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| section_id ▼ | title_number | title_name | chapter | subchapter | part_number | part_name | subpart | subpart_name | section_number | section_heading | agency | authority | source_citation | amendment_citations | full_text |
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| 20:20:1.0.2.8.16.1.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | A | Subpart A—General | § 220.1 Introduction of part. | SSA | (a) This part explains how disability determinations are made by the Railroad Retirement Board. In some determinations of disability entitlement, as described below, the Board makes the decision of disability under the Railroad Retirement Act based on the regulations set out in this part. However, in certain other determinations of disability entitlement (as also described below) the Board has the authority to decide whether the claimant is disabled as that term is defined in the Social Security Act and the regulations of the Social Security Administration. (b) In order for a claimant to become entitled to a railroad retirement annuity based on disability for his or her regular railroad occupation, or to become entitled to a railroad retirement annuity based on disability for any regular employment as an employee, widow(er), or child, he or she must be disabled as those terms are defined in the Railroad Retirement Act. In order for a claimant to become entitled to a period of disability, to early Medicare coverage based on disability, to benefits under the social security overall minimum, or to a disability annuity as a surviving divorced spouse or remarried widow(er), the claimant must be found disabled as that term is defined in the Social Security Act. | ||||
| 20:20:1.0.2.8.16.1.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | A | Subpart A—General | § 220.2 The basis for the Board's disability decision. | SSA | (a) The Board makes disability decisions for claims of disability under the Railroad Retirement Act. These decisions are based either on the rules contained in the Board's regulations in this part or the rules contained in the regulations of the Social Security Administration, whichever is controlling. (b) A disability decision is made only if the claimant meets other basic eligibility requirements for the specific disability benefit for which he or she is applying. For example, a claimant for an occupational disability annuity must first meet the eligibility requirements for that annuity, as explained in part 216 of this chapter, in order for the Board to make a disability decision. | ||||
| 20:20:1.0.2.8.16.1.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | A | Subpart A—General | § 220.3 Determinations by other organizations and agencies. | SSA | Determinations of the Social Security Administration or any other governmental or non-governmental agency about whether or not a claimant is disabled under the laws, regulations or standards administered by that agency shall be considered by the Board but are not binding on the Board. | ||||
| 20:20:1.0.2.8.16.10.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | J | Subpart J—Residual Functional Capacity | § 220.120 The claimant's residual functional capacity. | SSA | [68 FR 60293, Oct. 22, 2003, as amended at 74 FR 63601, Dec. 4, 2009] | (a) General. The claimant's impairment(s), and any related symptoms, such as pain, may cause physical and mental limitations that affect what the claimant can do in a work setting. The claimant's residual functional capacity is what the claimant can still do despite the claimant's limitations. If the claimant has more than one impairment, the Board will consider all of the claimant's impairment(s) of which the Board is aware. The Board will consider the claimant's ability to meet certain demands of jobs, such as physical demands, mental demands, sensory requirements, and other functions, as described in paragraphs (b), (c), and (d) of this section. Residual functional capacity is an assessment based upon all of the relevant evidence. It may include descriptions (even the claimant's own) of limitations that go beyond the symptoms, such as pain, that are important in the diagnosis and treatment of the claimant's medical condition. Observations by the claimant's treating or examining physicians or psychologists, the claimant's family, neighbors, friends, or other persons, of the claimant's limitations, in addition to those observations usually made during formal medical examinations, may also be used. These descriptions and observations, when used, must be considered along with the claimant's medical records to enable us to decide to what extent the claimant's impairment(s) keeps the claimant from performing particular work activities. This assessment of the claimant's remaining capacity for work is not a decision on whether the claimant is disabled, but is used as the basis for determining the particular types of work the claimant may be able to do despite the claimant's impairment(s). Then, using the guidelines in §§ 220.125 and 220.134 of this part the claimant's vocational background is considered along with the claimant's residual functional capacity in arriving at a disability determination or decision. In deciding whether the claimant's disability continues or ends, the residual functional capacity assessme… | |||
| 20:20:1.0.2.8.16.10.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | J | Subpart J—Residual Functional Capacity | § 220.121 Responsibility for assessing and determining residual functional capacity. | SSA | (a) For cases at the initial or reconsideration level, the responsibility for determining residual functional capacity rests with the bureau of retirement claims. This assessment is based on all the evidence the Board has, including any statements regarding what the claimant can still do that have been provided by treating or examining physicians, consultative physicians, or any other physician designated by the Board. In any case where there is evidence which indicates the existence of a mental impairment, the bureau of retirement claims will not make a residual functional capacity determination without making every reasonable effort to ensure that a qualified psychiatrist or psychologist has provided a medical review of the case. (b) For cases at the hearing level or the three-member-Board review level, the responsibility for deciding residual functional capacity rests with the hearings officer or the three-member Board, respectively. | ||||
| 20:20:1.0.2.8.16.11.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.125 When vocational background is considered. | SSA | (a) General. The Board will consider vocational factors when the claimant is applying for— (1) An employee annuity based on disability for any regular employment; (See § 220.45(b)) (2) Widow(er) disability annuity; or (3) Child's disability annuity based on disability before age 22. (b) Disability determinations in which vocational factors must be considered along with medical evidence. When the Board cannot decide whether the claimant is disabled on medical evidence alone, the Board must use other evidence. (1) The Board will use information from the claimant about his or her age, education, and work experience. (2) The Board will consider the doctors' reports, and hospital records, as well as the claimant's own statements and other evidence to determine a claimant's residual functional capacity and how it affects the work the claimant can do. Sometimes, to do this, the Board will need to ask the claimant to have special examinations or tests. (See § 220.50.) (3) If the Board finds that the claimant can no longer do the work he or she has done in the past, the Board will determine whether the claimant can do other work (jobs) which exist in significant numbers in the national economy. | ||||
| 20:20:1.0.2.8.16.11.155.10 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.134 Medical-vocational guidelines in appendix 2 of this part. | SSA | (a) The Dictionary of Occupational Titles includes information about jobs (classified by their exertional and skill requirements) that exist in the national economy. Appendix 2 of this part provides rules using this data reflecting major functional and vocational patterns. (b) The Board applies that rules in appendix 2 of this part in cases where a claimant is not doing substantial gainful activity and is prevented by a severe impairment(s) from doing vocationally relevant past work. (c) The rules in appendix 2 of this part do not cover all possible variations of factors. The Board does not apply these rules if one of the findings of fact about the claimant's vocational factors and residual functional capacity is not the same as the corresponding criterion of a rule. In these instances, the Board gives full consideration to all relevant facts in accordance with the definitions and discussions under vocational considerations. However, if the findings of fact made about all factors are the same as the rule, the Board uses that rule to decide whether that claimant is disabled. | ||||
| 20:20:1.0.2.8.16.11.155.11 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.135 Exertional and nonexertional limitations. | SSA | [68 FR 60294, Oct. 22, 2003] | (a) General. The claimant's impairment(s) and related symptoms, such as pain, may cause limitations of function or restrictions which limit the claimant's ability to meet certain demands of jobs. These limitations may be exertional, nonexertional, or a combination of both. Limitations are classified as exertional if they affect the claimant's ability to meet the strength demands of jobs. The classification of a limitation as exertional is related to the United States Department of Labor's classification of jobs by various exertional levels (sedentary, light, medium, heavy, and very heavy) in terms of the strength demands for sitting, standing, walking, lifting, carrying, pushing, and pulling. Sections 220.132 and 220.134 of this part explain how the Board uses the classification of jobs by exertional levels (strength demands) which is contained in the Dictionary of Occupational Titles published by the Department of Labor, to determine the exertional requirements of work which exists in the national economy. Limitations or restrictions which affect the claimant's ability to meet the demands of jobs other than the strength demands, that is, demands other than sitting, standing, walking, lifting, carrying, pushing or pulling, are considered nonexertional. Sections 220.100(b)(5) and 220.180(h) of this part explain that if the claimant can no longer do the claimant's past relevant work because of a severe medically determinable impairment(s), the Board must determine whether the claimant's impairment(s), when considered along with the claimant's age, education, and work experience, prevents the claimant from doing any other work which exists in the national economy in order to decide whether the claimant is disabled or continues to be disabled. Paragraphs (b), (c), and (d) of this section explain how the Board applies the medical-vocational guidelines in appendix 2 of this part in making this determination, depending on whether the limitations or restrictions imposed by the claimant's impairment(s) and related sympt… | |||
| 20:20:1.0.2.8.16.11.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.126 Relationship of ability to do work and residual functional capacity. | SSA | (a) If the claimant can do his or her previous work (his or her usual work or other applicable past work), the Board will determine he or she is not disabled. (b) If the residual functional capacity is not enough for the claimant to do any of his or her previous work, the Board must still decide if the claimant can do any other work. To determine whether the claimant can do other work, the Board will consider the claimant's residual functional capacity, and his or her age, education, and work experience. Any work (jobs) that the claimant can do must exist in significant numbers in the national economy (either in the region where he or she lives or in several regions of the country). | ||||
| 20:20:1.0.2.8.16.11.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.127 When the only work experience is arduous unskilled physical labor. | SSA | (a) Arduous work. Arduous work is primarily physical work requiring a high level of strength or endurance. The Board will consider the claimant unable to do lighter work and therefore, disabled if he or she has— (1) A marginal education (see § 220.129); (2) Work experience of 35 years or more during which he or she did arduous unskilled physical labor; and (3) A severe impairment which no longer allows him or her to do arduous unskilled physical labor. (b) Exceptions. The Board may consider the claimant not disabled if— (1) The claimant is working or has worked despite his or her impairment(s) (except where work is sporadic or not medically advisable); or (2) Evidence shows that the claimant has training or past work experience which enables him or her to do substantial gainful activity in another occupation with his or her impairment, either full-time or on reasonably regular part-time basis. | ||||
