[Federal Register Volume 60, Number 78 (Monday, April 24, 1995)]
[Rules and Regulations]
[Pages 20023-20029]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-9897]
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SOCIAL SECURITY ADMINISTRATION
20 CFR Parts 404 and 416
[Regulations Nos. 4 and 16]
RIN 0960-AD63
Testing Modifications to the Disability Determination Procedures
AGENCY: Social Security Administration (SSA).
ACTION: Final rules.
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SUMMARY: We are adding new rules which provide authority to test
procedures that modify the disability determination process we
currently follow under titles II and XVI of the Social Security Act
(the Act). We intend to test up to four model procedures either singly
or in combination. These tests will provide us with information so we
can determine the effectiveness of the models in improving the
disability process. The intended result is to enable us to make
recommendations for national implementation of improvements identified
by the tests. These final rules only refer to the changes to the
disability procedures we may test. Unless specified, all other
regulations related to the disability determination process remain
unchanged. Videoconferencing may be used with any of the models.
EFFECTIVE DATE: These rules are effective April 24, 1995.
FOR FURTHER INFORMATION CONTACT: Henry D. Lerner, Legal Assistant,
Office of Regulations, Social Security Administration, 6401 Security
Blvd., Baltimore, MD 21235, (410) 965-1762.
SUPPLEMENTARY INFORMATION:
Background
We published a notice of proposed rulemaking (NPRM) in the Federal
Register on October 22, 1993, (58 FR 54532) proposing to establish the
authority to test model projects designed to improve the disability
determination process. The initial public comment period was 30 days. A
30-day extension of the public comment period was published in the
Federal Register on December 6, 1993, (58 FR 64207) and the comment
period ended on January 5, 1994. The comments we received on the NPRM
and the changes we have made in the final rules are discussed below.
On April 15, 1994, the Social Security Administration (SSA)
published a notice in the Federal Register (59 FR 18188) setting out a
proposal to redesign the initial and administrative appeals system for
determining an individual's entitlement to Social Security and
Supplementary Security Income (SSI) disability payments. Comments on
this comprehensive and far reaching proposal developed by SSA's
Disability Process Reengineering Team (the Team) were requested, and
during the comment period that began on April 1, 1994, and ended on
June 14, 1994, SSA received over 6,000 written responses. They came
from a broad spectrum of respondents including: Professional
associations, claimant representatives, claimant advocacy groups,
Federal and State agencies, State governments, employee unions, Federal
and State employees, and other members of the public. Comments also
were received by members of the Team who conducted briefings and spoke
with more than 3,000 individuals about their reaction to the proposal.
The commenters expressed their belief that improvements were needed to
provide better service and to manage the claims process more
effectively. While some concerns were expressed, the commenters praised
SSA and the Team for taking on the task of redesigning the disability
claim process.
The Team made revisions to the redesign proposal and submitted them
to the Commissioner of Social Security on June 30, 1994. The
Commissioner accepted the recommendations of the Team on September 7,
1994, with the full understanding that certain aspects of the redesign
proposal recommended by the Team would require extensive research and
testing to determine whether they can be implemented. The plan approved
by the Commissioner was published in the Federal Register on September
19, 1994 (59 FR 47887). The proposed changes to the disability
determination process contained in the plan approved by the
Commissioner that are the same as or similar to changes we proposed to
test in the NPRM include:
Making the process more personalized by assigning a
disability claim manager who is knowledgeable about the case to be the
claimant's principal contact with SSA;
Providing the claimant with an opportunity for a
predecision interview with the decisionmaker(s) when the decisionmaker
finds that the evidence in the claim file is insufficient to make a
fully favorable determination or requires an initial determination
denying the claim;
Eliminating the reconsideration step of the administrative
review process and providing a claimant who is dissatisfied with his or
her initial determination with the opportunity to request a hearing
before an administrative law judge (ALJ).
These final rules were developed based on the NPRM, the comments we
received on it which are discussed below, and the Commissioner's
acceptance on September 7, 1994, of the Team's recommendations to
redesign the disability process. Under the final rules we plan to test
one or more modifications to the current disability determination
process to determine whether the modifications should become permanent.
