96-6375. Signature Requirements for State Agency Medical and Psychological Consultants in Disability Determinations  

  • [Federal Register Volume 61, Number 54 (Tuesday, March 19, 1996)]
    [Rules and Regulations]
    [Pages 11133-11136]
    From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
    [FR Doc No: 96-6375]
    
    
    
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    SOCIAL SECURITY ADMINISTRATION
    
    20 CFR Parts 404 and 416
    
    [Regulations Nos. 4 and 16]
    RIN 0960-AD88
    
    
    Signature Requirements for State Agency Medical and Psychological 
    Consultants in Disability Determinations
    
    AGENCY: Social Security Administration (SSA).
    
    ACTION: Final rules.
    
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    SUMMARY: We are revising the requirements of the Social Security and 
    Supplemental Security Income (SSI) regulations regarding the 
    certifications required on the disability determination forms used by 
    State agencies to certify determinations of disability. Present 
    regulations require that, unless the disability determination is made 
    by a State agency disability hearing officer, disability determinations 
    made by a State agency will be made by a State agency medical or 
    psychological consultant and a State agency disability examiner. This 
    includes determinations made on technical, non-medical, rather than 
    medical, grounds. We are revising our rules to remove the requirement 
    that a medical or psychological consultant sign the disability 
    determination forms used by the State agency to certify each 
    determination, when there is no medical evidence to be evaluated. In 
    such cases, the disability examiner may make the determination alone.
    
    EFFECTIVE DATE: April 18, 1996.
    
    FOR FURTHER INFORMATION CONTACT: Harry J. Short, Legal Assistant, 
    Division of Regulations and Rulings, Social Security Administration, 
    6401 Security Boulevard, Baltimore, Maryland 21235, (410) 965-6243.
    
    SUPPLEMENTARY INFORMATION:
    
    Background
    
        The Social Security Act (the Act) provides, in title II, for the 
    payment of disability insurance benefits to individuals insured under 
    the Act. Title II also provides for the payment of child's insurance 
    benefits based on disability and widow's and widower's insurance 
    benefits for disabled widows, widowers, and surviving divorced spouses 
    of insured individuals. In addition, the Act provides, in title XVI, 
    for SSI payments to persons who are aged, blind, or disabled and who 
    have limited income and resources. For adults under both the title II 
    and title XVI programs and for persons claiming child's insurance 
    benefits based on disability under the title II program,
    
    [[Page 11134]]
    ``disability'' means the inability to engage in any substantial gainful 
    activity by reason of any medically determinable impairment which has 
    lasted or can be expected to last for a continuous period of not less 
    than 12 months or result in death. For an individual under age 18 
    claiming SSI benefits based on disability, ``disability'' means that 
    the individual's impairment(s) is of comparable severity to one that 
    would disable an adult (i.e., the impairment(s) substantially reduces 
    the individual's ability to function independently, appropriately, and 
    effectively in an age-appropriate manner such that the individual's 
    impairment(s) and resulting limitations are comparable to those that 
    would disable an adult). The individual's impairment(s) must also meet 
    the statutory duration requirement.
        Sections 221 and 1633(a) of the Act and Secs. 404.1503 and 416.903 
    of our regulations provide that State agencies make disability and 
    blindness determinations for the Commissioner of Social Security for 
    most persons living in the State. Sections 404.1615(c) and 416.1015(c) 
    of the regulations provide that disability determinations will be made 
    by either: (1) a State agency medical or psychological consultant and a 
    State agency disability examiner or (2) a State agency disability 
    hearing officer. In addition, a single decisionmaker may make the 
    determination of disability for purposes of the tests we are conducting 
    under the authority of the final rules we published on April 24, 1995, 
    ``Testing Modifications to the Disability Determination Procedures,'' 
    (60 FR 20023). (To be codified at 20 CFR 404.906 and 416.1406). These 
    final rules do not affect the procedures we are following for the 
    purposes of those tests.
        Sections 404.1615(e) and 416.1015(f) of the regulations require the 
    State agency to certify each determination of disability to the Social 
    Security Administration (SSA) on forms provided by SSA. The term 
    ``determination of disability'' is defined in Secs. 404.1602 and 
    416.1002 of the regulations to mean one or more of the following 
    decisions: whether or not a person is under a disability; the date a 
    person's disability began; or the date a person's disability ended.
        When a disability determination is made jointly by a State agency 
    medical or psychological consultant and a State agency disability 
    examiner, the medical or psychological consultant is responsible for 
    the medical portion of the determination, and the disability examiner 
    is responsible for the remainder of the determination. Under our 
    current procedures for these cases, both the disability examiner and 
    the medical or psychological consultant must certify the determination 
    on forms which we provide as required in the regulations.
        In some instances the requirement for the medical or psychological 
    consultant's certification is unnecessary because the determination is 
    made on technical, non-medical, grounds alone, without consideration of 
    any medical evidence. Many medical and psychological consultants who 
    work with the State agencies do so on a part-time basis and are not 
    always available to sign disability determination forms. This can 
    result in delays of cases that are otherwise complete because no 
    medical evaluation or expertise is necessary.
        This happens, for example, when an individual who has no history of 
    medical treatment or examination--and, hence, no existing medical 
    records that we can obtain--refuses to attend a consultative 
    examination purchased at our expense. In such a case, the State agency 
    makes its determination on technical, non-medical, rather than medical, 
    grounds. It denies such a claim because, without the individual's 
    cooperation, the evidence needed to determine whether the individual is 
    disabled cannot be obtained. Nevertheless, our current rules require 
    that a medical or psychological consultant sign the standard disability 
    determination form in such a case, even though there is no medical 
    evidence and no medical findings that can be made.
    
