Background

Military personnel wounded since 2001—the exact number is not known— may qualify for financial benefits from several federal agencies. While SSA,  VA, and DOD each provide disability benefits that are available to  wounded warriors, these programs have different eligibility criteria and  serve different purposes. SSA has two programs, Disability Insurance (DI)  and Supplemental Security Income (SSI), to provide benefits for those  whose disabilities prevent them from working. VA’s disability  compensation program and DOD’s disability retirement program provide  benefits to those with service-connected disabilities. (See app. II for a  table summarizing the three agencies’ disability programs.)

		Varying Estimates of the Total Number of Wounded Warriors Since 2001

Estimates of the number of military personnel wounded, ill, or injured  since 2001 vary widely depending on what conditions are counted and the  source of data used. DOD has reported that about 34,000 servicemembers  have been wounded in action in the OEF/OIF campaigns through the  beginning of June 2009. On the other hand, our analysis of VA data shows  that almost 250,000 OEF/OIF veterans were receiving VA disability  compensation benefits as of July 2008. This figure may be larger than  DOD’s estimate because, for example, some wounded warriors’ service- related medical conditions may have only appeared or been recognized  after they separated from the military. Yet another estimate comes from a  2008 study by the RAND Corporation. Based on a survey of individuals  deployed in support of OEF and OIF, this study estimated that more than  500,000 OEF/OIF veterans and servicemembers likely suffer from at least  one of three mental health or cognitive conditions—PTSD, major  depression, and probable TBI—that are likely linked to combat  experience. The RAND estimate, unlike the VA estimate, includes  wounded warriors whose medical conditions may not even have been  medically diagnosed.

		SSA Disability Benefits

To be eligible for either DI or SSI, an adult must be unable to engage in  “substantial gainful activity”—typically work that results in earnings above  a monthly threshold established each year by SSA—because of a medically  determinable physical or mental impairment that is expected to last at  least 12 months or result in death. Established in 1956, the DI program  provides monthly benefits to individuals (and sometimes their  dependents) whose work history qualifies them for disability benefits and  whose impairment is disabling. To qualify for DI, individuals must have  worked a certain minimum amount of time in employment covered by  Social Security; the monthly amount of DI benefits is based on the  worker’s past average monthly earnings. In fiscal year 2008, the average  monthly DI benefit payment was $997. SSI is a means-tested income  assistance program created in 1972 that provides a financial safety net for  people who are aged, blind, or disabled, and have low incomes and limited  assets. Unlike the DI program, SSI has no prior work requirements. The  basic federal SSI benefit is the same for all individual beneficiaries. This  basic, monthly SSI benefit may be reduced if an individual has other  income or receives in-kind (noncash) support or maintenance. In fiscal  year 2008, the average monthly SSI benefit payment was $476. Some  individuals with disabilities can receive both DI and SSI benefits if they  meet both DI’s work history requirements and SSI’s income and asset  limits.
The process to determine a claimant’s eligibility for SSA disability benefits  is complex, involving several state and federal offices. A claimant first  completes an application, or claim, for DI or SSI benefits, which includes  information regarding illnesses, injuries, or conditions and a signature  giving SSA permission to request medical records from medical care  providers. Once the SSA field office staff verify that nonmedical eligibility  requirements are met, the claim is sent to the state’s Disability  Determination Services (DDS) office for determination of medical  disability. If the claim is approved, a claimant will be notified and will  receive benefits, including limited retroactive benefits for some DI  claimants. If the claim is rejected, a claimant has 60 days to request that  the DDS reconsider its decision. If the DDS reconsideration determination  concurs with the initial denial of benefits, the claimant has 60 days to  appeal and request a hearing before an SSA administrative law judge  (ALJ). A claimant may appeal an unfavorable ALJ decision to SSA’s  Appeals Council—which includes administrative appeals judges (AAJ) and  appeals officers—and, finally, to the federal courts. SSA and DDS officials  (for example. disability examiners, ALJs, and AAJs) determine disability  based on evidence, such as medical findings and statements of functional  capacity, obtained during the initial determination process and updated as  necessary at each appeal level.

		VA Disability Compensation Benefits

VA’s disability compensation program compensates veterans for the  average loss in civilian earning capacity that results from injuries or  diseases incurred or aggravated during military service, regardless of  current employment status or income. VA uses the Department of  Veterans Affairs Schedule for Rating Disabilities (VASRD) as criteria to  determine the disability percentage rating. Disability ratings range from 0  (least severe) to 100 percent (most severe) in increments of 10 percent.  For example, an amputation of a thumb could result in a 40 percent rating,  while an amputation of a ring finger could result in a 20 percent rating. If  the veteran is found to have one or more service-connected disabilities  with a combined rating of at least 10 percent, VA will pay monthly  compensation, with amounts higher for those with higher ratings. As of  December 2008, a veteran without dependents rated at 20 percent disabled  receives monthly compensation of $243, whereas a veteran without  dependents rated at 100 percent disabled receives $2,673 monthly. The  veteran can be re-evaluated if the extent of the veteran’s disability changes  or if new or newly recognized medical conditions or illnesses occur and  are determined to have been caused or aggravated by military service. The  veteran may, upon re-evaluation, receive a different percentage rating than  they initially received.

		DOD Disability Retirement Benefits

DOD’s disability system awards compensation to those servicemembers  who are found to be no longer medically fit for duty, and, if they do not  recover, separates them from the military. Like VA, DOD uses the VASRD  as criteria to determine the disability percentage rating. The amount of  DOD disability payment is based on whether the disability is service- related, the years of service, and the disability rating percentage.  Servicemembers who receive a disability rating of 30 percent or higher— regardless of their years of service—generally will be retired and may be  eligible for lifelong benefits, including retirement pay and health insurance  for the servicemember and their family. These servicemembers are placed  on the Permanent Disability Retired List (PDRL). Servicemembers with  fewer than 20 years of service who are separated with a disability rating of  20 percent or less receive a single lump-sum severance payment; those  with at least 20 years of service who receive a disability rating under 30  percent are placed on the PDRL and receive on-going monthly benefits.  Servicemembers may also be placed on the Temporary Disability Retired  List (TDRL) if they are found to be medically unfit for duty by military  examiners, but their service-related illnesses or injuries are not stable  enough to assign them a permanent disability rating. Once a permanent  disability rating can be assigned, depending on the rating and the  servicemember’s years of military service, DOD may place those on the  TDRL on the PDRL, grant them a one-time severance payment, or find  them fit to return to military service.

		SSA Disability Coverage for Wounded Warriors

Military servicemembers pay Social Security payroll taxes and may qualify  for DI benefits on the basis of their service if they have a sufficient number  of work quarters. Military service, for Social Security purposes, includes  service in the Army, Navy, Air Force, Marines, and Coast Guard, including  service in the Reserves and National Guard. Those who served in the  military during certain periods of time are given credits that increase the  earnings that SSA looks at in determining DI eligibility and benefit levels.  Individuals are considered to have earned an additional $300 per quarter  for military service between 1957 and 1977, and an additional $100 for  every $300 actually earned—up to a maximum of $1,200—per calendar  year between 1978 and 2001. In addition to DI benefits, wounded warriors  may qualify for SSI benefits if they have low income and assets.
Furthermore, active duty servicemembers may receive DI benefits while  also receiving military pay. Social Security law gives SSA the discretion to  determine when an individual is actually performing work at the  substantial gainful activity level, regardless of the individual’s income.  Accordingly, in determining eligibility for benefits in cases when an  applicant is receiving military pay, but is also receiving medical treatment  or is on limited duty status, SSA assesses not the servicemember’s actual  earnings, but rather what the servicemember would be paid in the civilian  labor market for their work. If the wage that the servicemember could  theoretically receive in the civilian workforce is less than SSA’s substantial  gainful activity level, then SSA will not automatically disqualify the  servicemember from receiving disability benefits.

		Impact of VA and DOD Disability Decisions on SSA Decisions

Given that the SSA, VA, and DOD disability programs have different  purposes and eligibility criteria, not all wounded warriors found to be  disabled by VA or DOD—even those found 100 percent disabled—will  necessarily qualify for SSA disability benefits. SSA’s DI program, for  example, is an insurance program designed to replace workers’ income if  they become unable to work due to disability. If an individual can perform  any kind of work in the U.S. economy, then this person is not eligible for  DI benefits. By contrast, VA’s disability compensation program is  designed to compensate veterans for the average loss of earnings resulting  from a particular disability—regardless of the actual effect on an  individual veteran’s capacity to work. A veteran could be rated 100 percent  disabled under the VASRD by VA and receive VA disability benefits, but  also be working and earning more than SSA’s substantial gainful activity  level, and therefore be ineligible for SSA benefits.
While SSA programs have different eligibility criteria than VA or DOD  programs, and SSA makes its own disability decisions separate from those  of VA or DOD, SSA regulations state that SSA eligibility determinations are  to take disability decisions by other agencies into account. SSA regulations  specify that the agency must evaluate all the evidence in a case record that  may have a bearing on its disability decision, including decisions by other  governmental and nongovernmental agencies. SSA has issued guidance to  its adjudicative staff—including DDS claims examiners and SSA ALJs and  AAJs—that when making a disability decision they must consider all the  evidence in the case file, including a finding of disability by another agency  such as VA. Adjudicators should explain the consideration given to a  finding of disability by another agency in the case record for initial and  reconsideration claims or in the notice of decision for hearing claims.  However, the SSA regulations also note that a finding of disability by  another government agency, related to a different benefit program, is not  binding on SSA’s own disability determination.

