[Title 20 CFR Q]
[Code of Federal Regulations (annual edition) - April 1, 1996 Edition]
[Title 20 - EMPLOYEES' BENEFITS]
[Chapter III - SOCIAL SECURITY ADMINISTRATION]
[Part 404 - FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )]
[Subpart Q - Determinations of Disability]
[From the U.S. Government Publishing Office]
20
EMPLOYEES' BENEFITS
2
1996-04-01
1996-04-01
false
Determinations of Disability
Q
Subpart Q
EMPLOYEES' BENEFITS
SOCIAL SECURITY ADMINISTRATION
FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- )
Subpart Q--Determinations of Disability
Sec. 404.1601 Purpose and scope.
This subpart describes the standards of performance and
administrative requirements and procedures for States making
determinations of disability for the Secretary under title II of the
Act. It also establishes the Secretary's responsibilities in carrying
out the disability determination function.
(a) Sections 404.1601 through 404.1603 describe the purpose of the
regulations and the meaning of terms frequently used in the regulations.
They also briefly set forth the responsibilities of the Secretary and
the States covered in detail in other sections.
(b) Sections 404.1610 through 404.1618 describe the Secretary's and
the State's responsibilities in performing the disability determination
function.
(c) Sections 404.1620 through 404.1633 describe the administrative
responsibilities and requirements of the States. The corresponding role
of the Secretary is also set out.
(d) Sections 404.1640 through 404.1650 describe the performance
accuracy and processing time standards for measuring State agency
performance.
(e) Sections 404.1660 through 404.1661 describe when and what kind
of assistance the Secretary will provide State agencies to help them
improve performance.
(f) Sections 404.1670 through 404.1675 describe the level of
performance below which the Secretary will consider a State agency to be
substantially failing to make disability determinations consistent with
the regulations and other written guidelines and the resulting action
the Secretary will take.
(g) Sections 404.1680 through 404.1683 describe the rules for
resolving disputes concerning fiscal issues and providing hearings when
we propose to find that a State is in substantial failure.
(h) Sections 404.1690 through 404.1694 describe when and what action
the Secretary will take and what action the State will be expected to
take if the Secretary assumes the disability determination function from
a State agency.
Sec. 404.1602 Definitions.
For purposes of this subpart:
Act means the Social Security Act, as amended.
[[Page 469]]
Class or classes of cases means the categories into which disability
claims are divided according to their characteristics.
Determination of disability or disability determination means one or
more of the following decisions:
(a) Whether or not a person is under a disability;
(b) The date a person's disability began; or
(c) The date a person's disability ended.
Disability means disability or blindness as defined in sections
216(i) and 223 of the Act or as defined in title IV of the Federal Mine
Safety and Health Act of 1977, as amended.
Disability determination function means making determinations as to
disability and carrying out related administrative and other
responsibilities.
Disability program means, as appropriate, the Federal programs for
providing disability insurance benefits under title II of the Act and
disability benefits under title IV of the Federal Mine Safety and Health
Act of 1977, as amended.
Initial means the first level of disability adjudication.
Other written guidelines means written issuances such as Social
Security Rulings and memoranda by the Commissioner of Social Security,
the Deputy Commissioner for Programs, or the Associate Commissioner for
Disability and the procedures, guides, and operating instructions in the
Disability Insurance sections of the Program Operations Manual System,
that are instructive, interpretive, clarifying, and/or administrative
and not designated as advisory or discretionary. The purpose of
including the foregoing material in the definition is to assure uniform
national application of program standards and service delivery to the
public.
Regulations means regulations in this subpart issued under sections
205(a), 221 and 1102 of the Act, unless otherwise indicated.
Secretary means the Secretary of the Department of Health and Human
Services or the Secretary's delegate.
State means any of the 50 States of the United States, the
Commonwealth of Puerto Rico, the District of Columbia, or Guam. It
includes the State agency.
State agency means that agency of a State which has been designated
by the State to carry out the disability determination function.
We, us, and our refers to the Social Security Administration (SSA)
or the Secretary, as appropriate.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11018, Mar. 14, 1991]
Sec. 404.1603 Basic responsibilities for us and the State.
(a) General. We will work with the State to provide and maintain an
effective system for processing claims of those who apply for and who
are receiving benefits under the disability program. We will provide
program standards, leadership, and oversight. We do not intend to become
involved in the State's ongoing management of the program except as is
necessary and in accordance with these regulations. The State will
comply with our regulations and other written guidelines.
(b) Our responsibilities. We will:
(1) Periodically review the regulations and other written guidelines
to determine whether they insure effective and uniform administration of
the disability program. To the extent feasible, we will consult with and
take into consideration the experience of the States in issuing
regulations and guidelines necessary to insure effective and uniform
administration of the disability program;
(2) Provide training materials or in some instances conduct or
specify training, see Sec. 404.1622;
(3) Provide funds to the State agency for the necessary cost of
performing the disability determination function, see Sec. 404.1626;
(4) Monitor and evaluate the performance of the State agency under
the established standards, see Secs. 404.1644 and 404.1645; and
(5) Maintain liaison with the medical profession nationally and with
national organizations and agencies whose interests or activities may
affect the disability program.
