House Oversight and Government Reform Subcommittee on Energy Policy, Health Care, and Entitlements Hearing
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Chairman Lankford, Ranking Member Speier, and Members of the Subcommittee:
I am pleased to discuss our prior work on the
My remarks today are based on our prior work that found several factors hindered SSA's efforts to assess disability program recipients' continued medical eligibility for benefits. I will discuss (1) SSA's efforts to monitor DI and SSI recipients' continued eligibility, and (2) factors associated with the medical improvement standard that affect these efforts. This information was drawn primarily from two reports we issued in 2006 and 2012, as well as a review of SSA's current related data we performed in March and
Background
SSA administers two disability programs that provide monthly cash benefits to eligible individuals: DI, enacted in 1956, and SSI, enacted in 1972. DI provides monthly cash benefits to eligible workers unable to work because of a long-term disability and who have paid into the
The disability determination process is the same for DI and SSI applicants. An SSA field office determines that an applicant has met SSA's nonmedical eligibility requirements for disability benefits, n5 and then the applicant's claim is sent to the state DDS for an initial review of the claimant's medical eligibility. n6 After assembling all medical and vocational information for the claim, a DDS examiner, in consultation with appropriate medical staff, determines whether the claimant meets the requirements of the law for having a disability. Claimants who are dissatisfied with the initial DDS determination may choose to pursue several levels of appeal, including: a "reconsideration" of the claim, conducted by DDS personnel who were not involved in the original decision; a hearing before an administrative law judge (ALJ); and a review of the claim by the
If SSA determines that an individual is disabled, the agency is required to conduct periodic CDRs to ensure that only recipients who remain disabled continue to receive benefits. n7 These reviews assess whether individuals are still eligible for benefits based on several criteria, including their current medical condition and ability to work. n8 DDS staff generally establish the timeframe for when SSA should conduct a CDR on the basis of the expected likelihood of a recipient's medical improvement. However, SSA also uses a profiling model to score and prioritize CDRs if funding is not available to conduct all scheduled CDRs.
In response to prior concerns that some recipients were being arbitrarily removed from the disability programs via the CDR process,
SSA Has a Backlog of More Than 1 Million DI and SSI Benefit Eligibility Reviews
SSA reported in
Children make up about one fifth of all SSI recipients, and we reported in 2012 that a large proportion of their CDRs were overdue. For example, CDRs for about one half of all child recipients with mental impairments (435,000) were overdue, according to our analysis of SSA data in 2012. n14 Of these recipients, about 344,000 (79 percent) had exceeded the scheduled date by at least a year, with about 205,000 (47 percent) exceeding their date by 3 years, and about 24,000 (6 percent) exceeding the scheduled date by 6 years. We also identified several cases which exceeded their scheduled date by 13 years or more. Of the 24,000 childhood CDRs pending 6 years or more, we found that about 70 percent (over 17,000) were for children who had been categorized as "medical improvement possible" at initial determination, while 25 percent (over 6,000) of these pending CDRs were for those children deemed medically expected to improve within 6 to 18 months of their initial determination (see fig. 2). Of these cases, we identified nine recipients who were expected to medically improve, but whose CDR had been pending for 13 years or more. Reviews of children who are expected to medically improve are more productive than reviews of children who are not expected to medically improve because they have a greater likelihood of benefit cessation and thus yield higher cost savings over time.
Figure 2: Childhood CDRs Pending for at Least 6 Years, by Anticipated Medical Improvement Category, for Children with Mental Impairments
Note: Percentages do not equal 100 percent due to rounding.
