Transcript CONTINUING DISABILITY REVIEWS

VCU
Benefits Assistance Resource Center
Overview of Continuing Disability
Reviews
John Coburn, Consultant
Virginia Commonwealth University
WHY CONDUCT
CDRs?
• SSA is required by law to evaluate an
individual’s impairments from time to
time to determine if the individual is still
eligible for payments based on
disability.
WHY CONDUCT
CDRs?
• Maintains programmatic integrity.
• CDRs result in unfavorable decisions in
very few cases.
ROLE OF
PABSS/BPAO
• PABSS may represent individuals in
CDR appeals with unfavorable decision
based on SGA determination.
• PABSS/BPAO can offer support and
counsel.
ROLE OF
PABSS/BPAO
• PABSS/BPAO can assist individual in
cooperating with SSA.
• PABSS/BPAO can inform individuals of
rights and filing deadlines.
When are CDRs
Conducted?
• Diary Dates (Medical Improvement
Expected, Medical Improvement
Possible, Medical Improvement Not
Expected).
When are CDRs
Conducted?
• SSA needs current medical or other
report to see if disability continues
(advance in medical technology).
When are CDRs
Conducted?
• Consumer returns to work and
successfully completes Trial Work
Period (and TWIIA exception does not
apply).
When are CDRs
Conducted?
• Substantial earnings are reported to the
wage record (and TWWIIA exception
does not apply).
• Consumer tells SSA that he/she has
recovered and returned to work (and
TWWIA exception does not apply).
When are CDRs
Conducted?
• VR says services are completed or you
are now working or you are able to
work.
• SSA receives report of no disability and
return to work from person who knows
the individual’s physical or mental
condition.
When are CDRs
Conducted?
• SSA receives evidence that raises
questions as to whether the disability
continues.
• Vocational re-examination diary date.
• For low-birth weight infants, first
birthday.
TWWIIA CDR
PROTECTION
• No CDR for individuals whose ticket is
assigned and “in use.”
• Work activity by individuals receiving
SSDI benefits for at least 24 months will
not trigger a medical CDR.
CDR DIARY
DATES
• Every individual’s case falls into one of
three categories:
– Medical Improvement Expected
– Medical Improvement Possible
– Medical Improvement Not Expected.
CDR DIARY
DATES
• In general, individuals do not know how
their case has been diaried.
• A diary category can be changed during
a continuing disability review.
Medical Improvement
Expected
• CDR is scheduled every
6-18 months.
• Individual is expected to recover.
Medical Improvement
Expected
• Sometimes scheduled within
written favorable decision.
• E.g.: Fractures, surgery planned and
recovery anticipated.
Medical Improvement
Not Expected
• CDR scheduled every 5-7 years.
• Disabling condition is static or
progressively disabling.
Medical Improvement
Not Expected
• Age, impairment consequences, and
attachment to labor market may be
taken into account.
• E.g.: Parkinson’s disease that meets
listing, amputation of leg at hip, AIDS.
Medical Improvement
Possible
• CDR scheduled every three years.
• Improvement cannot be predicted, but
severity is not at a level that is
considered permanent.
Medical Improvement
Possible
• E.g.: Hyperthyroidism, Regional
Enteritis, Chronic Ulcerative Colitis.
CDR Statistical
Profiling Diary CDRs
• “High Level of Medical Recovery”
• “Low Probability of Medical Recovery”
CDR Statistical
Profiling Diary CDRs
• Considers age, impairment, length of
time in disability status, basis for original
determination, data on prior CDRs, and
recent earnings.
CDR Statistical
Profiling Diary CDRs
• Assists SSA in process for determining
who will receive full CDR
Initial Diary
Procedures The Mailer Form
• “Low Probability of Medical Recovery”
• No longer than two pages of questions.
• Only 2.5% of cases are referred for full
CDR.
Initial Diary
Procedures The Mailer Form
• Some of these 2.5% are discontinued
at local level.
• In the 97.5% where CDR is deferred,
that deferral is not considered a CDR.
Initial Diary
Procedures The Automated Direct
Release System
• “Higher Likelihood of Medical
Improvement.”
Initial Diary
Procedures The Automated Direct
Release System
• Phone call from SSA and Mailing of
Multi-Page Questionnaire.
• CDR is conducted.
CDR:
Important Definitions
• Medical Improvement (MI): Any
decrease in severity of the impairment
that was present at the time of the most
recent favorable decision.
CDR:
Important Definitions
• Residual Capacity: What a person can
still do despite impairment. If
impairment does not meet or equal a
listing, SSA looks at residual capacity to
see if you can still do past work or with
age, education and work experience,
any other work.
CDR:
Important Definitions
• MI Related to Ability to Do Work:
Decrease in severity of impairment and
that decrease is related to an increase
in residual functional capacity.
CDR:
Important Definitions
• MI Not Related to Ability to Do Work:
Decrease in severity of impairment, but
no increase in residual functional
capacity.
The Five Automatic
Unfavorables
• A prior decision fraudulently obtained.
• Individual does not cooperate with SSA.
• SSA cannot find the individual
(suspension).
The Five Automatic
Unfavorables
• Individual fails to follow treatment
expected to restore ability to engage in
SGA.
• SSDI Only: Currently engaged in SGA
and completed TWP and Extended
Period of Eligibility.
