As part of the statement of task for this study, the U.S. Social Security Administration (SSA) asked the committee to “describe the decision-making processes of other government or private monetary disability benefit programs regarding the use of the selected assistive products and technologies.” To meet this objective, in addition to reviewing relevant policy and procedural documents, the committee spoke to representatives of the U.S. Department of Veterans Affairs’ (VA’s) Veterans Benefits Administration (VBA); Service Canada’s Canada Pension Plan (CPP) program; and two private disability insurance providers, Unum and Prudential Financial.1 The committee selected the VBA because it is another large U.S. federal disability program, and some VA disability beneficiaries also receive benefits from SSA. Service Canada’s CPP was selected because, like the SSA disability programs, it is a federally administered program funded by worker and employer contributions that provides disability and retirement benefits to
1 The amount of information provided to or obtained by the committee varied among the programs discussed in this chapter. There is much publicly available information about the programs and overall disability determination processes of SSA, the VA, and the CPP. With respect to specific questions of whether or how these agencies consider the use of assistive products and technologies in their decision-making processes, the committee had to rely more heavily on the written or oral information provided by each entity. There is significantly less publicly available information on the disability determination processes and procedures of private disability insurers. For this reason, the committee had to rely primarily on the information provided by the representatives of the two private disability insurance providers discussed in this chapter.
eligible individuals. Unum and Prudential were selected because they are two of the largest private disability insurance providers in the United States.
This chapter provides a brief overview of each of these programs, along with a description of their general disability determination processes and the evidence they consider in making determinations. The programs, including SSA’s disability programs, are then compared with respect to their consideration of relevant assistive products and technologies, the evidence required by adjudicators to make a determination, and the professionals permitted to provide this evidence. Annex Table 8-1 at the end of this chapter summarizes elements of each of the programs, allowing for comparisons among them. Differences among the programs, especially with respect to mission, and variability in the amount and detail of the information available to the committee limit to some extent the comparisons that can be made.
Social Security Administration
As described in Chapter 1, SSA oversees two programs that provide benefits based on disability through the Social Security Act: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). SSDI provides benefits to qualified individuals2 “who cannot work because they have a severe medical condition expected to last at least one year or result in death” and to certain members of their families (SSA, 2016a, p. 7). SSI provides “monthly payments to people with limited incomes and resources who are aged, blind, or disabled” (SSA, 2016a, p. 8). In 2015, the most recent year for which data are available, 10,806,466 individuals (including dependents) received an average monthly benefit of $1,022.29 through the SSDI program (SSA, 2017a, Table 5.A1). In that same year, 8,309,564 individuals (7,084,221 categorized as disabled and 67,851 as blind) received an average of $541.28 in monthly SSI benefits through federal payments, state supplementation, or both (SSA, 2017a, Table 7.A1).
SSA currently considers assistive devices in the nonmedical and medical areas of its program guidelines. During determinations of substantial gainful activity (SGA)3 and income eligibility for SSI benefits, the reasonable cost of items, devices, or services needed by applicants to enable work with their impairment is subtracted from eligible earnings, even when those
3 20 CFR §§ 404.1510, 416.910.
items or services are used for activities of daily living in addition to work. SSA also considers assistive devices in its medical disability determination process.
Veterans Benefits Administration
The VA provides monetary benefits to eligible veterans and their dependents and spouses through the VBA. The VBA’s mission, in cooperation with the other administrations within the VA, is to provide “benefits and services to the veterans and their families in a responsive, timely and compassionate manner in recognition of their service to the Nation” (VBA, 2017). The VBA provides disability compensation and other assistance services, including the Vocational Rehabilitation and Employment (VR&E) program, to veterans, survivors, and their families (VA, 2017). The VA describes disability compensation as “a monthly tax-free benefit paid to Veterans who are at least 10% disabled because of injuries or diseases that were incurred in or aggravated during active duty, active duty for training, or inactive duty training” (VA, 2016d). Veterans also may receive benefits for disabilities related or secondary to those that occurred during service or for disabilities presumed to be related to service, even when they occurred later (VA, 2016c). The VBA’s disability rating system and determination of service-related disabilities are discussed later in this chapter. Special monthly compensation can be paid in addition to disability compensation if applicants require aid and assistance by other persons or if they have certain impairments rendering them totally disabled (e.g., loss or loss of use of a hand or leg) (VA, 2016c). In fiscal year (FY) 2015, the VBA processed and completed more than 1.38 million disability compensation claims, with an average processing time of 93.1 days per claim (VA, 2016a). In the same year, 4,168,774 veterans received compensation benefits for service-related disabilities in an average amount of $14,444 per individual, or a total of $60.21 billion (VA, 2016b). Provision of assistive products and technologies to veterans falls under the auspices of the Veterans Health Administration (VHA) (see Chapter 7).
The VR&E program “assists Veterans with service-connected disabilities and an employment handicap and Service members who are in the process of transitioning from military to civilian employment prepare for, find, and keep suitable jobs” (VR&E, 2016). For individuals with service-related disabilities that are sufficiently severe as to preclude work, VR&E provides services to facilitate “their ability to live as independently as possible” (VR&E, 2016).