		Financial Interaction of SSA, DOD, and VA Benefits

Depending on their circumstances, wounded warriors may receive cash  benefits simultaneously from SSA and from DOD or VA. However, receipt  of DOD or VA benefits sometimes affects the amount of SSA benefits that  a wounded warrior may receive. Specifically, SSI benefits are reduced if  the beneficiary also receives benefits from certain other government  programs such as DOD or VA benefits. On the other hand, DI benefits are  not offset by VA or DOD disability benefits, so wounded warriors may  receive their full DI benefits along with benefits from these other agencies.  By contrast, DOD disability retirement benefits and VA disability  compensation benefits are awarded on the basis of the content of  disabilities incurred during military service rather than on the basis of  income. Wounded warriors may receive their full DOD or VA disability  benefits along with any SSA benefits.

	Thousands of Wounded Warriors Have Applied and Been Approved for SSA Disability Benefits, and Relatively Few Receiving DOD or VA Benefits Also Receive SSA Benefits

More than 16,000 wounded warriors have applied for SSA disability  benefits and their approval rate has been about 60 percent; in addition,  about 4 percent of wounded warriors receiving DOD or VA disability  benefits are also receiving SSA disability benefits. At least 16,000 wounded  warriors have applied for SSA disability benefits since 2001, with close to  90 percent of applications submitted in 2007 and 2008. A sizable minority  of wounded warriors submitted their applications more than a year after  injury, often foregoing some retroactive benefits because of this delay in  applying. About 60 percent of the applicants with no pending claims have  been approved for benefits by SSA, with a majority of the approved  claimants having a mental health disorder as their primary impairment.  Among wounded warriors who were receiving disability benefits from  DOD or VA, about 10 percent had applied for SSA disability benefits, and  about 4 percent of the total cohort of wounded warriors receiving DOD or  VA benefits were also receiving SSA benefits. Wounded warriors with  higher disability ratings were more likely to have applied and to be  receiving SSA disability benefits.

		At Least 16,000 Wounded Warriors Have Applied for SSA Disability Benefits— Often A Year Or More After Injury—and Their Approval Rate Has Been 60 Percent

Since 2001, at least 16,000 wounded warriors have applied for SSA  disability benefits. This figure represents the number of applicants whom  SSA has identified in its systems as wounded warriors, but because of  limitations with SSA’s data sources the total number of applicants is likely  higher. In its databases, SSA identifies wounded warriors as those  applicants who were disabled while in active military service on or after  October 1, 2001, regardless of where the disability occurred. SSA uses two  sources of information to identify wounded warrior applicants. First, DOD  provides SSA with a list every week of military personnel who have been  wounded, injured, or become ill while in support of the OEF/OIF  campaigns. According to DOD, though, while this list is the only data they  have available, it is not necessarily a comprehensive list of all military  personnel wounded, ill, or injured in OEF/OIF. In addition, applicants may  self-identify as wounded warriors when they submit their applications.  However, SSA only started collecting this information from applicants in  2005, so wounded warriors who applied before 2005 and are not in DOD’s  data would have been missed.
Meanwhile, we found that of the more than 16,000 wounded warriors  appearing in SSA’s data as having applied for SSA benefits, virtually all had  submitted claims for DI benefits, with many also submitting a claim for  SSI. (Applicants may file claims for DI benefits on the basis of their past  work history or SSI benefits on the basis of low income and assets.)  Among these 16,000 applicants, about 53 percent had applied for both DI  and SSI benefits concurrently, another 47 percent applied for DI benefits  only, and less than 1 percent applied for SSI benefits only.
We also found that the vast majority of the applicants submitted their  claims within the last two calendar years. Although wounded warriors  who have served since 2001 have applied for SSA disability benefits in  every year dating back to 2002, the number of claims submitted has  increased each year—almost 90 percent of the applicants submitted their  claims in 2007 or 2008 (see fig. 1).
While most of the wounded warriors for whom SSA has determined a  disability onset date submitted their applications to SSA within a year of  sustaining their wound, injury, or illness, a substantial number submitted  applications a year or more after injury. Among wounded warriors whose  claims were approved at the initial stage of adjudication and for whom  SSA has established a disability onset date, more than half submitted  their applications within a year of this onset date. But about 40 percent  submitted claims at least 12 months after disability onset, and almost a  quarter submitted claims at least 18 months after onset. (See fig. 2.) DI  claimants who file an application more than 17 months after disability  onset will forego some retroactive benefits, because their 12-month  retroactive benefit period will not extend all the way back to the end of  the 5-month waiting period (between the disability onset date and the date  a claimant can start receiving DI benefits). SSA has for some time been  considering a legislative proposal to change or waive the statutory  retroactive benefit period specifically for wounded warriors to help those  who may not apply soon enough after disability onset. An SSA official  reported that the agency’s consideration of such a proposal is based in  part on anecdotal evidence from local offices about wounded warriors not  applying for benefits in a timely manner. SSA has not provided us with any  further details about their potential proposal.
Turning to the claim outcomes for wounded warrior applicants identified  in SSA’s data, we found that the approval rate for these wounded warriors  was 60 percent. By comparison, among all individuals who filed a claim  for DI benefits in 2007, 32 percent had a claim approved by August 2008.  Specifically, about 7,600 of the wounded warrior applicants had at least  one claim allowed for either DI or SSI. The vast majority of these claim  allowances have come at the initial stage of adjudication. Of the  approximately 7,600 claimants with allowed claims, 96 percent had claims  allowed at the initial stage, and 4 percent at the hearings level. Of the  remaining wounded warriors with no allowed claim, the majority had their  claims denied, though many still had at least one claim pending a final  decision. (See fig. 3.)
Breaking out DI and SSI claims, we found that wounded warriors were  much more likely to have claims allowed for DI than for SSI, and a major  reason was that many wounded warriors exceeded SSI income and asset  requirements. Of the almost 16,000 wounded warriors who submitted a  claim for DI, about 7,500 had a DI claim allowed. Of the roughly 8,500 who  submitted a claim for SSI—often concurrently with their DI claim—fewer  than 900 had an SSI claim allowed. Wounded warriors’ SSI claims were  much more likely to be denied for technical—nonmedical—reasons. Of  those who applied for SSI, 64 percent were denied for technical reasons,  particularly for having income or resources above the program’s limits. In  contrast, of those who applied for DI, less than 1 percent were denied for  technical reasons, such as insufficient work history.
Finally, looking at the medical conditions of wounded warriors whose  claims were allowed, we found that the majority were found eligible on the  basis of mental health disorders. That is, the primary medical impairment  for about 60 percent of wounded warriors allowed at the initial or  reconsideration stages, fell into the overall category of mental disorders  (see fig. 4). By contrast, among all disabled workers who had DI claims  allowed in 2008, 23 percent had a mental disorder. Among wounded  warriors with mental disorders, the three most common specific  conditions—accounting for more than half of all the wounded warriors  with allowed claims—were anxiety disorders, mood or affective disorders,  and chronic brain syndrome. According to SSA officials, wounded  warriors with PTSD are included in either the anxiety disorder category or  the mood or affective disorder category. Also, those with TBI may be  classified as having chronic brain syndrome, or as having any of a number  of neurological conditions depending on their symptoms. Aside from  mental disorders, most of the remaining wounded warriors with allowed  claims had a musculoskeletal condition as their primary impairment. The  most common musculoskeletal conditions—accounting for about 13  percent of all wounded warriors with allowed claims—were back  disorders, amputations, and lower limb fractures.

