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Functional Assessment for Adults with Disabilities (2019)

Chapter: 8 Review of Selected Disability Benefit Programs

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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Suggested Citation:"8 Review of Selected Disability Benefit Programs." National Academies of Sciences, Engineering, and Medicine. 2019. Functional Assessment for Adults with Disabilities. Washington, DC: The National Academies Press. doi: 10.17226/25376.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

8 Review of Selected Disability Benefit Programs As part of the statement of task for this study, the U.S. Social Security Administration (SSA) asked the committee to “provide an overview of the functional assessment processes in at least three similar benefit programs that assess disability or vocational capabilities (national and state government programs, private sector programs, and foreign programs as applicable) and provide examples of forms, tools, guides, examinations, and other resources used by benefit programs that assess functional aspects of disability and vocational capabilities.” This chapter presents the committee’s response to that request. 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); Chesapeake Employers’ Insurance Company (the State of Maryland’s workers’ compensation program); and two private disability insurance providers, Prudential Financial and Sun Life Financial. This chapter also provides information on additional benefit programs, including the Washington State Department of Labor and Industries (L&I), the Canada Pension Plan (CPP), and the Disability Support Pension (DSP) (Australia). 1 The chapter presents a brief overview of each of these programs, along with descriptions of their disability determination processes and examples of the functional information they collect during assessment. It should be noted that the organizations and agencies described in this chapter are not intended to be a representative sample of the large numbers of such entities conducting disability assessment. Likewise, the information on foreign agencies was derived largely from a website and literature review, and is not intended to be representative of international practices. Annex Table 8-1 at the end of this chapter summarizes elements of each of the programs, allowing for comparisons among them. 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 the VBA, the CPP, and DSP. With respect to functional assessment in the programs’ disability determination processes, the committee had to rely more heavily on the written or oral information provided by each entity. Significantly less information is publicly available 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. 8-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

8-2 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES OVERVIEW OF SELECTED BENEFIT PROGRAMS Selected Federal Disability Benefit Programs Veterans Benefits Administration The VBA, one of three administrations forming the VA, provides benefits and services to service members, veterans, and their families. The VBA’s mission “is to serve as a leading advocate for Servicemembers, Veterans, their families and Survivors, delivering with excellence Veteran-centered and personalized benefits and services that honor their service, assist in their readjustment, enhance their lives, and engender their full trust” (VA, 2017b, p. 2). In fiscal year 2017, the VBA spent approximately $2.6 billion to administer benefits and services through six major program areas: compensation, pension and fiduciary, education, insurance, home loan guaranty, and vocational rehabilitation and employment (VA, 2017b). For fiscal year 2017, the total number of recipients for each program was as follows: compensation, 4,964,209; pension, 478,003; fiduciary, 211,282; education, 946,829; insurance, 6,007,606; home loan guaranty, 740,389; and vocational rehabilitation and employment, 132,218 (VA, 2017b). 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 Old Age Security (OAS), the CPP, and private pensions and savings (Government of Canada, 2018f). Funded through worker and employer contributions, the CPP provides benefits to contributors and their families in the event of retirement, disability, or death (Government of Canada, 2018a). The CPP provides benefits to residents living throughout Canada with the exception of Quebec, where the Quebec Pension Plan provides similar benefits. In fiscal year 2017, approximately 5.6 million CPP beneficiaries, including 335,000 people with disabilities and 83,000 of their children, received payments (Government of Canada, 2017). Disability benefits represented $4.3 billion (10 percent) of total CPP benefits paid out of $47.0 billion in employee and employer contributions during that fiscal year (Government of Canada, 2017). In 2018, monthly CPP disability benefits start at $485.20 and, depending on the individual’s previous CPP contributions, increase to a maximum of $1,335.83, with a monthly average of $971.23 (Government of Canada, 2018d). Eligible dependent children can receive a children’s benefit amounting to $244.64 monthly (Government of Canada, 2018d). Disability Support Pension (Australia) DSP, administered by the Australian Government Department of Human Services, provides financial support for people with a permanent physical, intellectual, or psychiatric condition that prevents them from working. From 2017 to 2018, DSP processed 104,000 claims, 31,000 of which were granted (Australian Government Department of Human Services, 2018g). Payments, provided every 2 weeks, depend on the individual’s age and living conditions. The maximum basic rates are as follows for those aged 21 or over with/without children or under 21 with children: $834.40 (single), $629.00 (couple, each), and $1,258.00 (couple, combined) (Australian Government Department of Human Services, 2018f). For individuals under 21 without children the maximum rates are as follows: $371.20 (single, under 18, and living at home); $572.90 (single, under 18, and independent); $420.70 (single, aged 18–20, and living at PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-3 home); $572.90 (single, aged 18–20, and independent); and $572.90 (a member of a couple, aged 20 or younger) (Australian Government Department of Human Services, 2018f). Selected State Workers’ Compensation Programs Chesapeake Employers’ Insurance Company Chesapeake Employers’ Insurance Company, formerly known as the Injured Workers’ Insurance Fund, provides workers’ compensation insurance to Maryland businesses. Chesapeake’s mission is “to provide Maryland businesses with a readily available source for workers’ compensation insurance that features high quality products and services at a fair price, and to protect workers and employers by championing workplace safety” (Chesapeake Employers Insurance, 2018a). In 2017, Chesapeake covered 20,889 injured workers for medical treatment, indemnity (lost time), or both (Chesapeake Employers Insurance, 2017). Washington State Department of Labor and Industries L&I “provides no-fault industrial insurance coverage for most employers and workers in Washington State” (L&I, 2018f). This coverage includes medical treatment and limited wage- replacement benefits for workers with job-related injuries and illnesses (L&I, 2018a). Claim managers work with doctors, employers, and counselors to help injured employees return to work. The department receives more than 150,000 claims each year (L&I, 2018h). Of accepted claims, 72 percent are administered by the State Fund Program (L&I, 2018h). The remaining 28 percent are self-administered by employers or contracted third-party administrators (L&I, 2018h); approximately 400 self-insured employers administer their own claims (L&I, 2018a). In fiscal year 2017, the State Fund Program insured 176,000 employers, covering 2.9 million employees; assessed $2.25 billion in premiums; and incurred $1.35 billion in benefits (L&I, 2018g). During the first half of fiscal year 2017, the program accepted 85 percent or 93,896 of the 109,962 claims received (L&I, 2018g). In that same fiscal year, 356 employers were self- insured, covering 917,127 workers, or about 25 percent of all workers covered by L&I (L&I, 2018g). Selected Private Disability Insurance Providers Prudential Financial Prudential Financial provides customers with a range of products and services, including group and individual disability insurance, life insurance, annuities, and retirement-related services (Prudential Financial, 2018a). In the disability realm, the company’s mission is 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, 2018b). Sun Life Financial Sun Life Financial is a financial services company that helps “clients achieve lifetime financial security and live healthier lives” (Sun Life Assurance Company of Canada, 2018). It offers a broad range of products and services to individuals, businesses, and institutions, PREPUBLICATION COPY: UNCORRECTED PROOFS