(c) Responsibilities of the State. The State will:
(1) Provide management needed to insure that the State agency
carries
[[Page 470]]
out the disability determination function so that disability
determinations are made accurately and promptly;
(2) Provide an organizational structure, adequate facilities,
qualified personnel, medical consultant services, and a quality
assurance function (Secs. 404.1620 through 404.1624);
(3) Furnish reports and records relating to the administration of
the disability program (Sec. 404.1625);
(4) Submit budgets (Sec. 404.1626);
(5) Cooperate with audits (Sec. 404.1627);
(6) Insure that all applicants for and recipients of disability
benefits are treated equally and courteously;
(7) Be responsible for property used for disability program purposes
(Sec. 404.1628);
(8) Take part in the research and demonstration projects
(Sec. 404.1629);
(9) Coordinate with other agencies (Sec. 404.1630);
(10) Safeguard the records created by the State in performing the
disability determination function (Sec. 404.1631);
(11) Comply with other provisions of the Federal law and regulations
that apply to the State in performing the disability determination
function;
(12) Comply with other written guidelines (Sec. 404.1633);
(13) Maintain liaison with the medical profession and organizations
that may facilitate performing the disability determination function;
and
(14) Assist us in other ways that we determine may promote the
objectives of effective and uniform administration.
Responsibilities for Performing the Disability Determination Function
Sec. 404.1610 How a State notifies us that it wishes to perform the disability determination function.
(a) Deemed notice. Any State that has in effect as of June 1, 1981,
an agreement with us to make disability determinations will be deemed to
have given us notice that it wishes to perform the disability
determination function, in lieu of continuing the agreement in effect
after June 1, 1981.
(b) Written notice. After June 1, 1981, a State not making
disability determinations that wishes to perform the disability
determination function under these regulations must notify us in
writing. The notice must be from an official authorized to act for the
State for this purpose. The State will provide an opinion from the
State's Attorney General verifying the authority of the official who
sent the notice to act for the State.
Sec. 404.1611 How we notify a State whether it may perform the disability determination function.
(a) If a State notifies us in writing that it wishes to perform the
disability determination function, we will notify the State in writing
whether or not it may perform the function. The State will begin
performing the disability determination function beginning with the
month we and the State agree upon.
(b) If we have previously found that a State agency has
substantially failed to make disability determinations in accordance
with the law or these regulations and other written guidelines or if the
State has previously notified us in writing that it does not wish to
make disability determinations, the notice will advise the State whether
the State agency may again make the disability determinations and, if
so, the date and the conditions under which the State may again make
them.
Sec. 404.1613 Disability determinations the State makes.
(a) General rule. A State agency will make determinations of
disability with respect to all persons in the State except those
individuals whose cases are in a class specifically excluded by our
written guidelines. A determination of disability made by the State is
the determination of the Secretary, except as described in
Sec. 404.1503(d)(1).
(b) New classes of cases. Where any new class or classes of cases
arise requiring determinations of disability, we will determine the
conditions under which a State may choose not to make the disability
determinations. We will provide the State with the necessary funding to
do the additional work.
(c) Temporary transfer of classes of cases. We will make disability
determinations for classes of cases temporarily transferred to us by the
State agency if the State agency asks us to do so and we agree. The
State agency
[[Page 471]]
will make written arrangements with us which will specify the period of
time and the class or classes of cases we will do.
Sec. 404.1614 Responsibilities for obtaining evidence to make disability determinations.
(a) The State agency will secure from the claimant, or other
sources, any evidence it needs to make a disability determination.
(b) We will secure from the claimant or other special arrangement
sources, any evidence we can obtain as adequately and more readily than
the State agency. We will furnish the evidence to the State agency for
use in making a disability determination.
(c) At our request, the State agency will obtain and furnish medical
or other evidence and provide assistance as may be necessary for us to
carry out our responsibilities--
(1) For making disability determinations in those classes of cases
described in the written guidelines for which the State agency does not
make the determination; or
(2) Under international agreements with respect to social security
benefits payable under section 233 of the Act.
Sec. 404.1615 Making disability determinations.
(a) When making a disability determination, the State agency will
apply subpart P, part 404, of our regulations.
(b) The State agency will make disability determinations based only
on the medical and nonmedical evidence in its files.
(c) Disability determinations will be made by either:
(1) A State agency medical or psychological consultant and a State
agency disability examiner;
(2) A State agency disability examiner alone when there is no
medical evidence to be evaluated (i.e., no medical evidence exists or we
are unable, despite making every reasonable effort, to obtain any
medical evidence that may exist) and the individual fails or refuses,
without a good reason, to attend a consultative examination (see
Sec. 404.1518); or
(3) A State agency disability hearing officer.
See Sec. 404.1616 for the definition of medical or psychological
consultant and Sec. 404.915 for the definition of disability hearing
officer. The State agency disability examiner and disability hearing
officer must be qualified to interpret and evaluate medical reports and
other evidence relating to the claimant's physical or mental impairments
and as necessary to determine the capacities of the claimant to perform
substantial gainful activity.
See Sec. 404.1572 for what we mean by substantial gainful activity.