		A Small Percentage of Wounded Warriors Receiving DOD or VA Benefits Also Receive SSA Benefits, and Those With Higher Disability Ratings Are More Likely to Receive Benefits From SSA

Among almost 251,000 wounded warriors receiving DOD or VA disability  benefits, we found that about 26,000 (10 percent) of this cohort had  applied for SSA disability benefits and about 9,000 (4 percent) were  receiving SSA benefits as of July 2008. It is likely that some applicants still  had claims pending as of July 2008—the cut-off date for our analysis—and  could have eventually been approved for benefits. It is also possible that  some of the applicants had been approved for SSA benefits in the past, but  were no longer receiving them in July 2008. Our analysis focused on  wounded warriors receiving DOD disability retirement VA disability  compensation benefits, or both, in July 2008 who had served in active duty  at any point since September 2001. The vast majority (92 percent) of the  cohort of 251,000 wounded warriors received benefits only from VA.  Another 2 percent received benefits only from DOD. The remaining  wounded warriors received benefits from more than one agency.   (See fig. 5.)
We also found that among wounded warriors receiving DOD or VA  disability benefits those with higher disability ratings were more likely to  have applied for and been receiving SSA disability benefits. Among the  approximately 7,400 wounded warriors rated as 100 percent disabled by  DOD or VA, 63 percent had applied for SSA benefits and 41 percent—of  the entire group of 7,400—were receiving them in July 2008. By  comparison, among those rated as less than 50 percent disabled, fewer  than 10 percent had applied for and fewer than 2 percent were receiving  SSA disability benefits. (See fig. 6.) Importantly, not all wounded warriors  rated as 100 percent disabled by DOD or VA will necessarily qualify for  SSA disability benefits, given differences in the purposes and eligibility  criteria between the agencies’ programs. Similarly, some wounded  warriors rated as less severely disabled by DOD or VA could qualify for  SSA benefits. DOD disability retirement and VA disability compensation  benefits —unlike SSA benefits—are awarded on the basis of service- connected disabilities. According to SSA officials, some veterans found by  DOD or VA to have only moderate service-connected disabilities could  have experienced an additional injury or illness after separating from the  military, which later qualified them for SSA benefits.

	Agencies Have Taken Steps to Conduct Outreach to Wounded Warriors on SSA Benefits but a Number of Challenges Exist

Outreach to help wounded warriors learn about and apply for disability  benefits under SSA has increased in recent years as a result of both agency  actions at the national level and local initiative taken at major medical  facilities for the wounded. The agencies involved— SSA, DOD, and VA— have taken individual and joint steps to specifically target this population,  tailor information to military needs, and, in effect, re-enforce the message  that wounded warriors may qualify for SSA benefits. At the local level we  found many instances of DOD staff and local SSA representatives working  in concert at DOD treatment facilities to convey this information to the  wounded. However, collaboration between VA and SSA was less prevalent  at VA medical centers. A number of challenges can affect agency efforts to  reach out and assist this population, particularly for those diagnosed with  PTSD and TBI.

		SSA, DOD, and VA Have Developed Programs and Initiatives to Reach Wounded Warriors, Particularly since 2007

SSA, DOD, and VA have taken individual and collaborative steps at the  national level to establish and maintain outreach to wounded warriors  who may qualify for SSA disability benefits.
Since 2007, SSA has increased its outreach efforts to wounded warriors by  initiating contact with DOD and VA medical facilities and tailoring its  information about disability benefits to meet their needs. SSA officials  reported that they had begun to specifically target the wounded warrior  population partly as a result of their participation in a 1-year pilot project  with the U.S. Navy. Conducted from 2006 to 2007, the pilot was designed  to help reduce the time it was taking for information to be disseminated  and decisions to be made on SSA benefits for servicemembers. Following  this project, SSA headquarters directed its field offices to increase their  efforts to work with DOD and VA medical facilities to conduct outreach.  SSA officials reported that their field offices have subsequently been in  contact with wounded warriors or staff at almost 30 DOD facilities and  more than 50 VA facilities across the country. In addition, the agency has  developed publications and established a Web site with SSA disability  benefits information that has been customized for wounded military  personnel and veterans. These resources explain, for example, how  military pay affects eligibility for SSA’s programs and how to apply. (See  fig. 7.) SSA officials told us although SSA does not have any formal  practices in place to determine whether or not outreach has been  effective, there is an internal workgroup—consisting of staff from  headquarters, regional, district, and DDS offices—that meets quarterly to  discuss and share successful local efforts in serving wounded warriors, as  well as best practices for reaching wounded warriors.
DOD has taken a number of steps to help wounded warriors learn about  and apply for SSA disability benefits, particularly since 2007. The  department has incorporated information about SSA benefits into the  many case management programs run by the service branches—programs  already providing a range of advice and assistance to wounded warriors  and their families. We found that these programs—the Army Wounded  Warrior Program, the Warrior Transition Brigade, the Marine Wounded  Warrior Regiment, and the Navy Safe Harbor Program—covered SSA  benefits in their case management review materials or list SSA as a  resource on their Web sites. (See fig. 8 for an example of one of the  assessment tools used in the case management programs to help ensure  SSA disability benefits are discussed.) Additionally, DOD case managers  for these programs received briefings from SSA as part of their training  regimen, according to DOD officials. A DOD official told us the agency has  also included SSA disability programs in the portfolio of information to be  disseminated through its Recovery Coordination Program, which was  included in the comprehensive recovery plan for wounded warriors  developed in response to the National Defense Authorization Act for  Fiscal Year 2008. This recovery plan does not formally spell out how  DOD case managers should conduct outreach on SSA benefits or work  with SSA.
DOD has also added SSA benefit information to a variety of resources  available to wounded warriors—for example, DOD’s Compensation and  Benefits Handbook dedicates a section to the subject. DOD also has Web  sites that contain some information about SSA and it has added links to  SSA’s own wounded warrior Web site. Meanwhile, information about SSA  disability benefits has also been included in joint briefings that DOD, VA,  and other agencies conduct at all DOD bases and military treatment  facilities for servicemembers who are being discharged from the military.
VA has also taken some steps to inform and help wounded warriors apply  for SSA disability benefits. In 2007, the agency, working with DOD,  established the Federal Recovery Coordination Program, which is a  counterpart to DOD’s Recovery Coordination Program, to provide a case  management framework for ensuring that the most severely wounded  warriors are engaged by SSA’s benefit programs, as well as by other  support services. Additionally, VA case managers for the Federal  Recovery Coordination Program have received information from SSA  specialists regarding SSA disability benefits. Meanwhile, staff from other  VA programs in existence prior to 2007, such as the Office of Seamless  Transition, told us they sometimes include the topic of SSA benefits when  case managers interview veterans about their clinical and nonclinical  needs. VA has also included SSA disability information in other resources  that are available to wounded warriors, such as VA’s Federal Benefits for  Veterans and Dependents and VA’s Web site. This Web site also has links  to SSA’s Web site. In addition, the agency’s Veterans Benefits  Administration (VBA), which administers VA disability compensation  benefits, includes on its application forms some limited information about  SSA benefits and SSA contact information. VBA officials told us, however,  that their disability compensation claims representatives do not have any  particular guidance or training for how or whether to refer wounded  warriors to SSA when they apply for VA benefits. According to a VA  official, while VA began a phone outreach campaign in 2006 to OEF/OIF  veterans to remind them about VA’s health and benefit services, this  campaign has not included information about SSA’s programs and  benefits.

			Local Agency Outreach Efforts at Treatment Facilities

Turning to the sites we contacted, we often found that DOD medical  treatment facilities were working with local SSA offices to better inform  wounded warriors about SSA disability benefits and help them apply. This  level of interaction was less common at VA sites. At all of the DOD military  treatment facilities we visited, including the four major facilities that treat  the most severely wounded warriors, SSA representatives were coming  onto the base to conduct briefings and field questions about SSA disability  benefits from wounded warriors and staff. At many of these locations, SSA  representatives had also taken benefit applications. For example, at Walter  Reed Army Medical Center, SSA representatives were holding office hours  twice a week to take applications, and provide regular briefings to  wounded warriors and case managers. At Brooke Army Medical Center,  SSA claims representatives were conducting presentations at weekly  briefings for recovering servicemembers and also taking benefit  applications. Moreover, according to our survey of wounded warriors who  had applied for SSA disability benefits they faced few obstacles to finding  SSA representatives, if and when they did seek help. Based on the survey,  we estimate that almost three quarters—73 percent—of wounded warrior  applicants found it was easy to make initial contact with an SSA  representative. Most of the local SSA staff we spoke with told us that in  recent years they have reached out to local DOD personnel to obtain  access to DOD’s facilities where potentially eligible wounded warriors can  be found. Some of the local SSA offices we spoke with noted that it had  taken some time to establish working relationships at some of the DOD  bases they contacted. For example, they said certain DOD personnel at the  Brooke Army Medical Center had not been routinely cooperative until the  base commander issued an order. In addition, several local SSA officials  told us that staff turnover at DOD facilities creates a challenge. For  example, officials from the Colorado Springs SSA office told us that  because of frequent staff turnover at Evans U.S. Army Hospital (Fort  Carson), new DOD staff are often unaware of SSA benefits and as a result  do not refer servicemembers to SSA who might be eligible for SSA  disability benefits.
In the course of our site visits, we also learned that in serving DOD  facilities and the wounded warrior population, most of the SSA offices we  conducted interviews at had representatives who had developed some  expertise in working with military personnel. Some local SSA officials told  us these representatives know what questions to ask and what documents  to collect to support wounded warriors’ claims. Wounded warriors also  reported that they found SSA officials helpful. Based on our survey, we  estimate that about 63 percent found the information they received from  SSA representatives to be helpful. In one location where SSA did not  employ specialized claims representatives, DOD case managers had  become more familiar with SSA disability benefits and had developed a  customized walk-through presentation to help wounded warriors better  navigate SSA’s application process. See figure 9 for an excerpt from this  presentation.
On the other hand, at the medical centers operated by VA through its  Veterans Health Administration, we found less contact underway between  local SSA and VA staff. According to VA officials at the medical centers we  contacted, none of them had an SSA representative onsite to answer  questions or take applications, though some of the VA officials we spoke  with thought it would be a good idea. Case managers at three of the five  sites we contacted said they refer veterans to a specific point of contact ata local SSA office who may specialize in wounded warrior claims. Officials  at the other two sites did not always have a point of contact at all of the  local SSA offices in the area. Case managers at one of these sites said tha when they refer veterans to SSA without a specific point of contact, the  veterans have challenges navigating SSA’s automated phone system or  reaching a live representative. In addition, case managers at two sites to us that they had received some training from SSA on SSA’s disability  benefits. However, case managers at the other sites told us they had n received training from SSA on SSA disability benefits and believed having such training would be beneficial. Table 1 summarizes the outreach  activities at DOD and VA medical facilities we contacted.
As for the regional VBA offices, officials at the offices we contacted said  their claims staff sometimes refer wounded warriors to SSA when they  apply for VA benefits. For example, officials at one regional office we  contacted said veterans applying for certain types of benefits are also  referred to SSA. However, according to officials at two of the sites we  contacted, they generally do not provide any SSA literature or work with  SSA personnel in local outreach efforts such as VA’s Stand Down event  and its Welcome Home event. When wounded warriors ask about SSA at these outreach events, regional office officials said they will generally  respond by providing SSA’s phone number.

