ISSUED: June 19, 1998
I. Purpose
Pursuant to Public Law (Pub. L.) 104-193, the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, SSA issued regulations to
implement revisions to the medical improvement review standard (MIRS) as
it applies to title XVI childhood disability cases. This
HALLEX instruction contains procedures
for processing title XVI childhood continuing disability review (CDR)
cases at the Administrative Law Judge and Appeals Council levels of the
administrative review process.
In a memorandum to OHA adjudicators dated April 3, 1998, the Associate
Commissioner for Hearings and Appeals transmitted procedures for
processing title XVI childhood disability CDR cases. This Temporary
Instruction incorporates those procedures into
HALLEX and replaces the prior memorandum
and instructions.
II. Background
Effective August 22, 1996, Pub. L. 104-193, the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996, provided a new statutory
definition of disability for children claiming Supplemental Security
Income (SSI) benefits based on disability, mandated elimination of the IFA
and changes to certain aspects of the mental disorders listings for
children, and made corresponding changes to the MIRS as it applies to
children claiming SSI benefits based on disability. The interim final
regulations implementing these statutory changes (published February 11,
1997) require a different CDR evaluation sequence for title XVI children
than for title II and adult title XVI beneficiaries. The CDR sequential
evaluation process is set out in
20 CFR §
416.994a. In addition, a correction to the codification of section
416.994a, as it appears in the April 1, 1997 edition of 20 CFR, Parts
400-499, was published in the
Federal Register on July 8, 1997 (62
FR 36460). The correction corrects the text of
20 CFR §
416.994a(e)(1) and
(f)(4).
Pub. L. 104-193 mandated “disability redeterminations” for
certain title XVI child beneficiaries and for title XVI adults who were
eligible as children in the month before the month of attainment of age
18. Pub. L. 104-193 also mandated that the Social Security Administration
(SSA) perform periodic CDRs for title XVI children with impairments that
SSA considers likely to improve and CDRs for children for whom low birth
weight is a contributing factor material to the determination of
disability. The provisions of Pub. L. No. 104-193 governing age 18
disability redeterminations and CDRs for low birth weight babies were also
amended by Pub. L. 105-33, the Balanced Budget Act of 1997, enacted on
August 5, 1997.
III. The CDR Evaluation Process - Title XVI Child — Flow
Chart
This chart outlines the CDR evaluation process under the MIRS for title
XVI children, which differs from the MIRS as it applies to title II and
adult title XVI beneficiaries (and from the MIRS sequence applicable to
children prior to August 22, 1996).
The CDR evaluation process is set out in 20 CFR § 416.994a, as it appears in the April 1, 1997 version of 20 CFR Parts 400-499, and as corrected in the Federal Register on July 8, 1997.
* If a Group I exception
(20 CFR
416.994a(f)) applies, go to step 3.
If a Group II exception
(20 CFR
416.994a(g)) applies, disability ceases.
IV. Hearing Office Procedures
A. Cases Pending At Hearing Level in Which DDS Established Cessation
Prior to August 22, 1996 - Hearing Held
For appeals of cessation dates established before August 22, 1996 (the
date of enactment of Pub. L. 104-193), the prior medical improvement
review standard (MIRS) rules apply in deciding the cessation issue for the
period prior to August 22, 1996. The prior rules for application of the
MIRS are found in the April 1, 1996 edition of
20 CFR §
416.994a and discussed in HALLEX
TI 5-4-30, pages 14-16.
Hearing offices should screen all title XVI childhood disability cases
with cessation dates prior to August 22, 1996 awaiting issuance of a
decision. The ALJ should apply the pre-August 22, 1996 MIRS to the period
prior to August 22, 1996.
1.
ALJ Prepared to Find Cessation Prior to August 22, 1996
If, after applying the pre-August 22, 1996 MIRS to the period prior to
August 22, 1996, the ALJ is prepared to find that the DDS-established
cessation is proper, or is prepared to find a later cessation date which
is still prior to August 22, 1996, the case should be processed and a
decision issued finding that disability ceased. There is no need to
consider the current MIRS in these cases.
2.
