[Federal Register Volume 59, Number 73 (Friday, April 15, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-8265]


[[Page Unknown]]

[Federal Register: April 15, 1994]


  
  
  
  
  
  
  
  
  
  
  
  
  
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Part II





Department of Health and Human Services





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Social Security Administration



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Disability Reengineering Project Proposal; Notice
DEPARTMENT OF HEALTH AND HUMAN SERVICES

Social Security Administration

 

Process Reengineering Program; Disability Reengineering Project 
Proposal

AGENCY: Social Security Administration, HHS.

ACTION: Announcement of proposal and request for comments.

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SUMMARY: The Disability Process Reengineering Team of the Social 
Security Administration (SSA) announces a proposal to redesign the 
disability claims process for Social Security Disability Insurance and 
Supplemental Security Income (SSI) Disability and Blindness benefits. 
This notice contains the Proposal (as well as background information) 
of the Disability Process Reengineering Team (composed of SSA and State 
Disability Determination Service (DDS) employees). The aim of the 
proposal is to achieve dramatic improvements in customer service to the 
public. Accordingly, we seek comments on the proposal to ensure that it 
meets the needs of the public. The comments will be weighed in the 
Agency's subsequent decisions on implementation.

DATES: To be sure that your comments are considered we must receive 
them no later than May 27, 1994.

ADDRESSES: Submit your comments as follows: (1) Mail them to the Social 
Security Administration, PO Box 17052, Baltimore, MD 21235, or (2) 
telefax them to (410) 966-9884, or (3) deliver them to 4-N-3 Operations 
Building, 6401 Security Boulevard, Baltimore, MD 21235, between 8 a.m. 
and 4:30 p.m. on regular business days. If you telefax your comments, 
please do not also mail a hard copy document.

FOR ADDITIONAL COPIES CONTACT: Social Security Administration, PO Box 
17052, Baltimore, MD 21235, (410) 966-8255. The Proposal is available 
in alternative formats for visually impaired individuals. Please use 
this same telephone number to request the document in an alternative 
format.

SUPPLEMENTARY INFORMATION:

Background--What is the Reengineering Program?

    SSA began an Agency-wide program of Process Reengineering in the 
summer of 1993. The Process Reengineering Program is one way SSA is 
seeking to improve its overall service delivery process.
    The Process Reengineering Program essentially asks the question, 
``If SSA had the opportunity today to design the processes, what would 
they look like?'' In other words ``how would we design a process if we 
were starting over?'' The Program's objective is to fundamentally 
rethink and radically redesign SSA's work processes to achieve dramatic 
improvements in critical measures of performance. In this rethinking 
and redesign process, the ultimate aim is to achieve dramatically 
improved levels of service from the customer's perspective while 
enriching and improving the work lives of employees.
    The Process Reengineering Program is the culmination of an 
investigation by SSA of the reengineering efforts conducted by 
companies, public organizations, academic institutions, and consulting 
firms with ``hands on'' experience. The very positive findings from 
that investigation, combined with our concerns about our ability to 
provide the very best service to the public, led to the conclusion that 
a process reengineering effort was absolutely critical to SSA's 
objective of providing ``world class'' service to the American public.
    Based on analysis of what has worked best in other organizations, 
SSA developed a customized reengineering methodology. This methodology 
uses a reengineering team approach and combines a strong customer focus 
with classic management analysis techniques and computer modeling and 
simulation to intensely review a single business process. While the 
reengineering team is comprised of employees and experts who are very 
knowledgeable about the SSA process being redesigned, the methodology 
focuses heavily on obtaining the views of a broad segment of the 
public.

What Does the Disability Project Address?

    Despite the outstanding efforts of SSA and State DDS employees 
throughout the country, we continue to have difficulty providing a 
level of service to claimants for disability benefits that approaches 
what would be considered ``good'' service. The steps in the current 
disability process have not changed in any important way since the 
beginning of the Disability Insurance program in the 1950s. Yet case 
loads, types of disabilities, and the demographic characteristics of 
individuals with disabilities who are potentially eligible for benefits 
have changed radically.
    The State DDSs make the initial decisions about whether an 
applicant for Disability Insurance or SSI benefits is disabled. In 
1989, SSA forwarded to the State DDSs 1.6 million claims for disability 
benefits in the Disability Insurance and SSI programs. Claims have 
increased significantly in every year since that time. In 1994, the 
number of disability claims we will forward to the State DDSs is 
expected to reach about 2.7 million. The number of requests for 
hearings on denied claims is expected to reach 522,000--an increase of 
about 60 percent in the last 3 years. The result is that many claimants 
have to wait much too long at each stage in the process. SSA and State 
DDS employees are working longer and harder, while becoming 
increasingly frustrated about their inability to provide the type of 
service the public deserves.
    For these reasons, the first SSA reengineering project focuses on 
the process for claiming benefits--beginning with the initial claim and 
continuing through the payment of benefits or the final administrative 
appeal--under both the Disability Insurance program and the disability 
component of the SSI program.
    The scope of the assignment to the disability reengineering project 
team did not include making any changes to the statutory definition of 
disability or the amount of benefits for which individuals are 
eligible. Other issues relating to the disability programs are being 
addressed by SSA in other ways, including the continuing disability 
review process and the referral of individuals for vocational 
rehabilitation services.

What the Proposal Contains

    The proposal contained in this announcement is the product of the 
disability reengineering team. It begins by providing background on the 
current disability determination process. It discusses input received 
in person, by telephone and by mail, from almost 3,000 Social Security 
and State DDS employees, 750 members of the external community of 
individuals and organizations interested in SSA's disability programs, 
and from focus groups conducted with members of the public.
    We next provide a conceptual proposal for a new disability claims 
process; it gives a view of how the new process will work from the 
applicant's perspective. Many readers will want to know how these 
concepts will actually work in detail. However, the development of that 
level of information will not be done until SSA is confident that the 
basic concepts presented here have the potential to achieve the level 
of service we seek to provide. We are committed to extensive future 
dialogue on the next level of detail once we make the final decision on 
these concepts.
    The proposal contains many charts, some of which may be difficult 
to read in the Federal Register format. We considered deleting some of 
them but decided that the greater public interest was served by 
publishing the entire proposal as it was presented on March 31, 1994, 
to the Executive Steering Committee.

How Should Comments Be Presented to the Project Team?

    The Project Team seeks public reaction to the concepts in the 
proposal. We are particularly interested in your response to the 
following questions concerning the proposal's goals:
     Does the proposal have the potential to provide a process 
that is easy for claimants and those who assist claimants to access and 
understand?
     Will it enable SSA and the State DDS to make the right 
decision the first time a case is adjudicated?
     Will it result in dramatically improved process times?
     Will it result in a more efficient use of SSA and State 
DDS personnel?
     Will it create jobs for employees in the process that are 
satisfying?
    In considering these questions, you are encouraged to identify 
factors that would assure that the concepts presented will achieve 
these goals. To the extent that the proposal is not seen as achieving 
these goals, alternative suggestions about how to do so will be 
welcome.

What Happens Next?

    The Project Team will receive all comments from the public and 
employees. The comments will be analyzed and used to revise and/or 
refine the proposal. The final proposal of the team will be presented 
to the Executive Steering Committee for the project for its review and 
recommendations. Members of this committee include SSA and HHS General 
Counsel executives, the presidents of the 8 union locals/councils that 
represent SSA employees, a State DDS Administrator, and the presidents 
of 6 associations of SSA and State DDS employees that work in the 
disability process.
    The Commissioner of Social Security will seek the advice and 
recommendations of the Executive Steering Committee in making her 
decisions on how SSA will proceed.

    Dated: March 29, 1994.
Rhoda M. G. Davis,
Director, Process Reengineering Program.

Introduction

    A claimant for disability benefits from the Social Security 
Administration faces a lengthy, bewildering process. An initial 
decision from SSA will likely take more than three months. Anywhere 
from 16 to 26 employees will handle the claim before the initial 
decision is reached. If that decision is a denial, and the request for 
reconsideration is also denied, chances are the claimant will hire an 
attorney. It will likely be an additional eight months or more before a 
response on the hearing is received, and even longer before a check is 
issued or eligible dependents' benefits are paid. As many as 45 
employees could handle the claim.
    If the claim for benefits is approved after a hearing, the claimant 
will view the SSA disability application process as one which requires 
jumping through lengthy bureaucratic hoops. Dealing in person or on the 
telephone with SSA field office staff and, possibly, the State 
disability determination service (DDS) staff at the initial and 
reconsideration levels, the claimant must appear at a hearing and 
finally talk to a person in a position to make a decision on the claim. 
The claimant will rate SSA employees as courteous and knowledgeable, 
but the disability determination process as bureaucratic and 
unresponsive.
    Congress agrees with this assessment; in May 1991, the House Ways 
and Means Committee cited SSA for an excellent job of delivering 
retirement benefits, but gave SSA a failing grade for the way it 
processes applications for disability benefits, with Chairman Dan 
Rostenkowski stating, ``* * * those who are unfortunate enough to 
become disabled find their problems compounded by inefficiencies at 
SSA.''
    SSA employees reiterate this belief, as illustrated in the 
following statement by a claims representative, ``I wish we could stop 
shuffling all this stuff back and forth. I don't really know what the 
DDS is looking for, so I try to do the best generic job I can on these 
forms.''
    The report of the National Performance Review reflected 
Administration concern by directing SSA to ``Improve Social Security 
disability claims processing to better serve people with disabilities * 
* *''.
    SSA has reached a critical juncture; disability claims receipts at 
the initial claims and appeals levels have reached all time highs--
Fiscal Year (FY) 1995 claims requiring a disability determination will 
increase 69 percent over FY 1990 levels; appeals workloads will 
increase 75 percent over FY 1990 receipt levels; employees in field 
offices, DDSs and hearing offices are overburdened despite recent 
significant increases in productivity. As an agency, SSA must vie for 
scarce administrative resources in an era of spending limitations and 
competing social spending priorities. The ability of SSA to cope with 
further workload increases is questionable; it is clear that only 
radical change can address the disability service delivery problems 
facing the Agency today.
    SSA is meeting this challenge with an unprecedented effort to 
reengineer the entire disability process--from the point a potential 
claimant first contacts the Agency to file for disability benefits, 
through the disability allowance or final administrative appeal. 
Reengineering the disability process involves asking the question, 
``Given what we know about technology and resources available to us 
today, how can we best design a disability process for the 1990s and 
beyond?'' This report will answer that question by proposing a radical 
redesign of disability program policies and procedures, to ensure 
dramatic improvements in the way the entire process works and is 
managed to serve the American public.
    The report represents the collective efforts and recommendations of 
the 18-member Disability Reengineering Team, composed of Federal and 
State DDS employees, operating under the auspices of the Director of 
the SSA Process Reengineering Program, and the SSA Executive Steering 
Committee formed to provide advice to the Commissioner on the 
disability reengineering process change proposal development.
    The Executive Steering Committee provided the following parameters 
for the disability reengineering proposal: ``Every aspect of the 
process except the statutory definition of disability, individual 
benefit amounts, the use of an administrative law judge as the 
presiding officer for administrative hearings and vocational 
rehabilitation for beneficiaries is within the scope of this 
reengineering effort.''
    The recommendations in this report represent the Team proposal to 
SSA for reengineering the disability process; this is not a final SSA 
proposal. The Commissioner of SSA asks interested parties to comment on 
the proposal within the next 60 days. The Team looks forward to 
receiving comments from the community concerned with the delivery of 
disability benefits.

Current Process

    The procedures in the current process have not changed in any 
significant way since the Social Security Disability Insurance (DI) 
program began in the 1950s, a time when caseloads, demographic 
characteristics of claimants, types of disabilities, and available 
technology were radically different.
    In the 1970s, Congress federalized State programs of cash 
assistance to the aged, blind and disabled into the Supplemental 
Security Income (SSI) program and added this to the responsibilities of 
SSA. SSA then adopted the DI disability determination procedures for 
SSI blind and disabled claims.

Overview

    A claim must now pass through from 1 to 4 decisional paths within 
SSA to receive a favorable disability decision. The initial claim, 
reconsideration, administrative law judge (ALJ) hearing and Appeals 
Council review levels all involve multi-step uniform procedures for 
evidence collection, review, and decisionmaking.
    The process starts at the initial level when an individual first 
applies for DI or SSI disability benefits on the basis of a disabling 
physical or mental condition. An individual calls the national toll-
free telephone number and is referred to a local SSA field office or 
visits or calls one of 1,300 local field offices to apply for benefits. 
Field office personnel assist with application completion, obtain 
detailed medical and vocational history and screen nonmedical 
eligibility factors. Field office personnel forward the claim to 1 of 
54 State disability determination services where medical evidence is 
developed and a final determination is made regarding the existence of 
a medically determinable impairment which meets the definition of 
disability.
    After possible quality assurance review in the DDS or in the SSA 
regional Disability Quality Branch, the claim is returned to the field 
office. Thirty-nine percent of these claims were paid in FY 1993; 
denials are retained pending possible appeal. Allowed DI claims are 
sent to one of 7 processing centers (which include the Office of 
Disability and International Operations and the 6 Program Service 
Centers) for final processing and storage, as well as adjudication of 
claims for dependents. Allowed SSI claims remain in the field office 
for payment and retention.
    An initial claim currently takes an average of 100 days to process 
from the time it is filed until a final decision is made according to 
SSA's computer-based processing time measurements. However, a better 
understanding of how long the process takes from the claimant's 
perspective comes from a 1993 study conducted by SSA's Office of 
Workforce Analysis, which showed that an average claimant waits up to 
155 days from the initial contact with SSA until receiving an initial 
claim decision notice. Sixteen to 26 employees will handle the claim 
during this period.

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    An appeal of the initial decision can be made within 60 days of the 
denial notice (see Fig. 2). Reconsiderations were requested on 48 
percent of denied claims in FY 1993. The local field office receives 
the request, updates the information, and forwards the claim file to 
the DDS for review, possible medical development, and final medical 
decision. The determination is made by a different adjudicative team 
than the one that made the initial determination.
    After possible quality assurance review in the DDS or in the 
regional Disability Quality Branch, about 14 percent of these claims 
are returned to the field office for payment, and forwarding to the 
processing centers, while the remaining denials are forwarded to the 
field office for retention, pending a request for a hearing before an 
ALJ. The average reconsideration itself takes about 50 days according 
to SSA's computer-based processing time reports--however, according to 
the Office of Workforce Analysis study, a claimant has now been 
involved with the SSA process for roughly 8 months from the point of 
initially contacting the Agency, and up to 36 different employees could 
have handled the claim.

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    Within 60 days of receiving an unfavorable reconsideration 
decision, a claimant can request a hearing before an ALJ (Fig. 3). In 
FY 1993, about 75 percent of all reconsideration denials were appealed 
to ALJs. At this point, a claimant has usually retained an attorney or 
other representative to assist in pursuing the claim for benefits. 
About 75 percent of all claimants retain a representative at the 
hearing. The local field office receives the request for hearing and 
forwards it with the claim file to one of 132 local SSA hearings 
offices. Hearing office personnel review the file for possible 
additional development, conduct a hearing, and render a final decision.
    Allowed DI claims are sent to a processing center for final action 
and storage, as well as adjudication of claims for dependents. Allowed 
SSI claims are returned to the local field office for income and 
resource development, and payment. Denied claims are forwarded to the 
Appeals Council for retention in case a request for review is filed. 
The hearing process itself takes about 265 days according to computer-
based reports. However, according to the Office of Workforce Analysis 
study, a claimant has been dealing with SSA for over a year and a half 
at this point in the process.

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    If still dissatisfied with an unfavorable decision, a claimant or 
representative has 60 days to request a review of the ALJ decision by 
the Appeals Council (Fig. 4). About 23 percent of hearing decisions are 
unfavorable and forwarded to the Appeals Council pending possible 
appeal. The Appeals Council considers about 18 percent of all ALJ 
dispositions, including cases it reviews on its own motion.
    Requests for Appeals Council review are typically received directly 
from the claimant's representative. The Appeals Council may either deny 
review, issue a decision, or remand the claim to an ALJ. The Appeals 
Council remands claims to the ALJ level about 27 percent of the time 
for subsequent development and decision. Denied claims, representing 
about 70 percent of the Appeals Council dispositions, are held in the 
Appeals Council for possible appeal to Federal District court.
    Allowed DI claims are sent to a processing center for final action 
and storage, as well as adjudication of claims for dependents. Allowed 
SSI claims are returned to the local field office for income and 
resource development, and payment. According to processing time 
reports, this part of the process takes on average about 100 days; 
however, according to the Office of Workforce Analysis study, a 
claimant has spent almost 2 years dealing with SSA since initially 
contacting the Agency.

Trends

    The current disability process served SSA and the public well for a 
number of years. However, over the last several years, as workloads 
have increased dramatically, the current process has been placed under 
increasing stress. The upward trend in the number of claims for 
benefits SSA has received is reflected as follows:

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    The growth in claims and benefits awarded is reflected in increases 
in the number of beneficiaries SSA pays and the growth in Federal 
program outlays over recent years.

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    The increase in workload has occurred concurrently with significant 
downsizing activity in SSA and staffing fluctuations in the State DDSs.

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    Even with the downsizing, the total costs for processing initial 
disability and appeals determinations (excluding the costs for 
processing the Sullivan v. Zebley court case) remain enormous--more 
than half of the total administrative costs (including DDS costs) for 
SSA in FY 1993 were devoted to this task.

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    Despite these funds, and despite directing a larger percentage of 
the SSA resources toward disability initial claims and appeals 
processing in recent years, average processing times for initial 
claims, as well as appeals, have escalated dramatically since 1988.

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    At least part of the increase in processing time results from the 
time added as the claim moves from one employee or facility to another 
(handoffs), and waits at each employee's workstation to be handled 
(queues). As workloads increase, the amount of time a claim waits at 
each processing point grows.
    ``Task time'' is the time employees actually devote to working 
directly on a claim, rather than the total amount of time it takes for 
a claimant to receive a final decision. Based on the Office of 
Workforce Analysis study, a claimant can wait as long as 155 days from 
the first contact with SSA until receiving an initial claim decision 
notice--of which only 13 hours of this is actual task time. The same 
study reveals a claimant can wait as long as 550 days from that initial 
contact through receipt of the hearing decision notice--of which only 
32 hours is actual task time.

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    The Team's research revealed that the problems of queues, handoffs, 
and task time are compounded by problems with the way SSA takes claims, 
collects evidence, and determines disability. These problems are 
discussed in the following section.

Research Summary and Analysis

Overview of Methodology and Findings

    The Team's methodology called for extensive site visits and 
interviews with members of the disability community. Team members 
visited 421 locations in 33 States and conducted over 3,600 interviews. 
Almost 2,900 of these involved front-line employees, managers and 
executives. The interviews provided insights into the problems 
confronting the disability program and recommendations for solving 
these problems. The Team conducted an additional 111 interviews by 
telephone.
    The Team also interviewed over 750 parties external to SSA--members 
of the medical, legal, advocate and interest group community--for their 
views. Finally, the Team has analyzed the results of focus groups 
involving disability claimants and the general public in order to 
determine what SSA customers experience and expect from the disability 
process.
    The information collected from these activities resulted in the 
framework for the analysis and recommendations that follow. At a 
minimum, the Team was determined to address the most pressing problems 
identified by SSA employees, claimants, and other interested parties. 
Not surprisingly, all three groups were in general agreement regarding 
many of the problems with the SSA disability process. All agreed that 
the current fragmented process takes too long to provide applicants a 
decision, and leaves them confused about who has responsibility for 
their claim, and puzzled about the status of their claim during various 
points in the process. Additionally, nearly all believe that many 
claimants can and should assume more responsibility for submitting 
evidence and pursuing their claim.
    Most view the reconsideration step as little more than a rubber 
stamp of the initial determination, creating additional work for 
employees and yet another bureaucratic obstacle for claimants and their 
representatives. Some believe a face-to-face interview with the 
decisionmaker is vital to reaching a fair, accurate determination; 
others believe just as strongly that the decision should be reached on 
the basis of a paper review, and that a face-to-face interview can lead 
to subjective decisions that are not based on objective criteria.
    Higher allowance rates at the ALJ level lead to the perception that 
different adjudicative standards apply at the initial and appeals 
levels. The public, in particular, believes that it is necessary to 
hire an attorney to maneuver through this process, and voices 
resentment at having to do so. Quality reviews and Appeals Council 
reviews are often mentioned as areas where opportunities exist for 
improving current processes.

The Case for Change

The Public and Third Parties Find the Current Process Confusing

    Many applicants enter the SSA disability process uninformed about 
the process itself and the definition of disability. They are unaware 
of the criteria for establishing disability and the evidence they will 
be required to submit. Even third parties and advocate organizations, 
often more knowledgeable than the general public about SSA procedures, 
experience difficulty obtaining meaningful information about the status 
of their clients' claims, finding that they often are transferred from 
one employee to another.
    Disability claimants face a ``one size fits all'' approach to the 
intake and processing of their claim, finding themselves answering 
questions they believe are intrusive and irrelevant to their claim. 
Front-line employees currently devote hours to completing forms and 
obtaining information which may not be necessary for a finding of 
disability. If the claim is approved, whether at the initial or 
appellate level, claimants and their representatives, as well as front-
line employees, are concerned about the complicated procedures and 
length of time it takes to effectuate payment and entitle eligible 
dependents.

Evidence Collection and Decision Methodology Pose Problems

    The collection of medical evidence presents problems as the case is 
developed in the DDS. Medical providers who have treated the claimant 
often do not understand the requirements for establishing disability, 
and find the forms for the collection of medical evidence confusing. In 
order to compensate for poor or missing medical evidence, DDSs purchase 
consultative examinations, devoting substantial resources to 
scheduling, purchasing, and processing these examinations.
    Once the medical evidence has been collected, the methodology used 
to reach a decision on the case is complex and controversial. Criteria 
originally developed to identify and evaluate cases simply and rapidly 
have grown increasingly complex as a result of court decisions and 
changes in medical technology. Today's 330 different vocational rules, 
which have been added to SSA's regulations since 1980, can lead to 
varying interpretations resulting in inconsistent decisions.
    Claimants and their representatives have learned their chances for 
a favorable decision improve if they appeal their claim to an ALJ. A 
variety of factors may be contributing to this. The facts of many cases 
change over time as a claimant's condition changes. ALJs often have 
access to information not considered at lower levels in the process 
because earlier decisionmakers are not as likely to have face-to-face 
interaction with the claimant. Finally, the fragmented nature of SSA's 
policy making, policy issuance, training and review apparatus all 
reinforce the differences.