		A Number of Challenges Affect Agencies’ Outreach Efforts to Wounded Warriors, Especially for Those with TBI and PTSD

Agency efforts to help wounded warriors learn about and apply for SSA  disability benefits early in the recovery process can be affected by  challenges, including some servicemembers not being ready to apply and  misinformation that may be passed among wounded warriors. According  to local officials from all three agencies we spoke with, wounded warriors  may not be ready or able to learn about SSA disability benefits early in  their recovery. Some may not have yet accepted the severity of their  injuries, while others have physical or psychological conditions that have  not stabilized. Case managers told us the timing of when they inform  wounded warriors about SSA disability benefits is therefore determined on a case-by-case basis. Based on our survey, we estimate that the timing of  when wounded warriors first learned about SSA disability benefits varied  widely, with 44 percent reporting they first heard about the benefit 12  months or longer after injury (see fig. 10).
It was also suggested by case managers and some recovering  servicemembers that wounded warriors may be hesitant to apply for SSA  benefits because of misinformation about SSA disability benefits given by  their colleagues. Wounded warriors were just as likely to first hear about  SSA disability benefits from their peers as from their anagers, according to our survey estimates (see fig. 11). Moreover, both  m wounded warriors and agency officials told us that the information about  SSA benefits that gets passed among military personnel is not always  accurate. For example, some recovering servicemembers said their peers   DOD or VA case  had told them they would not qualify for SSA disability benefits and others said they had heard that in order to avoid paying retroactive benefits, S SA  initially denies benefits to servicemembers who have been hospitalized for long periods of time.
Another challenge with regard to wounded warriors applying for SSA  disability benefits is reported to be the benefit application itself, which  reflects civilian more than military careers. At some of the sites we  contacted, case managers and wounded warriors themselves said it was  difficult for wounded warriors to complete the employment section of the  application because it does not take into account, for example, the  difference between a civilian 8-hour day and military duty, which requires  a 24-hour obligation. Of all the aspects of the application process we ask about in our survey, wounded warriors most often reported underst the SSA application to be difficult (see fig. 12).  ed  anding  an have  ds.
Finally, outreach efforts face an elusive target at times, given that TBI a PTSD are conditions that are not necessarily diagnosed early and that can develop months or years later. According to some agency officials,  servicemembers who have yet to be diagnosed with TBI and PTSD are not  nd  likely to receive information on all of the services, programs, or benefits to  which they could be entitled. Several agency officials reported they have  challenges in diagnosing TBI and PTSD, because these conditions are  often not as clearly apparent as some other physical disabilities. Wounded  warriors also may not realize they have these conditions and as such, may  not have sought out medical attention. A RAND study reported that 57  percent of wounded warriors who probably have undiagnosed TBI had not  been evaluated by a physician for brain injury.

	SSA Is Expediting Wounded Warrior Claims With Assistance From D and VA, but The Transfer Of D Medical Records Can Prolong Decision- Making

as established a nationwide policy requiring its district offices, the state  SSA has expedited the processing of wounded warrior benefit claims, with  ses in the transfer of DOD  assistance from VA and DOD; however, weaknes medical records to SSA can prolong decision-making for some cases. SSA  h DDS offices, hearing offices, and the Appeals Council to give priority to  wounded warrior claims. For its part, DOD has worked with SSA by  sharing wounded warriors’ key identification information that SSA can use to target their claims for expedited processing. VA has also worked with  SSA to accelerate information sharing to DDS offices. However, wounde warrior claim decisions can still be prolonged in some instances beca of challenges in receiving DOD medical records. DOD medical records are  transferred to SSA as paper documents, a process which can take weeks  or months, according to DDS officials. Although DOD stores some medical records electronically, DOD and SSA have not developed the capacity for  DOD to transfer its records electronically to SSA.

		With Assistance from D and VA, SSA Has Taken Steps to Expedite Wounded Warrior Claims