(d) An initial determination by the State agency that an individual
is not disabled, in any case where there is evidence which indicates the
existence of a mental impairment, will be made only after every
reasonable effort has been made to ensure that a qualified psychiatrist
or psychologist has completed the medical portion of the case review and
any applicable residual functional capacity assessment. (See
Sec. 404.1616 for the qualifications we consider necessary for a
psychologist to be a psychological consultant and Sec. 404.1617 for what
we mean by ``reasonable effort''.) If the services of qualified
psychiatrists or psychologists cannot be obtained because of impediments
at the State level, the Secretary may contract directly for the
services. In a case where there is evidence of mental and nonmental
impairments and a qualified psychologist serves as a psychological
consultant, the psychologist will evaluate only the mental impairment,
and a physician will evaluate the nonmental impairment. The overall
determination of impairment severity in combined mental and nonmental
impairment cases will be made by a medical consultant and not a
psychological consultant unless the mental impairment alone would
justify a finding of disability.
(e) The State agency will certify each determination of disability
to us on forms we provide.
(f) The State agency will furnish us with all the evidence it
considered in making its determination.
(g) The State agency will not be responsible for defending in court
any determination made, or any procedure for
[[Page 472]]
making determinations, under these regulations.
[52 FR 33926, Sept. 9, 1987, as amended at 56 FR 11018, Mar. 14, 1991;
61 FR 11135, Mar. 19, 1996]
Effective Date Note: At 61 FR 11135, Mar. 19, 1996, Sec. 404.1615
was amended by removing the ``or'' at the end of paragraph (c)(1), by
adding a semicolon after paragraph (c)(1), by redesignating paragraph
(c)(2) as paragraph (c)(3), and by adding a new paragraph (c)(2),
effective April 18, 1996.
Sec. 404.1616 Medical or psychological consultant.
A medical consultant must be a physician. A psychological consultant
used in cases where there is evidence of a mental impairment must be a
qualified psychologist. For disability program purposes a psychologist
will not be considered qualified unless he or she:
(a) Is licensed or certified as a psychologist at the independent
practice level of psychology by the State in which he or she practices;
and
(b) (1) Possesses a doctorate degree in psychology from a program in
clinical psychology of an educational institution accredited by an
organization recognized by the Council on Post-Secondary Accreditation;
or
(2) Is listed in a national register of health service providers in
psychology which the Secretary of Health and Human Services deems
appropriate; and
(c) Possesses 2 years of supervised clinical experience as a
psychologist in health service, at least 1 year of which is post masters
degree.
[52 FR 33927, Sept. 9, 1987]
Sec. 404.1617 Reasonable efforts to obtain review by a qualified psychiatrist or psychologist.
(a) The State agency must determine if additional qualified
psychiatrists and psychologists are needed to make the necessary reviews
(see Sec. 404.1615(d)). Where it does not have sufficient resources to
make the necessary reviews, the State agency must attempt to obtain the
resources needed. If the State agency is unable to obtain additional
psychiatrists and psychologists because of low salary rates or fee
schedules it should attempt to raise the State agency's levels of
compensation to meet the prevailing rates for psychiatrists' and
psychologists' services. If these efforts are unsuccessful, the State
agency will seek assistance from us. We will assist the State agency as
necessary. We will also monitor the State agency's efforts and where the
State agency is unable to obtain the necessary services, we will make
every reasonable effort to provide the services using Federal resources.
(b) Federal resources may include the use of Federal contracts for
the services of qualified psychiatrists and psychologists to review
mental impairment cases. Where Federal resources are required to perform
these reviews, which are a basic State agency responsibility, and where
appropriate, the State agency's budget will be reduced accordingly.
(c) Where every reasonable effort is made to obtain the services of
a qualified psychiatrist or psychologist to review a mental impairment
case, but the professional services are not obtained, a physician who is
not a psychiatrist will review the mental impairment case. For these
purposes, every reasonable effort to ensure that a qualified
psychiatrist or psychologist review mental impairment cases will be
considered to have been made only after efforts by both State and
Federal agencies as set forth in paragraphs (a) and (b) of this section
are made.
[52 FR 33927, Sept. 9, 1987]
Sec. 404.1618 Notifying claimants of the disability determination.
The State agency will prepare denial notices in accordance with
subpart J of this part whenever it makes a disability determination
which is wholly or partly unfavorable to the claimant.
Administrative Responsibilities and Requirements
Sec. 404.1620 General administrative requirements.
(a) The State will provide the organizational structure, qualified
personnel, medical consultant services, and a quality assurance function
sufficient to ensure that disability determinations are made accurately
and promptly. We may impose specific administrative requirements in
these areas and in those
[[Page 473]]
under ``Administrative Responsibilities and Requirements'' in order to
establish uniform, national administrative practices or to correct the
areas of deficiencies which may later cause the State to be
substantially failing to comply with our regulations or other written
guidelines. We will notify the State, in writing, of the administrative
requirements being imposed and of any administrative deficiencies it is
required to correct. We will allow the State 90 days from the date of
this notice to make appropriate corrections. Once corrected, we will
monitor the State's administrative practices for 180 days. If the State
does not meet the requirements or correct all of the deficiencies, or,
if some of the deficiencies recur, we may initiate procedures to
determine if the State is substantially failing to follow our
regulations or other written guidelines.