8-4 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES including short- and long-term disability, life, and other types of insurance. Sun Life’s goal with clients who have discontinued work as a result of illness or an injury is to learn why they are unable to work and how to get them back to work as soon as possible (Hamill, 2018). Therefore, the company focuses on assessing the ability to function in a work environment and increasing education on work modifications that can be performed to keep clients at work. DISABILITY DETERMINATION (ADJUDICATION) PROCESSES Selected Federal Disability Benefit Programs Veterans Benefits Administration The Compensation program “provides tax-free monthly benefits to Veterans in recognition of the effect of disabilities caused by diseases, events, or injuries incurred or aggravated during active military service” (VA, 2017a). Monthly benefits are also provided to surviving spouses, dependent children, and dependent parents. Eligibility is granted if the individual was discharged without dishonorable conditions and is at least 10 percent disabled by an injury or disease incurred or aggravated during active duty, active duty for training, or inactive-duty training (VA, 2017a). The VA process for assessing disability compensation claims has eight distinct steps (VA, 2018c). In the first step, the VA receives the claim. In the second step, the claim is assigned to a veterans service representative who reviews the information provided to determine whether additional evidence is needed. If additional information is not needed, the claim proceeds to the preparation for decision phase. In the third step, the representative gathers evidence by requesting it from various sources, such as the claimant, a medical professional, or a government authority. The claimant must submit all relevant evidence, including discharge or separation records, service treatment records, medical evidence from doctors, and hospital reports, to the VA to help the agency obtain all relevant information (VA, 2018d). The Veterans Claims Assistance Act (VCAA) defines claimants’ responsibilities in providing evidence to support a claim, as well as the VA’s responsibilities in helping claimants obtain that evidence (VA, 2018d). The VA is responsible for obtaining relevant records from any federal agency, such as the military, VA medical centers (including private facilities where the VA authorized treatment), and SSA. The VA is also responsible for providing a medical examination or obtaining a medical opinion. The claimant is responsible for obtaining records held by nonfederal agencies, such as state or local governments, private doctors and hospitals, and current or former employers. The VA can assist in obtaining these records. The claimant is also responsible for providing information needed by the VA to request records. Two types of evidence are required: medical evidence of a current physical or mental disability and evidence establishing the relationship between the current disability and an injury, disease, or event that occurred during military service. Medical records or medical opinions are required to support this relationship. During this step, the VA may ask the claimant to complete a compensation and pension (C&P) exam, which helps determine whether the disability is service- connected, the level of disability, and whether the current condition should receive a higher rating because it is worsening. Disability Benefits Questionnaires (DBQs) are used for veterans to provide disability- related information during the disability evaluation process. Veterans also have the option of PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-5 using their own health care provider instead of a VA facility to complete the questionnaire. DBQs help speed the processing of claims by supplying private health care providers with the information and questions about the disability needed for them to submit medical evidence that will enable the VA to evaluate a claim accurately (VA, 2018f). Providers with active medical licenses are authorized to complete DBQs. Mental health DBQs can be completed by a board-certified or board-eligible psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a clinical or counseling psychologist who has completed a 1-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; or a licensed clinical social worker, nurse practitioner, clinical nurse specialist, or physician assistant under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist (VA, 2018e). There are more than 70 DBQs covering a full range of medical conditions, all using standardized language to streamline the process. Check boxes rather than long narrative summaries are used to document medical conditions. The forms collect specific information relevant to the medical condition of the claimant. In step four, all of the evidence is reviewed. The VA provides detailed information for veterans to understand mental health examination (VA, 2018i). When evaluating mental health conditions, the VA thoroughly reviews both medical and nonmedical evidence and can rate an individual claimant for only one mental health condition. The VA reviews the evidence to gain an understanding of how symptoms of the claimant’s mental health condition impact social and industrial functioning and determines which mental health condition is related to the claim, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth or Fifth Edition (DSM-IV or DSM-5) and using the Mental Disorder Criteria in the VA Schedule for Rating Disabilities (VA, 2018i). In step five, the veterans service representative recommends a decision and prepares documents detailing that decision. In step six, the recommended decision is reviewed, and a final determination regarding award approval is made. A claim decision packet containing details of the decision or award is prepared for mailing (step seven), and the VA sends the decision packet to the claimant (step eight). The disability compensation amount depends on the claimant’s degree of disability based on the evidence submitted. The VA rates disability from 0 to 100 percent in 10 percent increments. Additional amounts are paid based on whether the claimant has a very severe disability or loss of limb(s); whether the claimant has a spouse, child(ren), or dependent parent(s); or whether the claimant has a seriously disabled spouse (VA, 2018b). If the VA finds that a veteran has multiple disabilities, the Combined Ratings Table is used to calculate a combined disability rating; the disability ratings are not additive. To calculate the combined rating, disabilities are arranged in order of severity, beginning with the most severe, and combined using the left column and top row of the Combined Ratings Table to determine where the values intersect (VA, 2018b). This value is then rounded to the nearest 10 percent. If there are more than two disabilities, the combined value for the first two is determined (as previously described), and this new value is then combined with the value for the third disability. PREPUBLICATION COPY: UNCORRECTED PROOFS

8-6 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES Canada Pension Plan The CPP disability benefit is “a taxable monthly payment that is available to people who have contributed to the CPP and who are not able to work regularly because of a disability” (Government of Canada, 2018e). To qualify as eligible for a CPP disability benefit, an individual must have a severe and prolonged disability, be under the age of 65, and meet the CPP contribution requirements (Government of Canada, 2018c). Contributions are required in 4 of the last 6 years or, for those having contributed for more than 25 years, 3 of the last 6 years (Government of Canada, 2018c). The CPP Adjudication Framework, a comprehensive framework of the policy elements of disability adjudication, provides decision makers with the information needed to adjudicate CPP disability applications. The framework consists of five components: a “severe” criterion for the prime indicator, a “severe” criterion for “incapable regularly of pursuing any substantially gainful occupation,” personal characteristics and socioeconomic factors, a “prolonged” criterion, and a reasonably satisfied standard of review for determining eligibility or continuing eligibility for CPP disability benefits (Government of Canada, 2018b). In the first of these components, the claimant’s medical condition is defined as the prime indicator in determining whether a disability is “severe” and “prolonged.” Multiple factors are considered in assessing the medical condition, including the nature of the condition and whether it is progressive, functional limitations due to the condition, the impact of treatment, statements/opinions expressed by the health professional and client, the existence of multiple medical conditions, and personal characteristics (Government of Canada, 2018b). To determine whether the nature of the medical condition is “severe” and can lead to the inability to work, a medical adjudicator uses his or her medical knowledge, the CPP legislation, and medical information provided by the individual and health professionals. When determining disability, the CPP focuses only on those functional limitations that affect the capacity to work. Functional limitation is defined as “an impairment that leads to less than normal performance of an individual” (Government of Canada, 2018b). The adjudicator also determines the impact of treatments on the medical condition and the person’s ability to work. For the CPP, individuals with two or more medical conditions are considered to have multiple conditions. Even if individual medical conditions are not considered to result in an inability to work, they may be considered to do so if they are among an individual’s multiple conditions. For the second component, the applicant “must demonstrate that he or she has a ‘severe’ and ‘prolonged’ physical or mental disability that prevents him or her from regularly pursuing any substantially gainful occupation” (Government of Canada, 2018b). To satisfy this disability test, three factors are considered in relation to work activity—performance, productivity, and profitability. The third component relates to personal characteristics and socioeconomic factors. Personal characteristics include age, education, and work experience and its impact on the individual’s medical condition, work capacity, and ability to perform in a substantially gainful occupation. The individual’s particular characteristics are considered only with respect to their direct effect on the ability to work. Socioeconomic factors are not considered in the determination of CPP disability. For the fourth component, after an individual meets the “severe” criterion, the “prolonged” criterion is assessed. Similar to SSA’s duration requirement, the CPP’s “prolonged” criterion has two components—“likely to result in death” or “likely to be long continued” and PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-7 “of indefinite duration” (Government of Canada, 2018b). Only one of these two components must be met. For the fifth component, the CPP uses a “reasonably satisfied” standard of proof when determining eligibility or continuing eligibility for disability benefits, established by considering all evidence pertinent to the medical condition, the capacity to work, and personal characteristics. Pertinent evidence refers to evidence collected from physicians; medical reports by family physicians, specialists, and/or other health care professionals; reports of diagnostic investigations; employer reports; and functional capacity assessments (Government of Canada, 2018b). Providers such as psychologists, neuropsychologists, physiotherapists, occupational therapists, and vocational rehabilitation professionals can provide evidence of work capacity. Examples of such evidence include functional capacity assessments, statements from educational institutions and employers, power-of-attorney documents, and certificates of incapacity. Since Canada has universal health insurance, it is reasonable to expect that claimants can obtain evidence of their impairment and its limitations, in contrast to the United States. The CPP compares and evaluates opinions expressed by all of these professionals and statements made by the applicant to obtain a total picture of the individual. If the overall available evidence supports a determination that the individual meets the “severe” and “prolonged” criteria, the disability benefit is granted. Disability Support Pension (Australia) To be eligible for DSP, applicants must be “between 16 and pension age; meet residency requirements; meet income and assets tests; and have a permanent and diagnosed disability or medical condition or get a Department of Veterans’ Affairs special rate disability pension due to total and permanent incapacity” (Australian Government Department of Human Services, 2018a). The applicant also may need to show participation in a Program of Support—resources for job preparation, work training, and injury management—and demonstrate that he/she cannot work or retrain to work for at least 15 hours a week in the next 2 years (Australian Government Department of Human Services, 2018a). During disability assessment, DSP seeks to understand how an individual’s disability or medical condition affects him or her. The applicant is responsible for providing current medical evidence from a treating health professional(s) about each of the medical conditions that may impact his or her ability to work. Examples of medical evidence that may be required include medical history reports; physiotherapy or audiology reports; psychologist reports, including results of IQ testing; and physical examination reports (Australian Government Department of Human Services, 2018c). More important, current information must be provided regarding the diagnosis, treatment, symptoms, functional impact, and prognosis of each medical condition that may impact the individual’s ability to work. Specific evidence is required for some medical conditions: mental health conditions, which require a diagnosis from a psychiatrist or clinical psychologist; intellectual impairment, which requires evidence from a psychologist, who must assess intellectual function and adaptive behavior and provide information that includes an IQ score or ability to undergo testing; ear conditions affecting hearing or balance, which require evidence that an audiologist or an ear, nose, and throat specialist supports the diagnosis; and eye conditions affecting vision, which require evidence that an ophthalmologist or ophthalmic surgeon supports the diagnosis (Australian Government Department of Human Services, 2018c). Applicants may be assessed as manifestly medically eligible if they “are permanently blind; have a terminal illness with a life expectancy of less than 2 years; have an intellectual PREPUBLICATION COPY: UNCORRECTED PROOFS