When CDRs are not conducted as scheduled, the potential for improper payments may increase as some recipients can receive benefits for which they are no longer eligible. In
For several reasons, SSA has placed a higher priority on conducting CDRs for DI recipients, although children's SSI benefits are more likely to be ceased after review. According to SSA officials, when CDR funding is less than what is needed to conduct all CDRs at the scheduled intervals, the agency has historically given priority to performing reviews considered to be the most cost-effective, as well as staying current with DI CDRs and performing two specific statutorily required SSI reviews. n17 SSA officials told us that it is more cost effective to conduct adult DI CDRs than childhood SSI CDRs, because ceasing benefits for a young adult DI recipient may potentially represent decades of saved benefits. For SSI, statutorily required age 18 redeterminations are cost effective for the same reason. Additionally, because DI benefit payments are, on average, almost twice as much as SSI childhood payments, CDRs of adult DI cases generally produce greater lifetime savings, according to SSA officials. However, SSA reported that it ceased about 12 percent of all adult DI claims that received a CDR. In comparison, our analysis of SSA's data showed that 32 percent of child SSI claims that received a CDR were ceased in fiscal year 2011. For example, of those childhood CDRs conducted for children under age 18 with mental impairments, SSA ceased benefits for about 28 percent on average in fiscal year 2011, with personality disorders and speech and language delay having the highest cessation rates, 39 and 38 percent, respectively. n18 Despite these high cessation rates, SSA and state DDS officials have acknowledged that the agency has not conducted reviews for child recipients in a timely manner, and in some cases, they have not conducted childhood CDRs prior to a child's age 18 redetermination.
In our 2012 report, we recommended that SSA eliminate the existing CDR backlog of cases for children with impairments who are likely to improve and, on an ongoing basis, conduct CDRs at least every 3 years for all children with impairments who are likely to improve, as resources are made available for these purposes. SSA generally agreed that it should complete more CDRs for SSI children but emphasized that it is constrained by limited funding and competing DI and SSI workloads. Moving forward, one of the major objectives in SSA's Fiscal Year 2013-2016 Strategic Plan n19 is to "increase efforts to accurately pay benefits," and the Plan indicates that SSA intends to conduct more CDRs, as funding is available. In addition, as part of the President's fiscal year 2014 budget request, SSA asked for
Several Factors Associated with the Medical Improvement Standard Have Challenged the Assessment of Recipients' Continued Eligibility
During CDRs, disability recipients that SSA determines have improved medically may cease receiving benefits; however, several factors may hinder SSA's ability to make this determination. In 2006, n21 our analysis of SSA data showed that 1.4 percent of all the people who left DI and SSI between fiscal years 1999 and 2005 did so because SSA found that they had improved medically; however, more recipients left for other reasons, including conversion to regular
* Guidance limitations--Limitations in the SSA guidance then in effect for applying the medical improvement standard may have resulted in inconsistent disability decisions. Specifically, in 2006, SSA guidance on CDRs instructed examiners to disregard "minor" changes in a recipient's condition without defining what constituted a minor change. In addition, when assessing whether improvements in recipients' medical conditions were related to their ability to work, the SSA guidance instructed examiners to ensure a "reasonable relationship" between the amount of improvement and the increase in the ability to perform basic work activities. However, at that time, the guidance did not require a specific amount of increase in functioning to better guide examiners in their decision making.
* Inadequate documentation--If a prior disability determination was inadequately documented, it can be challenging for the disability examiner to demonstrate medical improvement in a CDR. Because the prior decision is the starting point for conducting a CDR and examiners are required to find evidence of medical improvement since that last decision in order to cease benefits, inadequate documentation of evidence in prior decisions may make it difficult to assess medical improvement. In our 2006 survey, some DDS directors commented that cases decided on appeal were the most likely to lack adequate documentation. Several officials reported that guidance in effect at that time instructed ALJs to include enough information to make their decisions legally sufficient, but there was no specific instruction to include all of the evidence that would be needed to assess medical improvement as part of a future CDR.
* Presumed disability--According to our 2006 survey, n23 a majority of DDSs incorrectly presumed that a recipient had a disability when the CDR was being conducted, which may have made it more difficult for examiners to determine if a recipient had improved medically. We reported that this practice is contrary to the law as well as SSA regulations and policy, which require that CDR decisions be made on a "neutral basis." n24
* Reliance on judgment--The judgmental nature of the process for assessing medical improvement likely hinders its reliability. For example, one examiner may determine that a recipient has improved medically and discontinue benefits, while another examiner may determine that medical improvement has not been shown and will continue the individual's benefits. n25 Furthermore, we previously found that the amount of judgment involved in the decision-making process increases when the process involves certain types of impairments, such as psychological impairments, which are more difficult to assess than other impairments, such as physical impairments.
