I-5-4-30-C.Processing Supplemental Security Income Childhood Disability Continuing Disability Review (CDR) Cases Based on Public Law (Pub. L.) 104-193

Table of Contents
I Purpose
II Background
III The CDR Evaluation Process - Title XVI Child — Flow Chart
IV Hearing Office Procedures
V Appeals Council Procedures
VI Inquiries
Attachment 1 Sample Language When Claimant Had a Hearing On The Issue of Cessation Before Enactment of Public Law No. 104-193
Attachment 2 Sample Language When Claimant Had a Hearing On The Issue of Cessation Before Enactment of Public Law No. 104-193

ISSUED: June 19, 1998

I. Purpose

Pursuant to Public Law (Pub. L.) 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, SSA issued regulations to implement revisions to the medical improvement review standard (MIRS) as it applies to title XVI childhood disability cases. This HALLEX instruction contains procedures for processing title XVI childhood continuing disability review (CDR) cases at the Administrative Law Judge and Appeals Council levels of the administrative review process.

NOTE:

In a memorandum to OHA adjudicators dated April 3, 1998, the Associate Commissioner for Hearings and Appeals transmitted procedures for processing title XVI childhood disability CDR cases. This Temporary Instruction incorporates those procedures into HALLEX and replaces the prior memorandum and instructions.

II. Background

Effective August 22, 1996, Pub. L. 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, provided a new statutory definition of disability for children claiming Supplemental Security Income (SSI) benefits based on disability, mandated elimination of the IFA and changes to certain aspects of the mental disorders listings for children, and made corresponding changes to the MIRS as it applies to children claiming SSI benefits based on disability. The interim final regulations implementing these statutory changes (published February 11, 1997) require a different CDR evaluation sequence for title XVI children than for title II and adult title XVI beneficiaries. The CDR sequential evaluation process is set out in 20 CFR § 416.994a. In addition, a correction to the codification of section 416.994a, as it appears in the April 1, 1997 edition of 20 CFR, Parts 400-499, was published in the Federal Register on July 8, 1997 (62 FR 36460). The correction corrects the text of 20 CFR § 416.994a(e)(1) and (f)(4).

Pub. L. 104-193 mandated “disability redeterminations” for certain title XVI child beneficiaries and for title XVI adults who were eligible as children in the month before the month of attainment of age 18. Pub. L. 104-193 also mandated that the Social Security Administration (SSA) perform periodic CDRs for title XVI children with impairments that SSA considers likely to improve and CDRs for children for whom low birth weight is a contributing factor material to the determination of disability. The provisions of Pub. L. No. 104-193 governing age 18 disability redeterminations and CDRs for low birth weight babies were also amended by Pub. L. 105-33, the Balanced Budget Act of 1997, enacted on August 5, 1997.

III. The CDR Evaluation Process - Title XVI Child — Flow Chart

This chart outlines the CDR evaluation process under the MIRS for title XVI children, which differs from the MIRS as it applies to title II and adult title XVI beneficiaries (and from the MIRS sequence applicable to children prior to August 22, 1996). The CDR evaluation process is set out in 20 CFR § 416.994a, as it appears in the April 1, 1997 version of 20 CFR Parts 400-499, and as corrected in the Federal Register on July 8, 1997.

I-5-430C-III.gif

* If a Group I exception (20 CFR 416.994a(f)) applies, go to step 3.

If a Group II exception (20 CFR 416.994a(g)) applies, disability ceases.

IV. Hearing Office Procedures

A. Cases Pending At Hearing Level in Which DDS Established Cessation Prior to August 22, 1996 - Hearing Held

NOTE:

For appeals of cessation dates established before August 22, 1996 (the date of enactment of Pub. L. 104-193), the prior medical improvement review standard (MIRS) rules apply in deciding the cessation issue for the period prior to August 22, 1996. The prior rules for application of the MIRS are found in the April 1, 1996 edition of 20 CFR § 416.994a and discussed in HALLEX TI 5-4-30, pages 14-16.

Hearing offices should screen all title XVI childhood disability cases with cessation dates prior to August 22, 1996 awaiting issuance of a decision. The ALJ should apply the pre-August 22, 1996 MIRS to the period prior to August 22, 1996.

