Social Security Disability Programs: SSA Could Take Steps to Improve Its Assessment of Continued Eligibility
Released: 2014-04-09T00:00:00

Letter

Background

SSA administers two disability programs that provide monthly cash benefits to eligible individuals: DI, enacted in 1956, and SSI, enacted in 1972. DI provides monthly cash benefits to eligible workers unable to work because of a long-term disability and who have paid into the Social Security Trust Fund, whereas SSI provides monthly cash benefits to people with disabilities on the basis of need, regardless of whether they have paid into the Social Security Trust Fund. In order to be eligible for DI or SSI benefits based on a disability, an individual must meet the definition of disability for these programs—that is, they must have a medically determinable physical or mental impairment that (1) prevents the individual from engaging in any substantial gainful activity and (2) has lasted or is expected to last at least 1 year or result in death.

The disability determination process is the same for DI and SSI applicants. An SSA field office determines that an applicant has met SSA’s nonmedical eligibility requirements for disability benefits, and then the applicant’s claim is sent to the state DDS for an initial review of the claimant’s medical eligibility. After assembling all medical and vocational information for the claim, a DDS examiner, in consultation with appropriate medical staff, determines whether the claimant meets the requirements of the law for having a disability. Claimants who are dissatisfied with the initial DDS determination may choose to pursue several levels of appeal, including: a “reconsideration” of the claim, conducted by DDS personnel who were not involved in the original decision; a hearing before an administrative law judge (ALJ); and a review of the claim by the Appeals Council, which is comprised of administrative appeals judges and appeals officers. Final SSA decisions are also subject to review in federal district court.

If SSA determines that an individual is disabled, the agency is required to conduct periodic CDRs to ensure that only recipients who remain disabled continue to receive benefits. These reviews assess whether individuals are still eligible for benefits based on several criteria, including their current medical condition and ability to work. DDS staff generally establish the timeframe for when SSA should conduct a CDR on the basis of the expected likelihood of a recipient’s medical improvement. However, SSA also uses a profiling model to score and prioritize CDRs if funding is not available to conduct all scheduled CDRs.

In response to prior concerns that some recipients were being arbitrarily removed from the disability programs via the CDR process, Congress passed the Social Security Disability Benefits Reform Act of 1984, which, among other things, established a medical improvement standard. Under this standard, SSA may only discontinue benefits for an individual if it finds substantial evidence demonstrating both that a beneficiary’s medical condition has improved and that the individual is able to engage in substantial gainful activity. If SSA determines that these conditions have not been met in the course of conducting a CDR, the recipient may continue to receive benefits until the individual receives a subsequent CDR (which potentially could result in a discontinuation of benefits), dies, or transitions to Social Security retirement benefits.

SSA Has a Backlog of More Than 1 Million DI and SSI Benefit Eligibility Reviews

SSA reported in January 2014 that it is behind schedule in assessing the continued eligibility of DI and SSI recipients and has accumulated a backlog of 1.3 million CDRs. In recent years, SSA has cited resource limitations and a greater emphasis on processing initial claims and requests for hearings appeals as reasons for the decrease in the number of CDRs conducted. From fiscal years 2000 to 2011, the number of adult CDRs fell from more than 580,000 to about 180,000 (69 percent) and the number of childhood CDRs fell from more than 150,000 to about 45,000 (70 percent), according to our analysis of SSA data (see fig. 1). More specifically, CDRs for children under age 18 with mental impairments—a group that comprises a growing majority of all child SSI recipients—declined from more than 84,000 to about 16,000 (an 80 percent decrease).

