Transcript Continuing Disability Reviews

Continuing Disability Reviews
& Age-18 Redeterminations
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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.
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Timing of Medical CDRs
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MIE ?
MIP ?
MINE ?
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Medical Improvement
Expected (MIE)
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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.
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MIE + work activity = CDR
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MIE criteria at POMS DI 26525.025.
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Medical Improvement Not
Expected (MINE)
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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.
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Medical Improvement Possible
(MIP)
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Not MIE or MINE
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Review at least once every 3 years.
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MIP criteria at POMS DI 26525.035.
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Other Possible CDR Triggers
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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
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CDR Protection Under
TWWIIA (Ticket Users)
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No medical or work-triggered CDRs while
Ticket “in use” (TWWIIA § 101C). Ticket
assigned and “timely progress toward selfsupporting employment.”
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Effective 1/1/01; in Ticket states only.
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But Ticket use can’t stop a CDR in progress.
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CDR Protection Under TWWIIA
Long-Term SSDI Beneficiaries
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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.
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Medical Improvement
Standard
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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.
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Comparison Point Decision
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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.
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CDR SEQUENCE FOR ADULTS
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Step 1 – Is the claimant engaging in
Substantial Gainful Activity (SGA)?
Does not apply to Title XVI (SSI)
recipients.
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If YES, eligibility terminates.
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If NO, move on to Step 2.
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CDR SEQUENCE FOR ADULTS
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Step 2 – Does the recipient’s
impairment(s) meet or equal a listed
impairment?
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If YES, eligibility continues.
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If NO, move on to Step 3.
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CDR SEQUENCE FOR ADULTS
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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) ?
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If YES, move to Step 4.
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If NO, move to Step 5.
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CDR SEQUENCE FOR ADULTS
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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.
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CDR SEQUENCE FOR ADULTS
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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.
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1ST GROUP OF EXCEPTIONS
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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.
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2ND GROUP OF EXCEPTIONS
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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.
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CDR SEQUENCE FOR ADULTS
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Step 6 – Does the recipient have a
severe impairment considering the
recipient’s current impairment(s)?
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If YES, move to Step 7.
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If NO, eligibility terminates.
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CDR SEQUENCE FOR ADULTS
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Step 7 – Is the recipient able to
perform past work, considering the
current impairment(s)?
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If NO, move to Step 8.
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If YES, eligibility terminates.
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CDR SEQUENCE FOR ADULTS
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Step 8 – Is the recipient able to
perform other work, considering the
current impairment(s), age, education
and work history.
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If NO, eligibility continues.
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If YES, eligibility terminates.
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Summary of CDR Standard
Disability will only cease when:
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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. 21
CDR Appeal Process
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Hearing with disability hearing officer of
Disability Determination Services
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Hearing with Administrative Law Judge
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SSA Appeals Council
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Federal Court
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Benefits Pending Review
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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).
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Good Cause for Late Appeals
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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).
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Good Cause Factors
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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.
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Overpayment Potential
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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.
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Other Consequences of
Medical CDR Termination
If no longer medically disabled:
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Loss of Extended Medicare
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Loss of 1619(b) Status
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The Good News
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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%.
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