The Fragmented Process Contributes to Difficulties

    The fragmented nature of the disability process is driven by and 
exacerbated by the fragmentation in SSA's policy making and policy 
issuance mechanisms. Policy making authority rests in several 
organizations with few effective tools for ensuring consistent guidance 
to all disability decisionmakers. Different vehicles exist for 
conveying policy and procedural guidance to decisionmakers at different 
levels in the process. While the standards for disability 
decisionmaking are uniform, they are expressed in different wording in 
the various policy vehicles.
    Training on disability is not delivered in a consistent manner, nor 
is it provided simultaneously to disability decisionmakers across or 
among levels in the process. Mechanisms for reviewing application of 
policy among levels of the process are fragmented and inconsistent. 
Review of DDS decisions is heavily weighted toward allowances; no 
systematic quality assurance program is in place for hearing decisions 
although the opportunity for feedback from the appeals council or court 
cases is heavily weighted toward denials.
    The organizational fragmentation of the disability process creates 
the perception that no one is in charge of it. SSA measures the process 
from the perspective of the component organizations involved, rather 
than the perspective of the claimant. Multiple organizations (field 
offices, DDSs, hearings offices, Appeals Council operations, and 
processing centers) have jurisdiction over the claim at various points 
in time, with each line of authority managing toward its own goals 
without responsibility to the overall outcome of the process. 
Additionally, the impact of one component's work product on other 
components is not measured, further contributing to the fragmentation 
of the process. Each component's narrow responsibilities reinforce a 
lack of understanding among component employees of the roles and 
responsibilities of other employees in different components.

Customer Research and Demographics

Customer Research

    The National Performance Review report, released in the fall of 
1993, calls upon agencies to establish customer service standards equal 
to the best in the business to guide their operations. Federal agencies 
are encouraged to identify ``the customers who are, or should be served 
by the agency,'' and survey these customers ``to determine the kind and 
quality of services they want and their level of satisfaction with 
existing services.''
    SSA customers include the individuals who file for social security 
or supplemental security income disability benefits, or who are 
potential filers for these benefits. They were surveyed through a 
series of 12 focus groups conducted throughout the country last fall. 
Participants represented a demographically diverse cross-section of 
current claimants, including those who had been initially denied, and 
who filed for a reconsideration or hearing; new beneficiaries; and the 
general public. Two focus groups were conducted with non-English 
speaking participants.
    Focus group participants were quick to offer their frank opinions; 
the general view was that they:

--Wait too long for a decision--this is the most common complaint; the 
claim process is a struggle characterized by stress, fear, and the 
anger associated with running out of funds;
--Do not understand the program or process--what happens to the claim 
after initial contact with SSA is unclear, they view SSA multiple 
requests for medical information with skepticism, do not understand 
their decision and believe it was reached arbitrarily;
--Want more information and personal contact--while they would prefer 
to deal with one person for all claim business, their major preference 
is to receive accurate, consistent information from all SSA sources and 
to be provided substantive status reports on their claim;
--View the initial and reconsideration denials as bureaucratic 
precursors to final approval at the ALJ level--they believe the process 
is designed ``to make you go away'';
--Resent the need for attorney assistance to obtain benefits--the 
process should not be so complicated that an attorney is needed; and
--Want more active involvement in pursuit of their claim--they want to 
make their case directly to the decisionmaker, and would personally 
obtain needed additional evidence to speed the decision on their claim.

Demographics

    Changes in demographics of the general population and in SSA's 
claimant population present challenges as well as opportunities for SSA 
as it focuses on claimant needs and reengineers its disability 
determination process.
    American society has changed dramatically since the DI program 
began in the 1950s. This is reflected in an increased demand for SSA's 
services, changes in the characteristics of claimants seeking benefits, 
and complexities in claim related workloads and processes.
    The demographic character of the SSA disability claimant population 
has changed as well. The enactment of the SSI program in the 1970's 
added individuals who have sketchy work histories, increased the number 
of individuals filing based on disabilities such as mental impairments, 
and provided for eligibility of disabled children. Additionally, the 
requirements of the SSI program added complex and time consuming 
development of non-disability eligibility factors such as income, 
resources and living arrangements. The 1990 U.S. Supreme Court 
decision, Sullivan v. Zebley, resulted in increased claims for 
children; children comprised 21 percent of all SSI claims in 1992, up 
from 11 percent in 1988. Claims for homeless individuals and others 
with special needs have increased in recent years. These claimants 
require significant intervention and assistance to navigate the 
disability claims process.
    A trend in the general population which is reflected in SSA's 
disability claimant population is the increased number of people in the 
United States for whom English is not the native language. Recent 
national Census data indicate that 1 in 7 people speak a language other 
than English in the home; this is an increase of almost 38 percent in 
the last 10 years. SSA will need to accommodate the special 
communication needs of these claimants in its ongoing claimant contacts 
and in public information vehicles.
    Forty percent of claimants filing for disability benefits and 
polled in a recent SSA survey had filed for or received benefits from 
Aid to Families with Dependent Children, welfare or social services 
within the past year. Approximately three-fourths of them were awarded 
this assistance and three-fourths of those awardees were still 
receiving benefits when they applied for disability benefits. SSA has 
the opportunity to develop productive relationships with these entities 
to improve the processing of disability claims for mutual customers.
    Technological advances such as personal computers, facsimile 
machines, electronic mail, and videoconferencing are increasingly 
available to our claimants, their representatives, medical providers 
and other third parties involved in the disability process. SSA can 
take advantage of these capabilities to offer expanded service options 
and to modernize evidence collection.

New Process

Overview

    A claimant for disability benefits under the proposed process will 
be provided a full explanation of SSA's programs and processes at the 
initial contact with SSA. The claimant and third parties will be able 
to assist in the development of the claim, deal with a single contact 
point in the Agency, and request a personal interview with the 
decisionmaker at each level of the process. Additionally, if the 
claimant requests a hearing, the issues and evidence to be addressed at 
the hearing will be focused, the responsibilities of representatives 
clarified and, if the claim is approved, the effectuation of payment to 
the claimant, eligible dependents and the representative streamlined.
    The new process will result in a correct decision at the initial 
level by simplifying the decision methodology, providing consistent 
direction and training to all decisionmakers, enhancing the collection 
and development of medical evidence, and employing a single quality 
review process across all levels.
    A single claim manager will handle most aspects of the initial 
level claim, thus eliminating many steps caused by numerous employees 
handling discrete parts of the claim (handoffs) and the time lost as 
the claim waits at each employee's workstation to be handled (queues). 
This will reduce the time needed to rework files and redevelop 
information from the same medical sources. Levels of appeal will be 
combined and improved, reducing the need to redevelop nonmedical 
eligibility factors after a favorable decision because less time will 
have elapsed since initial filing.
    The proposed process will enable the current work force to handle 
an increased number of claims, freeing the most highly skilled staff 
(physicians and ALJs) to work on those cases and tasks that make the 
best use of their talents, and targeting expenditures for medical 
evidence to those areas most useful in determining disability.
    Employees will perform a wider range of functions, using their 
skills to their full potential, enabling them to meet the needs of 
claimants and minimize unnecessary rework. The proposed process will 
facilitate employees' ability to do the total job by providing 
technology and the support to use that technology.

The New Process--A Brief Description

    Under the proposed process, the number of appeal steps will be 
reduced and opportunities for personal interaction with decisionmakers 
will be increased. At the initial claim level, the claimant will be 
offered a range of options for filing a claim, pursuing evidence 
collection, and conferring with a decisionmaker, using various modes of 
technology to interact with SSA. At the hearing level, the claimant 
will have an additional opportunity to participate in a personal 
conference and meet with a decisionmaker.

BILLING CODE 4190-29-P

TN15AP94.016


A Disability Claim Manager Will Handle Initial Disability Claims 
Processing

    Claimants initially will deal almost exclusively with a disability 
claim manager--a front-line employee knowledgeable about the medical 
and nonmedical factors of entitlement--responsible for making the 
initial determination, with technical support if necessary, to allow or 
deny the claim.
    The disability claim manager will determine the level of 
development needed to make a disability decision using a simplified 
determination methodology; relying on evidence submitted by or through 
the efforts of the claimant (whenever the claimant is able to do this); 
requesting medical evidence or a functional assessment; or referring 
complex medical questions to a medical consultant for expert advice and 
opinion, if necessary. The disability claim manager will contact the 
claimant if the decision on a claim appears to be a denial. The claim 
manager will explain the situation including the evidence that was 
considered, and offer the claimant an opportunity to submit additional 
information as well as an option for an interview in-person or via 
telephone, before the claim is formally denied.
    All initial claims will be subject to a randomly selected 
postadjudicative national sample review designed to determine whether 
disability policies are being properly applied. Extensive ongoing 
training will enable adjudicators to consistently issue correct 
decisions. By the time the initial decision is issued, the claim will 
have been handled by seven or eight employees.

An Adjudication Officer Will Prepare the Claim for a Hearing

    A claimant wishing to appeal an unfavorable initial decision to an 
ALJ will continue to have 60 days to file a request for a hearing. The 
disability claim manager will assist the claimant with the request, and 
forward the claim to an adjudication officer. The adjudication officer 
will be responsible for explaining the hearing process to the claimant, 
as well as conducting personal conferences, preparing claims, and 
scheduling hearings. The adjudication officer will have the authority 
to allow the claim at any point prior to the hearing that sufficient 
evidence becomes available to support a favorable decision.

An ALJ Will Conduct the Hearing

    The ALJ will conduct the hearing and issue the decision. At any 
point in the process where the claim is approved, it will be returned 
to the claim manager for payment effectuation, whether the claim is DI, 
concurrent, or SSI. Denied claims will be forwarded to the Appeals 
Council, for retention in the event of civil action. At this point, an 
average claimant will have been dealing with SSA for approximately five 
months from the first contact with the Agency. A total of up to 14 
employees will have been involved with the process during this entire 
period.
    An ALJ decision will be the final decision of the Secretary, 
subject to judicial review, unless the Appeals Council reviews the ALJ 
decision on its own motion. The Appeals Council will conduct reviews of 
ALJ allowances and denials prior to effectuation, at its discretion, 
and on its own motion. The Appeals Council will also review all claims 
in which a civil action has been filed, and decide whether the ALJ 
decision should be defended as the final decision of the Secretary. If 
a claim is selected for own motion review, a total of 17 employees will 
have been involved in the process from first claimant contact with SSA 
through Appeals Council review.

Claimants Will Receive World-Class Service

    The time from a claimant's first contact with SSA until issuance of 
a final initial decision, will be reduced from an average of 155 days 
(as cited in SSA's Office of Workforce Analysis study) to less than 40 
days, enhancing SSA's capacity to provide world-class service. 
Available employees will be able to process a greater number of claims, 
and devote more time to each claimant, providing more personalized 
service.
    The time from a claimant's first contact with SSA until issuance of 
a hearing decision, will be reduced from an average of a year and a 
half (as cited in SSA's Office of Workforce Analysis study) to 
approximately 5 months.

BILLING CODE 4190-29-P

TN15AP94.017


TN15AP94.018


TN15AP94.019


TN15AP94.020


TN15AP94.021


BILLING CODE 4190-29-C

Detailed Description of New Process

Process Entry and Intake

SSA Will Customize Its Disability Claims Entry and Intake Processes to 
Maximize Access, Efficiency, Accuracy, and Personal Service
    The disability claims entry and intake processes will reflect the 
SSA commitment to providing world-class service to the public. The 
hallmarks of the process will be accessible, personal service that 
ensures timely and accurate decisions. SSA will work to make potential 
claimants better informed about the disability process and fully 
prepare them to participate in it. SSA will also be flexible in 
providing modes of access to the claims process that best meet the 
needs of claimants and the third parties who act on their behalf. SSA 
will provide claimants with a single point of contact for all claims-
related business. Finally, SSA will ensure that the disability 
decisionmaking process promotes timely and accurate decisions.
SSA Will Make Information About Its Disability Programs Available to 
Potential Claimants Prior to Entry Into the Process
    SSA will make available to the general public comprehensive 
information packets about the Disability Insurance (DI) and 
Supplemental Security Income (SSI) disability programs. The packets 
will include information about the purpose of the disability programs; 
the definition of disability; the basic requirements of the programs; a 
description of the adjudication process; the types of evidence needed 
to establish disability; and the claimant's role in pursuing a claim.
    SSA will make disability information packets commonly available in 
the community, both at facilities frequented by the general public 
(libraries, neighborhood resource centers, post offices, the Department 
of Veterans Affairs offices, and other Federal government 
installations) and at facilities frequented by potential claimants 
(hospitals, clinics, other health care providers, schools, employer 
personnel offices, State public assistance offices, insurance 
companies, and advocacy groups or third party organizations that assist 
individuals in pursuing disability claims). SSA studies have shown that 
claimants frequently rely on advice from their physicians and from 
State public assistance personnel in deciding whether to file a claim 
for disability benefits. Therefore, SSA will make a special effort to 
target its public information activities at these and other known 
sources of referrals for claims. SSA will also make the disability 
information packets available electronically.
    In addition to comprehensive program information, the packets will 
describe the types of information that a claimant will need to have 
readily available when the individual files a claim. It will also 
contain two basic forms: the first, designed for completion by the 
claimant, will include general identifying information and will serve 
as the claimant's starter application for benefits; the second, 
designed for completion by the treating source(s), will request 
specific medical information about a claimant's alleged impairments. 
SSA will encourage claimants to review the information in the packet 
and have the basic forms completed prior to telephoning or visiting an 
SSA office to apply for disability benefits. Claimants filing will be 
encouraged to immediately submit starter applications to protect the 
filing dates for benefits. The starter application will serve as a 
claim for both programs, but it will include a disclaimer should the 
claimant want to preclude filing for benefits based on need (i.e., 
SSI).
SSA Will Permit Claimants to Choose the Mode of Entry Into the Process 
That Best Meets Their Individual Needs
    The disability claims entry process will be multi-faceted, allowing 
claimants the maximum flexibility in deciding how they will participate 
in the process. Claimants may choose to enter the disability claims 
process by telephoning the SSA toll-free number, electronically, by 
mail, or by telephoning or visiting a local office. Claimants may also 
rely on third parties to provide them assistance in dealing with SSA. 
Finally, claimants may formally appoint representatives to act on their 
behalf in dealing with SSA. SSA field managers will also have the 
flexibility to tailor the various service options to their local 
conditions, considering the needs of client populations, individual 
claimants, and the availability of third parties who are capable of 
contributing to the application process.
    If an individual submits a starter application by mail or 
electronically, SSA will contact the claimant to schedule an 
appointment for a claims intake interview or, at the claimant's option, 
conduct an immediate intake interview by telephone.
    If an individual telephones SSA to inquire about disability 
benefits, the SSA contact will explain the requirements of the 
disability program, including the SSA definition of disability, and 
provide a general explanation of evidence requirements. The SSA contact 
will determine whether the individual has the disability information 
packet, and mail it or advise the claimant regarding possible means of 
electronic access. If an individual indicates a desire to file a claim 
at that time, the SSA contact will complete the starter application 
available on-line as part of the automated claims processing system to 
protect the claimant's filing date and schedule an appointment for a 
claims intake interview. The interview may be in person or by telephone 
at the claimant's option. If the individual has no medical treating 
sources, the SSA contact will annotate this information within the on-
line claim record.
    If a claimant visits an SSA office, the SSA contact will refer the 
claimant for an immediate claims intake interview or, at the claimant's 
option, complete the starter application and schedule a future 
appointment for an intake interview.
    In all cases, appointments for claims intake interviews will be 
made available within a reasonable time period, generally 3 to 5 
working days, but no later than two weeks.
    Local management will determine how to best accommodate claimants' 
needs in learning about the disability process and completing a claims 
intake interview. Depending on an individual's circumstances, such 
accommodation may involve: referral to the nearest location for 
obtaining an information packet which can then be mailed in; an 
immediate telephone or in-person interview; arranging for an on-site 
visit from an SSA representative; or referral to appropriate third 
parties who can provide assistance. Additionally, depending on the 
nature of the individual's disability, SSA may encourage the individual 
to file in person when it appears that a face-to-face interview will 
assist in the proper claims intake and development. Face-to-face 
interviews, when considered necessary by either the claimant or SSA, 
can also be accomplished via videoconferencing. In any case, SSA will 
make every reasonable effort to meet the needs of the claimant in 
completing the application process.
    Similarly, local managers will modify the claims entry and intake 
process to provide maximum flexibility for representatives who act on 
behalf of claimants or third parties who can assist claimants in 
completing the application process. Such accommodations may include, 
but are not limited to: (1) Using automated means to interact with SSA 
to protect a claimant's date of filing (e.g., telephone, fax, or E-
mail); (2) providing appointment slots for third parties to accompany 
claimants to interviews or to provide assistance during telephone 
claims on a claimant's behalf; (3) out-stationing SSA personnel at a 
third-party location to obtain applications and/or medical evidence, 
when appropriate; and (4) providing open appointment'' scheduling to 
permit claimants to contact SSA within a flexible band of time. 
Interested third parties will be encouraged to participate in the 
development of claims by becoming certified by SSA to do so.
    Local managers will also conduct outreach efforts that are designed 
to meet the needs of hard-to-reach populations or assist those 
individuals unable to access the SSA claims process without 
considerable intervention. As appropriate, outreach efforts may be 
facilitated through videoconferencing, teleconferencing or other 
electronic methods of obtaining and processing claims information to 
provide timely service despite claimants' geographic or social 
isolation.
A Disability Claim Manager Will Be Responsible for a Disability Claim 
From Intake Through Payment
    A disability claim manager will have responsibility for the 
complete processing of an initial disability claim. The disability 
claim manager will be a highly-trained individual who is well-versed in 
both the disability and nondisability aspects of the program and has 
the necessary knowledge, skills, and abilities to conduct personal 
interviews, develop evidentiary records, and adjudicate disability 
claims to payment. However, the disability claim manager will also be 
able to call on other SSA resources such as medical and technical 
support personnel to provide advice and assistance in the claims 
process.
    The disability claim manager will rely on an automated claims 
processing system that will permit the disability claim manager to: 
gather and store claims information; develop both disability and 
nondisability evidence; share necessary facts in a claim with SSA 
medical consultants and specialists in nondisability technical issues; 
analyze evidence and prepare well-rationalized decisions on both 
disability and nondisability issues; and produce clear and 
understandable notices that accurately convey all necessary information 
to claimants.
    The disability claim manager will be the focal point for claimant 
contacts throughout the claim intake and adjudication process. The 
disability claim manager will explain the disability program to the 
claimant, including the definition of disability and how SSA determines 
if a claimant meets the disability requirements. The disability claim 
manager will also convey what the claimant will be asked to do 
throughout the process; what the claimant may expect from SSA during 
this process, including anticipated timeframes for decision; and how 
the claimant can interact with the disability claim manager to obtain 
more information or assistance. The disability claim manager will 
advise the claimant regarding the right to representation and provide 
the appropriate referral sources for representation. The disability 
claim manager will also advise the claimant regarding community 
resources, including the names of organizations that could help the 
claimant pursue the claim. The goal will be to give claimants access to 
the decisionmaker and allow for ongoing, meaningful dialogue between 
the claimant and the disability claim manager.
Claims Intake and Development Will Be Directed at Reaching a Decision 
in the Most Timely and Accurate Manner
    The disability claim manager will conduct a thorough screening of 
the claimant's disability and nondisability eligibility factors. If the 
claimant appears ineligible for either disability program based on the 
claimant's allegations and evidence presented during the claim intake 
interview, the disability claim manager will explain this to the 
claimant. If the claimant decides not to file a claim, the disability 
claim manager will give the claimant an informal denial notice.
    If the claimant decides to file, the disability claim manager will 
complete appropriate application screens from the automated claims 
processing and decision support system. Impairment-specific questions 
will assist the claim manager in obtaining information that is relevant 
and necessary to a disability decision. Based on the claimant's 
statements and the evidence that is available at that interview, the 
disability claim manager will determine the most effective way to 
process the claim. If the evidence is sufficient to decide the claim, 
the disability claim manager will take necessary action to issue a 
decision and, if necessary, effectuate payment. The disability claim 
manager will determine what additional evidence is required to 
adjudicate the claim and will take steps to obtain that evidence. Such 
steps may include asking the claimant to obtain further medical or 
nonmedical evidence where feasible, requesting medical evidence 
directly from treating sources, or ordering further medical 
evaluations.
    The disability claim manager will decide whether to defer 
nondisability development (e.g., requesting SSI income and resource 
information, or developing DI dependents' claims) or do it 
simultaneously with development of the disability aspects of the claim. 
In making this decision, the disability claim manager will take into 
account the type of disability alleged, evidence and other information 
presented by the claimant, and other relevant circumstances, e.g., 
terminal illness, homelessness or difficulty in recontacting the 
claimant. Because the disability claim manager maintains ownership of 
the claim throughout the initial decision-making process, the 
disability claim manager will be in the best position to choose the 
most efficient and effective manner of providing claimants with timely 
and accurate decisions while meeting claimants' individual service 
needs.
    Although the disability claim manager will be responsible for the 
adjudication of an initial claim, the disability claim manager will 
call in other staff resources, as necessary. With respect to disability 
decisionmaking, the disability claim manager will, in appropriate 
circumstances, refer claims to medical consultants to obtain expert 
advice and opinion. Similarly, other staff resources will be called 
upon for technical support in terms of certain claimant contacts and 
status reports; development of nondisability issues including auxiliary 
claims or representative payee issues; and payment effectuation. 
However, the disability claim manager will make final decisions on both 
the disability and nondisability aspects of the claim.
Claimants Will Be Partners in the Processing of Their Disability Claims
    Throughout the disability claims process, SSA will encourage 
claimants to be full partners in the processing of their claims. To the 
extent that they are able, claimants and their families and other 
personal support networks will actively participate in the development 
of evidence to substantiate their claim for disability benefits. SSA 
will provide assistance and/or engage third party resources, when 
necessary and appropriate. SSA will keep claimants informed of the 
status of their claims, advise claimants regarding what additional 
evidence may be necessary, and inform claimants what, if anything, they 
can do to facilitate the process.
    At the completion of the claims intake interview, the disability 
claim manager will issue a receipt to the claimant that will identify 
what to expect from SSA and the anticipated timeframes. It will also 
identify what further evidence or information the claimant has agreed 
to obtain. Finally, it will provide the name and telephone number of 
the disability claim manager for any questions or comments which the 
claimant may have.
SSA Will Recognize That Some Third Parties Can Develop Complete 
Application Packages
    Certain third party organizations may be willing to provide a 
complete disability application package to SSA. Based on local 
management's assessment of service area needs and the availability of 
qualified organizations, SSA will certify third party organizations who 
are capable of providing a complete application package, including 
appropriate application forms and medical evidence necessary to 
adjudicate a disability claim. In such claims, SSA will permit the 
third party to identify potential claimants, screen for disability and 
nondisability criteria, and contact SSA to protect the filing date. The 
third party will interview the claimant; complete all applications and 
related forms; obtain completed treating source statements; and obtain 
additional medical evaluations, when appropriate. Using procedures 
agreed on with local management, the third party will submit claims for 
adjudication by a disability claim manager. The disability claim 
manager may elect to contact the claimant for the purpose of verifying 
identity or other claims-related issues, as appropriate. SSA will 
monitor such third parties to ensure that quality service is provided 
to claimants and to prevent fraud.
Claimants Will Have the Opportunity for a Personal Interview Before SSA 
Makes an Initial Disability Denial Decision
    When the evidence does not support an allowance, the disability 
claim manager will provide the claimant an opportunity for a personal 
interview before issuing the initial denial determination. The 
interview will be in person, by videoconference, or by telephone, at 
the claimant's option and as the disability claim manager determines is 
appropriate under the circumstances. In appropriate circumstances, the 
predenial interview may follow the initial intake interview. The 
purpose of the predenial interview will be to advise the claimant of 
what evidence has been considered and to identify what further 
evidence, if any, is available that bears on the issues. If such 
further evidence exists, the disability claim manager will advise the 
claimant to obtain the evidence or, as appropriate, assist the claimant 
in obtaining it.
Initial Disability Decisions Will Use a ``Statement of the Claim'' 
Approach
    The initial disability determination will use a ``statement of the 
claim'' approach. The statement of the claim will set forth the issues 
in the claim, the relevant facts, the evidence considered, including 
any evidence or information obtained during the predenial interview, 
and the rationale in support of the determination. The statement of the 
claim not only reflects the SSA commitment to fully explaining the 
basis for its action but also recognizes that claimants need clear 
information about the basis for the determination to make an informed 
decision regarding further appeal.
    Much of the information that will provide the basis for the 
statement of the claim will be available on-line as part of the 
automated claims processing and decision support system. Adjudicators 
will create the statement of the claim and whatever supplementary 
information is necessary for a legally sufficient notice to the 
claimant based on the information in the decision support system. For 
allowance decisions, the statement of the claim will be more 
abbreviated than for denial decisions; however, it will contain 
sufficient information to facilitate quality assurance reviews and/or 
continuing disability reviews. The statement of the claim will be part 
of the on-line claim record and will be available to other adjudicators 
as the basis and rationale for the Agency action, if the claimant seeks 
further administrative review.