    Change Made by This Rule
    
        We are addressing the above issue by revising Secs. 404.1615 and 
    416.1015 of the regulations to provide, in a new paragraph (c)(2), that 
    a State agency disability examiner alone may make the disability 
    determination when there is no medical evidence to be evaluated, such 
    as when there is no existing medical evidence and the individual 
    refuses to attend a consultative examination. We are redesignating 
    current paragraph (c)(2), which provides that a State agency disability 
    hearing officer may also make disability determinations, as paragraph 
    (c)(3).
    
    Public Comments
    
        On October 26, 1994, we published these revisions in a Notice of 
    Proposed Rulemaking (NPRM) in the Federal Register (59 FR 53769). We 
    invited interested persons, organizations, and groups to submit their 
    comments on the NPRM within 60 days.
        We received letters from four State agencies, three legal 
    advocates, and a vocational rehabilitation council. Five commenters 
    indicated support for the rule, two opposed it, and one provided 
    comments without indicating either support or opposition.
        Comment: One commenter requested that we broaden the provision to 
    state that the medical or psychological consultant's signature is not 
    required on the disability determination form if the consultant has 
    furnished a written medical severity assessment.
        Response: We are currently considering alternatives to our 
    procedures for documenting medical or psychological consultant 
    participation in the disability determination. In February 1994, we 
    provided temporary procedures for State agencies to document medical or 
    psychological consultant participation in certain cases with the 
    consultant's signature on a document other than the disability 
    determination form. We are also considering ways to expand this 
    procedure to other cases. We do not believe that a regulatory change 
    beyond the changes made by these final rules is appropriate at this 
    time.
        Comment: Another commenter recommended that we broaden the 
    provision to include cases in which there is some medical evidence, but 
    the substantive conclusion of whether an individual is disabled appears 
    obvious. The commenter also suggested including cases involving only 
    medical evidence from outside the period at issue in the case, and 
    cases that include some medical evidence but are still denied based on 
    failure to attend a consultative examination.
        Response: This kind of expansion would not be consistent with the 
    scope or intent of this rule. We believe that the presence of medical 
    evidence in connection with a claim for benefits is sufficient reason 
    to require the special expertise of a medical or psychological 
    consultant, even if the outcome seems ``obvious'' or the evidence seems 
    immaterial to a lay person. Therefore, we did not make these changes.
        Comment: Three commenters expressed concern about the scope and 
    meaning of the proposed provisions. All three were concerned that cases 
    with insufficient medical evidence will be denied on a technical basis; 
    i.e., without the participation of a medical or psychological 
    consultant. Two of these commenters requested clarification of the 
    phrase ``no medical evidence.'' Two stated that existing regulations 
    (Secs. 404.1516, 404.1518, 416.916, and 416.918) require a medical 
    evaluation of the case when an individual fails or refuses to attend a 
    consultative examination. They said that the decision should, 
    therefore, be made
    