ALJ Prepared to Find That Cessation Did
Not Occur Prior to August 22,
1996
If the ALJ, after applying the pre-August 22, 1996 MIRS to the period
prior to August 22, 1996 is prepared to find that cessation did not occur
prior to August 22, 1996, i.e., the claimant continues to be disabled as
of August 22, 1996, the ALJ will advise the claimant of the change in the
law (see sample language in Attachments 1 and 2) and provide the claimant
and representative, if any, the opportunity to:
(a)
submit additional evidence;
(b)
submit written comments; and/or
(c)
request a supplemental hearing
(See HALLEX
HA 01260.080, Continued
or Reopened Hearing.)
Following receipt of additional evidence/comments and/or after a
supplemental hearing, if requested, the ALJ will apply the appropriate
evaluation criteria (see C. below) and issue a decision. The applicable
evaluation criteria are contingent on whether the claimant would have been
subject to a childhood disability redetermination under Pub. L. 104-193
(i.e., IFA allowance, maladaptive behaviors material, or age-18 case). See
applicable evaluation criteria in section C. below.
B. Cases Pending At Hearing Level in Which DDS Established Cessation
Prior to August 22, 1996 - Hearing Not Yet Scheduled and New Receipts
(with pre-August 22, 1996 cessation dates)
Schedule the hearing in the usual manner. The Notice of Hearing sent to
the claimant and representative, if any, must include reference to the
pre-August 22, 1996 MIRS standard, as well as, the new disability
rules/MIRS for the period beginning August 22, 1996. Sample language
addressing the general and specific issues is included in section E.1.a.
below.
When deciding whether a cessation is appropriate at any time prior to
August 22, 1996, apply the pre-August 22, 1996 MIRS (see section A.1.
above). If the ALJ finds that cessation did
not occur prior to August 22, 1996,
apply the appropriate evaluation criteria in C. below to the period on and
after August 22, 1996.
For the period beginning on August 22, 1996, the evaluation criteria
applicable to an appeal of a CDR cessation of SSI childhood disability
benefits, when the cessation did not occur prior to August 22, 1996, are
contingent on whether the claim type is one that would require a
disability redetermination under Pub. L. 104-193, i.e.:
•
a case in which maladaptive behaviors in the prior personal/behavioral
area of functioning in former listings sections 112.00C.2 and
112.02B.2.c.(2) were material; i.e., the child would not have been found
disabled without consideration of those behaviors in that area of
functioning,
Not every case involving maladaptive behaviors requires a disability
redetermination. The controlling factor is whether the maladaptive
behaviors were material to finding the child disabled, e.g., the prior
personal/behavioral area of functioning (prior 112.02B.2.c.(2) of the
mental disorders listings) was involved in assessing the severity of the
impairment(s). For “maladaptive behaviors” in the prior
“personal/behavioral” area, see prior listing section
112.02B.2.c.(2) in the April 1, 1996 edition of 20 CFR, Appendix 1,
Subpart P, Part 404.
or
•
an age 18 case.
The ALJ decision must contain a discussion to support the evaluation
criteria applied, i.e., a clear statement as to whether or not the
requirements for a disability redetermination under Pub. L. 104-193 are
met (maladaptive behaviors were material in finding the child disabled at
the time of the original allowance, or still disabled at the comparison
point decision (CPD) if there was a prior CDR, or the case is an IFA
allowance or age-18 case).
1.
Case Type Does Not Require Disability Redetermination
If the case does not meet the requirements for a disability
redetermination under Pub. L. 104-193 as set out above, apply the
pre-August 22, 1996 MIRS for the period before August 22, 1996 and the
current MIRS for the period beginning August 22, 1996.
2.
Case Type Requires Disability Redetermination (IFA, Maladaptive Behaviors
Material, Age-18 Case)
Claimants meeting the childhood disability or age 18 redetermination
criteria, (i.e., IFA allowance, maladaptive behaviors material, age-18
case) will be evaluated as follows:
•
Apply the pre-August 22, 1996 MIRS for the period before August 22,
1996.
•
Apply the new childhood disability standard for
initial claims (except that step 1 of the
sequential evaluation process, i.e., SGA, will not apply) for the period
beginning August 22, 1996. The MIRS will not apply.
•
If the child has attained age 18, apply the adult standard for initial
claims for the period beginning with attainment of age 18 (except that
step 1 of the sequential evaluation process, i.e., SGA, will not apply).
The MIRS will not apply.
If the child attained age 18 before August 22, 1996, and after the
cessation date established by DDS, the age 18 standard would only apply
for months beginning on or after August 22, 1996 (see § 212(d) of
Pub. L. 104-193).