Disability Decision Methodology

The Methodology for Deciding Disability Claims Will Promote Consistent, 
Equitable, and Timely Disability Decisions

    SSA must have a structured approach to disability decisionmaking 
that takes into consideration the large number of claims (2.7 million 
initial disability decisions in FY 1994) and still provides a basis for 
consistent, equitable decisionmaking by adjudicators at each level. The 
approach must be simple to administer, facilitate consistent 
application of the rules at each level, and provide accurate results. 
It must also be perceived by the public as straightforward, 
understandable and fair. Finally, the approach must facilitate the 
issuance of timely decisions.
    The cornerstone of any approach is, of course, the statutory 
definition of disability. Under the statute, disability (for adults) 
means the: ``* * * inability to engage in any substantial gainful 
activity by reason of any medically determinable physical or mental 
impairment which can be expected to result in death or which has lasted 
or can be expected to last for a continuous period of not less than 12 
months * * * An individual shall be determined to be under a disability 
only if his physical or mental impairment or impairments are of such 
severity that he is not only unable to do his previous work but cannot, 
considering his age, education, and work experience, engage in any 
other kind of substantial gainful work which exists in the national 
economy * * *'' (section 223(d) of the Social Security Act)
    The decision-making approach is the foundation on which SSA will 
base the claim intake process and evidence collection. The focus will 
be, first, to establish a solid medical basis for documenting that an 
individual has a medically determinable physical or mental impairment. 
Second, once the evidence establishes a medically determinable 
impairment, SSA will use additional medical findings to provide a solid 
link between the disease entity and the loss of function caused by the 
impairment(s).

Disability Decisionmaking for Adult Claims Will Be a Four-Step 
Evaluation Process

    The disability decision methodology will consist of four steps that 
are based on the statutory definition of disability. They are:

Step 1--Is the individual engaging in substantial gainful activity?
    If yes, deny.
    If no, continue to Step 2.
Step 2--Does the individual have a medically determinable physical 
or mental impairment?
    If no, deny.
    If yes, continue to Step 3*.
Step 3--Does the individual have an impairment that is included in 
the Index of Disabling Impairments?
    If yes, allow*.
    If no, continue to Step 4.
Step 4--Does the individual have the functional ability to perform 
substantial gainful activity?
If yes, deny.
If no, allow*.

    *An impairment must meet the duration requirement of the 
statute; a denial is appropriate for any impairment that will not be 
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
    Any individual who is engaging in substantial gainful activity will 
not be found disabled regardless of the severity of the individual's 
physical or mental impairments. If a claimant is performing substantial 
gainful activity at the time a claim is filed, SSA will determine that 
the claimant is not disabled based on the demonstrated ability to 
engage in substantial gainful activity.
    Under the current process, in determining whether a claimant is 
performing or has performed substantial gainful activity, SSA generally 
considers the amount of the claimant's earnings, less any impairment-
related work expenses. However, there are several threshold levels of 
earnings that need to be considered and, depending on the actual amount 
earned, SSA evaluates whether a claimant's work is comparable to that 
of unimpaired individuals in the community who are doing the same or 
similar occupations, or whether the work is substantial gainful 
activity based on prevailing pay scales in the community.
    Under the new process, SSA will simplify the monetary guidelines 
for determining whether an individual (except those filing for benefits 
based on blindness) is engaging in substantial gainful activity. In 
making this determination, SSA will evaluate the work activity based on 
the earnings level that is comparable to the upper earnings limit in 
the current process (i.e., $500). A single earnings level will simplify 
the evidentiary development necessary to evaluate work activity and 
establish the appropriate onset date of disability. SSA will continue 
to exclude impairment-related work expenses in evaluating whether a 
claimant's earnings constitute substantial gainful activity. SSA will 
continue to use separate earnings criteria to evaluate the work 
activity of blind individuals as in the current process.
Step 2--Medically Determinable Impairment
    Because the statute requires that disability be the result of a 
medically determinable physical or mental impairment, the absence of a 
medically determinable impairment will justify a finding that the 
individual is not disabled.
    Under the current regulations, SSA considers, as a threshold 
matter, whether an individual has a medically determinable impairment 
or combination of impairments that is ``severe.'' A severe impairment 
is defined as one that significantly limits the individual's physical 
or mental abilities to do work activities such as walking, standing, 
sitting, hearing, seeing, understanding, carrying out, or remembering 
simple instructions, using judgment, etc.
    Under the new approach, SSA will consider whether a claimant has a 
medically determinable impairment, but will no longer impose a 
threshold severity requirement. Rather, the threshold inquiry will be 
whether the claimant has a medically determinable physical or mental 
impairment. To establish the presence of a medically determinable 
impairment, evidence must show an impairment that results from 
anatomical, physiological, or psychological abnormalities which are 
demonstrable by medically acceptable clinical and laboratory diagnostic 
techniques.
    SSA will continue to evaluate the existence of a medically 
determinable impairment based on a weighing of all evidence that is 
collected, recognizing that neither symptoms nor opinions of treating 
physicians alone will support a finding of disability. There must be 
medical signs and findings established by medically acceptable clinical 
or laboratory diagnostic techniques which show the existence of a 
physical or mental impairment that results from anatomical, 
physiological, or psychological abnormalities which, in the opinion of 
the Secretary, could reasonably be expected to produce the symptoms or 
substantiate any opinion evidence provided. Depending on the nature of 
a claimant's alleged impairments, SSA will consider the extent to which 
medical personnel other than physicians can provide evidence of a 
medically determinable impairment.
    There will be an exception to the requirement that evidence include 
medically acceptable clinical and/or laboratory diagnostic techniques. 
This will occur when, even if SSA accepted all of the claimant's 
allegations as true, SSA still could not establish a period of 
disability; under these circumstances, SSA will not require evidence to 
establish the existence of a medically determinable impairment. For 
instance, if a claimant describes a condition as one that will clearly 
not meet the 12-month duration requirement, (e.g., a simple fracture), 
SSA will deny the claim on the basis that even if the allegations were 
medically documented, SSA could not establish a period of disability.
Step 3--Index of Disabling Impairments
    If an individual has a medically determinable physical or mental 
impairment documented by medically acceptable clinical and laboratory 
techniques, and the impairment will meet the duration requirement, SSA 
will compare the claimant's impairment(s) against an index of severely 
disabling impairments. In contrast to the Listing of Impairments in the 
current regulations, the index will contain fewer impairments and have 
less detail and complexity. The index will describe impairments that 
will result in death or impairments that are so debilitating that any 
individual would be unable to engage in substantial gainful activity 
regardless of any reasonable accommodations that an employer might make 
in accordance with the Americans with Disabilities Act. The index will 
be designed to be equitable, easy to understand, and consistent with 
the statutory definition of disability.
    The index will function to quickly identify severely disabling 
impairments; the index will not attempt to describe ideal medical 
documentation requirements for each and every body system as occurs 
with the current Listings. The index will consist of descriptions of 
specific impairments and the medical findings that are used to 
substantiate the existence and severity of the particular disease 
entity. The index will not attempt to measure the functional impact of 
an impairment on the individual; functional impact will be considered 
at Step 4 in the process. The medical findings in the index will be as 
nontechnical as possible and will exclude such things as calibration or 
standardization requirements for specific tests and/or detailed test 
results (e.g., pulmonary function studies or electrocardiogram 
tracings). The index will be simple enough so that laypersons will be 
able to understand what is required to demonstrate a disabling 
impairment in the index. Additionally, SSA will draw no inferences or 
conclusions about the effect of a claimant's impairments on his or her 
ability to function merely because a claimant's impairment(s) does not 
meet the criteria in the index. Finally, SSA will no longer use the 
concept of medical equivalence'' in relation to the index, as it now 
uses in applying the Listing of Impairments.
Step 4--Ability to Engage in Any Substantial Gainful Activity
    In the final step in determining disability, SSA will consider 
whether an individual has the ability to perform substantial gainful 
activity despite any functional loss caused by a medically determinable 
physical or mental impairment. If an individual retains the ability to 
perform substantial gainful activity, then an individual does not meet 
the statutory definition of disability.
    Presently, there are no generally accepted measurement criteria for 
determining an individual's ability to function in relation to work-
related activities. Currently, SSA assesses residual functional 
capacity by analyzing the objective medical findings and other 
available evidence and translating this information into functional 
loss and residual capacity for work activities.
    Additionally, there are also no definitive sources for identifying 
the physical and mental requirements of ``baseline'' work functions 
that are required to engage in substantial gainful activity. SSA 
currently relies on the Department of Labor definitions regarding the 
physical and mental demands of work in the national economy, and relies 
on related reference sources and independent experts regarding the 
existence of particular occupations and jobs in the national economy.
    Under the new process, SSA will define the physical and mental 
requirements of substantial gainful activity and, will measure as 
objectively as possible whether an individual meets these requirements. 
How SSA will achieve this is described in the following sections.

SSA Will Develop Instruments That Provide A Standardized Measure of 
Functional Ability

    Under the current process, SSA relies on available clinical and 
laboratory findings, treating source opinions, the claimant's 
description of his or her abilities and limitations, and third party 
observations of the claimant's limitations in determining the 
claimant's residual functional capacity. Residual functional capacity 
is the claimant's remaining capacity for work activities despite the 
limitations or functional loss caused by his or her impairments.
    Under the new process, SSA will develop, with the assistance of the 
medical community and other outside experts from public and private 
disability programs, standardized criteria which can be used to measure 
an individual's functional ability. These standardized measures of 
functional ability will be linked to clinical and laboratory findings 
to the extent that SSA needs to document the existence of a medically 
determinable impairment that results from anatomical, physiological, or 
psychological abnormalities which could reasonably be expected to 
produce the functional loss. However, extensive development of all 
available clinical and laboratory findings is not necessarily effective 
in evaluating an individual's functional ability to perform basic work 
activities.
    Functional assessment instruments will be designed to measure, as 
objectively as possible, an individual's abilities to perform a 
baseline of occupational demands that includes the principal dimensions 
of work and task performance, including primary physical, 
neurophysical, psychological, and cognitive processes. Examples of task 
performance include, but are not limited to: Physical capabilities, 
such as sitting, standing, walking, lifting, pushing, pulling; mental 
capabilities, such as understanding, carrying out, and remembering 
simple instructions; using judgment; responding appropriately to 
supervisors and co-workers in usual work situations; and responding 
appropriately to changes in the routine work setting; and postural and 
environmental limitations. Functional assessment instruments will be 
designed to realistically assess an individual's abilities to perform a 
baseline of occupational demands.
    SSA will be primarily responsible for documenting functional 
ability using the standardized measurement criteria. In the near term, 
SSA will solicit functional information from treating medical sources, 
other nonmedical sources, and from claimants in a manner that is 
similar to the current process. In the future, the standardized 
measurement criteria will be widely available and accepted so that 
functional assessments may be performed by a variety of medical 
sources, including treating sources. The SSA goal will be to develop 
functional assessment instruments that are standardized, that 
accurately measure an individual's functional abilities and that are 
universally accepted by the public, the advocacy community, and health 
care professionals. Ultimately, documenting functional ability will 
become the routine practice of physicians and other health care 
professionals, such that a functional assessment with history and 
descriptive medical findings will become an accepted component of a 
standard medical report.
    The prospect of universal health coverage may offer a unique 
opportunity for SSA to work with the public and private sector to 
develop standards that both can use. For example, medical insurance 
payors (whether public or private) may want some way of measuring the 
effectiveness and necessity of treatment that is prescribed by the 
individual's treatment source; SSA will want these same types of 
measures to determine how well an individual is able to function 
despite his or her impairment(s). Similarly, if all individuals have 
treating sources under universal health coverage, SSA can expect that 
complete functional assessment measurements will be readily available 
from a treating source. Finally, universal health coverage may enable 
SSA to access medical records from health care providers who may be 
operating under some contractual or other relationship with Federal 
agencies and/or a statutory requirement that health care providers 
cooperate in providing evidence as a condition of receiving Federal 
funds.
    SSA will use the results of the standardized functional measurement 
in conjunction with a new standard that SSA will develop to describe 
basic physical and mental demands of a baseline of work that represents 
substantial gainful activity and that exists in significant numbers in 
the national economy.

SSA Will Identify Baseline Occupational Demands That Represent 
Substantial Gainful Activity

    Under the current regulations, after assessing a claimant's 
residual functional capacity, SSA evaluates whether the claimant can 
meet the physical and mental demands of his or her past relevant work. 
Past relevant work is usually work that a claimant performed in the 
last 15 years.
    If the claimant is unable to perform his or her past work, SSA then 
evaluates whether the claimant can perform other work in the national 
economy. In making this decision, SSA relies on medical-vocational 
guidelines (the ``Grid''). The Grid rules represent major functional 
and vocational patterns and reflect the analysis of various vocational 
factors (age, education and work experience) in combination with the 
claimant's residual functional capacity (which is used to determine the 
claimant's maximum sustained work capacity for sedentary, light, 
medium, heavy or very heavy work).
    In promulgating the Grid rules, SSA has taken administrative notice 
of the existence of unskilled jobs that exist in the national economy 
at the various functional levels. Therefore, when all the findings of 
fact regarding a claimant's functional ability and vocational factors 
coincide with the corresponding criterion of a rule, the existence of 
other work in the national economy is conclusively established. 
However, if any finding of fact does not coincide with the criterion of 
a rule, the rules can only provide a framework for decisionmaking. In 
these situations, adjudicators must consult vocational resources or 
obtain expert testimony to resolve the question of whether other work 
exists in the national economy that the claimant can perform.
    Under the new approach, SSA will conduct research and, working in 
conjunction with outside experts, will specifically identify the 
activities that comprise a baseline of occupational demands needed to 
perform substantial gainful activity. In the current process, an 
example of comparable ``baseline'' criteria are the functional 
requirements of unskilled, sedentary work. In establishing the 
functional activities that comprise an appropriate baseline of 
occupational demands, SSA will ensure that:
    (1) The functional activities are a realistic reflection of the 
demands of occupations that exist in significant numbers in the 
national economy;
    (2) The occupations are those that can be performed in the absence 
of prior skills or formal job training; and
    (3) The baseline of occupational demands that becomes the standard 
for evaluating the ability to perform substantial gainful activity 
considers any reasonable accommodations that employers are expected to 
make under the Americans with Disabilities Act.

The Effect of Age on Ability to Perform Substantial Gainful Activity

    The effect of aging on the ability to perform substantial gainful 
work is very difficult to measure, especially in the context of today's 
world when individuals are living longer than preceding generations. 
Despite this change, the demographic characteristics of those preceding 
generations continue to provide the framework for disability 
decisionmaking because SSA's approach for deciding disability has 
changed little since the inception of the DI program.
    The statute recognizes that age should be considered in assessing 
disability on the assumption that the ability to make a vocational 
adjustment to work other than work an individual has previously done 
may become more difficult with age. In determining the impact of age, 
recognition should be given to the changes that occur with each 
succeeding generation. Accordingly, in the new process, SSA will 
establish age criterion in relation to the full retirement age. The 
full retirement age will gradually increase over time, based on the 
recognition that succeeding generations can expect to remain in the 
workforce for longer periods than the preceding generation.
    In applying age criterion under the new process, an individual who 
falls within the prescribed number of years preceding the full 
retirement age will be considered as ``nearing full retirement.'' In 
establishing what the prescribed number of years should be, SSA will 
conduct research and consult with outside experts on the relationship 
between age and an individual's ability to make vocational adjustments 
to work other than work the individual has done in the recent past.
    SSA will rely on the age of the individual in relation to the full 
retirement age to decide which of two decision paths to follow as 
described in the next two sections.

Individuals Who Are Not Nearing Full Retirement

    For an individual who is not nearing full retirement, SSA will 
compare the individual's functional abilities against the functional 
demands of the baseline work. SSA will no longer rely on the medical-
vocational guidelines and/or expert testimony to identify whether work 
exists in the national economy that the claimant can perform. The 
ability to perform the baseline work will represent a realistic 
opportunity to perform substantial gainful activity that exists in 
significant numbers in the national economy and a finding of disability 
will not be appropriate.
    However, anyone, regardless of age, who cannot perform the baseline 
work will be considered unable to engage in substantial gainful 
activity, and a finding of disability will be justified. The range of 
work represented by less than the baseline will be considered so narrow 
that despite any other favorable factors, such as young age or higher 
education or training, an individual would not be expected to have a 
realistic opportunity to perform substantial gainful work in the 
national economy.
    For individuals who are not nearing full retirement, the ability or 
inability to perform previous work is not a significant factor. These 
individuals should be capable of making a vocational adjustment to 
other work, as long as they are functionally capable of performing the 
baseline work.

Individuals Who Are Nearing Full Retirement

    For individuals who are nearing full retirement, SSA will compare 
the individual's functional abilities against the functional demands of 
the individual's previous work. Individuals nearing full retirement age 
can not be expected to make a vocational adjustment to work other than 
work they have performed in the recent past. However, consistent with 
the statute, if an individual, even one nearing full retirement age, is 
capable of performing his or her previous work, SSA will find that the 
individual is not disabled.
    For those individuals who have no previous work, SSA will compare 
the individual's functional abilities to the baseline work, and a 
finding of not disabled will be appropriate if the individual is 
capable of performing the baseline work. In such claims, the fact that 
the individual has no previous work is usually not related to the 
existence of his or her impairment(s), and a finding of disability will 
not be appropriate for these individuals if they retain the capacity 
for the baseline work.

The Effect of Education on Ability to Perform Substantial Gainful 
Activity

    The statute also recognizes that education may play a role in an 
individual's ability to perform substantial gainful activity. 
Experience demonstrates that educational level alone, i.e., the 
numerical grade level that an individual has attained may not be a good 
indicator of ability to function. Education is generally completed in 
the remote past when compared to the age at which the majority of 
disability claimants file for benefits. Completion of a certain 
educational level in the remote past, without any practical application 
of that education in recent work activity, has no positive effect on an 
individual's ability to perform substantial gainful activity.
    In relying on standardized functional assessments, SSA will be 
measuring both the individual's physical and mental abilities, and 
education will be appropriately reflected in the assessment of an 
individual's cognitive abilities. However, further evaluation of a 
claimant's educational level will not be required because, in 
establishing the functional activities that comprise an appropriate 
baseline of occupational demands, SSA will not assume that individuals 
have prior skills or significant formal job training. Thus, additional 
formal education will have little impact on an individual's ability to 
perform the baseline of occupational demands.

