Testing Modifications to the Disability Determination Procedures

Federal RegisterApr 24, 1995

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SOCIAL SECURITY ADMINISTRATION

20 CFR Parts 404 and 416

[Regulations Nos. 4 and 16]

RIN 0960-AD63

Testing Modifications to the Disability Determination Procedures

AGENCY: Social Security Administration (SSA).

ACTION: Final rules.

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SUMMARY: We are adding new rules which provide authority to test

procedures that modify the disability determination process we

currently follow under titles II and XVI of the Social Security Act

(the Act). We intend to test up to four model procedures either singly

or in combination. These tests will provide us with information so we

can determine the effectiveness of the models in improving the

disability process. The intended result is to enable us to make

recommendations for national implementation of improvements identified

by the tests. These final rules only refer to the changes to the

disability procedures we may test. Unless specified, all other

regulations related to the disability determination process remain

unchanged. Videoconferencing may be used with any of the models.

EFFECTIVE DATE: These rules are effective April 24, 1995.

FOR FURTHER INFORMATION CONTACT: Henry D. Lerner, Legal Assistant,

Office of Regulations, Social Security Administration, 6401 Security

Blvd., Baltimore, MD 21235, (410) 965-1762.

SUPPLEMENTARY INFORMATION:

Background

We published a notice of proposed rulemaking (NPRM) in the Federal

authority to test model projects designed to improve the disability

determination process. The initial public comment period was 30 days. A

30-day extension of the public comment period was published in the

Federal Register on December 6, 1993, (58 FR 64207) and the comment

period ended on January 5, 1994. The comments we received on the NPRM

and the changes we have made in the final rules are discussed below.

On April 15, 1994, the Social Security Administration (SSA)

published a notice in the Federal Register (59 FR 18188) setting out a

proposal to redesign the initial and administrative appeals system for

determining an individual's entitlement to Social Security and

Supplementary Security Income (SSI) disability payments. Comments on

this comprehensive and far reaching proposal developed by SSA's

Disability Process Reengineering Team (the Team) were requested, and

during the comment period that began on April 1, 1994, and ended on

June 14, 1994, SSA received over 6,000 written responses. They came

from a broad spectrum of respondents including: Professional

associations, claimant representatives, claimant advocacy groups,

Federal and State agencies, State governments, employee unions, Federal

and State employees, and other members of the public. Comments also

were received by members of the Team who conducted briefings and spoke

with more than 3,000 individuals about their reaction to the proposal.

The commenters expressed their belief that improvements were needed to

provide better service and to manage the claims process more

effectively. While some concerns were expressed, the commenters praised

SSA and the Team for taking on the task of redesigning the disability

claim process.

The Team made revisions to the redesign proposal and submitted them

to the Commissioner of Social Security on June 30, 1994. The

Commissioner accepted the recommendations of the Team on September 7,

1994, with the full understanding that certain aspects of the redesign

proposal recommended by the Team would require extensive research and

testing to determine whether they can be implemented. The plan approved

by the Commissioner was published in the Federal Register on September

19, 1994 (59 FR 47887). The proposed changes to the disability

determination process contained in the plan approved by the

Commissioner that are the same as or similar to changes we proposed to

test in the NPRM include:

Making the process more personalized by assigning a

disability claim manager who is knowledgeable about the case to be the

claimant's principal contact with SSA;

Providing the claimant with an opportunity for a

predecision interview with the decisionmaker(s) when the decisionmaker

finds that the evidence in the claim file is insufficient to make a

fully favorable determination or requires an initial determination

denying the claim;

Eliminating the reconsideration step of the administrative

review process and providing a claimant who is dissatisfied with his or

her initial determination with the opportunity to request a hearing

before an administrative law judge (ALJ).

These final rules were developed based on the NPRM, the comments we

received on it which are discussed below, and the Commissioner's

acceptance on September 7, 1994, of the Team's recommendations to

redesign the disability process. Under the final rules we plan to test

one or more modifications to the current disability determination

process to determine whether the modifications should become permanent.

