VCU Benefits Assistance Resource Center Overview of Continuing Disability Reviews

1. VCUBenefits Assistance Resource CenterOverview of Continuing Disability Reviews John Coburn, Consultant Virginia Commonwealth University

2. 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.

3. WHY CONDUCTCDRs? • Maintains programmatic integrity. • CDRs result in unfavorable decisions in very few cases.

4. ROLE OFPABSS/BPAO • PABSS may represent individuals in CDR appeals with unfavorable decision based on SGA determination. • PABSS/BPAO can offer support and counsel.

5. ROLE OFPABSS/BPAO • PABSS/BPAO can assist individual in cooperating with SSA. • PABSS/BPAO can inform individuals of rights and filing deadlines.

6. When are CDRsConducted? • Diary Dates (Medical Improvement Expected, Medical Improvement Possible, Medical Improvement Not Expected).

7. When are CDRsConducted? • SSA needs current medical or other report to see if disability continues (advance in medical technology).

8. When are CDRsConducted? • Consumer returns to work and successfully completes Trial Work Period (and TWIIA exception does not apply).

9. When are CDRsConducted? • 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).

10. When are CDRsConducted? • 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.

11. When are CDRsConducted? • SSA receives evidence that raises questions as to whether the disability continues. • Vocational re-examination diary date. • For low-birth weight infants, first birthday.

12. 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.

13. CDR DIARYDATES • Every individual’s case falls into one of three categories: • Medical Improvement Expected • Medical Improvement Possible • Medical Improvement Not Expected.

14. 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.

15. Medical ImprovementExpected • CDR is scheduled every6-18 months. • Individual is expected to recover.

16. Medical ImprovementExpected • Sometimes scheduled withinwritten favorable decision. • E.g.: Fractures, surgery planned and recovery anticipated.

17. Medical ImprovementNot Expected • CDR scheduled every 5-7 years. • Disabling condition is static or progressively disabling.

18. 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.

19. Medical ImprovementPossible • CDR scheduled every three years. • Improvement cannot be predicted, but severity is not at a level that is considered permanent.

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

21. CDR StatisticalProfiling - Diary CDRs • “High Level of Medical Recovery” • “Low Probability of Medical Recovery”

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

23. CDR StatisticalProfiling - Diary CDRs • Assists SSA in process for determining who will receive full CDR

24. 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.

25. 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.

26. Initial DiaryProcedures - The Automated Direct Release System • “Higher Likelihood of Medical Improvement.”

27. Initial DiaryProcedures - The Automated Direct Release System • Phone call from SSA and Mailing of Multi-Page Questionnaire. • CDR is conducted.

28. 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.

29. 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.

30. 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.

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

32. The Five AutomaticUnfavorables • A prior decision fraudulently obtained. • Individual does not cooperate with SSA. • SSA cannot find the individual (suspension).

33. 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.

34. The CDR SequentialEvaluation • Includes the Five Automatic Unfavorables. • NOT the same as initial eligibility standard.

35. The CDR SequentialEvaluation • Results in very few unfavorable decisions. • Best learned by working through the possible scenarios.

36. Scenario #1 • IF: • Individual has an impairmentthat meets or equals a listing. • THEN: • Favorable Decision.

37. Scenario #2 • IF: • impairment doesn’t meet/equal listing; • there is no medical improvement; and • Medical Exception Improvements do not apply • THEN: Favorable Decision.

38. CDR-MedicalImprovementExceptions • Substantial evidence shows that you have undergone vocational therapy related to ability to work.

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

40. CDR-MedicalImprovementExceptions • 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

41. CDR-MedicalImprovementExceptions • 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.

42. Scenario #3 • IF: • no listing; • no medical improvement; • medical improvement exception does apply; and • no severe impairment • THEN: Unfavorable Decision.

43. Scenario #4 • IF: • no listing; • no medical improvement; • med. improvement exception applies; • severe impairment; and • can do past work • THEN: Unfavorable Decision.

44. 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.

45. 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.

46. Scenario #7 • IF: • no listing; • medical improvement; • not related to ability to work; and • no medical improvement exceptions • THEN:Favorable Decision.

47. Scenario #8 • IF: • no listing; • medical improvement; • med. Improve. not related to work; • med.improve. exception applies; & • no severe impairment • THEN:Unfavorable Decision.

48. 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.

49. 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.

50. 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.