect, affecting nearly 1 out of every 100 babies. CHD are the leading cause of all infant deaths in the United States.

Defects can range from a hole in the heart and obstructed blood flow to conditions such as HLHS where multiple parts of the left side of the heart do not develop completely.  Surgeries can range from catheterizations to major open heart bypass surgeries and transplants.  Symptoms may include bluish skin, shortness of breath and fatigue.

SSI disability benefits are available to children with Congenital Heart Defects.  There are several CHD listed on SSA’s compassionate allowance list.  Children may also meet several listings to qualify for benefits.  The listings are:

104.6 – Congenital Heart Disease

To qualify under listing 104.6, the child must have cyanotic heart disease with chronically low blood oxygen, demonstrated by one of the following:

[Read more…]

Autism Legislation

Massachusetts Advocates for Children posted an interesting summary of the Massachusetts legislative priorities for Autism Commission related bills.  One is particularly interesting in that it would require the Board of Education to provide a mechanism for Special Education teachers to receive an Autism Endorsement.  The endorsement will address the specific competencies needed for teachers to address the complex and unique needs of students with autism.  If passed, starting in 2016, IEP Teams for students with autism would include a teacher with an Autism Endorsement to ensure that the school can fully address the complex communication, behavioral, sensory, social, and academics needs of youth in the least restrictive environment.

To see a summary of the Bill, click here for the Massachusetts Advocates for Children website.

Redetermination For Children’s Disability at 18

Many parents have asked what happens to their child’s disability benefit when they turn 18.  Do they automatically lose the benefit?  The answer is no.

At age 18, the child must go through a process called a redetermination of benefits to determine whether or not their benefits should continue.  The reason for this process is because the standard to determine disability is different for adults as it is for children.  As a child, the Social Security Administration (SSA) determines limitations based on functioning over six domains of function.  When the child turns 18, SSA must examine the child’s limitations and how it affects their ability or capacity to work.

So how does SSA determine a child’s ability to work at age 18 with little or no work experience.  SSA will assess the child’s ability to work or enter the workforce based on limitations observed in school, part-time work or volunteer position, and discussing the child’s limitations with persons that may have made observations regarding the ability to work.

Documentation will be needed to show these limitations and may include:

  • Medical records
  • School records
  • Teacher statements
  • Counseling records
  • Statements by employers, charities, internships and volunteer opportunities
  • Statements by family