8-8 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES disability with an IQ of less than 70; or need nursing home level care” (Australian Government Department of Human Services, 2018b). If applicants fail to meet the criteria described above, their disability or medical condition needs to be fully diagnosed, treated, and stabilized. DSP will then assess how the condition affects the applicant’s ability to function daily. A Job Capacity Assessment may be used to help DSP assess functioning using impairment tables. DSP uses 15 impairment tables to determine an impairment rating. These tables include functions requiring physical exertion and stamina; upper-limb function; lower- limb function; spinal function; mental health function; functioning related to alcohol, drug, and other substance use; brain function; communication function; intellectual function; digestive and reproductive function; hearing and other functions of the ear; visual function; continence function; functions of the skin; and functions of consciousness (Australian Government, 2011). The tables are “function based rather than diagnosis based; describe functional activities, abilities, symptoms and limitations; and are designed to assign ratings to determine the level of functional impact of impairment and not to assess condition” (Australian Government, 2011, p. 5). Additional medical evidence is evaluated during a Disability Medical Assessment performed by a government-contracted doctor. An applicant is considered medically eligible for DSP benefits if his or her medical condition prevents working at least 15 hours per week in the next 2 years, and if he or she has an impairment rating of 20 points or more on a single impairment table or 20 points or more combined across more than one impairment (Australian Government Department of Human Services, 2018b). Individuals receiving DSP benefits may be required to follow a Participation Plan to encourage return to work. If their medical condition changes after benefits have been awarded, an Employment Services Assessment is performed to reassess the claimant’s medical condition and capacity to work (Australian Government Department of Human Services, 2018d, 2018e). Selected State Workers’ Compensation Programs Chesapeake Employers’ Insurance Company The process of disability assessment at Chesapeake encompasses claims management, health services, and fraud management and investigation functions and an in-house legal department. Within the health services department, in-house doctors, nurses, and medical specialists work with claims professionals to ensure appropriate medical treatment for injured workers. The goal is to return injured workers to work as soon as it is medically possible (Fisher and Smulyan, 2018). The health services team consists of 3 doctors, 20 nurses, a pharmacist, and a physical therapist (Chesapeake Employers Insurance, n.d.-b). Two orthopedic surgeons and a third physician with experience in workers’ compensation injuries provide advice on treatment interventions, as well as cost containment options such as generic and lower-cost prescriptions. Approximately 20 nurses provide telephonic case management and ensure that the medical treatment received by injured workers is appropriate and timely (Chesapeake Employers Insurance, n.d.-b). Nurses also coordinate with claims adjusters to ensure contact among injured workers, their employer, and medical providers (Chesapeake Employers Insurance, n.d.-b). The pharmacist monitors drug utilization and prescriptions, while the physical therapist monitors the progress of injured workers for short- and long-term goals. When an individual is injured, his or her employer reports the injury in an initial report to Chesapeake. The adjuster speaks with the injured worker to learn about the job situation and how PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-9 it contributed to the injury (Fisher and Smulyan, 2018). A medical history and a history of previous injury and/or surgery are also collected. Once the injury has been reported, medical care is initiated at an occupational health facility, a private physician’s office, or an emergency room/urgent care facility (Fisher and Smulyan, 2018). Thirty days of treatment, including physical therapy, is covered automatically to prevent delays in receiving care. Chesapeake’s goal for disability management is to achieve maximal medical improvement (MMI), defined as “the point at which the condition of an injured person is stabilized. No further recovery or improvement is expected, even with additional medical intervention” (Chesapeake Employers Insurance, 2018b). MMI status is determined through review of regular medical reports from physicians and ancillary providers. Psychological evaluations may also be used to identify behavioral health factors preventing a return to work (Fisher and Smulyan, 2018). Once MMI has been reached, a determination as to whether the individual can return to previous work activity can be made. If an individual is unable to return to previous work activity, the job analysis provided by the employer is used to identify modified duties (Fisher and Smulyan, 2018). An independent medical evaluation may be provided to determine preexisting conditions, conditions related to work injury or exposure, and current diagnosis. Washington State Department of Labor and Industries Under the L&I disability assessment process, an individual who is injured at work can file an accident report at a doctor’s office, on the L&I website, or by phone. If the applicant works for a self-insured employer, the accident report must be filed with the employer (L&I, 2018c). Workers may file claims within 1 year of their injury date or within 2 years of receiving a diagnosis of an occupational disease (L&I, 2018c). The accident report includes information about the applicant’s injury, employer, wages, diagnosis, and treatment, along with other background information (L&I, 2018c). The applicant’s doctor may complete a Physicians Initial Report. If the worker’s ability to work is limited, an Activity Prescription Form is completed (L&I, 2018c). This form rates the worker’s current capacity to work and may be completed by a qualified attending health care provider, including a doctor currently licensed in medicine (including osteopathic), surgery (including podiatric), or dentistry or a chiropractor who is a department-approved examiner (L&I, n.d.-a). After a claim has been filed, a Claim Arrival Card is sent to the worker by mail, along with information on benefits and return-to-work resources. Correspondence requesting additional information may also be included (L&I, 2018c). A claims manager may require that an independent medical examination (IME) be performed to determine the extent of the impairment or to learn more about the condition’s treatment or duration. The IME is scheduled and paid for by L&I (L&I, 2018d). L&I or the self-insured employer will approve the claim if the applicant’s doctor can certify that the applicant was injured at a specific time and place at work or has an occupational disease (L&I, 2018e). The benefits provided will cover medical bills and may include wage replacement, return-to-work assistance, and disability or pensions for the severely injured (L&I, 2018e). Selected Private Disability Insurance Providers Prudential Financial Prudential’s group disability insurance provides both short- and long-term disability benefits, return-to-work services, absence management, and health and productivity data analytics and consulting. When a claimant applies for disability insurance, Prudential’s goals PREPUBLICATION COPY: UNCORRECTED PROOFS