D. Pending CDR Cases in Which Cessation On or After August 22, 1996 is
Established by DDS
In CDR cases with a cessation date on or after August 22, 1996, schedule
the hearing in the usual manner. The Notice of Hearing sent to the
claimant and representative, if any, must include the new (current) MIRS
standard which will apply for the period on or after August 22, 1996.
Sample language addressing the general and specific issues is included in
section E.1.b. below.
There is a distinction between CDR
cessations and disability
redetermination cessations. The MIRS does
not apply to appeals of disability
redetermination cessations.
E. ALJ Decisional Language
1.
Issues
Because Pub. L. 104-193 amended the definition of disability and the MIRS
for title XVI children, revisions will be necessary with respect to the
statement of issues in the notice of hearing and in the decision. See the
following sample language below. Similar issues would be appropriate in
preparing the notice of hearing.
a.
Cases pending in HO with cessation prior to August 22, 1996 [Apply the
Pre-August 22, 1996 MIRS and current initial/MIRS standard]
The general issue is whether you continue to be eligible for Supplemental
Security Income, as an individual under age 18, within the meaning of
sections
1614(a)(3)(C) of
the Social Security Act.
The specific issue is whether you are still disabled as defined in the
Social Security Act. To decide whether you are still disabled for the
period before August 22, 1996, I will consider the medical improvement
review standard (MIRS) rules in effect before Public Law (Pub. L.) 104-193
was enacted. Those rules are found in the April 1, 1996 edition of
20 CFR
§416.994a.
If, using those rules, I find that you were still disabled up to August
22, 1996, and a disability redetermination is necessary under Pub. L.
104-193, new rules will apply. I will consider whether you are disabled
under the current childhood disability rules for initial claims, for the
period on and after August 22, 1996. Those rules are found in
20 CFR §
416.924. The exception to this is that step 1 of the sequential
evaluation process, the substantial gainful activity (SGA) step, will not
apply.
Under the rules in 20 CFR
§ 416.924, your impairment (or combination of impairments)
must meet, or medically or functionally equal, the requirements of a
listing in the Listing of Impairments in appendix 1 of subpart P of our
regulations.
If a disability redetermination is not necessary, I will consider whether
you are still disabled under the current MIRS rules in
20 CFR §
416.994a.
In addition, if the decision covers a period prior to age 18 and after
attainment of age 18, include the adult issue language for the period
beginning with attainment of age 18.
If the child attained age 18 before August 22, 1996, and after the
cessation date established by DDS, the age 18 standard would only apply
for months beginning on or after August 22, 1996 (see § 212(d) of
Pub. L. 104-193).
b.
New receipts with cessation on or after August 22, 1996 [Apply the Current
MIRS]
The general issue is whether you continue to be eligible for Supplemental
Security Income, as an individual under age 18, within the meaning of
sections 1614(a)(3)(C)
of the Social Security Act.
The specific issue is whether you are still disabled as defined in the
Social Security Act. To decide this, I will consider whether you are still
disabled under the medical improvement review standard (MIRS) rules in
20 CFR §
416.994a.
In addition, if the decision covers a period prior to age 18 and after
attainment of age 18, include the adult issue language for the period
beginning with attainment of age 18.
2.
Decisional Findings (CDR)
Specific findings should be made with respect to the pre-August 22, 1996
MIRS and/or the current initial standard or MIRS, as appropriate and set
out in C. above. The decision should include findings, appropriate to the
decision, using language along the following lines:
a.
For cases decided under the pre-August 22, 1996 standard (see A.1. above),
use MIRS decisional language and findings appropriate to that
period.
b.
For cases decided under the new (current) MIRS standard (see C.1. and D.
above), use the following sample findings, as appropriate:
•
The claimant was found to be disabled within the meaning of the Social
Security Act beginning __________.
•
The impairment(s) present as of ____________, the time of the most recent
favorable medical decision that the claimant was disabled was/were
____________.
•
The medical evidence establishes that there has been [no] improvement in
the claimant's medical impairment(s) since ________.
•
The following exception(s) to medical improvement applies:
__________.
•
The medical evidence establishes that the claimant currently has the
following medically determinable impairments: _____________.
[Findings on credibility of subjective complaints (including pain) should
be inserted as needed.]
•
The claimant's impairment(s) [still] [no longer) meets or equals the
severity of the listed impairment it met or equalled at the time of the
most recent favorable determination or decision.