Canada Pension Plan
Service Canada, which is part of Employment and Social Development Canada, “provides Canadians with a single point of access to a wide range of government services and benefits,” including the CPP (Government of Canada, 2017d). Similar to SSA’s Old Age, Survivor, and Disability Insurance (i.e., Social Security) in the United States, the CPP is a federal social insurance program, funded by worker and employer contributions, intended to provide benefits when a worker retires, becomes disabled, or dies. The CPP covers residents of all provinces and territories except Quebec, which has its own similar program, the Quebec Pension Plan. Although CPP disability benefits are awarded based on severe and prolonged disabilities, they are “not designed to pay for such things as medications and devices,” which fall under the purview of provincial programs (Government of Canada, 2017a). Disability determination guidelines for CPP adjudicators do not take assistive products and technologies into account, although adjudicators may include these items implicitly as “medical treatment” according to a CPP representative who spoke to the committee during a public session (Kidd, 2016). As noted, the provision of assistive devices for personal and/or vocational use falls under the purview of provincial governments, which are responsible for health care delivery through a variety of programs. In FY 2014, approximately 5.3 million CPP beneficiaries, including 329,000 people with disabilities and 83,000 children with disabled parents, received payments (Government of Canada, 2015a). Disability benefits represented $4.2 billion (11 percent) of total CPP benefits paid from $45.0 billion in employee and employer contributions during that year (Government of Canada, 2015a).
Selected Private Disability Insurance Providers
During two of the committee’s public sessions, invited speakers from Unum and Prudential Financial provided information about disability determination and consideration or provision of assistive devices in the private insurance sector. Unum is one of the leading providers of employment-based group and individual disability insurance in the United States, with a focus on return-to-work and other work capacity strategies (Jackson, 2016). Unum reports processing nearly 490,000 new claims and paying $5.5 billion in benefits in 2012 (Unum, 2017a). The company served more than 80,000 employers (representing more than 17 million participants) across the United States during the same year (Unum, 2017a). Similarly, Prudential is a group and individual disability insurance provider, with a mission to “enable customers’ employees to return to work as soon as possible after a disabling event” (Tugman and Kramschuster, 2016). Prudential reports the
provision of disability insurance for 2,500 clients (representing 1.3 million participants) for short-term disability and 3,100 clients (representing 2.1 million participants) for long-term disability (Prudential Financial, 2017).
The committee was unable to obtain specific guidelines on the processes used for consideration of assistive products and technologies in private insurance disability determinations, as details of eligibility for benefits are specified in client contracts. However, Unum “utilizes assistive devices and technology in support of occupational functioning” (Jackson, 2016), and Prudential specified that it covered assistive products and technologies primarily for return-to-work purposes, most commonly musculoskeletal aids such as modified workstations, chairs, or mobility devices (Tugman and Kramschuster, 2016).
Social Security Administration
In FY 2014, SSA processed 3,054,900 SSDI claims and 2,395,500 SSI claims, 2,181,700 of which were in the category of blind or disabled (SSA, 2015a, Tables 2.F5, 2.F6). As summarized in Chapter 1, SSA processes adult disability claims using a five-step “sequential evaluation process,” which assesses whether an individual may be found disabled (unable to engage in SGA [SSA, 2017b]) under the Social Security Act.
Step 1: Social Security field offices perform financial screens to deny claims for applicants who work and earn income above the SGA limit (Wixon and Strand, 2013). If an applicant is performing SGA, which encompasses “significant physical or mental activities” done (or of a kind usually done) “for pay or profit, whether or not a profit is realized,”4 then SSA will find the individual not disabled under the act. SGA for 2017 is specified as earnings of $1,170 per month for nonblind individuals and $1,950 for statutorily blind individuals (SSA, 2017b).
Step 2: Applicants receive medical screens to determine whether they have a medically determinable severe impairment (SSA, 2012a). If the applicant does not have a medically determinable severe impairment or combination of impairments that meets the duration requirement,5 SSA will find the individual not disabled under the act. If the applicant has
4 20 CFR § 404.1572.
5 20 CFR § 404.1509.
such an impairment or combination of impairments, SSA will identify the impairment(s) and proceed to Step 3.
Step 3: An applicant’s impairment is assessed using the Listing of Impairments (SSA, n.d.-b), a regulatory list of medical conditions and criteria created by SSA to assist in disability determination. If an applicant’s impairment “meets” or “equals” a listing and meets the duration requirement, the applicant is allowed benefits. To “meet” a listing, a claimant must have a medically determinable impairment that satisfies all of the criteria in the listing. An impairment “equals” a listing if it is “at least equal in severity and duration to the criteria of any listed impairment” (SSA, 2016d). If the applicant does not have an impairment(s) that meets or medically equals an impairment in the Listings or meets the duration requirement, SSA proceeds to Step 4.
Step 4: Residual functional capacity (RFC) is an individual’s “maximum capacity for performance taking into account the limitations resulting from their impairment(s)” (SSA, 2016b, p. 2). An RFC assessment includes a written analysis of functional capabilities, both exertional and nonexertional,6 based on all relevant available evidence. In this step, SSA assesses whether an applicant’s RFC allows him or her to perform past work. Specifically, Disability Determination Services (DDS) considers whether the applicant’s RFC meets or exceeds the skill requirements for his or her past relevant work (generally in the past 15 years prior to adjudication), based on the person’s capacity to perform work-related activities (Wixon and Strand, 2013). If it is determined that the applicant can perform his or her past work with his or her current RFC, the application for benefits is denied. If the applicant cannot still perform his or her past relevant work, SSA proceeds to the fifth and final step.
Step 5: An applicant’s RFC and vocational factors such as age, education, and work experience and transferable skills are considered in determining whether the applicant can perform other work in the national economy. Applicants who are determined unable to perform work in the national economy are allowed benefits, while those who are determined to be able to perform such work are denied. SSA uses a set of guidelines that combine medical–vocational patterns into “rules” for decision making, often referred to as “The Grid.” When a claim involves nonexertional impairments such as certain mental, sensory, or skin disorders, the analysis may involve consideration of more than one rule.
6 Assessment of RFC exertional capacity considers sitting, standing, walking, lifting, carrying, pushing, and pulling. Assessment of RFC nonexertional capacity considers “work-related limitations and restrictions that do not depend on a person’s physical strength,” including stooping, climbing, reaching, handling, fingering, seeing, hearing, understanding and remembering instructions, responding appropriately to supervision, and tolerating temperature extremes (SSA, 2016b).