The modifications we plan to test pursuant to these final rules that
were not contained in the NPRM, are based on, and are an outgrowth of,
the NPRM.
Some modifications of procedures that were in the NPRM, such as
having a single decisionmaker in the proposed claims intake and
determination model, the face-to-face predenial interview model and the
face-to-face Federal reconsideration models, are now found in these
final rules in the single decisionmaker model. Also, a modification
similar to, though less formal than, the predenial interview concept
that was part of the face-to-face predenial interview model is now
found in the predecision interview model.
Other modifications contained within the models described in the
NPRM and the redesign proposal are now combined in models in these
final rules. For example, the NPRM described a disability specialist as
a claims representative who would be given special disability program
training similar to the training that State agency disability examiners
receive. The disability specialist would be able to review the claim
before forwarding it to the State agency, request and evaluate existing
medical evidence and, if appropriate, arrange for a consultative
examination. With respect to applications for SSI payments based on
disability, the disability specialist would, where appropriate, make
presumptive disability findings. The second model in the NPRM, the
claims intake and determination model, described a process whereby the
applicant would be interviewed by a decisionmaker when a claim for
disability benefits or SSI payments based on disability was filed.
[[Page 20024]]
Whereas the NPRM described a disability specialist and a
decisionmaker at claims intake who could perform these functions, the
final rules now have a disability claim manager model and a single
decisionmaker model. The disability claim manager will assume primary
responsibility for the processing of any initial disability claim, and
he or she will act as the focal point for the claimant's contacts with
us throughout the claims intake process and until an initial
determination is issued. The disability claim manager will perform many
of the functions associated with a disability specialist, but will also
perform other functions. A disability claim manager will provide the
claimant with an explanation of the disability programs, including the
definition of disability and how we determine whether or not the
claimant meets the other requirements for entitlement to disability
benefits. The disability claim manager will also explain what the
claimant will be asked to do throughout the initial claims process and
provide information that will assist the claimant in pursuing his or
her claim. When tested in combination with the single decisionmaker
model, the disability claim manager will also be the decisionmaker,
similar to the decisionmaker in the claims intake and determination
model described in the NPRM.
The disability claim manager may work in a team environment with
medical consultants who provide assistance for case adjudication, as
well as with technical and other clerical personnel who may handle
other aspects of case development and payment effectuation. Each team
member will have a familiarity with all the steps in the process and an
understanding of how he or she assists another's efforts. Team members
will be able to draw upon each other's expertise on complex issues. We
expect that this team environment, combined with the proper training,
program tools and technological support, will eventually enable one
individual to handle the responsibilities of the disability claim
manager. This individual may be either a Federal employee or a State
agency employee. An individual employee serving as the disability claim
manager is basic to our objective of providing a single point of
contact for the claimant during the initial disability process.
In the near term, it may be necessary to have the duties of a
disability claim manager carried out by more than one individual and,
therefore, to expand the ``disability team'' described above to include
additional employees. The final rules will allow us to test the
disability claim manager function performed by one individual or a team
of individuals. If the disability claim manager model is being tested
in combination with the single decisionmaker model (i.e., the
disability claim manager would be the single decisionmaker for both the
medical and nonmedical aspects of the claim), and a State agency
employee is performing the duties of the disability claim manager, the
ultimate determination of whether or not the claimant is entitled to
benefits will be made by a team that includes a Federal employee. This
procedure is in accordance with current provisions of the Act which
authorize State agency employees only to make determinations of
disability and not determinations of entitlement to benefits based on
disability.
The disability models proposed in the NPRM were designed only to
modify those aspects of the disability determination process based upon
the medical factors of entitlement. That is why, for example, the face-
to-face predenial interview model proposed in the NPRM only provided
for direct appeal of disability issues to the ALJ. Since then, we have
decided to test ways to improve both the disability and nondisability
aspects of the disability determination process. The face-to-face
predenial interview model with limited direct appeal rights to the ALJ
has been changed in the final rules to a less formal predecision
interview model. As some commenters suggested, the predecision
interview model does not place conditions on a claimant's appeal
rights. It still provides, however, the claimant with the opportunity
for an interview with the decisionmaker(s) before an initial
determination denying the claim is made or when the evidence is
insufficient to make a fully favorable determination. The
decisionmaker(s) who will conduct the interview has the discretion to
determine which method of interview (face-to-face, videoconferencing,
or telephone) is most appropriate for each claimant's special needs.