  1. ALJ Prepared to Find Cessation Prior to August 22, 1996

    If, after applying the pre-August 22, 1996 MIRS to the period prior to August 22, 1996, the ALJ is prepared to find that the DDS-established cessation is proper, or is prepared to find a later cessation date which is still prior to August 22, 1996, the case should be processed and a decision issued finding that disability ceased. There is no need to consider the current MIRS in these cases.

  2. ALJ Prepared to Find That Cessation Did Not Occur Prior to August 22, 1996

    If the ALJ, after applying the pre-August 22, 1996 MIRS to the period prior to August 22, 1996 is prepared to find that cessation did not occur prior to August 22, 1996, i.e., the claimant continues to be disabled as of August 22, 1996, the ALJ will advise the claimant of the change in the law (see sample language in Attachments 1 and 2) and provide the claimant and representative, if any, the opportunity to:

    1. submit additional evidence;

    2. submit written comments; and/or

    3. request a supplemental hearing

    (See HALLEX I-2-6-80, Continued or Reopened Hearing.)

Following receipt of additional evidence/comments and/or after a supplemental hearing, if requested, the ALJ will apply the appropriate evaluation criteria (see C. below) and issue a decision. The applicable evaluation criteria are contingent on whether the claimant would have been subject to a childhood disability redetermination under Pub. L. 104-193 (i.e., IFA allowance, maladaptive behaviors material, or age-18 case). See applicable evaluation criteria in section C. below.

B. Cases Pending At Hearing Level in Which DDS Established Cessation Prior to August 22, 1996 - Hearing Not Yet Scheduled and New Receipts (with pre-August 22, 1996 cessation dates)

Schedule the hearing in the usual manner. The Notice of Hearing sent to the claimant and representative, if any, must include reference to the pre-August 22, 1996 MIRS standard, as well as, the new disability rules/MIRS for the period beginning August 22, 1996. Sample language addressing the general and specific issues is included in section E.1.a. below.

When deciding whether a cessation is appropriate at any time prior to August 22, 1996, apply the pre-August 22, 1996 MIRS (see section A.1. above). If the ALJ finds that cessation did not occur prior to August 22, 1996, apply the appropriate evaluation criteria in C. below to the period on and after August 22, 1996.

C. Evaluation Criteria

For the period beginning on August 22, 1996, the evaluation criteria applicable to an appeal of a CDR cessation of SSI childhood disability benefits, when the cessation did not occur prior to August 22, 1996, are contingent on whether the claim type is one that would require a disability redetermination under Pub. L. 104-193, i.e.:

  • an IFA allowance,

  • a case in which maladaptive behaviors in the prior personal/behavioral area of functioning in former listings sections 112.00C.2 and 112.02B.2.c.(2) were material; i.e., the child would not have been found disabled without consideration of those behaviors in that area of functioning,

    NOTE:

    Not every case involving maladaptive behaviors requires a disability redetermination. The controlling factor is whether the maladaptive behaviors were material to finding the child disabled, e.g., the prior personal/behavioral area of functioning (prior 112.02B.2.c.(2) of the mental disorders listings) was involved in assessing the severity of the impairment(s). For “maladaptive behaviors” in the prior “personal/behavioral” area, see prior listing section 112.02B.2.c.(2) in the April 1, 1996 edition of 20 CFR, Appendix 1, Subpart P, Part 404.

    or

  • an age 18 case.

    NOTE:

    The ALJ decision must contain a discussion to support the evaluation criteria applied, i.e., a clear statement as to whether or not the requirements for a disability redetermination under Pub. L. 104-193 are met (maladaptive behaviors were material in finding the child disabled at the time of the original allowance, or still disabled at the comparison point decision (CPD) if there was a prior CDR, or the case is an IFA allowance or age-18 case).

  1. Case Type Does Not Require Disability Redetermination

    If the case does not meet the requirements for a disability redetermination under Pub. L. 104-193 as set out above, apply the pre-August 22, 1996 MIRS for the period before August 22, 1996 and the current MIRS for the period beginning August 22, 1996.

  2. Case Type Requires Disability Redetermination (IFA, Maladaptive Behaviors Material, Age-18 Case)

    Claimants meeting the childhood disability or age 18 redetermination criteria, (i.e., IFA allowance, maladaptive behaviors material, age-18 case) will be evaluated as follows:

    • Apply the pre-August 22, 1996 MIRS for the period before August 22, 1996.