(b) The State is responsible for making accurate and prompt
disability determinations.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11018, Mar. 14, 1991]
Sec. 404.1621 Personnel.
(a) Equal employment opportunity. The State will comply with all
applicable Federal statutes, executive orders and regulations concerned
with equal employment opportunities.
(b) Selection, tenure, and compensation. The State agency will,
except as may be inconsistent with paragraph (a) of this section, adhere
to applicable State approved personnel standards in the selection,
tenure, and compensation of any individual employed in the disability
program.
(c) Travel. The State will make personnel available to attend
meetings or workshops as may be sponsored or approved by us for
furthering the purposes of the disability program.
(d) Restrictions. Subject to appropriate Federal funding, the State
will, to the best of its ability, facilitate the processing of
disability claims by avoiding personnel freezes, restrictions against
overtime work, or curtailment of facilities or activities.
Sec. 404.1622 Training.
The State will insure that all employees have an acceptable level of
competence. We will provide training and other instructional materials
to facilitate basic and advanced technical proficiency of disability
staff in order to insure uniformity and effectiveness in the
administration of the disability program. We will conduct or specify
training, as appropriate, but only if:
(a) A State agency's performance approaches unacceptable levels; or
(b) The material required for the training is complex or the
capacity of the State to deliver the training is in doubt and uniformity
of the training is essential.
Sec. 404.1623 Facilities.
(a) Space, equipment, supplies, and other services. Subject to
appropriate Federal funding, the State will provide adequate space,
equipment, supplies, and other services to facilitate making accurate
and prompt disability determinations.
(b) Location of facilities. Subject to appropriate Federal funding,
the State will determine the location where the disability determination
function is to be performed so that disability determinations are made
accurately and promptly.
(c) Access. The State will permit us access to the premises where
the disability determination function is performed and also where it is
managed for the purposes of inspecting and obtaining information about
the work and activities required by our regulations and assuring
compliance with pertinent Federal statutes and regulations. Access
includes personal onsite visits and other means, such as
telecommunications, of contacting the State agency to obtain information
about its functions. We will contact the State agency and give
reasonable prior notice of the times and purposes of any visits.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11019, Mar. 14, 1991]
Sec. 404.1624 Medical and other purchased services.
The State will determine the rates of payment to be used for
purchasing medical or other services necessary to make determinations of
disability. The rates may not exceed the highest rate paid by Federal or
other agencies in
[[Page 474]]
the State for the same or similar type of service. The State will
maintain documentation to support the rates of payment it uses.
Sec. 404.1625 Records and reports.
(a) The State will establish and maintain the records and furnish
the schedules, financial, cost, and other reports relating to the
administration of the disability programs as we may require.
(b) The State will permit us and the Comptroller General of the
United States (including duly authorized representatives) access to and
the right to examine records relating to the work which the State
performs under these regulations. These records will be retained by the
State for the periods of time specified for retention of records in the
Federal Procurement Regulations (41 CFR parts 1-20).
Sec. 404.1626 Fiscal.
(a) We will give the State funds, in advance or by way of
reimbursement, for necessary costs in making disability determinations
under these regulations. Necessary costs are direct as well as indirect
costs as defined in 41 CFR part 1-15, subpart 1-15.7 of the Federal
Procurement Regulations System for costs incurred before April 1, 1984;
and 48 CFR part 31, subpart 31.6 of the Federal Acquisition Regulations
System and Federal Management Circular A-74-4 \1\ as amended or
superseded for costs incurred after March 31, 1984.
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\1\ The circular is available from the Office of Administration,
Publications Unit, Rm. G-236, New Executive Office Bldg., Washington, DC
20503.
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(b) The State will submit estimates of anticipated costs in the form
of a budget at the time and in the manner we require.
(c) We will notify the State of the amount which will be made
available to it as well as what anticipated costs are being approved.
(d) The State may not incur or make expenditures for items of cost
not approved by us or in excess of the amount we make available to the
State.
(e) After the close of a period for which funds have been made
available to the State, the State will submit a report of its
expenditures. Based on an audit arranged by the State under Pub. L. 98-
502, the Single Audit Act of 1984, or by the Inspector General of the
Department of Health and Human Services or based on an audit or review
by the Social Security Administration (see Sec. 404.1627), we will
determine whether the expenditures were consistent with cost principles
described in 41 CFR part 1-15, subpart 1-15.7 for costs incurred before
April 1, 1984; and 48 CFR part 31, subpart 31.6 and Federal Management
Circular A-741-4 for costs incurred after March 31, 1984: and in other
applicable written guidelines in effect at the time the expenditures
were made or incurred.
(f) Any monies paid to the State which are used for purposes not
within the scope of these regulations will be paid back to the Treasury
of the United States.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11019, Mar. 14, 1991]
Sec. 404.1627 Audits.
(a) Audits performed by the State--(1) Generally. Audits of accounts
and records pertaining to the administration of the disability program
under the Act, will be performed by the States in accordance with the
Single Audit Act of 1984 (Pub. L. 98-502) which establishes audit
requirements for States receiving Federal assistance. If the audit
performed by the State meets our program requirements, we will accept
the findings and recommendations of the audit. The State will make every
effort to act upon and resolve any items questioned in the audit.