The modifications we plan to test pursuant to these final rules that

were not contained in the NPRM, are based on, and are an outgrowth of,

the NPRM.

Some modifications of procedures that were in the NPRM, such as

having a single decisionmaker in the proposed claims intake and

determination model, the face-to-face predenial interview model and the

face-to-face Federal reconsideration models, are now found in these

final rules in the single decisionmaker model. Also, a modification

similar to, though less formal than, the predenial interview concept

that was part of the face-to-face predenial interview model is now

found in the predecision interview model.

Other modifications contained within the models described in the

NPRM and the redesign proposal are now combined in models in these

final rules. For example, the NPRM described a disability specialist as

a claims representative who would be given special disability program

training similar to the training that State agency disability examiners

receive. The disability specialist would be able to review the claim

before forwarding it to the State agency, request and evaluate existing

medical evidence and, if appropriate, arrange for a consultative

examination. With respect to applications for SSI payments based on

disability, the disability specialist would, where appropriate, make

presumptive disability findings. The second model in the NPRM, the

claims intake and determination model, described a process whereby the

applicant would be interviewed by a decisionmaker when a claim for

disability benefits or SSI payments based on disability was filed.

[[Page 20024]]

Whereas the NPRM described a disability specialist and a

decisionmaker at claims intake who could perform these functions, the

final rules now have a disability claim manager model and a single

decisionmaker model. The disability claim manager will assume primary

responsibility for the processing of any initial disability claim, and

he or she will act as the focal point for the claimant's contacts with

us throughout the claims intake process and until an initial

determination is issued. The disability claim manager will perform many

of the functions associated with a disability specialist, but will also

perform other functions. A disability claim manager will provide the

claimant with an explanation of the disability programs, including the

definition of disability and how we determine whether or not the

claimant meets the other requirements for entitlement to disability

benefits. The disability claim manager will also explain what the

claimant will be asked to do throughout the initial claims process and

provide information that will assist the claimant in pursuing his or

her claim. When tested in combination with the single decisionmaker

model, the disability claim manager will also be the decisionmaker,

similar to the decisionmaker in the claims intake and determination

model described in the NPRM.

The disability claim manager may work in a team environment with

medical consultants who provide assistance for case adjudication, as

well as with technical and other clerical personnel who may handle

other aspects of case development and payment effectuation. Each team

member will have a familiarity with all the steps in the process and an

understanding of how he or she assists another's efforts. Team members

will be able to draw upon each other's expertise on complex issues. We

expect that this team environment, combined with the proper training,

program tools and technological support, will eventually enable one

individual to handle the responsibilities of the disability claim

manager. This individual may be either a Federal employee or a State

agency employee. An individual employee serving as the disability claim

manager is basic to our objective of providing a single point of

contact for the claimant during the initial disability process.

In the near term, it may be necessary to have the duties of a

disability claim manager carried out by more than one individual and,

therefore, to expand the ``disability team'' described above to include

additional employees. The final rules will allow us to test the

disability claim manager function performed by one individual or a team

of individuals. If the disability claim manager model is being tested

in combination with the single decisionmaker model (i.e., the

disability claim manager would be the single decisionmaker for both the

medical and nonmedical aspects of the claim), and a State agency

employee is performing the duties of the disability claim manager, the

ultimate determination of whether or not the claimant is entitled to

benefits will be made by a team that includes a Federal employee. This

procedure is in accordance with current provisions of the Act which

authorize State agency employees only to make determinations of

disability and not determinations of entitlement to benefits based on

disability.

