Non-Medical Criteria and the Five-Step Sequential Evaluation

Welcome to Season 1, Episode 3 of Winning Isn't Easy: Navigating Your Social Security Disability Claim. In this episode, we'll dive into the complicated topic of "Non-Medical Criteria and the Five-Step Sequential Evaluation."

Join host Nancy L. Cavey, a seasoned disability attorney, as she delves into the non-medical disability criteria and their crucial role in Social Security Disability claims. She’ll also break down the Five-Step Sequential Evaluation, the process used to determine if and when disability benefits are awarded. Don’t miss this essential guide to understanding what truly impacts your claim.

In this episode, we'll cover the following topics:

1 -  What Are Non-Medical Disability Criteria, and Why Is It Important in My Social Security Disability Claim?

2 - After the SSA Determines Your Insured Status, the Second Question Is Whether You Have a Medical Condition That Qualifies for Social Security Disability Benefits

3 - What Happens after the Social Security Administration Determines That I Have Met the Non-Medical Criteria - The Five-Step Sequential Evaluation

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Long-Term Disability ERISA Claims. Give it a listen: https://wiedisabilitypodcast.buzzsprout.com


Resources Mentioned In This Episode:

LINK TO YOUR RIGHTS TO SOCIAL SECURITY DISABILITY: https://mailchi.mp/caveylaw/your-rights-to-social-security-disability-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


Need Help Today?:

Need help with your Social Security Disability claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:15]:
 Hey, I'm Nancy Cavey. I am a Florida Social Security Disability attorney and I want to welcome you to the Social Security Disability version of a Winning Isn't Easy. Now, before I get started, I've got to give you a legal disclaimer. I have to tell you that the podcast is not legal advice. The Florida Bar association says I have to say this, so I've said it. Nothing, however, is going to prevent me from giving you an easy to understand overview of the Social Security disability claims process, the games that are played, and what you need to know to get the Social Security disability benefits you deserve. Now, in last week's episode I talked about with a guest the differences between Social Security Disability and ssi. Today I'm going to be covering what's called the non medical criteria and I'm going to give you more of an overview regarding the five step sequential evaluation.
 
 Speaker A [00:01:08]:
 It's important that you understand this so that you appreciate what goes into proving your entitlement to benefits. So I'm going to talk about the following things. What are non medical disability criteria and why is that important? In my Social Security Disability claim number two, after the Social Security Administration determines my insured status, the second question they're going to ask is whether or not I have a medical condition that qualifies for Social Security Disability benefits. And lastly, I'm going to talk about what happens after the Social Security Administration determines that I've met the non medical criteria. And we'll talk more about that five Step Sequential Evaluation get out your pen, your pad or your Chromebook and in the meantime we're going to take a break so that you get set up so you can take notes. Got it.
 
 Speaker B [00:02:06]:
 Filing for Social Security Disability or has your claim been denied already? Either way, you require a copy of your rights to Social Security Disability benefits, which will cover everything you need to know about the Social Security Disability claims process. Request your free copy of the book@avlaw.com today.
 
 Speaker A [00:02:31]:
 Welcome back to Winning Isn't Easy. What are the non medical disability criteria in a Social Security Disability claim and why is that important? There are many hurdles to getting Social Security benefits. Now, before the Social Security Administration uses the five step sequential evaluation to determine your entitlement to benefits, you have to get past the non medical disability criteria or otherwise you don't get to the five step sequential evaluation process. Now, non medical criteria are just that. While many criteria are in fact medical in nature, you also have to establish the non medical criteria to establish your entitlement or eligibility for benefits. And if you don't get past these non medical disability criteria, then you never get to the rest of the issues in your case. So one of the most important non medical disability criteria is your insured status. Why is that so important? Well, the first thing Social Security Administration is going to look at is your insured status to determine whether you have been employed, how long you were employed, and how much you paid in FICA premiums.
 
 Speaker A [00:03:49]:
 Remember those deductions from your paycheck. Now your age will determine how long you must have worked to be insured for Social Security purposes. And you can earn credits of coverage each quarter based on how much you earn. Generally, you have to have 20 quarters out of the last 40 quarters, or in other words, worked and earned sufficient income in five out of the last 10 years. The number of quarters required, it depends on your age as younger workers are required to have fewer quarters of coverage. Now your birth certificate can be used as proof of your age or Social Security can obtain that information from their computer database because obviously they got to figure out when were you born and what quarters of coverage are required based on your date of birth. Now that really is crucial because as I've said, there's some consequences if you don't have enough quarters of coverage. So what happens if you don't have enough quarters of coverage? First off, if Social Security says that you don't, I don't want you to assume that SSA's information is right.
 