8-10 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES include understanding all of the medical conditions impacting the employee, identifying functional capacity and restrictions and limitations, identifying prognosis and when and whether return to work is expected, and using vocational rehabilitation resources to facilitate a safe return to work (Kramschuster, 2018). The initial acquisition of clinical information encompasses a statement of disability by the employee; an attending physician’s statement; and medical records, including a history of surgery, therapy, and medications (Kramschuster, 2018). Once this information has been collected, the claims manager facilitates an internal review of the information with a vocational rehabilitation specialist and clinician—typically a registered nurse (Kramschuster, 2018). During this review, the claim is discussed in detail to determine whether the information is consistent, the prognosis is understood, and there is any current capacity for return to work at any level (Kramschuster, 2018). If additional information is needed, it is requested; otherwise, the file is sent to an internal clinician for a full file review to determine capacity to return to work. If the information is sufficient, Prudential will have a clear understanding of functional capacity and can make a determination. Sun Life Financial Sun Life Financial’s disability claims management process consists of a thorough assessment, starting with a comprehensive analysis of information related to the claimant’s injury and absence from work (Sun Life Assurance Company of Canada, n.d.). This information is collected through a telephone conversation between the claims handler and the claimant, followed by the submission of functional assessment forms and the Attending Physician Statement (APS). The information provided by the attending physician is key to the process (Hamill, 2018). Sun Life’s assessment includes engaging the claimant, with a focus on his or her functional abilities (Sun Life Assurance Company of Canada, n.d.). Ancillary information, such as medical records, pharmacy scans, information from the employer, publically available information, and in-person interviews or surveillance, is used before a decision is made (Hamill, 2018). This ancillary information includes the types of medications the claimant uses and physicians the claimant sees. Sun Life’s goal is to ensure optimal treatment and establish expectations for recovery to help the claimant understand that other factors can affect recovery, such as perceptions regarding recovery, workplace, family, and financial issues (Hamill, 2018). When establishing expectations for recovery, the discussion between the claimant and his or her physician is focused on identifying return-to-work goals and providing the claimant with information on work accommodations to help with return-to-work planning (Sun Life Assurance Company of Canada, n.d.). When in-depth rehabilitation, treatment, or other interventions are necessary, Sun Life strives to ensure that appropriate resources are involved. Sun Life will also negotiate return-to- work plans that align the claimant’s functional abilities with work demands. Predictive modeling and innovative data mining are used to improve claimant outcomes (Sun Life Assurance Company of Canada, n.d.). PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-11 COLLECTION OF FUNCTIONAL INFORMATION Selected Federal Disability Programs Veterans Benefits Administration The VA uses DBQs to collect functional information related to the impairments described in Chapter 7, including back conditions, heart conditions, mental disorders, and traumatic brain injury (TBI). During the collection of medical history in the DBQ for back (thoracolumbar spine) conditions, the veteran is asked to provide a description of flareups that impact the function of the thoracolumbar spine, as well as any functional loss or impairment to the back (VA, 2018a). The VA defines functional loss as “the inability, due to damage or infection in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or endurance” (VA, 2018a, p. 4). Factors that contribute to functional loss or impairment are identified using information from the medical history and a physical exam. The physical exam includes measurement of range of motion (ROM) using a goniometer. The VA requires repetitive-use testing in all joint exams. Specifically, three repetitions of ROM are performed. ROM measurements are taken for joint movements such as forward flexion, extension, right and left lateral flexion, and right and left lateral rotation. Information is collected on pain associated with ROM movements, as well as pain during weight-bearing and non- weight-bearing movement. The physical exam also includes muscle strength testing, with strength ratings such as normal strength, active movement against some resistance, active movement against gravity, and no muscle movement being assigned (VA, 2018a). In addition, functional information related to back conditions is collected from a reflex exam, sensory exam, and straight leg raising test. Finally, the form collects information on the functional impact of the diagnosed condition(s) on the individual’s ability to perform any type of occupational task. Functional information collected on the heart conditions DBQ encompasses ischemic and nonischemic heart disease, arrhythmias, valvular disease, and cardiac surgery (VA, 2018g). This information, including heart rate, rhythm, point of maximal impact, heart sounds, peripheral pulses, peripheral edema, and blood pressure, is collected from the physical exam. For all heart conditions, the VA requires a determination of the presence of cardiac hypertrophy and dilation. The suggested order of tests for cardiac hypertrophy/dilation is electrocardiogram (EKG), then chest X-ray (posterioranterior and lateral), then echocardiogram (VA, 2018g). An echocardiogram is necessary only if the EKG and chest X-ray results are negative. Tests included on the form that may reflect the veteran’s current functional status are EKG, chest X- ray, echocardiogram, holter monitor, multigated acquisition scan (MUGA), coronary artery angiogram, and computed tomography (CT) angiogram (VA, 2018g). In addition, the VA requires metabolic equivalents (METS) of task testing for all heart exams—either exercise-based or interview-based—to determine the activity level at which symptoms develop. The mental disorders DBQ provides options for indicating the veteran’s level of occupational and social impairment with regard to all mental diagnoses (VA, 2018h). Examples of these options include “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks, only during periods of significant stress, or, symptoms controlled by medication” and “occupational and social impairment deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood” (VA, 2018h, p. 2). The form also asks about multiple symptoms that may affect PREPUBLICATION COPY: UNCORRECTED PROOFS