•
The claimant has [does not have] a severe impairment or combination of
impairments.
•
The claimant's impairment(s) (or combination of impairments) meets [does
not meet] the requirements of a listing in the Listing of
Impairments.
•
The claimant's impairment(s) (or combination of impairments) [does not]
medically or functionally equal(s) the requirements of a listing in the
Listing of Impairments.
•
Therefore, the claimant has [does not have] a medically determinable
physical or mental impairment (or combination of impairments) which
results in marked and severe functional limitations.
•
The claimant's disability ceased on ________.
or
•
The claimant continues to be under a “disability” as defined
in the Social Security Act.
c.
For cases decided under the current standard for initial claims (see C.2.
above), the decision must contain a specific finding with respect to the
new definition of disability, as follows:
•
The claimant's impairment (or combination of impairments) meets [does not
meet], or medically or functionally equal(s), the requirements of a
listing in the Listings of Impairments in appendix 1 of subpart P.
•
Therefore, the claimant has [does not have] a medically determinable
physical or mental impairment (or combination of impairments) which
results in marked and severe functional limitations.
3.
Decisional Paragraph
The decisional paragraph must contain language along the following
lines:
Unfavorable
It is the decision of the Administrative Law Judge that the claimant's
eligibility for Supplemental Security Income under sections
1602 and
1614(a)(3)(C) of
the Social Security Act, ended effective _________, the end of the second
calendar month after the month in which the disability ceased.
Pub. L. 104-193 provides that benefit termination because of an
unfavorable redetermination decision cannot occur before July 1, 1997,
i.e., payments must be made through June 1997. Therefore, cases that
require a disability redetermination and the ALJ finds that disability
ceased, based on that redetermination, in any month before April 1997, the
decisional paragraph must be revised to reflect the above provision of
Pub. L. 104-193 regarding benefit termination.
Favorable
It is the decision of the Administrative Law Judge that the claimant
continues to be “disabled” under section
1614(a)(3)(C) of
the Social Security Act.
The component of the Social Security Administration responsible for
authorizing Supplemental Security Income payments will advise the claimant
regarding the nondisability requirements for these payments, and if
eligible, the amount and the month(s) for which payments will be
made.
F. Cover Notice for Transmitting Decision and Routing
Use the standard decision cover notice as appropriate. Follow existing
procedures for routing.
G. Hearing Office Tracking System (HOTS) Coding
In order to account to Congress for the expenditure of funds allocated
specifically for implementation of Pub. L. 104-193, SSA must distinguish
between redeterminations mandated by that law and redeterminations which
are done as part of the CDR process.
Hearing office staff will use the hearing type codes for cessations (11,
31, 41, etc.) for these title XVI CDR cases. However, staff will enter the
regulation basis codes, primary and secondary impairment codes, and an
“H” (special case code) into the HOTS. If an age-18
redetermination is done as part of the CDR, split the case by creating a
“21” record and enter “I” in the special case
code. See coding instructions in section VI. J. of the OHA childhood
disability instructions issued on June 6, 1997 (reissued on November 28,
1997 as HALLEX
HA 01540.030A) and the
memorandum dated March 12, 1998 from OHA's Associate Commissioner,
entitled “Impairment Codes for Supplemental Security Income (SSI)
Childhood Disability Cases.”
In the past, SSA used one code (3180) for children with an intellectual
disorder, children who had borderline intellectual functioning, and
children who had a learning disorder. A new, 4-digit impairment code
(3195) for the mental diagnostic category, borderline intellectual
functioning, has been established. In addition, the impairment code for
learning disorder is 3152. Borderline intellectual functioning (3195) and
learning disorder (3152) must not be
coded as 3180 (under intellectual disorder).
V. Appeals Council Procedures
A. ALJ Decision Establishes Cessation Before August 22, 1996
For any case in which the ALJ has issued a wholly or partially unfavorable
decision finding a cessation date before August 22, 1996 (the date of
enactment of Pub. L. 104-193), the pre-August 22, 1996 MIRS rules apply in
deciding the cessation issue
for the period prior to August 22, 1996.
These rules for application of the MIRS are found in the April 1, 1996
edition of 20 CFR §
416.994a and discussed in HALLEX
TI 5-4-30, pages 14-16.
The AC may take any of its usual actions in such cases including:
•
denying the request for review (R/R);
•
granting the R/R and issuing a decision;
•
remanding the case to an ALJ; or
1.
