How Social Security Determines If Someone Is Disabled
Social Security uses a process called "sequential evaluation" to determine if someone is disabled. SSA asks the following questions and determines the outcome.
Is the Claimant engaging in Substantial Gainful Activity?
Are the Claimant's impairments "severe"?
Will the Claimant's impairment last at least 12 months and/or result in death?
Does the Claimant's condition meet or equal a SSA listing?
Can the Claimant perform any of his/her past work?
Can the Claimant perform any other work generally existing in the economy?
https://secure.ssa.gov/apps10/poms.nsf/lnx/0422001001
Generally speaking, if you are not working or working very little and you have a condition that SSA has predetermine is disabling or if your conditions keep you from performing your past work and any other work then you should be found disabled.
Let's look into each one of these conditions:
Substantial Gainful Activity (SGA)
The very first question that SSA asks is if you are currently working or making more than the SGA limit. SGA for 2025 is $1,620.00 per month gross, or before taxes. You can see the current SGA limits here: https://www.ssa.gov/oact/cola/sga.html
There are additional rules regarding SGA (https://secure.ssa.gov/apps10/poms.nsf/subchapterlist!openview&restricttocategory=04105), but know that if you aren't working and earning more than SGA each month then your case will be forwarded along and will be medically evaluated.
Other income like investments, short-term disability and long-term disability usually are not considered SGA. It is usually just wages from performing actual work.
Severity
"Severity" is basically shorthand for medical issues/diagnoses that don't really have much of an impact in being able to work. For example, suppose you have a bad back and have difficulty with mobility, but also might need eyeglasses for mild near nearsightedness. In such a case, the back injury would be considered "severe" and vision problems would probably be considered "non-severe."
This allows SSA to not spend time evaluating and considering mild or slight conditions that don't really impact one's ability to work. Here is more on "severity:" https://secure.ssa.gov/apps10/poms.nsf/lnx/0424505001
Also note that many denial decisions will throw in the explanation that your conditions are not severe and therefore not disabling. Sometimes that might be the case, but many times that is just boilerplate language that is thrown in with every denial explanation.
Will the Disability last 12 months or more and/or result in death?
Social Security doesn't offer short-term disability or partial disability like some other programs do (workers comp, VA compensation). To be found disabled your impairment has to last or likely last 12 months or more or result in death. You are either long-term disabled or not; and essentially 100% disabled or not. https://secure.ssa.gov/apps10/poms.nsf/lnx/0425505025
Also, note that SSA does not pay benefits for the first 5 full months of disability on SSDI claims. So, basically SSDI cannot be used for temporary medical issues. They must be serious and not quickly resolved.
Does Your Condition Meet/Equal a SSA Listing?
SSA has predetermined that some medical conditions are so severe and disabling that they want to make sure that you are awarded benefits if you have such a condition. Here is what SSA considers automatically disabling: https://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm
Now, it is not uncommon for someone to have such a condition and still be denial initially or an appeal. Some of the listings still have an element of subjectivity to them and sometimes the decision maker may have just overlooked something in the medical records that might have made all the difference.
It is important to check your conditions against what is in SSA's big book of listings and see if you have what SSA is looking for. If you do, you want to make sure the decision maker sees it and knows about it.
If SSA determines your condition meets/equals are listing then you should be found disabled right then and there. If your condition does not meet/equal a listing, then you can still be found disabled if it is determined that you can't do any of your past work and if there is no other work that you can do.
Can You Do Any of Your Past Work?
SSA looks at the type of work you performed in the past 5 years. There are a lot of factors SSA considers to determine if certain jobs should be considered or not. For example, if you work a job for only a few days, then it will not likely be considered past relevant work. Here is some of the things SSA looks for: https://secure.ssa.gov/apps10/poms.nsf/lnx/0425005001
Essentially, SSA will look that the exertional demands of the job (whether it was sedentary, light, medium, or heavy) and at the skilled required to do the job (unskilled, semi-skilled, skilled, or highly skilled) and determine if someone with your impairments could still perform that type of work.
If you can't perform any of your past work, then SSA moves on to the last question of whether you can perform other work.
Can You Perform Other Work?
SSA look at your age, education, work experience and skills acquired to determine whether someone with your limitations can do other types of work.
Generally speaking, when you are under the age 50 you typically have to show that you cannot perform even sedentary work or unskilled work. Once you reach age 50 the standard becomes easier. There are breakpoints at age 50, 55, and 60; so the standard generally becomes easier to be found disabled the older you are and closer to retirement age.
So, if you are over age 50, you usually don't have to show that you cannot do any job; but usually just that type of work you were doing and not extremely physical work.
SSA has something called their "medical-vocational guidelines" or known to practitioners as "the grid" which guides decision makers on the outcome. Here is "the grid," it is outcome determinative in most cases: https://secure.ssa.gov/apps10/poms.nsf/lnx/0425025035
HOW LIKELY IS IT TO BE FOUND DISABLED?
So we have discussed the standard SSA uses to determine if someone is disabled; now, how likely is it that someone will be found disabled and how long does it take?
First, please note that approval rates and processing times change constantly and widely vary from state to state. But for example, here is a typical process and approval percentage nation-wide for all types of claim:
Initial Claim Stage
It typically takes at least 6 months to get a decision on your initial claim. Keep in mind that SSA doesn't pay for the first 5 full months of disability. So even if you stopped working yesterday due to your illness and then filed for Social Security disability today; even if SSA found you disabled within several months you still wouldn't be paid until the 5 full months passed.