    [[Page 11135]]
    with the participation of a medical or psychological consultant.
        Response: We have changed the proposed rules to clarify what we 
    mean by ``no medical evidence.'' The final rules do not apply if the 
    file contains some medical evidence, even if such evidence is 
    insufficient to make a determination or contains no findings to support 
    a determination that the claimant is disabled. In such a case, the 
    medical or psychological consultant and disability examiner must make 
    the determination as a team.
        We disagree with the commenters who stated that existing 
    regulations require a medical evaluation of the case when an individual 
    fails or refuses to attend a consultative examination. Our current 
    regulations (Secs. 404.1518 and 416.918) state only that if a claimant 
    does ``not have a good reason for failing or refusing to take part in a 
    consultative examination * * *, we may find that you are not disabled * 
    * * .'' This provision does not require a medical evaluation of such a 
    case, and we believe that it would be futile to attempt to make such an 
    evaluation in the absence of any medical evidence. Although we do not 
    necessarily agree that Secs. 404.1516 and 416.916 apply to this 
    situation, they do not prescribe any specific kind of case evaluation 
    (i.e., a medical evaluation). They merely provide that we will ``make a 
    decision based on information available in your case.''
        Comment: The same commenters were concerned that disability 
    examiners will not make adequate attempts to obtain medical evidence. 
    Two of these commenters stated that only a physician should decide 
    whether the case is unsupported by medical evidence. One observed that 
    the rule does not define ``medical evidence,'' and another stated that 
    a physician should be involved in deciding what is or is not medical 
    evidence.
        Response: These new rules do not alter the existing statutory and 
    regulatory requirement that, before we make a determination that an 
    individual is not disabled, we develop a complete medical history for 
    at least the 12 months preceding the month in which the application is 
    filed, unless there is reason to believe that development of an earlier 
    period is necessary or unless the claimant states that his or her 
    disability began less than 12 months before the application is filed. 
    These rules also do not alter the existing requirement that we make 
    every reasonable effort to obtain medical evidence from the 
    individual's own medical sources, as provided for in sections 
    223(d)(5)(B) and 1614(a)(3)(G) of the Act and Secs. 404.1512(d) and 
    416.912(d) of our regulations. We have revised these final rules to 
    emphasize that we will continue to do so.
        Our existing regulations, Secs. 404.1513 and 416.913, set forth the 
    requirements for the contents of medical evidence and reports, and 
    these rules do not change those requirements. We do not agree that a 
    physician's expertise is required to determine whether evidence is 
    ``medical evidence'', or to evaluate non-medical evidence.
        Comment: Two commenters requested a more definitive identification 
    of the circumstances that justify the provision.
        Response: We have clarified the circumstances under which the final 
    rules apply. They apply whenever there is no medical evidence to be 
    evaluated and the claimant fails or refuses, without a good reason, to 
    attend a consultative examination. The final versions of 
    Secs. 404.1615(c)(2) and 416.1015(c)(2) make this clear.
        Comment: A number of commenters observed that mental illness or 
    other factors may be the basis for an individual's failure to 
    cooperate.
        Response: Existing regulations include provisions on good cause for 
    failure to attend a consultative examination. Regulations 
    Secs. 404.1518 and 416.918 require us to consider an individual's 
    physical, mental, educational and linguistic limitations when 
    determining whether he or she has a good reason for failing to attend a 
    consultative examination. Nevertheless, in the final rules we have 
    clarified that they apply only if the individual fails or refuses to 
    attend a consultative examination without a good reason, and have 
    provided a cross-reference to Secs. 404.1518 and 416.918.
        Except for these clarifications, several minor, non-substantive 
    technical changes, and corrections to authority citations, we are 
    adopting the proposed rules as final rules.
    
    Regulatory Procedures
    
    Executive Order 12866
    
        We have consulted with the Office of Management and Budget (OMB) 
    and determined that these final rules do not meet the criteria for a 
    significant regulatory action under Executive Order 12866. Therefore, 
    they are not subject to OMB review.
    
