Transcript New Opportunities for SOAR in South Dakota

Using SOAR in the Continuing
Disability Review (CDR) Process
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Using SOAR in the Continuing
Disability Review (CDR) Process
P R E S E N T E D BY:
S A M H S A S O A R T E C H N I C A L A S S I S TA N C E C E N T E R
P O L I C Y R E S E A R C H A S S O C I AT E S , I N C .
U N D E R C O N T R A C T TO :
S U B S TA N C E A B U S E A N D M E N TA L H E A LT H S E R V I C E S A D M I N I S T R AT I O N
U . S . D E PA R T M E N T O F H E A LT H A N D H U M A N S E R V I C E S
Welcome!
KRISTIN LUPFER, PROJECT DIRECTOR
SAMHSA SOAR TECHNICAL ASSISTANCE CENTER
POLICY RESEARCH ASSOCIATES, INC.
Webinar Instructions
Muting
Recording availability
Downloading documents
Evaluation
Question instructions
Agenda
Overview of SSA’s Continuing Disability Review (CDR)
Process
•Alex Balaban, Chief- External Contacts Division, NJ Division of Disability
Determinations Service, Newark, New Jersey
CDR Practice Tips for the SOAR Provider
•Gai Lorenzen, Managing Attorney, LAW (Legal Action of Wisconsin), Racine,
Wisconsin
Questions and Answers
•SOAR Technical Assistance Center
Purpose
SOAR was originally developed for adults experiencing or atrisk of homelessness with serious mental illness, co-occurring
substance use disorders, or other physical disabilities.
SOAR critical components have been applied to successfully
represent adults at all stages of the appeals process and is also
used with CDRs!
Increase in SSA funding to do CDRs, so many are receiving
notice of a CDR.
Overview of CDRs
ALEX BALABAN, NEW JERSEY DISABILITY DETERMINATION SERVICES
Continuing Disability Reviews
 Social Security Act requires CDRs in order to
maintain the integrity of the SSI and SSDI
programs.
 NJ DDS has an excellent track record in processing
CDR claims
◦ FFY13 – 11 294 claims processed
◦ FFY14 – 12,062 claims processed
Timing of Medical CDRs
MIE: Medical Improvement Expected
MIP: Medical Improvement Possible
MINE: Medical Improvement Not Expected
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 26525.025
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 26525.040
Medical Improvement Possible (MIP)
Not MIE or MINE
Review at least once every 3 years
MIP criteria at POMS DI 26525.035
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 28001.015
CDR Protection Under TWWIIA (Ticket Users)
 No medical or work-triggered CDRs while Ticket to
Work “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
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
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 28010.001 – 28010.150
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 (CPD)
Only look at impairments for which there was medical
evidence at the time of the CPD
CDR SEQUENCE FOR ADULTS
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
CDR SEQUENCE FOR ADULTS
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
CDR SEQUENCE FOR ADULTS
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
CDR SEQUENCE FOR ADULTS
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
CDR SEQUENCE FOR ADULTS
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
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.
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.
CDR SEQUENCE FOR ADULTS
 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.
CDR SEQUENCE FOR ADULTS
 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
CDR SEQUENCE FOR ADULTS
 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
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.
CDR Appeal Process
 Hearing with disability hearing officer of Disability
Determination Services
Hearing with Administrative Law Judge
SSA Appeals Council
Federal Court
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).
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).
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 03101.020.
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 12027.005.
Other Consequences of
Medical CDR Termination
 If no longer medically disabled:
 Loss of Extended Medicare
 Loss of 1619(b) Status
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%.
CDR Steps for Children
1. Has there been Medical Improvement?
2. Any CPD impairment(s) meet/equal/functionally
equal listings at CPD?
3. Any/all impairments meet/equal/functionally equal
current listings?
TURNING 18
1. Children turning 18 will receive a redetermination
of eligibility under the adult disability standard.
2. This review is NOT a CDR.
3. This redetermination must occur before the child
reaches age 19.
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.
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.
CDR Practice Tips
GAI LORENZEN, LEGAL ACTION OF WISCONSIN (LAW)
Status of Representation/Relationship
 Relationship continues (differences?)
 Relationship ends
 Relationship status must be clearly communicated to
client
 Client needs to know what to expect going forward
On-going Relationship
“Written communication”
Relationship status to client.
The terms of the award to client-start date, end date,
retroactive award, prospective award, dates, basis of
award (type of disability).
Continuing Disability Review
What to do when receive documents for CDR.
Other information you deem relevant
Program Operations Manual System (POMS)
DI 130- Continuing Disability
DI 280- Continuing Disability Review Cases
DI 285- CDR Re-openings
DI 290- Reconsideration of CDR Cases and Re-opening
Applicable to Disability Hearings (Pre-DHU Processing)
TRIGGERS
“Permanent Disability”
“Expected to Improve”
“Possible Improvement”
 Other facts and circumstances
APPEAL/CONTINUING BENEFITS
Appeal Cessation of Benefits Decision
Timely request-60 days
Good Cause Exception for Late Appeals
Continue Benefits
Request to continue benefits-10 days, Form SSA-795
Overpayment if cessation decision upheld
Waiver of overpayment
Overpayment/Waiver
 POMS: SI 02260.010
Claimant “without fault”
POMS: SI02260.025
Against equity and good conscience to recover the
overpayment
Other Information
NOSSCR (National Organization Social Security
Claimant’s Representatives) -Continuing Disability
Review Committee-monitor process and report back to
NOSSCR members
Articles, Op-Eds
Caselaw
SOAR TA Center
For More Information on SOAR
Visit our website: http://soarworks.prainc.com
SAMHSA SOAR TA Center
345 Delaware Avenue
Delmar, New York 12054
(518) 439 – 7415
[email protected]
www.facebook.com/soarworks
@SOARWorks
Questions and Answers
Facilitated By:
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.