| 20:20:1.0.2.8.16.11.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.128 Age as a vocational factor. | SSA | (a) General. (1) Age refers to how old the claimaint is (chronological age) and the extent to which his or her age affects his or her ability to— (i) Adapt to a new work situation; and (ii) Do work in competition with others. (2) In determining disability, the Board does not consider age alone. The Board must also consider the claimant's residual functional capacity, education, and work experience. If the claimant is unemployed because of his or her age and can still do a significant number of jobs which exist in the national economy, the Board will find that he or she is not disabled. Appendix 2 of this part explains in detail how the Board considers age as a vocational factor. However, the Board does not apply these age categories mechanically in a borderline situation. (b) Younger person. If the claimant is under age 50, the Board generally does not consider that his or her age will seriously affect the ability to adapt to a new work situation. In some circumstances, the Board considers age 45 a handicap in adapting to a new work setting (see Rule 201.17 in appendix 2 of this part). (c) Person approaching advanced age. If the claimant is closely approaching advanced age (50-54), the Board considers that the claimant's age, along with a severe impairment and limited work experience, may seriously affect the claimant's ability to adjust to a significant number of jobs in the national economy. (d) Person of advanced age. The Board considers that advanced age (55 or over) is the point at which age significantly affects the claimant's ability to do substantial gainful activity. (1) If the claimant is severly impaired and of advanced age, and he or she cannot do medium work (see § 220.132), the claimant may not be able to work unless he or she has skills that can be used in less demanding jobs which exist in significant numbers in the national economy. (2) If the claimant is close to retirement age (60-64) and has a severe impairment, the Board will not consider him or her able to adjust to sedenta… | ||||
| 20:20:1.0.2.8.16.11.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.129 Education as a vocational factor. | SSA | (a) General. “Education” is primarily used to mean formal schooling or other training which contributes to the claimant's ability to meet vocational requirements, for example, reasoning ability, communication skills, and arithmetical ability. If the claimant does not have formal schooling, this does not necessarily mean that the claimant is uneducated or lacks these abilities. Past work experience and the kinds of responsibilities the claimant had when he or she was working may show that he or she has intellectual abilities, although the claimant may have little formal education. A claimant's daily activities, hobbies, or the results of testing may also show that the claimant has significant intellectual ability that can be used to work. (b) How the Board evaluates the claimant's education. The importance of the claimant's educational background may depend upon how much time has passed between the completion of the claimant's formal education and the beginning of the claimant's physical or mental impairment(s) and what the claimant has done with his or her education in a work or other setting. Formal education completed many years before the claimant's impairment(s) began, or unused skills and knowledge that were a part of the claimant's formal education, may no longer be useful or meaningful in terms of ability to work. Therefore, the numerical grade level that the claimant completed in school may not represent his or her actual educational abilities. These educational abilities may be higher or lower than the numerical grade level that the claimant completed. However, if there is no other evidence to contradict it, the Board uses the claimant's numerical grade level to determine the claimant's educational abilities. The term “education” also includes how well the claimant is able to communicate in English since this ability is often acquired or improved by education. In evaluating the claimant's educational level, the Board uses the following categories: (1) Illiteracy. Illiteracy means the inability to… | ||||
| 20:20:1.0.2.8.16.11.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.130 Work experience as a vocational factor. | SSA | (a) General. Work experience means skills and abilities the claimant has acquired through work he or she has done which show the type of work he or she may be expected to do. Work the claimant has already been able to do shows the kind of work that he or she may be expected to do. The Board considers that the claimant's work experience is relevant and applies when it was done within the last 15 years, lasted long enough for him or her to learn to do it, and was substantial gainful activity. This work experience is called “past relevant work.” The Board does not usually consider that work the claimant did 15 years or more before the time the Board is deciding whether he or she is disabled (or when the disability insured status requirement was last met, if earlier) applies. A gradual change occurs in most jobs so that after 15 years, it is no longer realistic to expect that skills and abilities acquired in a job done then continue to apply. The 15-year guide is intended to insure that remote work experience is not currently applied. If the claimant has no work experience or worked only “off-and-on” or for brief periods of time during the 15-year period, the Board generally considers that these do not apply. If the claimant has acquired skills through his or her past work, the Board considers the claimant to have these work skills unless he or she cannot use them in other skilled or semi-skilled work that he or she can do. If the claimant cannot use his or her skills in other skilled or semi-skilled work, the Board will consider his or her work background the same as unskilled. However, even if the claimant has no work experience, the Board may consider that the claimant is able to do unskilled work because it requires little or no judgment and can be learned in a short period of time. (b) Information about the claimant's work. (1) Sometimes the Board will need information about the claimant's past work to make a disability determination. The Board may request work information from— (i) The claimant; and (i… | ||||
| 20:20:1.0.2.8.16.11.155.7 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.131 Work which exists in the national economy. | SSA | (a) General. The Board considers that work exists in the national economy when it exists in significant numbers either in the region where the claimant lives or in several other regions of the country. It does not matter whether— (1) Work exits in the immediate area in which the claimant lives, (2) A specific job vacancy exists for the claimant; or (3) The claimant would be hired if the claimant applied for work. (b) How the Board determines the existence of work. Work exists in the national economy when there are a significant number of jobs (in one or more occupations) having requirements which the claimant is able to meet with his or her physical or mental ability and vocational qualifications. Isolated jobs that exist in very limited numbers in relatively few locations outside the region where the claimant lives are not considered “work which exists in the national economy.” The Board will not deny the claimant a disability annuity on the basis of the existence of these kinds of jobs. The Board will determine that the claimant is disabled if the work he or she can do does not exist in the national economy. If the work the claimant can do does exist in the national economy, the Board will determine that the claimant is not disabled. (c) Inability to obtain work. The Board will determine that the claimant is not disabled if he or she has the residual functional capacity and vocational abilities to do work which exists in the national economy but the claimant remains unemployed because of— (1) His or her inability to get work; (2) Lack of work in his or her local area; (3) The hiring practices of employers; (4) Technological changes in the industry in which the claimant has worked; (5) Cyclical economic conditions; (6) No job openings for the claimant; (7) The claimant not actually being hired to do work he or she could otherwise do; or (8) The claimant not wishing to do a particular type of work. (d) Administrative notice of job data. The following sources are used when the Board determine… | ||||
| 20:20:1.0.2.8.16.11.155.8 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.132 Physical exertion requirements. | SSA | To determine the physical exertion requirements of work in the national economy, jobs are classified as “sedentary”, “light”, “medium”, “heavy”, and “very heavy.” These terms have the same meaning as they have in the Dictionary of Occupational Titles, published by the Department of Labor. In making disability determinations the Board uses the following definitions: (a) Sedentary work. Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and the other sedentary criteria are met. (b) Light work. Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, the claimant must have the ability to do substantially all of these activities. If the claimant can do light work, the Board determines that he or she can also do sedentary work, unless there are additional limiting factors such as loss of fine dexerity or inability to sit for long periods of time. (c) Medium work. Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds. If the claimant can do medium work, the Board determines that he or she can also do sedentary and light work. (d) Heavy work. Heavy work involves lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50 pounds. If the claimant can do heavy work, the Board determines that he or… | ||||
| 20:20:1.0.2.8.16.11.155.9 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | K | Subpart K—Vocational Considerations | § 220.133 Skill requirements. | SSA | (a) General. To evaluate skills and to help determine the existence in the national economy of work the claimant is able to do, occupations are classified as unskilled, semi-skilled, and skilled. In classifying these occupations, the Board uses materials published by the Department of Labor. (b) Unskilled work. Unskilled work is work which needs little or no judgment to do simple duties that can be learned on the job in a short period of time (30 days). The job may or may not require considerable strength. A job is considered unskilled if the claimant can usually learn to do the job in 30 days, and little job training and judgment are needed. The claimant does not gain work skills by doing unskilled jobs. For example, jobs are considered unskilled if primary work duties are— (1) Handling; (2) Feeding; (3) Offbearing (placing or removing materials from machines which are automatic or operated by others); or (4) Machine tending. (c) Semi-skilled work. Semi-skilled work is work which needs some skills but does not require doing the more complex work duties. A job may be classified as semi-skilled where coordination and dexterity are necessary, as when hand or feet must be moved quickly to do repetitive tasks. Semi-skilled jobs may require— (1) Alertness and close attention to watching machine processes; (2) Inspecting, testing, or otherwise looking for irregularities; (3) Tending or guarding equipment, property, materials, or persons against loss, damage, or injury; or (4) Other types of activities which are similarly less complex than skilled work but more complex than unskilled work. (d) Skilled work. Skilled work requires qualifications in which a person uses judgment to determine the machine and manual operations to be performed in order to obtain the proper form, quality, or quantity of material to be produced. Skilled jobs may require— (1) Laying out work; (2) Estimating quality; (3) Determining suitability and needed quantities of materials; (4) Making precise measurements; (5) Reading… | ||||
| 20:20:1.0.2.8.16.12.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.140 General. | SSA | The work that a claimant has done during any period in which the claimant believes he or she is disabled may show that the claimant is able to do work at the substantial gainful activity level. If the claimant is able to engage in substantial gainful activity, the Board will find that the claimant is not disabled for any regular employment under the Railroad Retirement Act. Even if the work the claimant has done was not substantial gainful activity, it may show that the claimant is able to do more work than he or she actually did. The Board will consider all of the medical and vocational evidence in the claimant's file to decide whether or not the claimant has the ability to engage in substantial gainful activity. | ||||
| 20:20:1.0.2.8.16.12.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.141 Substantial gainful activity, defined. | SSA | Substantial gainful activity is work activity that is both substantial and gainful. (a) Substantial work activity. Substantial work activity is work activity that involves doing significant physical or mental activities. The claimant's work may be substantial even if it is done on a part-time basis or if the claimant does less, gets paid less, or has less responsibility than when the claimant worked before. (b) Gainful work activity. Gainful work activity is work activity that the claimant does for pay or profit. Work activity is gainful if it is the kind of work usually done for pay or profit, whether or not a profit is realized. (c) Some other activities. Generally, the Board does not consider activities like taking care of one's self, household tasks, hobbies, therapy, school attendance, club activities, or social programs to be substantial gainful activity. | ||||