The reconsideration elimination model has also been modified to allow
appeal to an administrative law judge if the claimant is dissatisfied
with the initial determination made in his or her claim, based upon
either disability or nondisability factors.
Finally, we decided not to test the face-to-face Federal
reconsideration model described in the NPRM because its primary
benefit, namely, an earlier opportunity to appear before a Federal
decisionmaker is now contained within the single decisionmaker model.
These regulations provide the authority to test major elements of
our Disability Redesign Plan. However, there are elements of the
Redesign not referenced in these final regulations. There are two
principal reasons why elements are omitted. First, we do not need
regulatory authority to test or implement many aspects of the Redesign
(e.g., improved public information materials or more efficient ways of
working with applicants to obtain medical evidence). Second, some
elements of the Redesign were not referenced in the NPRM, since the
Redesign was developed subsequent to issuance of the NPRM. Therefore,
separate regulations will be needed for those elements which are beyond
the scope of the original rulemaking.
For example, separate regulations are required to establish the
position of an adjudication officer who is authorized to issue some
disability decisions. Current implementation planning for the
Disability Redesign includes the development of regulations to test the
adjudication officer element in the Redesign. We plan to test the
adjudication officer in combination with one or more of the models
included in these regulations as well as other aspects of the Redesign
in some test sites. This will provide us with a body of information
about each individual part of the Redesign as well as the combined
effect on individuals and on program expenditures of the overall
Redesign.
Public Comments
We received comments on the NPRM from twenty-one commenters. The
commenters included attorneys, medical professionals, advocates, State
agency employees and Federal employees, and representatives of numerous
organizations that represent the disabled. We received no comments from
persons receiving benefits based on disability. Many commenters
supported and applauded us for undertaking tests of models that modify
the disability determination process. These commenters included the ARC
(formerly known as the Association for Retarded Citizens of the United
States); the American Academy of Pediatrics; the American Foundation
for the Blind; the United Cerebral Palsy Associations; the
Administrative Conference of the United States; the Council for
Exceptional Children; and the National Council on Disability. Some of
the comments we received were outside the scope of the proposed rules,
and therefore, have not been addressed. The substantive comments made
by the [[Page 20025]] commenters and our responses are summarized
below.
Comment: Many commenters raised concerns regarding the adequacy of
the training that would be provided to interviewers and decisionmakers
(particularly single decisionmakers).
Response: We will ensure that the interviewers and decisionmakers
who participate in our tests will be highly trained individuals who are
well versed in both the disability and nondisability aspects of the
disability programs and are individuals who have the necessary
knowledge, skills, and abilities to conduct personal interviews,
develop evidentiary records, and fully adjudicate disability claims, as
appropriate. These individuals will also be able to call on other SSA
resources, including medical and technical support personnel, to
provide advice and assistance in the claims process.
Comment: Several commenters raised concerns regarding the apparent
lack of involvement of the medical consultant in making disability
determinations because the medical consultant would not be required to
sign the disability determination forms used to certify the
determination of disability to us.
Response: The fact that we intend to test a model or combinations
of models where the determination of disability is made by a single
decisionmaker does not mean that the medical consultant is being
removed from the decisionmaking process. The decisionmaker will consult
with the medical consultant whenever appropriate. This means that the
decisionmaker will make reasonable efforts to ensure that a qualified
pediatrician or other appropriate specialist evaluates the claim
whenever a determination of disability is required in claims filed on
behalf of children under age 18 claiming SSI payments based on
disability. Similarly, before making a determination that an individual
is not under a disability in any case which indicates the existence of
a mental impairment, the decisionmaker will make every reasonable
effort to ensure that a qualified psychiatrist or psychologist
completes the medical portion of the case review and any applicable
residual functional assessment. In addition, the decisionmaker will
consult with the medical consultant in all other situations where the
decisionmaker finds that a consultation is appropriate. However, the
single decisionmaker concept is based on the premise that the
decisionmaker is fully competent to make an initial determination when
an individual files an application for benefits based on disability. It
also gives the decisionmaker flexibility to make such determinations
without having to wait for the medical consultant to take part formally
in the determination.