8-12 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES functioning, including “impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks”; “difficulty in understanding complex commands”; “difficulty in establishing and maintaining effective relationships”; and “intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene” (VA, 2018h, p. 4). The Residuals of TBI DBQ is used to evaluate the residuals of TBI (VA, 2011). The section on assessment of cognitive impairment and other residuals of TBI mentions that neurological testing may be necessary to complete it accurately. The section collects information on the veteran’s current level of functional status for 10 facets of TBI-related cognitive impairment and subjective symptoms: memory, attention, concentration, and executive functions; judgment; social interaction; orientation; motor activity (with intact motor and sensory system); visual spatial orientation; subjective symptoms; neurobehavioral effects; communication; and consciousness (VA, 2011). For subjective symptoms, information is collected on their interference with instrumental activities of daily living (IADLs). The form also collects information on “any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI,” such as motor dysfunction, hearing loss and/or tinnitus, speech disorder, and mental disorder (including emotional, behavioral, or cognitive) (VA, 2011, p. 62). Canada Pension Plan Applicants for CPP disability benefits are required to submit a medical report. A physician, a nurse practitioner, or—in geographically isolated communities—a registered nurse may complete the Medical Report for a Canada Pension Plan Disability Benefit (Service Canada, 2018). Information is collected on each medical condition, its impairments, and its functional limitations and treatment. Information on the condition’s prognosis (improve, deteriorate, remain the same, or unknown), expected duration (less than 1 year, more than 1 year), and frequency (recurrent/episodic, continuous, unknown) is also collected. Another section collects information that can be used to assess current and future restrictions on the patient’s ability to work. The form includes a list of grave medical conditions (with marked and severe functional limitations) that have a high probability of meeting the eligibility criteria for CPP disability benefits. The form also provides examples of functional limitations by physical abilities, behaviors and emotional abilities, communication and thinking abilities, and other daily abilities. Physical abilities may include restrictions related to changing body position (kneeling or squatting), maintaining body position (remaining seated or standing), fine hand use (turning a dial or knob), using transportation (as a passenger in a taxi or on a bus or the subway), and using a computer (being able to look at a computer screen for at least 20 minutes) (Service Canada, 2018). Behaviors and emotional abilities may include restrictions related to basic interpersonal interactions (showing respect and tolerance), maintaining formal relationships (with employers or service providers), and handling stress and other psychological demands (Service Canada, 2018). Communication and thinking abilities may include restrictions related to making conversation (with known individuals or strangers), thinking (sequencing thoughts in a structured, logical manner), and making decisions (identifying and choosing among several options) (Service Canada, 2018). Other daily abilities include restrictions related to toileting, dressing, looking after one’s health (taking medication as directed), acquiring goods and services, maintaining economic self-sufficiency (managing money), doing housework, preparing meals, and driving (Service Canada, 2018). PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-13 Disability Support Pension (Australia) As mentioned earlier, DSP uses impairment tables, “designed to assign ratings to determine the level of functional impact of impairment” to assess impairment in relation to work (Australian Government, 2011, p. 5). To select the correct table to use, the following steps are followed: “identify the loss of function; then refer to the Table related to the function affected; then identify the correct impairment rating” (Australian Government, 2011, p. 9). If a single condition causes multiple impairments, each impairment should be assessed with the relevant table. If two or more conditions cause a combined impairment, a single rating is assigned under a single table. Impairment tables related to both physical and mental functioning are discussed below. For Table 1 on functions requiring physical exertion and stamina, the introduction indicates that the table should be used “where the person has a permanent condition resulting in functional impairment when performing activities requiring physical exertion or stamina” (Australian Government, 2011, p. 12). It also states that the diagnosis must be made by an appropriately qualified medical practitioner. With respect to evidence, self-report of symptoms alone is not sufficient; corroborating evidence of the person’s impairment is necessary. Examples of corroborating evidence include a report from the person’s treating doctor; a report from a medical specialist confirming a diagnosis of a condition commonly associated with cardiac or respiratory impairment; and results of exercise, cardiac stress, or treadmill testing. The next section of the table includes multiple levels of functional impact on activities requiring physical exertion or stamina, with various point ratings: none = 0 points, mild = 5 points, moderate = 10 points, severe = 20 points, and extreme = 30 points. The table also provides detailed information for each functional impact level. For no functional impact, the person is “able to undertake exercise appropriate to their age for at least 30 minutes at a time; and has no difficulty completing physically active tasks around their home and community” (Australian Government, 2011, p. 12). If there is an extreme functional impact related to physical exertion or stamina, the person is “completely unable to perform activities requiring physical exertion or stamina or experiences symptoms (e.g., shortness of breath, fatigue, cardiac pain) when performing any activities requiring physical exertion or move around inside the home without assistance” (Australian Government, 2011, p. 14). For Table 5 on mental health function, the introduction indicates that the table should be used “where the person has a permanent condition resulting in functional impairment due to a mental health condition (including recurring episodes of mental health impairment)” (Australian Government, 2011, p. 22). It also states that the condition must be diagnosed by an appropriately qualified medical practitioner (includes a psychiatrist) with evidence from a clinical psychologist (if the diagnosis has not been made by a psychiatrist). In addition to self-report of symptoms, corroborating evidence is required, which may include a report from the person’s treating doctor; supporting letters, reports, or assessments relating to the person’s mental health or psychiatric illness; and interviews with the person and those providing care or support to the person. The table also includes a note stating that the signs and symptoms of mental health impairment may vary over time, and it is important not to rely solely on how the individual may present on the day of the assessment. More specifically, “for mental health conditions that are episodic or fluctuate, the rating that best reflects the person’s overall functional ability must be applied, taking into account the severity, duration and frequency of the episodes or fluctuations as appropriate” (Australian Government, 2011, p. 22). PREPUBLICATION COPY: UNCORRECTED PROOFS

8-14 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES The next section of the table provides multiple levels and point ratings of functional impact on activities involving mental health function. A person with no functional impact has no difficulties with most of the following: “self care and independent living; social/recreational activities and travel; interpersonal relationships; concentration and task completion; behavior, planning and decision-making; and work/training capacity” (Australian Government, 2011, p. 23). If there is an extreme functional impact, the person has extreme difficulty with these mental health functions (Australian Government, 2011). Selected State Workers’ Compensation Programs Chesapeake Employers’ Insurance Company Chesapeake collects functional information using a job analysis form and functional capacity evaluation. On the job analysis form, employees are asked how often—never, occasional (11–33 percent), frequent (34–66 percent), and constant (67–100 percent)—they perform various tasks, such as standing, sitting walking, stooping, kneeling, reaching, and fine manipulations (Chesapeake Employers Insurance, n.d.-c). They are also asked about the amount of weight that can be lifted, carried, pushed/pulled, and handled. This form utilizes the U.S. Department of Labor’s classification of five degrees of work in terms of lifting requirements: sedentary work, light work, medium work, heavy work, and very heavy work. Based on the evidence collected with this form, the physician completing the form will determine whether and when an employee can return to work on regular or transitional/modified duty. The functional capacity evaluation is performed by a physical therapy group to determine work capability (Chesapeake Employers Insurance, n.d.-a). Information is collected on lifting tasks, including the amount of weight lifted, how often (occasional, frequent, or constant), and the type of lift (floor to waist, knee to waist, waist to shoulder, waist to overhead, carry, push, or pull). In addition, information is collected on such tasks as sitting, standing, walking, and squatting. Information on active ROM and strength deficits is also collected. Worker performance findings on the form include the categories of symptom management, worker traits, and consistency of effort. Symptom management includes the following abilities: knowledge of appropriate strategies, demonstration of appropriate strategies, response to activity/evaluation, and effectiveness of current strategies (Chesapeake Employers Insurance, n.d.-a). Worker traits include productivity, safety, and interpersonal behavior. Consistency of effort includes observation of illness behavior, reliability of pain and disability reports, and physical effort (Chesapeake Employers Insurance, n.d.-a). Vocational information is also collected through a summary of duties and description of physical requirements; physical requirements can be assessed based on client report, employer report, U.S. Department of Labor’s Dictionary of Occupational Titles (DOT)/Occupational Information Network (O*NET), or a job description (Chesapeake Employers Insurance, n.d.-a). Washington State Department of Labor and Industries L&I collects functional information via the Activity Prescription Form (APF), the IME Doctor’s Estimate of Physical Capacities, the Functional Capacity Summary, and the Job Analysis Summary. The APF collects information on work status, including when the worker was released to the job where injury occurred, whether the worker can perform modified duties, whether the worker may work limited hours, and measurable objective findings related to work ability (L&I, 2018b). The IME Doctor’s Estimate of Physical Capacities consists of seven PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-15 sections (L&I, 2007). The first assesses the worker’s ability to sit, stand, and walk for durations at one time and during an entire 8-hour day. The second and third sections evaluate the worker’s ability to lift and carry, by both weight and frequency. The fourth and fifth sections address repetitive hand and foot tasks and movements. The sixth section assesses whole-body movements by frequency. The seventh section records specific activity restrictions involving unprotected heights; being around moving machinery; exposure to marked changes in temperature and humidity; driving automotive equipment; and exposure to dust, fumes, and gases. The Functional Capacity Summary and Job Analysis Summary similarly collect information on the amount of time (never, seldom, occasional, frequent, and constant) various tasks can be performed, such as climbing stairs, bending/stooping, kneeling, reaching forward, keyboarding, and fine manipulation (L&I, 2014, 2016). L&I also makes available a list of particular functional scales: the Patient Specific Functional and Pain Scale (PSFS), Functional Activity Back Questionnaire (FABQ), STarT Back Screening Tool (SBST-9), Tampa Scale-11 (TSK-11), Yellow Flags Questionnaire (YFQ), Bournemouth Questionnaire-Neck (BQ-N), Bournemouth Questionnaire-Back (BQ-B), Neck Disability Index (NDI), Revised Oswestry Disability Questionnaire, Roland-Morris Low Back Pain & Disability Questionnaire, QuickDASH (Q-DASH), Shoulder Pain & Disability Index (SPADI), Upper Extremity Functional Index (UEFI), Foot & Ankle Ability Measure (FAAM), and Lower Extremity Function Scale (LEFS) (L&I, n.d.-b). Selected Private Disability Insurance Providers Prudential Financial Prudential provides multiple forms for use by physicians to collect medical information, including the Capacity Questionnaire, Mental Status Examination, Behavioral Health Capacity Questionnaire, Kurtzke Functional Systems Scores, Visual Capacity Questionnaire, and Psychiatric Work Readiness Assessment (Prudential Financial, 2018c). The Capacity Questionnaire is a full-time work capacity assessment tool (reviewing 8-hour days for 5 days per week) (Prudential Financial, 2017). Specifically, the Capacity Questionnaire asks the physician completing the form whether the patient is capable of full-time work for 8 hours per day, 5 days per week or part-time transitional work. The form also collects information on the percentage of time—never (0 percent), occasionally (1–33 percent), frequently (34–66 percent), or constantly (67–100 percent)—during a typical day that the patient can perform various tasks, such as standing, walking, sitting, reaching overhead, stooping, and kneeling/crawling. The physician must also document any other medically necessary restrictions and/or limitations and any accommodative measures that would allow the patient to increase work capacity. The Mental Status Examination form collects information on various aspects of functioning to determine whether the patient is within normal limits with respect to appearance, attitude, behavior, speech, mood, affect, thought process, thought content, cognition, and insight/judgment (Prudential Financial, 2016). Specifically for cognition, information is collected on orientation, concentration/attention, recent memory, remote memory, calculations, and abstractions. The Behavioral Health Capacity questionnaire asks multiple questions related to functional capacity, restricted to within the last 14 days (Prudential Financial, 2015a). Functional information collected includes description of any work the patient should not do because of psychiatric symptoms/disease, psychosocial stressors that caused the patient to leave work, PREPUBLICATION COPY: UNCORRECTED PROOFS

