	Background

SSA administers two disability programs that provide monthly cash  benefits to eligible individuals: DI, enacted in 1956, and SSI, enacted in  1972. If SSA determines that an individual is disabled, the agency is required to  conduct periodic CDRs to ensure that only recipients who remain  disabled continue to receive benefits. SSA Has a Backlog of More Than 1 Million DI and SSI Benefit Eligibility Reviews

SSA reported in January 2014 that it is behind schedule in assessing the  continued eligibility of DI and SSI recipients and has accumulated a  backlog of 1.3 million CDRs. In recent years, SSA has cited resource  limitations and a greater emphasis on processing initial claims and  requests for hearings appeals as reasons for the decrease in the number  of CDRs conducted. 1). Children make up about one fifth of all SSI recipients, and we reported in  2012 that a large proportion of their CDRs were overdue. We also identified several cases which  exceeded their scheduled date by 13 years or more. Of the 24,000  childhood CDRs pending 6 years or more, we found that about 70 percent  (over 17,000) were for children who had been categorized as “medical  improvement possible” at initial determination, while 25 percent (over  6,000) of these pending CDRs were for those children deemed medically  expected to improve within 6 to 18 months of their initial determination  (see fig. 2). When CDRs are not conducted as scheduled, the potential for improper  payments may increase as some recipients can receive benefits for which  they are no longer eligible. In September 2011, SSA’s Office of the  Inspector General estimated that SSA had paid about $1.4 billion in SSI  benefits to approximately 513,000 recipients under age 18 who should  have not received them—some of whom were pending reviews for 5 or  more years. In our 2012 report, we recommended that SSA eliminate the existing  CDR backlog of cases for children with impairments who are likely to  improve and, on an ongoing basis, conduct CDRs at least every 3 years  for all children with impairments who are likely to improve, as resources  are made available for these purposes. Several Factors Associated with the Medical Improvement Standard Have Challenged the Assessment of Recipients’ Continued Eligibility

During CDRs, disability recipients that SSA determines have improved  medically may cease receiving benefits; however, several factors may  hinder SSA’s ability to make this determination. In 2006, our analysis of  SSA data showed that 1.4 percent of all the people who left DI and SSI  between fiscal years 1999 and 2005 did so because SSA found that they  had improved medically; however, more recipients left for other reasons,  including conversion to regular Social Security retirement benefits or  death. At that time, we identified a number of factors that challenged  SSA’s ability to assess DI and SSI recipients using the medical  improvement standard. Guidance limitations—Limitations in the SSA guidance then in effect  for applying the medical improvement standard may have resulted in  inconsistent disability decisions. Inadequate documentation—If a prior disability determination was  inadequately documented, it can be challenging for the disability  examiner to demonstrate medical improvement in a CDR. We  reported that this practice is contrary to the law as well as SSA  regulations and policy, which require that CDR decisions be made on  a “neutral basis.”
Reliance on judgment—The judgmental nature of the process for  assessing medical improvement likely hinders its reliability. These issues have implications for the consistency and fairness of SSA’s  medical improvement decision-making process, and in 2006, we  recommended that SSA clarify policies for assessing medical  improvement. Since then, SSA has taken some steps that may help  address the issues we raised but has not fully implemented the actions  we recommended.
Why GAO Did This Study

SSA administers DI and SSI, two disability programs that provided $189 billion in cash benefits to eligible adults and children in 2012. Both the numbers of DI and SSI recipients, as well as program costs, have grown in recent years and are poised to grow further in the future. Both the initial determination of an individual's medical eligibility at the time of application and CDRs after benefits have been granted are key to ensuring the integrity of these programs. CDRs also provide a check on program growth in a time of constrained federal resources. Since 1984, federal law has generally required SSA to find substantial evidence demonstrating medical improvement during a CDR before ceasing a recipient's benefits—known as the medical improvement standard.
In this statement, GAO describes (1) SSA's efforts to monitor DI and SSI beneficiaries' continued eligibility, and (2) factors associated with the medical improvement standard that affect these efforts. This testimony is primarily based on GAO products related to these issues from 2006 and 2012. GAO also updated selected information related to SSA's CDR backlog, budget requests, and guidance for assessing medical improvement as of 2014.

What GAO Found

The Social Security Administration (SSA) reported in January 2014 that it is behind schedule in assessing the continued eligibility of recipients in its two disability programs, Disability Insurance (DI) and Supplemental Security Income (SSI),and has accumulated a backlog of 1.3 million continuing disability reviews (CDRs). From fiscal years 2000 to 2011, the numbers of adult and child CDRs conducted fell about 70 percent. Children make up about one fifth of all SSI recipients, and GAO reported in 2012 that many of their CDRs were overdue. For example, more than 24,000 CDRs for children with mental impairments were overdue by 6 or more years, including over 6,000 CDRs for children who were expected to medically improve within 6 to 18 months of their initial determination. GAO also identified several cases which exceeded their scheduled review date by 13 years or more. When CDRs are not conducted as scheduled, the potential for improper payments increases as some recipients receive benefits for which they are no longer eligible. In September 2011, SSA's Office of the Inspector General estimated that SSA had paid about $1.4 billion in SSI benefits to children who should have not received them. SSA attributes delays in performing CDRs to resource limitations and other factors; SSA also generally gives lower priority to conducting CDRs for children receiving SSI. In 2012, GAO recommended that SSA eliminate the existing CDR backlog for children with impairments who are likely to improve, and regularly conduct reviews for this group. While SSA generally agreed with GAO's recommendation, the CDR backlog remains.
During CDRs, disability recipients that SSA determines to have improved medically may be removed from the program; however, several factors may hinder SSA's ability to make this determination. In 2006, GAO reported that 1.4 percent of people who left the disability programs did so because SSA found that they had improved medically. At that time, GAO identified several factors that hindered SSA's ability to assess whether DI and SSI recipients met the medical improvement standard. These included: (1) limitations in SSA guidance for applying the standard; (2) inadequate documentation of prior disability determinations; (3) failure to abide with the requirement that CDR decisions be made on a neutral basis—without a presumption that the recipient remained disabled; and (4) the judgmental nature of the process for assessing medical improvement. Since 2006, SSA has taken some steps to address these issues; however, the agency has not fully clarified policies for assessing medical improvement, as GAO recommended.

What GAO Recommends

GAO is not making any new recommendations at this time.