Comment: Several commenters wanted us to include quality
assessments of accuracy in our evaluation of all possible approaches to
improved disability determinations. The commenters' concerns stem
partially from the use of a single decisionmaker in some of the
proposed models and from the fact that medical consultants will not be
required to sign the disability determination forms used to certify the
determination of disability to us.
Response: Our evaluation of the models we test will include quality
assurance procedures to ensure a thorough assessment of the accuracy of
the disability determinations made under the test procedures. As
previously noted, decisionmakers will comply with the statutory
requirements regarding the use of medical consultants in SSI childhood
disability claims, and in all denials of claims based upon mental
impairments. In addition, such consultation will take place with
respect to any other claim in which the decisionmaker finds it is
appropriate to consult with the medical consultant.
Comment: One commenter was concerned with how we would evaluate the
success and impact of the model procedures.
Response: We will have a study design and evaluation plan in place
to assure a valid and accurate assessment of the degree to which the
modifications to the disability determination process we test attain
the goals we wish to achieve before any national implementation of the
modifications begins.
Comment: Several commenters expressed concerns that the proposed
models did not appear to make any provisions for applicants requiring
special assistance--e.g., individuals with mental impairments, older
persons, the homeless, etc.
Response: The modifications to the disability determination process
we test will not compromise any provisions that we currently have to
provide accommodations for those individuals who require special
assistance. As we stated in the summary sections of the NPRM and final
rules, all other regulations related to the disability determination
procedures remain unchanged unless specified. This would include
provisions for claimants who may require special assistance. In fact,
the disability claim manager model we now intend to test provides even
more flexibility and opportunity to assist claimants who may require
special assistance. The disability claim manager, acting as the focal
point for the claimant's contacts with us throughout the initial
disability process, will explain the disability programs to the
claimant, including the definition of disability and how SSA determines
if a claimant meets the disability requirements of the Act. The
disability claim manager will also tell the claimant what he or she
will be asked to do throughout the process, what the claimant may
expect from SSA during the process, and how the claimant can interact
with the disability claim manager to obtain more information or
assistance. The disability claim manager will also advise the claimant
regarding the right to representation and provide the appropriate
referral sources for representation.
Comment: Several commenters were concerned regarding the use of
videoconferencing as a substitute for personal face-to-face interviews,
because videoconferencing may not carry the same weight as a face-to-
face interview and the lack of personal contact could make the
applicant feel depersonalized. In addition, some commenters expressed
concerns that videoconferencing may not be an option for those
claimants with special needs such as those with visual or hearing-
related disabilities, or for those individuals who could not provide
their own videoconferencing equipment.
Response: The testing of videoconferencing as an alternative to a
personal face-to-face interview was proposed and is included in these
final rules because it has the potential of becoming a viable and more
convenient alternative for many claimants who would find it a hardship
or impossibility to travel for an interview, but who still wanted to
take advantage of the opportunity of an interview with the
decisionmaker prior to the determination of disability. An interview
conducted via video or via the telephone will carry the same weight as
an interview conducted face-to-face. In these final rules the
decisionmaker(s) who will conduct the interview has the discretion to
determine which method of interview (face-to-face, videoconferencing,
or telephone) is most appropriate for each claimant's special needs. If
we decide to conduct a claimant's interview via videoconferencing, we
will provide the necessary videoconferencing services for the claimant.
We are exploring and testing the option of videoconferencing at all
levels of the claims process, both within and outside the projects to
be done under these regulations. [[Page 20026]] Regulatory authority to
offer it as a service option is not needed.
Comment: We received several comments regarding claimant due
process rights and the possibility that they could be compromised by
some of the models.
Response: None of the models we intend to test will compromise or
diminish the claimant's due process rights. In fact, the disability
claim manager model we now intend to test provides a process that is
committed to keeping the claimant more informed regarding his or her
rights and allows the claimant to obtain information and assistance
more easily. Also, in the context of ensuring a fair and correct
initial determination of disability, the predecision interview model
provides the claimant an opportunity to have an interview with the
decisionmaker(s) and to submit additional evidence before an initial
determination denying the claim is made or when the evidence in file is
insufficient to make a fully favorable determination.