The disability models proposed in the NPRM were designed only to

modify those aspects of the disability determination process based upon

the medical factors of entitlement. That is why, for example, the face-

to-face predenial interview model proposed in the NPRM only provided

for direct appeal of disability issues to the ALJ. Since then, we have

decided to test ways to improve both the disability and nondisability

aspects of the disability determination process. The face-to-face

predenial interview model with limited direct appeal rights to the ALJ

has been changed in the final rules to a less formal predecision

interview model. As some commenters suggested, the predecision

interview model does not place conditions on a claimant's appeal

rights. It still provides, however, the claimant with the opportunity

for an interview with the decisionmaker(s) before an initial

determination denying the claim is made or when the evidence is

insufficient to make a fully favorable determination. The

decisionmaker(s) who will conduct the interview has the discretion to

determine which method of interview (face-to-face, videoconferencing,

or telephone) is most appropriate for each claimant's special needs.

The reconsideration elimination model has also been modified to allow

appeal to an administrative law judge if the claimant is dissatisfied

with the initial determination made in his or her claim, based upon

either disability or nondisability factors.

Finally, we decided not to test the face-to-face Federal

reconsideration model described in the NPRM because its primary

benefit, namely, an earlier opportunity to appear before a Federal

decisionmaker is now contained within the single decisionmaker model.

These regulations provide the authority to test major elements of

our Disability Redesign Plan. However, there are elements of the

Redesign not referenced in these final regulations. There are two

principal reasons why elements are omitted. First, we do not need

regulatory authority to test or implement many aspects of the Redesign

(e.g., improved public information materials or more efficient ways of

working with applicants to obtain medical evidence). Second, some

elements of the Redesign were not referenced in the NPRM, since the

Redesign was developed subsequent to issuance of the NPRM. Therefore,

separate regulations will be needed for those elements which are beyond

the scope of the original rulemaking.

For example, separate regulations are required to establish the

position of an adjudication officer who is authorized to issue some

disability decisions. Current implementation planning for the

Disability Redesign includes the development of regulations to test the

adjudication officer element in the Redesign. We plan to test the

adjudication officer in combination with one or more of the models

included in these regulations as well as other aspects of the Redesign

in some test sites. This will provide us with a body of information

about each individual part of the Redesign as well as the combined

effect on individuals and on program expenditures of the overall

Redesign.

Public Comments

We received comments on the NPRM from twenty-one commenters. The

commenters included attorneys, medical professionals, advocates, State

agency employees and Federal employees, and representatives of numerous

organizations that represent the disabled. We received no comments from

persons receiving benefits based on disability. Many commenters

supported and applauded us for undertaking tests of models that modify

the disability determination process. These commenters included the ARC

(formerly known as the Association for Retarded Citizens of the United

States); the American Academy of Pediatrics; the American Foundation

for the Blind; the United Cerebral Palsy Associations; the

Administrative Conference of the United States; the Council for

Exceptional Children; and the National Council on Disability. Some of

the comments we received were outside the scope of the proposed rules,

and therefore, have not been addressed. The substantive comments made

by the [[Page 20025]] commenters and our responses are summarized

below.

Comment: Many commenters raised concerns regarding the adequacy of

the training that would be provided to interviewers and decisionmakers

(particularly single decisionmakers).

Response: We will ensure that the interviewers and decisionmakers

who participate in our tests will be highly trained individuals who are

well versed in both the disability and nondisability aspects of the

disability programs and are individuals who have the necessary

knowledge, skills, and abilities to conduct personal interviews,

develop evidentiary records, and fully adjudicate disability claims, as

appropriate. These individuals will also be able to call on other SSA

resources, including medical and technical support personnel, to

provide advice and assistance in the claims process.

Comment: Several commenters raised concerns regarding the apparent

lack of involvement of the medical consultant in making disability

determinations because the medical consultant would not be required to

sign the disability determination forms used to certify the

determination of disability to us.