In addition, SSA includes two options for faster disability determinations. Compassionate Allowances permit faster identification of medical conditions (e.g., acute leukemia, amyotrophic lateral sclerosis [ALS], pancreatic cancer) that are most likely to meet SSA’s current definition of disability with minimal but sufficient objective medical evidence, allowing the applicant to receive benefits more quickly (SSA, 2015b). In Quick Disability Determinations, initial applications are screened using a computer-based predictive model to identify cases in which a favorable disability determination is highly likely and medical evidence is easily available. The model allows these high-likelihood claims to receive priority and be expedited in cases involving more serious impairments (SSA, 2015b).
Veterans Benefits Administration
The VBA disability determination process can be divided into two main steps: the development of medical evidence and the rating process (IOM, 2007). Claims are processed by the Veterans Service Centers (VSCs) in VBA regional offices and are handled by six specialized teams: public contact, triage, predetermination, rating, postdetermination, and appeals—before a determination is made. Medical evidence collected by the predetermination team includes information from public and private medical records as well as the applicant’s attending physicians regarding the extent of impairment, functional limitations, and disability. This evidence is often supplemented by a compensation and pension (C&P) examination ordered by the rating veterans service representative (RVSR) during the determination process and performed by a VHA clinician or medical contractor. To be evaluated for a disability under VBA guidelines, individuals must have an impairment related to their service. This relationship to service may be a direct connection, an aggravation (existing condition aggravated by service), secondary (illness or injury experienced after service that is related to a different impairment with a service connection), or a presumption (an unproven but likely connection, such as in the case of chronic diseases presumed to be connected to exposure during service).
The VBA disability rating process is based on the VA Schedule for Rating Disabilities (VASRD), consisting of approximately 800 unique diagnostic codes allowing adjudicators to compare an applicant’s illness or injury with standardized disability evaluation criteria (Flohr, 2016). VBA disability compensation is paid to beneficiaries on a monthly basis, and the rates of compensation are dependent on the VBA disability rating system in increments of 10 percent, from 10 percent to 100 percent disabling (where a rating of 100 percent is a complete impairment of earning capacity). Thus, in contrast to the binary SSA determination process whereby applicants are found to be either disabled or not disabled, the VBA system allows veterans
receiving benefits to be considered partially disabled. In addition, they may work while receiving benefits, with no limit on their earnings (IOM, 2015, p. 70). The RVSR is tasked with considering an applicant’s medical evidence in assigning evaluation level(s) for the person’s impairment(s) based on VASRD tables, codes, and corresponding percentage levels. Disability ratings are then compiled and used by the VSC postdetermination team to process awards and notify claimants of benefit-related decisions.
Canada Pension Plan
Service Canada uses an adjudication framework to evaluate applications for CPP disability benefits (Government of Canada, 2015b). In a process similar to that of SSDI, applications for benefits in this program are assessed only if applicants have made the required contributions to the CPP through participation in the eligible Canadian labor market for 4 of the last 6 years at or above the minimum earning level ($5,400 in 2016), or for 3 of the last 6 years if the individual has contributed at or above the minimum earning level for at least 25 years (Government of Canada, 2017c). The adjudication framework includes five components used to implement federal policy regarding disability evaluation. As with SSA disability programs, CPP disability determination does not account for a continuum of severity; instead, applicants are deemed eligible or ineligible for benefits based on the outcome of their claim (Kidd, 2016). Two of the framework components do address the severity and duration of the applicant’s impairment(s). First the applicant must meet the “severe criterion for the prime indicator,” which requires the existence of a medical condition (the prime indicator) that is severe, meaning it regularly inhibits any type of work, not just the work usually done. Second, the “severe disability” must be prolonged, meaning it is “long term and of indefinite duration, or is likely to result in death” (Government of Canada, 2015b).
A third component of the adjudication process is demonstration by the applicant that he or she is “incapable regularly of pursing any substantially gainful occupation” as a result of the physical or mental impairment. This criterion includes consideration of work activity with respect to performance, productivity, and profitability. A substantially gainful occupation is defined as “an occupation that provides a salary or wages equal to the maximum annual amount a person could receive as a disability pension” (Government of Canada, 2015b).
A fourth component of the CPP adjudication process takes account of personal characteristics, “intrinsic factors that are unique to a particular person” and directly impact an applicant’s regular capacity to engage in a substantially gainful occupation (Government of Canada, 2015b). Personal characteristics, which are evaluated on a case-by-case basis in the context
of the medical condition, include age, education, and work experience. Personal characteristics alone do not qualify an applicant for disability benefits. Socioeconomic factors such as unemployment rates, access to jobs, or preferred working hours are not considered in making a disability determination (Government of Canada, 2015b).
The fifth component of the adjudication framework is a “reasonably satisfied” standard of proof for making disability determinations, which is synonymous with the term “more likely than not.” Adjudicators are instructed to use this standard when assessing eligibility for the CPP. Applying this standard entails considering the listed medical condition, the likely progression of the impairment, the applicant’s functional limitations, the impact of treatment, testimony from medical sources, and additional medical issues to determine whether the individual is “more likely than not” incapable of regular pursuit of any substantially gainful occupation (Government of Canada, 2015b).
Selected Private Disability Insurance Providers
Disability determination for private insurance varies by company. Although there are different, policy-specific definitions of disability, a core concept is the inability “to perform the material and substantial duties of [one’s] occupation as it is defined in the national economy” as a result of illness or injury (Unum, 2017b; see also Prudential Financial, 2015).
Unum’s claims are evaluated by a disability benefits specialist (DBS) who integrates all of the relevant information, including results of clinical tests and medical records. Medical and vocational staff then review all of this information as well as contact the applicant’s attending clinicians. The DBS uses the results of this review to compile restrictions and limitations on employment based on the medical condition. Specific eligibility and benefit amounts are based on contracted agreements with Unum clients, either individuals or employers. If these agreements include the potential for work site modification, a vocational rehabilitation consultant evaluates the claimant’s current essential job duties and identifies limitations in the ability to perform these duties in accordance with the DBS’s findings (Jackson, 2016).
Prudential employs a similar approach, wherein a disability claims manager reviews the claimant’s file along with clinician reports to determine the severity of the medical impairment and individual’s prognosis. These results are combined with a workplace assessment performed by a vocational rehabilitation specialist detailing physical, environmental, and cognitive occupational demands that may limit or inhibit a claimant’s full return to work (Tugman and Kramschuster, 2016).
Types of Evidence
Social Security Administration SSA currently defines evidence as any information related to an individual’s claim that is submitted to SSA by the claimant or anyone else as well as information that SSA obtains while developing the claim. Evidence generally is categorized as objective medical evidence (signs, laboratory findings, or both), medical opinions, other medical evidence from medical sources, evidence from nonmedical sources, and prior administrative medical findings of the state or federal DDS medical consultants and psychological consultants.
Every SSA disability claim must include evidence that supports the individual’s claim that he or she is blind or disabled. Medical evidence may come from individual medical sources and from various health care facilities where the claimant has received health care services. The medical evidence may be in any format, such as paper and electronic medical records. It may reflect a clear length of treatment that provides a longitudinal account of the impairment(s), or it may reflect individual examinations or singular hospitalizations.
Before determining whether an individual is disabled, SSA will develop the individual’s complete medical history for at least the 12-month period preceding the month in which the individual files the application unless there is a reason to believe that development for a different period is necessary. SSA will make every reasonable effort (as defined in its regulations) to help the individual obtain his or her medical reports from his or her own medical sources when he or she gives SSA permission to request the reports.
If existing evidence is insufficient to enable a determination, SSA may contact the claimant’s medical sources for additional information and/or order a consultative examination. A consultative examination includes additional tests or assessments that provide better understanding of the existence and severity of the claimant’s impairment(s), and it produces a written statement describing what the claimant can still perform functionally despite the impairment(s) (unless the disability claim is in relation to statutory blindness). It is preferred that the consultative examination be performed by the claimant’s own medical provider unless that clinician prefers not to do so or lacks the requisite equipment; there exist conflicts or inconsistencies that could not feasibly be resolved by the clinician; or SSA’s prior experience working with the clinician indicates that this individual may not be a productive source (SSA, n.d.-c).
In addition to medical evidence, an SSA claimant may submit evidence from nonmedical sources. This evidence can help demonstrate the ways in which the assessed impairment impacts the claimant’s ability to function in
a work setting. Evidence may come from a variety of nonmedical sources, including public/private agencies, schools, parents or other family members, caregivers, social workers, and employers (SSA, n.d.-c).
Veterans Benefits Administration The VBA requires fulfilment of three evidentiary requirements before a disability claim can be adjudicated: evidence of military status (e.g., discharge or separation papers), service treatment records, and additional medical evidence (VA, 2015). VBA protocol designates the evidentiary responsibilities of the claimant as obtaining appropriate records from agencies outside the federal government, such as state or local agencies, private doctors or hospitals, and former employers, as well as providing adequate information to the VBA so information can be obtained. In turn, the VBA is responsible for obtaining appropriate records from federal agencies, such as the military, VBA medical centers, or SSA, as well as providing a medical examination or opinion if necessary.
Evidence included in a VBA disability claim is similar to that required by SSA, encompassing both medical and lay evidence. This evidence must be found to be credible—“inherently believable or [have] been received from a competent source”—and probative—“relevant to the issue in question, and . . . have sufficient weight, either by itself or in combination with other evidence, to persuade the decision-maker about a fact” (VA, 2013).
Canada Pension Plan In the process of making CPP disability determinations, Service Canada adjudicators take into account all pertinent evidence, including medical evidence, work impairments and capacity, claimant interviews, clinician interviews, medical reports from treatment sources, diagnostic tests, reports from employers, and functional capacity assessments. Federal records on past use of social services, such as employment insurance, also are taken into account (Government of Canada, 2015b). Service Canada categorizes medical evidence permitted in a disability determination as either objective or subjective. Objective evidence includes symptoms, deficits, or impairments that can be observed or measured through diagnostic tests, laboratory findings, or functional observations. Subjective evidence, which may be supported by objective information, is evidence that cannot be directly observed or measured, such as physician interviews or descriptions in a medical record.
Selected Private Disability Insurance Providers Prudential and Unum both provided information regarding types of evidence they consider in their disability insurance determinations. Prudential evaluations use medical evidence from medical records and the claimant’s attending physician(s) as well as that provided by in-house physicians or registered nurses. Once the claimant has been determined to have a disability preventing total return to
work and is receiving disability benefits through his or her employer contract, functional capacity and limitations are assessed. Functional evidence is identified by the claimant’s attending physician as well as Prudential clinicians. This evidence is combined with information from the Prudential vocational rehabilitation specialist, who identifies physical, environmental, and cognitive demands of the claimant’s current employment, along with potential accommodations or assistive devices. Unum also uses medical and functional evidence to process a disability claim and potentially facilitate a return to work. Medical evidence includes a claimant’s medical records as well as evidence from his or her attending physician(s) detailing restrictions and limitations resulting from the specific impairment. Medical evidence is considered along with essential job duties identified by the vocational rehabilitation consultant to identify potential accommodations or assistive devices that may facilitate a safe and successful return to work.
Professionals Providing the Evidence
Social Security Administration According to SSA regulations, all medical sources can provide medical evidence for a disability claim. However, only certain medical sources can provide the objective medical evidence necessary to establish the existence of impairment. These medical sources, called acceptable medical sources, include licensed physicians (medical or osteopathic doctors), licensed or certified psychologists (including school psychologists or licensed/certified individuals performing the same function in a school setting),7 licensed optometrists,8 licensed podiatrists,9 and qualified speech-language pathologists.10,11 For claims filed on or after March 27, 2017, acceptable medical sources also include advanced practice registered nurses (APRNs), physician assistants (PAs), and audiologists (SSA, 2016e).12
7 Evidence from school psychologists or qualified professionals performing the same function is considered only for claims of intellectual disability, learning disability, or borderline intellectual function.
8 Evidence from licensed optometrists is considered only for claims regarding visual disorders.
9 Evidence from licensed podiatrists is considered only for claims regarding impairments of the foot or foot and ankle, as state treatment laws permit.
10 To be considered qualified, speech-language pathologists must be licensed by a “state professional licensing agency or be fully certified by the state education agency” in that state or “hold a certificate of clinical competence from the American Speech-Language-Hearing Association.”
11 20 CFR § 404.1513.
12 APRNs and PAs are acceptable medical sources for evaluation of impairments within their licensed scope of practice only. Audiologists are acceptable medical sources for evaluation of impairments related to hearing loss, auditory processing disorders, and balance disorders within their licensed scope of practice only.
Veterans Benefits Administration The VBA defines competent medical evidence as evidence provided by sources with education, training, or experience qualifying them to provide medical diagnoses, statements, or opinions. Medical evidence may additionally include “statements conveying sound medical principles found in medical treatises” or “statements contained in authoritative writings such as medical and scientific articles and research reports or analyses.” Conversely, competent lay evidence is defined as evidence provided by a source who lacks specialized education, experience, or training but who has “knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.”13
Canada Pension Plan Service Canada designates professionals who are able to provide medical evidence as “qualified family physicians, specialists, and other health professionals.” Additional specifications identify professionals able to provide evidence for a claimant’s capacity to work, including psychologists, neuropsychologists, physiotherapists, occupational therapists, and vocational rehabilitation professionals (Government of Canada, 2015b).
Selected Private Disability Insurance Providers The committee was unable to obtain specific information regarding the requirements of private insurance companies with respect to sources of evidence. Prudential disability claim forms indicate that medical evidence should be obtained from a primary care physician, supplemented by evidence from “all other physicians [the claimant has] consulted for this condition” (Prudential Financial, 2016). Unum disability claim forms require evidence from attending physicians or other health care providers, without reference to specific provider qualifications or education (Unum, 2016).
Social Security Administration Initial and reconsideration-level SSA disability determinations occur at state DDSs through collaboration among a disability examiner (DE), a medical consultant, and/or a psychological consultant (PC) (SSA, 2016c). DE training requirements are regulated at the state level, but on average, DEs must have 2 years of training, mentorship, and experience with cases to be fully trained in the DDS, with additional experience allowing them to assess increasingly complex claims and vocational issues (Owen, 2009). Essential DE skills include an understanding of medical conditions, vocational factors, medical terminology, and SSA regulatory guidelines. Medical consultants, who must be licensed physicians,
13 38 CFR § 3.159.
evaluate physical impairments.14 PCs, who must be licensed psychiatrists or qualified psychologists, evaluate mental impairments. To be qualified as a PC, a psychologist must be (1) a “licensed or certified psychologist at the independent practice level of psychology” in that state; (2) either in possession of a doctorate degree in psychology from a clinical psychology program15 or “in a national register of health service providers in psychology which the Commissioner of Social Security deems appropriate”; and (3) possess 2 years of supervised clinical experience as a psychologist, at least one of which is after a master’s degree (SSA, 2016c).
Veterans Benefits Administration VBA adjudicators are disability rating specialists identified as veterans service representatives or RVSRs, depending on their VSC team and role. These adjudicators may be health professionals, including nurses or physicians (Flohr, 2016). Medical examiners who are commissioned to perform C&P examinations as part of the disability determination process are VHA employees or medical contractors with certification to perform the required testing or evaluation. VHA examiners who perform these evaluations are monitored by the Compensation and Pension Examination Program, a joint initiative of the VHA and VBA establishing baseline performance for examiners, performance improvement initiatives, performance monitoring, and provision of feedback. These performance requirements also mandate that C&P examiners have full knowledge of the requirements of the disability determination and examination process (IOM, 2007). Non-VHA examiners are medical contractors employed by QTC Medical Group, the “largest provider of government-outsourced occupational health and disability examination services in the nation” (QTC, 2012). These examiners must meet specific QTC requirements and undergo training and performance monitoring through an internal quality assurance program approved by the VBA medical director.
Canada Pension Plan CPP medical adjudicators are health professionals who review applications for benefits. These professionals are trained nurses with additional relevant knowledge of CPP legislation, regulations, policies, and procedures. Nurses who act as disability adjudicators are drawn from a variety of medical specialties (Government of Canada, 2015b).
Selected Private Disability Insurance Providers Training and qualifications for disability adjudicators vary throughout the private disability insurance
14 See Bipartisan Budget Act of 2015, section 832 (H.R. 1314).
15 Acceptable doctorate degrees in psychology must be received from a medical institution accredited by an organization recognized by the Council for Higher Education Accreditation (formerly known as the Council on Post-Secondary Accreditation).
sector. Prudential employs a team of internal disability claims managers, along with vocational rehabilitation specialists, who are experienced case managers with a master’s degree or higher in rehabilitation counseling and national Commission on Rehabilitation Counselor Certification. A vocational rehabilitation specialist works with employers, claimants, and attending physicians to develop and implement return-to-work plans, depending on the claimant’s individual impairment. Prudential also employs board-certified physicians and registered nurses to assist in the disability determination and vocational rehabilitation process (Tugman and Kramschuster, 2016). Unum disability claims are processed by a contracted DBS with the help of vocational rehabilitation consultants, who are master’s-level rehabilitation specialists with additional training in counseling philosophy. Medical evidence is reviewed and supported by on-site physicians in more than 30 specialties, registered nurses, and behavioral health specialists (Jackson, 2016).
Wheeled and Seated Mobility Devices
Disability determination for SSA programs does not include use of a wheeled and seated mobility device (WSMD) as a criterion for a successful claim. Instead, SSA considers “most adults who must use a [WSMD] for ambulation to have an impairment that meets or medically equals a Listing generally because of their inability to ambulate effectively” (SSA, 2016b). SSA guidelines define the inability to ambulate effectively as “an extreme limitation of the ability to walk; i.e., an impairment(s) that interferes very seriously with the individual’s ability to independently initiate, sustain, or complete activities” (SSA, n.d.-a). Ambulation, in this case, denotes independent mobility without the use of handheld assistive device(s) if the device(s) limits the functional abilities of both upper extremities (SSA, n.d.a). Accordingly, within the sequential evaluation process, SSA reports that function in the context of WSMD use has never been evaluated beyond Step 3 (meeting or medically equaling a listing) for applicants who must use a WSMD (SSA, 2016b). Listings that are commonly used to allow an application for a person using a WSMD are musculoskeletal system (disorders of the spine, amputation); skin disorders (burns); and neurological (central nervous system vascular accident, cerebral palsy, spinal cord or nerve root lesions, multiple sclerosis, muscular dystrophy). If these claims were to be assessed in Steps 4 and/or 5 of the evaluation process, policy indicates that RFC would be evaluated with a focus on the applicant’s ability to “use both hands to manipulate and handle small objects and to see small objects at
close range” (SSA, 2016b). These are good examples of nonexertional abilities whose impairment, when combined with the inability to stand or walk for most of the workday, can affect an individual’s ability to perform SGA.
Similarly, the VBA adjudication process does not include use of a WSMD as an explicit factor in determining disability. Instead, the impairment is evaluated based on the functional impairment or loss of use that is the underlying cause of the functional inability (Flohr, 2016). This functional assessment criterion requires the RVSR to consider not only medical evidence pertaining to this impairment but also the effects of the impairment requiring the use of a WSMD on the individual’s ordinary activity.16 If an individual requires constant use of a WSMD, the impairment is likely to be considered complete loss of function of both lower extremities and to be rated as such on the disability rating scale. If an individual requires periodic use of a WSMD, the impairment will correspond to a different level on the disability rating scale according to functional assessment criteria (Flohr, 2016).
Service Canada guidelines for the administration of CPP disability benefits do not include specific consideration of WSMD use in the disability determination process. Guidance stipulates that “the CPP disability benefit is not designed to pay for such things as medications and assistive devices” (Government of Canada, 2017b). However, disability adjudicators are instructed to assess the impact of treatment as part of medical evidence for a claim, defined as “what is needed to restore or improve the health and function of a particular person, or what is needed to prevent or delay deterioration” (Government of Canada, 2015b). The use of a WSMD provides “insight and necessary coping mechanisms for adapting to the person’s identified limitations” (Government of Canada, 2015b, Section 2.3) and therefore, theoretically, could be considered by medical adjudicators in their assessment of a person’s ability to engage in substantially gainful employment in the short term and the future.
With respect to the private disability insurance industry, representatives from Prudential reported that the majority of diagnoses handled by their company are musculoskeletal in origin, resulting in the provision or consideration of assistive devices that will allow the claimant to “return to work,” such as sit/stand workstations, ergonomic workstations, mobility aids, or WSMDs (Tugman and Kramschuster, 2016). Representatives from Unum likewise stated that a majority of their company’s short- and long-term disability claims (excluding maternity claims) are musculoskeletal in origin. They also said, however, that WSMDs are rarely encountered in the realm of private insurance, being considered for only an estimated 5 percent of claims processed by the company (Jacksonn, 2016).
16 38 CFR § 4.10.
As with WSMDs, SSA disability determination guidelines do not include use of upper-extremity prostheses (UEPs) as an explicit criterion for a successful claim. According to SSA, “most people who must use [bilateral] upper extremity prostheses have an impairment(s) that meets or medically equals a listing generally because of their ‘inability to perform fine and gross movements effectively’” (SSA, 2016b). SSA defines the inability to perform fine and gross movements effectively as “an extreme loss of function of both upper extremities . . . that interferes very seriously with the person’s ability to independently initiate, sustain, or complete activities” (SSA, n.d.-a). It is important to note that SSA guidelines for applicants missing an upper extremity were created when prosthetic technology was less common and “use of such prostheses generally precluded fine manipulative abilities, as they were generally equipped with a hook or pincers” (SSA, 2016b). Most SSA applicants who use bilateral UEPs will have their claim approved at Step 3 of the sequential evaluation process because their impairment typically meets or medically equals a listing (SSA, 2016b). The most common listings used to approve people with these devices are musculoskeletal system listings (disorders of the spine, amputation, soft tissue injury) and skin disorders listings (burns) (SSA, 2016b). If an applicant’s RFC is assessed in Steps 4 and/or 5 of the evaluation process, the adjudicator looks for a reduction of strength and nonexertional capacities. If strength and nonexertional limitations are combined with standing and walking limitations, the claim is often approved (SSA, 2016b). For cases of amputation specifically, loss or partial loss of an upper extremity is considered based on “the condition of the remaining stump, the person’s ability to use [a] prosthesis, and the person’s remaining ability for fine and gross manipulation” (SSA, 2012b).
