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Continuing Disability Reviews & Age-18 Redeterminations

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Presentation on theme: "Continuing Disability Reviews & Age-18 Redeterminations"— Presentation transcript:

1 Continuing Disability Reviews & Age-18 Redeterminations
Social Security Act requires CDRs in order to maintain the integrity of the SSI and SSDI programs. GAO determined that 4.3 million people were due or overdue for a CDR in 1996.

2 Timing of Medical CDRs MIE ? MIP ? MINE ?

3 Medical Improvement Expected (MIE)
Review as early as 6 months after initial determination (if at least 1 year from onset of disability) and not more than 3 years from initial determination. Typically, 6-18 months. MIE + work activity = CDR MIE criteria at POMS DI e.g. generally not MIE if age 54 ½ or more at diary date unless recovery almost certain.

4 Medical Improvement Not Expected (MINE)
Generally MINE if over age 54 ½ or have permanent impairments. Review at least every 7 years, but not more than every 5 years. MINE criteria at POMS DI

5 Medical Improvement Possible (MIP)
Not MIE or MINE Review at least once every 3 years. MIP criteria at POMS DI

6 Other Possible CDR Triggers
Completion of 9-month trial work period. Work, increased earnings, IRWEs in EPE. Initial 1619(a) eligibility. Initial 1619(b) eligibility (after medical review). Vocational diary set up because of voc. training, therapy or education program. Self- or 3rd party reports of work or recovery. Advances in medical treatment or technology Changes in the law (e.g., substance abuse). See POMS DI Must be CDR within 12 months of initial 1619(a) eligibility. No requirement for CDR within 12 months of 1619(b) eligibility. Also, certain 1619 status changes + earnings high enough to preclude cash SSI.

7 CDR Protection Under TWWIIA (Ticket Users)
No medical or work-triggered CDRs while Ticket “in use” (TWWIIA § 101C). Ticket assigned and “timely progress toward self-supporting employment.” Effective 1/1/01; in Ticket states only. But Ticket use can’t stop a CDR in progress. Section 301, participation in vocational rehabilitation program, won’t stop CDR, but will put off the cessation of benefits if criteria are met: The beneficiary/recipient is participating in a vocational rehabilitation plan approved under the Rehabilitation Act of 1973, as amended, and The beneficiary/recipient is not expected to medically recover at the beginning of the rehabilitation program, but does recover and is no longer considered disabled, and The Commissioner of Social Security determines that completion of the training program or participation for a specified period of time will significantly increase the likelihood that the person may be permanently removed from the disability rolls.

8 CDR Protection Under TWWIIA Long-Term SSDI Beneficiaries
No work-triggered CDRs if on SSDI 24+ months (TWWIIA § 111). Effective 1/1/02 in all states. BUT…No protection from regularly scheduled medical CDRs. NO TICKET NEEDED.

9 Medical Improvement Standard
Benefits may not usually be terminated unless there is a finding that the recipient’s condition has medically improved. The medical improvement standard requires a decrease in the medical severity of the recipient’s impairments, based on changes in signs, symptoms and/or laboratory findings. See POMS DI – What’s a medical finding (sign, symptom or laboratory finding) e.g., scores on a hearing test; blood pressure levels; T-cell count; MMPI results; observed symptoms such as pressured speech or lack of affect. This is same standard used for EXR. Sometimes delay because SSA must find the file with the most recent favorable medical decision or review.

10 Comparison Point Decision
In evaluating medical improvement, the recipient’s current impairment(s) are compared with his/her impairments at the time of the most recent favorable medical decision or review. This is called the Comparison Point Decision. Only look at impairments for which there was medical evidence at the time of the CPD.

Step 1 – Is the claimant engaging in Substantial Gainful Activity (SGA)? Does not apply to Title XVI (SSI) recipients. If YES, eligibility terminates. If NO, move on to Step 2. POMS DI ff has CDR info. After TWP is complete, work activity during TWP may be considered in determining whether person is capable of performing SGA. This work is not considered during the TWP.

Step 2 – Does the recipient’s impairment(s) meet or equal a listed impairment? If YES, eligibility continues. If NO, move on to Step 3. What’s a listed impairment: Hand out example. The Listing of Impairments describes, for each major body system, impairments that are considered severe enough to prevent a person from doing any gainful activity (or in the case of children under age 18 applying for SSI, cause marked and severe functional limitations). Most of the listed impairments are permanent or expected to result in death, or a specific statement of duration is made. For all others, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. Part A of the Listing of Impairments contains medical criteria that apply to adults age 18 and over. The medical criteria in part A may also be applied in evaluating impairments in persons under age 18 if the disease processes have a similar effect on adults and younger persons. Part B contains additional medical criteria that apply only to the evaluation of impairments of persons under age 18. Certain criteria in part A do not give appropriate consideration to the particular effects of the disease processes in childhood, i.e., when the disease process is generally found only in children or when the disease process differs in its effect on children and adults. Additional criteria are included in part B, and the impairment categories are, to the extent possible, numbered to maintain a relationship with their counterparts in part A. In evaluating disability for a person under age 18, part B will be used first. If the medical criteria in part B do not apply, then the medical criteria in part A will be used. See bluebook at

Step 3 – Has there been medical improvement in the impairment(s) that existed at the time of the last favorable medical decision or review (the CPD) ? If YES, move to Step 4. If NO, move to Step 5. Don’t count temporary remissions as medical improvement.