    • Apply the new childhood disability standard for initial claims (except that step 1 of the sequential evaluation process, i.e., SGA, will not apply) for the period beginning August 22, 1996. The MIRS will not apply.

    • If the child has attained age 18, apply the adult standard for initial claims for the period beginning with attainment of age 18 (except that step 1 of the sequential evaluation process, i.e., SGA, will not apply). The MIRS will not apply.

NOTE:

If the child attained age 18 before August 22, 1996, and after the cessation date established by DDS, the age 18 standard would only apply for months beginning on or after August 22, 1996 (see § 212(d) of Pub. L. 104-193).

D. Pending CDR Cases in Which Cessation On or After August 22, 1996 is Established by DDS

In CDR cases with a cessation date on or after August 22, 1996, schedule the hearing in the usual manner. The Notice of Hearing sent to the claimant and representative, if any, must include the new (current) MIRS standard which will apply for the period on or after August 22, 1996. Sample language addressing the general and specific issues is included in section E.1.b. below.

NOTE:

There is a distinction between CDR cessations and disability redetermination cessations. The MIRS does not apply to appeals of disability redetermination cessations.

E. ALJ Decisional Language

  1. Issues

    Because Pub. L. 104-193 amended the definition of disability and the MIRS for title XVI children, revisions will be necessary with respect to the statement of issues in the notice of hearing and in the decision. See the following sample language below. Similar issues would be appropriate in preparing the notice of hearing.

    1. Cases pending in HO with cessation prior to August 22, 1996 [Apply the Pre-August 22, 1996 MIRS and current initial/MIRS standard]

      The general issue is whether you continue to be eligible for Supplemental Security Income, as an individual under age 18, within the meaning of sections 1614(a)(3)(C) of the Social Security Act.

      The specific issue is whether you are still disabled as defined in the Social Security Act. To decide whether you are still disabled for the period before August 22, 1996, I will consider the medical improvement review standard (MIRS) rules in effect before Public Law (Pub. L.) 104-193 was enacted. Those rules are found in the April 1, 1996 edition of 20 CFR §416.994a.

      If, using those rules, I find that you were still disabled up to August 22, 1996, and a disability redetermination is necessary under Pub. L. 104-193, new rules will apply. I will consider whether you are disabled under the current childhood disability rules for initial claims, for the period on and after August 22, 1996. Those rules are found in 20 CFR § 416.924. The exception to this is that step 1 of the sequential evaluation process, the substantial gainful activity (SGA) step, will not apply.

      Under the rules in 20 CFR § 416.924, your impairment (or combination of impairments) must meet, or medically or functionally equal, the requirements of a listing in the Listing of Impairments in appendix 1 of subpart P of our regulations.

      If a disability redetermination is not necessary, I will consider whether you are still disabled under the current MIRS rules in 20 CFR § 416.994a.

      In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the adult issue language for the period beginning with attainment of age 18.

      NOTE:

      If the child attained age 18 before August 22, 1996, and after the cessation date established by DDS, the age 18 standard would only apply for months beginning on or after August 22, 1996 (see § 212(d) of Pub. L. 104-193).

    2. New receipts with cessation on or after August 22, 1996 [Apply the Current MIRS]

      The general issue is whether you continue to be eligible for Supplemental Security Income, as an individual under age 18, within the meaning of sections 1614(a)(3)(C) of the Social Security Act.

      The specific issue is whether you are still disabled as defined in the Social Security Act. To decide this, I will consider whether you are still disabled under the medical improvement review standard (MIRS) rules in 20 CFR § 416.994a.

    In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the adult issue language for the period beginning with attainment of age 18.

  2. Decisional Findings (CDR)

    Specific findings should be made with respect to the pre-August 22, 1996 MIRS and/or the current initial standard or MIRS, as appropriate and set out in C. above. The decision should include findings, appropriate to the decision, using language along the following lines:

    1. For cases decided under the pre-August 22, 1996 standard (see A.1. above), use MIRS decisional language and findings appropriate to that period.

    2. For cases decided under the new (current) MIRS standard (see C.1. and D. above), use the following sample findings, as appropriate:

      • The claimant was found to be disabled within the meaning of the Social Security Act beginning __________.