| 20:20:1.0.2.8.16.12.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.142 General information about work activity. | SSA | (a) The nature of the claimant's work. If the claimant's duties require use of the claimant's experience, skills, supervision and responsibilities, or contribute substantially to the operation of a business, this tends to show that the claimant has the ability to work at the substantial gainful activity level. (b) How well the claimant performs. The Board considers how well the claimant does his or her work when the Board determines whether or not the claimant is doing substantial gainful activity. If the claimant does his or her work satisfactorily, this may show that the claimant is working at the substantial gainful activity level. If the claimant is unable, because of his or her impairments, to do ordinary or simple tasks satisfactorily without more supervision or assistance than is usually given other people doing similar work, this may show that the claimant is not working at the substantial gainful activity level. If the claimant is doing work that involves minimal duties that make little or no demands on the claimant and that are of little or no use to the claimant's railroad or non-railroad employer, or to the operation of a business if the claimant is self-employed, this does not show that the claimant is working at the substantial gainful activity level. (c) If the claimant's work is done under special conditions. Even though the work the claimant is doing takes into account his or her impairment, such as work done in a sheltered workshop or as a patient in a hospital, it may still show that the claimant has the necessary skills and ability to work at the substantial gainful activity level. (d) If the claimant is self-employed. Supervisory, managerial, advisory or other significant personal services that the claimant performs as a self-employed person may show that the claimant is able to do substantial gainful activity. (e) Time spent in work. While the time the claimant spends in work is important, the Board will not decide whether or not the claimant is doing substantial gainful activi… | ||||
| 20:20:1.0.2.8.16.12.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.143 Evaluation guides for an employed claimant. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 64 FR 62976, Nov. 18, 1999; 72 FR 21101, Apr. 30, 2007] | (a) General. The Board uses several guides to decide whether the work the claimant has done shows that he or she is able to do substantial gainful activity. (1) The claimant's earnings may show the claimant has done substantial gainful activity. The amount of the claimant's earnings from work the claimant has done may show that he or she has engaged in substantial gainful activity. Generally, if the claimant worked for substantial earnings, this will show that he or she is able to do substantial gainful activity. On the other hand, the fact that the claimant's earnings are not substantial will not necessarily show that the claimant is not able to do substantial gainful activity. The Board will generally consider work that the claimant is forced to stop after a short time because of his or her impairment(s) as an unsuccessful work attempt and the claimant's earnings from that work will not show that the claimant is able to do substantial gainful activity. (2) The Board considers only the amount the claimant earns. The Board does not consider any income not directly related to the claimant's productivity when the Board decides whether the claimant has done substantial gainful activity. If the claimant's earnings are subsidized, the amount of the subsidy is not counted when the Board determines whether or not the claimant's work is substantial gainful activity. Thus, where work is done under special conditions, the Board only considers the part of the claimant's pay which the claimant actually “earns.” For example, where a handicapped person does simple tasks under close and continuous supervision, the Board would not determine that the person worked at the substantial gainful activity level only on the basis of the amount of pay. A railroad or non-railroad employer may set a specific amount as a subsidy after figuring the reasonable value of the employee's services. If the claimant's work is subsidized and the claimant's railroad and non-railroad employer does not set the amount of the subsidy or does not a… | |||
| 20:20:1.0.2.8.16.12.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.144 Evaluation guides for a self-employed claimant. | SSA | (a) If the claimant is a self-employed claimant. The Board will consider the claimant's activities and their value to the claimant's business to decide whether the claimant has engaged in substantial gainful activity if the claimant is self-employed. The Board will not consider the claimant's income alone since the amount of income the claimant actually receives may depend upon a number of different factors like capital investment, profit sharing agreements, etc. The Board will generally consider work that the claimant is forced to stop after a short time because of his or her impairment(s) as an unsuccessful work attempt and the claimant's income from that work will not show that the claimant is able to do substantial gainful activity. The Board will evaluate the claimant's work activity on the value to the business of the claimant's services regardless of whether the claimant receives an immediate income for his or her services. The Board considers that the claimant has engaged in substantial gainful activity if— (1) The claimant's work activity, in terms of factors such as hours, skills, energy output, efficency, duties, and responsibilities, is comparable to that of unimpaired persons in the claimant's community who are in the same or similar businesses as their means of livelihood; (2) The claimant's work activity, although not comparable to that of unimpaired persons, is clearly worth the amount shown in § 220.143(b)(2) when considered in terms of its value to the business, or when compared to the salary that an owner would pay to an employed person to do the work the claimant is doing; or (3) The claimant renders services that are significant to the operation of the business and receives a substantial income from the business. (b) What the Board means by significant services —(1) Claimants who are not farm landlords. If the claimant is not a farm landlord and the claimant operates a business entirely by himself or herself, any services that the claimant renders are significant to the business. If … | ||||
| 20:20:1.0.2.8.16.12.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | L | Subpart L—Substantial Gainful Activity | § 220.145 Impairment-related work expenses. | SSA | (a) General. When the Board figures the claimant's earnings in deciding if the claimant has done substantial gainful activity, the Board will subtract the reasonable costs to the claimant of certain items and services which, because of his or her impairment(s), the claimant needs and uses to enable him or her to work. The costs are deductible even though the claimant also needs or uses the items and services to carry out daily living functions unrelated to his or her work. Paragraph (b) of this section explains the conditions for deducting work expenses. Paragraph (c) of this section describes the expenses the Board will deduct. Paragraph (d) of this section explains when expenses may be deducted. Paragraph (e) of this section describes how expenses may be allocated. Paragraph (f) of this section explains the limitations on deducting expenses. Paragraph (g) of this section explains the Board's verification procedures. (b) Conditions for deducting impairment-related work expenses. The Board will deduct impairment-related work expenses if— (1) The claimant is otherwise disabled as defined in § 220.26; (2) The severity of the claimant's impairment(s) requires the claimant to purchase (or rent) certain items and services in order to work; (3) The claimant pays the cost of the item or service. No deduction will be allowed to the extent that payment has been or will be made by another source. No deduction will be allowed to the extent that the claimant has been, could be, or will be reimbursed for such cost by any other source (such as through a private insurance plan, Medicare or Medicaid, or other plan or agency). For example, if the claimant purchases crutches for $80 but the claimant was, could be, or will be reimbursed $64 by some agency, plan, or program, the Board will deduct only $16; (4) The claimant pays for the item or service in a month he or she is working (in accordance with paragraph (d) of this section); and (5) The claimant's payment is in cash (including checks or other forms of money). Paym… | ||||
| 20:20:1.0.2.8.16.13.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | M | Subpart M—Disability Annuity Earnings Restrictions | § 220.160 How work for a railroad employer affects a disability annuity. | SSA | A disability annuity is not payable and the annuity must be returned for any month in which the disabled annuitant works for an employer as defined in part 202 of this chapter. | ||||
| 20:20:1.0.2.8.16.13.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | M | Subpart M—Disability Annuity Earnings Restrictions | § 220.161 How work affects an employee disability annuity. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 68 FR 39010, July 1, 2003] | In addition to the condition in § 220.160, the employee's disability annuity is not payable and the employee must return the annuity payment for any month in which the employee earns more than $400 (after deduction of impairment-related work expenses) in employment or self-employment of any kind. Any annuity amounts withheld because the annuitant earned over $400 in a month may be paid after the end of the year, as shown in § 220.164. The $400 monthly limit no longer applies when the employee attains retirement age and the disability annuity is converted to a full age annuity. See § 220.145 for the definition of impairment-related work expenses. | |||
| 20:20:1.0.2.8.16.13.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | M | Subpart M—Disability Annuity Earnings Restrictions | § 220.162 Earnings report. | SSA | (a) General. Any annuitant receiving an annuity based on disability must report to the Board any work and earnings as described in §§ 220.160 and 220.161. The report may be a written or oral statement by the annuitant, or a person acting for the annuitant, made or sent to a representative of the Board. The report should include the name and address of the railroad or non-railroad employer, a description of the work and the amount of gross wages (before deductions) or the net income from self-employment (earnings after deducting business expenses). (b) Employee reports. In addition to the requirement described in (a), a report of earnings over $400 a month must be made before the employee accepts a disability annuity (the annuity payment is issued and not returned) for the second month after the first month in which earnings are over $400. Along with the report, the employee must return the annuity payment for any month in which he or she earns over $400. | ||||
| 20:20:1.0.2.8.16.13.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | M | Subpart M—Disability Annuity Earnings Restrictions | § 220.163 Employee penalty deductions. | SSA | If the employee earns over $400 in a month and does not report it within the time limit shown in § 220.162(b), a penalty is imposed. The penalty deduction for the first failure to report equals the annuity amount for the first month in which the employee earned over $400. The deduction for a second or later failure to report equals the annuity amount for each month in which the employee earned over $400 and failed to report it on time. | ||||
| 20:20:1.0.2.8.16.13.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | M | Subpart M—Disability Annuity Earnings Restrictions | § 220.164 Employee end-of-year adjustment. | SSA | (a) General. After the end of a year, the employee whose annuity was withheld for earnings over $400 in a month receives a form on which to report his or her earnings for the year. (b) Earnings are less than $5000. If the employee's yearly earnings are less than $5000, all annuity payments and penalties withheld during the year because of earnings over $4800 are paid. (c) Earnings are $5000 or more. (1) If the employee's yearly earnings are $5000 or more, the annuity payments are adjusted so that the employee does not have more than one regular deduction for every $400 of earnings over $4800. The last $200 or more of earnings over $4800 is treated as if it were $400. If the annuity rate changes during the year, any annuities due at the end of the year are paid first for months in which the annuity rate is higher. Penalty deductions may also apply as described in paragraph (c)(2) of this section. (2) If the employee's yearly earnings are $5000 or more and the employee failed to report monthly earnings over $400 within the time limit described in § 220.162(b), penalty deductions will also apply. If it is the employee's first failure to report, the penalty deduction is equal to one month's annuity. If it is the employee's second or later failure to report, the penalty deduction equals the annuity amount for each month in which the employee earned over $400 and failed to report it on time. (d) This section is illustrated by the following examples: | ||||
| 20:20:1.0.2.8.16.14.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | N | Subpart N—Trial Work Period and Reentitlement Period for Annuitants Disabled for Any Regular Employment | § 220.170 The trial work period. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 72 FR 21102, Apr. 30, 2007] | (a) Definition of the trial work period. The trial work period is a period during which the annuitant may test his or her ability to work and still be considered disabled. The trial work period begins and ends as described in paragraph (e) of this section. During this period, the annuitant may perform “services” (see paragraph (b) of this section) in as many as 9 months, but these months do not have to be consecutive. The Board will not consider those services as showing that the annuitant's disability has ended until the annuitant has performed services in at least 9 months. However, after the trial work period has ended, the Board will consider the work the annuitant did during the trial work period in determining whether the annuitant's disability has ended at any time after the trial work period. (b) What the Board means by services. When used in this section, services means any activity (whether legal or illegal), even though it is not substantial gainful activity, which is done in employment or self-employment for pay or profit, or is the kind normally done for pay or profit. We generally do not consider work done without remuneration to be services if it is done merely as therapy or training, or if it is work usually done in a daily routine around the house, or in self-care. (1) If the claimant is an employee. The Board will consider the claimant's work as an employee to be services if: (i) Before January 1, 2002, the claimant's earnings in a month were more than the amount(s) indicated in Table 1 of this section for the year(s) in which the claimant worked. (ii) Beginning January 1, 2002 , the claimant's earnings in a month are more than an amount determined for each calendar year to be the larger of: (A) Such amount for the previous year, or (B) The amount established by the Social Security Administration for such year as constituting the amount of monthly earnings used to determine whether a person has performed services for counting trial work period months. (2) If the claimant is self-e… | |||