SSA Will Rely on Medical Consultants to Provide Necessary Expertise in 
the Decisionmaking Process

    SSA will continue to rely on medical consultants to provide expert 
advice and opinion regarding medical questions and issues that will 
arise in deciding disability claims. Disability adjudicators at all 
levels of the administrative review process will call on the services 
of medical consultants to interpret medical evidence, analyze specific 
medical questions, and provide expert opinions on existence, severity 
and functional consequences of medically determinable impairments. If a 
medical consultant is called on to offer expert advice and opinion, the 
medical consultant will provide a written analysis of the issues and 
rationale in support of his or her opinion. The written analysis will 
be included in the record and will be considered with the other medical 
evidence of record by disability adjudicators at all levels of 
administrative review. Additionally, medical consultants will assist in 
the training of other consultants and disability adjudicators; contact 
other health care professionals to resolve medical questions on 
specific claims; perform public relations and training with the medical 
community; and participate in SSA quality assurance efforts.

Childhood Disability Methodology

    As with adults, SSA must have a structured approach to disability 
decisionmaking in childhood claims that takes into consideration the 
relatively large number of claims and still provides a basis for 
consistent, equitable decisionmaking by adjudicators at all levels of 
administrative review. The approach for childhood claims must also 
derive from the statute. Under the statute,

    An individual will be considered to be disabled for purposes of 
this title if he is unable to engage in any substantial gainful 
activity by reason of any medically determinable physical or mental 
impairment which can be expected to result in death or which has 
lasted or can be expected to last for a continuous period of not 
less than 12 months (or in the case of a child under the age of 18, 
if he suffers from any medically determinable physical or mental 
impairment of comparable severity). (Section 1614(a)(3)(A) of the 
Social Security Act).

Disability Decisionmaking For Childhood Claims Will Be a Four-Step 
Evaluation Process

    The disability decision methodology for childhood claims will 
consist of four steps that are based on the statutory definition of 
disability.
    As with adults, the approach is one that provides accurate 
decisions that can be achieved efficiently and cost-effectively, 
primarily by ensuring that documentation requirements are directed 
toward the ultimate finding of disability. The four steps are:

Step 1--Is the child engaging in substantial gainful activity?
    If yes, deny.
    If no, continue to Step 2.
Step 2--Does the child have a medically determinable physical or 
mental impairment?
    If no, deny.
    If yes, continue to Step 3*.
Step 3--Does the child have an impairment that is included in the 
Index of Disabling Impairments?
    If yes, allow*.
    If no, continue to Step 4.
Step 4--Does the child have the functional ability to perform 
activities that are comparable to an adult's ability to engage in 
substantial gainful activity?
    If yes, deny.
    If no, allow*.

    *An impairment must meet the duration requirement of the 
statute; a denial is appropriate for any impairment that will not be 
disabling for 12 months.
Step 1--Engaging in Substantial Gainful Activity
    Any child who is engaging in substantial gainful activity will not 
be found disabled regardless of the severity of his or her physical or 
mental impairments. The guidelines for determining whether a child is 
engaging in substantial gainful activity will be identical to the 
guidelines for adults. Although the issue of work activity will arise 
infrequently in childhood claims, the step is warranted for two 
reasons:
    (1) The approach for adults and children should be as similar as 
possible; and
    (2) As a child approaches age 18, it is increasingly likely that 
work activity may be an issue.
Step 2--Medically Determinable Impairment
    Because the statute requires that disability be the result of a 
medically determinable physical or mental impairment, the absence of a 
medically determinable impairment will justify a finding that a child 
is not disabled. To establish the presence of a medically determinable 
impairment, evidence must show an impairment that results from 
anatomical, physiological, or psychological abnormalities which are 
demonstrable by medically acceptable clinical and laboratory diagnostic 
techniques.
    The same guidelines and rules that apply for adults will apply 
equally for children. SSA will continue to evaluate the existence of a 
medically determinable impairment based on a weighing of all evidence 
that is collected, recognizing that neither symptoms nor opinions of 
treating physicians alone will support a finding of disability. There 
must be medical signs and findings established by medically acceptable 
clinical or laboratory diagnostic techniques which show the existence 
of a physical or mental impairment that results from anatomical, 
physiological, or psychological abnormalities which, in the opinion of 
the Secretary, could reasonably be expected to produce the symptoms or 
substantiate any opinion evidence.
    SSA will use the same exception for evidence collection in 
childhood claims that will be applied in adult claims. If a child has a 
medically determinable physical or mental impairment that is not an 
exception to further development, SSA will then evaluate whether the 
impairment(s) is included in the index of disabling impairments.
Step 3--Index of Disabling Impairments
    If a child has a medically determinable physical or mental 
impairment documented by medically acceptable clinical and laboratory 
techniques and the impairment will meet the duration requirement, SSA 
will compare the child's impairment(s) against an index of disabling 
impairments. As with adults, the index for childhood claims will 
function to quickly identify severely disabling impairments; the index 
will not attempt to describe ideal medical documentation requirements 
for each and every body system.
    The index for childhood claims will consist of descriptions of 
specific impairments and the medical findings that are used to 
substantiate the existence and severity of the particular disease 
entity. As with adults, the childhood index will not attempt to measure 
the functional impact of an impairment on the child; functional impact 
will be considered at Step 4 in the process. The medical findings in 
the index will be as nontechnical as possible and will be simple enough 
so that laypersons will be able to understand what is required to 
substantiate a disabling impairment in the index. As with adults, SSA 
will draw no inferences or conclusions about the effect of a child's 
impairments on his or her ability to function merely because a child's 
impairment(s) is not included in the index. Additionally, SSA will no 
longer use the concept of medical equivalence'' or functional 
equivalence in relation to the childhood Index.
Step 4--Comparable Severity to Adult Ability to Engage in Substantial 
Gainful Activity
    In evaluating disability in adults, SSA will evaluate an 
individual's functional ability to perform work-related activities 
consistent with the ability to engage in any substantial gainful 
activity. The difficulty with evaluating childhood claims is the 
standard against which any functional measurement criteria are 
compared. For older children, it is relatively easy because at some age 
(somewhere between 14 and 18) the standard approaches the adult 
standard, i.e., ability to engage in substantial gainful activity. 
However, for younger children, the standard can be more difficult to 
describe. Under the current process, SSA uses a standard that measures 
the degree to which a child engages in age-appropriate activities which 
corresponds fairly well with developmental milestones for different age 
categories. However, the difficulty with this approach is that it may 
not appropriately define how much functional loss or interference with 
growth and maturity is comparable to inability to perform any 
substantial gainful activity.
    Consistent with the adult approach, SSA will develop baseline 
criteria for a child's activities that are comparable to an adult's 
ability to perform substantial gainful activity. In establishing a 
baseline of functional activities, the functional abilities for a child 
will represent a realistic comparison to an adult's ability to work.

Functional Assessment Instruments

    Consistent with the approach for adult claims, SSA will develop, 
with the assistance of the medical community and educational experts, 
standardized criteria which can be used to measure a child's functional 
ability. These standardized measures of functional ability will be 
linked to clinical and laboratory findings to the extent that SSA needs 
to document the existence of a medically determinable impairment that 
results from anatomical, physiological, or psychological abnormalities 
which could reasonably be expected to produce the functional loss.
    These functional assessment instruments will be designed to 
measure, as objectively as possible, a child's abilities to perform a 
baseline of functions that are comparable to the baseline of 
occupational demands for an adult. SSA will conduct additional research 
to specifically identify activities that are comparable to those that 
comprise a baseline of occupational demands needed to perform 
substantial gainful activity by adults.
    SSA will be primarily responsible for documenting functional 
ability using the standardized measurement criteria. Ultimately, the 
course of documenting and developing for the functional abilities for 
childhood claims will mirror the adult approach.

Comparability Standard

    SSA will develop realistic standards which represent activities 
that are comparable to an adult's ability to engage in substantial 
gainful activity. The standards will focus on a skill acquisition 
threshold designed to measure broad areas of skill that are required to 
ultimately develop the ability to engage in substantial gainful 
activity. If the child is progressing satisfactorily in the development 
of these skills, then the child will not have an impairment of 
comparable severity and SSA will not find the child disabled.

Evidentiary Development

SSA's Ability To Issue Timely and Accurate Disability Decisions Depends 
on the Efficient Collection of Quality Medical Evidence

    SSA's ability to provide timely and accurate disability decisions 
depends to a significant degree on the quality of medical evidence it 
can obtain and the speed with which it can obtain it. The medical 
evidence collection process accounts for a considerable portion of the 
total time involved in processing disability claims.
    Traditionally, the procurement of medical evidence has involved 
multiple, often repetitive, requests for information from a variety of 
health care providers. Health care providers believe that these 
requests burden them with far too much paperwork and offer far too 
little in the way of compensation for the time invested. Conversely, 
adjudicators often find that this evidence is primarily treatment-
oriented and fails to provide the highly specialized clinical 
information required by the current Listings, or the functional 
information that is frequently necessary at various points in 
disability decision-making process. Health care professionals, 
particularly physicians, readily concede that their training is 
oriented towards diagnosis and treatment, not the assessment of 
function. Thus, the timely collection of medical information depends to 
a significant degree on health care providers who have only a 
tangential interest and understanding of the disability program, its 
requirements, and, most importantly, the vital role that health care 
providers' information has in the disability decision process.

Evidence Collection Will Focus on Core Diagnostic and Functional 
Information Necessary to a Disability Decision

    The goals of the evidence collection process will be to focus 
requests for evidence on the critical diagnostic and functional 
assessment information necessary for a disability decision and to form 
a new partnership with the sources of this information so that it can 
be obtained in the most efficient, cost-effective manner. Medical 
evidence development will be driven by the four-step approach SSA will 
use to decide disability. Two of the core elements of that approach 
are: (1) Identifying an individual's medically determinable impairments 
(including those that meet the Index of Disabling Impairments 
criteria); and (2) assessing the functional consequences of those 
impairments. SSA will develop medical evidence that is sufficient to 
satisfy the core elements but target evidentiary development so that 
SSA obtains only the evidence that is necessary to reach an accurate 
decision on the ultimate question of disability.

Treating Sources Will be the Preferred Sources for Medical Evidence

    SSA will give primary emphasis to obtaining medical information 
from treating sources by way of brief, but specific, diagnostic 
information regarding an individual's medically determinable 
impairments and the functional consequences of those impairments. 
Treating source statements will include diagnostic information about a 
claimant's impairments, the clinical and laboratory findings which 
provide the basis for the diagnosis, onset and duration, response to 
treatment, and the functional limitations that can reasonably be linked 
to the clinical and laboratory findings. SSA will develop, in 
conjunction with the appropriate health care professionals and other 
public and private disability programs, standardized criteria which can 
be used to measure, as accurately and objectively as possible, an 
individual's functional ability. SSA will also seek health care 
providers' assistance in educating the medical community on the 
clinical application of these instruments. Once developed and 
universally accepted as the appropriate standard by the medical 
community, the standardized measurement criteria will be widely 
available. If a standardized functional assessment is available from a 
treating source, SSA will obtain that information and accept it as 
probative evidence. SSA may also request that the treating source or 
another examining source perform the standardized functional assessment 
at SSA expense.

SSA Will Use a Standardized Form To Request Medical Evidence From 
Treating Sources

    SSA will develop a standardized form which effectively tailors the 
request for evidence to the specific diagnostic and functional 
assessment information necessary to make a disability decision. The 
standard form will also be available in electronic form to permit 
treating sources to submit evidence electronically. Standardizing 
requests for evidence in this manner will facilitate the participation 
of claimants, representatives and third parties in the evidence 
collection process.
    The form will permit treating sources to provide necessary 
diagnostic and functional assessment information on a single document. 
In appropriate circumstances, SSA will accept a treating source's 
statement on the standardized form as to these issues without resorting 
to the traditional, wholesale procurement of actual medical records. 
Depending on the nature and extent of an individual's impairments and 
treating sources, statements from multiple medical sources may be 
appropriate. In completing standard forms, treating sources will 
certify that they have in their possession the medical documentation 
referred to in the statement and that said documentation will be 
promptly submitted at the request of SSA. The certification approach is 
consistent with evidence collection methods used by private disability 
insurance carriers, which request specific medical records in 
individual claims, as appropriate to the individual circumstances, or 
at random as part of a quality assurance program. SSA will monitor 
treating source completion of the standardized forms and verify 
evidence when appropriate.

SSA Will Provide Incentives for Treating Sources To Cooperate in the 
Development of Medical Evidence

    SSA will acknowledge the value of treating source information by 
establishing a national fee reimbursement schedule for medical 
evidence. Additionally, the fee reimbursement schedule will utilize a 
sliding-scale mechanism to reward the early submission of medical 
information. A national, sliding-scale fee schedule will provide 
incentives for treating sources to cooperate in the evidentiary 
development process and invest quality time to provide medical 
certifications on behalf of their patients.
    SSA will focus professional educational efforts and medical 
relations outreach at the local and/or regional level to ensure that 
treating sources are kept informed of program requirements and made 
aware of specific evidentiary needs or problems as they arise in the 
adjudication process.

SSA Will Use Consultative Examinations When There is No Treating Source 
Able or Willing To Provide Necessary Evidence or There Are Unresolved 
Conflicts in the Record

    If a claimant has no treating source, or a treating source is 
unable or unwilling to provide the necessary evidence, or there is 
conflict in the evidence that can not be resolved through evidence from 
treating sources, SSA will refer the claimant for an appropriate 
consultative examination. Because the standardized measurement criteria 
for assessing function will be widely available, consulting sources 
will be able to perform functional assessments that, in the absence of 
adequate treating source information or where there are unresolved 
conflicts in the evidence, will be considered probative evidence. 
Depending on the service area, SSA will consider contracting with large 
health care providers to furnish consultative examinations for a 
specified geographic location.
    As part of an ongoing training and medical relations program, SSA 
will ensure that providers of consultative examinations are provided 
adequate training on disability requirements, both initially and as 
program changes occur.

Administrative Appeals Process

The Administrative Appeals Process Will Be Simple and Accessible and 
Maintain Public Confidence in the Integrity of the Process

    The administrative appeals process will be simplified to increase 
the accessibility of the process. The public perceives multiple, 
mandatory appeal steps as obstacles to receiving timely, fair, and 
accurate decisions. SSA will reduce the number of mandatory appeals 
steps in the administrative process. Streamlining the appeals process 
in this manner will not only promote more timely decisions but also 
ensure that claimants do not inappropriately withdraw from the claims 
process based on a perception that it is too difficult or time-
consuming to pursue their appeal rights.
    Claimants will be able to fully participate in the administrative 
appeals process with or without a representative. SSA will ensure that 
claimants are fully advised of their right to representation and SSA 
will routinely provide the appropriate referral sources for 
representation. SSA will also encourage the early participation of a 
representative when the claimant has appointed one and will give the 
representative responsibility for developing evidence necessary to 
decide a claim. However, the decision whether to appoint a 
representative must remain with the claimant and SSA will neither 
encourage nor discourage claimants in seeking representation.
    The administrative appeals process will function so that it 
maintains the public's confidence in the integrity of the system. To 
instill such confidence, SSA will provide an initial decisionmaking 
process that is thorough and results in fully developed records with 
fair and accurate decisions. Additionally, SSA will explain the basis 
of a decision in clear and understandable language. Finally, SSA will 
ensure that disability claims are decided on the merits of the evidence 
and that SSA regulations and policies have been consistently applied at 
all levels of administrative review.
    As noted previously, the initial disability determination will use 
a ``statement of the claim'' approach which will set forth the issues 
in the claim, the relevant facts, the evidence considered, including 
any evidence or information obtained during the predenial interview, 
and the rationale in support of the determination. The statement of the 
claim will be part of the on-line claim record and will stand as the 
basis and rationale for the Agency action, if the claimant seeks 
further administrative review. SSA will standardize claim file 
preparation and assembly, including the use of appropriate electronic 
records, at all levels of administrative process until such time as the 
claims record is fully electronic.

The Next Level of Administrative Appeal Will Be an Administrative Law 
Judge Hearing

    Because the initial determination will be the result of a process 
that ensures fully developed evidentiary records and ample opportunity 
for the claimant to personally present additional evidence prior to an 
adverse determination, there will be no need for any intermediate 
appeal (e.g., reconsideration) prior to the administrative law judge 
(ALJ) hearing. If the claimant disagrees with the initial 
determination, the claimant may, within 60 days of receiving notice, 
request an ALJ hearing.

An Adjudication Officer Will Conduct All Prehearing Proceedings

    If a claimant decides to request an ALJ hearing, an adjudication 
officer will conduct an interview in person, by telephone, or by 
videoconference, and become the primary point of contact for the 
claimant. The adjudication officer will have the same knowledge, skills 
and abilities as the adjudicators who decide claims initially. The 
adjudication officer will also have specialized knowledge regarding 
hearings and appeals procedures. The adjudication officer will be the 
focal point for all prehearing activities but will be expected to work 
closely with the ALJ, medical consultants and the disability claim 
manager, when appropriate. The adjudication officer will explain the 
hearing process; advise the claimant regarding the right to 
representation; provide the appropriate referral sources for 
representation; give the claimant, where appropriate, copies of 
necessary claim file documents to facilitate the appointment of a 
representative; and encourage the claimant to decide about the need for 
and choice of a representative as soon as is practical.
    The adjudication officer will also identify the issues in dispute 
and whether there is a need for additional evidence. If the claimant 
has a representative, the representative will have the responsibility 
to develop evidence. The adjudication officer will also conduct 
informal conferences with the representative, in person or by 
telephone, to identify the issues in dispute and prepare written 
stipulations as to those issues not in dispute. If the claimant submits 
additional evidence, the adjudication officer may refer the claim for 
further medical consultation, as appropriate. The adjudication officer 
will have full authority to issue a revised favorable decision if the 
evidence so warrants. If the adjudication officer issues a favorable 
decision, the adjudication officer will refer the claim back to the 
disability claim manager to effectuate payment.
    The adjudication officer will consult with the ALJ during the 
course of prehearing activities, as necessary and appropriate to the 
circumstances in the claim. As a preliminary matter, the adjudication 
officer will also set a date for the hearing that is 45 days after the 
hearing request. The adjudication officer may exercise discretion in 
establishing an earlier or later hearing date depending on the 
individual circumstances. Electronic access to ALJs' calendars will 
facilitate timely scheduling of hearings. The adjudication officer will 
refer the prepared record to an ALJ only after all evidentiary 
development is complete and the claimant or a representative agrees 
that the claim is ready to be heard.
    The ALJ will retain the authority and ability to develop the 
record. However, use of an adjudication officer realigns most, if not 
all, prehearing activities so that the burden of ensuring their 
completion rests with other members of the adjudicative team. ALJs' 
primary function will be hearing and deciding claims.

The Administrative Law Judge Hearing Will be a De Novo, Nonadversarial 
Proceeding

    The ALJ hearing will be a de novo proceeding in which the ALJ 
considers and weighs the evidence and reaches a new decision.
    A de novo hearing is consistent with the role of an ALJ envisioned 
under the Administrative Procedure Act. Under that scheme, the ALJ is 
an independent decisionmaker who must apply an agency's governing 
statute, regulations and policies, but who is not subject to direction 
and control by the agency with respect to the decisional outcome in any 
individual claim. ALJs are independent triers of fact who perform their 
evidentiary factfinding function free from agency influence. At the 
same time, the Administrative Procedure Act ensures that an ALJ's 
decision is subject to review by the agency, thus giving the agency 
full power over policy. Policy responsibility remains exclusively with 
the agency while the public has assurance that the facts are found by 
an official who is not subject to agency influence.
    A hearing before an ALJ will remain an informal adjudicatory 
proceeding as it is under the current process. The claimant will have 
the right to be represented by an attorney or a non-attorney with the 
decision regarding representation made by the claimant alone. An 
informal, nonadversarial proceeding is consistent with the public's 
strong preference for a simple, accessible hearing process that 
permits, but does not require, an attorney. An informal process 
facilitates the earlier and faster resolution of the issues in dispute, 
thus promoting more timely decisions.
    As an independent factfinder in a nonadversarial proceeding, the 
ALJ will still have a role in protecting both SSA interests and the 
claimant's interests, particularly when the claimant is unrepresented. 
However, an improved initial determination process with its focus on 
early and comprehensive evidentiary development, predenial personal 
conferences, fully rationalized initial decisions, and prehearing 
analysis of contested issues should ensure that the Agency position is 
fully explored and presented to the ALJ. Moreover, the primary burden 
of compiling an evidentiary record will be shifted to the 
representative--if one is appointed--or to the claimant (when able to 
do so), with assistance (when appropriate), from SSA personnel.
    Adjudication officers and other decision writers will assist ALJs 
in preparing hearing decisions, using the same decision support system 
that supports the preparation of initial disability determinations. A 
simplified disability decisional methodology, in conjunction with the 
use of prehearing stipulations that frame the issues in dispute, will 
result in shorter, more focused hearing decisions. If the ALJ issues a 
favorable decision, he or she will refer the claim back to the 
disability claim manager to effectuate payment.

The Administrative Law Judge Decision Will Be the Final Decision of the 
Secretary Subject to Judicial Review Unless the Appeals Council Reviews 
the Administrative Law Judge Decision On Its Own Motion

    Under the new process, if a claimant is dissatisfied with the ALJ's 
decision, the claimant's next level of appeal will be to Federal 
district court. A claimant's request for Appeals Council review will no 
longer be a prerequisite to seeking judicial review.
    As under the current process, the Appeals Council will continue to 
have a role in ensuring that claims subject to judicial review have 
properly prepared records and that the Federal courts only consider 
claims where appellate review is warranted. Accordingly, the Appeals 
Council, working with Agency counsel, will evaluate all claims in which 
a civil action has been filed and decide, within a fixed time limit 
whether it wishes to defend the ALJ's decision as the final decision of 
the Secretary. If the Appeals Council decides to review a claim on its 
own motion, it will seek voluntary remand from the court for the 
purpose of affirming, reversing or remanding the ALJ's decision. 
Favorable Appeals Council decisions will be returned to the disability 
claim manager to effectuate payment.
    Additionally, the Appeals Council will have a role in a 
comprehensive quality assurance system. As part of this system which is 
described in greater detail below, the Appeals Council will also 
conduct its own motion reviews of ALJ decisions (both allowances and 
denials) prior to effectuation. If the Appeals Council decides to 
review a claim on its own motion, the Appeals Council may affirm, 
reverse or remand the ALJ's decision. The Appeals Council's review will 
be limited to the record that was before the ALJ.