 Speaker A [00:05:00]:
 You may have worked for an employer who didn't report your earnings or the correct amount of your earnings. So if they say no, you don't have enough quarters of coverage, you want to ask for a copy of the earnings record. You want to look at it closely to see if there's any error. Now if you don't have enough quarters of coverage, you are just not eligible for Social Security disability benefits. And an alternative would be to apply for Supplemental Security Income benefits if you meet the asset test requirements. Let's talk a moment about correcting your Social Security earnings so that you can apply for Social Security disability benefits. Now remember, regardless of how disabled you might be, if you don't have enough quarters of coverage, you're just not insured for Social Security disability purposes and you're not eligible. Before you apply for benefits, you should go online and set up a Social Security account@www.ssa.gov myaccount and check your earnings records.
 
 Speaker A [00:05:59]:
 You want to see if you've got the applicable quarters of coverage because you don't want to apply for Social Security benefits and Be told that you don't have enough quarters of coverage, that fight will just begin and your application will go nowhere until that issue is resolved. So what's an earnings record? Well, it's a list of all the years that you worked and paid into the Social Security system and how much you paid in Social Security tax. Again, depending on your age, you, you must have paid into the Social Security system 20 out of the last 40 quarters before you became disabled. Now, the amount that you have to earn to get a work credit changes every year. So you need to know that number for each year as you check your earnings records. If Social Security is saying you are not insured for Social Security purposes because you don't have enough quarters of coverage. So I'm often asked, what are the common mistakes in an earnings record? Now, there are lots of mistakes, but if you find an error or think there's an error, you're going to have to correct those errors through the irs. Now, normally you can only go back three years, but there are exceptions to that rule.
 
 Speaker A [00:07:12]:
 And as a matter of course, I think you should be checking your earnings record every year to make sure your employer has reported or correctly reported your earnings to the IRS and that the IRS has directly recorded that information. I'm sure that's the first time anybody has told you that, but I think that that's something that people should do sort of as their New Year's check list item. So add that to the things that you do in the New Year's and the goals that you want to achieve. I want to check my earnings record. Now, there are some exceptions to this because normally you're going to only go back three years. And as a matter of course, you want the IRS ultimately to fix these issues. And you're going to have to submit maybe pay stubs and other information to establish the amount of your earnings and ask IRS to fix it. Now, once they have fixed in quote, the problem, you can proceed with your claim as if you're insured.
 
 Speaker A [00:08:17]:
 Social Security is not going to correct your earnings record even if you give them proof. It's the IRS that has to do the correction. Now, another way to do that is to file an amended tax return and you potentially can get extra quarters of coverage. But you have to do that in consultation with a tax professional. And I normally see this with clients who are operating small businesses businesses and they're self employed. And they'll be surprised if you have to prove that the reported income was earned and received. Again, something you do in consultation with your Tax preparer and the irs. Nothing that a Social Security disability lawyer is going to get involved in.
 
 Speaker A [00:09:03]:
 Now, if you don't have enough quarters of coverage, we have an alternative, and that's the Supplemental Security Income alternative. That's known as ssi. And it's not an insured based program and work credits are not an issue. But it's asset based. And if you have too much in the way of assets, you're not eligible for benefits, regardless of how disabled you might be. I know this is a little complicated and technical, but as a Social Security lawyer, one of the first things I want to know as prospective clients call in is are you insured? Do you have enough quarters of coverage? And if you don't know, we're going to send you to the local office to call or we're going to ask you to get on www.ssa.gov to see that and we're going to want a copy of it because we don't want to file a claim and get a denial on the basis that you were not insured. And if we can't help you because you are not insured, we're going to be talking to you about whether you might qualify for ssi. So this is one of the first questions out of the box.
 
 Speaker A [00:10:06]:
 Not necessarily are you disabled? Why did you stop working? Who are your doctors? Got it. Let's take a break. Welcome back to Winning Isn't Easy, the Social Security Disability Edition. Now what I want to talk about is this. After the Social Security Administration determines your insured status, the second question they're going to ask is whether you have a medical condition that qualifies for Social Security disability benefits. Your doctor may have told you that you can't work anymore or you're having problems at work and your employer is suggesting that it's time to stop work. None of that means anything in the context of a Social Security disability claim. The Social Security Administration has, as we've talked about, a unique definition of disability.
 