The CDR Sequential
Evaluation
• Includes the Five Automatic
Unfavorables.
• NOT the same as initial eligibility
standard.
The CDR Sequential
Evaluation
• Results in very few unfavorable
decisions.
• Best learned by working through the
possible scenarios.
Scenario #1
• IF:
– Individual has an impairment
that meets or equals a listing.
• THEN:
– Favorable Decision.
Scenario #2
• IF:
– impairment doesn’t meet/equal listing;
– there is no medical improvement; and
– Medical Exception Improvements do not
apply
• THEN: Favorable Decision.
CDR-Medical
Improvement
Exceptions
• Substantial evidence shows that you
have undergone vocational therapy
related to ability to work.
CDR-Medical
Improvement
Exceptions
• Substantial evidence shows individual is
a beneficiary of advances in medical or
vocational therapy or technology related
to ability to work.
CDR-Medical
Improvement
Exceptions
• Substantial evidence shows that based
on new or improved diagnostic or
evaluative techniques, the impairment is
not as disabling as it was considered at
the time of the most recent favorable
decision
CDR-Medical
Improvement
Exceptions
• Substantial evidence demonstrates any
prior disability decision was in error.
• SSDI ONLY: Individual is currently
engaged in SGA and has completed
Trial Work Period and Extended Period
of Eligibility.
Scenario #3
• IF:
– no listing;
– no medical improvement;
– medical improvement exception does
apply; and
– no severe impairment
• THEN: Unfavorable Decision.
Scenario #4
• IF:
– no listing;
– no medical improvement;
– med. improvement exception applies;
– severe impairment; and
– can do past work
• THEN: Unfavorable Decision.
Scenario #5
• IF:
– no listing;
– no medical improvement;
– med. improvement exception applies;
– severe impairment;
– cannot do past work; and
– can do other work
• Then: Unfavorable Decision.
Scenario #6
• IF:
– no listing;
– no medical improvement;
– med. improvement exception applies;
– severe impairment;
– cannot do past work; and
– cannot do other work
• THEN: Favorable Decision.
Scenario #7
• IF:
– no listing;
– medical improvement;
– not related to ability to work; and
– no medical improvement exceptions
• THEN: Favorable Decision.
Scenario #8
• IF:
– no listing;
– medical improvement;
– med. Improve. not related to work;
– med.improve. exception applies; &
– no severe impairment
• THEN: Unfavorable Decision.
Scenario #9
• IF
– no listing;
– medical improvement;
– not related to work;
– med. improvement exception applies;
– severe impairment; and
– can do past work
• THEN: Unfavorable Decision.
Scenario #10
• IF:
– no listing;
– medical improvement;
– not related to work;
– medical exception applies;
– severe impairment;
– cannot do past work; and
– can do other work
• THEN: Unfavorable Decision.
Scenario #11
• IF:
– no listing;
– medical improvement;
– not related to ability to work;
– medical improvement exception applies;
– severe impairment;
– cannot do past work; and
– cannot do other work
• THEN: Favorable Decision.
Scenario #12
• IF:
– no listing;
– medical improvement;
– related to ability to do work; and
– no severe impairment
• THEN: Unfavorable Decision.
Scenario #13
• IF:
– no listing;
– medical improvement;
– related to ability to work;
– severe impairment; and
– can do past work
• THEN: Unfavorable Decision.
Scenario #14
• IF:
– no listing;
– medical improvement;
– related to ability to work;
– severe impairment;
– cannot do past work; and
– can do other work
• THEN: Unfavorable Decision.
Scenario #15
• IF:
– no listing;
– medical improvement;
– related to ability to work;
– severe impairment;
– cannot do past work; and
– cannot do other work
• THEN: Favorable Decision.
CDR Appeal
Process
• Individual will receive written decision.
• If individual disagrees, he/she files a
Request for Reconsideration (60 days).
• Regular Appeal Process (Admin.Law
Judge, Appeals Council, Fed. Court)
Continued Benefits
Pending Appeal
• Individual must AFFIRMATIVELY
request benefits pending appeal.
• Benefits can continue through ALJ
decision.
• Must request at each level of appeal.
Continued Benefits
Pending Appeal
• Must request within 10 days, absent
good cause.
• Overpayment will result if final decision
is unfavorable.
Section 301
Exception
• Allows benefits to continue
despite medical improvement.
• Must be participating in an approved
vocational rehabilitation program and
this participation must increase
likelihood that person will be
permanently removed from the rolls.
Section 301
Exception
• Must have begun program prior to
disability cessation.
Emerging Issue:
CDR and Ticket Assignment
• CDR begins on date of notice that
states that SSA is beginning to review
your disability case.
• Ticket is assigned when EN submits
paperwork and it is received by
Maximus.
Emerging Issue:
CDR and Ticket Assignment
• Often times, there is a time lag
between handing over the ticket and
actual receipt by Maximus.
• Encourage consumers to follow-up with
EN on submitting paperwork.
Emerging Issue:
CDR and Ticket Assignment
• PABSS has been successful in
resolving these “close call” issues in
favor of individuals.
CONTACT
INFORMATION
JOHN COBURN
HEALTH & DISABILITY ADVOCATES
(312) 223-9600
[email protected]