The SSA’s Continuing Disability Review (CDR) – a Primer
SSA determines eligibility for disability benefits via medical record review & other processes. Here is an outline of SSA’s continuing disability review.
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The SSA (Social Security Administration) periodically reviews the case of every one receiving SSDI (Social Security Disability Insurance) or SSI (Supplemental Security Income) disability benefits, via a continuing disability review (CDR). This type of review is intended to verify whether the claimant is still disabled and unable to work. If the SSA determines through a medical record review and other investigations that the claimant’s medical condition has improved sufficiently that he/she can work, the claimant’s social security benefits will end. CDRs are of two types: Work Review and Medical Review. During a Work Review, if the SSA finds out if the beneficiary is earning more than substantial gainful activity or SGA, their benefits may be terminated. For 2019, the monthly SGA amount for statutorily blind persons is $2,040. For non-blind people, it is $1,220. SGA for the blind does not apply to SSI benefits, whereas SGA for non-blind disabled applies to both SSDI and SSI benefits. In a medical review, the SSA would focus on identifying whether an individual meets the medical requirements to collect disability benefits. Under the MIRS (Medical Improvement Review Standard), SSDI benefits cannot be stopped due to updates in SSA disability. The reviewers are barred from substituting their own judgment for that of the original adjudicator. A disabled beneficiary needn’t undergo a medical CDR based on work activity alone if they have received disability benefits for at least 24 months, or are participating in the SSA’s Ticket to Work Program. In case a beneficiary qualifies for protection from a medical CDR based on work activity, he/she will still undergo a regularly scheduled medical CDR. Here are some other important things to know about CDRs. •
Benefits could be terminated if the claimant fails to respond. Since there is a huge backlog of CDRs, the beneficiary may receive a disability update report questionnaire instead of a notice to undergo a full medical review.
The
questionnaire is a report on whether the beneficiary’s health status has improved as well as recent medical care, employment, or training activity. If improvement or work activity is reported, it could prompt a full medical review. If the beneficiary fails to complete and return the questionnaire also, a full medical review may be asked for. In case the beneficiary doesn’t report any work activity or improvement, a full medical review is postponed. •
The frequency of medical CDRs depends on the severity of the beneficiary’s condition. The SSA assigns review schedules ranging from every 6 months to every 7 years based on the likelihood that the beneficiary may experience medical
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improvement. If the medical improvement is “Expected,” the case will be reviewed typically within 6 to 18 months after the benefits start. If the medical improvement is “Possible,” the case will be reviewed no sooner than 3 years, and if medical improvement is “Not Expected,” the case will be reviewed no sooner than 5 to 7 years. •
The SSA can terminate benefits if the beneficiary: o
Is engaging in substantial gainful activity.
o
Cannot be located or fail without good reason to cooperate in a continuing disability review.
o
Had obtained the prior determination fraudulently.
o
Does not follow the prescribed medical treatment that would be expected to restore work capacity.
•
The SSA cannot terminate benefits unless they find solid evidence of medical improvement that enables the beneficiary to engage in substantial gainful activity. If the claimant’s health has not improved, or his/her disability prevents them from working, the SSA will not take any action. The SSA must make at least one of the following findings to terminate benefits. o
The beneficiary has improved medically and is able to engage in substantial gainful activity.
o
Based on improved diagnostic methods, the beneficiary’s disability is found to be not as disabling as considered earlier, and he/she is able to perform substantial gainful activity.
o
The
beneficiary
has
benefitted
from
advanced
medical/vocational
therapy/technology and can now perform SGA. o
The earlier finding was wrong. This can be proved by evidence on the record or newly obtained evidence related to that finding.
•
The beneficiary can appeal a CDR decision. The appeal can be made within 60 days of the SSA determining the claimant is no longer disabled and discontinues benefits. They have to complete a Request for Reconsideration form SSA-789-U4 from the local Social Security field office; the form is also available online at the SSA website. They can have a face-to-face hearing with a disability hearing officer who will make the decision on the appeal.
•
The beneficiary may be able to continue to receive benefits, including Medicare, even if he/she is not longer considered medically eligible. This is possible if he/she participates in an approved vocational rehabilitation program (public or private)
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before their eligibility ended, and the SSA determines that the above mentioned program will increase his/her permanent independence and self-sufficiency. •
The beneficiary can request provisional benefits during the appeals process. The SSA may provide up to 6 months of provisional benefits including Medicare, while the case is being reviewed. Beneficiaries do not have to repay provisional benefits even if the appeal is denied. If the benefits are to continue during the appeals process, the Request for Reconsideration must be submitted within 10 days of receiving the denial. It must include a specific request to continue benefits during the appeal.
•
The beneficiary can restart benefits if he/she becomes ineligible under a work review. This is possible if the beneficiary becomes unable to work and earn SGA because of the same or some related medical condition, and he/she files the request for reinstatement of benefits with the SSA within 60 months from the month his/her benefits are terminated.
•
The SSA will not schedule a beneficiary for a medical CDR if he or she is participating in the Ticket to Work program. This is for those beneficiaries who assigned their Ticket to an approved service provider before receiving notice of a medical CDR. If a medical CDR has been scheduled before the beneficiary had assigned the ticket, the SSA will go ahead with the medical CDR.
Applying for disability benefits can prove challenging, which makes obtaining legal counsel a valuable proposition for applicants. Experienced lawyers with the support of a good medical review company will determine if the applicant’s case is a legally valid one. They will help the claimants file the application, and also provide the necessary support to appeal in case the claim is denied. Moreover, attorneys would also provide important information about CDRs and other formalities that every disability applicant should know about.
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