Response: The fact that we intend to test a model or combinations

of models where the determination of disability is made by a single

decisionmaker does not mean that the medical consultant is being

removed from the decisionmaking process. The decisionmaker will consult

with the medical consultant whenever appropriate. This means that the

decisionmaker will make reasonable efforts to ensure that a qualified

pediatrician or other appropriate specialist evaluates the claim

whenever a determination of disability is required in claims filed on

behalf of children under age 18 claiming SSI payments based on

disability. Similarly, before making a determination that an individual

is not under a disability in any case which indicates the existence of

a mental impairment, the decisionmaker will make every reasonable

effort to ensure that a qualified psychiatrist or psychologist

completes the medical portion of the case review and any applicable

residual functional assessment. In addition, the decisionmaker will

consult with the medical consultant in all other situations where the

decisionmaker finds that a consultation is appropriate. However, the

single decisionmaker concept is based on the premise that the

decisionmaker is fully competent to make an initial determination when

an individual files an application for benefits based on disability. It

also gives the decisionmaker flexibility to make such determinations

without having to wait for the medical consultant to take part formally

in the determination.

Comment: Several commenters wanted us to include quality

assessments of accuracy in our evaluation of all possible approaches to

improved disability determinations. The commenters' concerns stem

partially from the use of a single decisionmaker in some of the

proposed models and from the fact that medical consultants will not be

required to sign the disability determination forms used to certify the

determination of disability to us.

Response: Our evaluation of the models we test will include quality

assurance procedures to ensure a thorough assessment of the accuracy of

the disability determinations made under the test procedures. As

previously noted, decisionmakers will comply with the statutory

requirements regarding the use of medical consultants in SSI childhood

disability claims, and in all denials of claims based upon mental

impairments. In addition, such consultation will take place with

respect to any other claim in which the decisionmaker finds it is

appropriate to consult with the medical consultant.

Comment: One commenter was concerned with how we would evaluate the

success and impact of the model procedures.

Response: We will have a study design and evaluation plan in place

to assure a valid and accurate assessment of the degree to which the

modifications to the disability determination process we test attain

the goals we wish to achieve before any national implementation of the

modifications begins.

Comment: Several commenters expressed concerns that the proposed

models did not appear to make any provisions for applicants requiring

special assistance--e.g., individuals with mental impairments, older

persons, the homeless, etc.

Response: The modifications to the disability determination process

we test will not compromise any provisions that we currently have to

provide accommodations for those individuals who require special

assistance. As we stated in the summary sections of the NPRM and final

rules, all other regulations related to the disability determination

procedures remain unchanged unless specified. This would include

provisions for claimants who may require special assistance. In fact,

the disability claim manager model we now intend to test provides even

more flexibility and opportunity to assist claimants who may require

special assistance. The disability claim manager, acting as the focal

point for the claimant's contacts with us throughout the initial

disability process, will explain the disability programs to the

claimant, including the definition of disability and how SSA determines

if a claimant meets the disability requirements of the Act. The

disability claim manager will also tell the claimant what he or she

will be asked to do throughout the process, what the claimant may

expect from SSA during the process, and how the claimant can interact

with the disability claim manager to obtain more information or

assistance. The disability claim manager will also advise the claimant

regarding the right to representation and provide the appropriate

referral sources for representation.

Comment: Several commenters were concerned regarding the use of

videoconferencing as a substitute for personal face-to-face interviews,

because videoconferencing may not carry the same weight as a face-to-

face interview and the lack of personal contact could make the

applicant feel depersonalized. In addition, some commenters expressed

concerns that videoconferencing may not be an option for those

claimants with special needs such as those with visual or hearing-

related disabilities, or for those individuals who could not provide

their own videoconferencing equipment.

Response: The testing of videoconferencing as an alternative to a

personal face-to-face interview was proposed and is included in these

final rules because it has the potential of becoming a viable and more

convenient alternative for many claimants who would find it a hardship

or impossibility to travel for an interview, but who still wanted to

take advantage of the opportunity of an interview with the

decisionmaker prior to the determination of disability. An interview

conducted via video or via the telephone will carry the same weight as

an interview conducted face-to-face. In these final rules the

decisionmaker(s) who will conduct the interview has the discretion to

determine which method of interview (face-to-face, videoconferencing,

or telephone) is most appropriate for each claimant's special needs. If

we decide to conduct a claimant's interview via videoconferencing, we

will provide the necessary videoconferencing services for the claimant.