Comment: Several commenters were interested in having us test the
models that involved face-to-face contact with the decisionmaker(s)
prior to the initial disability determination in combination with the
reconsideration elimination model.
Response: These final rules provide us with the flexibility to test
models individually or in combination with other models. Therefore, we
may test model(s) involving the opportunity for face-to-face contact
between the claimant and the decisionmaker(s) with the reconsideration
elimination model.
Comment: Several commenters were concerned with the fact that the
face-to-face predenial interview model only provided direct appeal of
disability issues involved in the initial determination to the ALJ.
Response: These final rules have been revised to allow appeal of
both disability and nondisability factors to the ALJ whenever any of
the first three models are tested in combination with the
reconsideration elimination model. As stated earlier, the face-to-face
predenial interview model with limited direct appeal rights to the
administrative law judge has been changed in the final rule to a less
formal predecision interview model. The predecision interview model
does not place conditions on a claimant's appeal rights, but still
provides the claimant with the opportunity for a face-to-face interview
with the decisionmaker(s) when the decisionmaker finds that the
evidence in the file is insufficient to make a fully favorable
determination or requires an initial determination denying the claim.
The reconsideration elimination model has also been modified to allow
appeal to the ALJ if the claimant is dissatisfied with the initial
determination made on his or her claim, based upon either medical or
nonmedical factors.
Comment: Several commenters were concerned that there was no
specific indication as to whether children's claims would be included
in the tests.
Response: As stated previously, the summary section of the NPRM and
these final rules state that all other regulations related to the
disability determination procedures remain unchanged unless specified.
That includes the rules for determinations of disability in children.
We have no plans to exclude claims filed by or behalf of children from
the tests. As stated previously, the decisionmaker will make reasonable
efforts to ensure that a qualified pediatrician or other appropriate
specialist evaluates the claim whenever a determination of disability
is required in claims filed by or on behalf of children under age 18
claiming SSI benefits based on disability. We have no intention of
compromising any of the safeguards currently in place to protect the
rights of children in the disability determination process.
Comment: Several commenters were concerned that the models would
generate increased workload demands (particularly the elimination of
the reconsideration model and its predicted effect of increasing ALJ
workloads) and some felt that some of the models would be too costly.
Response: These types of concerns are one of the reasons why we
proposed testing, rather than implementing changes to our current
rules. If the model process or combination of processes we test proves
to be prohibitively costly or to create unmanageable workloads or both,
we will either drop the model from consideration or revise the model
process to address the problem.
Regulatory Procedures
Executive Order 12866
The Office of Management and Budget (OMB) has reviewed these final
rules and determined they do not meet the criteria for a significant
regulatory action under E.O. 12866.
Paperwork Reduction Act
Data collection involved in the evaluation of any of the models may
necessitate new reporting or recordkeeping requirements which may need
clearance by OMB. These requirements are still being developed. When
specifics have been determined, any necessary request for clearance
will be forwarded to OMB as required by the Paperwork Reduction Act.
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. Therefore, a regulatory flexibility analysis as
provided in Pub. L. 96-354, the Regulatory Flexibility Act, is not
required.
(Catalog of Federal Domestic Assistance Program Nos. 93.802, Social
Security-Disability Insurance; 93.807, Supplemental Security Income)
List of Subjects
20 CFR Part 404
Administrative practice and procedure, Death benefits, Disability
benefits, Old-Age, Reporting and recordkeeping requirements, Survivors
and Disability insurance.
20 CFR Part 416
Administrative practice and procedure, Aged, Blind, Disability
benefits, Public assistance programs, Reporting and recordkeeping
requirements, Supplemental Security Income.
Dated: February 15, 1995.
Shirley Chater,
Commissioner of Social Security.
Approved: March 30, 1995.
Donna E. Shalala,
Secretary of Health and Human Services.
