VCU Benefits Assistance Resource Center Overview of Continuing Disability Reviews John Coburn,...

VCUBenefits Assistance Resource Center

Overview of Continuing Disability

Reviews

John Coburn, Consultant

Virginia Commonwealth University

WHY CONDUCTCDRs?

• 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 CONDUCTCDRs?

• Maintains programmatic integrity.

• CDRs result in unfavorable decisions in very few cases.

ROLE OFPABSS/BPAO

• PABSS may represent individuals in CDR appeals with unfavorable decision based on SGA determination.

• PABSS/BPAO can offer support and counsel.

ROLE OFPABSS/BPAO

• PABSS/BPAO can assist individual in cooperating with SSA.

• PABSS/BPAO can inform individuals of rights and filing deadlines.

When are CDRsConducted?

• Diary Dates (Medical Improvement Expected, Medical Improvement Possible, Medical Improvement Not Expected).


• SSA needs current medical or other report to see if disability continues (advance in medical technology).


• Consumer returns to work and successfully completes Trial Work Period (and TWIIA exception does not apply).


• 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).


• 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.


• 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 CDRPROTECTION

• 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 DIARYDATES

• Every individual’s case falls into one of three categories:

– Medical Improvement Expected– Medical Improvement Possible– Medical Improvement Not Expected.

CDR DIARYDATES

• In general, individuals do not know how their case has been diaried.

• A diary category can be changed during a continuing disability review.

Medical ImprovementExpected

• CDR is scheduled every6-18 months.

• Individual is expected to recover.

Medical ImprovementExpected

• Sometimes scheduled withinwritten favorable decision.

• E.g.: Fractures, surgery planned and recovery anticipated.

Medical ImprovementNot Expected

• CDR scheduled every 5-7 years.

• Disabling condition is static or progressively disabling.

Medical ImprovementNot 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 ImprovementPossible

• CDR scheduled every three years.

• Improvement cannot be predicted, but severity is not at a level that is considered permanent.

Medical ImprovementPossible

• E.g.: Hyperthyroidism, Regional Enteritis, Chronic Ulcerative Colitis.

CDR StatisticalProfiling - Diary CDRs

• “High Level of Medical Recovery”

• “Low Probability of Medical Recovery”


• Considers age, impairment, length of time in disability status, basis for original determination, data on prior CDRs, and recent earnings.


• Assists SSA in process for determining who will receive full CDR

Initial DiaryProcedures - 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 DiaryProcedures -

The Mailer Form

• Some of these 2.5% are discontinuedat local level.

• In the 97.5% where CDR is deferred, that deferral is not considered a CDR.


The Automated Direct

Release System

• “Higher Likelihood of Medical Improvement.”


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.


• 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.


• MI Related to Ability to Do Work: Decrease in severity of impairment and that decrease is related to an increase in residual functional capacity.


• MI Not Related to Ability to Do Work: Decrease in severity of impairment, but no increase in residual functional capacity.

The Five AutomaticUnfavorables

• A prior decision fraudulently obtained.

• Individual does not cooperate with SSA.

• SSA cannot find the individual (suspension).

The Five AutomaticUnfavorables

• 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 SequentialEvaluation

• Includes the Five Automatic Unfavorables.

• NOT the same as initial eligibility standard.

The CDR SequentialEvaluation

• 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-MedicalImprovementExceptions

• Substantial evidence shows that you have undergone vocational therapy related to ability to work.


• Substantial evidence shows individual is a beneficiary of advances in medical or vocational therapy or technology related to ability to work.


• 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


• 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


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


Scenario #7

• IF:– no listing;– medical improvement;– not related to ability to work; and – no medical improvement exceptions


Scenario #8

• IF:– no listing;– medical improvement;– med. Improve. not related to work;– med.improve. exception applies; &

– no severe impairment


Scenario #9

• IF– no listing;– medical improvement;– not related to work;– med. improvement exception applies;– severe impairment; and – can do past work


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


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


Scenario #12

• IF:– no listing;– medical improvement;– related to ability to do work; and

– no severe impairment


Scenario #13

• IF:– no listing;– medical improvement;– related to ability to work;– severe impairment; and – can do past work


Scenario #14

• IF:– no listing;– medical improvement;– related to ability to work;– severe impairment;– cannot do past work; and – can do other work


Scenario #15

• IF:– no listing;– medical improvement;– related to ability to work;– severe impairment;– cannot do past work; and – cannot do other work


CDR AppealProcess

• 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 301Exception

• Allows benefits to continuedespite 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 301Exception

• 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.

CONTACTINFORMATION

JOHN COBURN

HEALTH & DISABILITY ADVOCATES

(312) 223-9600

[email protected]

VCU Benefits Assistance Resource Center Overview of Continuing Disability Reviews John Coburn,...

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