(2) Questioned items. Items questioned as a result of an audit under
the Single Audit Act of 1984 of a cross-cutting nature will be resolved
by the Department of Health and Human Services, Office of Grant and
Contract Financial Management. A cross-cutting issue is one that
involves more than one Federal awarding agency. Questioned items
affecting only the disability program will be resolved by SSA in accord
with paragraph (b)(2) of this section,
(3) State appeal of audit determinations. The Office of Grant and
Contract Financial Management will notify the State of its determination
on questioned cross-cutting items. If the State
[[Page 475]]
disagrees with that determination, it may appeal in writing within 60
days of receiving the determination. State appeals of a cross-cutting
issue as a result of an audit under the Single Audit Act of 1984 will be
made to the Department of Health and Human Services' Departmental
Appeals Board. The rules for hearings and appeals are provided in 45 CFR
part 16.
(b) Audits performed by the Secretary--(1) Generally. If the State
does not perform an audit under the Single Audit Act of 1984 or the
audit performed is not satisfactory for disability program purposes, the
books of account and records in the State pertaining to the
administrations of the disability programs under the Act will be audited
by the Department of Health and Human Services' Inspector General or
audited or reviewed by SSA as appropriate. These audits or reviews will
be conducted to determine whether the expenditures were made for the
intended purposes and in amounts necessary for the proper and efficient
administration of the disability programs. Audits or reviews will also
be made to inspect the work and activities required by the regulations
to ensure compliance with pertinent Federal statutes and regulations.
The State will make every effort to act upon and resolve any items
questioned in an audit or review.
(2) Questioned items. Expenditures of State agencies will be audited
or reviewed, as appropriate, on the basis of cost principles and written
guidelines in effect at the time the expenditures were made or incurred.
Both the State and the State agency will be informed and given a full
explanation of any items questioned. They will be given reasonable time
to explain items questioned. Any explanation furnished by the State or
State agency will be given full consideration before a final
determination is made on the audit or review report.
(3) State appeal of audit determinations. The appropriate Social
Security Administration Regional Commissioner will notify the State of
his or her determination on the audit or review report. If the State
disagrees with that determination, the State may request reconsideration
in writing within 60 days of the date of the Regional Commissioner's
notice of the determination. The written request may be made, through
the Associate Commissioner, Office of Disability, to the Commissioner of
Social Security, room 900, Altmeyer Building, 6401 Security Boulevard,
Baltimore, Maryland 21235. The Commissioner will make a determination
and notify the State of the decision in writing no later than 90 days
from the date the Social Security Administration receives the State's
appeal and all supporting documents. The decision by the Commissioner on
other than monetary disallowances will be final and binding upon the
State. The decision by the Commissioner on monetary disallowances will
be final and binding upon the State unless the State appeals the
decision in writing to the Department of Health and Human Services,
Departmental Appeals Board within 30 days after receiving the
Commissioner's decision. See Sec. 404.1683.
[56 FR 11019, Mar. 14, 1991]
Sec. 404.1628 Property.
The State will have title to equipment purchased for disability
program purposes. The State will be responsible for maintaining all
property it acquires or which we furnish to it for performing the
disability determination function. The State will identify the equipment
by labeling and by inventory and will credit the SSA account with the
fair market value of disposed property.
In the event we assume the disability determination function from a
State, ownership of all property and equipment acquired with SSA funds
will be transferred to us effective on the date the State is notified
that we are assuming the disability determination function or we are
notified that the State is terminating the relationship.
Sec. 404.1629 Participation in research and demonstration projects.
We will invite State participation in federally funded research and
demonstration projects to assess the effectiveness of the disability
program and to ascertain the effect of program policy changes. Where we
determine that State participation is necessary for the project to be
complete, for example, to provide national uniformity in a
[[Page 476]]
claims process, State participation is mandatory.
Sec. 404.1630 Coordination with other agencies.
(a) The State will establish cooperative working relationships with
other agencies concerned with serving the disabled and, insofar as
practicable, use their services, facilities, and records to:
(1) Assist the State in developing evidence and making
determinations of disability; and
(2) Insure that referral of disabled or blind persons for
rehabilitation services will be carried out effectively.
(b) The State may pay these agencies for the services, facilities,
or records they provide. The State will include these costs in its
estimates of anticipated costs and reports of actual expenditures.
Sec. 404.1631 Confidentiality of information and records.
The State will comply with the confidentiality of information,
including the security of systems, and records requirements described in
20 CFR part 401 and pertinent written guidelines (see Sec. 404.1633).
Sec. 404.1632 Other Federal laws and regulations.
The State will comply with the provisions of other Federal laws and
regulations that directly affect its responsibilities in carrying out
the disability determination function; for example, Treasury Department
regulations on letters of credit (31 CFR part 205).
Sec. 404.1633 Policies and operating instructions.
(a) We will provide the State agency with written guidelines
necessary for it to carry out its responsibilities in performing the
disability determination function.
