Revised on: February 7, 2020

WAC 388-449-0005 Sequential Evaluation Process Step 1 - How does the department determine if you are performing substantial gainful employment?

Substantial Gainful Activity (SGA) is an earnings standard that is adjusted periodically by the Social Security Administration (SSA). An individual may be financially eligible for ABD cash but not meet disability requirements if they are earning above the SGA limit. When a (financially eligible) client has earnings over the SGA standard, contact the client to ensure:

1. The work is not under special conditions, such as a sheltered workshop; or
2. The work is not occasional or part-time because the client's impairment limits their hours or ability to work.

We exclude the following work related activities when determining SGA:

1. AmeriCorps
2. University Year for Action
3. Retired Senior Volunteer
4. Foster Grandparent Program
5. Older American Community Services Programs
6. Service Corps of Retired Executives (SCORE)
7. Active Corps of Executives (ACE)

WAC 388-449-0035 How does the department assign severity ratings to my impairment?

WAC 388-449-0040 How does the department determine the severity of mental impairments?

WAC 388-449-0045 How does the department determine the severity of physical impairments?

WAC 388-449-0050 How does the department determine the severity of multiple impairments?

WAC 388-449-0060 Sequential Evaluation Process step II - How does the department review medical evidence to determine if I am eligible for benefits?

1. The severity of an impairment is the extent to which it affects the individual's ability to perform basic work activities.
2. The Disability Specialist determines severity based on medical and other evidence received by the Department. When the individual needs help obtaining necessary evidence (e.g. meets Equal Access criteria or requests assistance), the Disability Specialist assists the individual in obtaining necessary evidence.
3. Severity ratings are assigned to all medically determinable impairments, meaning all impairments that could reasonably result from a condition diagnosed by an acceptable medical source identified in WAC 388-449-0010.
4. Severity ratings are assigned by the Disability Specialist based on the overall medical evidence and input received from the contracted Review of Medical Evidence (RME).

1. When an individual has multiple impairments, we consider whether the impairments have a cumulative effect on their ability to perform basic work activities.
2. The Disability Specialist assigns a higher overall severity if the cumulative effect of multiple impairments results in a greater impact on the individual's ability to perform one or more basic work activity.

Clarifying Information

1. ABD Disability Determinations are made by a team consisting of a Disability Specialist and a contracted doctor.
2. The contracted doctor reviews the diagnosis, severity, functional limitations, duration and onset date recorded by the Disability Specialist if the individual has at least a moderate overall severity that has lasted or is expected to last 12 months or more or result in death.
3. The Disability Specialist makes necessary adjustments to the diagnosis, severity, functional impairments, and onset date based on the contracted doctor's professional medical opinion when supported by objective medical evidence. All adjustments are made prior to determining whether the individual meets the disability criteria in Step 2 of the ABD Sequential Evaluation Process (SEP).
4. If the severity ratings or functional limitations provided by the evaluating medical provider are adjusted, the Disability Specialist must clearly describe the reason why we rejected the medical evidence provider's opinion and identify the medical evidence used to make the determination.
5. If the overall impairment is of at least a moderate severity and the impairment has lasted or is expected to last 12 months or more or result in death, the Disability Specialist proceeds with the ABD Sequential Evaluation process.
6. The Disability Specialist denies ABD at Step II if:
   1. The overall impairment is mild, meaning there is not a significant impact on the ability to perform at least one basic work activity.
   2. The impairment has not lasted or is not expected to last 12 months or more or result in death; or
   3. Medical evidence indicates substance use is material to the impairment as defined in WAC 388-449-0015.

Purpose:

Process to determine if a person's impairments meet the SSA listings of impairments criteria.

WAC 388-449-0070 Sequential Evaluation Process step III — How does the department determine if you meet SSA listing of impairments criteria?

Clarifying Information 

1. Individuals whose impairments meet the SSA listing of impairments criteria are determined to be disabled regardless of their ability to do past work or other work.
2. The listing of impairments have very specific criteria defined by SSA that must be met in order to determine a person is disabled at this step.
3. The overall mental or physical impairment severity must be at least marked to consider an for meeting listing criteria.
4. If the specific diagnostic and other medical criteria for a specific listing is met, the functional impairments that meet the remainder of the listing criteria do not need to be the direct result of the disabling impairments. Other impairments or the treatment of the primary or secondary impairments may contribute to the person's  functional limitations.
   