Quality Assurance

Quality Assurance Will be a System of Agency Accountability

    SSA will be accountable to the public, the ultimate judge of the 
quality of SSA service, and SSA will strive to consistently meet or 
exceed the public's expectations. SSA will have a comprehensive quality 
assurance program that defines its quality standards, continually 
communicates them to employees in a clear and consistent manner, and 
provides employees with the means to achieve them. SSA will devote 
resources to building quality into the system of adjudication to ensure 
that the right decision is made the first time. SSA will also 
systematically review the quality of the overall system of adjudication 
to ensure the integrity of the administrative process and promote 
uniform application of agencies policies nationally. Finally, SSA will 
measure customer satisfaction against the SSA standards for service.

Ensuring That the Right Decision is Made the First Time Requires an 
Investment in Employees

    SSA's ability to ensure that the right decision is made the first 
time depends on a well-trained, competent, and highly motivated 
workforce that has the program tools and technological support to issue 
quality decisions.
    SSA will make an investment in comprehensive employee training to 
ensure that employees have the necessary knowledge and skills to 
perform the duties of their positions. SSA will develop national 
training programs for initial job training and orientation as well as 
continuing education to maintain job knowledge and skills. Such 
training will include general communication skills and how to deal 
effectively with the public generally, and disability claimants in 
particular. National training programs will also address changes to 
program policy.
    In addition to initial program training, continuing education 
opportunities will be made available to employees to enhance current 
performance or career development. These opportunities may be in the 
form of self-help instruction packages, videotapes, satellite 
broadcasts, or non-SSA training or educational opportunities. SSA will 
ensure that employees are given sufficient time and opportunity to 
complete the required continuing education. Employees will be 
encouraged to provide feedback on the value of these continuing 
education opportunities, including the quality of training materials, 
methods, and instructors.
    Employees, other than ALJs (because of Administrative Procedure Act 
limitations), who complete initial training and pass a set of 
performance evaluations based on national quality standards will 
receive a certificate of competence. This certificate will attest that 
the employee has successfully completed both initial training and a 
probationary period on the job. Certification will be renewed yearly 
upon successfully completing required training and having no less than 
a fully satisfactory performance rating. Those employees not certified 
initially or renewed will be provided an improvement plan with goals 
and time targets for improved performance.
    In addition to formal program training, SSA will rely on a 
streamlined and targeted system of in-line quality reviews and 
monitoring of adjudicative practices. The elements include a mentoring 
process for new employees and peer review for experienced employees. 
SSA will encourage peers to discuss difficult claims or issues and 
resolve them informally whenever possible. Peer reviews and mentoring 
will not only promote timely and accurate development of disability 
claims, but will also foster a spirit of teamwork. They will also 
promote earlier identification and resolution of problems with policy 
or procedures. As part of this process, managers will be expected to 
oversee the adjudication process. They will conduct spot checks at key 
points in the adjudication process or perform special reviews based on 
profiles of error-prone claims. The goal of these reviews is to provide 
immediate, constructive feedback on identified errors to reduce or 
eliminate their possible recurrence.
    To ensure that adjudicators have the necessary program tools to 
issue accurate decisions, SSA will use a single mechanism for the 
presentation of all substantive policies used in determining 
eligibility for benefits. Additionally, an integrated claims processing 
system will provide the necessary technological support for 
adjudicators at all levels of the administrative process. Among other 
things, the claim processing system will facilitate the preparation of 
accurate decisions by providing on-line editing capacity to identify 
errors in advance and decision support software to assist in analysis 
and decisionmaking.
    Although comprehensive employee education and an in-line review 
system will build quality into the system of adjudication with the goal 
of error prevention, SSA must still monitor quality on a systematic, 
national basis. Accordingly, all employees will be subject to and 
receive continuous feedback from comprehensive end-of-line reviews as 
described in the following section.

Quality Measurement Will Focus on Comprehensive End-of-Line Reviews

    Another component of quality assurance is an integrated system of 
national postadjudicative monitoring to ensure the integrity of the 
administrative process and to promote national uniformity in the 
adjudication of disability claims. This system will include 
comprehensive review of the whole adjudicatory process including both 
disability and nondisability issues, allowances and denials, and at all 
levels of decisionmaking. The review will focus on whether accurate 
decisions were made at the first possible step in the process. This 
type of review will not be aimed at correcting errors in individual 
claims but, rather, will be the means to oversee, monitor and provide 
feedback on the application of agency policies at all levels of 
decisionmaking. Reliance on an integrated claim processing system will 
facilitate the selection of a statistically valid sample of claims for 
this review.
    SSA will use the results from these end-of-line reviews to identify 
areas for improvement in policies, processes or employee education and 
training. SSA will also use the results to profile error-prone claims 
with the goal of preventing errors at the front end.

SSA Will Conduct Surveys to Measure Customer Satisfaction

    To measure whether SSA has met or exceeded the public's service 
expectations, SSA must measure their level of satisfaction with the 
level of service SSA provides. Customer surveys and periodic focus 
groups will be the most frequently used methods of determining the 
public's views on the quality of SSA service. SSA will also survey 
representatives and third parties who provide assistance or act on 
claimants' behalf in dealing with SSA. Survey results will be 
communicated to staff on a timely basis, both as Agency feedback and 
individual feedback, along with any plans to address identified 
problems.
    SSA will also seek employee feedback on how well SSA has met their 
expectations. Employee feedback will be sought on a wide array of 
issues including Agency goals and performance indicators, training and 
mentoring needs, and the quality of operating instructions. Although 
formal mechanisms will be used to obtain feedback periodically, each 
employee will be encouraged to provide continuous feedback on how to 
make improvements in the process.

Measurements

SSA Will Measure Disability Service From the Perspective of the 
Claimant

    SSA's management information will be revised to assess the 
performance of the Agency as a whole in providing service to claimants 
for disability benefits. Management information regarding the 
contributions at each step in the process to the final product, as well 
as to the work product passed on to other steps will be available. For 
example, current component processing time measures will be replaced by 
a measure of time from the first point of contact with SSA until final 
claimant notification. Meaningful, timely management information will 
be facilitated by a seamless claim processing system with a common 
database that is used by all individuals who contribute to each step in 
the process.
    Other measures, such as cost, productivity, pending workload, and 
accuracy will be developed or revised to assess the performance of the 
Agency as a whole and the participants in the process who contribute to 
this performance. Measurements for public awareness, as well as 
claimant and employee satisfaction will add to this assessment.

New Process Enablers

    Reengineering is dependent upon a number of key factors that 
provide the framework for the new process design. Each of these 
enablers'' is an essential element in the new disability determination 
process.

Process Unification

    Under the Social Security Act, the Secretary has been granted broad 
authority to promulgate regulations to govern the disability 
determination process. In addition to the regulations, SSA publishes 
Social Security Rulings and Acquiescence Rulings. Social Security 
Rulings are precedential court decisions, policy statements, and policy 
interpretations that SSA has adopted as binding policy. Acquiescence 
Rulings explain how a decision by a U.S. Court of Appeals will be 
applied when the court's holding is at variance with the Agency's 
interpretation of a provision of the statute or regulations.
    These source documents provide the basic framework for the policies 
that regulate eligibility for benefits. Administrative law judges (ALJ) 
and the Appeals Council use these source documents in making disability 
decisions. However, they are not directly used by decisionmakers at the 
first two levels of the process, i.e., initial and reconsideration 
determinations. Guidance for these decisionmakers is provided in a 
series of administrative publications specifically designed for and 
aimed at the audiences responsible for adjudicating these claims.
    The Program Operations Manual System instructions provide the 
substance of law, regulations, and rulings for adjudication issues in a 
structure format that does not necessarily repeat the wording of the 
source documents for field offices, State disability determination 
services (DDS), the processing centers, and quality assurance 
reviewers. The Program Operations Manual System is supplemented by 
other administrative issuances to clarify or elaborate specific policy 
issues. The Program Operations Manual System also provides basic 
operating instructions to the initial, reconsideration and quality 
components responsible for processing claims. The Hearings, Appeals, 
and Litigation Law Manual provides operating instructions and summaries 
of court decisions to hearing offices and the Appeals Council.
    Neither the Program Operations Manual System or the Hearings, 
Appeals, and Litigation Law Manual is binding on ALJ decisionmaking 
because this material is not considered Agency policy under the 
Administrative Procedures Act. Only those regulations and 
interpretative rulings published in the Federal Register, in accordance 
with the Administrative Procedures Act guidelines, can be binding on 
ALJs. Other decisionmakers are bound by interpretative guidance in the 
Program Operations Manual System and supplemental issuances. This 
situation fosters the perception that different policy standards are 
used at different levels of decisionmaking in the claims process.
    SSA will develop a single presentation of all substantive policies 
used in the determination of eligibility for benefits. All 
decisionmakers will be bound by these same policies. These policies 
will be published in accordance with the Administrative Procedures Act. 
In addition, to facilitate the flow of work in the new process, a 
single operating manual will be developed.

Public and Professional Education

    Public and professional education is essential for the proper 
understanding of and participation in the disability claims process. 
The goal is to ensure that those individuals and groups involved in the 
disability process have a better understanding of SSA disability 
programs, their medical and nonmedical requirements, and the nature of 
the decisionmaking process.
    SSA will make information widely available for the general 
population. Pamphlets, factsheets, posters, videos, information on 
diskettes and on computer bulletin board systems will be developed. 
This information will be written in a simple, straight forward and 
understandable manner. It will be available in many languages and 
dialects and will accommodate vision and hearing impaired individuals. 
Videotapes will be available to show in SSA offices, welfare offices 
and in places where medical care is provided. It will explain the 
definition of disability, stressing the durational and level-of-
severity requirements while giving real life examples. Insured status 
requirements for SSA disability insurance (DI) and income and resource 
limitations for supplemental security income (SSI) will be explained in 
general terms.
    This same information will be distributed to third parties who may 
be referral sources for disability claims. It will serve to provide 
them with basic information about medical and nonmedical eligibility 
criteria and the options available for filing claims.
    SSA will work with nationally and locally interested and involved 
groups to develop direct lines of communications about the disability 
process and program. These efforts will not be limited to providing 
information, but will include opening and maintaining a dialogue about 
the disability process as part of an ongoing organizational 
relationship.
    Professionals who work with the disabled population will require 
more detail. The current ``Understanding SSI'' booklet will be enhanced 
to include more information on the disability aspects of the SSI 
program--including the requirements and process, as well as the options 
available to claimants or interested third parties to speed up the 
process. A similar booklet for the DI program will be developed. These 
booklets will serve as training manuals and reference tools, and will 
include information and examples about providing functional 
assessments. Special efforts will be made to have coverage of these 
booklets included in courses which are part of a social service 
delivery curriculum at the post-secondary and graduate levels.
    SSA will conduct outreach efforts with the legal community, to 
ensure that information about the disability programs is widely 
available to the organized bar and the Federal judiciary. Policy 
documents, regularly updated electronically, and rules of 
representation will be available at forums sponsored by the organized 
bar and in initial orientation and continuing legal education programs 
designed for Federal judges.
    Treating physicians, medical providers and other treating 
professionals need up-to-date information on medical evidence 
requirements. SSA will conduct educational outreach with the medical 
community to provide them with a better understanding of the SSA 
disability programs, the medical and functional requirements for 
eligibility, and the best ways to provide medical information needed 
for decisionmaking. In addition to the use of printed materials, SSA 
will arrange briefings and training sessions in association with 
medical organizations and societies at the local, State and national 
levels, as well as through hospital staff meetings.
    Those medical providers who conduct consultative examinations for 
SSA will need ongoing training regarding changes in the disability 
program. SSA will prepare training programs for this audience which 
will utilize written, audiotape, videotape, and computerized training 
methods.

Claimant Partnership

    As part of their partnership with SSA, claimants will be encouraged 
to actively participate at all levels of the adjudication process and 
will be fully informed of their rights and responsibilities. SSA's 
interaction with claimants will facilitate claimant responsibility and 
active participation in the processing of their claims. The resources 
of interested and capable third parties will be garnered to assist 
claimants and SSA in fulfilling their partnership responsibilities.
    The majority of claimants are able to complete simple forms, attend 
appointments, and obtain medical and nonmedical documentation, either 
on their own or with the assistance of third parties. Other claimants 
are unable to accomplish some of these tasks, even with the assistance 
of third parties. Still others have substantial difficulty fulfilling 
any of these tasks, and may have no third party to assist them. Given 
the range of claimant capabilities, SSA will retain ultimate 
responsibility for development of claims when claimants are not 
formally represented.

What SSA Will Do

    SSA's interaction with claimants will focus on enabling their 
participation in the process. Understandable public information 
materials and application packets will be widely available. 
Explanations of the program, the process, and claimant responsibilities 
will be furnished at the point individuals first make contact with SSA. 
SSA will also work with third parties, such as family members and 
community-based organizations, to provide additional claimant support.
    In addition, SSA will provide ongoing assistance and appropriate 
status information throughout the process. The opportunity for personal 
contact with the disability claim manager will be afforded to each 
claimant prior to the issuance of an initially unfavorable decision. A 
claimant will be advised of evidence that has been considered in making 
the disability determination and provided an opportunity to present 
additional evidence for consideration.
    Claimants will be provided the opportunity to fully participate in 
the appeals process. Decision rationales, appeal rights, and 
representation rights will be explained in clear, understandable 
language.

What Claimants Will Do

    Early, ongoing dialogue between claimants and SSA will ensure that 
claimants have access to information and resources they need to 
actively pursue their claims and make informed choices.
    Claimants will be asked to do more to facilitate development of 
supporting information when they are able, particularly with respect to 
medical evidence. When they file for disability benefits, claimants 
having had medical treatment will be asked to request that their 
treating sources complete standardized forms. Information about this 
requirement will be publicized in the general community and given to 
claimants and third parties when they first contact SSA. Third parties 
will be encouraged to assist claimants who are unable to fulfill this 
obligation on their own. However, when necessary, a disability claim 
manager will assist claimants in obtaining evidence.
    To encourage the release of evidence by treating medical sources, 
SSA will network with the treating source community to overcome the 
lack of understanding and possible resistance to providing patient 
information. SSA will develop fax, E-mail, and other electronic means 
for physicians to provide direct certification information.
    There will be situations where claimants have no treating sources, 
or where treating sources provide insufficient medical evidence to make 
a disability determination. SSA will work with willing treating sources 
and other medical providers to assist in developing medical evidence 
(including testing and examination) in these circumstances.
    SSA will encourage private insurers and public agencies that refer 
claimants to SSA as a condition of receiving other benefits to provide 
medical evidence for these individuals.
    Claimants will be able to fully participate in the appeals process 
with or without a representative. During the appeal process, claimants 
and/or their representatives will have primary responsibility for 
compiling an evidentiary record. SSA will provide appropriate 
assistance for unrepresented claimants.

Assistance to Claimants

    Many claimants today rely on other individuals; private and public 
organizations; and for-profit and nonprofit organizations to pursue 
their claims. Although they assist claimants, these individuals and 
organizations do not serve as official representatives. In most 
instances, those who assist in the process have the best interests of 
the claimant in mind. However, some individuals and organizations have 
been instrumental in attempts to defraud programs or take unfair 
advantage of claimants. In the future, SSA will develop ongoing 
relationships with community organizations to ensure that competent 
third-party resources are available to assist the claimants.
    Examples of resources that SSA will help develop include:

--Transportation and escort services for indigent claimants and those 
who experience difficulty in getting to consultative examinations. This 
would include a combination of volunteer services and reimbursement for 
transportation on a contract basis. These services will be immediately 
available as the need dictates.
--Enhancement of medical provider capacity to identify potentially 
eligible patients, secure claims and provide medical evidence. This 
type of activity has been successfully demonstrated through the use of 
seed monies from SSA in the SSI outreach program. An additional 
financial benefit to the providers will be realized through concurrent 
Medicaid eligibility for patients.
--Software with compatible format design which will allow direct input 
of claims-related information to SSA. This will be available to 
claimant advocates and medical providers ensuring the rapid and 
accurate transmission of information. After a certification process, 
eligible users will be kept apprised of software, procedural, and 
policy changes. SSA will perform ongoing document verification to 
ensure the integrity of claims submitted by such users.

    SSA will have an ongoing demonstration program that provides funds 
for truly innovative projects that test models for national 
implementation.
    In order to expedite the referral of potentially eligible 
individuals, SSA will develop productive working relationships with 
Federal, State and local programs that serve individuals with 
disabilities. While eligibility requirements vary significantly for 
programs such as Food Stamps, Aid to Families with Dependent Children, 
General Assistance, foster care and adoption assistance, and Veterans 
Benefits, effective working relationships can be built around 
agreements that expand sharing of authorized information and awareness 
of program requirements.
    Other programs will be able to use SSA-developed decisional support 
systems to evaluate potentially eligible persons prior to referral. 
This information will be transferred to SSA through compatible 
databases. To further enhance these relationships, disability claim 
managers will be available in remote locations, such as Department of 
Veterans Affairs homeless program sites, where the workload warrants 
their presence. With appropriate information available at these sites, 
the on-site disability claim manager will be able to complete the 
entire initial application process, with access to other program 
experts through information systems. Local managers will be encouraged 
to develop and maintain appropriate working relationships with local 
Federal, State and third-party resources.

The Payoff Will be Greater Customer Satisfaction

    Active participation by claimants, supported by SSA's efforts and 
the contributions of third parties will result in a fundamental shift 
in claimant expectations and satisfaction with the SSA disability 
process. From the SSA perspective, the results will be better service 
to customers through timely, fully supported decisions rendered at all 
decisional levels; better use of SSA resources focused on helping those 
who need assistance; and greater public confidence in the disability 
adjudication process.

Workforce Maximization

Teamwork

    The teamwork concept is a fundamental ingredient in the new 
process. The disability claim manager will be the focal point at the 
initial claim level, assisted by technical and medical support staff. 
The adjudication officer will be the focal point at the prehearing 
level, relying on technical and medical support staff, as well as 
interacting with the disability claim manager and the administrative 
law judge (ALJ), as necessary. The ALJ will be the focal point at the 
hearing level, receiving support from technical and medical support 
staff, and also interacting with the adjudication officer and 
disability claim manager, as necessary.
    Each team member will have at least a basic familiarity with all 
the steps in the process and an understanding of how he/she complements 
another's efforts. Everyone will achieve a greater sense of 
participation, closure, and accomplishment because of shared 
responsibility for performing the whole process. Team members will 
maintain ownership of the process and the outcomes. The teams will 
function effectively and efficiently because:

--All members will have electronic access to the claim throughout the 
process and thus be better able to engage in meaningful discussions 
with the claimant.
--Handoffs, rework, and non-value steps will be significantly reduced 
and fewer employees will be involved in shepherding each claim through 
the process. This will enhance SSA's capacity to provide world-class 
service by allowing employees to devote more time to each claimant, 
providing more personalized service.
--Team members will be knowledgeable but will also be able to draw upon 
each other's expertise on complex issues.
--Improved automated systems will enable members of the team to work 
together using a shared data base even when they are not co-located.
--Communication between team members and other disability claim 
managers will encourage consistent application of disability policy.
--Customer service is the primary focus at all steps of the process and 
an integral part of the teams' goals. This focus and commitment will 
increase claimant satisfaction.
--Team members will work closely with social service and medical/
professional agencies and advocacy groups in the service area to 
improve their ability to obtain the necessary medical and functional 
information to appropriately evaluate disabling conditions.
--Varying levels of job complexity will provide the opportunity for 
personal development, growth, and learning.

Disability Claim Managers

    Disability claim managers will be responsible for intake of DI and 
SSI disability/blindness benefit claims, development of all evidence 
(medical and nonmedical) required to adjudicate those claims, final 
adjudication of claims, ongoing communication with claimants, and 
issuance of notices and/or payment actions. In carrying out these 
responsibilities, disability claim managers will work in a team 
environment with medical and nonmedical experts who provide advice and 
assistance with complex case adjudication, as well as support personnel 
who handle more routine aspects of case development and payment 
effectuation. Tasks will be facilitated by a fully automated intake 
process, developmental and decisional expert system applications, 
personalized automated notices, and automated payment computations.
    Disability claim managers will be able to:

--Provide claimants with current and accurate information about their 
claims;
--Anticipate documentation needs and eliminate development that is not 
necessary in favorable determinations;
--Eliminate time lost and rework caused by frequent handoffs and 
queues;
--Access expert advice through shared databases, thus eliminating the 
need to transfer files;
--Provide claimants with complete information if their claims are 
proposed for denial and enhance claimants' ability to rebut such 
outcomes easily and early in the process; and
--Effectuate payment quickly, thus avoiding the need for recontacts and 
verification of nondisability factors of eligibility.

Adjudication Officers

    Adjudication officers will be responsible for claims from the point 
of receiving hearing requests until they are ready to be heard by ALJs. 
In carrying out their responsibilities, adjudication officers will work 
in a team environment with medical and nonmedical experts, requesting 
advice and counsel from ALJs as necessary.
    Adjudication officers will be able to:

--Address the claimants' questions and concerns regarding their claims;
--Identify and discuss issues in dispute with claimants and determine 
the need for additional evidence. If the claimant is represented, 
conduct personal conferences with the representative and prepare 
written stipulations as to those issues not in dispute;
--Review claim records prior to hearings and issue revised decisions if 
additional information or evidence so warrants or refer claims for 
medical consultation; and
--Take responsibility for all evidentiary development and refer 
prepared records to the ALJs.