 Speaker A [00:11:15]:
 You have to establish after you establish your insurance status that you have a medical condition that meets certain criteria. So what is a medically determinable impairment and why does it matter? As we have talked about, Social Security uses a five step sequential evaluation. Determine your entitlement to benefits. And it's step one. The very first step after you get past the non medical issues of SGA is do you have a medically determinable impairment? So what is that? Social Security defines that as a physical or mental impairment that results from anatomical, physiological or psychological abnormalities that are demonstrated by medically acceptable clinical and laboratory diagnostic technique. What does that mean in English? Well, it depends on the nature of your medical condition. So let me give you an example. You have migraine headaches or fibromyalgia.
 
 Speaker A [00:12:17]:
 There is no gold standard test that can be used to definitively say that you have migraines or fibromyalgia. There are some exams, but generally the diagnosis is made based on certain symptoms you report and a rule out. In the case of fibromyalgia, they use it, among other things, a tender point test, if you will, pursuant to the American College of Rheumatology. But a lot of those types of conditions are based on subjective symptoms, and Social Security can accept these symptoms as a medically acceptable basis for your diagnosis. But on the other hand, let's say you have rheumatoid arthritis. They're going to expect that you have a positive rheumatological study or an explanation in the medical records why your doctor suspects that you have rheumatoid arthritis, notwithstanding negative medical testing. Well, what about a herniated disc? If you've got a herniated disc in your spine, Social Security is going to expect that you have physical findings and MRI or diagnostic findings consistent with the herniated disc and symptoms consistent with the herniated disc. In other words, radicular pain.
 
 Speaker A [00:13:31]:
 In other words, Social Security is looking for the diagnosis to be based on something other than your description of symptoms. Now, if your claim has been denied, step one, on the basis that you don't have a medically determinable impairment, you're going to only have 60 days in which to file an appeal. That's time for you to find an experienced Social Security disability attorney that can help address the basis of denial and move your case forward. This is not a do it yourself process. And by the way, if you delay and you miss the deadline of 60 days, you get to start all over and get back in line in some parts of the United States is taking over a year just to get that application assigned to a claims examiner. And you don't want to have to get back in that line, if you will, to start all over again. So what are the three criteria for establishing that your medical condition meets the definition of disability? So again, this is technical, but one of the first hurdles we have to overcome. The Social Security Administration requires that you have all of the following.
 
 Speaker A [00:14:45]:
 Number one, a severe medical condition. Your medical condition, or the totality of your medical conditions has to interfere with basic work activity and daily activities. For example, if you have a back condition that prevents you from standing at the assembly line or standing at a kitchen sink. Your back condition might be severe enough to qualify for Social Security disability number two, you have to have a long term medical condition. In other words, it must have lasted or be expected to last for at least a year. So if your back condition, for example, has caused you to have surgery, you probably will be disabled for at least a year. Now, I have people who have total hips replacements, and they call me and say, well, I want to file a claim as I'm, I'm a month out of surgery and I'm still having problems. And I'm saying, well, Social Security is going to issue a denial because you may not have been disabled for at least a year.
 
 Speaker A [00:15:40]:
 So call me back when you're having complications. The same thing with a stroke. Now, in terms of a stroke, Social Security thinks that people will recover from the residuals of a stroke in a year. In those cases, I'm more inclined to go ahead and file a claim knowing it's going to take over a year before the claims examiner is assigned. But I tell my prospective clients, look, we may have to pull that application if you recover. And I've had clients who had strokes that are out for two years and then go back to work. So we have a closed period of time. So that's an important factor.
 
 Speaker A [00:16:16]:
 Now, the third question is, are we totally disabled or do we have an inability to engage in substantial gainful activity? Social Security does not pay for partial disability. Now, you can work and apply for Social Security benefits so long as you're earning under the 1550 per month gross, which is current for 2024. That number changes every year. And the Social Security Administration has very special rules to determine whether or not your activity is considered substantial gainful activity. If you exceed the money earnings limit, it doesn't matter how disabled you are. Social Security is going to say you're not entitled to benefits. And ultimately, what you can end up being eligible for is ssi. Now, in the next segment, I'm going to talk about the five step sequential evaluation.
 