      • The impairment(s) present as of ____________, the time of the most recent favorable medical decision that the claimant was disabled was/were ____________.

      • The medical evidence establishes that there has been [no] improvement in the claimant's medical impairment(s) since ________.

      • The following exception(s) to medical improvement applies: __________.

      • The medical evidence establishes that the claimant currently has the following medically determinable impairments: _____________.

        [Findings on credibility of subjective complaints (including pain) should be inserted as needed.]

      • The claimant's impairment(s) [still] [no longer) meets or equals the severity of the listed impairment it met or equalled at the time of the most recent favorable determination or decision.

      • The claimant has [does not have] a severe impairment or combination of impairments.

      • The claimant's impairment(s) (or combination of impairments) meets [does not meet] the requirements of a listing in the Listing of Impairments.

      • The claimant's impairment(s) (or combination of impairments) [does not] medically or functionally equal(s) the requirements of a listing in the Listing of Impairments.

      • Therefore, the claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

      • The claimant's disability ceased on ________.

        or

      • The claimant continues to be under a “disability” as defined in the Social Security Act.

    3. For cases decided under the current standard for initial claims (see C.2. above), the decision must contain a specific finding with respect to the new definition of disability, as follows:

      • The claimant's impairment (or combination of impairments) meets [does not meet], or medically or functionally equal(s), the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P.

      • Therefore, the claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

  3. Decisional Paragraph

    The decisional paragraph must contain language along the following lines:

    Unfavorable

    It is the decision of the Administrative Law Judge that the claimant's eligibility for Supplemental Security Income under sections 1602 and 1614(a)(3)(C) of the Social Security Act, ended effective _________, the end of the second calendar month after the month in which the disability ceased.

    NOTE:

    Pub. L. 104-193 provides that benefit termination because of an unfavorable redetermination decision cannot occur before July 1, 1997, i.e., payments must be made through June 1997. Therefore, cases that require a disability redetermination and the ALJ finds that disability ceased, based on that redetermination, in any month before April 1997, the decisional paragraph must be revised to reflect the above provision of Pub. L. 104-193 regarding benefit termination.

    Favorable

    It is the decision of the Administrative Law Judge that the claimant continues to be “disabled” under section 1614(a)(3)(C) of the Social Security Act.

    The component of the Social Security Administration responsible for authorizing Supplemental Security Income payments will advise the claimant regarding the nondisability requirements for these payments, and if eligible, the amount and the month(s) for which payments will be made.

F. Cover Notice for Transmitting Decision and Routing

Use the standard decision cover notice as appropriate. Follow existing procedures for routing.

G. Hearing Office Tracking System (HOTS) Coding

NOTE:

In order to account to Congress for the expenditure of funds allocated specifically for implementation of Pub. L. 104-193, SSA must distinguish between redeterminations mandated by that law and redeterminations which are done as part of the CDR process.

Hearing office staff will use the hearing type codes for cessations (11, 31, 41, etc.) for these title XVI CDR cases. However, staff will enter the regulation basis codes, primary and secondary impairment codes, and an “H” (special case code) into the HOTS. If an age-18 redetermination is done as part of the CDR, split the case by creating a “21” record and enter “I” in the special case code. See coding instructions in section VI. J. of the OHA childhood disability instructions issued on June 6, 1997 (reissued on November 28, 1997 as HALLEX TI 5-4-30A) and the memorandum dated March 12, 1998 from OHA's Associate Commissioner, entitled “Impairment Codes for Supplemental Security Income (SSI) Childhood Disability Cases.”

NOTE:

In the past, SSA used one code (3180) for children with mental retardation, children who had borderline intellectual functioning, and children who had a learning disorder. A new, 4-digit impairment code (3195) for the mental diagnostic category, borderline intellectual functioning, has been established. In addition, the impairment code for learning disorder is 3152. Borderline intellectual functioning (3195) and learning disorder (3152) must not be coded as 3180 under mental retardation).

V. Appeals Council Procedures

A. ALJ Decision Establishes Cessation Before August 22, 1996

For any case in which the ALJ has issued a wholly or partially unfavorable decision finding a cessation date before August 22, 1996 (the date of enactment of Pub. L. 104-193), the pre-August 22, 1996 MIRS rules apply in deciding the cessation issue for the period prior to August 22, 1996. These rules for application of the MIRS are found in the April 1, 1996 edition of 20 CFR § 416.994a and discussed in HALLEX TI 5-4-30, pages 14-16.

