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2 Review of the Social Security Administration and Other Selected Capability Determination Processes
Pages 31-66

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From page 31...
... , and Service Canada.1 Additionally, with America's Health Insurance Plans (AHIP) serving as an intermediary, the committee was provided with information compiled from five disability income protection insurers.
From page 32...
... Of these programs, SSA and the VA had much information publicly available, while much less information was available on the OPM and Service Canada programs. No information regarding private insurance company programs was publicly available; information provided in this report relies exclusively on the limited information compiled by AHIP.
From page 33...
... . Currently, there are approximately 16,000 OPM annuitants with representative payees (Spear, 2015)
From page 34...
... exists or other federally or provincially appointed administration has been put into place" (Service Canada, 2015b) .5 Information on the number of beneficiaries with trustees was unavailable.
From page 35...
... Other relevant information provided to the committee by AHIP is discussed throughout this chapter.6 It is important to note that this information is limited and does not reflect a comprehensive discussion of the various issues involved in the capability determination processes of disability income protection insurers. DEFINING THE BENEFICIARY'S ABILITY TO MANAGE FUNDS As noted in Chapter 1, SSA (2003)
From page 36...
... After this first step, the case is referred to the state DDS agency, where a disability examiner develops medical evidence and makes the initial determination of disability. Following that initial determination, the case is returned to the field office for appropriate action (e.g., nonmedical case development, computation of benefit amount, benefit payment)
From page 37...
... For the VA, a beneficiary's competency is considered "whenever qualifying evidence raises a question as to the mental capacity to contract or to manage his/her own affairs, including disbursement of funds without limitation."11 If the issue of competency is raised without supporting medical evidence or a statement from a responsible medical authority, additional medical evidence concerning competency must be developed.12 (See the discussion of types and sources of evidence below.) The question of incompetency is raised if a beneficiary receives a 100 percent disability rating for a mental condition.13 However, the 100 percent disability rating alone does not necessarily mean the person is unable to manage his or her benefits.
From page 38...
... DDS disability examiners -- nonclinicians who receive 8-12 weeks of training in the SSA Listing of Impairments -- collect and analyze medical evidence from the applicant's doctors and from hospitals, clinics, or institutions where the individual received treatment, as well as lay information about activities of daily living and work history. New examiners complete the Disability Examiner Basic Training Program (DEBT)
From page 39...
... To ensure consistency with SSA's language and allow for comparisons between SSA's capability determination process and that of other agencies and organizations, the committee discusses evidence of capability in accordance with this terminology. All of the programs reviewed rely on some combination of legal, medical, and lay evidence, although the primary evidence required for determining capability differs among organizations.
From page 40...
... These arrangements are binding and must be recognized, and CPP and/or OAS benefits must be paid directly to federally or provincially appointed administrators. In contrast, a finding of legal incompetency by a court is not binding with respect to the competency of a veteran in the VA system.15,16 However, such a legal finding does raise the question of competency, triggering the need to develop necessary medical evidence, and is to be given great weight in the VA process in conjunction with the medical evidence.17 Evaluators are instructed to render an incompetency rating only when the evidence is clear and convincing and leaves no doubt as to the person's incompetency.18 ­ Court appointment of a fiduciary without a judicial determination of 15  M21-1, Part III, Subpart IV, 8.A.1b.
From page 41...
... . In contrast, the VA, OPM, and Service Canada require medical evidence to find a beneficiary incompetent.
From page 42...
... . Lay Evidence Lay evidence comprises anything other than legal or medical evidence, as defined above, that provides material and relevant facts as to 21  A "rating activity is a group of specially qualified employees vested with the authority to make decisions and take other actions on claims that require a rating decision," including competency (VA, 2015b)
From page 43...
... For the VA, lay evidence may be considered following an initial determination of incompetency. For example, "after development of information with regard to social, economic, and industrial adjustment, the Veterans Service Center Manager may be of the opinion that a beneficiary rated, or proposed to be rated, incompetent is actually capable of handling, without limitation, the funds payable." Such evidence is then referred back to the 23  SSA defines evidence of a medical nature as evidence "from a physician, psychologist or other qualified medical practitioner who is in a position to provide a meaningful assessment of the beneficiary's ability to manage funds." All other nonlegal evidence, from other professionals and lay persons familiar with the beneficiary, is considered lay evidence.
From page 44...
... SSA operating instructions provide an extensive list of recommended questions for field office staff conducting face-to-face interviews, but no such information is provided to medical professionals or persons providing lay evidence of capability. The form provided to the treating physician by the SSA field o ­ ffice (SSA-787; see Appendix C)
From page 45...
... 30. lay evidence, outlines the specific information necessary for a competency determination (OPM, 2013)
From page 46...
... DEVELOPING EVIDENCE AND DETERMINING CAPABILITY Social Security Administration SSA field offices and state DDS agencies both play a role in developing evidence of capability. DDS disability examiners are responsible for requesting medical records from all sources listed on the disability application and developing all medical evidence for a disability claim.
From page 47...
... As evidence of capability is developed during the initial determination stage, the discussion of SSA's process for determining financial capability focuses primarily on the SSA field office and the state DDS agency. However, it is important to note here that some individuals are determined to have a disability following appeal of the initial disability determination.
From page 48...
... •  What are the most important things to spend money on? Shelter The following questions provide essential information in determining the ability to meet basic daily needs, stability in living arrangements, and existing support network.
From page 49...
... If •  you ran out of food before your check came, what would you do? If Medical The following questions could provide essential information regarding the benefi ciary's ability to meet basic medical needs.
From page 50...