Children make up about one fifth of all SSI recipients, and we reported in 2012 that a large proportion of their CDRs were overdue. For example, CDRs for about one half of all child recipients with mental impairments (435,000) were overdue, according to our analysis of SSA data in 2012. Of these recipients, about 344,000 (79 percent) had exceeded the scheduled date by at least a year, with about 205,000 (47 percent) exceeding their date by 3 years, and about 24,000 (6 percent) exceeding the scheduled date by 6 years. We also identified several cases which exceeded their scheduled date by 13 years or more. Of the 24,000 childhood CDRs pending 6 years or more, we found that about 70 percent (over 17,000) were for children who had been categorized as “medical improvement possible” at initial determination, while 25 percent (over 6,000) of these pending CDRs were for those children deemed medically expected to improve within 6 to 18 months of their initial determination (see fig. 2). Of these cases, we identified nine recipients who were expected to medically improve, but whose CDR had been pending for 13 years or more. Reviews of children who are expected to medically improve are more productive than reviews of children who are not expected to medically improve because they have a greater likelihood of benefit cessation and thus yield higher cost savings over time.

When CDRs are not conducted as scheduled, the potential for improper payments may increase as some recipients can receive benefits for which they are no longer eligible. In September 2011, SSA’s Office of the Inspector General estimated that SSA had paid about $1.4 billion in SSI benefits to approximately 513,000 recipients under age 18 who should have not received them—some of whom were pending reviews for 5 or more years. The Inspector General estimated that SSA will continue to make improper payments of approximately $461.6 million annually until these reviews are completed. Furthermore, in its May 2012 CDR report, SSA estimated a program savings of $9.30 for every $1 invested in conducting CDRs and projected that those CDRs conducted for adult DI and SSI recipients and for child SSI recipients combined in fiscal year 2010 would have saved federal programs the present value of estimated lifetime benefits of $3.5 billion.

For several reasons, SSA has placed a higher priority on conducting CDRs for DI recipients, although children’s SSI benefits are more likely to be ceased after review. According to SSA officials, when CDR funding is less than what is needed to conduct all CDRs at the scheduled intervals, the agency has historically given priority to performing reviews considered to be the most cost-effective, as well as staying current with DI CDRs and performing two specific statutorily required SSI reviews. SSA officials told us that it is more cost effective to conduct adult DI CDRs than childhood SSI CDRs, because ceasing benefits for a young adult DI recipient may potentially represent decades of saved benefits. For SSI, statutorily required age 18 redeterminations are cost effective for the same reason. Additionally, because DI benefit payments are, on average, almost twice as much as SSI childhood payments, CDRs of adult DI cases generally produce greater lifetime savings, according to SSA officials. However, SSA reported that it ceased about 12 percent of all adult DI claims that received a CDR. In comparison, our analysis of SSA’s data showed that 32 percent of child SSI claims that received a CDR were ceased in fiscal year 2011. For example, of those childhood CDRs conducted for children under age 18 with mental impairments, SSA ceased benefits for about 28 percent on average in fiscal year 2011, with personality disorders and speech and language delay having the highest cessation rates, 39 and 38 percent, respectively. Despite these high cessation rates, SSA and state DDS officials have acknowledged that the agency has not conducted reviews for child recipients in a timely manner, and in some cases, they have not conducted childhood CDRs prior to a child’s age 18 redetermination.

In our 2012 report, we recommended that SSA eliminate the existing CDR backlog of cases for children with impairments who are likely to improve and, on an ongoing basis, conduct CDRs at least every 3 years for all children with impairments who are likely to improve, as resources are made available for these purposes. SSA generally agreed that it should complete more CDRs for SSI children but emphasized that it is constrained by limited funding and competing DI and SSI workloads. Moving forward, one of the major objectives in SSA’s Fiscal Year 2013- 2016 Strategic Plan is to “increase efforts to accurately pay benefits,” and the Plan indicates that SSA intends to conduct more CDRs, as funding is available. In addition, as part of the President’s fiscal year 2014 budget request, SSA asked for $1.227 billion to create a new Program Integrity Administrative Expenses account that the agency says would establish a more reliable stream of mandatory program integrity funding. While additional funding may help address the CDR backlog, we continue to have concerns about the agency’s ability to manage limited funds in a manner that adequately balances its public service priorities with its stewardship responsibility. Because SSA has noted that it considers SSI childhood CDRs to be a lower priority than other CDRs, it is unclear whether the agency will use new increases in funding to review children most likely to medically improve—reviews that could yield a high return on investment.