Administrative Law Judges

    Administrative law judges (ALJ) will be responsible for hearing and 
deciding appeals. ALJs will receive support from technical and medical 
personnel, including decision writers. ALJs will also work with 
adjudication officers and disability claim managers as necessary.
    ALJs will be able to:

--Review and focus on fully developed claims records prior to hearings;
--Deal with claimants who have already made informed decisions 
regarding representation before they appear at hearings; and
--In most circumstances, close the record at the conclusion of 
hearings, deliberate on issues and render prompt decisions.

BILLING CODE 4190-29-P

TN15AP94.022


BILLING CODE 4190-29-C

Workforce Enrichment/Empowerment

    The work in the new process will raise job satisfaction and 
increase employee skills in the following way:
    Employees involved with the initial level of claims will perform 
multiple tasks instead of singular activities, thus their roles will 
expand to encompass more of the ``whole'' job. This increases the sense 
of accomplishment as employees experience the direct relationship 
between their actions and the final product. Those at the prehearing 
step will also be able to do more of the ``whole'' job, including 
taking action to allow claims much earlier in the process. For medical 
consultants and ALJs, tasks will be eliminated that are not 
commensurate with professional skill levels. Employees will feel more 
of a sense of ownership for the services they perform as a member of a 
team focused on serving claimants.
    Entry level positions will be developed in which employees work as 
part of the team while gaining experience and qualifying for greater 
responsibility. Adequate resources and sufficient training and 
mentoring will allow them to acquire the skills they need to process 
the claim from intake through adjudication rather than guessing what 
someone else needs or using the current all-encompassing approach to 
information gathering.
    The new process will rely heavily on increased employee empowerment 
applying information technology and professional judgment to complete 
tasks more effectively and efficiently without constant checking, 
direction and micro-management. Recognition and reward processes will 
be revised to emphasize contributions to team outcomes and acquisition 
of knowledge bases. Continuous quality improvement activities will 
foster ongoing incremental process change.

Representatives: Fees, New Rules and Standards of Conduct

    The Social Security Act and implementing regulations have long 
recognized the representational rights of claimants and have provided 
an administrative framework designed to ensure that claimants will have 
access to the legal community in the pursuit of their claims. Since the 
inception of the disability program, representatives have played a 
significant role in the disability process. The rate of representation 
in SSA disability claims has risen from approximately 55% in fiscal 
year (FY) 1982 to 75% in FY 1993. Focus groups of claimants and the 
general public have indicated that the disability program is too 
complex to understand and the process too fragmented and difficult for 
them to navigate alone. While many claimants resent having to pay a 
representative to establish entitlement to government-sponsored 
benefits, they feel that they have no choice if they want to be 
successful in this pursuit. While the rate of representation has risen, 
so too has the average fee for representation. The average fee received 
by representatives has jumped from approximately $1,500 in FY 1987 to 
$2,500 in FY 1993, further adding to the dismay of claimants. As more 
claimants seek representation and fees continue to climb, SSA has a 
heightened responsibility to monitor representational activity and to 
safeguard the interests of claimants. The proposed process will utilize 
new rules of representation and standards of conduct to ensure that 
representatives, as key players in the disability process, fulfill 
their responsibilities and adequately serve the needs of the claimants 
they represent.
    Under the present statutory and regulatory scheme, representatives 
are not permitted to charge and collect a fee in any case without first 
obtaining the approval of the Secretary. There are two distinct 
procedures available to representatives for obtaining fee approval. The 
``fee petition'' method requires the representative to itemize the 
services rendered and the time expended. The Secretary must evaluate 
each individual petition and determine the reasonable fee, considering 
such factors as case complexity, time expended, skills needed, and the 
results obtained. There is no maximum fee set by law for this 
procedure.
    The second method, commonly referred to as the ``fee agreement 
procedure'', involves an agreement between the claimant and the 
representative whereby the fee is agreed to be no more than 25% of the 
retroactive benefits due, or $4,000, whichever is less. The agreement 
must be executed and submitted to the Secretary prior to the 
determination of the claim. While there is a maximum fee under this 
procedure, the Secretary does not have to conduct an individual 
evaluation of the reasonableness of the fee unless either the claimant, 
the representative, or the administrative law judge (ALJ) files a 
protest of the fee. The fee may be reduced by the Secretary only on the 
basis of evidence of the failure of the representative to adequately 
represent the interests of the claimant or on the basis of evidence 
that the fee is clearly excessive for the services rendered. Under 
limited circumstances, the representative may ask the Secretary to 
increase the fee.
    In addition to approving all fees under both DI and SSI of the 
Social Security Act, there are withholding and direct payment of fee 
provisions that apply only to DI claims where an attorney is involved. 
Specifically, the Secretary must withhold and pay to the attorney the 
lesser of (1) 25% of the retroactive benefits due the claimant, or (2) 
the fee approved by the Secretary under either the fee petition or fee 
agreement procedures. The intent of this procedure is to provide an 
incentive for attorneys to accept Social Security claims work in order 
to increase claimant access to attorneys. In FY 1993, SSA paid nearly 
$300 million in fees to attorneys out of claimants' retroactive DI 
benefits. This withholding and payment provision does not apply to SSI 
claims because Congress did not find it appropriate to reduce a 
claimant's benefits in order to pay an attorney in a means-test 
program. However, even though SSA does not withhold and pay attorneys 
fees in these cases, it is estimated that SSI claimants paid over $133 
million in fees to their representatives in FY 1992. Thus, the total 
cost to claimants for representation in 1993 approached the $500 
million mark.
    Since the inception of the fee agreement procedure in 1991, fee 
agreements have been rapidly replacing fee petitions as the vehicle for 
procuring agency approval of fees. SSA received 52,297 fee agreements 
in FY 1992, representing 39% of all fee approval requests. In FY 1993, 
fee agreements jumped to 87,395, accounting for 63% of all fee approval 
requests. Fees are generally higher under the fee agreement procedure, 
averaging $2,800 in FY 1993 as compared to an average fee of $2,200 for 
fee petitions. One of the factors causing higher fees under the fee 
agreement procedure is the lengthy processing time for disability 
claims; the longer it takes to issue a decision, the greater the 
retroactive benefits due the claimant. Under the fee agreement 
procedure, the fee is based on the amount of retroactive benefits due, 
and there may be little or no correlation to the time expended by the 
representative or the skills involved in rendering representational 
services. By eliminating fragmentation and handoffs, the proposed 
process will significantly reduce processing time. SSA will issue 
decisions faster, the amount of resulting retroactive benefits will be 
reduced, and resulting fees will likewise be reduced.
    However, as the fee agreement procedure continues to claim an ever-
increasing share of the total number of fee requests filed each year, 
more and more fees will be based upon a predetermined, mathematical 
formula rather than by an independent evaluation of the quality of 
services rendered. In order to maintain the emphasis on quality in 
representational matters, the proposed process will adopt new 
representation rules and standards of conduct to effectively safeguard 
the rights and interests of claimants. These new regulations will:

--Establish qualifications for representatives, attorneys and non-
attorneys, to ensure that claimants receive competent representation;
--Define the duties and responsibilities of representatives, including 
the duty to fully develop the record in a timely manner and to respond 
to requests to submit evidence;
--Establish a code of professional conduct for representatives in all 
matters before SSA, including conduct at prehearing conferences, 
hearings, and interaction with SSA employees and claimants generally;
--Provide a forum for claimants to air their grievances and file 
charges against representatives for failure to provide adequate 
representation or otherwise violating the rules of representation and 
standards of conduct;
--Provide meaningful sanctions against representatives, including 
suspension and disqualification from appearing before the agency in a 
representative capacity, for violating any of the provisions contained 
in the rules of representation and standards of conduct.

    Without disturbing the statutory intent of facilitating claimant 
access to representatives, the simplified and user-friendly new process 
may well result in more claimants pursuing their claims without 
representation. However, the issue of representation will remain a 
matter of personal choice. In addition, the proposed process will 
reduce the trend of inflationary fees by eliminating the artificially 
high retroactive benefits that result from excessively long processing 
times. Finally, while current statutes and regulations attempt to 
protect claimants from fee abuses, they fall short of extending to 
claimants the assurances which they need most: that the representatives 
they retain will be qualified, will have the obligation to fully 
develop the record on their behalf, will adequately represent their 
interests, and will be accountable for misconduct or dereliction of 
duty. The new rules and standards of conduct provide the framework for 
these assurances.

Information Technology

    Information technology will be a vital element in the redesign of 
the disability claim process. To the fullest extent possible, SSA will 
take advantage of the ``Information Highway'' and those technological 
advances that can improve the disability process and help provide 
world-class service. Existing Agency design plans for Intelligent 
Workstation/Local Area Network (IWS/LAN) and a Modernized Disability 
System are critical enablers for successful implementation of the 
proposed process redesign. Reengineering of the disability process is 
on the critical path of the design and development of the Modernized 
Disability System and implementation of IWS/LAN.
    The Modernized Disability System and IWS/LAN will provide an 
integrated system to support the entire reengineered disability 
process. This system will provide electronic connectivity throughout 
the process. Current SSA systems that support disability processing 
operate independently of each other. Field offices, DDSs and hearing 
offices all have their own systems. The DDSs have their own baseline 
automation systems, but for the most part can only use the systems 
within the particular State on that State's machines. Likewise, hearing 
offices have a disability processing system that applies only to claim 
processing inside the hearings and appeals organization. Each 
organization independently inputs claim information into their systems 
and no automated information can be passed outside the organization for 
subsequent, much less parallel, claim processing.
    The reengineered process relies on the ability to build a single 
electronic claim record as it goes from point to point in the 
disability process. This includes the ability for any facility to 
process the medical and nonmedical segments of claims for another 
facility. This is the primary benefit of the IWS/LAN and Modernized 
Disability System architectures. Both architectures are a prerequisite 
for enabling reengineering of the entire disability process.

The Enabling Platform

    The IWS/LAN architecture and Modernized Disability System design 
will support a major objective of the redesigned disability process-
seamless, reengineered electronic processing of disability claims from 
the first contact with the claimant to the final decision, including 
all levels of administrative appeal. All employees will use the same 
hardware, the same claim assignment and scheduling software, the same 
claim processing software, the same case control system, the same 
fiscal and accounting software, the same integrated quality assurance 
functionality, and the same management information system throughout 
all stages of the process. Therefore, data will need to be input and 
validated one time only, leading to more consistent decisions in 
establishing both the medical and nonmedical aspects of DI and SSI 
claims. All employees will also have access to decision support systems 
for those complex entitlement decisions. Since all facilities will be 
able to access the same record, all SSA representatives will be able to 
respond to inquiries from the same base of information. This will 
produce more consistent and accurate Agency responses to inquiries.
    SSA will continue to move aggressively toward the goal for complete 
electronic, paperless processing with all aspects of the claims 
process. Key tenants of reengineered electronic, paperless processing 
will be encouraging electronic information exchanges with medical 
evidence providers--and then keeping information received 
electronically in that same (or a similar) digitized format for claim 
processing, use of cost effective scanning/imaging of decision 
supporting paper records, abstraction and/or summarization of key, 
paper-based information by employees via direct keying, and finally, 
direct keying of information into the claim processing system by 
employees, third parties, and/or claimants. Direct keying of 
information into the electronic file will be minimized whenever 
possible by reliance on data propagation from other SSA files and 
comprehensive database support throughout the claims processing 
systems.
    Although full realization of a completely automated system will be 
a long-term initiative, a number of aspects of the redesigned process 
will be quickly realized and made possible by IWS/LAN and Modernized 
Disability System support in the very near future.

Redesign of Access to Services

    Information technology will be applied in several ways to enhance 
the claimants' and representatives' access to services and information 
under the new process. Through reengineering, claimants will be able to 
conduct business with SSA via telephone, self-help workstations, 
kiosks, videoconferencing, and electronic data transfer at SSA 
facilities and other satellite locations. SSA will provide TV/VCRs and/
or kiosks in SSA facilities and public places where there is a high 
concentration of potential customers to dispense information about SSA 
programs, the requirements for eligibility, and the information 
requirements for filing an application. The better informed the 
customers, the better prepared they are at the time of the interview. 
This reduces recontacts and allows the customer to more fully 
participate in the timely pursuit of their claim.
    Waiting rooms will be equipped with self-help workstations housed 
in private cubicles. They will help to pre-screen program eligibility 
and furnish application requirement information for walk-in claimants. 
These workstations can also be used as front-end interviewing devices 
that collect preliminary application information from claimants. The 
preliminary information will be used to access SSA databases to gather 
all known information on the claimant, including earnings history and 
any prior filings.
    Application information will include the telephone numbers from 
which claimants or representatives will make telephone inquiries. SSA 
office telephone systems will be equipped with automatic number 
identification technology (also known as ``caller ID''). Using this 
technology, SSA will be able to provide improved service by responding 
to telephone inquiries with increased assurance that the caller is the 
claimant or representative.

Customer Self-Help Redesign

    An efficient paper application form designed to be easily read and 
indexed by scanning equipment will be widely available as part of a 
comprehensive consumer information publication about the disability 
program that will be stocked in SSA facilities and other appropriate 
community-based locales. Self-help instructional material will also be 
mailed to some applicants who inquire about disability benefits by 
calling SSA. Up-front completion of the form will not be a requirement 
of filing, but will enhance the intake process for applicants. The 
Modernized Disability System will have the capability to accept scanned 
information from the application form and integrate all relevant 
information into the electronic file.
    In addition, an electronic application form will be made available 
to claimants with access to a personal computer and modem using an SSA 
bulletin board service or through other publicly available bulletin 
board services. The information will be completed and returned 
electronically to SSA via an agreed upon electronic filing method.
    Finally, as previously mentioned, some claimants will begin the 
application process by completing a brief electronic application form 
using SSA self-help workstations in SSA offices and other community-
based locations.

Enhanced Third Party Support

    SSA will conduct forums and produce video and computer-based 
training materials for third parties who wish to participate in 
assisting customers to file applications and gather medical evidence. 
Wherever possible, physicians and health care organizations, advocates, 
community counseling services, and other professionals who regularly 
provide assistance to SSA claimants will be supplied with SSA software 
to electronically complete Agency forms. The data will be transferred 
to SSA using agreed upon methods. As long as these parties comply with 
certain stipulations, SSA will supply updates to software and 
procedures, and/or establish an SSA bulletin board from which these 
third parties can download current software.
    SSA will allow representatives access to electronic claim folders. 
This access will be limited to the authorized representative (attorney 
or non-attorney) of the claimant and will be allowed from self-help 
workstations at an SSA facility, or via an agreed upon electronic data 
transfer method.

Evidence Collection Redesign

    Medical Evidence of Record is to the disability process what the 
earnings record is to the Retirement and Survivors' Insurance program. 
SSA will marshall its resources for an ``Evidence Modernization 
Project'' as was successfully done for the Earnings Modernization 
Project. The success of Earnings Modernization was due, in no small 
part, to the partnership SSA established with the employer community to 
streamline and focus the wage reporting requirements. The redesigned 
disability process approach provides for similar partnership with 
medical providers and the necessary streamlining of evidence collection 
requirements.
    SSA will expand its acceptance of interpretive data from the 
medical community. Instead of relying solely on actual medical records, 
SSA will focus on obtaining certifications of the diagnostic and 
functional information needed to make disability determinations. These 
standardized certifications will be designed to solicit from the 
treating source the specific information needed and enable SSA to 
process the information in a timely and accurate manner.
    Electronic standardized treating source information will be 
transmitted from physicians to SSA and associated with the appropriate 
electronic record. If additional medical evidence is needed and it is 
not already electronic, it will be scanned and stored digitally, or it 
may be abstracted and stored electronically. ``Fax ID'' and ``caller 
ID'' will be established with all parties submitting evidence or who 
have rights to legitimately request evidence. As was done during 
Earnings Modernization with the employer community, SSA will take 
advantage of the expanding use of computer applications by medical 
providers by working with software vendors that currently service the 
medical community to include an application for treating source 
reporting in office automation software.
    The paper version of the standardized treating source form will be 
designed so that the data can be read by scanning equipment into SSA 
claims processing systems. The form will be designed to support the 
structure of the Modernized Disability System.
    A single vendor payment system utilized by all appropriate 
employees will be used to pay certain evidence providers for 
information which they provide SSA to aid in making a disability 
determination. To further paperless processing, SSA will adopt a 
``signature on file'' policy for the claimant's evidence release 
authorization to eliminate routing of paper medical release forms.
    SSA will also set up information exchanges with other Federal and 
State agencies and major medical providers using pin/password access to 
data stores as well as caller/fax ID to conduct information exchange 
over the telephone.

Reengineered Tools For Decisionmakers

    The ability of decisionmakers to conduct thorough interviews and 
evidence evaluation, and timely and accurate claims adjudication is 
predicated on the implementation of the functionality provided by the 
IWS/LAN hardware and software components, and the decision support 
features of the Modernized Disability System. The IWS/LAN environment 
provides access from the decisionmakers' desktop to electronic policy 
and procedures, multiple/simultaneous information processing and 
retrieval sessions with SSA claims processing systems, simultaneous 
access to both intelligent workstation-based office automation software 
and SSA claims processing systems, and access to modern information-
handling and transfer technologies such as fax. With all of the tools 
at the decisionmakers' fingertips, time is not wasted in logging on and 
off claim processing systems to get to other claim processing systems 
or office automation applications, nor is time lost by having to log 
off the system in order to leave the workstation to research manual 
reference materials.
    Expert system software will be included in SSA claims processing 
systems to assist disability decisionmakers in the analysis and 
evaluation of complex eligibility factors, and to ensure that the 
correct procedures for disability evaluation are followed. While 
conducting interviews, disability decisionmakers will use the decision 
support features of the Modernized Disability System which ask specific 
questions based on claimants' alleged impairments.
    This will provide more personalized service for claimants since the 
decision support questions will be tailored to their particular 
impairments. The decision support system will use the accumulated data 
of the electronic record to automatically produce ``statement of the 
claim'' summaries and decision rationales used throughout the 
determination process.
    Where disability decision team members cannot be physically co-
located, they can remain in communication by using two-way TV and other 
videoconferencing technologies. Handoffs, and the queues associated 
with each handoff, can also be minimized by the use of expert systems 
because much of the specialized knowledge that a task requires will be 
electronically stored in the knowledgebase of the expert system and 
immediately available. Therefore, the number of situations where 
employees will have to handoff claims to other employees having more 
technical expertise will be reduced.
    Expert systems will also be developed to improve the delivery of 
disability policy. Disability policy will be developed and stored in a 
format that can be integrated into computer systems as the source of 
context-sensitive help screens and decision-support messages. SSA 
components responsible for disability policy will be responsible for 
updating the system with policy language revisions that do not require 
programming changes.

Quality Assurance and Management Information Redesign

    Quality assurance features fully supported by the Modernized 
Disability System will be integrated throughout the new process. For 
example, the national end-of-line quality review sample will be 
electronically selected and automatically routed to appropriate staff. 
In-line programmatic quality assurance, enhanced by the use of decision 
support systems, will be programmed into the computer applications and 
will help to identify errors of both oversight and substance, and also 
support routine analysis to aid in avoiding future similar errors. An 
on-line technical review will occur each time information is added to 
the electronic record.
    Quality assurance and productivity measures will be incorporated in 
a new, total-process management information system. Meaningful, timely 
management information for the disability process is dependent on a 
seamless data processing system used by all components which affords a 
common case control system and a common data base. SSA's claim 
processing systems integrated on an Agency-wide IWS/LAN platform will 
provide this seamless environment.
    The Modernized Disability System management information design 
supports the new process goal of providing access from a desktop 
computer to total-process management information data no more than 24 
hours old. In addition to the routine, published national reports 
generated from the management information system, other reports needed 
by national or local entities, or individual employees will be 
preformatted and system-generated on demand. Managers and empowered 
employees will have the flexibility to change parameters and to access 
the full data base, permitting comparison of peer performance and trend 
analysis. The system would also permit custom, ad hoc reports for 
special studies or immediate special purpose activities with access to 
the full data base. Tools including user-friendly report generator 
software and statistical forecasting and modeling applications will be 
available on the intelligent workstation to assist users in the data 
analysis.

Appendix I--Reengineering Design Partners

Director, SSA Process Reengineering Program
Rhoda Davis--Office of the Commissioner, Baltimore, MD.
Disability Process Reengineering Team
William Anderson--Office of Disability, Baltimore, MD.
Mary Ann Bennett--Office of Budget, Baltimore, MD.
Bryant Chase--Office of the Deputy Commissioner for Systems, Baltimore, 
MD.
Kayla Clark--Office of Hearings and Appeals, Seattle, WA.
Judith Cohen--Office of Supplemental Security Income, Baltimore, MD.
Judge Alfred Costanzo, Jr.--Office of Hearings and Appeals, Pittsburgh, 
PA.
Kelly Croft--Office of Workforce Analysis, Baltimore, MD.
Mary Fischer Doyle--Office of Hearings and Appeals, Falls Church, VA.
Virginia Lighthizer--Chicago Region, Detroit Conner Branch Office, 
Detroit, MI.
Rebecca Manship--Disability Determination Service, Sacramento, CA.
Mary Meiss--Office of Hearings and Appeals, Philadelphia, PA.
Michael Moynihan--Office of Disability and International Operations, 
Baltimore, MD.
Donna Mukogawa--Office of the Regional Commissioner, Chicago, IL.
William Newton, Jr.--Office of Disability and International Operations, 
Baltimore, MD.
Ralph Perez--Atlanta Region, Miami South District Office, Miami, FL.
Dr. Nancie Schweikert--Disability Determination Section, Nashville, TN.
Ronald Sribnik--Office of Regulations, Baltimore, MD.
Sharon Withers--Philadelphia Region, Welch District Office, Welch, WV.