These issues have implications for the consistency and fairness of SSA's medical improvement decision-making process, and in 2006, we recommended that SSA clarify policies for assessing medical improvement. Since then, SSA has taken some steps that may help address the issues we raised but has not fully implemented the actions we recommended. In 2009, SSA began implementing an electronic claims analysis tool for use during initial disability determinations to (a) document a disability adjudicator's detailed analysis and rationale for either allowing or denying a claim, and (b) ensure that all relevant SSA policies are considered during the disability adjudication process. In addition, SSA reported in
Chairman Lankford, Ranking Member Speier, and Members of the Subcommittee, this completes my prepared statement. I would be pleased to respond to any questions that you may have at this time.
n1 Beyond this review, we did not update our analyses from our prior reports.
n2 GAO, Social Security Disability Programs: Clearer Guidance Could Help SSA Apply the Medical Improvement Standard More Consistently, GAO-07-8 (
n3 GAO, Supplemental Security Income: Better Management Oversight Needed for Children's Benefits, GAO-12-497 (
n4 42 U.S.C. [Subsec.] 423(d)(1)(A) and 1382c(a)(3)(A). Substantial gainful activity is generally work activity involving significant physical or mental activities that is done for pay or profit, whether or not a profit is realized. 20 C.F.R. [Subsec.] 404.1572 and 416.972. In 2012, the substantial gainful activity threshold was
n5 For example, field office staff are to ensure that an SSI applicant meets income and resource requirements and determine if a DI applicant has a sufficient work history.
n6 Although SSA is responsible for administering these programs, the law allows for initial determinations of disability to be made by state agencies, known as DDS offices. See 42 U.S.C. [Sec.] 421(a)(1).The work performed at DDS offices is federally funded and is carried out in accordance with applicable federal laws, as well as SSA regulations, policies, and guidelines.
n7 SSA's regulations pertaining to CDRs for DI and SSI can be found at 20 C.F.R. [Subsec.] 404.1589 and 416.989, respectively.
n8 In addition to medical CDRs, SSA also conducts "work CDRs" in which it assesses if an individual's earnings exceeded program limits. This testimony focuses on medical CDRs.
n9 Pub. L. No. 98-460 [Sec.] 2, 98
n10 The regulations implementing the act define improvement as any decrease in the medical severity of the recipient's impairment(s) since the last time SSA reviewed his or her disability, based on improvements in symptoms, signs, or laboratory findings.
n11 42 U.S.C. [Subsec.] 423(f)(1) and 1382c(a)(4)(A)(i). The medical improvement standard for individuals under the age of 18 who receive SSI benefits is different. See 42 U.S.C. [Sec.] 1382c(a)(4)(B). The law also identifies certain other limited circumstances under which benefits may be discontinued, besides the medical improvement standard. See 42 U.S.C. [Sec.] 423(f) and [Sec.] 1382c(a)(4)(A) and (C).
n12 In general, DDS staff consider the likelihood of a recipient's medical improvement when establishing the timeframe for when SSA should conduct a CDR. Improvement categories and general time frames used are (1) "medical improvement expected," 6 to 18 months; (2) "medical improvement possible," 3 years; and (3) "medical improvement not expected," 5 to 7 years. For adults receiving SSI, SSA conducts CDRs using two methods: (1) SSA headquarters sends some cases to the DDS for a full medical review, and (2) SSA mails a questionnaire to other recipients and reviews their responses to determine continued eligibility. At this time, SSA does not use the mailer process for SSI child recipients. For comparability in the number of CDRs for adults and children, the CDR data in this section apply to full medical reviews only.