The AC may take any of its usual actions in such cases including:

  • denying the request for review (R/R);

  • granting the R/R and issuing a decision;

  • remanding the case to an ALJ; or

  • dismissing the R/R.

  1. AC Denies R/R

    No special action or notice is required when the AC denies a request for review of an ALJ decision finding cessation before August 22, 1996.

  2. AC Grants Review and Issues Decision

    If the AC grants a request for review of a wholly unfavorable or partially favorable ALJ decision which established cessation prior to August 22, 1996, the AC must first apply the pre-August 22, 1996 MIRS rules for the period prior to August 22, 1996. These prior rules are found in the April 1, 1996 edition of 20 CFR § 416.994a. If, after applying the pre-August 22, 1996 MIRS, the AC is prepared to find that cessation occurred before August 22, 1996, there is no need to consider the current MIRS.

    If the AC is prepared to find that cessation did not occur prior to August 22, 1996, i.e., the claimant continues to be disabled on August 22, 1996, the AC must apply the current applicable evaluation criteria under Pub. L. 104-193 for the period beginning August 22, 1996. The criteria applied will depend on whether the case is one that requires a disability redetermination under Pub. L. 104-193, i.e., IFA allowance, maladaptive behaviors material, or age-18 case (see C. below).

  3. AC Remands Case to ALJ

    If the AC remands the case to an ALJ for further proceedings, the AC Order of Remand will advise the ALJ to apply the pre-August 22, 1996 medical improvement review standard (MIRS) for the period prior to August 22, 1996 and the applicable current evaluation standard under Pub. L. 104-193 for the period beginning August 22, 1996. The applicable evaluation standard for the period beginning August 22, 1996 depends on whether a disability redetermination is necessary under Pub. L. 104-193 (see C. below).

B. ALJ Decision Establishes Cessation On or After August 22, 1996

  1. AC Denies R/R

    No special action or notice is required when the AC denies a request for review of an ALJ decision finding cessation on or after August 22, 1996.

  2. AC Grants R/R and Issues Decision

    If the AC is prepared to find cessation on or after August 22, 1996, the AC must apply the current applicable evaluation criteria under Pub. L. 104-193 for the period beginning August 22, 1996. The criteria applied will depend on whether the case is one that requires a disability redetermination under Pub. L. 104-193, i.e., an IFA allowance, a maladaptive behaviors material, or age-18 case (see C. below).

  3. AC Remands Case to ALJ

    If the AC remands the case to an ALJ for further proceedings, the AC Order of Remand will advise the ALJ to apply the pre-August 22, 1996 MIRS for the period prior to August 22, 1996 and the applicable current evaluation standard under Pub. L. 104-193 for the period beginning August 22, 1996 (see C. below).

C. Evaluation Criteria

For the period beginning on August 22, 1996, the evaluation criteria applicable to an appeal of a CDR cessation of SSI childhood disability benefits, when the cessation did not occur prior to August 22, 1996, are contingent on whether the claim type is one that would require a disability redetermination under Pub. L. 104-193, i.e.:

  • an IFA allowance,

  • a case in which maladaptive behaviors in the prior personal/behavioral area of functioning in former listings sections 112.00C.2 and 112.02B.2.c.(2) were material; i.e., the child would not have been found disabled without consideration of those behaviors in that area of functioning,

    NOTE:

    Not every case involving maladaptive behaviors requires a disability redetermination. The controlling factor is whether the maladaptive behaviors were material to finding the child disabled, e.g., the prior personal/behavioral area of functioning (prior 112.02B.2.c.(2) of the mental disorders listings) was involved in assessing the severity of the impairment(s). For “maladaptive behaviors” in the prior “personal/behavioral” area, see prior listing section 112.02B.2.c.(2) in the April 1, 1996 edition of 20 CFR, Appendix 1, Subpart P, Part 404.

    or

  • an age-18 case.

    NOTE:

    The AC decision must contain a discussion to support the evaluation criteria applied, i.e., a clear statement as to whether or not the requirements for a disability redetermination under Pub. L. 104-193 are met (maladaptive behaviors were material in finding the child disabled at the time of the original allowance, or still disabled at the comparison point decision (CPD) if there was a prior CDR, or the case is an IFA allowance or age-18 case).