For the reasons set out in the preamble, parts 404 and 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 J is amended as follows:
1. The authority citation for subpart J of part 404 continues to
read as follows:
Authority: Secs. 201(j), 205 (a), (b), (d)-(h), and (j), 221(d),
and 1102 of the Social Security Act; 31 U.S.C. 3720A; 42 U.S.C.
401(j), 405(a), (b), (d)-(h), and (j), 421(d), and 1302, sec. 5 of
Pub. L. 97-455, 96 Stat. 2500; sec. 6 of Pub. L. 98-460, 98 Stat.
1802.
2. Section 404.906 is revised to read as follows:
Sec. 404.906 Testing modifications to the disability determination
procedures.
(a) Applicability and scope. Notwithstanding any other provision in
this part or part 422 of this chapter, we are establishing the
procedures set out [[Page 20027]] in this section to test modifications
to our disability determination process. These modifications will
enable us to test, either individually or in one or more combinations,
the effect of: having disability claim managers assume primary
responsibility for processing an application for disability benefits;
providing persons who have applied for benefits based on disability
with the opportunity for an interview with a decisionmaker when the
decisionmaker finds that the evidence in the file is insufficient to
make a fully favorable determination or requires an initial
determination denying the claim; having a single decisionmaker make the
initial determination with assistance from medical consultants, where
appropriate; and eliminating the reconsideration step in the
administrative review process and having a claimant who is dissatisfied
with the initial determination request a hearing before an
administrative law judge. The model procedures we test will be designed
to provide us with information regarding the effect of these procedural
modifications and enable us to decide whether and to what degree the
disability determination process would be improved if they were
implemented on a national level.
(b) Procedures for cases included in the tests. Prior to commencing
each test or group of tests in selected site(s), we will publish a
notice in the Federal Register. The notice will describe which model or
combinations of models we intend to test, where the specific test
site(s) will be, and the duration of the test(s). The individuals who
participate in the test(s) will be randomly assigned to a test group in
each site where the tests are conducted. Paragraphs (b) (1) through (4)
of this section lists descriptions of each model.
(1) In the disability claim manager model, when you file an
application for benefits based on disability, a disability claim
manager will assume primary responsibility for the processing of your
claim. The disability claim manager will be the focal point for your
contacts with us during the claims intake process and until an initial
determination on your claim is made. The disability claim manager will
explain the disability programs to you, including the definition of
disability and how we determine whether you meet all the requirements
for benefits based on disability. The disability claim manager will
explain what you will be asked to do throughout the claims process and
how you can obtain information or assistance through him or her. The
disability claim manager will also provide you with information
regarding your right to representation, and he or she will provide you
with appropriate referral sources for representation. The disability
claim manager may be either a State agency employee or a Federal
employee. In some instances, the disability claim manager may be
assisted by other individuals.
(2) In the single decisionmaker model, the decisionmaker will make
the disability determination and may also determine whether the other
conditions for entitlement to benefits based on disability are met. The
decisionmaker will make the disability determination after any
appropriate consultation with a medical or psychological consultant.
The medical or psychological consultant will not be required to sign
the disability determination forms we use to have the State agency
certify the determination of disability to us (see Sec. 404.1615).
However, before an initial determination is made that a claimant is not
disabled in any case where there is evidence which indicates the
existence of a mental impairment, the decisionmaker will make every
reasonable effort to ensure that a qualified psychiatrist or
psychologist has completed the medical portion of the case review and
any applicable residual functional capacity assessment pursuant to our
existing procedures (see Sec. 404.1617). In some instances the
decisionmaker may be the disability claim manager described in
paragraph (b)(1) of this section. When the decisionmaker is a State
agency employee, a team of individuals that includes a Federal employee
will determine whether the other conditions for entitlement to benefits
are met.
(3) In the predecision interview model, if the decisionmaker(s)
finds that the evidence in your file is insufficient to make a fully
favorable determination or requires an initial determination denying
your claim, a predecision notice will be mailed to you. The notice will
tell you that, before the decisionmaker(s) makes an initial
determination about whether you are disabled, you may request a
predecision interview with the decisionmaker(s). The notice will also
tell you that you may submit additional evidence. You must request a
predecision interview within 10 days after the date you receive the
predecision notice. You must also submit any additional evidence within
10 days after you receive the predecision notice. If you request a
predecision interview, the decisionmaker(s) will conduct the
predecision interview in person, by videoconference, or by telephone as
the decisionmaker(s) determines is appropriate under the circumstances.