AC Denies R/R
No special action or notice is required when the AC denies a request for
review of an ALJ decision finding cessation before August 22, 1996.
2.
AC Grants Review and Issues Decision
If the AC grants a request for review of a wholly unfavorable or partially
favorable ALJ decision which established cessation prior to August 22,
1996, the AC must first apply the pre-August 22, 1996 MIRS rules for the
period prior to August 22, 1996. These prior rules are found in the April
1, 1996 edition of 20
CFR § 416.994a. If, after applying the pre-August 22, 1996
MIRS, the AC is prepared to find that cessation occurred before August 22,
1996, there is no need to consider the current MIRS.
If the AC is prepared to find that cessation did not occur prior to August
22, 1996, i.e., the claimant continues to be disabled on August 22, 1996,
the AC must apply the current applicable evaluation criteria under Pub. L.
104-193 for the period beginning August 22, 1996. The criteria applied
will depend on whether the case is one that requires a disability
redetermination under Pub. L. 104-193, i.e., IFA allowance, maladaptive
behaviors material, or age-18 case (see C. below).
3.
AC Remands Case to ALJ
If the AC remands the case to an ALJ for further proceedings, the AC Order
of Remand will advise the ALJ to apply the pre-August 22, 1996 medical
improvement review standard (MIRS) for the period prior to August 22, 1996
and the applicable current evaluation standard under Pub. L. 104-193 for
the period beginning August 22, 1996. The applicable evaluation standard
for the period beginning August 22, 1996 depends on whether a disability
redetermination is necessary under Pub. L. 104-193 (see C. below).
B. ALJ Decision Establishes Cessation On or After August 22,
1996
1.
AC Denies R/R
No special action or notice is required when the AC denies a request for
review of an ALJ decision finding cessation on or after August 22,
1996.
2.
AC Grants R/R and Issues Decision
If the AC is prepared to find cessation on or after August 22, 1996, the
AC must apply the current applicable evaluation criteria under Pub. L.
104-193 for the period beginning August 22, 1996. The criteria applied
will depend on whether the case is one that requires a disability
redetermination under Pub. L. 104-193, i.e., an IFA allowance, a
maladaptive behaviors material, or age-18 case (see C. below).
3.
AC Remands Case to ALJ
If the AC remands the case to an ALJ for further proceedings, the AC Order
of Remand will advise the ALJ to apply the pre-August 22, 1996 MIRS for
the period prior to August 22, 1996 and the applicable current evaluation
standard under Pub. L. 104-193 for the period beginning August 22, 1996
(see C. below).
For the period beginning on August 22, 1996, the evaluation criteria
applicable to an appeal of a CDR cessation of SSI childhood disability
benefits, when the cessation did not occur prior to August 22, 1996, are
contingent on whether the claim type is one that would require a
disability redetermination under Pub. L. 104-193, i.e.:
•
a case in which maladaptive behaviors in the prior personal/behavioral
area of functioning in former listings sections 112.00C.2 and
112.02B.2.c.(2) were material; i.e., the child would not have been found
disabled without consideration of those behaviors in that area of
functioning,
Not every case involving maladaptive behaviors requires a disability
redetermination. The controlling factor is whether the maladaptive
behaviors were material to finding the child disabled, e.g., the prior
personal/behavioral area of functioning (prior 112.02B.2.c.(2) of the
mental disorders listings) was involved in assessing the severity of the
impairment(s). For “maladaptive behaviors” in the prior
“personal/behavioral” area, see prior listing section
112.02B.2.c.(2) in the April 1, 1996 edition of 20 CFR, Appendix 1,
Subpart P, Part 404.
or
•
an age-18 case.
The AC decision must contain a discussion to support the evaluation
criteria applied, i.e., a clear statement as to whether or not the
requirements for a disability redetermination under Pub. L. 104-193 are
met (maladaptive behaviors were material in finding the child disabled at
the time of the original allowance, or still disabled at the comparison
point decision (CPD) if there was a prior CDR, or the case is an IFA
allowance or age-18 case).
1.
Case Type Does Not Require Disability Redetermination
If the case does not meet the requirements for a disability
redetermination under Pub. L. 104-193 as set out above, apply the
pre-August 22, 1996 MIRS for the period before August 22, 1996 and the
current MIRS for the period beginning August 22, 1996.
2.