   EXAMPLE- Terry has been diagnosed with systemic sclerosis and major depression. The Disability Program Specialist takes all the medical and other evidence into consideration when determining if Terry meets the functional impairment criteria for listing 14.04 (Systemic sclerosis). The Disability Program Specialist does not need determine whether Terry's documented fatigue, weight loss, and social impairments are the result of the systemic sclerosis or the major depression.
5. A person whose impairments do not meet listing criteria may found to be disabled at Step 4 or Step 5 of the Sequential Evaluation process.

​Worker Responsibilities

Select the body system for the most disabling impairment (SSA Blue Book):

1. Review the overview for the listings in the appropriate body system.
2. Determine the specific listing subcategory that describes the person’s impairment. Some listings are specific to only one diagnosis, others describe a chronic condition within a body system that may have multiple diagnosis or underlying causes for the listed impairments.
3. Compare the description of listing subcategory with the medical evidence.
   • Does the person’s impairment, based on available medical evidence, match the description?
   • If the person’s impairment doesn’t match the description, the person cannot be approved at this step. Continue with the evaluation process (STEP 4).
   • For some listing categories, a documented diagnosis is all that is necessary to establish that an impairment meets a listing subcategory
4. Compare the medical evidence testing and documentation requirements to the medical evidence in the ECR.
   • Does the available medical evidence meet the specific requirements given for listing category and sub category?
   • If the testing or medical documentation doesn’t match the specific criteria, the person cannot be approved at this step. Continue with the evaluation process (STEP 4).
5. Compare the description of functional impairments with the medical evidence, other evidence and functional assessment. Typically the person must meet one the functional limitation descriptions associated with a listing. For mental illness and some physical disorders, the person’s functional limitations must meet all of the criteria listed or specific set as described for the specific listing subcategory.
   • Does the person’s functional limitations, based on available medical and other evidence, match all of the necessary criteria for the listing subcategory?
   • If the person’s impairment doesn’t meet the functional criteria, the person cannot be approved at this step. Continue with the evaluation process (Step 4).
6. If the person’s impairments meet all the required diagnostic, testing, documentation, and functional impairment criteria for a specific listing subcategory:
   1. Approve disability for ABD.
   2. Document the testing (if applicable) and functional limitations that allowed for an approval at this step of the process.

WAC 388-449-0080Sequential Evaluation Process step IV — How does the department evaluate if I am able to perform relevant past work?

Clarifying Information

An individual who is 55 years of age or older meets ABD disability criteria if their impairment prevents them from performing all relevant past work from within the past 15 years.

​WorkerResponsibilities

Social Service Intake Interview

1. In order to be considered relevant past work:
2. The work must have been performed within the past five years;
   
   1. The past work must be considered a “substantial gainful activity" as defined in WAC 388-449-0005; and
   2. The individual must have performed the work long enough to meet the Specific Vocational Preparation(SVP) level identified in the Dictionary of Occupational Titles (DOT) for the corresponding job listing.
      1. We will not consider past work that started and stopped in fewer than 30 calendar days to be considered past relevant work (PRW).
3. Assign an exertional level (e.g. sedentary, light, medium, heavy) to the each specific relevant past work experience that is consistent with the Strength Rating identified in the DOT for the specific job title. Specific DOT job titles can be located using the DOT Search function.
4. Document any transferable skills the individual gained during each relevant past work episode based on the individual’s specific job duties. Transferable skills are considered at Step 5 of the Sequential Evaluation Process (SEP).

Sequential Evaluation Process

1. If the individual is neither denied ABD at Step 1 or Step 2, nor approved for ABD at Step 3, the Disability Specialist determines whether the individual is capable of performing relevant past work.
2. For each relevant past work episode, the Disability Specialist compares the skill and physical demands identified for the specific corresponding DOT job title to the individual’s residual functional capacity to determine whether the individual is capable of returning to past work.
3. When determining residual functional capacity, the Disability Specialist gives full consideration to all limitations supported by available medical and other evidence. Limitations include:
   1. mental (e.g. social and cognitive factors);
   2. exertional (e.g. work level);
   3. non-exertional (e.g.visual/auditory limitations, inability to work at heights,chemical sensitivities); and
   4. functional limitations (e.g. restrictions related to unrelieved pain or the effects of prescribed medication)resulting from a medically determinable impairment that are supported by available medical and other evidence.
4. ABD is denied if the individual is capable of returning to relevant past work.
5. If the individual is not capable of returning to relevant past work, the Disability Specialist proceeds to Step 5 of the Sequential Evaluation Process (SEP) and considers whether the individual is capable of performing other work available in the national economy.