... . As noted above, if the medical evidence is unclear or unconvincing (i.e., is insufficient to make a competency determination)
From page 51...
...  concur with the incompetency determination and appoint a fiduciary; (2) conclude that the beneficiary is incompetent, but able to manage VA benefits with supervision (supervised direct payment)
From page 52...
... If you knowingly violate any amount as the Veterans Service Center Manager determines the veteran is able to manage with continuing supervision by the Veterans Service Center Manager, provided a fiduciary is not otherwise required."33 This option provides the beneficiary with greater autonomy in managing his or her benefits, and allows for an assessment of the beneficiary's performance 33  38 CFR 13.56.
From page 53...
... Office of Personnel Management Depending on the complexity of the case, a customer specialist (GS-7) , junior legal administrative specialist (GS-5 to GS-11)
From page 54...
... A customer specialist handles routine issues, such as cases for which there is a court order establishing that a representative payee is needed. For less clear-cut cases, a legal administrative specialist seeks out and assesses the necessary medical and lay evidence to make a decision concerning competency.
From page 55...
... Unlike SSA, the VA, and OPM, Service Canada has no formal appeals process for individuals who are deemed incapable, as "any decision by the Department regarding an appointment of a trustee for the purposes of administering CPP and/or OAS benefits is made under the Minister's discretion and is therefore not appealable" (Service Canada, 2015b, p.
From page 56...
... . It is not known how many beneficiaries with representative payees are determined to need a payee at the time of the initial determination versus some later time, as SSA does not collect data that differentiate new appointments from change-of-payee actions.38 The VA has a process for reviewing beneficiaries who have previously been rated incompetent.
From page 57...
... However, a unique aspect of the OPM program in this regard is its use of computerized matching; although such matching is primarily for analysis of benefit disbursement from other programs that may impact OPM benefits, it may also provide information that brings capability into question. All of the programs reviewed rely on some combination of legal, medical, and lay evidence, although the primary evidence relied upon for deter­ mining capability differs among organizations.
From page 58...
... professionals regarding capability. SSA operating instructions provide an extensive list of recommended questions for field office staff conducting face-to-face interviews, but no such information is provided to medical professionals or persons providing lay evidence of capability.
From page 59...
... Presentation to the Committee to Evaluate the Social Security Administration's Capability Determination Process for Adult Beneficiaries, February 3, Washington, DC. Service Canada.
From page 60...
... 2015e. GN 00502.020 Determining capability -- adult beneficiaries.
From page 61...
... : 59 million Pension: 300,000 Supplemental Security Income (SSI) : 8.3 million Beneficiaries with 8.7 million 177,000 16,000 N/A Representative OASDI: 5.6 million Payee SSI: 3.2 million Presumption of Yes Yes Yes Yes Capability Potential Triggers Beneficiary has difficulty 100 percent disability Correspondence from Contact from person for Questioning • answering questions rating for a mental someone familiar with familiar with Capability • getting evidence or condition beneficiary suggesting beneficiary, such as a information necessary to Finding of legal inability to manage affairs family member, friend, pursue the claim incompetence by a Information received in or neighbor • understanding explanations court response to surveys of and reporting instructions annuitants Beneficiary has mental or physical Information arising from impairment resulting in further inquiry into • severe disorientation nonresponse to survey, • severe impairment of intellect or survey returned as • gross deficit in judgment undeliverable • inability to communicate Computerized matching with other benefit programs 61 continued
From page 62...
... Combination of medical Lay (requires two affidavits and lay (Certificate from persons familiar with of Incapability form beneficiary) must be filled out by a medical professional -- other professional permitted in rare circumstances; queries for information on medical diagnosis, as well as on financial competence and performance)
From page 63...
... at ratings an appointment of a evidence by claims office collocated with trustee for the purposes representative not involved in fiduciary hub conducts of administering CPP original decision; face-to-face requested hearings, [Canada Pension Plan] interview may be requested to reviews original and and/or OAS [Old resolve any problems additional evidence, Age Security]
From page 64...
... ANNEX TABLE 2-1  Continued 64 U.S. Department of Office of Personnel Social Security Administration Veterans Affairs Management Service Canada Review No formal process for ongoing The VA field examiners Not specifically for Upon initial appointment review contact incompetent reevaluation of of trustee, staff "must May be reevaluated whenever beneficiaries every competency establish whether there is indication or evidence 1 to 3 years to Representative payee survey the case should be that incapable beneficiary has review both their administered every 2 reviewed at a later date become capable or capable incompetence ratings years to ensure benefits in order to determine beneficiary has become and their fiduciaries' expended in best interest if the condition of incapable performance of beneficiary; unclear the beneficiary has Staff must "consider reviewing"a Competency may also be whether information improved to the extent capability in specific reviewed any time new from this survey may that the trusteeship situations: medical evidence is trigger reevaluation of should be terminated"b • continuing disability reviews received; may include competency When beneficiary informs • SSI redeterminations evidence from department that he • discovery that a beneficiary • hospital summary or she has regained manages any other benefits • report of release to or capability • beneficiary appeal discharge from nonbed When trustee notifies • any other contact with the care department beneficiary beneficiary or payee that • report of other has regained capacity raises a question of capability material change in condition Upon receipt of evidence, Veterans Service Representative (VSR)
From page 65...
... to physicians and persons providing lay evidence Unique Aspects Supervised direct pay Uses computerized matching and Features with other benefits paying organizations, including SSA and the U.S. Department of Labor, to analyze benefit disbursement to federal employees that may impact OPM benefits; may provide information that brings capability into question a "‘Consider reviewing' doesn't necessarily mean conducting a full capability development.


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