Step 4 – Is the medical improvement (MI) related to the recipient’s ability to work? Compare the current “fictional” Residual Functional Capacity (RFC) with the old (or “reconstructed”) RFC at the CPD. If listing met at CPD, determine if currently met. If YES, move to Step 6. If NO, move to Step 5. Examples of elements of RFC: ability to sit, stand, walk; ability to concentrate; follow simple instructions; respond appropriately to supervision. Minor changes in RFC shouldn’t show MI related to the ability to work. Age and time on the rolls should be considered in assessing current RFC. Also compare listing at CPD and now. If listing has changed, compare to listing as it was at time of CPD.

Step 5 – Do any of the first or second group of exceptions apply to the recipient’s case? If one of the first group of exceptions apply, go to Step 6 even though MI not related to ability to work. If one of the second group of exceptions apply benefits are terminated or suspended. If no exceptions apply, eligibility continues. 1st group of exceptions has to do with factors that improve the chances of recipient returning to work, even if medical improvement has not occurred or is not related to ability to work. The more specific and targeted the vocational therapy, the more likely it is to be related to the ability to work.

16 1ST GROUP OF EXCEPTIONS Recipient is the beneficiary of advances in medical or vocational therapy or technology related to the ability to work. Recipient has undergone vocational therapy related to the ability to work. Doesn’t apply if in 1619 currently or within last 12 months. Based on new or improved diagnostic evaluative techniques the impairment(s) is not as disabling as it was considered at the time of the earlier decision. 1st group of exceptions has to do with factors that improve the chances of recipient returning to work, even if medical improvement is not related to ability to work.

17 2ND GROUP OF EXCEPTIONS A prior determination or decision was fraudulently obtained. The recipient fails to cooperate with SSA. The recipient fails to follow prescribed treatment which would be expected to restore the ability to work. “Good cause” exceptions exist to the treatment requirement, i.e., inability to afford treatment or religious objections. Punitive. Sometimes the impairment itself causes the failure to follow prescribed treatment, e.g., with mental illness. I would argue that this is good cause. Failure to cooperate might be not attending a CE, not showing up for a hearing, not responding at all to CDR notice. Homeless people are particularly at risk. There may be good cause for failure to cooperate that would make the exception not apply.

Step 6 – Does the recipient have a severe impairment considering the recipient’s current impairment(s)? If YES, move to Step 7. If NO, eligibility terminates.

Step 7 – Is the recipient able to perform past work, considering the current impairment(s)? If NO, move to Step 8. If YES, eligibility terminates.

Step 8 – Is the recipient able to perform other work, considering the current impairment(s), age, education and work history. If NO, eligibility continues. If YES, eligibility terminates.

21 Summary of CDR Standard
Disability will only cease when: There has been medical improvement related to the ability to work or certain exceptions to the medical improvement standard apply; and The impairments together with the vocational profile (age, education, work experience) do not prevent the person from engaging in SGA, unless a group 2 exception applies.

22 CDR Appeal Process Hearing with disability hearing officer of Disability Determination Services Hearing with Administrative Law Judge SSA Appeals Council Federal Court

23 Benefits Pending Review
Benefits pending review are available through the ALJ hearing level of appeal. In order to secure benefits pending appeal, the appeal must be filed within 10 days (5 days for mailing presumed) of denial and an request for benefits pending appeal must be made. Regular appeals must be filed within 60 days of denial (+ 5 days for mailing).

24 Good Cause for Late Appeals
Must request extension in writing and give reasons why not timely. Applies to 10-day “benefits pending” as well as 60-day regular appeal deadline. Applies to beneficiary and others acting for him/her (e.g., rep payee, representative).

25 Good Cause Factors Physical, mental, educational and linguistic limitations that prevented claimant from filing or understanding need to file timely appeal Confusing, misleading, or incomplete information furnished by SSA. Other circumstances that might impede efforts to pursue claim (e.g., illness, homelessness). Good Cause criteria in POMS GN

26 Overpayment Potential
If the claimant loses on appeal, SSA will assess an overpayment. Waiver will be possible and “no fault” will be found if the appeal was filed with a “good faith” belief that eligibility existed. See POMS DI

27 Other Consequences of Medical CDR Termination
If no longer medically disabled: Loss of Extended Medicare Loss of 1619(b) Status BUT… the good news is the about 80% of people reviewed are found to be still medically disabled initially. After appeals, less than 10% are terminated from benefits.

28 The Good News About 80% of CDRs result in continuation of benefits at the first step of the review. Appealing brings the continuation rate up to nearly 90%.

29 CDR TIMETABLE FOR KIDS Every 3 years, unless MINE,
§212 of the 1996 Welfare Act requires a child’s case to be reviewed: Every 3 years, unless MINE, By the child’s 1st birthday, if eligibility was based on low birth weight.

30 TURNING 18 Children turning 18 will receive a redetermination of eligibility under the adult disability standard. This review is NOT a CDR. This redetermination must occur before the child reaches age 19.

31 AGE 18 REDETERMINATION When SSA initiates the redetermination it will provide notice of the review as well as the right to submit additional evidence supporting the continuation of disability under the adult standard.

32 Redetermination Rights
If SSA determines that the “child” is no longer disabled, notice of the decision will issue. Full administrative and court review appeal rights apply to this determination. Benefits pending review are also available but must be affirmatively requested.

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