(b) The State agency making determinations of disability will comply
with our written guidelines that are not designated as advisory or
discretionary. (See Sec. 404.1602 for what we mean by written
guidelines.)
(c) A representative group of State agencies will be given an
opportunity to participate in formulating disability program policies
that have an affect on their role in carrying out the disability
determination function. State agencies will also be given an opportunity
to comment before changes are made in written guidelines unless delay in
issuing a change may impair service to the public.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11020, Mar. 14, 1991]
Performance Standards
Sec. 404.1640 General.
The following sections provide the procedures and guidelines we use
to determine whether the State agency is substantially complying with
our regulations and other written guidelines, including meeting
established national performance standards. We use performance standards
to help assure effective and uniform administration of our disability
programs and to measure whether the performance of the disability
determination function by each State agency is acceptable. Also, the
standards are designed to improve overall State agency performance in
the disability determination process and to ensure that benefits are
made available to all eligible persons in an accurate and efficient
manner. We measure the performance of a State agency in two areas--
processing time and quality of documentation and decisions on claims.
State agency compliance is also judged by State agency adherence to
other program requirements.
[56 FR 11020, Mar. 14, 1991]
Sec. 404.1641 Standards of performance.
(a) General. The performance standards include both a target level
of performance and a threshold level of performance for the State
agency. The target level represents a level of performance that we and
the States will work to attain in the future. The threshold level is the
minimum acceptable level of performance. Performance below the threshold
level will be the basis for the Secretary's taking from the State agency
partial or complete
[[Page 477]]
responsibility for performing the disability determination function.
Intermediate State agency goals are designed to help each State agency
move from its current performance levels to the target levels.
(b) The target level. The target level is the optimum level of
performance. There are three targets--one for combined title II and
title XVI initial performance accuracy, one for title II initial
processing time, and one for title XVI initial processing time.
(c) The threshold level. The threshold level is the minimum
acceptable level of performance. There are three thresholds--one for
combined title II and title XVI initial performance accuracy, one for
title II initial processing time, and one for title XVI initial
processing time.
(d) Intermediate goals. Intermediate goals are levels of performance
between the threshold levels and the target levels established by our
appropriate Regional Commissioner after negotiation with each State
agency. The intermediate goals are designed to help the State agencies
reach the target levels. Failure to meet these goals is not a cause for
considering the State agency to be substantially failing to comply with
the performance standards. However, failure to meet the intermediate
goals may result in consultation and an offer of optional performance
support depending on the availability of our resources.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11020, Mar. 14, 1991]
Sec. 404.1642 Processing time standards.
(a) General. Title II processing time refers to the average number
of days, including Saturdays, Sundays, and holidays, it takes a State
agency to process an initial disability claim from the day the case
folder is received in the State agency until the day it is released to
us by the State agency. Title XVI processing time refers to the average
number of days, including Saturdays, Sundays, and holidays, from the day
of receipt of the initial disability claim in the State agency until
systems input of a presumptive disability decision or the day the case
folder is released to us by the State agency, whichever is earlier.
(b) Target levels. The processing time target levels are:
(1) 37 days for title II initial claims.
(2) 43 days for title XVI initial claims.
(c) Threshold levels. The processing time threshold levels are:
(1) 49.5 days for title II initial claims.
(2) 57.9 days for title XVI initial claims.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11020, Mar. 14, 1991]
Sec. 404.1643 Performance accuracy standard.
(a) General. Performance accuracy refers to the percentage of cases
that do not have to be returned to State agencies for further
development or correction of decisions based on evidence in the files
and as such represents the reliability of State agency adjudication. The
definition of performance accuracy includes the measurement of factors
that have a potential for affecting a decision, as well as the
correctness of the decision. For example, if a particular item of
medical evidence should have been in the file but was not included, even
though its inclusion does not change the result in the case, that is a
performance error. Performance accuracy, therefore, is a higher standard
than decisional accuracy. As a result, the percentage of correct
decisions is significantly higher than what is reflected in the error
rate established by SSA's quality assurance system.
(b) Target level. The State agency initial performance accuracy
target level for combined title II and title XVI cases is 97 percent
with a corresponding decision accuracy rate of 99 percent.
(c) Intermediate Goals. These goals will be established annually by
SSA's regional commissioner after negotiation with the State and should
be used as stepping stones to progress towards our targeted level of
performance.
(d) Threshold levels. The State agency initial performance accuracy
threshold level for combined title II and title XVI cases is 90.6
percent.
[[Page 478]]
Sec. 404.1644 How and when we determine whether the processing time standards are met.
(a) How we determine processing times. For all initial title II
cases, we calculate the mean number of days, including Saturdays,
Sundays and holidays, from the day the case folder is received in the
State agency until the day it is released to us by the State agency. For
initial title XVI cases, we calculate the mean number of days, including
Saturdays, Sundays, and holidays, from the day the case folder is
received in the State agency until the day there is a systems input of a
presumptive disability decision or the day the case folder is released
to us by the State agency, whichever is earlier.
(b) Frequency of review. Title II processing times and title XVI
processing times are monitored separately on a quarterly basis. The
determination as to whether or not the processing time thresholds have
been met is made at the end of each quarter each year. Quarterly State-
by-State mean processing times are compared with the threshold levels
for both title II and title XVI.