Case Type Requires Disability Redetermination (IFA, Maladaptive Behaviors
Material, Age-18 Case)
Claimants meeting the childhood disability redetermination criteria,
(i.e., IFA allowance, maladaptive behaviors material, or age-18 case) will
be evaluated as follows:
•
Apply the pre-August 22, 1996 MIRS for the period before August 22,
1996.
•
Apply the new childhood disability standard for
initial claims (except that step 1 of the
sequential evaluation process, i.e., SGA, will not apply) for the period
beginning August 22, 1996. The MIRS will not apply.
•
If the child has attained age 18, apply the adult standard for initial
claims for the period beginning with attainment of age 18 (except that
step 1 of the sequential evaluation process, i.e., SGA, will not apply).
The MIRS will not apply.
D. Protest Case - Favorable ALJ Decision
The Appeals Council will follow existing procedures for handling protest
cases. If the AC exercises own motion or reopening authority, follow
“8001” procedures in HALLEX
.
E. Appeals Council Decisional Language
1.
Issues
Because Pub. L. 104-193 amended the definition of disability and the MIRS
for title XVI children, revisions will be necessary with respect to the
statement of issues in the decision. See the following sample language
below.
a.
Cases with cessation prior to August 22, 1996 [Apply the Pre-August 22,
1996 MIRS to the period before August 22, 1996, and current initial/MIRS
standard on and after August 22, 1996.]
The general issue is whether the claimant continues to be eligible for
Supplemental Security Income, as an individual under age 18, within the
meaning of sections
1614(a)(3)(C) of
the Social Security Act.
The specific issue is whether the claimant is still disabled as defined in
the Social Security Act. To decide whether the claimant was still disabled
for the period before August 22, 1996, the Appeals Council considers the
medical improvement review standard (MIRS) rules in effect before Public
Law (Pub. L.) 104-193 was enacted. Those rules are found in the April 1,
1996 edition of 20 CFR
§ 416.994a.
If, using those rules, the Appeals Council finds that the claimant was
still disabled up to August 22, 1996, and a disability redetermination is
necessary under Pub. L. 104-193, new rules will apply. The Appeals Council
then considers whether the claimant is disabled under the current
childhood disability rules for initial claims, for the period on and after
August 22, 1996. Those rules are found in
20 CFR §
416.924. The exception to this is that step 1 of the sequential
evaluation process, the substantial gainful activity (SGA) step will not
apply.
Under the rules in 20 CFR
§ 416.924, the impairment (or combination of impairments) must
meet or medically or functionally equal the requirements of a listing in
the Listing of Impairments in appendix 1 of subpart P of our
regulations.
If a disability redetermination is not necessary, the Appeals Council
considers whether you are still disabled under the current MIRS rules in
20 CFR §
416.994a.
In addition, if the decision covers a period prior to age 18 and after
attainment of age 18, include the adult issue language for the period
beginning with attainment of age 18.
If the child attained age 18 before August 22, 1996, and after the
cessation date established by DDS, the age 18 standard would only apply
for months beginning on or after August 22, 1996 (see § 212(d) of
Pub. L. 104-193).
b.
New receipts with cessation on or after August 22, 1996 [Apply the current
MIRS]
The general issue is whether the claimant continues to be eligible for
Supplemental Security Income, as an individual under age 18, within the
meaning of sections
1614(a)(3)(C) of
the Social Security Act.
The specific issue is whether the claimant is still disabled as defined in
the Social Security Act. To decide this, the Appeals Council considers
whether the claimant is still disabled under the medical improvement
review standard (MIRS) rules in
20 CFR §
416.994a.
In addition, if the decision covers a period prior to age 18 and after
attainment of age 18, include the adult issue language for the period
beginning with attainment of age 18.
2.
Decisional Findings (CDR)
Specific findings should be made with respect to the pre-August 22, 1996
MIRS and/or the current initial standard or MIRS, as appropriate and set
out in C. above. The decision should include findings, appropriate to the
decision, using language along the following lines:
a.
For cases decided under the pre-August 22, 1996 standard (see A.1. above),
use MIRS decisional language and findings appropriate to that
period.
b.
For cases decided under the new (current) MIRS standard (see C.1. and D.
above), use the following sample findings, as appropriate:
•
The claimant was found to be disabled within the meaning of the Social
Security Act beginning __________.