Special Thanks to

Linda Kaboolian--Kennedy School of Government, Harvard University, 
Cambridge, MA.
Miriam Kahn--Process Reengineering Staff, Baltimore, MD.
Kenneth Nibali--Process Reengineering Staff, Baltimore, MD.
Leonard Ross--Office of Workforce Analysis, Baltimore, MD.
John Shaddix--Office of Telecommunications, Baltimore, MD.
Sandi Sweeney--Process Reengineering Staff, Baltimore, MD.
Latesha Taylor--Process Reengineering Staff, Baltimore, MD.
Process Reengineering Program Executive Steering Committee
Shirley Chater--Commissioner, SSA.
Lawrence Thompson--Principal Deputy Commissioner, SSA.
Rhoda Davis--Director, Process Reengineering Program, SSA.
Dennis Brown--Moderator, Association of OHA Analysts.
Bruce Bucklinger--President, OHA Managers' Association.
Robert Burgess--President, National Association of Disability 
Examiners.
Mary Chatel--President, National Council of Social Security Management 
Associations, Inc.
Herbert Collender--President, SSA/AFGE National Council of Payment 
Center Locals (Council 109).
Renato DiPentima--Deputy Commissioner for Systems, SSA.
John Dyer--Deputy Commissioner for Finance, Assessment and Management, 
SSA.
Richard Eisinger--Senior Executive Officer, SSA.
George Failla--Director, Office of Information Resources Management, 
SSA.
Gilbert Fisher--Assistant Deputy Commissioner for Programs, SSA.
Howard Foard--Assistant Deputy Commissioner for Policy and External 
Affairs, SSA.
Hilton Friend--Acting Associate Commissioner for Disability, SSA.
John Gage--President, SSA/AFGE SSA Headquarters (Local 1923).
Randolph Gaines--Acting Associate General Counsel, SSA.
Robert Green--SSA Regional Commissioner, Boston.
Joseph Gribbin--Associate Commissioner for Program and Integrity 
Reviews, SSA.
James Hill--President, National Treasury Employees Union (Chapter 224).
Arthur Johnson--Chief Spokesperson, SSA/AFGE General Committee.
Charles Jones--Director, Michigan Disability Determination Services.
David Knoll--President, SSA National Federation of Federal Employees 
Council of Consolidated Locals.
Demos Kuchulis--President, National Association of Senior Social 
Security Attorneys .
Antonia Lenane--Chief Policy Officer, SSA.
Huldah Lieberman--Assistant Deputy Commissioner for Operations, SSA.
Rose Lucas--President, SSA/AFGE National Council of Data Operations 
Centers (Council 221).
James Marshall--President, SSA/AFGE National Council of SSA/OHA Locals 
(Council 215).
Larry Massanari--SSA Regional Commissioner, Philadelphia.
Francis O'Byrne--President, Association of Administrative Law Judges, 
Inc.
Ruth Pierce--Deputy Commissioner for Human Resources, SSA.
Daniel Skoler--Associate Commissioner for Hearings and Appeals, SSA.
Witold Skwierczynski--President, SSA/AFGE National Council of SSA Field 
Operations Locals (Council 220).
Earl Tucker--President, SSA/AFGE National Council of Social Security 
Regional Offices, Program Integrity Review (Council 224).
Janice Warden--Deputy Commissioner for Operations, SSA.
Andrew Young--Deputy Commissioner for Programs, SSA.

Appendix II--Methodology

Business Process Reengineering

    The Process Reengineering Program is the culmination of a rigorous 
SSA investigation of the reengineering efforts and methodologies of 
those companies, public organizations, academic institutions, and 
consulting firms with the most ``hands on'' experience in this field. 
The positive findings from this detailed review, combined with concerns 
about existing business processes within SSA and the quality of SSA 
service to the public, led management to the conclusion that a process 
reengineering effort was critical to the SSA objective of providing 
``world-class'' administration and service.
    Based largely on analysis of what has worked best in the private 
and public sectors, a customized reengineering methodology was 
developed within SSA. It uses a reengineering team approach that 
combines a strong ``customer'' focus with classic management analysis 
techniques, and computer modeling and simulation, to intensely review a 
single business process. The objective is not to make small, 
incremental improvements in the various pieces of the process, but to 
redesign it as a whole, from start to finish, so that it becomes many 
times more efficient and, in so doing, significantly improves SSA 
service to the public.
    A senior SSA manager was selected to serve as Director of the 
Process Reengineering Program. The Director leads all SSA process 
reengineering efforts, is the primary liaison with the Commissioner and 
Executive Staff, nominates topics for examination, chairs project 
steering committees, and directs a small professional staff and 
revolving group of managers/consultants.
    SSA uses special, multi-disciplinary teams of individuals to 
conduct reengineering analyses and identify the best ways to redesign 
and significantly improve processes. Teams are comprised of outstanding 
employees, all of whom are subject matter experts in operational, 
programmatic, policy, systems, administrative, and other areas relevant 
to the business process.
    Reengineering teams focus on identifying those procedural and 
policy changes to the process that will: make it more claimant and 
service oriented; greatly increase productivity and process speed; take 
advantage of opportunities offered by new technology; and improve the 
empowerment and professional enrichment of the employees who are part 
of the process. Although teams follow the same basic reengineering 
protocol, continual customization is both expected and encouraged.

Disability Process Reengineering

    Project Employees within SSA and DDS at all levels recognize that 
there are significant problems with the disability claims process. They 
are dissatisfied with the long processing times and high backlogs which 
result in less than satisfactory service to claimants. The disability 
process reengineering project has allowed those who have long worked in 
the process, and with claimants and their representatives, to 
investigate the causes of current problems. With considerable input 
from other employees and those outside the process, they have developed 
the proposal for solving those problems.
    The Secretary of the Department of Health and Human Services, Donna 
Shalala, and the Commissioner of Social Security, Shirley Sears Chater, 
have placed improvements in the disability process as critical to the 
delivery of world-class service by SSA. They have strongly supported 
the work of the project team. Their adoption of the proposal will 
depend on the response of the employees and the public to it.
    An Executive Steering Committee was formed to meet on a regular 
basis to provide advice to the Commissioner on development of the 
disability reengineering process change proposal, and to ensure that 
support occurred at the highest levels of the Agency. The Executive 
Steering Committee established the parameters and expectations for the 
project. The expectation goals were driven by targets set forth in the 
Agency Strategic Plan and are based on percentages of service and/or 
productivity:

Parameters and Expectations for Reengineering the Disability 
Determination Process (9/15/93)

Definition of Process
    The ``process'' to be reengineered is the initial and 
administrative appeals system for determining an individual's 
entitlement to Social Security and Supplemental Security Income 
disability payments. It includes all actions from an individual's 
initial contact with SSA through payment effectuation or final 
administrative denial. The system for determining whether an individual 
continues to be entitled to receive disability payments is not part of 
this ``process.''
    Rationale: The process to be reengineered must be defined broadly 
to increase the opportunity for improvement. The continuing disability 
review system is not included because it is conceptually and 
practically distinct from the initial disability determination process.
Parameters
    Every aspect of the process except the statutory definition of 
disability, individual benefit amounts, the use of an administrative 
law judge as the presiding officer for administrative hearings, and 
vocational rehabilitation for beneficiaries, is within the scope of 
this reengineering effort. However, analysis and ideas for change 
should proceed and be presented on two tracks: Improvements achievable 
without changes in statute or regulations and innovations that may 
require such change.
    Rationale: The timing of legislative or regulatory change is beyond 
SSA's control. Such change could not reasonably be expected to be 
implemented in less than 2 years. However, limiting the reengineering 
effort to aspects of the process not requiring change in statute or 
regulations was rejected as limiting too greatly the possibility of 
major improvement/innovation in the process. The two-track approach 
provides for both shorter term incremental improvements and longer 
term, more radical change.
Expectations
    1. Unless otherwise specified here, the recommendations for change 
should be consistent with the goals and objectives set forth in the 
Agency Strategic Plan.
    2. Recommendations for change, taken as a whole, should not cause 
changes in benefit outlays unless as a necessary result of improvements 
in service, such as more timely processing and payment of claims.
    3. Process changes should improve service and/or productivity, on a 
combined basis, by at least 25 percent by the end of FY 1997 over 
levels projected in the FY 1994 budget (it would require about an 
additional $500 million currently to realize such improvement) and 
decisional accuracy should not decrease. By FY 2000 additional actions, 
including any necessary statutory and regulatory changes, should 
provide a further 25 percent improvement.
    The Executive Steering Committee facilitated good ongoing 
communications between components and the Team, and communicated the 
need and reason for reengineering the disability process. They were 
familiar with the current process problems and were kept apprised of 
research completed by the Team. In February, the Executive Steering 
Committee was expanded to include the Presidents of the American 
Federation of Government Employees, the National Federation of Federal 
Employees, and the National Treasury Employees Union locals, councils 
and chapters representing SSA employees; and the Presidents of the SSA/
DDS professional and management associations recognized by SSA as 
having an interest in disability issues.
    Upon receipt of this proposal, the Executive Steering Committee 
will make an impact assessment, cognizant of competing pressures and 
implementation challenges. During the dialogue period, the Executive 
Steering Committee will share and discuss the proposal, provide 
feedback, and identify implementation questions. Based on the comments 
received and issues identified, they will provide advice on the next 
steps.
    The 18 members of the Disability Reengineering Team, all of whom 
are SSA or State DDS employees, have varied and extensive backgrounds 
in all aspects of the disability program. Team members attended a high 
quality, intensive 3-day SSA reengineering methodology training 
session, and completed extensive reading assignments on reengineering. 
Some Team members visited organizations who had reengineered their 
business processes to learn about successes as well as opportunities 
for improvement.
    The Team used the following methods to obtain the information 
necessary to develop a redesigned disability process.

Briefings

    Members of the Team received extensive briefings from:

--All SSA components that work with any aspect of the disability 
process; and
--Dr. Frank S. Bloch, Professor of Law and Director of the Clinical 
Education Center at Vanderbilt, who discussed the results of his study 
comparing disability programs and processes of the United States, 
Canada, and Western Europe. His work encompasses eligibility 
requirements and program goals, benefit award structure and short-term 
benefits, administrative organization, and procedures for claim 
processing and appeals.

Scan Visits

    The Team made fact-finding visits to numerous SSA and DDS offices, 
and to other public and private organizations throughout the country 
who have an interest in working with SSA to improve the disability 
process. Team members conducted numerous telephone interviews with 
representatives of offices/groups whom they could not personally visit. 
They also publicized surface/electronic mail addresses and fax and 
voice telephone numbers for those who were not contacted or had 
additional information to provide.
    Prior to site visits/contacts, Team members provided those 
organizations and individuals with general information about the 
reengineering effort, key research areas, and some unconventional ideas 
about the disability process so that the interviewees would have an 
opportunity to think about process issues. The Team encouraged 
interviewees to provide open and honest opinions, suggestions, and 
ideas.
    Appendix III contains a list of the sites visited and telephone 
interviews conducted.

Focus Groups

    A series of 12 focus groups were held throughout the country to 
obtain input from members of our claimant population and the general 
public regarding their experiences with and expectations of the SSA 
disability process. The focus groups provided the Team valuable 
information about claimants' expectations and preferences, as well as 
concerns about the current process. Appendix III contains a list of the 
focus group sites and composition.

Benchmarking

    ``Internal benchmarking'' refers to the identification and 
understanding of site-specific best practices that currently exist 
within the Agency and is focused on the improvement and standardization 
of internal operations. The Team completed this phase of benchmarking 
by reviewing lists of sites engaging in ``best practices'' which were 
submitted by various SSA components, and visiting or telephoning as 
many of these SSA and DDS offices as possible.
    ``External benchmarking'' is essentially the same, except the hunt 
for best practices and proven process innovations is expanded to 
comparable companies and organizations outside of SSA. It is focused 
outside the organization and is concerned with the relative performance 
of one specific function or process. Appendix III contains the 
companies/organizations the Team used as benchmarking partners.
    A valuable part of the benchmarking exercise was the opportunity to 
validate assumptions related to the disability process, note issues 
that required further investigation, and identify potential improvement 
opportunities.

Process Analysis

    The Team utilized a document prepared by the SSA Office of 
Workforce Analysis in April 1993 which outlines the ``as-is'' 
disability claim and appeal processes of SSA. The document contains a 
description of claim processing tasks performed by line-employees in 
the seven operational components that deal with the disability claim 
process.
    Team members conducted studies on issues such as claimant burden 
time, gap analysis, and administrative costs. They also collected, 
reviewed, and researched an extensive amount of existing procedural 
guides, laws/regulations, studies conducted by internal and external 
components, processing time and quality management information, 
workflows, cost data, etc.
    Intensive deliberations, concept debates, and analysis on ideas for 
change were instrumental in the creation of the redesigned process.

Computer Modeling

    Computer models are close representations of work processes that, 
if properly constructed, allow for better understanding, testing or 
forecasting, and study. Team members worked with modeling professionals 
in SSA and the private sector to build the models used to develop 
assumptions about a redesigned process. The assumptions used for the 
proposal are shown in appendix IV.
    Models were built to represent both the current and proposed 
processes. These models helped the Team predict the best features and 
performance of the new disability process; to better judge the 
magnitude of change from one process to another; and to do some ``what-
if-nothing-changes'' analysis to get a feel for the impact of 
inactivity.

Proposal

    The dominant product of the entire effort--this proposal--outlines 
the best process improvement and process innovation ideas from the 
Team. The proposal as written by the Team, will be presented to the 
Executive Steering Committee, and will be made widely available within 
SSA and the DDS community, as well as to the broadest possible public 
for comment.

Appendix III--Research

Logistic Accomplishments

Sites Visited: 421
States Visited: 33
Individual Interviews: 3,600+

Specific Sites

 35 SSA central office components
 10 regional offices, OHA ROs and ROPIRS
 7 DHHS regional OGC offices
 37 State DDSs
 64 field offices
 28 hearing offices
 9 processing centers and other large installations
 10 teleservice centers
 14 area director offices
 181 sites ``external'' to SSA and DDSs
 6 union/management associations

Telephone Interviews

31 field offices
 1 teleservice center
 3 area director offices
 4 hearing offices
 26 DDSs
 46 sites external to SSA and DDSs

BILLING CODE 4190-29-P

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Appendix IV--Model Assumptions

    Computer software packages were used to model and simulate the 
effects the changes in this proposal will have at both the micro (local 
office) and macro (national) level. Some of the general guidelines and 
assumptions used for the proposed process are listed below.
    Due to increased public information programs, claimants will be 
better prepared with respect to information and documentation needs 
prior to filing their claim.
    The time that disability claim managers spend interviewing will be 
reduced as a decision support system will assist them in asking the 
claimant impairment-specific medical and nonmedical questions. Based on 
triage decisions they make throughout the interview, the disability 
claim managers will ask the claimant only the questions that are 
pertinent to the decisionmaking process.
    The application and medical certification forms will be scanned or 
electronically transferred and associated with the electronic record. A 
disability claim manager will only key identifying information from the 
application form into the electronic record.
    Claim files will be much smaller in size as SSA accepts medical 
certification statements in lieu of extensive medical documentation.
    Time to obtain medical evidence will decrease as collection focuses 
on core diagnostic and functional information needed to make a decision 
and uses a standardized form.
    Changes to the current process, such as the disability claim 
manager concept, the predenial interview, and fully rationalized 
disability decisions, will increase claimant satisfaction with SSA's 
decisional process and ultimately decrease the appeal rate and number 
of refilings.
    A decision support system and an electronic record will assist 
adjudicators to prepare notices of decision.
    The percentage of claimants represented will decrease as the 
processing time decreases, claimant participation increases, and 
increased customer service leads to a higher level of claimant 
satisfaction and understanding of the process.
    Guidelines and assumptions used for the proposed process include 
those listed below.
    A brief description of each task is provided. The task time, shown 
in minutes, is the estimated time it will take employees to complete 
the described work. The lapse time, shown in work days, represents the 
amount of time between actions. Three numbers are provided: the middle 
number represents the most common task or lapse time, while the first 
and third numbers represent the low and high extremes. The task and 
lapse times shown represent times likely when the proposed process is 
fully up and running.
    Percentages are shown to represent frequency of occurrences.

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Appendix V--Next Steps

Proposal for an Implementation Blueprint

    Building a redesigned disability claim process will not be an easy 
task--impacts will be felt by almost everyone internal and external to 
SSA who is involved in the disability claim process. Claimants, their 
representatives, disability advocate organizations, professional 
associations, SSA and DDS employees and employee representatives will 
feel the effects of the transition to a new way of doing business.
    There will be a vast number of decisions to be made about the way 
the new process will be built and its infrastructure designed. Timing 
of the myriad decisions is crucial to ensure that required 
organizational, budgetary, human resource, technological, logistical, 
and regulatory changes occur in the proper sequence.
    The Team has developed a proposal that outlines the most 
significant redesign implementation steps. The steps are grouped 
according to areas of impact. Some of the steps will be sequential 
while others will be simultaneous.
I. Organization
    SSA will develop an organizational structure that ensures 
coordination and effective support of the entire disability claim 
process. An implementation team will be established to plan and 
coordinate the general aspects of the redesign changes with existing 
SSA components, States, unions, and professional associations.
    In addition to implementing the proposed process, the 
implementation team will be responsible for determining the impacts on 
other business processes. Some of these impacts may require changes in 
other processes.
    The following steps will be completed in order to achieve these 
goals:

--Obtain executive approval to proceed with implementation
--Develop disability process management structure/organization/
ownership
--Build implementation team
--Develop plan for change management
--Develop method for processing current work while implementation takes 
place
--Outline interdependent steps of implementation
--Analyze risk factors to be encountered in meeting timeframes
--Create clear objectives to provide rapid recognition of improvement/
success
--Establish tangible success scorecard
--Establish major milestones and managerial checkpoints for 
implementation
--Monitor progress and adjust implementation schedules accordingly for 
future sites
--Complete first implementation phase
--Analyze success of first phase, make necessary implementation changes 
and prepare for additional implementation sites
--Complete full implementation
II. Communications
    SSA will develop a comprehensive communications plan that 
systematically and logically addresses the needs of everyone associated 
with the disability claim process and enhances the implementation of 
the redesigned process. The following steps will be completed in order 
to achieve this goal:

--Determine who will need to be notified of the new process and at what 
intervals
--Develop models needed to assist staff, claimants and stakeholders to 
visualize the new organization, new roles, new responsibilities
--Select communications media, including new methods or modes
--Determine communications tools to be used in providing continuing 
updates throughout the implementation process
--Design communications plan
--Schedule communications releases
--Begin media campaign to describe new process
--Begin media campaign to describe interim measures to get to new 
process
--Notify stakeholders, employees, and other interested parties of 
initial sites selected and implementation schedule
--Announce achievement of successfully completed milestones
III. Program Management
    A. Costs
    SSA will determine the full cost of the redesigned disability claim 
process, its implementation and its related impact. The following steps 
will be completed in order to achieve this goal:

--Estimate cost of new process operation
--Obtain necessary funding for first-phase operating expenses
--Estimate initial implementation costs
--Obtain necessary funding for first-phase implementation costs
--Determine impact of new process on current DDS budgets and indirect 
costs to the States and take necessary resulting actions
--Develop method for tracking and monitoring implementation costs
--Monitor process and implementation costs, making adjustments as 
necessary

    B. Management Information
     SSA will develop the means to gather, analyze and report the 
information required to operate the redesigned disability claim 
process. The following steps will be completed in order to achieve this 
goal:

--Establish management information needs for oversight agencies
--Establish management information needs for SSA
--Establish management information needs for implementation site 
employees
--Design and test validity of new management information reporting 
mechanisms
--Institute new management information system

    C. Quality
    As an important element in the redesigned process, SSA will develop 
new methods for assuring the delivery of world-class service. The new 
methods will be integrated with training, policy, and management 
information facets of the redesigned process. The following steps will 
be completed in order to achieve this goal:

--Design quality control process
--Test and validate quality control process
--Establish quality feedback mechanisms
--Institute new quality control process

    D. State Roles
    SSA will analyze comments received during the 60-day dialogue 
period and make determinations regarding State roles. The following 
steps will be completed in order to achieve this goal:

--Identify where DDS employees fit in the new process
--Determine regulatory and statutory changes needed
--Negotiate changes under current statute and regulations for 
implementation sites
IV. Human Resources
    A. Training
     Major changes arising out of the new way of doing business mandate 
that employees be fully trained to meet the needs of the new process. 
Much training will be done on a large scale in short periods of time. 
Alternate training media, e.g., satellite training, self-paced 
computer-based training, videotape training, etc. will be used to reach 
large audiences effectively. The following steps will be completed in 
order to achieve this goal:

--Assign lead for developing, organizing and managing the training 
program
--Determine national and site-specific training needs
--Determine what instructions need to be written
--Ascertain format for training materials
--Develop means to ensure current work is completed while training 
takes place
--Establish training timetable
--Determine teaching resource needs and source of those resources
--Obtain instructor resources
--Obtain training supplies
--Secure necessary training facilities
--Plan and coordinate training sessions
--Begin training
--Monitor training results and make adjustments as necessary
--Complete all initial training activities

    B. Personnel
    SSA will effectively prepare for and, to the extent possible, 
minimize negative effects of the transition to the redesigned process 
on employees. Plans will consider the effect on the work environment, 
career enhancements, job responsibilities, possible workforce shifts, 
and performance evaluation. The following steps will be completed:

--Determine volume and qualifications of staff needed to perform new 
process
--Create, modify, or eliminate job types for the new process
--Develop change management assistance for employees
--Develop performance monitoring systems and incentives
--Determine tools employees need to perform new process
--Develop position descriptions and performance plans
--Establish long-term plan to ensure national availability of qualified 
staff
--Analyze staff availability at implementation sites for new process 
and old process
--Determine anticipated costs of moving personnel to work sites, 
temporarily and/or permanently
--Determine staffing needs
--Obtain necessary funding to move staff
--Obtain tools for employees
--Establish local management and key staff teams
--Select remaining staff
--Move staff as necessary
--Begin new process
V. Statutory/Regulatory/Policy
    A. Policy
    Extensive policy changes will take place prior to and during 
process implementation. As regulatory and statutory modifications 
occur, procedural re-writes will address their impact on SSA claim 
processing policy. New, more effective means of organizing and issuing 
Agency policy will be used to accomplish these tasks. The following 
steps will be completed in order to achieve these goals:

--Ascertain what procedures and workflows need to be modified, 
eliminated, or established
--Determine appropriate policy and procedure format(s)
--Develop screens and forms to be incorporated in new process
--Determine methods for policy and procedure dissemination
--Develop method for monitoring policy implementation
--Design new workflow
--Write procedures needed to nationally implement immediate changes
--Issue new procedures
--Monitor, analyze and re-write procedures as necessary
--Write procedures to support regulatory and statutory changes
--Issue long-term procedures
--Monitor, analyze, and re-write procedures as necessary

    B. Statutory/Regulatory
    A large number of regulations and statutory sections will need to 
be modified to support the implementation of the redesigned process. 
SSA will develop faster, more effective means for gaining the necessary 
changes. The following steps will be completed in order to achieve this 
goal:

--Write necessary regulations to support new process
--Propose elimination of unnecessary regulations
--Obtain final approval for regulatory changes
--Seek changes to necessary statutes to support new process
--Congressional approval of statutory changes
--Establish methods for statutory and regulatory change dissemination
--Disseminate statutory and regulatory changes to all necessary parties
VI. Logistics
    A. Implementation sites
    Implementation will impact the physical work environment. Decisions 
on number, location, size, and layout of offices will be designed into 
the implementation plan. The following steps will be taken:

--Ascertain type of sites needed
--Analyze demographic, geographic, and fiscal considerations for site 
selection
--Select site management team to orchestrate site preparation
--Determine number of first-implementation sites
--Recommend implementation sites
--Receive implementation site approval
--Evaluate implementation facilities for necessary space and layout 
modifications
--Determine new or additional equipment and furniture needs at 
implementation sites
--Evaluate supplies and forms needed for new process
--Obtain funding for site work, supplies and equipment
--Prepare site and equipment leases
--Order supplies and forms needed for new process
--Order new equipment
--Complete site preparation work at implementation facilities
--Install equipment
--Deliver supplies and forms to sites
--Deliver new employees' possessions

    B. Technology
    Increased use of automated processes; decisional support software; 
electronic claimant records; electronic interaction between SSA, 
claimants, and the medical community; and telecommunications in the 
redesigned process dictates that SSA expand and accelerate the current 
comprehensive technology design plan. The following steps will be 
completed to achieve these goals:

--Review and modify pertinent Agency tactical plans
--Analyze impact of change on computer programs currently being used or 
planned in SSA
--Reevaluate hardware and software needs
--Modify existing SSA software to support the new process
--Develop and validate new software
--Procure hardware
--Install necessary hardware
--Install software
--Test hardware and software, making necessary adjustments
--Implement new systems

Summary of Current Statutory and Regulatory Provisions Affected by the 
New Disability Process

    Title II of the Social Security Act--
    Disability Determinations: Section 221(a) through (j)--Disability 
Insurance Benefit Payments (Definition of Disability): section 
223(d)(5)(B).
    Title XVI of the Social Security Act--
    Meaning of Terms (Aged, Blind, or Disabled Individual): section 
1614(a)(3)(G)--Administration: section 1633.
Regulations (parts 404, 416 and 422)
    The following sections of subpart G of Reg. No. 404 and subpart C 
of Reg. No. 416:


Secs. 404.610/416.310  What makes an application a claim for 
benefits.
Sec. 404.614  When an application or other form is considered filed.
Sec. 416.325  When an application is considered filed.


    The following sections of subpart J of Reg. No. 404 and subpart N 
of Reg. No. 416:


Secs. 404.900/416.1400  Introduction.
Secs. 404.902/416.1402  Administrative actions that are initial 
determinations.
Secs. 404.904/416.1404  Notice of the initial determination.
Secs. 404.905/416.1405  Effect of an initial determination.
Secs. 404.907/416.1407  Reconsideration--general.
Secs. 404.908/416.1408  Parties to a reconsideration.
Secs. 404.909/416.1409  How to request reconsideration.
Secs. 404.913/416.1413  Reconsideration procedures.
Sec. 416.1413a  Reconsiderations of initial determinations on 
applications.
Secs. 404.929/416.1429  Hearing before an administrative law judge--
general.
Secs. 404.930/416.1430  Availability of a hearing before an 
administrative law judge.
Secs. 404.932/416.1432  Parties to a hearing before an 
administrative law judge.
Secs. 404.933/416.1433  How to request a hearing before an 
administrative law judge.
Secs. 404.935/416.1435  Submitting evidence prior to a hearing 
before an administrative law judge.
Secs. 404.936/416.1436  Time and place for a hearing before an 
administrative law judge.
Secs. 404.938/416.1438  Notice of a hearing before an administrative 
law judge.
Secs. 404.939/416.1439  Objections to the issues.
Secs. 404.940/416.1440  Disqualification of the administrative law 
judge.
Secs. 404.941/416.1441  Prehearing case review.
Secs. 404.944/416.1444  Administrative law judge hearing 
procedures--general.
Secs. 404.946/416.1446  Issues before an administrative law judge.
Secs. 404.948/416.1448  Deciding a case without an oral hearing 
before an administrative law judge.
Secs. 404.955/416.1455  The effect of an administrative law judge's 
decision.
Secs. 404.960/416.1460  Vacating a dismissal of a request for a 
hearing before an administrative law judge.
Secs. 404.961/416.1461  Prehearing and posthearing conferences.
Secs. 404.967/416.1467  Appeals Council review--general.
Secs. 404.968/416.1468  How to request Appeals Council review.
Secs. 404.969/416.1469  Appeals Council initiates review.
Secs. 404.970/416.1470  Cases the Appeals Council will review.
Secs. 404.971/416/1471  Dismissal by the Appeals Council.
Secs. 404.972/416.1472  Effect of dismissal of request for Appeals 
Council review.
Secs. 404.973/416.1473  Notice of Appeals Council review.
Secs. 404.976/416.1476  Procedures before Appeals Council on review.
Secs. 404.977/416.1477  Case remanded by the Appeals Council.
Secs. 404.979/416.1479  Decision of Appeals Council.
Secs. 404.981/416.1481  Effect of Appeals Council's decision or 
denial of review.
Secs. 404.982/416.1482  Extension of time to file action in Federal 
district court.
Secs. 404.992/416.1492  Notice of a revised determination or 
decision.
Secs. 404.993/416.1493  Effect of revised determination or decision.


    The following sections of subpart P of Reg. No. 404 and subpart I 
of Reg. No. 416:


Secs. 404.1501/416.901  Scope of subpart.
Secs. 404.1502/416.902  General definitions and terms for this 
subpart.
Secs. 404.1503/416.903  Who makes disability and blindness 
determinations.
Secs. 404.1505/416.905  Basic definition of disability.
Secs. 404.1511/416.911  Definition of a disabling impairment.
Secs. 404.1512/416.912  Evidence of your impairment.
Secs. 404.1513/416.913  Medical evidence of your impairment.
Secs. 404.1515/416.915  Where and how to submit evidence.
Secs. 404.1517/416.917  Consultative examination at our expense.
Secs. 404.1519/416.919  The consultative examination.
Secs. 404.1519a/416.919a  When we will purchase a consultative 
examination and how we will use it.
Secs. 404.1519k/416.919k  Purchase of medical examinations, 
laboratory tests, and other services.
Secs. 404.1519m/416.919m  Diagnostic tests or procedures.
Secs. 404.1519n/416.919n  Informing the examining physician or 
psychologist of examination scheduling, report content, and 
signature requirements.
Secs. 404.1519q/416.919q  Conflict of interest.
Secs. 404.1519s/416.919s  Authorizing and monitoring the 
consultative examination.
Secs. 404.1519t/416.919t  Consultative examination oversight.
Secs. 404.1520/416.920  Evaluation of disability in general.
Secs. 404.1520a/416.920a  Evaluation of mental impairments.
Secs. 404.1521/416.921  What we mean by an impairment(s) that is not 
severe.
Secs. 404.1522/416.922  When you have two or more unrelated 
impairments--initial claims.
Secs. 404.1523/416.923  Multiple impairments.
Sec. 416.924   How we determine disability for children.
Sec. 416.924a  Age as a factor of evaluation in childhood 
disability.
Sec. 416.924b  Functioning in children.
Sec. 416.924c  Other factors we will consider.
Sec. 416.924d  Individualized functional assessment for children.
Sec. 416.924e  Guidelines for determining disability using the 
individualized functional assessment.
Sec. 404.1525/416.925  Listing of impairments in Appendix 1.
Secs. 404.1526/416.926  Medical equivalence.
Sec. 416.926a  Equivalence for children.
Secs. 404.1527/416.927  Evaluating medical opinions about your 
impairment(s) or disability.
Secs. 404.1529/416.929  How we evaluate symptoms, including pain.
Sec. 416.931  The meaning of presumptive disability or presumptive 
blindness.
Sec. 416.932  When presumptive payments begin and end.
Sec. 416.933  How we make a finding of presumptive disability or 
presumptive blindness.
Sec. 416.934  Impairments which may warrant a finding of presumptive 
disability or presumptive blindness.
Secs. 404.1545/416.945  Your residual functional capacity.
Secs. 404.1546/416.946  Responsibility for assessing and determining 
residual functional capacity.
Secs. 404.1560/416.960  When your vocational background will be 
considered.
Secs. 404.1561/416.961  Your ability to do work depends upon your 
residual functional capacity.
Secs. 404.1562/416.962  If you have done only arduous unskilled 
physical labor.
Secs. 404.1563/416.963  Your age as a vocational factor.
Secs. 404.1564/416.964  Your education as a vocational factor.
Secs. 404.1565/416.965  Your work experience as a vocational factor.
Secs. 404.1566/416.966  Work which exists in the national economy.
Secs. 404.1567/416.967  Physical exertion requirements.
Secs. 404.1568/416.968  Skill requirements.
Secs. 404.1569/416.969  Listing of Medical-Vocational Guidelines in 
Appendix 2.
Secs. 404.1569a/416.969a  Exertional and nonexertional limitations.
Secs. 404.1574/416.974  Evaluation guides if you are an employee.
Secs. 404.1575/416.975  Evaluation guides if you are self-employed.
Secs. 404.1584/416.984  Evaluation of work activity of blind people.
Appendix 1  Listing of Impairments.
Appendix 2  Medical-Vocational Guidelines.


    The entire subpart Q of Reg. No. 404 and the entire subpart J of 
Reg. No. 416.
    The following sections of subpart R of Reg. No. 404 and subpart O 
of Reg. No. 416:


Secs. 404.1700/416.1500  Introduction.
Secs. 404.1703/416.1503  Definitions.
Secs. 404.1705/416.1505  Who may be your representative.
Secs. 404.1707/416.1507  Appointing a representative.
Secs. 404.1710/416.1510  Authority of a representative.
Secs. 404.1715/416.1515  Notice or request to a representative.
Secs. 404.1720/416.1520  Fee for a representative's services.
Secs. 404.1725/416.1525  Request for approval of a fee.
Secs. 404.1728/416.1528  Proceedings before a State or Federal 
court.
Secs. 404.1730/416.1530  Payment of fees.
Secs. 404.1735/416.1535  Services in a proceeding under title II of 
the Act.
Secs. 404.1740/416.1540  Rules governing representatives.
Secs. 404.1745/416.1545  What happens to a representative who breaks 
the rules.


    The following sections of subpart B of Reg. No. 422:


Sec. 422.130  Claim Procedure.
Sec. 422.140  Reconsideration of initial determination.


    The following sections of subpart C of Reg. No. 422:

Sec. 422.203  Hearings.
Sec. 422.205  Review by Appeals Council.
Sec. 422.210  Court review.


    The following sections of subpart F of Reg. No. 422:


Sec. 422.505  Applications and related forms for retirement, 
survivors, and disability insurance benefit programs.
Sec. 422.525  Where applications and other forms are available.
Sec. 422.527  Private printing and modification of prescribed 
applications and other forms.

Appendix VI--Examples of Forms and Publications

Disability Information Packets

    All forms that a claimant will need to file an application for 
benefits will be contained in the disability information packet which 
SSA will make available to the public. Claimants may obtain these 
packets by visiting or calling any local SSA office or calling the 
toll-free 800 telephone number. SSA will also make these packets 
available at other public locations such as post offices, public 
libraries, and local, State and Federal offices. Bulk supplies of the 
packets will also be available to third parties who play a role in the 
intake process. The information packet will contain two forms--an 
application and a medical certification form. During the Team's 
research, which included benchmarking activities, it was discovered 
that other government agencies and private organizations successfully 
utilize this approach.
Application Form
    This is a ``starter'' form that serves the purpose of initiating 
the application process. It will solicit basic identification data 
regarding the claimant as well as information concerning the nature of 
the benefits sought (i.e., DI, SSI, children's, widow's, etc.). The 
application form will ask for minimal information, will be easily 
understood, and will require little or no assistance. The claimant's 
signature will be required on the form to meet the legal requirements 
of a formal ``application''.
Medical Certification Form
    This form is for completion by the claimant's primary treating 
source. Rather than systematically collecting all medical evidence of 
record, SSA will use this form to solicit core diagnostic and 
functional information from the treating source. The form will use both 
narrative and ``check box'' formats to elicit identification of each of 
the claimant's medically determinable impairments; the objective data 
(signs, symptoms, clinical and laboratory findings) supporting the 
diagnoses; the treatment prescribed and response; the onset and 
expected duration of the impairments; and an assessment of the 
claimant's ability to perform work-related activities. The treating 
source signature certifies that the information is accurate and based 
upon records within their possession, which they agree to promptly 
furnish if requested.
    The medical certification concept is similar to that used by many 
private disability insurance carriers, workers' compensation programs 
throughout the country, and the Canadian Government. The SSA medical 
report builds upon the concept of the forms used by other organizations 
to target the specific information called for in the new process.

SSA Publications

    SSA rules, pamphlets, factsheets, flyers, posters, and other 
materials, will be printed and available for distribution throughout 
the country at designated public places accessible to claimants, 
representatives, the medical community, public and private social 
service agencies, third parties, and advocacy groups. This will ensure 
that these partners in the new process can be well informed and will 
allow SSA to achieve its goal of providing world-class service to its 
customers.

Appendix VII--Process Change Recommendations That Were Outside the 
Parameters

    In conducting the internal and external scans, the Reengineering 
Team received many ideas and suggestions for change. The ideas that 
follow are recurring suggestions for change that the Reengineering Team 
did not consider because they exceeded the scope of the Team's mission 
or the parameters established by the Executive Steering Committee. They 
may be considered for further study or action by SSA or Congress, as 
appropriate. Inclusion here does not constitute endorsement by the 
Reengineering Team.

Time-Limited Benefits

    Consider time-limited benefits which would subject individuals, 
whose impairments are expected to improve or where medical improvement 
is possible, to automatic benefit termination after a specified time. 
Duration of entitlement would depend on the nature of the impairment, 
i.e., the timeframe could vary according to the impairment the same way 
the current continuing disability review diary duration does. 
Individuals would be notified at the time their claims are allowed how 
long they will receive benefits. Before the automatic termination of 
benefits, SSA would notify individuals when benefits would end, and 
explain that they must refile or submit new medical information that 
confirms they continue to meet the definition of disability. Time-
limited benefits would counteract the mindset that disability benefits 
are permanent. To be successful, time-limited benefits would have to be 
linked to a return to work program or participation in vocational 
rehabilitation services.

Integration of Mandatory Vocational Rehabilitation Services for 
Claimants

    Consider focusing more resources on enforcing vocational 
rehabilitation participation, and discussing rehabilitation and return 
to work earlier in the application process. At the time of an initial 
determination, a vocational rehabilitation program should be prescribed 
and required for the claimant to follow during the period of 
entitlement. Special efforts should be made so that rehabilitation 
agencies would work with disabled children, drug addicts, and 
alcoholics. If SSA determines that the rehabilitation program is not 
proceeding as scheduled, a new decision, based on current information, 
would be made regarding the claimant's ability to successfully continue 
and complete the rehabilitation program.

Changes in Payment of Benefits to Certain SSI Claimants

    Consider providing benefits to some SSI claimants in the form of 
program support rather than cash. For example, some children might 
benefit from a system for vouchering or crediting funds for medical or 
therapeutic treatment, remedial education, and/or job training. This 
would present an opportunity for disabled children to get additional 
assistance with education, learn job skills and maximize their 
potential. Disabled child recipients should be required to stay in 
school, or if homebound, continue in an educational program as a 
requirement to continue receiving benefits. Similarly, for adults 
receiving disability based on substance addiction, a system could be 
established for vouchering or crediting funds for medical or 
therapeutic treatment, education, job training, and for food, clothing, 
and lodging.

Incentives for the Medical Community to Provide Evidence on Their 
Patients or to be Consultative Examination Providers

    To enhance SSA's ability to obtain needed medical evidence, 
consider enacting legislation to require release of medical information 
to SSA without the need for a signed consent form or based on signature 
in file and to require timely release of any physician or hospital 
records produced or maintained by a Medicare/Medicaid provider. 
Legislation should also be enacted to allow physicians to repay their 
federally funded medical school loans by working as consultative 
examination providers or SSA medical consultants. SSA should also 
consider seeking a special tax credit system for reimbursement to 
medical providers for evidence of record on their patients. Physicians 
who opt for this new tax credit would be required to participate in 
training on completion of forms and to submit timely and accurate 
information.

Establish One Court to Handle All SSA Disability Cases

    Consider supporting the establishment of a new Federal court of 
appeals with sole jurisdiction for reviewing the final decision of the 
Secretary in disability cases. District courts would no longer have 
jurisdiction in disability cases.

Eliminate SSA's Involvement With Representative Payees

    Consider providing direct payment to all adult claimants unless 
they have a legal representative or have been found legally 
incompetent. SSA would no longer develop for capability or make 
determinations as to whether benefits are being used in an individual's 
best interests.

Change the Administrative Law Judge Position to a Hearings Officer 
Position

    There are a number of Federal agencies whose administrative appeals 
processes use hearing officers or administrative judges who are not 
appointed as administrative law judges pursuant to the Administrative 
Procedure Act. Because the SSA hearing process is nonadversarial and 
informal, it was suggested that there is no need for an Administrative 
Procedure Act-protected administrative law judge.

Eliminate the Two-Year Waiting Period for Medicare

    DI claimants must be eligible for disability benefits for two years 
before they can qualify for Medicare, while in most States SSI 
claimants receive Medicaid concurrently with the SSI award. Claimants 
who file for both DI and SSI may receive Medicaid coverage with SSI, 
but may lose it when DI payments begin after the end of the 5-month 
waiting period. In many cases, the claimant's primary concern is for 
medical care; enabling access to appropriate medical care could lead to 
or speed up medical recovery.

Require Claimants to Establish That Employers Have Made all the 
Accommodations Required Under the Americans With Disabilities Act

    The Americans with Disabilities Act defines an individual with a 
disability as someone who has, or is perceived to have, or who has a 
history of a physical or mental impairment that substantially limits 
one or more major life activities. Any employer with 25 or more 
employees (15 or more employees as of June 26, 1994) is prohibited from 
discriminating against qualified job applicants and employees with 
disabilities. Qualified individuals are those who can perform the 
essential functions of the job they hold or desire, with or without 
reasonable accommodations. Consider requiring individuals who are 
qualified under the Americans with Disabilities Act to have a signed 
statement from their former employer which outlines the steps that have 
been taken to make reasonable accommodations for the disability.

Provide Presumptive Disability Payments in DI Claims

    Consider providing presumptive disability benefits to DI claimants. 
Presumptive disability benefits are now provided prior to final 
decision to SSI claimants who are likely to be allowances. These 
payments can be given for up to six months and, if the claimant is 
denied, no repayment of the benefit is required. There is a growing 
number of DI claimants with the same financial needs as SSI claimants.

Establish a Family Maximum for SSI Benefits

    Consider establishing a family maximum for SSI benefits as exists 
in DI. With the increasing number of children receiving SSI disability 
benefits, consideration should be given to equalizing Federal cash 
support to DI and SSI families.

Eliminate the Waiting Period for DI Benefits

    Consider eliminating the five-month waiting period. The same 
definition of disability is used for both DI and SSI claimants, yet DI 
claimants must serve a five-month waiting period before they are 
eligible for DI disability benefits.

Limit Payment of Disability Benefits to Residents of the United States

    Consider ceasing the payment of disability benefits to people who 
reside outside the United States. The vocational factors that are 
considered in determining ability to work are based on the United 
States national job economy and it should not be assumed that an 
individual would meet the SSA definition of disability in another labor 
market.

Change the Earnings Amounts for Determining Trial Work Period Months

    Consider setting more reasonable levels for determining trial work 
period months to encourage claimants to attempt returning to work.

Use a Single Earnings Test for All Claimants

    Consider standardizing the annual work test for all claimants under 
age 65. This would serve as an incentive for claimants to return to 
work and reduce the number of work issue continuing disability reviews 
that need to be developed.

Reduce the Number of Actions Required to Process Multiple Benefit 
Payments on One Social Security Number

    Issuance of multiple payments on one social security number is very 
labor intensive. To simplify the process, consider adopting one of the 
following options: Issue a single check for all benefits due on the 
beneficiary's account number to the beneficiary and require him/her to 
disburse monies to the auxiliaries; pay total family benefits to the 
head of the household (if other than the beneficiary) which would 
eliminate multiple checks, multiple letters, and multiple payment 
actions dealing with the family unit; or pay a flat rate for each 
auxiliary. This would eliminate the need to calculate auxiliary 
benefits on each account.

Change the Definition of Disability to Eliminate the Consideration of 
Age, Education, and Previous Work in Determining Disability

    Reconsider the definition of disability so that only medical 
factors are considered. With the enactment of the ADA, the number of 
job opportunities and the availability of services to people with 
disabilities has been greatly enhanced and determining disability 
should be based on a strict medical test.

[FR Doc. 94-8265 Filed 4-14-94; 8:45 am]
BILLING CODE 4190-29-P