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Ten Key Facts You Need to Know About Continuing Disability Reviews

If you obtain Social Security Disability Insurance (SSDI) benefits, at some point you may receive a letter and questionnaire from the Social Security Administration (SSA) telling you it is reviewing your medical condition.

You have been chosen to undergo a Continuing Disability Review (CDR).

Here are 10 key facts you need to know about CDRs.

  1. There are two types of CDRS

SSA conducts work continuing disability reviews and medical continuing disability reviews.

Work review

Under a work review, SSA looks at earnings to determine if an individual is earning more than substantial gainful activity (SGA), which is $1,090 per month. If you are earning more than SGA, your benefits may be terminated. Work activity or earnings can trigger a work or medical review.

Medical review

A medical review determines if an individual is meeting the medical requirements to collect disability benefits. Under the Medical Improvement Review Standard (MIRS) SSDI benefits cannot cease due to updates in SSA disability criteria. Reviewers are also barred from substituting their judgment for that of the original adjudicator. These restrictions make it more difficult for the SSA to terminate eligibility than to continue it.

A disabled beneficiary will not have to undergo a medical CDR based on work activity alone if they :

  • Have received disability benefits for at least 24 months; or
  • Are participating in the Ticket to Work program.

If a beneficiary qualifies for protection from a medical CDR based on work activity, they will still undergo a regularly scheduled medical CDR

  1. The frequency of medical CDRs is based on the severity of your condition

The SSA assigns individual review schedules ranging from every six months to every seven years based on the likelihood that you will experience medical improvement. If medical improvement is:

  • “Expected,” the case will normally be reviewed within six to 18 months after benefits start.
  • “Possible,” a case will normally be reviewed no sooner than three years.
  • “Not expected,” the cases will normally be reviewed no sooner than five to seven years.
  1. Failure to respond could result in the termination of your benefits.

Due to a current backlog of about 1.3 million CDRs, you may receive a Disability Update Report questionnaire instead of a notice that you will undergo full medical review. This questionnaire is a self-report on whether your health status has improved; and any recent medical care, employment, or training activity. If you report improvement or work activity, this information can trigger a full medical review, as does failure to complete and return the questionnaire. If you do not report any improvement or work activity (and there are no other reasons to suspect improvement), a full medical review is deferred.

  1. The SSA cannot terminate benefits unless it finds substantial evidence of medical improvement enabling you to engage in substantial employment.

Generally, if your health has not improved or your disability still keeps you from working, no action will be taken. Specifically, the SSA must make at least one of the following four findings to terminate benefits:

  • You have improved medically and are able to engage in substantial gainful activity.
  • You have benefitted from advances in medical or vocational therapy or technology, or undergone vocational therapy, and are now able to perform SGA.
  • Based on new or improved diagnostic techniques, your impairment is found to be not as disabling as previously thought and you are able to engage in SGA.
  • An earlier determination was in error. This can be demonstrated by evidence on the record or newly obtained evidence related to that determination.
  1. The SSA can terminate benefits under the following conditions:
  • You are engaging in SGA.
  • The prior determination was fraudulently obtained.
  • You cannot be located, or fail without good cause to cooperate in a CDR.
  • You do not follow prescribed medical treatment that would be expected to restore work capacity.
  1. You may be able to continue to receive benefits even if you are no longer considered medically eligible.

If you improve medically and are no longer considered medically eligible, you may continue receiving benefits, including Medicare, if:

  • You participate in an approved vocational rehabilitation program (public or private) before your eligibility ended; and
  • The SSA determines (with information provided by the vocational program) that the program likely will increase your permanent independence and self-sufficiency.
  1. You can appeal a CDR decision

If the SSA determines you are no longer disabled and discontinues benefits, you can:

  • Appeal the decision within 60 days.
  • Complete a Request for Reconsideration form SSA-789-U4 from the local Social Security field office. The form is available online at http://www.socialsecurity.gov/forms/ssa-789.pdf.
  • Have a face-to-face hearing with a disability hearing officer who will make the decision on the appeal.
  1. You can request provisional benefits during the appeal process.

The SSA can provide up to six months of provisional benefits (including Medicare) while your case is being reviewed. Beneficiaries do not have to repay provisional benefits even if the appeal is denied.

Important note: For benefits to continue during the time the case is being decided, the Request for Reconsideration must be submitted within 10 days of receiving the denial and include a specific request for continuation of benefits during the appeal.

  1. You may restart benefits if you become ineligible under a work review.

If you become ineligible for SSDI benefits due to work at the SGA level, you may request to reinstate benefits at a later time, without filing a new application, provided:

  • You become unable to work and earn SGA because of the same or related medical condition.
  • You file the request for reinstatement with Social Security within 60 months from the month your benefits are terminated.
  1. If you are participating in the Ticket to Work program, SSA will not schedule you for a medical CDR.

If you assign your Ticket to an approved service provider before you receive notice of a medical CDR, you will not have to undergo the medical review while you are participating in the program and making progress within the SSA’s timeframes. However, if a medical CDR had been scheduled before you assigned your ticket, the SSA will continue with the medical CDR. Visit AllsupES.com or call (866) 540-5105 for more information on assigning your Ticket.

For more information on CDRs, contact your local Social Security field office or the SSA at (800) 772-1213 and TTY (800) 325-0778.