| 20:20:1.0.2.8.16.14.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | N | Subpart N—Trial Work Period and Reentitlement Period for Annuitants Disabled for Any Regular Employment | § 220.171 The reentitlement period. | SSA | (a) General. (1) The reentitlement period is an additional period after the 9 months of trial work during which the annuitant may continue to test his or her ability to work if he or she has a disabling impairment(s). (2) The disability annuity of an employee, child, or widow(er) who is disabled for any regular employment will not be paid for— (i) Any month, after the 3rd month, in this period in which the annuitant does substantial gainful activity; or (ii) Any month in this period in which the annuitant works for an employer covered by the Railroad Retirement Act (see § 220.160). (3) The disability annuity of an employee who is disabled for any regular employment will not be paid for any month in this period in which the employee annuitant earns more than $400 in employment or self-employment (see §§ 220.161 and 220.164). (4) If the disability annuity of an employee, child or widow(er) who is disabled for any regular employment is stopped because of work during the trial work period or reentitlement period, and the disability annuitant discontinues that work before the end of either period, the disability annuity may be started again without a new application or a new determination of disability. (b) When the reentitlement period begins and ends. The reentitlement period begins with the first month following completion of nine months of trial work but cannot begin earlier than December 1, 1980. It ends with whichever is earlier— (1) The month before the first month in which the annuitant's impairment(s) no longer exists or is not medically disabling; or (2) The last day of the 36th month following the end of the annuitant's trial work period. (c) When the annuitant is not entitled to a reentitlement period. The annuitant is not entitled to a reentitlement period if— (1) He or she is not entitled to a trial work period; or (2) His or her disability ended before the annuitant completed nine months of trial work in that period in which he or she was disabled. | ||||
| 20:20:1.0.2.8.16.15.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.175 Responsibility to notify the Board of events which affect disability. | SSA | If the annuitant is entitled to a disability annuity because he or she is disabled for any regular employment, the annuitant should promptly tell the Board if— (a) His or her impairment(s) improves; (b) He or she returns to work; (c) He or she increases the amount of work; or (d) His or her earnings increase. | ||||
| 20:20:1.0.2.8.16.15.155.10 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.184 If the annuitant becomes disabled by another impairment(s). | SSA | If a new severe impairment(s) begins in or before the month in which the last impairment(s) ends, the Board will find that disability is continuing. The impairment(s) need not be expected to last 12 months or to result in death, but it must be severe enough to keep the annuitant from doing substantial gainful activity, or severe enough so that he or she is still disabled. | ||||
| 20:20:1.0.2.8.16.15.155.11 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.185 The Board may conduct a review to find out whether the annuitant continues to be disabled. | SSA | After the Board finds that the annuitant is disabled, the Board must evaluate the annuitant's impairment(s) from time to time to determine if the annuitant is still eligible for disability cash benefits. The Board calls this evaluation a continuing disability review. The Board may begin a continuing disability review for any number of reasons including the annuitant's failure to follow the provisions of the Railroad Retirement Act or these regulations. When the Board begins such a review, the Board will notify the annuitant that the Board is reviewing the annuitant's eligibility for disability benefits, why the Board is reviewing the annuitant's eligibility, that in medical reviews the medical improvement review standard will apply, that the Board's review could result in the termination of the annuitant's benefits, and that the annuitant has the right to submit medical and other evidence for the Board's consideration during the continuing disability review. In doing a medical review the Board will develop a complete medical history of at least the preceding 12 months in any case in which a determination is made that the annuitant is no longer under a disability. If this review shows that the Board should stop payment of cash benefits, the Board will notify the annuitant in writing and give the annuitant an opportunity to appeal. In § 220.186 the Board describes those events that may prompt it to review whether the annuitant continues to be disabled. | ||||
| 20:20:1.0.2.8.16.15.155.12 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.186 When and how often the Board will conduct a continuing disability review. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 65 FR 20372, Apr. 17, 2000; 74 FR 63603, Dec. 4, 2009] | (a) General. The Board conducts continuing disability reviews to determine whether or not the annuitant continues to meet the disability requirements of the law. Payment of cash benefits or a period of disability ends if the medical or other evidence shows that the annuitant is not disabled under the standards set out in section 2 of the Railroad Retirement Act or section 223(f) of the Social Security Act. (b) When the Board will conduct a continuing disability review. A continuing disability review will be started if— (1) The annuitant has been scheduled for a medical improvement expected diary review; (2) The annuitant has been scheduled for a periodic review in accordance with the provisions of paragraph (d) of this section; (3) The Board needs a current medical or other report to see if the annuitant's disability continues. (This could happen when, for example, an advance in medical technology, such as improved treatment for Alzheimer's disease or a change in vocational therapy or technology raises a disability issue.); (4) The annuitant returns to work and successfully completes a period of trial work; (5) Substantial earnings are reported to the annuitant's wage record; (6) The annuitant tells the Board that he or she has recovered from his or her disability or that he or she has returned to work; (7) A State Vocational Rehabilitation Agency tells the Board that— (i) The services have been completed; or (ii) The annuitant is now working; or (iii) The annuitant is able to work; (8) Someone in a position to know of the annuitant's physical or mental condition tells the Board that the annuitant is not disabled, that the annuitant in not following prescribed treatment, that the annuitant has returned to work, or that the annuitant is failing to follow the provisions of the Social Security Act, the Railroad Retirement Act, or these regulations, and it appears that the report could be substantially correct; or (9) Evidence the Board receives raises a question as to whether the annuitant's disabil… | |||
| 20:20:1.0.2.8.16.15.155.13 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.187 If the annuitant's medical recovery was expected and the annuitant returned to work. | SSA | If the annuitant's impairment was expected to improve and the annuitant returned to full-time work with no significant medical limitations and acknowledges that medical improvement has occurred, the Board may find that the annuitant's disability ended in the month he or she returned to work. Unless there is evidence showing that the annuitant's disability has not ended, the Board will use the medical and other evidence already in the annuitant's file and the fact that he or she has returned to full-time work without significant limitations to determine that the annuitant is no longer disabled. (If the annuitant's impairment is not expected to improve, the Board will not ordinarily review his or her claim until the end of the trial work period, as described in § 220.170.) | ||||
| 20:20:1.0.2.8.16.15.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.176 When disability continues or ends. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 68 FR 39010, July 1, 2003] | There is a statutory requirement that, if an annuitant is entitled to a disability annuity, the annuitant's continued entitlement to such an annuity must be reviewed periodically until the employee or child annuitant reaches full retirement age and the widow(er) annuitant reaches age 60. When the annuitant is entitled to a disability annuity as a disabled employee, disabled widow(er) or as a person disabled since childhood, there are a number of factors to be considered in deciding whether his or her disability continues. The Board must first consider whether the annuitant has worked and, by doing so, demonstrated the ability to engage in substantial gainful activity. If so, the disability will end. If the annuitant has not demonstrated the ability to engage in substantial gainful activity, then the Board must determine if there has been any medical improvement in the annuitant's impairment(s) and, if so, whether this medical improvement is related to the annuitant's ability to work. If an impairment(s) has not medically improved, the Board must consider whether one or more of the exceptions to medical improvement applies. If medical improvement related to ability to work has not occurred and no exception applies, the disability will continue. Even the medical improvement related to ability to work has occurred or an exception applies (see § 220.179 for exceptions), in most cases the Board must also show that the annuitant is currently able to engage in substantial gainful activity before it can find that the annuitant is no longer disabled. | |||
| 20:20:1.0.2.8.16.15.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.177 Terms and definitions. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63601, Dec. 4, 2009] | There are several terms and definitions which are important to know in order to understand how the Board reviews whether a disability for any regular employment continues: (a) Medical improvement. Medical improvement is any decrease in the medical severity of an impairment(s) which was present at the time of the most recent favorable medical decision that the annuitant was disabled or continued to be disabled. A determination that there has been a decrease in medical severity must be based on a comparison of prior and current medical evidence showing changes (improvement) in the symptoms, signs or laboratory findings associated with the impairment(s). Postoperatively, a myelogram still shows evidence of a persistant deficit in his lumbar spine. He had pain in his back, and pain and a burning sensation in his right foot and leg. There were no muscle weakness or neurological changes and a modest decrease in motion in his back and leg. When the Board reviewed the annuitant's claim to determine whether his disability should be continued, his treating physician reported that he had seen the annuitant regularly every 2 to 3 months for the past 2 years. No further myelograms had been done, complaints of pain in the back and right leg continued especially on sitting or standing for more than a short period of time. The annuitant's doctor further reported a moderately decreased range of motion in the annuitant's back and right leg, but again no muscle atrophy or neurological changes were reported. Medical improvement has not occurred because there has been no decrease in the severity of the annuitant's back impairment as shown by changes in symptoms, signs or laboratory findings. (b) Medical improvement not related to ability to do work. Medical improvement is not related to the annuitant's ability to work if there has been a decrease in the severity of the impairment(s) (as defined in paragraph (a) of this section) present at the time of the most recent favorable medical decision, but no increase in that annuitant… | |||
| 20:20:1.0.2.8.16.15.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.178 Determining medical improvement and its relationship to the annuitant's ability to do work. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63602, Dec. 4, 2009] | (a) General. Paragraphs (a), (b), and (c) of § 220.177 discuss what is meant by medical improvement, medical improvement not related to the ability to work and medical improvement that is related to the ability to work. How the Board will arrive at the decision that medical improvement has occurred and its relationship to the ability to do work, is discussed in paragraphs (b) and (c) of this section. (b) Determining if medical improvement is related to ability to work. If there is a decrease in medical severity as shown by the symptoms, signs and laboratory findings, the Board then must determine if it is related to the annuitant's ability to do work. In § 220.177(d) the relationship between medical severity and limitation on functional capacity to do basic work activities (or residual functional capacity) and how changes in medical severity can affect the annuitant's residual functional capacity is explained. In determining whether medical improvement that has occurred is related to the annuitant's ability to do work, the Board will assess the annuitant's residual functional capacity (in accordance with § 220.177(d)) based on the current severity of the impairment(s) which was present at that annuitant's last favorable medical decision. The annuitant's new residual functional capacity will then be compared to the annuitant's residual functional capcity at the time of the Board's most recent favorable medical decision. Unless an increase in the current residual functional capacity is based on changes in the signs, symptoms, or laboratory findings, any medical improvement that has occurred will not be considered to be related to the annuitant's ability to do work. (c) Additional factors and considerations. The Board will also apply the following in its determinations of medical improvement and its relationship to the annuitant's ability to do work: (1) Previous impairment was medically disabling. If the Board's most recent favorable decision was based on the fact that the annuitant's impairment(s) at th… | |||