Several Factors Associated with the Medical Improvement Standard Have Challenged the Assessment of Recipients’ Continued Eligibility

During CDRs, disability recipients that SSA determines have improved medically may cease receiving benefits; however, several factors may hinder SSA’s ability to make this determination. In 2006, our analysis of SSA data showed that 1.4 percent of all the people who left DI and SSI between fiscal years 1999 and 2005 did so because SSA found that they had improved medically; however, more recipients left for other reasons, including conversion to regular Social Security retirement benefits or death. At that time, we identified a number of factors that challenged SSA’s ability to assess DI and SSI recipients using the medical improvement standard.

Guidance limitations—Limitations in the SSA guidance then in effect for applying the medical improvement standard may have resulted in inconsistent disability decisions. Specifically, in 2006, SSA guidance on CDRs instructed examiners to disregard “minor” changes in a recipient’s condition without defining what constituted a minor change.

In addition, when assessing whether improvements in recipients’ medical conditions were related to their ability to work, the SSA guidance instructed examiners to ensure a “reasonable relationship” between the amount of improvement and the increase in the ability to perform basic work activities. However, at that time, the guidance did not require a specific amount of increase in functioning to better guide examiners in their decision making.

Inadequate documentation—If a prior disability determination was inadequately documented, it can be challenging for the disability examiner to demonstrate medical improvement in a CDR. Because the prior decision is the starting point for conducting a CDR and examiners are required to find evidence of medical improvement since that last decision in order to cease benefits, inadequate documentation of evidence in prior decisions may make it difficult to assess medical improvement. In our 2006 survey, some DDS directors commented that cases decided on appeal were the most likely to lack adequate documentation. Several officials reported that guidance in effect at that time instructed ALJs to include enough information to make their decisions legally sufficient, but there was no specific instruction to include all of the evidence that would be needed to assess medical improvement as part of a future CDR.

Presumed disability—According to our 2006 survey, a majority of DDSs incorrectly presumed that a recipient had a disability when the CDR was being conducted, which may have made it more difficult for examiners to determine if a recipient had improved medically. We reported that this practice is contrary to the law as well as SSA regulations and policy, which require that CDR decisions be made on a “neutral basis.”

Reliance on judgment—The judgmental nature of the process for assessing medical improvement likely hinders its reliability. For example, one examiner may determine that a recipient has improved medically and discontinue benefits, while another examiner may determine that medical improvement has not been shown and will continue the individual’s benefits. Furthermore, we previously found that the amount of judgment involved in the decision-making process increases when the process involves certain types of impairments, such as psychological impairments, which are more difficult to assess than other impairments, such as physical impairments.

These issues have implications for the consistency and fairness of SSA’s medical improvement decision-making process, and in 2006, we recommended that SSA clarify policies for assessing medical improvement. Since then, SSA has taken some steps that may help address the issues we raised but has not fully implemented the actions we recommended. In 2009, SSA began implementing an electronic claims analysis tool for use during initial disability determinations to (a) document a disability adjudicator’s detailed analysis and rationale for either allowing or denying a claim, and (b) ensure that all relevant SSA policies are considered during the disability adjudication process. In addition, SSA reported in February 2013 that it was developing a tool to help hearing offices standardize and document the hearing decision process and outcome. However, SSA’s guidance for assessing medical improvement may continue to present challenges when applying the standard. As of April 2014, the guidance does not provide any specific measures for what constitutes a “minor” change in medical improvement, and it instructs examiners to exercise judgment in deciding how much of a change justifies an increase in the ability to work.

Chairman Lankford, Ranking Member Speier, and Members of the Subcommittee, this completes my prepared statement. I would be pleased to respond to any questions that you may have at this time.

Contacts and Acknowledgments

If you or your staff have any questions about this testimony, please contact me at (202) 512-7215. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. GAO staff who made key contributions to this testimony include James Bennett, Holly Dye, Rachel Frisk, Isabella Johnson, Kristen Jones, Sheila McCoy, and Walter Vance.

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