  1. Case Type Does Not Require Disability Redetermination

    If the case does not meet the requirements for a disability redetermination under Pub. L. 104-193 as set out above, apply the pre-August 22, 1996 MIRS for the period before August 22, 1996 and the current MIRS for the period beginning August 22, 1996.

  2. Case Type Requires Disability Redetermination (IFA, Maladaptive Behaviors Material, Age-18 Case)

    Claimants meeting the childhood disability redetermination criteria, (i.e., IFA allowance, maladaptive behaviors material, or age-18 case) will be evaluated as follows:

    • Apply the pre-August 22, 1996 MIRS for the period before August 22, 1996.

    • Apply the new childhood disability standard for initial claims (except that step 1 of the sequential evaluation process, i.e., SGA, will not apply) for the period beginning August 22, 1996. The MIRS will not apply.

    • If the child has attained age 18, apply the adult standard for initial claims for the period beginning with attainment of age 18 (except that step 1 of the sequential evaluation process, i.e., SGA, will not apply). The MIRS will not apply.

D. Protest Case - Favorable ALJ Decision

The Appeals Council will follow existing procedures for handling protest cases. If the AC exercises own motion or reopening authority, follow “8001” procedures in HALLEX I-3-6-55.

E. Appeals Council Decisional Language

  1. Issues

    Because Pub. L. 104-193 amended the definition of disability and the MIRS for title XVI children, revisions will be necessary with respect to the statement of issues in the decision. See the following sample language below.

    1. Cases with cessation prior to August 22, 1996 [Apply the Pre-August 22, 1996 MIRS to the period before August 22, 1996, and current initial/MIRS standard on and after August 22, 1996.]

      The general issue is whether the claimant continues to be eligible for Supplemental Security Income, as an individual under age 18, within the meaning of sections 1614(a)(3)(C) of the Social Security Act.

      The specific issue is whether the claimant is still disabled as defined in the Social Security Act. To decide whether the claimant was still disabled for the period before August 22, 1996, the Appeals Council considers the medical improvement review standard (MIRS) rules in effect before Public Law (Pub. L.) 104-193 was enacted. Those rules are found in the April 1, 1996 edition of 20 CFR § 416.994a.

      If, using those rules, the Appeals Council finds that the claimant was still disabled up to August 22, 1996, and a disability redetermination is necessary under Pub. L. 104-193, new rules will apply. The Appeals Council then considers whether the claimant is disabled under the current childhood disability rules for initial claims, for the period on and after August 22, 1996. Those rules are found in 20 CFR § 416.924. The exception to this is that step 1 of the sequential evaluation process, the substantial gainful activity (SGA) step will not apply.

      Under the rules in 20 CFR § 416.924, the impairment (or combination of impairments) must meet or medically or functionally equal the requirements of a listing in the Listing of Impairments in appendix 1 of subpart P of our regulations.

      If a disability redetermination is not necessary, the Appeals Council considers whether you are still disabled under the current MIRS rules in 20 CFR § 416.994a.

      In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the adult issue language for the period beginning with attainment of age 18.

      NOTE:

      If the child attained age 18 before August 22, 1996, and after the cessation date established by DDS, the age 18 standard would only apply for months beginning on or after August 22, 1996 (see § 212(d) of Pub. L. 104-193).

    2. New receipts with cessation on or after August 22, 1996 [Apply the current MIRS]

      The general issue is whether the claimant continues to be eligible for Supplemental Security Income, as an individual under age 18, within the meaning of sections 1614(a)(3)(C) of the Social Security Act.

      The specific issue is whether the claimant is still disabled as defined in the Social Security Act. To decide this, the Appeals Council considers whether the claimant is still disabled under the medical improvement review standard (MIRS) rules in 20 CFR § 416.994a.

    In addition, if the decision covers a period prior to age 18 and after attainment of age 18, include the adult issue language for the period beginning with attainment of age 18.

  2. Decisional Findings (CDR)

    Specific findings should be made with respect to the pre-August 22, 1996 MIRS and/or the current initial standard or MIRS, as appropriate and set out in C. above. The decision should include findings, appropriate to the decision, using language along the following lines:

    1. For cases decided under the pre-August 22, 1996 standard (see A.1. above), use MIRS decisional language and findings appropriate to that period.