[46 FR 29204, May 29, 1981, as amended at 56 FR 11020, Mar. 14, 1991]
Sec. 404.1645 How and when we determine whether the performance accuracy standard is met.
(a) How we determine performance accuracy. We determine a State
agency's performance accuracy rate on the basis of decision and
documentation errors identified in our review of the sample cases.
(b) Frequency of review. Title II and title XVI initial performance
accuracy are monitored together on a quarterly basis. The determinations
as to whether the performance accuracy threshold has been met is made at
the end of each quarter each year. Quarterly State-by-State combined
initial performance accuracy rates are compared to the established
threshold level.
Sec. 404.1650 Action we will take if a State agency does not meet the standards.
If a State agency does not meet two of the three established
threshold levels (one of which must be performance accuracy) for two or
more consecutive calendar quarters, we will notify the State agency in
writing that it is not meeting the standards. Following our
notification, we will provide the State agency appropriate performance
support described in Secs. 404.1660, 404.1661 and 404.1662 for a period
of up to 12 months.
[56 FR 11020, Mar. 14, 1991]
Performance Monitoring and Support
Sec. 404.1660 How we will monitor.
We will regularly analyze State agency combined title II and title
XVI initial performance accuracy rate, title II initial processing time,
and title XVI initial processing time. Within budgeted resources, we
will also routinely conduct fiscal and administrative management reviews
and special onsite reviews. A fiscal and administrative management
review is a fact-finding mission to review particular aspects of State
agency operations. During these reviews we will also review the quality
assurance function. This regular monitoring and review program will
allow us to determine the progress each State is making and the type and
extent of performance support we will provide to help the State progress
toward threshold, intermediate, and/or target levels.
[56 FR 11020, Mar. 14, 1991]
Sec. 404.1661 When we will provide performance support.
(a) Optional support. We may offer, or a State may request,
performance support at any time that the regular monitoring and review
process reveals that support could enhance performance. The State does
not have to be below the initial performance accuracy rate of 90.6
percent to receive performance support. Support will be offered, or
granted upon request, based on available resources.
(b) Mandatory support. (1) We will provide a State agency with
mandatory performance support if regular monitoring and review reveal
that two of three threshold levels (one of which must be performance
accuracy) are not met for two consecutive calendar quarters.
[[Page 479]]
(2) We may also decide to provide a State agency with mandatory
performance support if regular monitoring and review reveal that any one
of the three threshold levels is not met for two consecutive calendar
quarters. Support will be provided based on available resources.
(3) The threshold levels are:
(i) Combined title II and title XVI initial performance accuracy
rate--90.6 percent,
(ii) Title II initial processing time--49.5 days, and
(iii) Title XVI initial processing time--57.9 days.
[56 FR 11020, Mar. 14, 1991]
Sec. 404.1662 What support we will provide.
Performance support may include, but is not limited to, any or all
of the following:
(a) An onsite review of cases processed by the State agency
emphasizing adherence to written guidelines.
(b) A request that necessary administrative measures be implemented
(e.g., filling staffing vacancies, using overtime, assisting with
training activities, etc.).
(c) Provisions for Federal personnel to perform onsite reviews,
conduct training, or perform other functions needed to improve
performance.
(d) Provisions for fiscal aid to allow for overtime, temporary
hiring of additional staff, etc., above the authorized budget.
[56 FR 11020, Mar. 14, 1991]
Substantial Failure
Sec. 404.1670 General.
After a State agency falls below two of three established threshold
levels, one being performance accuracy, for two consecutive quarters,
and after the mandatory performance support period, we will give the
State agency a 3-month adjustment period. During this 3-month period we
will not require the State agency to meet the threshold levels.
Following the adjustment period, if the State agency again falls below
two of three threshold levels, one being performance accuracy, in two
consecutive quarters during the next 12 months, we will notify the State
that we propose to find that the State agency has substantially failed
to comply with our standards and advise it that it may request a hearing
on that issue. After giving the State notice and an opportunity for a
hearing, if it is found that a State agency has substantially failed to
make disability determinations consistent with the Act, our regulations
or other written guidelines, we will assume partial or complete
responsibility for performing the disability determination function
after we have complied with Secs. 404.1690 and 404.1692.
[56 FR 11021, Mar. 14, 1991]
Sec. 404.1671 Good cause for not following the Act, our regulations, or other written guidelines.
If a State has good cause for not following the Act, our
regulations, or other written guidelines, we will not find that the
State agency has substantially failed to meet our standards. We will
determine if good cause exists. Some of the factors relevant to good
cause are:
(a) Disasters such as fire, flood, or civil disorder, that--
(1) Require the diversion of significant personnel normally assigned
to the disability determination function, or
(2) Destroyed or delayed access to significant records needed to
make accurate disability determinations;
(b) Strikes of State agency staff or other government or private
personnel necessary to the performance of the disability determination
function;
(c) Sudden and unanticipated workload changes which result from
changes in Federal law, regulations, or written guidelines, systems
modification or systems malfunctions, or rapid, unpredictable caseload
growth for a 6-month period or longer.
[56 FR 11021, Mar. 14, 1991]
Sec. 404.1675 Finding of substantial failure.
