Medical CDRs & Age-18 Redeterminations

Overview

This tool covers the Supplemental Security Income (SSI) program’s two types of medical reviews: the medical Continuing Disability Review (CDR) and the Age-18 Redetermination. You will also find important information about special rules for medical CDR holds and the Section 301 Safety Net.

About the Medical Continuing Disability Review (CDR)

An SSI medical CDR determines if an SSI beneficiary still meets SSI disability criteria.

The review first considers if the individual’s condition has medically improved. If it is decided that the condition has improved, the review then considers whether the individual is still disabled under SSI criteria. The medical CDR for children uses SSI’s disability criteria for children, while the adult CDR uses the disability criteria for adults. (For more about SSI disability criteria, see Tool 1.)

A medical CDR can play out in two different ways:

• SSI benefits continue: This happens if there is no medical improvement, or if there has been improvement but the individual still meets the disability criteria.
• SSI benefits end: This occurs if there has been medical improvement and the individual’s disability no longer meets SSI’s criteria. However, beneficiaries have the right to appeal that decision (see Tool 1). In addition, for youth ages 18 through 22, the Section 301 Safety Net may apply (see below).

Timing for Medical CDRs

The CDR schedule depends on the likelihood that an individual’s condition will medically improve.

Most SSI beneficiary cases are categorized as Medical Improvement Possible and for those individuals, the review occurs every 3–5 years. A review occurs more often if the case is categorized as Medical Improvement Expected, or less often for Medical Improvement Not Expected.

An adult who has a Ticket to Work and meets certain criteria should not experience a medical CDR. This is because SSA will put medical CDRs on hold during this time period (see below).

The CDR Process for a Child under Age 18

All children under age 18 get a full medical CDR. Social Security Administration (SSA) staff typically begin a child's CDR by discussing it with the parent or other person who serves as the representative payee. This discussion occurs during an in-person appointment at an SSA field office or by phone. The SSA claims specialist will ask the parent/payee to complete required forms. These forms ask about the child’s disabilities or medical condition, and the type of educational services that the child receives.

Since childhood disability criteria considers how the child functions in both school and non-school settings when compared to peers who are not disabled, parents should be sure to address these issues on any SSA forms they fill out. Parents must also make sure that SSA receives any special education records that address these issues.

After these initial steps, the case is forwarded to the State Disability Determination Services (DDS) office. This office, which is under contract with SSA, does the full CDR work up and makes a decision:

• SSI benefits continue: If the DDS office finds that the child is still disabled, benefits will continue, and SSI will set a new review date in the future.
• SSI benefits end: If the DDS office finds that the child is no longer disabled, as it will in many cases, SSA must send a notice informing the parent/payee of the decision and of the right to appeal. (For more about appeals, see Tool 1.)

The Age-18 Redetermination

All youth who receive SSI at age 18 are subject to an Age-18 Redetermination. The Age-18 Redetermination usually occurs when the young adult is between ages 18 and 20. It determines whether the beneficiary meets the SSI disability criteria for adults. Unlike the medical CDR, which looks for evidence of medical improvement, this review is a new, initial determination. It follows the same review process used for any new adult SSI application.

An Age-18 Redetermination has two possible results:

• SSI benefits continue: If SSA, through the State DDS, determines that the beneficiary’s condition meets SSI’s disability standard for adults, benefits will continue with a new review date set.
• SSI benefits end: If SSA determines that the condition does not meet the adult disability standard, as it will in many cases, SSI benefits will be terminated—subject to the right to appeal (see Tool 1). In addition, the Section 301 Safety Net may apply (see below).

The CDR Process for Adults

The adult CDR process is similar to that described above for children, but with a few differences.

Approximately 40 percent of adult SSI beneficiaries are selected for a full medical CDR. The remaining 60 percent go through the much shorter “mailer process.”