    2. For cases decided under the new (current) MIRS standard (see C.1. and D. above), use the following sample findings, as appropriate:

      • The claimant was found to be disabled within the meaning of the Social Security Act beginning __________.

      • The impairment(s) present as of ____________, the time of the most recent favorable medical decision that the claimant was disabled was/were ________________.

      • The medical evidence establishes that there has been [no] improvement in the claimant's medical impairment(s) since ________.

      • The following exception(s) to medical improvement applies: __________.

      • The medical evidence establishes that the claimant currently has the following medically determinable impairments: _____________.

        [Findings on credibility of subjective complaints (including pain) should be inserted as needed.]

      • The claimant's impairment(s) [still] [no longer] meets or equals the severity of the listed impairment it met or equalled at the time of the most recent favorable determination or decision.

      • The claimant has [does not have] a severe impairment or combination of impairments.

      • The claimant's impairment(s) (or combination of impairments) meets [does not meet] the requirements of a listing in the Listing of Impairments.

      • The claimant's impairment(s) (or combination of impairments) [does not] medically or functionally equal(s) the requirements of a listing in the Listing of Impairments.

      • Therefore, the claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

      • The claimant's disability ceased on ________.

        or

      • The claimant continues to be under a “disability” as defined in the Social Security Act.

    3. For cases decided under the current standard for initial claims (see C.2. above), the decision must contain a specific finding with respect to the new definition of disability, as follows:

      • The claimant's impairment (or combination of impairments) meets [does not meet] or medically or functionally equal(s) the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P.

      • The claimant has [does not have] a medically determinable physical or mental impairment (or combination of impairments) which results in marked and severe functional limitations.

  3. Decisional Paragraph

    Unfavorable

    It is the decision of the Appeals Council that the claimant's eligibility for Supplemental Security Income under sections 1602 and 1614(a)(3)(C) of the Social Security Act ended effective _________, the end of the second calendar month after the month in which the disability ceased.

    NOTE:

    Pub. L. 104-193 provides that benefit termination because of an unfavorable redetermination decision cannot occur before July 1, 1997, i.e., payments must be made through June 1997. Therefore, cases that require a disability redetermination and the Appeals Council finds that disability ceased, based on that redetermination, in any month before April 1997, the decisional paragraph must be revised to reflect the above provision of Pub. L.104-193 regarding benefit termination.

    Favorable

    It is the decision of the Appeals Council that the claimant continues to be “disabled” under section 1614(a)(3)(C) of the Social Security Act.

    The component of the Social Security Administration responsible for authorizing Supplemental Security Income payments will advise the claimant regarding the nondisability requirements for these payments, and if eligible, the amount and the month(s) for which payments will be made.

F. OHA Case Control System (CCS) Coding

When the AC reviews a case and issues a decision, the analyst must provide the appropriate regulation basis code and impairment codes. Follow the coding instructions in section VII. K. of the OHA childhood disability instructions issued on June 6, 1997 (reissued on November 28, 1997 as HALLEX TI 5-4-30A) and in the memorandum dated March 12, 1998 from OHA's Associate Commissioner, entitled “Impairment Codes for Supplemental Security Income (SSI) Childhood Disability Cases.”

NOTE:

In the past, SSA used one code (3180) for children with mental retardation, children who had borderline intellectual functioning, and children who had a learning disorder. A new, 4-digit impairment code (3195) for the mental diagnostic category, borderline intellectual functioning, has been established. In addition, the impairment code for learning disorder is 3152. Borderline intellectual functioning (3195) and learning disorder (3152) must not be coded as 3180 (under mental retardation).

VI. Inquiries

Hearing Office personnel should direct any questions concerning this instruction to their Regional Office. Regional Office personnel only should contact the Division of Field Practices and Procedures in the Office of the Chief Administrative Law Judge at (703) 605-8530. Headquarters personnel should route questions to their Branch Chiefs who may contact the Office of Appellate Operations at 605-7100.