A finding of substantial failure with respect to a State may not be
made unless and until the State is afforded an opportunity for a
hearing.
[[Page 480]]
Hearings and Appeals
Sec. 404.1680 Notice of right to hearing on proposed finding of substantial failure.
If, following the mandatory performance support period and the 3-
month adjustment period, a State agency again falls below two of three
threshold levels (one being performance accuracy) in two consecutive
quarters in the succeeding 12 months, we will notify the State in
writing that we will find that the State agency has substantially failed
to meet our standards unless the State submits a written request for a
hearing with the Department of Health and Human Services' Departmental
Appeals Board within 30 days after receiving the notice. The notice will
identify the threshold levels that were not met by the State agency, the
period during which the thresholds were not met and the accuracy and
processing time levels attained by the State agency during this period.
If a hearing is not requested, the State agency will be found to have
substantially failed to meet our standards, and we will implement our
plans to assume the disability determination function.
[56 FR 11021, Mar. 14, 1991]
Sec. 404.1681 Disputes on matters other than substantial failure.
Disputes concerning monetary disallowances will be resolved in
proceedings before the Department of Health and Human Services'
Departmental Appeals Board if the issue cannot be resolved between us
and the State. Disputes other than monetary disallowances will be
resolved through an appeal to the Commissioner of Social Security, who
will make the final decision. (See Sec. 404.1627.)
[56 FR 11021, Mar. 14, 1991]
Sec. 404.1682 Who conducts the hearings.
If a hearing is required, it will be conducted by the Health and
Human Services Departmental Grant Appeals Board (the Board).
Sec. 404.1683 Hearings and appeals process.
The rules for hearings and appeals before the Board are provided in
45 CFR part 16. A notice under Sec. 404.1680 of this subpart will be
considered a ``final written decision'' for purposes of Board review.
Assumption of Disability Determination Function
Sec. 404.1690 Assumption when we make a finding of substantial failure.
(a) Notice to State. When we find that substantial failure exists,
we will notify the State in writing that we will assume responsibility
for performing the disability determination function from the State
agency, whether the assumption will be partial or complete, and the date
on which the assumption will be effective.
(b) Effective date of assumption. The date of any partial or
complete assumption of the disability determination function from a
State agency may not be earlier than 180 days after our finding of
substantial failure, and not before compliance with the requirements of
Sec. 404.1692.
Sec. 404.1691 Assumption when State no longer wishes to perform the disability determination function.
(a) Notice to the Secretary. If a State no longer wishes to perform
the disability determination function, it will notify us in writing. The
notice must be from an official authorized to act for the State for this
purpose. The State will provide an opinion from the State's Attorney
General verifying the authority of the official who gave the notice.
(b) Effective date of assumption. The State agency will continue to
perform whatever activities of the disability determination function it
is performing at the time the notice referred to in paragraph (a) of
this section is given for not less than 180 days or, if later, until we
have complied with the requirements of Sec. 404.1692. For example, if
the State is not making disability determinations (because we previously
assumed responsibility for making them) but is performing other
activities related to the disability determination function at the time
it gives notice, the State will continue to do these activities until
the requirements of this paragraph are met. Thereafter, we will assume
complete responsibility
[[Page 481]]
for performing the disability determination function.
Sec. 404.1692 Protection of State employees.
(a) Hiring preference. We will develop and initiate procedures to
implement a plan to partially or completely assume the disability
determination function from the State agency under Sec. 404.1690 or
Sec. 404.1691, as appropriate. Except for the State agency's
administrator, deputy administrator, or assistant administrator (or his
equivalent), we will give employees of the State agency who are capable
of performing duties in the disability determination function preference
over any other persons in filling positions with us for which they are
qualified. We may also give a preference in hiring to the State agency's
administrator, deputy administrator, or assistant administrator (or his
equivalent). We will establish a system for determining the hiring
priority among the affected State agency employees in those instances
where we are not hiring all of them.
(b) Determination by Secretary of Labor. We will not assume
responsibility for performing the disability determination function from
a State until the Secretary of Labor determines that the State has made
fair and equitable arrangements under applicable Federal, State and
local law to protect the interests of employees who will be displaced
from their employment because of the assumption and who we will not
hire.
Sec. 404.1693 Limitation on State expenditures after notice.
The State agency may not, after it receives the notice referred to
in Sec. 404.1690, or gives the notice referred to in Sec. 404.1691, make
any new commitments to spend funds allocated to it for performing the
disability determination function without the approval of the
appropriate SSA regional commissioner. The State will make every effort
to close out as soon as possible all existing commitments that relate to
performing the disability determination function.
Sec. 404.1694 Final accounting by the State.
The State will submit its final claims to us as soon as possible,
but in no event later than 1 year from the effective date of our
assumption of the disability determination function unless we grant an
extension of time. When the final claim(s) is submitted, a final
accounting will be made by the State of any funds paid to the State
under Sec. 404.1626 which have not been spent or committed prior to the
effective date of our assumption of the disability determination
function. Disputes concerning final accounting issues which cannot be
resolved between the State and us will be resolved in proceedings before
the Grant Appeals Board as described in 45 CFR part 16.