If you make a late request for a predecision interview, or submit
additional evidence late, but show in writing that you had good cause
under the standards in Sec. 404.911 for missing the deadline, the
decisionmaker(s) will extend the deadline. If you do not request the
predecision interview, or if you do not appear for a scheduled
predecision interview and do not submit additional evidence, or if you
do not respond to our attempts to communicate with you, the
decisionmaker(s) will make an initial determination based upon the
evidence in your file. If you identify additional evidence during the
predecision interview, which was previously not available, the
decisionmaker(s) will advise you to submit the evidence. If you are
unable to do so, the decisionmaker(s) may assist you in obtaining it.
The decisionmaker(s) also will advise you of the specific timeframes
you have for submitting any additional evidence identified during the
predecision interview. If you have no treating source(s) (see
Sec. 404.1502), or your treating source(s) is unable or unwilling to
provide the necessary evidence, or there is a conflict in the evidence
that cannot be resolved through evidence from your treating source(s),
the decisionmaker(s) may arrange a consultative examination or resolve
conflicts according to existing procedures (see Sec. 404.1519a). If you
attend the predecision interview, or do not attend the predecision
interview but you submit additional evidence, the decisionmaker(s) will
make an initial determination based on the evidence in your file,
including the additional evidence you submit or the evidence obtained
as a result of the predecision notice or interview, or both.
(4) In the reconsideration elimination model, we will modify the
disability determination process by eliminating the reconsideration
step of the administrative review process. If you receive an initial
determination on your claim for benefits based on disability, and you
are dissatisfied with the determination, we will notify you that you
may request a hearing before an administrative law judge. If you
request a hearing before an administrative law judge, we will apply our
usual procedures contained in subpart J of this part.
PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND
DISABLED
Subpart N is amended as follows:
1. The authority citation for subpart N of part 416 continues to
read as follows:
[[Page 20028]] Authority: Secs. 1102, 1631, and 1633 of the
Social Security Act; 42 U.S.C. 1302, 1383, and 1383b.
2. Section 416.1406 is revised to read as follows:
Sec. 416.1406 Testing modifications to the disability determination
procedures.
(a) Applicability and scope. Notwithstanding any other provision in
this part or part 422 of this chapter, we are establishing the
procedures set out in this section to test modifications to our
disability determination process. These modifications will enable us to
test, either individually or in one or more combinations, the effect
of: having disability claim managers assume primary responsibility for
processing an application for SSI payments based on disability;
providing persons who have applied for benefits based on disability
with the opportunity for an interview with a decisionmaker when the
decisionmaker finds that the evidence in the file is insufficient to
make a fully favorable determination or requires an initial
determination denying the claim; having a single decisionmaker make the
initial determination with assistance from medical consultants, where
appropriate; and eliminating the reconsideration step in the
administrative review process and having a claimant who is dissatisfied
with the initial determination request a hearing before an
administrative law judge. The model procedures we test will be designed
to provide us with information regarding the effect of these procedural
modifications and enable us to decide whether and to what degree the
disability determination process would be improved if they were
implemented on a national level.
(b) Procedures for cases included in the tests. Prior to commencing
each test or group of tests in selected site(s), we will publish a
notice in the Federal Register. The notice will describe which model or
combinations of models we intend to test, where the specific test
site(s) will be, and the duration of the test(s). The individuals who
participate in the test(s) will be randomly assigned to a test group in
each site where the tests are conducted. Paragraph (b) (1) through (4)
of this section lists descriptions of each model.
(1) In the disability claim manager model, when you file an
application for SSI payments based on disability, a disability claim
manager will assume primary responsibility for the processing of your
claim. The disability claim manager will be the focal point for your
contacts with us during the claims intake process and until an initial
determination on your claim is made. The disability claim manager will
explain the SSI disability program to you, including the definition of
disability and how we determine whether you meet all the requirements
for SSI payments based on disability. The disability claim manager will
explain what you will be asked to do throughout the claims process and
how you can obtain information or assistance through him or her. The
disability claim manager will also provide you with information
regarding your right to representation, and he or she will provide you
with appropriate referral sources for representation. The disability
claim manager may be either a State agency employee or a Federal
employee. In some instances, the disability claim manager may be
assisted by other individuals.
