Continuing Disability Reviews & Age-18 Redeterminations

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 26525.025.

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 26525.040.

5. Medical Improvement Possible(MIP) • Not MIE or MINE • Review at least once every 3 years. • MIP criteria at POMS DI 26525.035.

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 28001.015

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.

8. CDR Protection Under TWWIIALong-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 28010.001 – 28010.150.

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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

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.

17. 2ND GROUPOF 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.

18. 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.

19. 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.

20. 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.

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 03101.020.

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 12027.005.

27. Other Consequences of Medical CDR Termination If no longer medically disabled: • Loss of Extended Medicare • Loss of 1619(b) Status

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%.