We are exploring and testing the option of videoconferencing at all

levels of the claims process, both within and outside the projects to

be done under these regulations. [[Page 20026]] Regulatory authority to

offer it as a service option is not needed.

Comment: We received several comments regarding claimant due

process rights and the possibility that they could be compromised by

some of the models.

Response: None of the models we intend to test will compromise or

diminish the claimant's due process rights. In fact, the disability

claim manager model we now intend to test provides a process that is

committed to keeping the claimant more informed regarding his or her

rights and allows the claimant to obtain information and assistance

more easily. Also, in the context of ensuring a fair and correct

initial determination of disability, the predecision interview model

provides the claimant an opportunity to have an interview with the

decisionmaker(s) and to submit additional evidence before an initial

determination denying the claim is made or when the evidence in file is

insufficient to make a fully favorable determination.

Comment: Several commenters were interested in having us test the

models that involved face-to-face contact with the decisionmaker(s)

prior to the initial disability determination in combination with the

reconsideration elimination model.

Response: These final rules provide us with the flexibility to test

models individually or in combination with other models. Therefore, we

may test model(s) involving the opportunity for face-to-face contact

between the claimant and the decisionmaker(s) with the reconsideration

elimination model.

Comment: Several commenters were concerned with the fact that the

face-to-face predenial interview model only provided direct appeal of

disability issues involved in the initial determination to the ALJ.

Response: These final rules have been revised to allow appeal of

both disability and nondisability factors to the ALJ whenever any of

the first three models are tested in combination with the

reconsideration elimination model. As stated earlier, the face-to-face

predenial interview model with limited direct appeal rights to the

administrative law judge has been changed in the final rule to a less

formal predecision interview model. The predecision interview model

does not place conditions on a claimant's appeal rights, but still

provides the claimant with the opportunity for a face-to-face interview

with the decisionmaker(s) when the decisionmaker finds that the

evidence in the file is insufficient to make a fully favorable

determination or requires an initial determination denying the claim.

The reconsideration elimination model has also been modified to allow

appeal to the ALJ if the claimant is dissatisfied with the initial

determination made on his or her claim, based upon either medical or

nonmedical factors.

Comment: Several commenters were concerned that there was no

specific indication as to whether children's claims would be included

in the tests.

Response: As stated previously, the summary section of the NPRM and

these final rules state that all other regulations related to the

disability determination procedures remain unchanged unless specified.

That includes the rules for determinations of disability in children.

We have no plans to exclude claims filed by or behalf of children from

the tests. As stated previously, the decisionmaker will make reasonable

efforts to ensure that a qualified pediatrician or other appropriate

specialist evaluates the claim whenever a determination of disability

is required in claims filed by or on behalf of children under age 18

claiming SSI benefits based on disability. We have no intention of

compromising any of the safeguards currently in place to protect the

rights of children in the disability determination process.

Comment: Several commenters were concerned that the models would

generate increased workload demands (particularly the elimination of

the reconsideration model and its predicted effect of increasing ALJ

workloads) and some felt that some of the models would be too costly.

Response: These types of concerns are one of the reasons why we

proposed testing, rather than implementing changes to our current

rules. If the model process or combination of processes we test proves

to be prohibitively costly or to create unmanageable workloads or both,

we will either drop the model from consideration or revise the model

process to address the problem.

Regulatory Procedures

Executive Order 12866

The Office of Management and Budget (OMB) has reviewed these final

rules and determined they do not meet the criteria for a significant

regulatory action under E.O. 12866.

Paperwork Reduction Act

Data collection involved in the evaluation of any of the models may

necessitate new reporting or recordkeeping requirements which may need

clearance by OMB. These requirements are still being developed. When

specifics have been determined, any necessary request for clearance

will be forwarded to OMB as required by the Paperwork Reduction Act.

Regulatory Flexibility Act

We certify that these regulations will not have a significant

economic impact on a substantial number of small entities because they

affect individuals. Therefore, a regulatory flexibility analysis as

provided in Pub. L. 96-354, the Regulatory Flexibility Act, is not

required.