| 20:20:1.0.2.8.16.15.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.179 Exceptions to medical improvement. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63602, Dec. 4, 2009] | (a) First group of exceptions to medical improvement. The law provides for certain limited situations when the annuitant's disability can be found to have ended even though medical improvement has not occurred, if he or she can engage in substantial gainful activity. These exceptions to medical improvement are intended to provide a way of finding that the annuitant is no longer disabled in those limited situations where, even though there has been no decrease in severity of the impairment(s), evidence shows that the annuitant should no longer be considered disabled or never should have been considered disabled. If one of these exceptions applies, the Board must also show that, taking all of the annuitant's current impairment(s) into account, not just those that existed at the time of the Board's most recent favorable medical decision, the annuitant is now able to engage in substantial gainful activity before his or her disability can be found to have ended. As part of the review process, the annuitant will be asked about any medical or vocational therapy that he or she has received or is receiving. Those answers and the evidence gathered as a result as well as all other evidence, will serve as the basis for the finding that an exception applies. (1) Substantial evidence shows that the annuitant is the beneficiary of advances in medical or vocational therapy or technology (related to his or her ability to work). Advances in medical or vocational therapy or technology are improvements in treatment or rehabilitative methods which have increased the annuitant's ability to do basic work activities. The Board will apply this exception when substantial evidence shows that the annuitant has been the beneficiary of services which reflect these advances and they have favorably affected the severity of his or her impairment(s) or ability to do basic work activities. This decision will be based on new medical evidence and a new residual functional capacity assessment. In many instances, an advanced medical therapy or te… | |||
| 20:20:1.0.2.8.16.15.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.180 Determining continuation or cessation of disability. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63603, Dec. 4, 2009] | Evaluation steps. To assure that disability reviews are carried out in a uniform manner, that decisions of continuing disability can be made in the most expeditious and administratively efficient way, and that any decisions to stop a disability annuity are made objectively, neutrally and are fully documented, the Board will follow specific steps in reviewing the question of whether an annuitant's disability continues. The Board's review may cease and the disability may be continued at any point if the Board determines that there is sufficient evidence to find that the annuitant is still unable to engage in substantial gainful activity. The steps are— (a) Is the annuitant engaging in substantial gainful activity? If he or she is (and any applicable trial work period has been completed), the Board will find disability to have ended (see § 220.179(a)(5)); (b) If the annuitant is not engaging in substantial gainful activity, does he or she have an impairment or combination of impairments which is medically disabling? If the annuitant's impairment(s) is medically disabling, his or her disability will be found to continue; (c) If the annuitant's impairment(s) is not medically disabling, has there been medical improvement as defined in § 220.177(a)? If there has been medical improvement as shown by a decrease in medical severity, see step (d). If there has been no decrease in medical severity, then there has been no medical improvement; (See step (e)); (d) If there has been medical improvement, the Board must determine whether it is related to the annuitant's ability to do work in accordance with paragraphs (a) through (d) of § 220.177, (i.e., whether or not there has been an increase in the residual functional capacity based on the impairment(s) that was present at the time of the most recent favorable medical determination). If medical improvement is not related to the annuitant's ability to do work, see step (e). If medical improvement is related to the annuitant's ability to do work, see step (f); (e) If the B… | |||
| 20:20:1.0.2.8.16.15.155.7 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.181 The month in which the Board will find that the annuitant is no longer disabled. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63603, Dec. 4, 2009] | If the evidence shows that the annuitant is no longer disabled, the Board will find that his or her disability ended in the earliest of the following months— (a) The month the Board mails the annuitant a notice saying that the Board finds that he or she is no longer disabled based on evidence showing: (1) There has been medical improvement in the annuitant's impairments related to the ability to work and the annuitant has the capacity to engage in substantial gainful work under the rules set out in §§ 220.177 and 220.178; or (2) There has been no medical improvement in the annuitant's impairments related to the ability to work but the annuitant has the capacity to engage in substantial gainful work and one of the exceptions to medical improvement set out in § 220.179(a)(1), (2), (3) or (4) applies. (b) The month in which the annuitant demonstrated his or her ability to engage in substantial gainful activity (following completion of a trial work period); (c) The month in which the annuitant actually does substantical gainful activity where such annuitant is not entitled to a trial work period; (d) The month in which the annuitant returns to full-time work, with no significant medical restrictions and acknowledges that medical improvement has occurred, and the Board expected the annuitant's impairment(s) to improve; (e) The first month in which the annuitant failed without good cause to do what the Board asked, when the rule set out in paragraph (b)(2) of § 220.179 applies; (f) The first month in which the question of continuing disability arose and the Board could not locate the annuitant after a suitable investigation (see § 220.179(b)(3)); (g) The first month in which the annuitant failed without good cause to follow prescribed treatment, when the rule set out in paragraph (b)(4) of § 220.179 applies; or (h) The first month the annuitant was told by his or her physician that he or she could return to work provided there is no substantial conflict between the physician's and the annuitant's statements r… | |||
| 20:20:1.0.2.8.16.15.155.8 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.182 Before a disability annuity is stopped. | SSA | Before the Board stops a disability annuity, it will give the annuitant a chance to explain why it should not do so. | ||||
| 20:20:1.0.2.8.16.15.155.9 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | O | Subpart O—Continuing or Stopping Disability Due to Substantial Gainful Activity or Medical Improvement | § 220.183 Notice that the annuitant is not disabled. | SSA | (a) General. If the Board determines that the annuitant does not meet the disability requirements of the law, the disability annuity will generally stop. Except in the circumstance described in paragraph (d) of this section, the Board will give the annuitant advance written notice when the Board has determined that he or she is not now disabled. (b) What the advance written notice will tell the annuitant. The advance written notice will provide— (1) A summary of the information the Board has and an explanation of why the Board believes the annuitant is no longer disabled. If it is because of medical reasons, the notice will tell the annuitant what the medical information in his or her file shows. If it is because of the annuitant's work activity, the notice will tell the annuitant what information the Board has about the work he or she is doing or has done, and why this work shows that he or she is not disabled. If it is because of the annuitant's failure to give the Board information the Board needs or failure to do what the Board asks, the notice will tell the annuitant what information the Board needs and why, or what the annuitant has to do and why; (2) The date the disability annuity will stop; (3) An opportunity for the annuitant to submit evidence within a specified period to support continuance of disability before the decision becomes final; and (4) An explanation of the annuitant's rights to reconsideration and appeal after the decision becomes final. (c) What the annuitant should do if he or she receives an advance written notice. If the annuitant agrees with the advance written notice, he or she does not need to take any action. If the annuitant desires further information or disagrees with what the Board has told him or her, the annuitant should immediately write or visit a Board office. If the annuitant believes he or she is now disabled, the annuitant should tell the Board why. The annuitant may give the Board any additional or new information, including reports from doctors, hospitals,… | ||||
| 20:20:1.0.2.8.16.2.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | B | Subpart B—General Definitions of Terms Used in This Part | § 220.5 Definitions as used in this part. | SSA | Act means the Railroad Retirement Act of 1974. Application refers only to a form described in part 217 of this chapter. Board means the Railroad Retirement Board. Claimant means the person for whom an application for an annuity, period of disability or Medicare coverage is filed. Eligible means that a person would meet all the requirements for payment of an annuity but has not yet applied. Employee is defined in part 203 of this title. Entitled means that a person has applied and has proven his or her right to have the annuity, period of disability, or Medicare coverage begin. Medical source refers to both a treating source and a source of record. Review physician means a medical doctor either employed by or under contract to the Board who upon request reviews medical evidence and provides medical advice. Social security overall minimum refers to the provision of the Railroad Retirement Act which guarantees that the total monthly annuities payable to an employee and his or her family will not be less than the total monthly amount which would be payable under the Social Security Act if the employee's railroad service were credited as employment under the Social Security Act. Source of record means a hospital, clinic or other source that has provided a claimant with medical treatment or evaluation, as well as a physician or psychologist who has treated or evaluated a claimant but does not have an ongoing relationship with him or her. Treating source means the claimant's own physician or psychologist who has provided the claimant with medical treatment or evaluation and who has an ongoing treatment relationship with him or her. | ||||
| 20:20:1.0.2.8.16.3.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.10 Disability for work in an employee's regular railroad occupation. | SSA | [63 FR 7541, Feb. 13, 1998] | (a) In order to receive an occupational disability annuity an eligible employee must be found by the Board to be disabled for work in his or her regular railroad occupation because of a permanent physical or mental impairment. In this subpart the Board describes in general terms how it evaluates a claim for an occupational disability annuity. In accordance with section 2(a)(2) of the Railroad Retirement Act this subpart was developed with the cooperation of employers and employees. This subpart is supplemented by an Occupational Disability Claims Manual (Manual) 1 which was also developed with the cooperation of employers and employees. 1 The Manual may be obtained from the Board's headquarters at 844 North Rush Street, Chicago, IL 60611. (b) In accordance with section 2(a)(2) of the Railroad Retirement Act, the Board shall select two physicians, one from recommendations made by representatives of employers and one from recommendations made by representatives of employees. These individuals shall comprise the Occupational Disability Advisory Committee (Committee). This Committee shall periodically review, as necessary, this subpart and the Manual and make recommendations to the Board with respect to amendments to this subpart or to the Manual. The Board shall confer with the Committee before it amends either this subpart or the Manual. | |||