n13 With respect to children receiving SSI benefits, under Title XVI of the Social Security Act, SSA is generally required to (1) conduct a CDR at least every 3 years on all child recipients under age 18 whose impairments are likely to improve (or, at the Commissioner's option, recipients whose impairments are unlikely to improve) (42 U.S.C. [Sec.] 1382c(a)(3)(H)(ii)(I)); (2) conduct a CDR within 12 months after the birth of a child who was granted benefits in part because of low birth weight (42 U.S.C. [Sec.] 1382c(a)(3)(H)(iv)); and (3) redetermine, within 1 year of the individual's 18th birthday (or whenever the Commissioner determines the individual is subject to a redetermination), the eligibility of any individual who was eligible for SSI childhood payments in the month before attaining age 18, by applying the criteria used in determining initial eligibility for adults (42 U.S.C. [Sec.] 1382c(a)(3)(H)(iii)). For children under the age of 18--except for the initial CDR for low birth weight babies--DDS offices are directed by SSA policy to determine when recipients will be due for CDRs on the basis of their potential for medical improvement, and select and schedule a review date--otherwise known as a "diary date"--for each recipient's CDR.
n14 A total of about 861,000 child recipients with mental impairments were receiving SSI benefits as of
n15 The SSA Inspector General estimated that SSA did not complete 79 percent of childhood CDRs and 10 percent of age 18 redeterminations on the basis of the results of 275 cases of physical and mental impairments they reviewed. To estimate the amount of SSI payments made because SSA had not completed a timely childhood CDR, the Inspector General calculated the amount of SSI payments made between the 1-year anniversary of the scheduled CDR date and the earlier of the month of cessation or
n16 This represents the combined savings to the SSI, DI,
n17 In particular, SSA officials identified the following two reviews: age 18 redeterminations, which are required within 1 year after a child turns age 18, and reviews required within 12 months after birth for recipients whose low birth weight was a contributing factor material to the determination of their disability. 42 U.S.C. [Sec.] 1382c(a)(3)(H)(iii) and (iv), respectively.
n18 The cessation rates cited in this paragraph reflect "initial cessations," meaning that the agency concluded at the end of the CDR that the claimant involved no longer met the eligibility standards to continue receiving benefits, and therefore started the process to cease benefits. Claimants may subsequently avail themselves of an appeals process, which can result in a reversal of the initial cessation.
n19 SSA, Strategic Plan: Security Value for America, Fiscal Years 2013-2016 (Feb. 2012).
n20 This proposal was also included in the President's fiscal year 2015 budget request. According to a statement by Acting Commissioner
n21 See GAO, Social Security Disability Programs: Clearer Guidance Could Help SSA Apply the Medical Improvement Standard More Consistently, GAO-07-8 (
n22 As previously noted, beyond our review of currently available data, we did not update our 2006 analyses.
n23 We conducted a national Web-based survey of all 55 Disability Determination Services (DDS) directors in the 50 states, the
n24 At the time our 2006 report was issued, SSA defined neutral basis as a review that neither presumes that a recipient (1) is still disabled because he or she was previously found disabled and (2) is no longer disabled because he or she was selected for a CDR. See also 42 U.S.C. [Sec.] 423(f), 42 U.S.C. [Sec.] 1382c(a)(4), 20 C.F.R. [Sec.] 404.1594(b)(6), and 20 C.F.R. [Subsec.] 416.994(b)(1)(vi) and 416.994a(a)(2).
n25 In one of the CDR cases that we reviewed for our 2006 report, the examiner conducting the initial CDR determined that medical improvement was shown and discontinued the individual's benefits. The recipient was initially awarded disability benefits for a back injury with limited range of motion in the recipient's back. When the CDR was conducted, the examiner evaluated all of the relevant evidence and concluded that the individual's range of motion had improved. The examiner also noted that the individual's allegations of pain did not correlate with the findings from both the physical exam and the laboratory findings. As a result, the examiner concluded that medical improvement had occurred. On appeal to reconsideration 6 months later, a different DDS examiner conducted a review using the same medical evidence as the original examiner, but determined that medical improvement had not occurred, and continued benefits. The examiner conducting the appeal concluded that the recipient continued to experience pain consistent with the back condition, and thus medical improvement was not shown. However, we had no basis for determining which decision was correct.
n26 See SSA Program Operations
n27 See POMS section DI 28015.320.
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