Social Security Disability: Additional Outreach and Collaboration on Sharing Medical Records Would Improve Wounded Warrior's Access to Benefits
Released: 2009-10-15T00:00:00

Letter

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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