| 20:20:1.0.2.8.16.3.155.10 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.19 Payment of the disability annuity during the trial work period and the reentitlement period. | SSA | (a) The employee who is entitled to an occupational disability annuity will not be paid an annuity for each month in the trial work period or reentitlement period in which he or she— (1) Works for an employer covered by the Railroad Retirement Act (see § 220.160); or (2) Earns more than $400 (after deduction of impairment-related work expenses) in employment or self-employment (see §§ 220.161 and 220.164). See § 220.145 for the definition of impairment-related work expenses. (b) If the employee's occupational disability annuity is stopped because of work during the trial work period or reentitlement period, and the employee discontinues that work before the end of either period, the disability annuity may be started again without a new application and a new determination of disability. | ||||
| 20:20:1.0.2.8.16.3.155.11 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.20 Notice that an annuitant is no longer disabled. | SSA | The regulation explaining the Board's responsibilities in notifying the annuitant, and the annuitant's rights when the disability annuity is stopped is found in § 220.183. | ||||
| 20:20:1.0.2.8.16.3.155.12 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.21 Initial evaluation of a previous occupational disability. | SSA | (a) In some cases, the Board may determine that a claimant is not currently disabled for work in his or her regular occupation but was previously disabled for a specified period of time in the past. This can occur when— (1) The disability application was filed before the claimant's occupational disability ended, but the Board did not make the initial determination of occupational disability until after the claimant's disability ended; or (2) The disability application was filed after the claimant's occupational disability ended but no later than the 12th month after the month the disability ended. (b) When evaluating a claim for a previous occupational disability, the Board follows the steps in § 220.13 to determine whether an occupational disability existed, and follows the steps in §§ 220.16 and 220.17 to determine when the occupational disability ended. | ||||
| 20:20:1.0.2.8.16.3.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.11 Definitions as used in this subpart. | SSA | [63 FR 7541, Feb. 13, 1998] | Functional capacity test means one of a number of tests which provide objective measures of a claimant's maximal work ability and includes functional capacity evaluations which provide a systematic comprehensive assessment of a claimant's overall strength, mobility, endurance and capacity to perform physically demanding tasks, such as standing, walking, lifting, crouching, stooping or bending, climbing or kneeling. Independent Case Evaluation (ICE) means the process for evaluating claims not covered by appendix 3 of this part. Permanent physical or mental impairment means a physical or mental impairment or combination of impairments that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. Regular railroad occupation means an employee's railroad occupation in which he or she has engaged in service for hire in more calendar months than the calendar months in which he or she has been engaged in service for hire in any other occupation during the last preceding five calendar years, whether or not consecutive; or has engaged in service for hire in not less than one-half of all of the months in which he or she has been engaged in service for hire during the last preceding 15 consecutive calendar years. If an employee last worked as an officer or employee of a railway labor organization and if continuance in such employment is no longer available to him or her, the “regular occupation” shall be the position to which the employee holds seniority rights or the position which he or she left to work for a railway labor organization. Residual functional capacity has the same meaning as found in § 220.120. | |||
| 20:20:1.0.2.8.16.3.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.12 Evidence considered. | SSA | [56 FR 12980, Mar. 28, 1991. Redesignated at 63 FR 7541, Feb. 13, 1998] | The regulations explaining the employee's responsibility to provide evidence of disability, the kind of evidence, what medical evidence consists of, and the consequences of refusing or failing to provide evidence or to have a medical examination are found in § 220.45 through § 220.48. The regulations explaining when the employee may be requested to report for a consultative examination are found in § 220.50 and § 220.51. The regulations explaining how the Board evaluates conclusions by physicians concerning the employee's disability, how the Board evaluates the employee's symptoms, what medical findings consist of, and the need to follow prescribed treatment are found in § 220.112 through § 220.115. | |||
| 20:20:1.0.2.8.16.3.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.13 Establishment of permanent disability for work in regular railroad occupation. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 63 FR 7541, Feb. 13, 1998; 74 FR 63600, Dec. 4, 2009] | The Board will presume that a claimant who is not allowed to continue working for medical reasons by his employer has been found, under standards contained in this subpart, disabled unless the Board finds that no person could reasonably conclude on the basis of evidence presented that the claimant can no longer perform his or her regular railroad occupation for medical reasons. (See § 220.21 if the claimant is not currently disabled, but was previously occupationally disabled for a specified period of time in the past). The Board uses the following evaluation process in determining disability for work in the regular occupation: (a) The Board evaluates the employee's medically documented physical and mental impairment(s) to determine if the employee is medically disabled. In order to be found medically disabled, the employee's impairments must be severe enough to prevent a person from doing any substantial gainful activity. The Board makes this determination based on the guidelines set out in § 220.100(b)(3). If the Board finds that an employee has an impairment which is medically disabling, it will find the employee disabled for work in his or her regular occupation without considering the duties of his or her regular occupation. (b) If the Board finds that the claimant does not have an impairment described in paragraph (a) of this section, it will— (1) Determine the employee's regular railroad occupation, as defined in § 220.11, based upon the employee's own description of his or her job; (2) Evaluate whether the claimant is disabled as follows: (i) The Board first determines whether the employee's regular railroad occupation is an occupation covered under appendix 3 of this part. Second, the Board will determine whether the employee's claimed impairment(s) is covered under appendix 3 of this part. If claimant's regular railroad occupation or impairment(s) is not covered under appendix 3 of this part, then the Board will determine if the employee is disabled under ICE as set forth in paragraph (b)(2)(iv) of… | |||
| 20:20:1.0.2.8.16.3.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.14 Weighing of evidence. | SSA | [63 FR 7542, Feb. 13, 1998] | (a) Factors which support greater weight. Evidence will generally be given more weight if it meets one or more of the following criteria: (1) The residual functional capacity evaluation is based upon functional objective tests with high validity and reliability; (2) The medical evidence shows multiple impairments which have a cumulative effect on the employee's residual functional capacity; (3) Symptoms associated with limitations are consistent with objective findings; (4) There exists an adequate trial of therapies with good compliance, but poor outcome; (5) There exists consistent history of conditions between treating physicians and other health care providers. (b) Factors which support lesser weight. Evidence will generally be given lesser weight if it meets one or more of the following criteria: (1) There is an inconsistency between the diagnoses of the treating physicians; (2) There is inconsistency between reports of pain and functional impact; (3) There is inconsistency between subjective symptoms and physical examination findings; (4) There is evidence of poor compliance with treatment regimen, keeping appointments, or cooperating with treatment; (5) There is evidence of exam findings which is indicative of exaggerated or potential malingering response; (6) The evidence consists of objective findings of exams that have poor reliability or validity; (7) The evidence consists of imaging findings which are nonspecific and largely present in the general population; (8) The evidence consists of a residual functional capacity evaluation which is supported by limited objective data without consideration for functional capacity testing. | |||
| 20:20:1.0.2.8.16.3.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.15 Effects of work on occupational disability. | SSA | (a) Disability onset when the employee works despite impairment. An employee who has stopped work in his or her regular occupation due to a permanent physical or mental impairment(s) may make an effort to return to work in his or her regular occupation. If the employee is subsequently forced to stop that work after a short time because of his or her impairment(s), the Board will generally consider that work as an unsuccessful work attempt. In this situation, the Board may determine that the employee became disabled for work in his or her regular occupation before the last date the employee worked in his or her regular occupation. No annuity will be payable, however, until after the last date worked. (b) Occupational disability annuitant work restrictions. The restrictions which apply to an annuitant who is disabled for work in his or her regular occupation are found in §§ 220.160 through 220.164. | ||||
| 20:20:1.0.2.8.16.3.155.7 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.16 Responsibility to notify the Board of events which affect disability. | SSA | If the annuitant is entitled to a disability annuity because he or she is disabled for work in his or her regular occupation, the annuitant should promptly tell the Board if— (a) His or her impairment(s) improves; (b) He or she returns to any type of work; (c) He or she increases the amount of work; or (d) His or her earnings increase. | ||||
| 20:20:1.0.2.8.16.3.155.8 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.17 Recovery from disability for work in the regular occupation. | SSA | (a) General. Disability for work in the regular occupation will end if— (1) There is medical improvement in the annuitant's impairment(s) to the extent that the annuitant is able to perform the duties of his or her regular occupation; or (2) The annuitant demonstrates the ability to perform the duties of his or her regular occupation. The Board provides a trial work period before terminating a disability annuity because of the annuitant's return to work. (b) Definition of the trial work period. The trial work period is a period during which the annuitant may test his or her ability to work and still be considered occupationally disabled. It begins and ends as described in paragraph (e) of this section. During this period, the annuitant may perform “services” (see paragraph (c) of this section) in as many as 9 months, but these months do not have to be consecutive. The Board will not consider those services as showing that the annuitant's occupational disability has ended until the annuitant has performed services in at least 9 months. However, after the trial work period has ended, the Board will consider the work the annuitant did during the trial work period in determining whether the annuitant's occupational disability has ended at any time after the trial work period. (c) What the Board means by services in an occupational disability case. When used in this section, “services” means any activity which, even though it may not be substantial gainful activity as defined in § 220.141, is— (1) Done by a person in employment or self-employment for pay or profit, or is the kind normally done for pay or profit; and (2) The activity is a return to the same duties of the annuitant's regular occupation or the activity so closely approximates the duties of the regular occupation as to demonstrate the ability to perform those duties. (d) Limitations on the number of trial work periods. The annuitant may have only one trial work period during each period in which he or she is occupationally disabled. (e) W… | ||||
| 20:20:1.0.2.8.16.3.155.9 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | C | Subpart C—Disability Under the Railroad Retirement Act for Work in an Employee's Regular Railroad Occupation | § 220.18 The reentitlement period. | SSA | (a) General. The reentitlement period is an additional period after the nine months of trial work during which the annuitant may continue to test his or her ability to work if the annuitant has a disabling impairment. (b) When the reentitlement period begins and ends. The reentitlement period begins with the first month following completion of nine months of trial work but cannot begin earlier than December 1, 1980. It ends with whichever is earlier— (1) The month before the first month in which the annuitant's impairment(s) no longer exists or is not medically disabling; or (2) The last day of the 36th month following the end of the annuitant's trial work period. (c) When the annuitant is not entitled to a reentitlement period. The annuitant is not entitled to a reentitlement period if— (1) The annuitant is not entitled to a trial work period; or (2) The annuitant's disability ended before the annuitant completed nine months of trial work in that period in which he or she was disabled. | ||||
| 20:20:1.0.2.8.16.4.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.25 General. | SSA | The definition and discussion of disability for any regular employment are found in §§ 220.26 through 220.184. | ||||