(2) In the single decisionmaker model, the decisionmaker will make
the disability determination and may also determine whether the other
conditions of eligibility for SSI payments based on disability are met.
The decisionmaker will make the disability determination after any
appropriate consultation with a medical or psychological consultant.
The medical or psychological consultant will not be required to sign
the disability determination forms we use to have the State agency
certify the determination of disability to us (see Sec. 416.1015).
However, before an initial determination is made that a claimant is not
disabled in any case where there is evidence which indicates the
existence of a mental impairment, the decisionmaker will make every
reasonable effort to ensure that a qualified psychiatrist or
psychologist has completed the medical portion of the case review and
any applicable residual functional capacity assessment pursuant to our
existing procedures (see Sec. 416.1017). Similarly, in making an
initial determination with respect to the disability of a child under
age 18 claiming SSI payments based on disability, the decisionmaker
will make reasonable efforts to ensure that a qualified pediatrician,
or other individual who specializes in a field of medicine appropriate
to the child's impairment(s), evaluates the claim of such child (see
Sec. 416.903(f)). In some instances the decisionmaker may be the
disability claim manager described in paragraph (b)(1) of this section.
When the decisionmaker is a State agency employee, a team of
individuals that includes a Federal employee will determine whether the
other conditions of eligibility for SSI payments are met.
(3) In the predecision interview model, if the decisionmaker(s)
finds that the evidence in your file is insufficient to make a fully
favorable determination or requires an initial determination denying
your claim, a predecision notice will be mailed to you. The notice will
tell you that, before the decisionmaker(s) makes an initial
determination about whether you are disabled, you may request a
predecision interview with the decisionmaker(s). The notice will also
tell you that you may also submit additional evidence. You must request
a predecision interview within 10 days after the date you receive the
predecision notice. You must also submit any additional evidence within
10 days after the date you receive the predecision notice. If you
request a predecision interview, the decisionmaker(s) will conduct the
predecision interview in person, by videoconference, or by telephone as
the decisionmaker(s) determines is appropriate under the circumstances.
If you make a late request for a predecision interview, or submit
additional evidence late, but show in writing that you had good cause
under the standards in Sec. 416.1411 for missing the deadline, the
decisionmaker(s) will extend the deadline. If you do not request the
predecision interview or if you do not appear for a scheduled
predecision interview and do not submit additional evidence, or if you
do not respond to our attempts to communicate with you, the
decisionmaker(s) will make an initial determination based upon the
evidence in your file. If you identify additional evidence during the
predecision interview, which was previously not available, the
decisionmaker(s) will advise you to submit the evidence. If you are
unable to do so, the decisionmaker(s) may assist you in obtaining it.
The decisionmaker(s) also will advise you of the specific timeframes
you have for submitting any additional evidence identified during the
predecision interview. If you have no treating source(s) (see
Sec. 416.902), or your treating source(s) is unable or unwilling to
provide the necessary evidence, or there is a conflict in the evidence
that cannot be resolved through evidence from your treating source(s),
the decisionmaker(s) may arrange a consultative examination or resolve
conflicts according to existing procedures (see Sec. 416.919a). If you
attend the predecision interview, or do not attend the predecision
interview but you submit additional evidence, the decisionmaker(s) will
make an initial determination based on the evidence in your file,
including the additional evidence you submit or the evidence
[[Page 20029]] obtained as a result of the predecision notice or
interview, or both.
(4) In the reconsideration elimination model, we will modify the
disability determination process by eliminating the reconsideration
step of the administrative review process. If you receive an initial
determination on your claim for SSI payments based on disability, and
you are dissatisfied with the determination, we will notify you that
you may request a hearing before an administrative law judge. If you
request a hearing before an administrative law judge, we will apply our
usual procedures contained in subpart N of this part.
[FR Doc. 95-9897 Filed 4-21-95; 8:45 am]
BILLING CODE 4190-29-P