    Regulatory Flexibility Act
    
        We certify that these regulations will not have a significant 
    economic impact on a substantial number of small entities because they 
    affect individuals' eligibility for program benefits under the Social 
    Security Act. Therefore, a regulatory flexibility analysis is not 
    required.
    
    Paperwork Reduction Act
    
        These regulations will impose no additional reporting or 
    recordkeeping requirements necessitating clearance by OMB.
    
    (Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
    Security-Disability Insurance; and 96.006, Supplemental Security 
    Income)
    
    List of Subjects
    
    20 CFR Part 404
    
        Administrative practice and procedure, Blind, Death benefits, 
    Disability benefits, Old-Age, Survivors and Disability Insurance, 
    Reporting and recordkeeping requirements, Social security.
    
    20 CFR Part 416
    
        Administrative practice and procedure, Aged, Blind, Disability 
    benefits, Public assistance programs, Supplemental Security Income 
    (SSI), Reporting and recordkeeping requirements.
    
        Dated: March 8, 1996.
    Shirley S. Chater,
    Commissioner of Social Security.
    
        For the reasons set out in the preamble, subpart Q of part 404 and 
    subpart J of part 416 of chapter III of title 20 of the Code of Federal 
    Regulations are amended as set forth below:
    
    PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
    (1950-- )
    
    Subpart Q--[Amended]
    
        1. The authority citation for subpart Q of part 404 continues to 
    read as follows:
    
        Authority: Secs. 205(a), 221, and 702(a)(5) of the Social 
    Security Act (42 U.S.C. 405(a), 421, and 902(a)(5)).
    
        2. Section 404.1615 is amended by removing the ``or'' at the end of 
    paragraph (c)(1), by adding a semicolon after paragraph (c)(1), by 
    redesignating paragraph (c)(2) as paragraph (c)(3), and by adding a new 
    paragraph (c)(2) to read as follows:
    
    
    Sec. 404.1615  Making disability determinations.
    
    * * * * *
        (c) * * *
        (2) A State agency disability examiner alone when there is no 
    medical evidence to be evaluated (i.e., no medical evidence exists or 
    we are unable, despite making every reasonable effort, to obtain any 
    medical evidence
    
    [[Page 11136]]
    that may exist) and the individual fails or refuses, without a good 
    reason, to attend a consultative examination (see Sec. 404.1518); or
    * * * * *
    
    PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND 
    DISABLED
    
    Subpart J--[Amended]
    
        3. The authority citation for subpart J continues to read as 
    follows:
    
        Authority: Secs. 702(a)(5), 1614, 1631, and 1633 of the Social 
    Security Act (42 U.S.C. 902(a)(5), 1382c, 1383, and 1383b).
    
        4. Section 416.1015 is amended by removing the ``or'' at the end of 
    paragraph (c)(1), by redesignating paragraph (c)(2) as paragraph 
    (c)(3), and by adding a new paragraph (c)(2) to read as follows:
    
    
    Sec. 416.1015  Making disability determinations.
    
    * * * * *
        (c) * * *
        (2) A State agency disability examiner alone when there is no 
    medical evidence to be evaluated (i.e., no medical evidence exists or 
    we are unable, despite making every reasonable effort, to obtain any 
    medical evidence that may exist) and the individual fails or refuses, 
    without a good reason, to attend a consultative examination (see 
    Sec. 416.918); or
    * * * * *
    [FR Doc. 96-6375 Filed 3-18-96; 8:45 am]
    BILLING CODE 4190-29-P
    
    

Document Information

Effective Date:
4/18/1996
Published:
03/19/1996
Department:
Social Security Administration
Entry Type:
Rule
Action:
Final rules.
Document Number:
96-6375
Dates:
April 18, 1996.
Pages:
11133-11136 (4 pages)
Docket Numbers:
Regulations Nos. 4 and 16
RINs:
0960-AD88: Federal OASDI and SSI for the Aged, Blind, and Disabled; Signature Requirements for State Agency Medical and Psychological Consultants in Disability Determinations (465F)
RIN Links:
https://www.federalregister.gov/regulations/0960-AD88/federal-oasdi-and-ssi-for-the-aged-blind-and-disabled-signature-requirements-for-state-agency-medica
PDF File:
96-6375.pdf
CFR: (3)
20 CFR 416.918)
20 CFR 404.1615
20 CFR 416.1015