8-16 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES whether there is cognitive disease and how it was measured, and what barriers to returning to work exist. The Kurtzke Functional Systems Scores (FSS) assessment, based on neurological examination of functions, includes such categories as pyramidal functions, brainstem functions, sensory functions, cerebellar functions, bowel and bladder functions, cerebral (or mental) functions, and visual functions (Prudential Financial, 2014a). The Visual Capacity Questionnaire asks about visual functions that include best corrected acuity, field of vision, muscle function, two-eye depth perception, color perception, intraocular pressure, and fundus exam (Prudential Financial, 2014b). The form also asks whether the patient is able to do various tasks and for what percentage of an 8-hour work day. Tasks include walk on uneven surfaces, balance, drive motorized vehicles, climb, bend, use computer, and read instructions. The form also asks whether a low-vision assessment can help in establishing visual functional capacity and/or accommodation needs. The Psychiatric Work Readiness assessment, which is completed by a physician, asks whether the employee has work restrictions or limitations due to a psychiatric condition (Prudential Financial, 2015b). The form defines “restriction,” “limitation,” and “treatment plan.” Restriction would “indicate your recommendation that the employee not perform a specified activity because of risk to self or others” (Prudential Financial, 2015b, p. 1). Limitation would “indicate your opinion that the employee is not cognitively or otherwise capable of performing a specified activity” (Prudential Financial, 2015b, p. 1). The treatment plan describes “in detail treatment methods that specifically target the psychiatric impairment” (Prudential Financial, 2015b, p. 1). For each restriction or limitation, the form asks the physician to provide a specific treatment plan for restoring work readiness in that particular area. Sun Life Financial For both long- and short-term disability benefits, Sun Life provides questionnaires for the claimant, attending physician, and employer to complete. The Attending Physician Statement (APS) can be completed by a “family doctor, a doctor at a walk-in clinic, a specialist or nurse practitioner—any medical professional who is a doctor of medicine and has treated you for your condition” (Sun Life Financial, n.d.-c, p. 3). Information is collected on the current diagnosis; what the condition is related to, such as a workplace injury or auto accident; symptoms and frequency of symptoms; and severity. In the clinical findings and observations section of the APS, the attending physician is asked to attach any test results, investigations, or consultation reports. The form also asks whether any formal functional tests have been performed and for the claimant to provide a copy of the report. In addition, the physician is asked whether the patient exhibits difficulty (specifying “none, slight, moderate, severe”) in the following abilities: memory, decision making, concentration/focus, speech, sleep, sensation, walking, and climbing (Sun Life Financial, n.d.-c). The form also collects information on cardiac conditions and asks for functional capacity as defined by the American Heart Association. Options include Class I (no limitation), Class II (slight limitation), Class III (marked limitation), and Class IV (complete limitation). If functional capacity is Class III or IV, a copy of a stress test or cardiac echograms should be included. Information on hospitalizations and medications is collected as well. The attending physician can also complete a form that provides information on activities of daily living (ADLs) (Sun Life Financial, n.d.-b). This information includes whether no assistance is needed, stand-by assistance is needed, or physical hands-on assistance is needed. ADLs listed on the form include bathing, continence, dressing, eating, toileting, and transferring PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-17 (getting into a bed or wheelchair). The ADL questionnaire also asks about the presence of a cognitive impairment, defined as “an individual has a deterioration or loss in intellectual capacity resulting from injury, sickness, advance age or Alzheimer’s disease and similar forms of irreversible dementia and the individual needs another person’s assistance or verbal cuing for the individual’s protection or for the protection of others” (Sun Life Financial, n.d.-b, p. 2). Claimants provide information describing their injury/illness, treatment, doctors seen for their injury/illness, and job duties they currently cannot complete. The Disability Job Demands questionnaire asks for information related to the plan member’s specific job duties. Questions related to the conditions of the job are asked about work in varying conditions, such as outside, in extremes of cold or heat, in a noisy environment, or around toxic fumes (Sun Life Financial, n.d.-a). The questionnaire also asks about the percentage of time the plan member lifts or carries various weights. In addition, the plan member provides information on work activities that include walking, climbing, bending/crouching, and kneeling/crawling and the percentage of time performed. Information on cognitive and nonphysical aspects of the job is collected as well. SUMMARY Annex Table 8-1 provides a comparison of the size of the disability programs reviewed herein, as well as their disability focus and the types of functional information they collect, which include physical abilities, mental abilities, and ADLs. Although most of the programs use generic forms to collect functional information, both the VBA and DSP report that they use an impairment-specific approach in collecting this information. The VBA provides applicants with more than 70 DBQs with which to collect disability information for a full range of medical conditions. DSP utilizes 15 impairment tables categorized by functioning to assign ratings used to determine the level of functional impact of impairments. Annex Table 8-1 also shows that the VBA, the CPP, and Sun Life Financial collect information on ADLs to assess functioning. The VBA’s residuals of TBI DBQ collects information on whether subjective symptoms mildly or moderately interfere with IADLs. The CPP’s Medical Report provides examples of daily abilities that may be affected by a medical condition, including toileting, dressing, doing housework, and preparing meals. Sun Life Financial’s ADL questionnaire collects information on various ADLs—bathing, dressing, toileting, transferring, continence, and eating—providing definitions of each. FINDINGS AND CONCLUSIONS Findings 8-1. The mission and size of different disability benefits programs vary greatly. State workers’ compensation programs (e.g., Chesapeake Employers’ Insurance Company, Washington State Department of Labor and Industries) and private disability insurers (e.g., Sun Life Financial, Prudential Financial) focus on and facilitate the return of individuals to work. The Veterans Benefits Administration’s (VBA’s) mission is to compensate veterans who become disabled as a result of their military service, independently of whether an individual is able to work. The Canadian Pension Plan (CPP) and Australia’s Disability Support Pension (DSP) are federal government programs that provide disability benefits to qualified individuals who are unable to perform work at the level specified by the PREPUBLICATION COPY: UNCORRECTED PROOFS