| 20:20:1.0.2.8.16.4.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.26 Disability for any regular employment, defined. | SSA | An employee, widow(er), or child is disabled for any regular employment if he or she is unable to do any substantial gainful activity because of a medically determinable physical or mental impairment which meets the duration requirement defined in § 220.28. In the case of a widow(er), the permanent physical or mental impairment must have prevented work in any regular employment before the end of a specific period (see § 220.30). In the case of a child, the permanent physical or mental impairment must have prevented work in any regular employment since before age 22. To meet this definition of disability, a claimant must have a severe impairment, which makes him or her unable to do any previous work or other substantial gainful activity which exists in the national economy. To determine whether a claimant is able to do any other work, the Board considers a claimant's residual functional capacity, age, education and work experience. See § 220.100 for the process by which the Board evaluates disability for any regular employment. This process applies to employees, widow(er)s, or children who apply for annuities based on disability for any regular employment. This process does not apply to surviving divorced spouses or remarried widow(er)s who apply for annuities based on disability. | ||||
| 20:20:1.0.2.8.16.4.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.27 What is needed to show an impairment. | SSA | A physical or mental impairment must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by the claimant's statement of symptoms. (See § 220.113 for further information about what is meant by symptoms, signs, and laboratory findings.) (See also § 220.112 for the effect of a medical opinion about whether or not a claimant is disabled.) | ||||
| 20:20:1.0.2.8.16.4.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.28 How long the impairment must last. | SSA | Unless the claimant's impairment is expected to result in death, it must have lasted or must be expected to last for a continuous period of at least 12 months. This is known as the duration requirement. | ||||
| 20:20:1.0.2.8.16.4.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.29 Work that is considered substantial gainful activity. | SSA | Work is considered to be substantial gainful activity if it— (a) Involves doing significant and productive physical or mental duties; and (b) Is done or is intended to be done for pay or profit. (See § 220.141 for a detailed explanation of what is substantial gainful activity.) | ||||
| 20:20:1.0.2.8.16.4.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | D | Subpart D—Disability Under the Railroad Retirement Act for Any Regular Employment | § 220.30 Special period required for eligibility of widow(er)s. | SSA | In order to be found disabled for any regular employment, a widow(er) must have a permanent physical or mental impairment which prevented work in any regular employment since before the end of a specific period as defined in part 216 of this chapter. | ||||
| 20:20:1.0.2.8.16.5.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | E | Subpart E—Disability Determinations Governed by the Regulations of the Social Security Administration | § 220.35 Introduction. | SSA | In addition to its authority to decide whether a claimant is disabled under the Railroad Retirement Act, the Board has authority in certain instances to decide whether a claimant is disabled as that term is defined in the Social Security Act. In making these decisions the Board must apply the regulations of the Social Security Administration in the same manner as does the Secretary of Health and Human Services in making disability decisions under the Social Security Act. Regulations of the Social Security Administration concerning disability are found at part 404, subpart P of this title. | ||||
| 20:20:1.0.2.8.16.5.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | E | Subpart E—Disability Determinations Governed by the Regulations of the Social Security Administration | § 220.36 Period of disability. | SSA | (a) General. In order to receive an annuity based upon a disability, an employee must be found disabled under the Railroad Retirement Act. If an employee is found disabled under the Railroad Retirement Act, the Board will determine whether he is disabled under the Social Security Act to qualify for a period of disability as defined in that Act. (b) Period of disability —(1) Definition and effect. A period of disability is a continuous period of time during which an employee is disabled as that term is defined in § 404.1505 of this title. A period of disability established by the Board— (i) Preserves the disabled employee's earnings record as it is when the period begins; (ii) Protects the insured status required for entitlement to social security overall minimum; (iii) May cause an increase in the rate of an employee, spouse, or survivor annuity; or (iv) May permit a disabled employee to receive Medicare benefits in addition to an annuity under the Railroad Retirement Act. (2) Effect on benefits. The establishment of a period of disability for the employee will never cause a denial or reduction in benefits under the Railroad Retirement Act or Social Security Act, but it will always be used to establish Medicare entitlement before age 65. (3) Who may establish a period of disability. The Railroad Retirement Board or the Social Security Administration may establish a period of disability. However, the decision of one agency is not binding upon the other agency. (4) When the Board may establish a period of disability. The Board has independent authority to decide whether or not to establish a period of disability for any employee who was awarded an annuity under the Railroad Retirement Act, or who— (i) Has applied for a disability annuity; and (ii) Has at least 10 years of railroad service. (5) When an employee is entitled to a period of disability. An employee is entitled to a period of disability if he or she meets the following requirements: (i) The employee is disabled under the Social S… | ||||
| 20:20:1.0.2.8.16.5.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | E | Subpart E—Disability Determinations Governed by the Regulations of the Social Security Administration | § 220.37 When a child's disability determination is governed by the regulations of the Social Security Administration. | SSA | (a) In order to receive an annuity based upon disability, a child of a deceased employee must be found disabled under the Railroad Retirement Act. However, in addition to this determination, the child must be found disabled under the Social Security Act in order to qualify for Medicare based upon disability. (b) Although the child of a living employee may not receive an annuity under the Railroad Retirement Act, he or she, if found disabled under the Social Security Act, may qualify for the following: (1) Inclusion as a disabled child in the employee's annuity rate under the social security overall minimum. (2) Entitlement to Medicare based upon disability. | ||||
| 20:20:1.0.2.8.16.5.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | E | Subpart E—Disability Determinations Governed by the Regulations of the Social Security Administration | § 220.38 When a widow(er)'s disability determination is governed by the regulations of the Social Security Administration. | SSA | In order to receive an annuity based upon disability, a widow(er) must be found disabled under the Railroad Retirement Act. However, in addition to this determination, the widow(er) must be found disabled under the Social Security Act in order to qualify for early Medicare based upon disability. | ||||
| 20:20:1.0.2.8.16.5.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | E | Subpart E—Disability Determinations Governed by the Regulations of the Social Security Administration | § 220.39 Disability determination for a surviving divorced spouse or remarried widow(er). | SSA | A surviving divorced spouse or a remarried widow(er) must be found disabled under the Social Security Act in order to qualify for both an annuity under the Railroad Retirement Act and early Medicare based upon disability. Disability determinations for surviving divorced spouses and remarried widow(er)s are governed by the applicable regulations of the Social Security Administration, found at § 404.1577 of this title. | ||||
| 20:20:1.0.2.8.16.6.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | F | Subpart F—Evidence of Disability | § 220.45 Providing evidence of disability. | SSA | [89 FR 78238, Sept. 25, 2024] | (a) General. You are responsible for providing all evidence of the claimed disability and the effect of the disability on your ability to work. You must inform the Board about or submit all evidence known to you that relates to the claimed disability. This duty is ongoing and requires you to disclose any additional related evidence about which you become aware. This duty applies at each level of the administrative review process, including the appeals level, if the evidence relates to the period on or before the date of the hearings officer's decision. The Board will assist you, when necessary, in obtaining the required evidence. At its discretion, the Board will arrange for an examination by a consultant at the expense of the Board as explained in §§ 220.50 and 220.51. (b) Kind of evidence. (1) You must provide medical evidence proving that you have an impairment(s) and how severe it is during the time you claim to be disabled. The Board will consider only impairment(s) you claim to have or about which the Board receives evidence. Before deciding that you are not disabled, the Board will develop a complete medical history ( i.e., evidence from the records of your medical sources) covering at least the preceding 12 months, unless you say that your disability began less than 12 months before you filed an application. The Board will make every reasonable effort to help you in getting medical reports from your own medical sources when you give the Board permission to request them. Every reasonable effort means that the Board will make an initial request and, after 20 days, one follow-up request to your medical source to obtain the medical evidence necessary to make a determination before the Board evaluates medical evidence obtained from another source on a consultative basis. The medical source will have 10 days from the follow-up request to reply (unless experience indicates that a longer period is advisable in a particular case). In order to expedite processing, the Board may order a consultative exam from … | |||
| 20:20:1.0.2.8.16.6.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | F | Subpart F—Evidence of Disability | § 220.46 Medical evidence. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 90 FR 4627, Jan. 16, 2025] | (a) Acceptable medical sources. The Board needs reports about the claimant's impairment(s) from acceptable medical sources. Acceptable medical sources are— (1) Licensed physicians (medical or osteopathic doctors); (2) Licensed or certified psychologists at the independent practice level; (3) Licensed or certified school psychologists, or other licensed or certified individuals with another title who perform the same function as a school psychologist in a school setting (for impairments of intellectual disability, learning disabilities, and borderline intellectual functioning only); (4) Licensed optometrists (for impairments of visual disorders, or for the measurement of visual acuity and visual fields only, depending on the scope of practice in the State in which the optometrist practices); (5) Licensed podiatrists (for impairments of the foot only, or foot and ankle only, depending on the scope of practice in the State in which the podiatrist practices); (6) Qualified speech-language pathologists (for speech or language impairments only.) For this source, qualified means that the speech-language pathologist must be licensed by the State professional licensing agency, or be fully certified by the State education agency in the State in which the speech-language pathologist practices, or hold a Certificate of Clinical Competence in Speech-Language Pathology from the American Speech-Language-Hearing Association; (7) Licensed audiologists (for impairments of hearing loss, auditory processing disorders, and balance disorders within the licensed scope of practice only); (8) Licensed Advanced Practice Registered Nurses or other licensed advance practice nurses with another title (for impairments within the individual's licensed scope of practice only); (9) Licensed Physician Assistants/Physician Associates (for impairments within the individual's licensed scope of practice); or (10) Persons authorized to furnish a copy or summary of the records of a medical facility. Generally, the copy or summary should b… | |||
| 20:20:1.0.2.8.16.6.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | F | Subpart F—Evidence of Disability | § 220.47 Purchase of existing medical evidence. | SSA | The Board needs specific medical evidence to determine whether a claimant is disabled. The claimant is responsible for providing that evidence. However, at its discretion, the Board will pay the reasonable cost to obtain medical evidence that it needs and requests from physicians not employed by the Federal government and other non-Federal providers of medical services. | ||||
| 20:20:1.0.2.8.16.6.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | F | Subpart F—Evidence of Disability | § 220.48 If the claimant fails to submit medical or other evidence. | SSA | The Board may request a claimant to submit medical or other evidence. If the claimant does not submit that evidence, the Board will make a decision on other evidence which is either already available in the claimant's case or which the Board may develop from other sources, including reports of consultative examinations. | ||||