Since 2005, SSA has identified wounded warrior applicants for the purpose of expediting their claims. SSA attempts to identify wounded, injured, or taken ill during military service since October 1,  2 001, regardless of whether the disabling event occurred domestically or  overseas. In order to give priority to these cases, SSA identifies wounded  warriors in two ways. First, starting in 2005, applicants can self identify  as  a wounded warrior when submitting the disability application. SSA add ed  questions on its disability claims application to enable servicemembers orveterans to identify themselves as having served in the military and to  indicate their dates of service. Secondly, in a 2008 memorandum of  understanding, DOD agreed to send weekly electronic updates to SSA with the key identification information of servicemembers who were wounded,  injured or became ill in the OEF/OIF theaters, to further assure that  military applicants are identified. Any applicant is automatically iden as a wounded warrior if their name appears on the DOD list.
The agency requires that its district offices, DDS offices, and hearing offices give priority to wounded warrior claims. SSA uses a process  originally developed to expedite terminally ill (critical) case a for all wounded warrior disability claims. For such cases, SSA staff who  receive a disability claim request via SSA’s toll free phone number are hin 3   required to schedule an applicant interview at an SSA field office wit working days, if possible, to take the full application. Then the SSA field  office refers the application to a state DDS office for review, and follows  up within 7 days to ensure receipt by the DDS system. DDS staff, in tur n,  are required to prioritize wounded warrior cases, by considering them as  early as possible. Moreover, DDS staff are instructed to comprehensively  consider these cases by exploring all potential physical and mental  impairments, including those that may be suggested by any of the medicalevidence, such as signs of PTSD. Lastly, as with critical cases, SSA staff atthe hearing stage are required to schedule wounded warrior cases in the  first available open hearing slots.
Additionally, SSA and DDS offices track and monitor wounded warrior  cases to ensure that they receive expedited handling. SSA’s regional  offices track these claims through  the different stages of the disability  determination process, including appeals. One SSA regional office, for  example, generates reports listing all wounded warrior cases, including  the level of adjudication for each claim and its status. Also, officials i some DDS offices told us that they generate reports on processing time specifically for wounded warrior cases, such as reports that list the  pending wounded warrior cases, which may include other details of the  claim. Officials in one DDS office stated that they monitor all wounded  warrior cases at specific intervals after they have been received from  SSA—30 days, 45 days, and 90 days—to ensure cases are not unnece delayed.
To support agency processing of wounded warrior cases, SSA officials reported that they have created specific training and briefing materials for  SSA and D DS staff, including information about TBI and PTSD. According  to an SSA official, the agency provided on-site training at local offices a through videoconferences, and instructed staff to be alert to reported  symptoms that may be related to TBI and PTSD. The SSA official told us  that within DDS offices, all disability examiners received some training on  TBI and PTSD. In addition to training, SSA reported that it provides  training materials and guidance for staff to use when handling wounded  warrior cases. For example, SSA issued guidance in August 2007 that cites  indicators of possible TBI conditions, such as exposure to an improv ised  explosive device blast, a motor vehicle accident, or a fall. This policy also specifies clinical markers, such as the loss of consciousness for more than 6 hours following traumatic brain injury. At several DDS offices, DDS staff reported that they received training material from SSA on TBI and PTSD.  Finally, SSA issued guidance and reminders to staff on the proper  treatment of wages for active duty soldiers.
In spite of their wounded warrior training, all of the nine DDS offic contacted reported difficulties, for several reasons, in making  determinations on TBI and PTSD cases. First, though officials at almost all  the DDS offices we spoke with reported that DOD and VA records  generally provide enough information regarding physical disabilities, this  is not necessarily the case regarding psychological problems. The DDS  officials told us that, consequently, they generally need to order more  consultative exams to assess potential cases of TBI or PTSD. Secondly,  some DDS officials also reported that servicemembers sometimes ask  them not to include a diagnosis of TBI or PTSD in their records. According  to officials in two of these DDS offices, servicemembers have either been  reluctant to discuss symptoms of PTSD with DDS staff, or asked DDS staff  not to pursue a mental health disability claim. Finally, because PTSD and  in some cases, TBI, may take several months to manifest, and because  these conditions may improve over time, officials in some DDS offices said  it can be difficult to determine whether they meet the 12-month duration  requirement. To address this challenge, SSA has a specific TBI policy: If a  TBI disability determination is not possible within 3 months of injury, SSA  and DDS staff are required to defer adjudication until at least 3 months  es we  after injury, and may defer again until at least 6 months after injury, in  order to observe and evaluate the claimant’s condition.
Given these challenges, eight of the nine DDS offices we visited had  assigned specific, experienced examiners to process wounded warrior  n  claims. An SSA official stated that those DDS examiners who focus o wounded warrior cases—ranging between three and five specialists at  each of several DDS offices we visited—received more extensive training.
These officials reported employing special techniques for working with wounded warriors. For example, some officials told us they can draw  t  conclusions from pieces of evidence in DOD and VA medical records tha  to  indicate possible PTSD or TBI, and then collect additional information make a determination regarding the presence of those conditions, even if such conditions have not been officially diagnosed. Also, an official in one ,  DDS office reported that she looks at the VA disability evaluation decision when available, for useful information about an applicant’s medical  condition; though officials in that office and several others said VA’s actual  disability decisions do not affect their own determinations. Further,  officials told us they work aggressively to obtain medical records from the VA, DOD, or private medical facilities. Officials in one DDS office said they conduct a special review of any wounded warrior claim that is going to be  denied to ensure that all the evidence was considered appropriately.  Lastly, because wounded warrior claimants may take more time to  respond to information requests, one DDS official typically gives them more time, and will do more to track down their needed information records.
To furthe worked with VA to improve the quality of and speed with which VA  forwards veterans’ medical records to the DDS offices. According to an SSA official, due to DDS concerns about the timeliness and condition VA medical records, SSA and VA began to work together in 1999 to  improve data sharing. A period of pilot testing resulted in the creation of  the Standard Summary, which is an electronic extraction of a standa set of pertinent medical records from a patient’s overall records that is  transmitted electronically to DDS offices upon request. In 2006, VA issued  a directive to formalize use of the Standard Summary by VA medical  facilities. Generally, the Standard Summary includes 2 years of patient  health information and 4 years of major exams and patient discharge  summaries. Specifically, the Standard Summary includes information su e  as the onset dates of all known health problems for a patient, the futur clinic appointments scheduled for a patient with VA providers, and all  outpatient medical visits. (See app. IV for a list of elements included in th r expedite claims processing for wounded warriors, SSA has  e  Standard Summary.) In order to establish usage of the Standard Summa ry,  the appropriate local VA staff are encouraged to work with local DDS staff  to enter an agreement and ensure that their computer systems are  compatible. Individual DDS offices may also work with VA hospitals to  tailor the data extracted by the Standard Summary for their needs.  official told us that, as of June 2009, roughly 75 percent of VA hospitals  nationwide were using the Standard Summary to send information to DDS  offices.

		Delays in Obtaining DOD Records Can Slow SSA’s Eligibility Determinations

Wounded warrior claim decisions are prolonged in some instances  because of difficulties in obtaining DOD medical records, most DDS  officials reported. Generally, DOD military treatment facilities (MTF)  provide paper-based records to DDS offices. Many of the DDS offices we  visited reported lengthy wait times—ranging from a few weeks to a few  months—to receive paper records from MTFs. Corroborating this point,  DOD case managers at several MTFs also reported delays in obtaining  wounded warrior medical records. Several DDS officials we spoke with  said such delays can slow down the disability determination process. DDS  staff in some locations reported that local MTFs had made efforts to  reduce these delays. For example, an official in the Texas DDS office  noted that the Carl R. Darnall Army Medical Center and Brooke Army  Medical Center (the local MTFs) agreed to allow a DDS staffer onsite full  time in the records office to respond to DDS medical record requests. At  several other DDS offices, staff reported that local MTFs responded to  their requests for faster records response by designating a point of contact  to handle all DDS requests, which has improved response time.
Decision making can also be affected by the cumbersome nature of DOD  records. Many DDS staff said DOD records are lengthy, and can number  hundreds, if not thousands, of pages. They also noted that some medical  documents that are referenced in the records are missing when received  by DDS offices, or can sometimes be redundant.
DOD has, in recent years, begun to computerize military medical records  and make them transferable to VA, in part due to a recent statutory  requirement. According to DOD officials, DOD currently stores certain  types of information—such as patient consultations and evaluation  notes—in electronic medical records at 21 MTFs, representing more than  half of DOD’s inpatients. The agency is working toward storing more  records electronically. Furthermore, after a 10 year joint effort, DOD is  transferring some medical records electronically to VA. For example, since  January 2009, DOD and VA have been electronically exchanging drug  allergy information on more than 27,000 shared patients. Ultimately, better  exchange of electronic medical records could allow servicemembers to  transition seamlessly between the two departments with a single,  comprehensive medical record. In part, DOD and VA’s electronic records  exchange is spurred by recent legislation. Congress has mandated that  DOD and VA jointly develop and implement, by September 30, 2009,  electronic health record systems or capabilities that are fully  interoperable and comply with applicable federal interoperability  standards.
By comparison, DOD and SSA’s electronic exchange efforts are far less  developed. An SSA official told us the agency would like to work with  DOD to develop some mechanism for obtaining medical records  electronically. For their part, DOD officials also expressed interest in  working with SSA to resolve the issue of electronic records transfer.  Nevertheless, the agencies have no formal plans to do so. SSA and DOD  have told us that one approach for sharing records electronically could be  through the Nationwide Health Information Network (NHIN), an emerging  new federal technology.  Although SSA, DOD, and VA are all participating  in this technology initiative, the NHIN is still under development in a pilot  testing phase.

	Conclusions

Wounded warriors with severe disabilities, who have made significant  sacrifices in the line of duty, may face challenges in supporting themselves  financially. Disability benefits available through SSA can be a critical part  of the financial assistance they receive. Congress has required that DOD  and VA help wounded warriors gain access to the benefits and services  they need, including SSA disability benefits, and to consult with other  relevant federal agencies in doing so. Outreach to wounded warriors about  SSA benefits has, in fact, been stepped up since 2007, particularly by SSA  and DOD in several key sites where there has been a well-coordinated  message reinforced by each agency. These efforts may well have  contributed to the substantial increase in wounded warrior applications  for SSA disability benefits since 2007. Certainly, significant challenges  remain to reaching those warriors who are currently being discharged, as  evidenced by the numbers who have reported to us difficulties with the  SSA benefit application, or the fact that nearly one in four of those with  approved claims has foregone retroactive benefits because they did not  apply soon enough after their injury. The sooner that SSA completes its  analysis of whether a legislative fix to the retroactive benefits formula is  warranted, the sooner this information can be brought to the Congress for  consideration.
While VA has also taken steps to help wounded warriors who have  become veterans, collaboration between VA and SSA at VA medical  centers has not been consistent. Furthermore, VA does not provide its  claims processing staff with any guidance on referring veterans to SSA  when they apply for veterans’ benefits. Yet the risk of not reaching  wounded warriors is greater once they are discharged and re-enter civilian  life. Absent a commensurate level of outreach on the part of VA and SSA,  it seems likely that some veterans who are, in fact, severely disabled, will  not receive all the financial support to which they are entitled. Of  particular concern are veterans discharged prior to 2007—when the focus  on outreach increased—and those with impairments such as PTSD and  TBI, which may emerge after discharge from the military. While not all  veterans rated as 100 percent disabled by DOD or VA will necessarily be  eligible for SSA benefits, the fact that more than one-third of these  severely disabled veterans have not even applied for SSA disability  benefits suggests there is more to be done in this area.
Finally, SSA policies for accelerating the processing of wounded warrior  applications appear to have had a positive effect. Yet some wounded  warriors will still experience a long wait for an eligibility determination if  their DOD medical records are slow to be transferred. The inability of  DOD and SSA to share records electronically undermines SSA’s ability to  fully expedite the process. Yet SSA and DOD lack a strategy for integrating  their systems to enable such transfers. Fortunately, electronic records  exchange is an issue that has attention across a number of federal  agencies, and current technology initiatives may present models for DOD  and SSA to consider using.

	Recommendations for Executive Action

To improve wounded warriors’ access to SSA disability benefits, we are  making the following recommendations:  1.  The Commissioner of Social Security should move ahead with his  consideration of the need for a legislative proposal to amend the DI  program’s retroactive benefit period for wounded warriors, given the  unique challenges faced by this population in applying for benefits in a  timely manner. 2.  The Secretary of Veterans Affairs and the Commissioner of Social  Security should work together to improve outreach to veterans on SSA  disability benefits. In doing so, the VA and SSA should, in particular,  seek to reach veterans who either were discharged between 2001 and  2007; have disabilities that manifest after service such as PTSD; or  were assigned a 100 percent disability rating. Specific actions that VA  could take include issuing guidance to VA medical centers and regional  offices for referring veterans to SSA and including information about  SSA disability benefits in VA’s phone outreach campaign to OEF/OIF  veterans. In addition, SSA could work with VA to ensure stronger  coordination between local SSA offices and VA medical facilities, for  example by making sure that VA medical centers have a point of  contact at a local SSA office or receive training from SSA staff on SSA  benefits.  3.  The Secretary of Defense and the Commissioner of Social Security  should work together to better meet SSA’s need for obtaining military  medical records in a timely manner for processing DI and SSI  applications from wounded warriors. This effort should consider how  to ensure records that are stored electronically are also electronically  transferable.

	Agency Comments

We provided a draft of this report to the Secretary of Defense, the  Secretary of Veterans Affairs, and the Commissioner of Social Security for  review and comment. In their comments, SSA and VA agreed with our  findings and recommendations and noted actions they plan to take to  address our recommendations.  For example, SSA indicated that it plans to  move ahead with a legislative proposal to amend the disability benefit  retroactive period for wounded warriors, and VA indicated that VBA  officials plan to meet with SSA officials to discuss how the two agencies  can ensure that veterans receive information about SSA disability benefits.   DOD provided no formal comments.  All three agencies also provided  technical comments, which were incorporated as appropriate. SSA’s and  VA’s comments are reproduced in appendices V and VI.
As agreed with your office, unless you publicly announce the content of  this report early, we plan not to further distribute until 30 days from the  report date. We are sending copies of this report to the Secretary of  Defense, the Secretary of Veterans Affairs, the Commissioner of Social  Security, relevant congressional committees, and others who are  interested. We will also provide copies to others on request. The report is  also available at no charge on GAO’s Web site at http://www.gao.gov/.
Please contact me at (202) 512-7215 or bertonid@gao.gov if you or your  staff have any questions about this report. Contact points for the Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors are listed in appendix VII.

Appendix I: Objectives, Scope, and Methodology

We were asked to examine (1) the number of wounded warriors who have  applied and been approved for Social Security Administration (SSA)  disability benefits, and the extent to which wounded warriors who receive  Department of Defense (DOD) or Department of Veterans Affairs (VA)  disability benefits also receive SSA benefits; (2) the extent to which SSA,  DOD, and VA have worked to inform wounded warriors about and help  them apply for SSA disability benefits, and the challenges that confront  this outreach effort; and (3) whether the agencies have taken any steps to  facilitate the processing of wounded warriors’ SSA disability benefit  claims. In addressing these questions, we have focused our research on  wounded warriors who have become wounded, injured, or ill while in  active duty since 2001. More specifically, to answer the questions, we  reviewed policy and other documents from SSA, DOD, and VA and  interviewed officials responsible for outreach or case management  policies at each agency. We also interviewed officials from several  organizations that represent veterans, including Disabled American  Veterans, Paralyzed Veterans of America, Vietnam Veterans of America,  and the United Spinal Association. To learn about agencies’ efforts at the  local level, we interviewed staff—and sometimes recovering  servicemembers—at a number of DOD and VA medical facilities, SSA field  offices, Disability Determination Services (DDS) offices, and VA regional  offices. We obtained and analyzed administrative data from SSA, DOD, and  VA on wounded warriors’ utilization of financial benefits from all three  agencies. Finally, we conducted a mail survey of wounded warriors who  had applied for SSA disability benefits during fiscal year 2008. We  conducted this performance audit from March 2008 through September  2009 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

	Interviews with Local Staff and Recovering Servicemembers

To learn about local efforts by SSA, DOD, and VA to conduct outreach to  wounded warriors and facilitate claims processing, we selected 12 sites  where wounded warriors receive medical care—7 DOD medical treatment  facilities (MTF) and 5 VA medical centers (see fig. 14). We selected these  locations based on several factors. First, we selected the four military  treatment facilities that serve most of the severely wounded  servicemembers: Walter Reed Army Medical Center, National Naval  Medical Center (Bethesda), Naval Medical Center San Diego, and Brooke  Army Medical Center. We also selected two of the four VA polytrauma  centers that serve severely wounded servicemembers and veterans: VA  Palo Alto Health Care System and Hunter Holmes McGuire VA Medical  Center. We then selected additional sites (1) that are in regions of the  country where varying numbers of wounded warriors had SSA disability  benefit claims pending between July 2007 and March 2008, (2) that have  varying numbers of recovering servicemembers in affiliated Army warrior  transition brigades, and (3) that according to SSA have varying levels of  collaboration with local SSA offices.
At the selected locations, we conducted on-site or telephone interviews  with a range of local staff from different agencies. We spoke with DOD and  VA case managers, hospital management staff, VA liaisons, and medical  records personnel about their practices for informing wounded warriors  about SSA benefits, helping them apply, or both. At almost every site we  also contacted the SSA district offices and DDS offices that serve the  medical facility. At the SSA and DDS offices, we spoke with office  managers and other staff, including public affairs staff, claims examiners,  and claims representatives about their practices for informing wounded  warriors about SSA benefits, helping them apply, and processing wounded  warrior claims.
At five of the MTFs we also held discussion groups with recovering  servicemembers to learn about their experiences in hearing about and  applying for SSA disability benefits. We interviewed a total of 45  servicemembers and 1 veteran at these five sites. At each of these sites, we  asked MTF personnel to identify servicemembers who were wounded, ill,  or injured since October 2001 and had applied, or were in the process of  applying, for SSA benefits. See table 2 for the list of offices we contacted.
We also contacted three Veterans Benefits Administration (VBA) regional  offices that administer VA disability compensation benefits—Atlanta,  Georgia; Waco, Texas; and San Diego, California. We selected these  locations based primarily on their proximity to DOD and VA sites we  contacted. At these locations we spoke with VBA public liaisons or  regional office management staff about their practices for informing  discharged veterans about SSA benefits and helping them apply.

	Analysis of Administrative Data

To examine wounded warriors’ utilization of SSA disability benefits, we  obtained and analyzed administrative data from several SSA databases. We  analyzed data from the electronic folder’s Structured Data Repository  (SDR) on wounded warriors’ claims at the initial, reconsideration, and  hearing stages of adjudication, including claimant demographic  information, date of disability onset, date of application, primary  diagnosis, and the decision on the claim. We analyzed data from the  Master Beneficiary Record (MBR) on Disability Insurance (DI) claims that  were denied for technical—nonmedical—reasons, including the  application date and the reason for denial. We analyzed data from the  Supplemental Security Record (SSR) on Supplemental Security Income  (SSI) claims that were denied for technical reasons, again including  application date and reason for denial. Finally, we used data from SSA’s  831 file to analyze the elapsed time from application date to DDS decision  date, both for wounded warriors and for SSA’s overall DI and SSI  caseloads. SSA provided us with data on all applicants who have been  flagged in its systems as wounded warriors. Applicants have been flagged  as wounded warriors when they self-identify (since 2005) or when they  appear on a list of wounded warriors provided weekly by DOD (since  2008). In addition, SSA identified wounded warriors who appear on the  DOD list—which is cumulative and includes those wounded in Operation  Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)—but who  applied prior to 2008, when SSA started using this list to flag applicants. To  assess the reliability of these SSA data, we reviewed agency documents,  interviewed agency officials, and performed electronic testing of certain  data. We found several limitations with the data, including the lack of  complete data on claims at the Appeals Council and federal court stages of  adjudication, and unreliable application date data for claims beyond the  initial stage. However, we found the data we used to be sufficiently  reliable for our reporting objectives.
In addition, to determine the extent to which wounded warriors receiving  DOD or VA disability benefits also receive SSA disability benefits, we  obtained data from DOD and VA and asked SSA to match these data  against its databases. DOD provided us with monthly data from the Retired  Pay File for the period January 2000 to September 2008, on individuals  who were first on the Temporary Disability Retired List (TDRL) or  Permanent Disability Retired List (PDRL) in January 2000 or later. These  data included the individuals’ social security numbers, DOD disability  rating, and monthly benefit amount received. We created a customized file  of DOD data by extracting the data only for those individuals who were on  the TDRL or PDRL in July 2008 and first appeared on the TDRL or PDRL in  November 2001 or later, i.e. who were in active duty in October 2001 or  later. (The Retired Pay File does not include an indicator of whether an  individual is disabled as a result of service in the OEF/OIF campaigns.) VA  provided us with data from its VETSNET system on veterans receiving VA  disability compensation benefits as of July 2008, who were identified in  VETSNET as being OEF/OIF veterans. OEF/OIF veterans are identified by  VA in two ways: (1) through a regular match of VA data with a Defense  Manpower Data Center (DMDC) file containing the social security  numbers of OEF/OIF veterans, and (2) by VA staff when they take  disability benefit applications from veterans. The data file provided by VA  included veterans’ social security number, disability ratings, and benefit  amounts received in July 2008. We then asked SSA to match the social  security numbers contained in the DOD and VA files against its MBR and  SSR databases, to determine whether these individuals had ever applied  for SSA disability benefits and if they were receiving SSA benefits in July  2008. To assess the reliability of the VA and DOD data, we interviewed  agency officials, reviewed agency documents, and performed electronic  testing of certain data. We found several limitations with the data,  including the fact that those identified as OEF/OIF veterans in VA’s data  may not include all veterans who served since 2001 and are receiving VA  disability compensation benefits. However, we found the data we used to  be sufficiently reliable for our reporting objectives.

	Survey of Wounded Warriors

To learn about the experiences and opinions of wounded warriors who  have applied for SSA disability benefits, we conducted a survey of a  random sample of wounded warriors who had applied for SSA disability  benefits during fiscal year 2008. We conducted this mail survey from  December 2008 to March 2009. The survey included questions on topics  such as how wounded warriors learned about SSA disability benefits,  when they learned about SSA benefits, and what challenges, if any, they  faced in completing the SSA application.

		Developing the Survey Sample

To identify our sample of wounded warriors, we used SSA’s SDR, MBR,  and SSR databases, which contain data on SSA applicants who have been  identified as wounded warriors. We drew a random sample of 350  wounded warriors out of a total universe of 10,438 wounded warriors who  SSA’s databases indicated had applied for disability benefits in fiscal year  2008. We considered respondents to be in scope for our survey if they had  applied for disability benefits in fiscal year 2008 and had not separated  from the military prior to 2001.

		Confidence Intervals in Survey Response and Nonresponse Bias Analysis

Survey results based on probability samples are subject to sampling error.  The sample is only one of a large number of samples we might have drawn  from the respective population. Because each sample could have provided  different estimates, we express our confidence in the precision of our two  particular samples’ results as 95 percent confidence intervals. These are  intervals that would contain the actual population values for 95 percent of  the samples we could have drawn. As a result, we are 95 percent confident  that each of the confidence intervals in this report will include the true  values in the respective study populations. Unless otherwise noted, the  margin of error for percentage estimates from this survey is plus or minus  8 percentage points or less at the 95 percent level of confidence.
The overall response rate for our survey was 53 percent. To assess the  potential for bias in our estimates, we used SSA administrative data to  examine differences between the respondents and nonrespondents to our  survey. Our analysis showed that respondents to our survey were typically  older and more educated than individuals in our sample who did not  respond to the survey; these differences were significant at the 95 percent  confidence level. In light of these results, we conducted three separate  sets of tests to compare individuals in different age and education  categories. The first set of tests examined demographic and usage  variables from the survey—that is, whether or not wounded warrior had  received information or application assistance, or had taken certain steps  in the course of completing the SSA disability application. The second set  of tests examined wounded warriors’ opinions about sources of  information or assistance and steps taken in the course of applying for  benefits. The third set of tests examined item nonresponse for each item in  the survey. Only two of the initial differences we observed persisted after  adjusting for multiple comparisons. First, we found that older  respondents were more likely to have served in the Reserves or National  Guard than their younger counterparts. However, we did not find any  significant differences in demographics, usage of specific resources,  opinions, or item nonresponse between respondents that served in the  Reserves or National Guard and those that did not. Second, we found that  college-educated individuals were more likely than those without a college  degree to have found information from VA personnel helpful—of  individuals with an opinion, 100 percent of college educated individuals  found VA personnel to be very or somewhat helpful, compared to 76  percent of those without a college degree.
Our failure to detect systematic differences does not guarantee that our  results are free from potential nonresponse bias; as with any survey, to the  extent respondents differ from nonrespondents in undetected ways, our  results should be interpreted with caution. However, with the exception of  the two items noted above, we were unable to detect large or systematic  differences in the reported experiences and opinions of individuals in  different age or education categories, and believe it is not misleading to  generalize the results to the population of wounded warrior SSA disability  applicants in fiscal year 2008.

		Efforts to Minimize Nonsampling Errors

The practical difficulties of conducting any survey may also introduce  other types of errors, commonly referred to as nonsampling errors. For  example, difficulties in how a particular question is interpreted, in the  sources of information that are available to respondents, or in how the  data were entered into a database or were analyzed can introduce  unwanted variability into the survey results. With this survey, we took  steps to minimize these nonsampling errors. For example, GAO staff with  subject matter expertise designed the questionnaires in collaboration with  GAO survey specialists. Then the draft questionnaires were pretested with  wounded warriors to ensure that the questions were relevant and clearly  stated—with the purpose of reducing nonsampling error. When the data  were analyzed, a second, independent GAO analyst independently verified  all analysis.

		Efforts to Increase Response Rate for Survey of Wounded Warriors

We took several steps to enhance our response rate. We resent the survey  to nonrespondents after about 5 weeks, and conducted follow-up phone  calls to nonrespondents encouraging them to complete the survey, with  the option to complete the survey over the phone with GAO staff, after  about 7 weeks. If in the course of our phone calling we learned a correct  address, we sent another copy of the survey to the current address. These  comprehensive nonrespondent follow-up efforts, as well as our  nonresponse bias analysis, give us confidence that our overall survey  results can be generalized to the population of wounded warriors applying  for SSA disability benefits in fiscal year 2008.

	Important Outreach Practices

We used a set of six important outreach practices as criteria for assessing  the three agencies’ outreach to wounded warriors regarding SSA disability  benefits:    outlining of strategic goals for the campaign and determination of a  identification and researching of the target audience to understand some  of its key characteristics, such as size of the population, ethnic and racial  composition, linguistic groups, geographic location, and awareness or  knowledge of the outreach subject;    establishment of strategic partnerships with other entities that are  stakeholders in the issue to get help with planning and implementing the  outreach campaign; targeting of the outreach message with audience specific, culturally  sensitive content and use of mediums and languages that are the most  appropriate for the audience;   reinforcement of the message with repetition and different mediums,  especially when targeting people who may be challenging to serve; and   development and implementation of measures for evaluating the  effectiveness of the outreach campaign.
We identified these practices through a review of prior GAO and external  reports that addressed outreach campaigns primarily for social and  employment programs. We also contacted several external organizations  that have some expertise in outreach for social programs to obtain their  feedback on the identified practices. Comments were received from the  National Association of Social Workers and the National League of Cities,  and these comments were incorporated into our final set of practices.

Appendix II: Summary of Major Disability Benefit Programs Available to Wounded Warriors

	DI: Replace lost income for workers under age 65 who have paid into Social Security but can no longer work because of a disability.

Disability compensation.  Compensate veterans for average  reduction in earnings capacity due to  their disabilities.
Disability retirement. Provide  financial support to servicemembers  whose disabling conditions render  them unable to perform their military  duties.
SSI: Provide cash payments assuring  a minimum income for aged, blind, or  disabled individuals who have very  limited income and assets.
DI and SSI (adult disability).  Applicant is unable to perform  substantial gainful activity due to  condition, which is expected to last at  least a year or to result in death.
Applicant must be a veteran with a  diagnosis of an injury or disease that  is found to be disabling. Also, there  must be evidence of an in-service  occurrence or aggravation of the  injury or disease.
Servicemembers must have a  permanent disability that renders  them unfit to perform their military  duties. Also, the injury must be  connected to service in the military.
DI. Must have worked a minimum  amount of time in employment  covered by Social Security.
SSI. Total earned and unearned  countable income must be below the  federal benefit rate. First $20 of  unearned income and various types  of public assistance are not counted.  Also, must have less than $2,000 in  countable resources for an individual.
Individuals are deemed disabled or  not disabled. No percentage ratings  or partial disability determinations.
Claimant is assigned a rating for  each service-connected disability  based on the VA’s Schedule for  Rating Disabilities (VASRD). Ratings  range from 0 to 100 percent.
Servicemembers are assigned a  rating for each unfitting condition  based on the VASRD, with ratings  ranging from 0 to 100 percent.
Individual unemployability (IU)  benefits provide certain veterans with  compensation at the 100-percent  level if their disabilities prevent them  from working, even though their  disability was rated below 100  percent under the VASRD.
If the disabilities are deemed  noncompensable, because they were  not in the line of duty,  servicemembers are separated  without benefits. If servicemembers  receive a disability rating of less than  30 percent, they receive a lump sum  payment upon separation. (If  servicemembers have 20 or more  years of service and a disability  rating below 30 percent, they could  still be eligible for disability  retirement.) If servicemembers have  a disability rating of 30 percent or  greater, they will be separated from  the military and receive monthly cash  benefit payments (PDRL) unless  conditions are not stable, whereas  the servicemembers are placed on  TDRL.
DI. Based on past average monthly  earnings.
SSI. Basic monthly payment is the  same for all beneficiaries. This basic  amount is reduced when beneficiary  receives certain types of earned and  unearned income.
If the veteran is found to have one or  more service-connected disabilities  with a combined rating of at least 10  percent, VA will pay monthly  compensation. The benefits range by  rating, with a higher rating resulting in  greater compensation. Veterans with  severe disabilities may be entitled to  special monthly compensation, which  provides payments greater than the  compensation payable under the  VASRD for the disability.
If the unfitting disabilities are  determined to be service-connected,  DOD takes into account the years of  service and the disability rating  percentage.
One of about 1,300 SSA field offices  assesses a claimant’s nonmedical  eligibility. If the claimant meets these  criteria, a state DDS office evaluates  the claimant’s medical eligibility.  Claimants may appeal an initial DDS  decision back to the DDS, then to an  administrative law judge (ALJ), the  SSA appeals council, and ultimately  the federal court.
One of VA’s 57 regional offices  assesses eligibility and assists in  obtaining relevant evidence to  substantiate the claim. Such  evidence includes veterans’ military  service records (including medical  records), medical examinations, and  treatment records from VA medical  facilities and private medical service  providers. Claimants may appeal an  initial VA decision to the Board of  Veterans’ Appeals, then, ultimately,  to different levels of federal courts.
The servicemember goes through a  medical evaluation board (MEB)  proceeding, where medical evidence  is evaluated, and potentially unfit  conditions are identified. The  member then goes through an  informal physical evaluation board  (PEB) process, where a  determination of fitness or unfitness  for duty is made and, if found unfit for  duty, a combined percentage rating  is assigned for all unfit conditions and  the servicemember is discharged  from duty. If servicemembers  disagree with the informal PEB’s  findings and recommendations, they  can, under certain conditions, appeal  to the formal PEB’s reviewing  authority The services differ in how  many opportunities they offer  servicemembers to appeal.

Appendix III: Complete Results of Wounded Warrior Survey

Below are the questions on our survey of wounded warriors, followed by  the breakdown of answers we received. We received a total of 182  responses from wounded warriors. All answers are generalizable to the  overall population of wounded warriors who applied for SSA disability  benefits during fiscal year 2008, with a margin of error of plus or minus 8  percent or less, except questions 6g and 7f. A nonresponse bias analysis  revealed that older and college educated individuals were more likely to  respond to our survey than their younger and less-educated colleagues,  but did not reveal systematic differences in wounded warriors’ overall  experiences and opinions in applying for SSA benefits. For a complete  description of our survey methods and nonresponse bias analysis, see  appendix I.

	Section 1: Information about your military service

1.  In what branch of the military do/did you serve? 2.  Are you now or were you at any point a National Guard or Reserve  member?
3.  As of today, have you separated from military service?
If so, in what year did you separate from military service?

	Section 2: How you learned about SSA benefits

4.  After you were wounded, injured, or became ill, how did you first learn  about Social Security disability benefits? (Check only one answer)
Another servicemember or separated  servicemember  DOD medical center or DOD personnel (for  example, nurse case manager, social worker,  AW2 Advocate, WTU or WWR squad leader)
VA medical center or other VA personnel (for  example, nurse case manager, social worker,  benefits counselor)
5.  How long after you were wounded, injured, or became ill did you first  learn about Social Security disability benefits? (Check one answer)
6.  After you first learned about Social Security disability benefits, how  helpful, if at all, was any of the additional information you may have  received about Social Security disability benefits from any of the  following sources? (Check one answer in each row. If you did not  receive any information from a source, check the first column.)
Did not  receive  information  from this  source  6b. Another  servicemember(s)  or separated  servicemember(s) 6c. Family  member(s)  6d. Social  Security  Administration  representative (s) 6e. DOD medical  center or other  DOD personnel  (for example,  nurse case  manager, social  worker, AW2  Advocate, WTU  or WWR squad  leader)  6f. VA medical  center or other  VA personnel (for  example, nurse  case manager,  social worker,  benefits  counselor)  6g. Someone  else (please  specify)

	Section 3: Your experience completing the application for SSA benefits

7.  How helpful, if at all, was any of the assistance you may have received  from any of the following people in helping you complete your Social  Security disability benefits application? (Check one answer in each  row. If you did not receive any assistance from a person, check the  first column.)
Number of  wounded  warrior  respondents  7a. Another  servicemember(s)  or separated  servicemember(s) 7b. Family  member(s)  7c. Social  Security  Administration  representative  7d. DOD medical  center or other  DOD personnel  (for example,  nurse case  manager, social  worker, AW2  Advocate, WTU  or WWR squad  leader)  7e. VA medical  center or other  VA personnel (for  example, nurse  case manager,  social worker,  benefits  counselor)  7f. Someone else  (please specify)
8.  How long after you were wounded, injured, or became ill did you first  apply for Social Security benefits?
9.  When completing the Social Security disability benefits application,  how easy or difficult were the following? (Check one answer in each  row. If you did not do this, check the first column.)
10. Were you aware that if an application for Social Security disability  benefits is denied, the decision can be appealed?

Appendix IV: VA Standard Summary

We have reproduced the Standard Summary template as it appears in VA’s  2006 directive, Veterans Health Administration Directive 2006-024, to  formalize use of the Standard Summary. The VA SSA-DDS Standard  Summary is an electronic extraction of a standardized set of pertinent  medical records from a patient’s overall VA records.

Appendix V: Comments from the Social Security Administration

Appendix VI: Comments from the Department of Veterans Affairs

Appendix VII: GAO Contact and Staff Acknowledgments

	Staff Acknowledgments

In addition to the contact named above, Brett Fallavollita, Lorin Obler,  David Forgosh, Rebecca Makar, and Joy Myers made major contributions  to this report; Bonnie Anderson, Rebecca Beale, Elizabeth Curda, Patricia  Owens, and Kelly Shaw provided guidance; Stuart Kaufman, Anna Maria  Ortiz, Minette Richardson, Beverly Ross, Vanessa Taylor, and Walter  Vance provided methodological support; Susan Bernstein helped draft the  report; Jessica Botsford and Daniel Schwimer provided legal advice; and  Matthew Goldstein provided research assistance.

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Military Disability Retirement: Closer Monitoring Would Improve the  Temporary Retirement Process. GAO-09-289. Washington, D.C.: April 13,  2009.
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Summary:
Why GAO Did This Study

Disability benefits available through the Social Security Administration (SSA) can be an important source of financial support for some wounded warriors, and Congress has mandated that the Departments of Defense (DOD) and Veterans Affairs (VA) help them learn about and apply for such benefits. GAO was asked to determine: (1) how many wounded warriors have applied and been approved for SSA benefits and the extent to which they are receiving benefits from across the three agencies; (2) what steps DOD, VA, and SSA have taken to inform wounded warriors about SSA benefits, and the challenges that confront this process; and (3) steps taken by all three agencies to facilitate the processing of wounded warrior disability claims. Focusing on those wounded since 2001, GAO reviewed policy documents, contacted DOD and VA medical facilities, surveyed wounded warriors, and analyzed administrative data.

What GAO Found

As of December 2008, about 7,600 of the16,000 wounded warriors who have applied for SSA disability benefits since 2001 have been approved. The majority filed their applications since 2007. Also, a sizable minority of approved claimants filed long enough after injury that they lost some retroactive benefits; SSA is considering a legislative proposal to change the retroactive period for wounded warriors. Among wounded warriors receiving DOD or VA disability benefits, 4 percent were receiving SSA benefits. In addition, more than 6 percent had applied but were not receiving SSA benefits; some still had claims pending. Those with higher disability ratings from DOD or VA were more likely to receive SSA benefits. To varying degrees, SSA, DOD, and VA have increased outreach to help wounded warriors learn about and apply for SSA disability benefits. Since 2007, SSA has increased its outreach to DOD and VA medical facilities and has tailored benefit information for wounded warriors. DOD--and to some extent VA--have incorporated SSA information into their case management practices as well. Locally, DOD and SSA staff have worked together to reach servicemembers, but collaboration has been less common at VA hospitals. Meanwhile, there are challenges to reaching and working with this population. Many of the wounded warriors may not be ready or able to hear about SSA benefits early in their recovery. Also, brain injuries and mental health disorders can impede many wounded warriors' ability to absorb outreach information and complete the benefit application. With help from DOD and VA, SSA has been able to expedite processing of wounded warrior claims. SSA has established a nationwide policy requiring its offices to give priority to wounded warrior claims. For their part, DOD helps SSA identify claimants who are wounded warriors, and VA has expedited the transfer of its medical records and histories to SSA. However, DOD's paper-based transfer of medical records to SSA is slow, which can prolong the process by weeks or months, according to claims processing staff.