•
The impairment(s) present as of ____________, the time of the most recent
favorable medical decision that the claimant was disabled was/were
________________.
•
The medical evidence establishes that there has been [no] improvement in
the claimant's medical impairment(s) since ________.
•
The following exception(s) to medical improvement applies:
__________.
•
The medical evidence establishes that the claimant currently has the
following medically determinable impairments: _____________.
[Findings on credibility of subjective complaints (including pain) should
be inserted as needed.]
•
The claimant's impairment(s) [still] [no longer] meets or equals the
severity of the listed impairment it met or equalled at the time of the
most recent favorable determination or decision.
•
The claimant has [does not have] a severe impairment or combination of
impairments.
•
The claimant's impairment(s) (or combination of impairments) meets [does
not meet] the requirements of a listing in the Listing of
Impairments.
•
The claimant's impairment(s) (or combination of impairments) [does not]
medically or functionally equal(s) the requirements of a listing in the
Listing of Impairments.
•
Therefore, the claimant has [does not have] a medically determinable
physical or mental impairment (or combination of impairments) which
results in marked and severe functional limitations.
•
The claimant's disability ceased on ________.
or
•
The claimant continues to be under a “disability” as defined
in the Social Security Act.
c.
For cases decided under the current standard for initial claims (see C.2.
above), the decision must contain a specific finding with respect to the
new definition of disability, as follows:
•
The claimant's impairment (or combination of impairments) meets [does not
meet] or medically or functionally equal(s) the requirements of a listing
in the Listings of Impairments in appendix 1 of subpart P.
•
The claimant has [does not have] a medically determinable physical or
mental impairment (or combination of impairments) which results in marked
and severe functional limitations.
3.
Decisional Paragraph
Unfavorable
It is the decision of the Appeals Council that the claimant's eligibility
for Supplemental Security Income under sections
1602 and
1614(a)(3)(C) of
the Social Security Act ended effective _________, the end of the second
calendar month after the month in which the disability ceased.
Pub. L. 104-193 provides that benefit termination because of an
unfavorable redetermination decision cannot occur before July 1, 1997,
i.e., payments must be made through June 1997. Therefore, cases that
require a disability redetermination and the Appeals Council finds that
disability ceased, based on that redetermination, in any month before
April 1997, the decisional paragraph must be revised to reflect the above
provision of Pub. L.104-193 regarding benefit termination.
Favorable
It is the decision of the Appeals Council that the claimant continues to
be “disabled” under section
1614(a)(3)(C) of
the Social Security Act.
The component of the Social Security Administration responsible for
authorizing Supplemental Security Income payments will advise the claimant
regarding the nondisability requirements for these payments, and if
eligible, the amount and the month(s) for which payments will be
made.
F. OHA Case Control System (CCS) Coding
When the AC reviews a case and issues a decision, the analyst must provide
the appropriate regulation basis code and impairment codes. Follow the
coding instructions in section VII. K. of the OHA childhood disability
instructions issued on June 6, 1997 (reissued on November 28, 1997 as
HALLEX
HA 01540.030A) and in
the memorandum dated March 12, 1998 from OHA's Associate Commissioner,
entitled “Impairment Codes for Supplemental Security Income (SSI)
Childhood Disability Cases.”
In the past, SSA used one code (3180) for children with an intellectual
disorder, children who had borderline intellectual functioning, and
children who had a learning disorder. A new, 4-digit impairment code
(3195) for the mental diagnostic category, borderline intellectual
functioning, has been established. In addition, the impairment code for
learning disorder is 3152. Borderline intellectual functioning (3195) and
learning disorder (3152) must not be
coded as 3180 (under intellectual disorder).
VI. Inquiries
Hearing Office personnel should direct any questions concerning this
instruction to their Regional Office. Regional Office personnel only
should contact the Division of Field Practices and Procedures in the
Office of the Chief Administrative Law Judge at (703) 605-8530.
Headquarters personnel should route questions to their Branch Chiefs who
may contact the Office of Appellate Operations at 605-7100.
Attachment 1. Sample Language When Claimant Had a Hearing On The Issue of
Cessation Before Enactment of Public Law No. 104-193
CDR CASE THAT REQUIRES REDETERMINATION EFFECTIVE AUGUST 22, 1996 — ALJ Is Prepared To Find Cessation Did Not Occur Prior to August 22, 1996
We are writing to tell you about changes in the law that may affect your
Supplemental Security Income (SSI) claim.