WAC 388-449-0100 Sequential Evaluation Process step V — How does the department evaluate if I can perform other work when determining disability?

​Clarifying Information

1. If an individual is not approved at Step 3 and not denied at Steps 1, 2, or 4 of the Sequential Evaluation Process (SEP), the Disability Specialist determines if the individual can perform other work.
2. When determining if the individual is capable of performing other work, the Disability Specialist gives full consideration to the individual's residual functional capacity, age, education, and work experience.
   
   NOTE: The Social Security Administration (SSA) defines residual functional capacity (RFC)as the most the individual can do despite their impairment based on an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis. A "Regular and continuing basis" means 8 hours a day, for 5 days a week, or an equivalent work schedule. See SSR 96-8p for additional details.
3. If the individual meets the approval criteria detailed in the Physical, Mental, or Combination tables in WAC 388-449-0100, they are considered unable to perform other work and ABD is approved.
4.  If the individual does not meet the ABD approval criteria detailed in the Physical, Mental, or Combination tables, the Disability Specialist determines whether the individual is capable of performing at least two jobs available in the national economy.
5. If the Disability Specialist determines the individual is capable of performing other work available in the national economy, the Disability Specialist must list at least two specific jobs from the Dictionary of Occupational Titles (DOT) that the individual is able to perform given their residual functional capacity, age, education, and work experience.
6. If the Disability Specialist cannot identify at least two examples of jobs the individual can perform despite their impairment, ABD is approved.

Revised on August 15, 2024

WAC 388-449-0150 When does my eligibility for the Aged, Blind, or Disabled (ABD) cash benefits end?

Review and Termination of ABD Cash

1. The Disability Specialist must review current medical evidence and determine whether the individual meets ABD disability criteria detailed in WAC 388-449-0001 (3) at least every 24 months.
   
   1. The Disability Specialist must initiate the Disability Review far enough in advance to request and consider available medical evidence from the individual's treating medical providers and request clarification and/or additional medical records when necessary to determine ongoing ABD eligibility.
   2. An ABD Disability Review is not required for recipients aged 65 or older.

2. The Disability Specialist may initiate an early Disability Review at any time if the Department receives information indicating that the individual is no longer likely to meet SSI disability criteria.
3. Eligibility for ABD cash ends when a final disability determination is made by the Social Security Administration (SSA) or when the individual no longer meets ABD disability criteria detailed in WAC 388-449-0001 (3).
4. A final disability determination includes an SSI or SSDI denial at the SSA Appeals Council level or an unfavorable determination at the initial, reconsideration, or hearing level for which the individual fails to file a timely appeal (and SSA has not granted good cause for a late appeal).
5. When SSA denies an application at the Initial, Reconsideration, or Hearing level, the SSI Facilitator reviews the SSA determination and performs a brief review of all available medical evidence to identify if the client's conditions have improved or deteriorated.
   
   1. If the client no longer appears to meet ABD disability criteria, the SSI Facilitator notifies the Disability Specialist that an early Disability Review is needed. The Disability Specialist reviews the medical evidence in detail and, if warranted, requests current medical evidence.
   2. If the client appears likely to meet ABD disability criteria, the SSI Facilitator determines an early ABD Disability Review is not necessary and continues with the SSI Facilitation process.
6. If SSA denied the application due to income or resources, the Disability Specialist or SSI Facilitator notifies financial regarding the denial. Financial reviews the case to determine if the client continues to meet ABD income and resource requirements.
   
   1. ABD recipients must follow through with the SSI application process which may include spending down or selling resources. Refer to the SSI Facilitation Participation in the SSI Process and Medical Treatment section for more information.
7. If SSI/SSDI was denied or terminated due to a failure to follow an SSA program rule or application requirement, we consider ABD eligibility once the client takes necessary steps (within their power) to resolve their non-cooperation.  Example: Client denied due to failure to follow through with Consultative Examination (CE).
   
   1. Failing to follow an SSA program rule or application requirement is not the same as failing to meet an SSA program rule or requirement. For example, if a client has failed to meet eligibility criteria (e.g., resources), we would still consider ABD eligibility.