(Catalog of Federal Domestic Assistance Program Nos. 93.802, Social

Security-Disability Insurance; 93.807, Supplemental Security Income)

List of Subjects

20 CFR Part 404

Administrative practice and procedure, Death benefits, Disability

benefits, Old-Age, Reporting and recordkeeping requirements, Survivors

and Disability insurance.

20 CFR Part 416

Administrative practice and procedure, Aged, Blind, Disability

benefits, Public assistance programs, Reporting and recordkeeping

requirements, Supplemental Security Income.

Dated: February 15, 1995.

Shirley Chater,

Commissioner of Social Security.

Approved: March 30, 1995.

Donna E. Shalala,

Secretary of Health and Human Services.

For the reasons set out in the preamble, parts 404 and 416 of

chapter III of title 20 of the Code of Federal Regulations are amended

as set forth below.

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE

(1950- )

Subpart J is amended as follows:

1. The authority citation for subpart J of part 404 continues to

read as follows:

Authority: Secs. 201(j), 205 (a), (b), (d)-(h), and (j), 221(d),

and 1102 of the Social Security Act; 31 U.S.C. 3720A; 42 U.S.C.

401(j), 405(a), (b), (d)-(h), and (j), 421(d), and 1302, sec. 5 of

Pub. L. 97-455, 96 Stat. 2500; sec. 6 of Pub. L. 98-460, 98 Stat.

1802.

2. Section 404.906 is revised to read as follows:

Sec. 404.906 Testing modifications to the disability determination

procedures.

(a) Applicability and scope. Notwithstanding any other provision in

this part or part 422 of this chapter, we are establishing the

procedures set out [[Page 20027]] in this section to test modifications

to our disability determination process. These modifications will

enable us to test, either individually or in one or more combinations,

the effect of: having disability claim managers assume primary

responsibility for processing an application for disability benefits;

providing persons who have applied for benefits based on disability

with the opportunity for an interview with a decisionmaker when the

decisionmaker finds that the evidence in the file is insufficient to

make a fully favorable determination or requires an initial

determination denying the claim; having a single decisionmaker make the

initial determination with assistance from medical consultants, where

appropriate; and eliminating the reconsideration step in the

administrative review process and having a claimant who is dissatisfied

with the initial determination request a hearing before an

administrative law judge. The model procedures we test will be designed

to provide us with information regarding the effect of these procedural

modifications and enable us to decide whether and to what degree the

disability determination process would be improved if they were

implemented on a national level.

(b) Procedures for cases included in the tests. Prior to commencing

each test or group of tests in selected site(s), we will publish a

notice in the Federal Register. The notice will describe which model or

combinations of models we intend to test, where the specific test

site(s) will be, and the duration of the test(s). The individuals who

participate in the test(s) will be randomly assigned to a test group in

each site where the tests are conducted. Paragraphs (b) (1) through (4)

of this section lists descriptions of each model.

(1) In the disability claim manager model, when you file an

application for benefits based on disability, a disability claim

manager will assume primary responsibility for the processing of your

claim. The disability claim manager will be the focal point for your

contacts with us during the claims intake process and until an initial

determination on your claim is made. The disability claim manager will

explain the disability programs to you, including the definition of

disability and how we determine whether you meet all the requirements

for benefits based on disability. The disability claim manager will

explain what you will be asked to do throughout the claims process and

how you can obtain information or assistance through him or her. The

disability claim manager will also provide you with information

regarding your right to representation, and he or she will provide you

with appropriate referral sources for representation. The disability

claim manager may be either a State agency employee or a Federal

employee. In some instances, the disability claim manager may be

assisted by other individuals.

(2) In the single decisionmaker model, the decisionmaker will make

the disability determination and may also determine whether the other

conditions for entitlement to benefits based on disability are met. The

decisionmaker will make the disability determination after any

appropriate consultation with a medical or psychological consultant.