The disability determination process used by the VBA does not specifically include the use of UEPs; instead, upper-extremity amputation or loss of use is assessed using the disability rating scale. Functional impairment or the potential capacity restored by the use of prostheses is not assessed according to the rating scale, just the existence and severity of the amputation or loss of use. Impairments can be evaluated at 90 percent if the amputation/loss of use occurs at the shoulder and at 60 percent if the impairment occurs lower in the extremity (e.g., elbow). A joint replacement or prosthetic implant is evaluated at 100 percent for 1 year postimplantation and then reevaluated to assess the functional capabilities of that joint. When evaluating function for applicants using UEPs, the functional benefit of the prostheses is not taken into account; evaluations are performed without the prostheses. This contrasts with VBA guidelines for evaluations
of lower-limb amputations, which take into account whether a prosthetic device provides a functional benefit for the applicant.17
As with WSMDs, Service Canada guidelines for the administration of CPP disability benefits do not include consideration of the use of UEPs in the disability determination process. Rather, these devices are considered indirectly through the impact of treatment (i.e., ability to successfully wear a device and use it for a sustained period of time) on an applicant’s ability to perform substantially gainful employment.
Little evidence was available to the committee regarding the details and sucess rates of claims involving use of UEPs submitted to private disability insurers. The Unum representative stated that in 2015, the company processed fewer than 100 amputation-related claims and that this number had remained below 100 for the past 3 years (Jackson, 2016). Both Prudential and Unum rarely encounter such claims, including claimants using UEPs (Jackson, 2016; Tugman and Kramschuster, 2016).
Hearing-Related Products and Technologies
SSA has specific guidelines regarding the use and consideration of hearing-related products and technologies in the disability determination process. In Step 3 of the sequential evaluation process, to determine whether an applicant’s impairment meets or medically equals a listing related to hearing impairment (not treated with cochlear implantation), the adjudicator considers only the individual’s ability to hear without hearing aids. Past SSA guidelines allowed for Step 3 testing using hearing aids, but this provision was modified in current guidelines because (1) hearing aids could not be used consistently for exams as a result of applicants’ forgetting the aids or bringing ones that were malfunctioning; (2) generic hearing aids are now less common because of more customizable technology; (3) clinical practice rarely involves performing aided hearing tests; (4) aided testing does not represent the ability to use the devices in other environments or over the long term; and (5) criteria for listing-level impairments include that a hearing impairment must be severe enough that the use of aids is unlikely to allow significant improvement (SSA, 2016b). If an applicant’s hearing loss is treated with cochlear implantation, he or she is eligible to receive disability benefits for 1 year after the initial implantation, at which point the impairment(s) is reassessed using word recognition testing (SSA, n.d.-b). If an applicant’s hearing loss does not meet or medically equal a listing in this step, RFC is evaluated using hearing aids (SSA, 2016b). Particular attention is paid in Steps 4 and 5 of the sequential evaluation process to the individual’s ability to communicate, which is impacted by an inability to hear.
17 38 CFR § 4.10.
VBA adjudicators are instructed to assess disability applicants based on the results of uncorrected hearing tests. If additional exams are requested, they are conducted by a state-licensed audiologist without the use of hearing aids (Flohr, 2016).
Service Canada guidelines for the administration of CPP disability benefits do not include consideration of hearing-related products and technologies in the disability determination process. These devices are considered indirectly through the impact of treatment (i.e., ability to successfully wear a device and use it for a sustained period of time) on an applicant’s ability to perform substantially gainful employment.
Consideration of hearing-related products and technologies in the private disability insurance sector focuses on the provision of these devices to facilitate return-to-work capabilities, as a claimant’s impairment will allow. Prudential includes amplified telephones or headsets, teletypewriters, and vibrating pagers for notification as assistive products commonly provided for its clients to assist with return to work (Tugman and Kramschuster, 2016). Unum includes hearing-related computer technology or devices, as well as white noise machines for tinnitus, as assistive technologies commonly provided or subsidized under employer contracts (Jackson, 2016).
Speech-Related Products and Technologies
According to SSA protocol, the ability to produce speech by any means includes the use of “mechanical or electronic devices that improve voice or articulation” (SSA, n.d.-b). It is evaluated on the basis of “(1) audibility—the ability to speak at a level sufficient to be heard; (2) intelligibility—the ability to articulate and link phonetic units of speech with sufficient accuracy to be understood; and (3) functional efficiency—the ability to produce and sustain [a] serviceably fast rate of speech output over a useful period of time” (SSA, 2003). Although the use of speech-related products and technologies is not included as a criterion in SSA guidelines, applicants using these devices are assessed based on an underlying condition(s) that may meet or medically equal listings generally (Step 3). These listings often include special senses and speech systems listings (loss of speech) and neurological disorders listings (central nervous system vascular accident) (SSA, 2016b). If the impairment does not meet or medically equal a listing related to speech impairment, SSA adjudicators are instructed to assess the claimant’s speech and communication limitations in the determination of RFC. At Step 4 of the sequential evaluation process, SSA will determine whether the RFC allows the individual to perform his or her past relevant work. At Step 5, SSA considers the RFC together with the individual’s vocational factors (e.g., age, education, and work experience) to determine whether the individual can perform other work in the national economy (SSA, 2016b).
According to VBA protocol, speech impairments are not evaluated separately from their underlying conditions. Underlying conditions may include such impairments as traumatic brain injury or ALS; the associated speech impairment is not listed separately from the primary impairment on a VBA disability application. In addition, speech-generating assistive devices and other speech-related technologies are not taken into account when an applicant’s impairment is assessed (Flohr, 2016).
Service Canada guidelines for the administration of CPP disability benefits do not include consideration of speech-related products and technologies in the disability determination process. These devices are considered indirectly through the impact of treatment (i.e., ability to successfully wear a device and use it for a sustained period of time) on an applicant’s ability to perform substantially gainful employment.
Information regarding consideration or provision of speech-related products and technologies in the private disability insurance industry was not available to the committee. This category of products was not listed by Prudential or Unum as assistive devices commonly provided for employees in return-to-work contracts.