NOTE: 

1. If the individual is coded as Equal Access (EA), the Disability Specialist and SSI Facilitator must follow all requirements of the EA plan when reviewing disability and document steps taken.

a. Screen for EA and implement any necessary accommodations when an individual frequently fails to follow through and/or expresses difficulty understanding program requirements.

Related Procedures (Staff Only):
Determining ABD Eligibility after a Final Disability Determination

Disability and Incapacity Reviews

Determining a New or Worsening Condition after an ABD Termination

ABD Early Disability Review

Revised on: July 18, 2019

WAC 388-449-0010 What evidence do we consider to determine disability?

WAC 388-449-0015 What medical evidence do I need to provide?

Clarifying Information- WAC 388-449-0010

1. A diagnosis of a medically determinable impairment must be from an “acceptable medical source” as defined in WAC 388-449-0010. The diagnosis must be supported by objective medical evidence described in WAC 388-449-0015 and be based on an examination within 5 years of the application date.
2. After a diagnosis is established, we can use medical evidence from “treating medical sources” as current medical evidence.
3. Once we have a diagnosis and current medical evidence, we may include “other evidence” as supporting documentation.

Clarifying Information- WAC 388-449-0015

1. Statements regarding how the impairment(s) limit a client’s functioning must be consistent with objective medical evidence.
2. We only use primary diagnoses that produce potentially disabling symptoms or impairments.
   1. Symptoms can be the direct result of the disease or injury, or a result of treatment for the condition.
   2. Some examples of diagnoses that don’t typically qualify as a potentially disabling impairment are:
      1. Hypertension;
      2. Hepatitis;
         1. Hepatitis is typically asymptomatic or produces mild symptoms. If the disease has progressed, interferon treatment could result in significant fatigue, but may not meet the duration requirement for disability.
   3. Pain cannot be used as a diagnosis.
   4. Once a diagnosis has been established by an “acceptable medical source,” written evidence from treating professionals or non-medical sources can be used to determine how the impairment affects the client’s ability to function.

Revised December 12, 2011

Example Scenarios

The following tables contain examples of phrases found in chart notes and the corresponding rating:

Bob applies for ABD cash and states knee pain is keeping him from working. Note that radiological findings are not requested or necessary in the scenarios describe below.

Tyler applies for ABD cash and states back pain is keeping him from working.

Amy applies for ABD cash and states she can’t work because she has diabetes.

Disability Determination Process

WAC 388-449-0001 What are the disability requirements for the Aged, Blind, or Disabled (ABD) program?

WAC 388-449-0005 Sequential Evaluation Process Step 1. How does the department decide if you are performing substantial gainful employment?

WAC 388-449-0010 What medical evidence do we consider to determine disability?

WAC 388-449-0015 What medical evidence do I need to provide?

WAC 388-449-0020 How does the department evaluate functional capacity for mental health impairments?

WAC 388-449-0030 How does the department evaluate functional capacity for physical impairments?

WAC 388-449-0035 How does the department assign severity ratings to my impairment?

WAC 388-449-0040 How does the department determine the severity of mental impairments?

WAC 388-449-0045 How does the department determine the severity of physical impairments?

WAC 388-449-0050 How does the department determine the severity of multiple impairments?

WAC 388-449-0060 Sequential Evaluation Process step II - How does the department review medical evidence to determine if I am eligible for benefits?

WAC 388-449-0070 Sequential Evaluation Process step III - How does the department determine if you meet SSA listing of impairments criteria?

WAC 388-449-0080 Sequential Evaluation Process step IV - How does the department evaluate if I am able to perform relevant past work.

WAC 388-449-0100 Sequential Evaluation Process step V - How does the department evaluate if I can perform other work when determining disability?

SSI Application Requirements

WAC 388-449-0150 When does my eligibility for Aged, Blind, or Disabled (ABD) cash benefits end?

WAC 388-449-0200 Am I eligible for cash assistance for the Aged, Blind, or Disabled (ABD) while waiting for Supplemental Security Income (SSI)?

WAC 388-449-0210 What is interim assistance and how do I assign it to the department?

Treatment and Referral Requirements

WAC 388-449-0220 How does alcohol or drug dependence affect my eligibility for the ABD cash and Pregnant Women Assistance programs?

WAC 388-449-0225 Am I required to participate in vocational rehabilitation services if I receive an ABD cash grant?