The medical or psychological consultant will not be required to sign

the disability determination forms we use to have the State agency

certify the determination of disability to us (see Sec. 404.1615).

However, before an initial determination is made that a claimant is not

disabled in any case where there is evidence which indicates the

existence of a mental impairment, the decisionmaker will make every

reasonable effort to ensure that a qualified psychiatrist or

psychologist has completed the medical portion of the case review and

any applicable residual functional capacity assessment pursuant to our

existing procedures (see Sec. 404.1617). In some instances the

decisionmaker may be the disability claim manager described in

paragraph (b)(1) of this section. When the decisionmaker is a State

agency employee, a team of individuals that includes a Federal employee

will determine whether the other conditions for entitlement to benefits

are met.

(3) In the predecision interview model, if the decisionmaker(s)

finds that the evidence in your file is insufficient to make a fully

favorable determination or requires an initial determination denying

your claim, a predecision notice will be mailed to you. The notice will

tell you that, before the decisionmaker(s) makes an initial

determination about whether you are disabled, you may request a

predecision interview with the decisionmaker(s). The notice will also

tell you that you may submit additional evidence. You must request a

predecision interview within 10 days after the date you receive the

predecision notice. You must also submit any additional evidence within

10 days after you receive the predecision notice. If you request a

predecision interview, the decisionmaker(s) will conduct the

predecision interview in person, by videoconference, or by telephone as

the decisionmaker(s) determines is appropriate under the circumstances.

If you make a late request for a predecision interview, or submit

additional evidence late, but show in writing that you had good cause

under the standards in Sec. 404.911 for missing the deadline, the

decisionmaker(s) will extend the deadline. If you do not request the

predecision interview, or if you do not appear for a scheduled

predecision interview and do not submit additional evidence, or if you

do not respond to our attempts to communicate with you, the

decisionmaker(s) will make an initial determination based upon the

evidence in your file. If you identify additional evidence during the

predecision interview, which was previously not available, the

decisionmaker(s) will advise you to submit the evidence. If you are

unable to do so, the decisionmaker(s) may assist you in obtaining it.

The decisionmaker(s) also will advise you of the specific timeframes

you have for submitting any additional evidence identified during the

predecision interview. If you have no treating source(s) (see

Sec. 404.1502), or your treating source(s) is unable or unwilling to

provide the necessary evidence, or there is a conflict in the evidence

that cannot be resolved through evidence from your treating source(s),

the decisionmaker(s) may arrange a consultative examination or resolve

conflicts according to existing procedures (see Sec. 404.1519a). If you

attend the predecision interview, or do not attend the predecision

interview but you submit additional evidence, the decisionmaker(s) will

make an initial determination based on the evidence in your file,

including the additional evidence you submit or the evidence obtained

as a result of the predecision notice or interview, or both.

(4) In the reconsideration elimination model, we will modify the

disability determination process by eliminating the reconsideration

step of the administrative review process. If you receive an initial

determination on your claim for benefits based on disability, and you

are dissatisfied with the determination, we will notify you that you

may request a hearing before an administrative law judge. If you

request a hearing before an administrative law judge, we will apply our

usual procedures contained in subpart J of this part.

PART 416--SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND

DISABLED

Subpart N is amended as follows:

1. The authority citation for subpart N of part 416 continues to

read as follows:

[[Page 20028]] Authority: Secs. 1102, 1631, and 1633 of the

Social Security Act; 42 U.S.C. 1302, 1383, and 1383b.

2. Section 416.1406 is revised to read as follows:

Sec. 416.1406 Testing modifications to the disability determination

procedures.