 Speaker A [00:17:09]:
 Got it. Let's take a break.
 
 Speaker B [00:17:13]:
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 Speaker A [00:17:45]:
 Welcome back to Winning Isn't easy. Our Social Security Disability Podcast what happens after the Social Security administration determines that you have met the non medical criteria? Now, that involves a discussion of the five step sequential evaluation. It's Social Security's job at that point to determine whether or not you meet that test. Number one, do you have a medically determinable impairment or impairments? Number two, is your impairment or impairments expected to result in your death or has already lasted or can be expected to last for a continuous period of 12 months? Number three, does your impairment or impairments meet or equal a medical listing? Number four, does your impairment or impairments prevent you from performing the lightest and simplest job you held in the five years before your disability is decided? Number five, does your impairment or impairments prevent you from performing other substantial gainful activity in the national economy in view of your age, your work experience, your education, and your restrictions and limitations? Now, as a very experienced Social Security disability attorney, I think one of the ways to get at the listing, to get at the issue of whether you can go back to your past relevant work, and to get at the issue of whether you can do other work is to have your physicians complete some forms called residual functional capacity forms. And I think there are probably about 50 or 60 of them based on different medical conditions. We Social Security lawyers have created them and these are forms that Social Security will never tell you about and your doctor doesn't necessarily know about them. Now, there are doctors who do a lot of Social Security work and they're familiar with the forms. But the key here, in my view, is to have your physician, if they're willing to complete a residual functional capacity form.
 
 Speaker A [00:19:44]:
 The way these forms are drafted is they will generally try to meet the elements of a listing. So your doctor is addressing the listing elements, but more importantly, your doctor is addressing your functional abilities, your ability to sit, stand, stoop, walk, bend, to lift, to maintain pace and production, to deal with breaks, to deal with issues of absenteeism. From a psychological standpoint, the issue is going to be your ability to pay attention, to concentrate, to get along with others, to do simple, routine, repetitive tasks, to be in attendance, to meet pace and production requirements from a psychological standpoint. And so the way we get at that is through these residual functional capacity forms. In my view, what your doctor puts on the RFC form should be consistent with the history that you're telling your doctor about your symptoms and functionality. Now, there are times when doctors won't fill these out. So what we try to do is to make sure that the client is giving a good interval history. But there are some times when I have to say to my client, look, you may love this doctor, but this doctor isn't going to help us.
 
 Speaker A [00:20:58]:
 And given the length of time it takes to get through the claims process, I want you to think about finding another doctor who would be willing to work with you in supporting you your Social Security claim by taking a good history about your symptoms and functionality. But to fill out the residual functional capacity forms. I will tell you, if you're a veteran, that's a particular problem because the VA medical records, in my humble opinion, don't do a very good job of recording a person's history, their symptoms and functionality, their interval history, about any changes. And the doctors, despite VA regulations, will not fill out these residual functional capacity forms. So again, sometimes I have to suggest to my veterans that they use private pay insurance if they have it, or tricare, champus or whatever to see doctors outside of the VA system so that we have the necessary medical records and residual functional capacity forms to show that you meet steps three or if you don't, that you meet steps four and five. Remember, the game here at Step four is to prove that you can't go back to the lightest and simplest job you held in the five years before you became disabled, which is generally pretty easy. But where the rubber meets the mat is step five, proving that you can't do other work in the national economy and view your age, education, work experience and restrictions. That boils down to an ability generally to do a sedentary job on a full time, sustained basis.
 
 Speaker A [00:22:30]:
 So think about jobs like sorting nuts and bolts, addressing envelopes, scanning things. Anything that can be done sitting down is fair game for the Social Security Administration to say hey. In view of your age, in view of your education, in view of your work experience, in view of your restrictions, you can do that sedentary job. And if you can do a sedentary job, Social Security will deny your claim. So we want to attack that from the very beginning with your history of your symptoms and functionality and if possible, those residual functional capacity forms. Got it? Well, I hope you've enjoyed today episode of Winning Isn't Easy. If you've enjoyed this, please like our page, leave a review, share it with your friends and family, and please subscribe to this podcast. That way you'll be notified every time a new episode comes out.
 
 Speaker A [00:23:20]:
 Tune in to next week's insightful episode of Winning Isn't Easy. And in that episode I'm going to delve into the listing of impairments and what you need to know about getting your benefits at step three. Thanks.