8-18 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES program. The CPP serves by far the greatest number of beneficiaries relative to the other programs examined, and Prudential the least. 8-2. The VBA uses more than 70 disability benefit questionnaires to collect functional information about specific diseases and organ systems across the entire range of medical conditions. If a veteran is found to have more than one disability, a rating table is used to calculate a combined disability rating. 8-3. The CPP Adjudication Framework consists of five components: a severity criterion for the prime medical condition, severity criteria for the inability to regularly pursue “any substantially gainful occupation,” personal characteristics and socioeconomic factors, a criterion related to the length of disability (“prolongation”), and a reasonably satisfied standard of review for determining eligibility or continuing eligibility for CPP disability benefits. 8-4. The goal of the Chesapeake Employers’ Insurance Company (the state of Maryland’s workers’ compensation program) is for workers to achieve maximal clinical and functional improvement after a work-related illness or injury, to the point at which the condition is stabilized and no further recovery or improvement is expected, even with additional medical intervention. This goal, reflected in the program’s mission to return individuals to work, is similar to those of other state workers’ compensation programs, as well as private disability insurers, but differs from those of the federal programs examined. This difference necessitates a different approach to disability assessment in terms of functional and prognostic evaluation instruments and rehabilitation. 8-5. Prudential Financial, a private disability insurance company, has several goals when a claimant applies for assistance, including understanding all of the medical conditions impacting the employee, identifying functional capacity and restrictions and limitations, identifying prognosis and when and whether return to work is expected, and using vocational rehabilitation resources to facilitate a safe return to work. Most of the disability assessments are performed by company staff, which may include the claims manager, a registered nurse, and a vocational rehabilitation specialist. 8-6. Although many of the benefit programs examined by the committee collect functional information on physical and mental abilities, only the VBA, the CPP, and Sun Life Financial collect information on activities of daily living. 8-7. Only two of the benefit programs (VBA and DSP) use forms tailored to specific types of impairments to collect functional information; the remainder (the CPP, Chesapeake, Washington State, Prudential, and Sun Life) use generic questionnaires. Conclusions 8-1. The resources of the disability benefit programs examined for developing cases and gathering functional information differ dramatically. The programs vary greatly in size and have somewhat different goals, which can affect methods used and availability of staff to collect information. The willingness of both the private and public disability programs to share their methods and assessment instruments would help strengthen the processes both nationally and internationally. 8-2. In general, programs with a mission of rehabilitation and returning individuals to work (e.g., workers’ compensation programs and private disability insurers) have a different approach to disability assessment and management relative to organizations charged solely with disability compensation (e.g., the VBA, the CPP, and DSP). PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-19 REFERENCES Australian Government. 2011. Social Security (tables for the assessment of work-related impairment for disability support pension) determination 2011. https://www.dss.gov.au/sites/default/files/documents/05_2012/dsp_impairment_final_tables.pdf (accessed April 4, 2019). Australian Government Department of Human Services. 2018a. Disability support pension eligibility. https://www.humanservices.gov.au/individuals/services/centrelink/disability-support- pension/eligibility (accessed April 4, 2019). Australian Government Department of Human Services. 2018b. Disability support pension: How we assess your disability or condition. https://www.humanservices.gov.au/individuals/services/centrelink/disability-support- pension/eligibility/how-we-assess-your-disability-or-condition (accessed April 4, 2019). Australian Government Department of Human Services. 2018c. Disability support pension: Medical evidence. https://www.humanservices.gov.au/individuals/services/centrelink/disability-support- pension/claiming/medical-evidence (accessed April 4, 2019). Australian Government Department of Human Services. 2018d. Disability support pension: Participation requirements. https://www.humanservices.gov.au/individuals/services/centrelink/disability-support- pension/participation-and-reporting/participation-requirements (accessed April 4, 2019). Australian Government Department of Human Services. 2018e. Employment services assessments. https://www.humanservices.gov.au/individuals/enablers/employment-services-assessments/37496 (accessed April 4, 2019). Australian Government Department of Human Services. 2018f. Payment rates for disability support pension. https://www.humanservices.gov.au/individuals/enablers/payment-rates-disability-support- pension/39881 (accessed April 4, 2019). Australian Government Department of Human Services. 2018g. 2017–18 Annual Report. https://www.humanservices.gov.au/sites/default/files/2018/10/8802-1810-annual-report-web-2017- 2018.pdf (accessed April 4, 2019). Chesapeake Employers Insurance. 2017. 2017 Annual report. https://www.ceiwc.com/pdf/2018/2018%20Annual%20Report/Chesapeake%20Employers%202017% 20Annual%20Report%20Rev.%20PDF.pdf (accessed April 4, 2019). Chesapeake Employers Insurance. 2018a. About Chesapeake Employers’ Insurance Company. https://www.ceiwc.com/about-chesapeake/company-overview/index.html (accessed April 4, 2019). Chesapeake Employers Insurance. 2018b. Recent Chesapeake Employers success cases at the Maryland Workers’ Compensation Commission. https://www.ceiwc.com/i-am-an-employer/forms-and- publications-forms-pdfs/Articles%20Library/2011/Recent%20Cases%20- %20December%20%202011.html (accessed April 4, 2019). Chesapeake Employers Insurance. n.d.-a (unpublished). Functional capacity evaluation summary. Townson, MD: CEIWC. Chesapeake Employers Insurance. n.d.-b. Making a difference: Health & claims services. https://www.ceiwc.com/pdf/2018/Chesapeake%20Health%20&%20Claims%20Services%20Promoti onal%20Brochure%20Low%20Res%201-30-18....pdf (accessed April 4, 2019). Chesapeake Employers Insurance. n.d.-c (unpublished). Sample job analysis. Towson, MD: CEIWC. Fisher, S., and W. I. Smulyan. 2018. The process of disability management at Chesapeake Employers’ Insurance Compnay: Workers’ compensation perspective. Presentation to the Committee on Functional Assessment for Adults with Disabilities, Washington, DC, April 19. Government of Canada. 2017. Annual report of the Canada Pension Plan for fiscal year 2016 to 2017. https://www.canada.ca/content/canadasite/en/employment-social- development/programs/pensions/reports/annual-2017.html (accessed April 4, 2019). Government of Canada. 2018a. Canada Pension Plan—Overview. https://www.canada.ca/en/services/benefits/publicpensions/cpp.html (accessed April 4, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