The committee identified a number of general points of comparison among the different disability programs examined: the size of the program as of FY 2015 (if available); whether the program’s mission is primarily personal (to improve the well-being of the claimant) or vocational (to facilitate return to work or workplace accommodations); and whether the disability determination system used is binary (disabled versus not disabled) or graduated (degree of disability on a continuum). SSA oversees the largest program the committee examined, with more than 19 million individuals and their dependents receiving disability payments through the SSDI or SSI program in FY 2015. During that same period, the VBA served more than 4 million veterans with disabilities, followed by CPP, with 329,000 beneficiaries (and 83,000 dependents) receiving disability benefits, and the private disability insurance companies, with Unum serving 80,000 and Prudential serving 5,600 employers, respectively. In general, government-sponsored programs (SSA, VBA, and CPP) describe the purpose of their disability benefits programs as supporting and providing living assistance to individuals with disabilities, with a focus on meeting their personal and financial needs. In contrast, representatives from both Unum and Prudential indicated that the focus of their disability determination processes is primarily on facilitating return to work or vocational assistance if possible. It should be noted that
the VBA also supports return to work and vocational assistance through its VR&E program.
8-1. Unum utilizes assistive products and technologies in support of occupational functioning in its private insurance disability determinations.
8-2. Prudential Financial specified that assistive products and technologies—most commonly musculoskeletal aids such as modified workstations, chairs, or mobility devices—were covered primarily for return-to-work purposes.
8-3. Disability determination guidelines for Canada Pension Plan (CPP) adjudicators do not explicitly take assistive products and technologies into account, although these devices are implicitly considered by adjudicators as being “medical treatment” or “necessary coping mechanisms.”
8-4. In both the Social Security Administration (SSA) and Veterans Benefits Administration (VBA) programs, applicants using wheeled and seated mobility devices are evaluated based on loss of function due to the underlying impairment. Adults who must use a wheeled and seated mobility device (WSMD) for ambulation may meet or equal SSA listings generally because of their “inability to ambulate effectively.” CPP’s assessment of a person’s ability to engage in substantial gainful employment in the short term and the future takes WSMDs into account since they provide “insight and necessary coping mechanisms for adapting to the person’s identified limitations.”
8-5. During functional assessments, SSA adjudicators consider an applicant’s ability to use upper-extremity prostheses (UEPs) in the case of amputation(s). With regard to lower-extremity amputations, SSA policy requires that adjudicators consider how an individual ambulates with the prosthesis in place. If the individual is medically capable of wearing a lower-extremity prosthetic device and lacks good cause for not doing so, SSA will find that person not disabled. In contrast, applicants for VBA benefits are required to undergo functional assessment without their UEPs.
8-6. When determining whether an applicant meets or medically equals a listing related to hearing impairment, SSA considers only the individual’s ability to hear without hearing aids. VBA adjudicators also test disability applicants without the use of hearing aids.
8-7. Consideration of hearing-related products and technologies in the private disability insurance sector focuses on the provision of these
devices to facilitate return to work as a claimant’s impairment will allow.
8-8. SSA evaluates applicants on their ability to produce speech by any means, including “mechanical or electronic devices that improve voice or articulation.” VBA applicants using speech-related products or technologies are assessed based on the underlying conditions leading to their impairments. The VBA does not consider speech-generating devices or other speech-related technologies when impairments are assessed.
8-1. The mission of a disability benefits program affects the extent to which the program provides (or “helps beneficiaries to obtain”) assistive products and technologies and related services designed to facilitate their ability to work.
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|Social Security Administration||Veterans Benefits Administration|
|Size of Program||Fiscal year 2015:
Social Security Disability Insurance (SSDI): 10,806,466 (including dependents); Supplemental Security Income (SSI): 8,309,564
|Fiscal year 2015:
|Disability focus (vocational versus personal)/mission||Vocational (inability to engage in any substantial gainful activity due to physical or mental impairment)||Personal (compensation for service-related disability)|
|Binary vs. graduated rating system||Binary||Graduated|
|Wheeled and Seated Mobility Devices|
|Factor in consideration of severity||No||No|
|Factor in consideration of function/vocation||No||No|
|Factor in consideration of severity||No||No|
|Factor in consideration of function/vocation||Yes (may be considered in residual functional capacity [RFC] assessment)||No|
|Factor in consideration of severity||No||No|
|Factor in consideration of function/vocation||Yes (considered in RFC assessment)||No|
|Factor in consideration of severity||Yes (ability to produce speech by any means, which includes devices that improve voice/articulation)||No|
|Factor in consideration of function/vocation||Yes||No|
|Service Canada||Private Insurance|
|Fiscal year 2014:
329,000 Canada Pension Plan (CPP) beneficiaries with disabilities (83,000 dependents)
|5,600 employers (clients); 3.4 million participants||80,000 employers (clients); more than 17 million participants|
|Vocational (inability regularly to pursue any substantially gainful occupation due to a medical condition)||Vocational/return to work (inability to perform the material and substantial duties of one’s occupation because of sickness or injury)||Vocational/return to work (inability to perform the material and substantial duties of one’s occupation because of sickness or injury)|
|Binary||Policy dependent||Policy dependent|
|Not specifically (CPP considers impact of treatment)||Yes (may provide some types of wheeled and seated mobility devices [WSMDs] to facilitate return to work)||Yes (may provide some types of WSMDs to facilitate return to work)|
|Not specifically (CPP considers impact of treatment)||Unknown||Unknown|
|Not specifically (CPP considers impact of treatment)||Yes (may provide some types of hearing assistive technologies to facilitate return to work)||Yes (may provide some types of hearing assistive technologies to facilitate return to work)|
|Not specifically (CPP considers impact of treatment)||Unknown||Unknown|
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