(a) Applicability and scope. Notwithstanding any other provision in

this part or part 422 of this chapter, we are establishing the

procedures set out in this section to test modifications to our

disability determination process. These modifications will enable us to

test, either individually or in one or more combinations, the effect

of: having disability claim managers assume primary responsibility for

processing an application for SSI payments based on disability;

providing persons who have applied for benefits based on disability

with the opportunity for an interview with a decisionmaker when the

decisionmaker finds that the evidence in the file is insufficient to

make a fully favorable determination or requires an initial

determination denying the claim; having a single decisionmaker make the

initial determination with assistance from medical consultants, where

appropriate; and eliminating the reconsideration step in the

administrative review process and having a claimant who is dissatisfied

with the initial determination request a hearing before an

administrative law judge. The model procedures we test will be designed

to provide us with information regarding the effect of these procedural

modifications and enable us to decide whether and to what degree the

disability determination process would be improved if they were

implemented on a national level.

(b) Procedures for cases included in the tests. Prior to commencing

each test or group of tests in selected site(s), we will publish a

notice in the Federal Register. The notice will describe which model or

combinations of models we intend to test, where the specific test

site(s) will be, and the duration of the test(s). The individuals who

participate in the test(s) will be randomly assigned to a test group in

each site where the tests are conducted. Paragraph (b) (1) through (4)

of this section lists descriptions of each model.

(1) In the disability claim manager model, when you file an

application for SSI payments based on disability, a disability claim

manager will assume primary responsibility for the processing of your

claim. The disability claim manager will be the focal point for your

contacts with us during the claims intake process and until an initial

determination on your claim is made. The disability claim manager will

explain the SSI disability program to you, including the definition of

disability and how we determine whether you meet all the requirements

for SSI payments based on disability. The disability claim manager will

explain what you will be asked to do throughout the claims process and

how you can obtain information or assistance through him or her. The

disability claim manager will also provide you with information

regarding your right to representation, and he or she will provide you

with appropriate referral sources for representation. The disability

claim manager may be either a State agency employee or a Federal

employee. In some instances, the disability claim manager may be

assisted by other individuals.

(2) In the single decisionmaker model, the decisionmaker will make

the disability determination and may also determine whether the other

conditions of eligibility for SSI payments based on disability are met.

The decisionmaker will make the disability determination after any

appropriate consultation with a medical or psychological consultant.

The medical or psychological consultant will not be required to sign

the disability determination forms we use to have the State agency

certify the determination of disability to us (see Sec. 416.1015).

However, before an initial determination is made that a claimant is not

disabled in any case where there is evidence which indicates the

existence of a mental impairment, the decisionmaker will make every

reasonable effort to ensure that a qualified psychiatrist or

psychologist has completed the medical portion of the case review and

any applicable residual functional capacity assessment pursuant to our

existing procedures (see Sec. 416.1017). Similarly, in making an

initial determination with respect to the disability of a child under

age 18 claiming SSI payments based on disability, the decisionmaker

will make reasonable efforts to ensure that a qualified pediatrician,

or other individual who specializes in a field of medicine appropriate

to the child's impairment(s), evaluates the claim of such child (see

Sec. 416.903(f)). In some instances the decisionmaker may be the

disability claim manager described in paragraph (b)(1) of this section.

When the decisionmaker is a State agency employee, a team of

individuals that includes a Federal employee will determine whether the

other conditions of eligibility for SSI payments are met.

(3) In the predecision interview model, if the decisionmaker(s)

finds that the evidence in your file is insufficient to make a fully

favorable determination or requires an initial determination denying

your claim, a predecision notice will be mailed to you. The notice will

tell you that, before the decisionmaker(s) makes an initial

determination about whether you are disabled, you may request a

predecision interview with the decisionmaker(s). The notice will also

tell you that you may also submit additional evidence. You must request

a predecision interview within 10 days after the date you receive the

predecision notice. You must also submit any additional evidence within

10 days after the date you receive the predecision notice. If you

request a predecision interview, the decisionmaker(s) will conduct the

predecision interview in person, by videoconference, or by telephone as

the decisionmaker(s) determines is appropriate under the circumstances.

If you make a late request for a predecision interview, or submit

additional evidence late, but show in writing that you had good cause

under the standards in Sec. 416.1411 for missing the deadline, the

decisionmaker(s) will extend the deadline. If you do not request the

predecision interview or if you do not appear for a scheduled