8-20 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES Government of Canada. 2018b. Canada Pension Plan adjudication framework. https://www.canada.ca/en/employment-social- development/programs/disability/benefits/framework.html (accessed April 4, 2019). Government of Canada. 2018c. Canada Pension Plan disability benefit—Eligibility. https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit/eligibility.html (accessed April 4, 2019). Government of Canada. 2018d. Canada Pension Plan disability benefit—How much could you receive. https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit/benefit- amount.html (accessed April 4, 2019). Government of Canada. 2018e. Canada Pension Plan disability benefit—Overview. https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit.html (accessed April 4, 2019). Government of Canada. 2018f. Service Canada. https://www.canada.ca/en/employment-social- development/corporate/portfolio/service-canada.html (accessed April 4, 2019). Hamill, T. 2018. Functional assessment of adults applying for disability benefits. Presentation to the Committee on Functional Assessment for Adults with Disabilities, Washington, DC, April 19. Kramschuster, J. 2018. Functional assessment and RTW. Presentation to the Committee on Functional Assessment for Adults with Disabilities, Washington, DC, April 19. L&I (Washington State Department of Labor & Industries). 2007. IME doctor’s estimate of physical capacities. https://www.lni.wa.gov/Forms/pdf/F242-387-000.pdf (accessed April 4, 2019). L&I. 2014. Job analysis summary. https://www.lni.wa.gov/FormPub/Detail.asp?DocID=2657 (accessed April 4, 2019). L&I. 2016. Functional capacity summary. https://www.lni.wa.gov/FormPub/Detail.asp?DocID=2803 (accessed April 4, 2019). L&I. 2018a. About Labor and Industries (L&I). https://www.lni.wa.gov/Main/AboutLNI/?F=MainFooter (accessed April 4, 2019). L&I. 2018b. Activity prescription form. https://www.lni.wa.gov/forms/pdf/F242-385-000.pdf (accessed April 4, 2019). L&I. 2018c. Filing your claim. https://www.lni.wa.gov/ClaimsIns/Claims/File/FilingClaim/default.asp (accessed April 4, 2019). L&I. 2018d. Independent medical exams. https://www.lni.wa.gov/ClaimsIns/Claims/File/IME/default.asp (accessed April 4, 2019). L&I. 2018e. Injured? What you need to know: Approved claim. https://www.lni.wa.gov/ClaimsIns/Claims/Guide/phase3.asp (accessed April 4, 2019). L&I. 2018f. Intro to L&I’s workers’ comp insurance. https://www.lni.wa.gov/ClaimsIns/Insurance/Learn/Intro/Default.asp (accessed April 4, 2019). L&I. 2018g. L&I facts and figures. https://www.lni.wa.gov/News/files/LNIFactsAndFigures.pdf (accessed April 4, 2019). L&I. 2018h. Medical examiners’ handbook. http://www.lni.wa.gov/IPUB/252-001-000.pdf (accessed April 4, 2019). L&I. n.d.-a. Completing the activity prescription form. https://www.lni.wa.gov/ClaimsIns/Providers/Claims/ActivityRx/Completing.asp (accessed April 4, 2019). L&I. n.d.-b. Patient Specific Functional and Pain Scales (PSFS). https://www.lni.wa.gov/ClaimsIns/Files/OMD/IICAC/2018DocFuncImprovfunctionalscales.pdf (accessed April 5, 2019). Prudential Financial. 2014a. Kurzke functional systems scores (FSS). http://www.prudential.com/media/managed/GL.2012.238.pdf (accessed April 4, 2019). Prudential Financial. 2014b. Prudential visual capacity questionnaire. http://www.prudential.com/media/managed/GL.2009.345.pdf (accessed April 4, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-21 Prudential Financial. 2015a. Behavioral health capacity questionnaire. http://www.prudential.com/media/managed/GL.2015.021.pdf (accessed April 4, 2019). Prudential Financial. 2015b. Psychiatric work readiness assessment. http://www.prudential.com/media/managed/GL.2015.038.pdf (accessed April 4, 2019). Prudential Financial. 2016. Mental status examination form. http://www.prudential.com/media/managed/GL.2011.093.pdf (accessed April 4, 2019). Prudential Financial. 2017. Capacity questionnaire. http://www.prudential.com/media/managed/GL.2012.240.pdf (accessed April 4, 2019). Prudential Financial. 2018a. About Prudential Financial. https://www.prudential.com/about (accessed April 4, 2019). Prudential Financial. 2018b. Disability insurance and absence management: The numbers tell the story. https://www.prudential.com/employers/group-insurance/products/disability-insurance (accessed April 4, 2019). Prudential Financial. 2018c. Resource center for physicians. https://www.prudential.com/links/forms/group-insurance- physicians/?pswid=Z7_K8HEHHG0L884C0AEFNFT411G23&urile=wcm%3Apath%3A%2Fwps%2 Fwcm%2Fconnect%2Fportal%20site%2Fz6_000000000000000000000000a0%2Fz6_9a0i18c0l0po8 0am2vkmno2g20%2Fz6_9a0i18c0lgos30a6cm62v52085%2Fz6_k8hehhg0lgsge0aer96u6e3k75%2Fz 6_k8hehhg0lgojc0aefq2gbm28a5%2Fz6_k8hehhg0lo1m00al0noo2c1m52 (accessed April 4, 2019). Service Canada. 2018. Medical report for a Canada Pension Plan disability benefit. https://catalogue.servicecanada.gc.ca/apps/EForms/pdf/en/ISP-2519.pdf (accessed April 4, 2019). Sun Life Assurance Company of Canada. 2018. Who we are. http://www.sunlife.com/Global/About+us/Who+we+are?vgnLocale=en_CA (accessed April 4, 2019). Sun Life Assurance Company of Canada. n.d. Absence and disability management: Supporting optimum health management. http://www.sunlife.ca/static/canada/Sponsor/About%20Group%20Benefits/Group%20benefits%20pr oducts%20and%20services/Absence%20and%20Disability%20Management/PDF6683-E.pdf (accessed April 4, 2019). Sun Life Financial. n.d.-a. Disability job demands questionnaire. https://www.sunlife.ca/static/canada/Sponsor/About%20Group%20Benefits/Forms/Package- Standard-PS-STD-LTD-E_RE.pdf (accessed April 4, 2019). Sun Life Financial. n.d.-b. Long term disability activities of daily living questionnaire. http://forms.sunlife-usa.com/onlineordering/get_file.cfm?form_id=28087 (accessed April 4, 2019). Sun Life Financial. n.d.-c. Long term disability plan member package: Attending physician’s questionnaire claim for long-term disability benefits. https://www.sunlife.ca/static/canada/Sponsor/About%20Group%20Benefits/Forms/PDF%20static%2 0files/Package-Standard-PM-LTD-E.pdf (accessed April 4, 2019). Tugman, K., and J. Kramschuster. 2016. The use of assistive technology in return-to-work. Presentation to the Committee on the Use of Selected Assistive Products and Technologies in Eliminating or Reducing the Effects of Impairments, Washington, DC, September 27. VA (U.S. Department of Veterans Affairs). 2011. DBQ initial evaluation of residuals of traumatic brain injury (I-TBI) disability. https://www.dcms.uscg.mil/Portals/10/CG-1/PSC/PSD/docs/VBA%20- %20Initial%20evaluation%20of%20TBI%20residuals.pdf?ver=2017-03-28-105323-973 (accessed April 4, 2019). VA. 2017a. Compensation. https://www.benefits.va.gov/REPORTS/abr/docs/FY17-Compensation.pdf (accessed April 4, 2019). VA. 2017b. Veterans Benefits Administration annual benefits report fiscal year 2017. https://www.benefits.va.gov/REPORTS/abr/docs/FY17-Introduction-Appendix.pdf (accessed April 4, 2019). VA. 2018a. Back (thoracolumbar spine) conditions disability benefits questionnaire. https://www.vba.va.gov/pubs/forms/VBA-21-0960M-14-ARE.pdf (accessed April 4, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

8-22 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES VA. 2018b. Compensation: Benefit rates. https://www.benefits.va.gov/compensation/rates-index.asp (accessed April 4, 2019). VA. 2018c. Compensation: Claims process. https://www.benefits.va.gov/compensation/process.asp (accessed April 4, 2019). VA. 2018d. Compensation: Evidence requirements. https://www.benefits.va.gov/compensation/evidence.asp (accessed April 4, 2019). VA. 2018e. Compensation: Frequently asked questions. https://www.benefits.va.gov/COMPENSATION/dbq_FAQS.asp (accessed April 4, 2019). VA. 2018f. Compensation: Overview. https://www.benefits.va.gov/compensation/dbq_overview.asp (accessed April 4, 2019). VA. 2018g. Heart conditions disability benefits questionnaire. https://www.vba.va.gov/pubs/forms/VBA- 21-0960A-4-ARE.pdf (accessed April 4, 2019). VA. 2018h. Mental disorders disability benefits questionnaire. https://www.vba.va.gov/pubs/forms/VBA- 21-0960P-2-ARE.pdf (accessed April 4, 2019). VA. 2018i. VA compensation and pension: Understanding mental health examinations. https://www.benefits.va.gov/COMPENSATION/docs/claimexam-mentalhealth-exams.pdf# (accessed April 4, 2019) PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-23 Chapter 8 Annex Tables begin on next page. PREPUBLICATION COPY: UNCORRECTED PROOFS

8-24 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-25 PREPUBLICATION COPY: UNCORRECTED PROOFS

8-26 FUNCTIONAL ASSESSMENT FOR ADULTS WITH DISABILITIES PREPUBLICATION COPY: UNCORRECTED PROOFS

REVIEW OF SELECTED DISABILITY BENEFIT PROGRAMS 8-27 PREPUBLICATION COPY: UNCORRECTED PROOFS

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The U.S. Social Security Administration (SSA) provides disability benefits through the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs. To receive SSDI or SSI disability benefits, an individual must meet the statutory definition of disability, which is “the inability to engage in any substantial gainful activity [SGA] 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.” SSA uses a five-step sequential process to determine whether an adult applicant meets this definition.

Functional Assessment for Adults with Disabilities examines ways to collect information about an individual’s physical and mental (cognitive and noncognitive) functional abilities relevant to work requirements. This report discusses the types of information that support findings of limitations in functional abilities relevant to work requirements, and provides findings and conclusions regarding the collection of information and assessment of functional abilities relevant to work requirements.

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