When you apply for SSDI or SSI disability with SSA, once SSA does the initial processing of the claim they will ship the case to the state disability determinations office where you live. They will do the work-up on your case. This typically involves gathering the relevant medical records, having you fill out questionnaires, and possibly sending you to one or more of their doctors. The state agency actually makes the determination of whether you are disabled or not.
Expect all of this to take at least 6 months. The national average of getting approved at this stage is roughly 1/3 approved and 2/3 denied.
Reconsideration Stage
If you do get denied initially, that doesn't not necessarily mean you have a bad case. A lot of good cases get denied initially; and unfortunately, some poor cases get approved. If you get denied you have 60 days to appeal the decision. Most states have something called "reconsideration."
At reconsideration the state agency will look at your case again; update your medical records; maybe send you to another doctor; and possibly have more forms for you to fill out.
Expect the reconsideration stage to take at least 2 months, but sometimes you can get quick decisions here. The national average of getting approved at the reconsideration stage is roughly 10% to 20%. This is usually just another hurdle to get people to give us. If you get denied initially, then expect to get another denial at reconsideration; although sometimes things reverse.
Hearing Stage
If you are denied at the reconsideration stage, you have 60 days to appeal the denial to the hearing or ALJ stage. ALJ stands for Administrative Law Judge. If you are denied initially, this is probably your best chance for approval. This is your chance to actually tell an actual decision maker face-to-face about your conditions. SSA now allows you to choose between an in-person hearing, or a telephone or video hearing.
The hearings typically take around 45 minutes and follow a pretty standard procedure. You basically want to make sure you have all the medical evidence in the file and hopefully some supporting doctor statements. Your lawyer should give you a pre-hearing consultation to explain to you all the issues and let you know what to expect. And come hearing day, your attorney should be setting right next to you and advocating on your behalf.
It typically takes about 8 months to get a hearing from the time you appealed the reconsideration denial. Roughly about 50% of all cases at the hearing level are approved with approximately 40% denied and the other 10% dismissed, typically for not attending.
Post-Hearing Appeals
If you are denied at the hearing level, you can still appeal to something called the Appeals Council. It usually takes at least 10 months to get a decision from the Appeals Council and most of the time nothing changes from the ALJ's decision. You have roughly a 10% chance of something positive happening from the Appeal Council with the majority of that being a remand - meaning they will send the case back to the ALJ for a new hearing.
If you are denied at the Appeal Council, you can then file a complaint in Federal Court. These have a pretty high remand rate; typically over 50%. But you are probably waiting at least another year for a decision from Federal Court
If you are denied at the ALJ level, you usually have to choose between giving up; filing a new claim; or appealing it to the Appeals Council.
WHAT IS THE DIFFERNCE BETWEEN SSDI AND SSI?
There are two main disability programs the SSA provides. The disability standard is the same for both. The difference lies in how much to worked and paid into the Social Security system.
SSDI (Title II) is the program for those who have sufficient work history and paid into SSA enough to become "insured" for disability benefits. Typically you need at least 20 of the last 40 quarters of coverage (5 out of the last 10 years) from the time of you disability to be insured. For example, if you were disabled in 2025, then you need to have work enough in the previous 10 years where you have at least 5 years of work credits.
SSI (Title XVI) is basically the welfare arm of the SSA disability program. For those who don't have enough work credits you can still potentially get disability if you are of very limited means. SSA will look at any monthly income you might have and also any assets you may have to see if you qualify.
SSI payments can vary widely because income and other benefits are often deducted. Here is the current SSI monthly benefits amounts: https://www.ssa.gov/oact/cola/SSI.html
You can use this calculator from SSA to see if you might qualify for SSI if you don't have enough work credits. https://www.ssa.gov/ssi/eligibility
DO I NEED AN ATTORNEY AND HOW DOES THE ATTORNEY GET PAID?
An attorney is not required, but can come in very handy to help you navigate the disability process. There are a lot of potential pitfalls out there that can potentially effect not only whether you get disability benefits, but how much and when. And certainly, if your case reaches the hearing level, then most judges will advise you to get an attorney.
SSA has stepped in to regulate attorney fee's. In fact, SSA will pay the attorney directly if the attorney agrees to use SSA's pre-approved attorney fee agreement form. Under that agreement, the attorney is only paid if the Claimant is awarded benefits and the attorney's fee comes out of the Claimant's past-due benefits. The attorney is paid 25% of the past-due benefit amount up to a certain limit set by SSA.
So basically the attorney does not get paid unless the Claimant is award benefits and the attorney's fee comes out of past-due benefits. For example, let's say a Claimant was found disabled in December 2024, but that it was found that they disability started in January 2024, then the Claimant would be awarded past due benefits for that time period. If this past due benefit amount totaled $10,000, then the attorney's fee would be 25% of that - $2,500.
WHAT ABOUT MEDICARE AND MEDICAID?
If you are awarded SSDI (Title II) you become eligible for Medicare after you have received 24 months of disability benefits. This can be retroactive. For example, lets say you are found disabled by an ALJ in January of 2025 and that you were found disability all the way back to April of 2021. In a case like this, you would be eligible for Medicare immediately since you will have received more than 24 months of disability for your back pay.
If you are awarded SSI (Title XVI) you should be eligible for Medicaid.
HOW FAR BACK CAN SSA PAY ME?
For SSDI claims, SSA can potentially pay you back to 12 months before you first applied. For example, let's say you got hurt and had to stop working on January 1, 2023. You didn't file until August of 2024. You eventually were approved in May of 2025. Let's say that SSA says your disability started on January 1, 2023. Under this scenario you would get past due benefits back to August of 2023; 12 months before you first filed.
For SSI claims, SSA can only pay you back to when you first filed. So in the above example SSA could only pay you back to August of 2024, even if they said your disability started on January 1, 2023.