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 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 jcoburn@hdadvocates. org
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