| 20:20:1.0.2.8.16.7.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.50 Consultative examinations at the Board's expense. | SSA | A consultative examination is a physical or mental examination or test purchased for a claimant at the Board's request and expense. If the claimant's medical sources cannot provide sufficient medical evidence about the claimant's impairment(s) in order to enable the Board to determine whether the claimant is disabled, the Board may ask the claimant to have one or more consultative examinations or tests. The decision to purchase a consultative examination will be made on an individual case basis in accordance with the provisions of §§ 220.53 through 220.56. Selection of the source for the examination will be consistent with the provisions of § 220.64 (Program Integrity). | ||||
| 20:20:1.0.2.8.16.7.155.10 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.59 Requesting examination by a specific physician, psychologist or institution—hearings officer hearing level. | SSA | In an unusual case, a hearings officer may have reason to request an examination by a particular physician, psychologist or institution. Some examples include the following: (a) Conflicts in the existing medical evidence require resolution by a recognized authority in a particular specialty: (b) The impairment requires hospitalization for diagnostic purposes; or (c) The claimant's treating physician or psychologist is in the best position to submit a meaningful report. | ||||
| 20:20:1.0.2.8.16.7.155.11 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.60 Diagnostic surgical procedures. | SSA | The Board will not order diagnostic surgical procedures such as myelograms and arteriograms for the evaluation of disability under the Board's disability program. In addition, the Board will not order procedures such as cardiac catheterization and surgical biopsy. However, if any of these procedures have been performed as part of a workup by the claimant's treating physician or other medical source, the results may be secured and used to help evaluate an impairment(s)'s severity. | ||||
| 20:20:1.0.2.8.16.7.155.12 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.61 Informing the examining physician or psychologist of examination scheduling, report content and signature requirements. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63600, Dec. 4, 2009] | Consulting physicians or psychologists will be fully informed at the time the Board contacts them of the following obligations: (a) General. In scheduling full consultative examinations, sufficient time should be allowed to permit the examining physician to take a case history and perform the examination (including any needed tests). (b) Report content. The reported results of the claimant's medical history, examination, pertinent requested laboratory findings, discussions and conclusions must conform to accepted professional standards and practices in the medical field for a complete and competent examination. The facts in a particular case and the information and findings already reported in the medical and other evidence of record will dictate the extent of detail needed in the consultative examination report for that case. Thus, the detail and format for reporting the results of a purchased examination will vary depending upon the type of examination or testing requested. The reporting of information will differ from one type of examination to another when the requested examination relates to the performance of tests such as ventilatory function tests, treadmill exercise tests, or audiological tests. The medical report must be complete enough to help the Board determine the nature, severity, duration of the impairment, and residual functional capacity. Pertinent points in the claimant's medical history, such as a description of chest pain, will reflect the claimant's statements of his or her symptoms, not simply the physician's or psychologist's statements or conclusions. The examining physician's or psychologist's report of the consultative examination will include the objective medical facts. (c) Elements of a complete examination. A complete examination is one which involves all the elements of a standard examination in the applicable medical specialty. When a complete examination is involved, the report will include the following elements: (1) The claimant's major or chief complaint(s). (2) A d… | |||
| 20:20:1.0.2.8.16.7.155.13 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.62 Reviewing reports of consultative examinations. | SSA | (a) The Board will review the report of the consultative examination to determine whether the specific information requested has been furnished. The Board will consider these factors in reviewing the report: (1) Whether the report provides evidence which serves as an adequate basis for decision-making in terms of the impairment it assesses. (2) Whether the report is internally consistent. Whether all the diseases, impairments and complaints described in the history are adequately assessed and reported in the physical findings. Whether the conclusions correlate the findings from the claimant's medical history, physical examination and laboratory tests and explain all abnormalities. (3) Whether the report is consistent with the other information available to the Board within the specialty of the examination requested. Whether the report fails to mention an important or relevant complaint within the speciality that is noted on other evidence in the file (e.g., blindness in one eye, amputations, flail limbs or claw hands, etc.). (4) Whether the report is properly signed. (b) If the report is inadequate or incomplete, the Board will contact the examining consultative physician or psychologist, give an explanation of the Board's evidentiary needs, and ask that the physician or psychologist furnish the missing information or prepare a revised report. (c) Where the examination discloses new diagnostic information or test results which are significant to the claimant's treatment, the Board will consider referral of the consultative examination report to the claimant's treating physician or psychologist. (d) The Board will take steps to ensure that consultative examinations are scheduled only with medical sources who have the equipment required to provide an adequate assessment and record of the level of severity of the claimant's alleged impairments. | ||||
| 20:20:1.0.2.8.16.7.155.14 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.63 Conflict of interest. | SSA | All implications of possible conflict of interest between Board medical consultants and their medical practices will be avoided. Board review physicians or psychologists will not perform consultative examinations for the Board's disability programs without prior approval. In addition, they will not acquire or maintain, directly or indirectly, including any member of their families, any financial interest in a medical partnership or similar relationship in which consultative examinations are provided. Sometimes one of the Board's review physicians or psychologists will have prior knowledge of a case (e.g., the claimant was a patient). Where this is so, the physician or psychologist will not participate in the review or determination of the case. This does not preclude the physician or psychologist from submitting medical evidence based on prior treatment or examination of the claimant. | ||||
| 20:20:1.0.2.8.16.7.155.15 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.64 Program integrity. | SSA | The Board will not use in its program any individual or entity who is excluded, suspended, or otherwise barred from participation in the Medicare or Medicaid programs, or any other Federal or Federally-assisted program; who has been convicted, under Federal or State law, in connection with the delivery of health care services, of fraud, theft, embezzlement, breach of fiduciary responsibility or financial abuse; who has been convicted under Federal or State law of unlawful manufacture, distribution, prescription, or dispensing of a controlled substance; whose license to provide health care services is revoked or suspended by any State licensing authority for reasons bearing on professional competence, professional conduct, or financial integrity; who has surrendered such a license while formal disciplinary proceedings involving professional conduct were pending; or who has had a civil monetary assessment or penalty imposed on such individual or entity for any activity described in this section or as a result of formal disciplinary proceedings. Also see §§ 220.53 and 220.57(b). | ||||
| 20:20:1.0.2.8.16.7.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.51 Notice of the examination. | SSA | If the Board arranges for an examination or test, the claimant will be provided with reasonable notice of the date, time, and place of the examination or test and the name of the person who will do it. The Board will also give the examiner any necessary background information about the claimant's impairment(s). | ||||
| 20:20:1.0.2.8.16.7.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.52 Failure to appear at a consultative examination. | SSA | (a) General. The Board may find that the claimant is not disabled if he or she does not have good reason for failing or refusing to take part in a consultative examination or test which was arranged by the Board. If the individual is already receiving an annuity and does not have a good reason for failing or refusing to take part in a consultative examination or test which the Board arranged, the Board may determine that the individual's disability has stopped because of his or her failure or refusal. The claimant for whom an examination or test has been scheduled should notify the Board as soon as possible before the scheduled date of the examination or test if he or she has any reason why he or she cannot go to the examination or test. If the Board finds that the claimant has a good reason for failure to appear, another examination or test will be scheduled. (b) Examples of good reasons for failure to appear. Some examples of good reasons for not going to a scheduled examination or test include— (1) Illness on the date of the scheduled examination or test; (2) Failure to receive notice or timely notice of an examination or test; (3) Receipt of incorrect or incomplete information about the examination or test; or (4) A death or serious illness in the claimant's immediate family. (c) Objections by a claimant's physician. The Board should be notified immediately if the claimant is advised by his or her treating physician not to take an examination or test. In some cases, the Board may be able to secure the information which is needed in another way or the treating physician may agree to another type of examination for the same purpose. | ||||
| 20:20:1.0.2.8.16.7.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.53 When the Board will purchase a consultative examination and how it will be used. | SSA | (a)(1) General. The decision to purchase a consultative examination for a claimant will be made after full consideration is given to whether the additional information needed (e.g., clinical findings, laboratory tests, diagnosis, and prognosis, etc.) is readily available from the records of the claimant's medical sources. Upon filing an application for a disability annuity, a claimant will be required to obtain from his or her medical source(s) information regarding the claimed impairments. The Board will seek clarification from a medical source who has provided a report when that report contains a conflict or ambiguity, or does not contain all necessary information or when the information supplied is not based on objective evidence. The Board will not, however, seek clarification from a medical source when it is clear that the source either cannot or will not provide the necessary findings, or cannot reconcile a conflict or ambiguity in the findings provided from the source's records. Therefore, before purchasing a consultative examination, the Board will consider not only existing medical reports, but also the background report containing the claimant's allegations and information about the claimant's vocational background, as well as other pertinent evidence in his or her file. (2) When the Board purchases a consultative examination, we will use the report from the consultative examination to try to resolve a conflict or ambiguity if one exists. The Board will do this by comparing the persuasiveness and value of the evidence. The Board will also use a consultative examination to secure needed medical evidence the file does not contain such as clinical findings, laboratory tests, a diagnosis or prognosis necessary for decision. (b) Situations requiring a consultative examination. A consultative examination may be purchased when the evidence as a whole, both medical and non-medical, is not sufficient to support a decision on the claim. In addition, other situations, such as one or more of the following, wi… | ||||
| 20:20:1.0.2.8.16.7.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.54 When the Board will not purchase a consultative examination. | SSA | A consultative examination will not be purchased in the following situations (these situations are not all-inclusive): (a) In disabled widow(er) benefit claims, when the alleged month of disability is after the end of the 7-year period specified in § 216.38 and there is no possibility of establishing an earlier onset, or when the 7-year period expired in the past and all the medical evidence in the claimant's file establishes that he or she was not disabled on or before the expiration date. (b) When any issues about the actual performance of substantial gainful activity have not been resolved. (c) In childhood disability claims, when it is determined that the claimant's alleged childhood disability did not begin before the month of attainment of age 22. In this situation, the claimant could not be entitled to benefits as a disabled child unless found disabled before age 22. (d) When, on the basis of the claimant's allegations and all available medical reports in his or her case file, it is apparent that he or she does not have an impairment which will have more than a minimal effect on his or her capacity to work. (e) Childhood disability claims filed concurrently with the employee's claim and entitlement cannot be established for the employee. (f) