SSR 80-36 (Rescinded 2/9/1995)
PURPOSE: To establish policy concerning the types of impairments subject to findings of presumption disability (PD) and presumptive blindness (PB) by district office personnel.
CITATIONS (AUTHORITY): Section 1631(a)(4)(B) of the Social Security Act, as amended by section 4 of Public Law 94-569; Regulations No. 16, section 416.934.
PERTINENT HISTORY: The Social Security Act provides for the payment of supplemental security income (SSI) benefits for a period not to exceed 3 months prior to making a formal determination of disability or blindness if the individual is presumptively disabled or presumptively blind and otherwise eligible for SSI benefits. The initial policy which defined and implemented the PD provisions provided for only limited findings of PD by district office (DO) personnel, restricted to the following three impairment situations:
The DO PD categories were expanded in March 1975 to encompass additional impairment areas. These categories were designated as experimental, subject to revision if shown necessary by experience. Experience to date shows that the DO categories have acceptable accuracy rates. For example, the latest data show that 5 percent of the DO PD findings for the June 1977 quarter were subsequently reversed upon formal Disability Determination Services (DDS) determination; this compares to an 18 percent reversal rate for DDS PD findings for the same period. (DDS PD findings, however, are made on a wide range of impairments and involve judgmental evaluation.)
Initial policy also provided that individuals facing financial emergency who alleged total blindness could be paid the single advance payment, the finding being made by DO personnel in the same manner as the original three PD categories. Section 1631(a)(4)(B) was recently amended by section 4 of P.L. 94-569, which extended the presumptive provision to the blind. Following this amendment, "allegation of total blindness" was added as a DO category to provide for DO decisions of PB.
POLICY STATEMENT: The following policy for PD and PB determinations made by the DO is based on the experience with the experimental categories which have been applied by DO personnel. All DO PD and PB categories will be applied without medical evidence since DO personnel have neither routine access to medical reports nor the training to evaluate them. All categories of PD and PB made by the DO must relate to impairments that can be directly observed by DO personnel or can be readily verified by reliable third parties who can be contacted by phone by DO personnel. A finding of PD or PB will be made when these factors apply unless observations or phone contacts made by DO personnel are inconsistent with the applicant's description or allegation of the impairment.
Categories in which the DO may currently make PD and PB determinations, listed below, may be modified by Office of Operational Policy and Procedure, if warranted by program experience. This may include not only a change in the wording of a particular category, but also the elimination of an existing category in the event that continuing program experience should indicate that a category results in DO PD or PB determinations that are frequently reversed upon formal disability or blindness determination.
A reversal rate of over 10 percent, averaged over several months, should be considered excessive. Any category with this rate of reversal should be considered for deletion. This 10 percent goal, however, does not preclude attempts to lower the reversal rate before deleting a category. When there is a likelihood that a change in instructions or management emphasis will result in a lower reversal rate, these modifications may be implemented and tested for a reasonable period. Also, new categories may be added and tested to determine their usefulness and accuracy. All modifications or additions, however, must be consistent with the general policy regarding evidence and observable characteristics described in the first paragraph of this section.
In the case of categories (i) and (j), the impairment is largely manifested by behavior rather than physical characteristics; although in the case of category (i), Down's Syndrome, physical characteristics are present and a description of these characteristics can be included in the operating instructions to the DO to assist in the verification of this category. The verification of category (j), the general mental deficiency category, will usually be entirely dependent upon observations of behavior. In situations where the DO representative has an opportunity has an opportunity to observe the claimant, the claimant's general behavior may, in some cases, provide convincing confirmation of the allegation of severe mental deficiency. However, when the DO is unable to make a PD decision in this category because the alleged impairment is not readily apparent or because the claimant was not observed, the DO should contact a reliable lay source, supplied by the applicant, by phone to confirm the allegation. Contact sources include schools and organizations who assist persons with this impairment. Although the DO should not make direct requests for confirmation to medical sources, this does not preclude contact with an organization or institution merely because medical treatment constitutes one aspect of their services. Such organizations often have social workers or other contact personnel who can supply the necessary information. (Although categories (a) through (h) are usually readily observable, DO's may also use this type of phone contact for them, if appropriate, in a particular case.)
FURTHER INFORMATION: Final regulations covering these policies were published in the Federal Register on August 20, 1980, at 45 FR 55566.
CROSS REFERENCES: Claims Manual section 12752.
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