Attachment 1. Sample Language When Claimant Had a Hearing On The Issue of Cessation Before Enactment of Public Law No. 104-193

CDR CASE THAT REQUIRES REDETERMINATION EFFECTIVE AUGUST 22, 1996 — ALJ Is Prepared To Find Cessation Did Not Occur Prior to August 22, 1996

We are writing to tell you about changes in the law that may affect your Supplemental Security Income (SSI) claim.

The definition of disability for individuals under age 18 claiming SSI benefits based on disability has changed. The law now provides that we will consider a child disabled only if

  • he or she has a physical or mental condition or conditions that can be medically proven and which result in marked and severe functional limitations, and

  • the medically proven physical or mental condition or conditions must last at least 12 months or be expected to result in death.

To result in marked and severe functional limitations, the physical or mental condition or conditions must meet or medically or functionally equal the requirements of a listing in the Listing of Impairments in appendix 1 of subpart P of our regulations.

I will apply the new childhood disability rules for the period on and after August 22, 1996, the date the new law was enacted.

What You Can Do

Before I issue my decision, you have the opportunity to show that you meet the new disability rules. You may do any or all of the following:

  • give us additional information;

  • give us written comments;

  • ask for another hearing.

If you want another hearing, or want to send us additional information or comments, you must let us know in writing, within ten (10) days of the date you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period. You should send your request for another hearing or any additional information or comments to the address shown at the top of this letter.

What We Will Do

If I do not hear from you within 10 days of the date you get this letter, I will assume you do not want to ask for another hearing or give us additional information or comments. I will issue my decision based on the information you gave us at your earlier hearing, and the information now in your file.

If You Have Any Questions

If you have any questions, you may call or write to me at the telephone number and address shown at the top of this letter.

  [Name]
  Administrative Law Judge

[cc:
Representative's Name (if any) Address City, State, Zip]

Attachment 2. Sample Language When Claimant Had a Hearing On The Issue of Cessation Before Enactment of Public Law No. 104-193

CDR CASE — NO REDETERMINATION NEEDED — ALJ Is Prepared To Find Cessation Did Not Occur Prior to August 22, 1996

We are writing to tell you about changes in the law that may affect your Supplemental Security Income (SSI) claim.

The definition of disability for individuals under age 18 claiming SSI benefits based on disability has changed. The medical improvement review standard sequence we follow in determining whether an individual is still disabled has changed. The law now provides that under the new continuing disability sequence, I will consider:

(1) Whether there has been medical improvement in the impairment(s) (health problems) you had at the time of the most recent favorable determination or decision. If there has been no medical improvement, I will find that you are still disabled unless one of the exceptions to medical improvement discussed in 20 CFR § 416.994a(e) or (f) applies;

(2) Whether the impairment(s) still meets or equals the severity of the listed impairment that it met or equalled at the time of the most recent favorable determination or decision. If the impairment(s) still meets or equals that listed impairment, I will find that you are still disabled unless one of the exceptions to medical improvement discussed in 20 CFR § 416.994a(e) or (f) applies;

(3) Whether you are still disabled under the rules in 20 CFR § 416.924. Under those rules, we will consider a child disabled only if

  • he or she has a physical or mental condition or conditions that can be medically proven and which result in marked and severe functional limitations, and

  • the medically proven physical or mental condition or conditions must last at least 12 months or be expected to result in death.

To result in marked and severe limitations, your impairment(s) must meet or medically or functionally equal the requirements of a listing in the Listings of Impairments in appendix 1 of subpart P of our regulations.

I will apply the new childhood disability medical improvement review standard rules for the period on and after August 22, 1996, the date the new law was enacted.

What You Can Do

Before I issue my decision, you have the opportunity to show that you meet the new disability rules. You may do any or all of the following:

  • give us additional information;

  • give us written comments;

  • ask for another hearing.

If you want another hearing, or want to send us additional information or comments, you must let us know in writing, within ten (10) days of the date you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period. You should send your request for another hearing or any additional information or comments to the address shown at the top of this letter.

What We Will Do

If I do not hear from you within 10 days of the date you get this letter, I will assume you do not want to ask for another hearing or give us additional information or comments. I will issue my decision based on the information you gave us at your earlier hearing, and the information now in your file.

If You Have Any Questions

If you have any questions, you may call or write to me at the telephone number and address shown at the top of this letter.

  [Name]
  Administrative Law Judge

[cc:
Representative's Name (if any) Address City, State, Zip]