The definition of disability for individuals under age 18 claiming SSI
benefits based on disability has changed. The law now provides that we
will consider a child disabled only if
•
he or she has a physical or mental condition or conditions that can be
medically proven and which result in marked and severe functional
limitations, and
•
the medically proven physical or mental condition or conditions must last
at least 12 months or be expected to result in death.
To result in marked and severe functional limitations, the physical or
mental condition or conditions must meet or medically or functionally
equal the requirements of a listing in the Listing of Impairments in
appendix 1 of subpart P of our regulations.
I will apply the new childhood disability rules for the period on and
after August 22, 1996, the date the new law was enacted.
What You Can Do
Before I issue my decision, you have the opportunity to show that you meet
the new disability rules. You may do
any or all of the following:
•
give us additional information;
•
give us written comments;
If you want another hearing, or want to send us additional information or
comments, you must let us know
in writing, within ten (10) days of the date you get this letter.
We assume you got this letter 5 days after the date on it unless you show
us that you did not get it within the 5-day period. You should send your
request for another hearing or any additional information or comments to
the address shown at the top of this letter.
What We Will Do
If I do not hear from you within 10 days of the date you get this letter,
I will assume you do not want to ask for another hearing or give us
additional information or comments. I will issue my decision based on the
information you gave us at your earlier hearing, and the information now
in your file.
If You Have Any Questions
If you have any questions, you may call or write to me at the telephone
number and address shown at the top of this letter.
|
|
[Name] |
|
|
Administrative Law Judge |
[cc:
Representative's Name (if any)
Address
City, State, Zip]
Attachment 2. Sample Language When Claimant Had a Hearing On The Issue of
Cessation Before Enactment of Public Law No. 104-193
CDR CASE — NO REDETERMINATION NEEDED — ALJ Is Prepared To Find Cessation Did Not Occur Prior to August 22, 1996
We are writing to tell you about changes in the law that may affect your
Supplemental Security Income (SSI) claim.
The definition of disability for individuals under age 18 claiming SSI
benefits based on disability has changed. The medical improvement review
standard sequence we follow in determining whether an individual is still
disabled has changed. The law now provides that under the new continuing
disability sequence, I will consider:
(1) Whether there has been medical improvement in the impairment(s)
(health problems) you had at the time of the most recent favorable
determination or decision. If there has been no medical improvement, I
will find that you are still disabled unless one of the exceptions to
medical improvement discussed in
20 CFR §
416.994a(e) or
(f)
applies;
(2) Whether the impairment(s) still meets or equals the severity of the
listed impairment that it met or equalled at the time of the most recent
favorable determination or decision. If the impairment(s) still meets or
equals that listed impairment, I will find that you are still disabled
unless one of the exceptions to medical improvement discussed in
20 CFR §
416.994a(e) or
(f)
applies;
(3) Whether you are still disabled under the rules in
20 CFR §
416.924. Under those rules, we will consider a child disabled only
if
•
he or she has a physical or mental condition or conditions that can be
medically proven and which result in marked and severe functional
limitations, and
•
the medically proven physical or mental condition or conditions must last
at least 12 months or be expected to result in death.
To result in marked and severe limitations, your impairment(s) must meet
or medically or functionally equal the requirements of a listing in the
Listings of Impairments in appendix 1 of subpart P of our
regulations.
I will apply the new childhood disability medical improvement review
standard rules for the period on and after August 22, 1996, the date the
new law was enacted.
What You Can Do
Before I issue my decision, you have the opportunity to show that you meet
the new disability rules. You may do
any or all of the following:
•
give us additional information;
•
give us written comments;
If you want another hearing, or want to send us additional information or
comments, you must let us know
in writing, within ten (10) days of the date you get this letter.
We assume you got this letter 5 days after the date on it unless you show
us that you did not get it within the 5-day period. You should send your
request for another hearing or any additional information or comments to
the address shown at the top of this letter.
What We Will Do
If I do not hear from you within 10 days of the date you get this letter,
I will assume you do not want to ask for another hearing or give us
additional information or comments. I will issue my decision based on the
information you gave us at your earlier hearing, and the information now
in your file.
If You Have Any Questions
If you have any questions, you may call or write to me at the telephone
number and address shown at the top of this letter.
|
|
[Name] |
|
|
Administrative Law Judge |
[cc:
Representative's Name (if any)
Address
City, State, Zip]