SSA’s Self-Help Mailer asks the beneficiary or their payee to provide medical, employment, educational, and other relevant information for the past 2 years. SSA evaluates this information. About 92 percent of the time, the review determines that the individual is still disabled, and benefits continue. The other 8 percent of the time, more information is needed to make a decision. If more information is needed, the individual will be asked to complete a full medical CDR.

SSA refers full medical CDRs to the State DDS office, which will focus on the beneficiary’s ability to work despite their medical condition. Unless the adult was in a public school program within the past 2 years, the review will probably not seek information from educators. School records can be important, however, if they reflect on disability-related deficits that are relevant in the workplace.

Like children’s medical CDRs, SSA often starts with a personal contact and will ask the beneficiary or their payee to complete several required forms. If a VR counselor is assisting, the counselor should urge the recipient or payee to complete these forms carefully or to ask a service provider or SSA for assistance.

The result of an adult medical CDR is one of two outcomes:

• SSI benefits continue: Often, DDS will find that the person is still disabled, and SSI will continue with a future review date set.
• SSI benefits end: If the review finds the person no longer disabled, SSA must send a notice informing the person, or the payee, of the decision. The notice must mention that it can be appealed (for more about appeals, see Tool 1).

Two Special Rules for Medical CDRs and Age-18 Redeterminations

A medical CDR or an Age-18 Redetermination can cause uncertainty and anxiety. This is because they can cause SSI benefits to end. These benefits are often a key source of income. Plus, any loss of SSI may eliminate Medicaid eligibility in most states. Two special programs can make those reviews less concerning:

SSI beneficiaries can get special protection from medical CDRs if they are using the Ticket to Work program. In addition, even if SSA finds that a person is no longer disabled after a CDR or Age-18 Redetermination, SSI payments can continue through the Section 301 Safety Net if the beneficiary is in a qualifying educational or vocational rehabilitation program.

Ticket to Work Can Put Medical CDRs on Hold

Adult beneficiaries of SSI or Social Security Disability Insurance (SSDI), ages 18 through 64, can assign their Ticket to Work to receive services through an Employment Network (EN). The purpose of these services is to help beneficiaries meet work goals. The EN gets paid only when a beneficiary meets certain levels of progress toward an employment goal.

A beneficiary can also get free services from a State VR agency to support a work goal. If a beneficiary assigns their Ticket to the State VR agency serving them, they are treated as getting services through the Ticket to Work program for the purposes of putting a hold on a medical CDR.

If a beneficiary has assigned their Ticket to Work to an Employment Network or is receiving services from a State VR agency through a written, Individual Plan for Employment (IPE), SSA will put a hold on their scheduled medical CDR if they are making “timely progress,” through incremental steps toward self-supporting employment.

Timely progress requirements can be met by:

• Working with wages increasing incrementally over a period of years.
• Making incremental progress in an education or training program. For example, a beneficiary could be earning a high school diploma or GED, or earning credits toward a college degree. Another example is making progress in a technical, trade, or vocational school.
• Having a combination of work and education/training program activity.

Section 301 Safety Net

Section 301 allows SSI to continue after SSA finds the person to be no longer disabled. Section 301 protection can occur if the person is involved in an educational or vocational program that will likely lead to employment and no future need for SSI. 

To get 301 protection, the person must generally meet two criteria:

• The program began before SSA found the person to be no longer disabled.
• Staying in the program makes it more likely that the person will not qualify for SSI in the future. However, as noted below, in some cases, this part of the criteria does not need to be met.

Common ways to keep benefits using Section 301 are these:

• The SSI beneficiary is age 18 through 21 and remaining in school while receiving special education services with an Individualized Education Plan (IEP). There is no need for a vocational program or to show that the person will be unlikely to qualify for SSI in the future.
• The person is age 14 through 64 and receives services from the State VR agency with an IPE and a work goal. In this case, there needs to be a finding that this makes it more likely that the beneficiary will not qualify for SSI in the future.

Although the beneficiary has a separate right to continued SSI benefits by appealing, sometimes beneficiaries fail to appeal, do not ask for continued benefits, or appeals are exhausted while Section 301 protections continue.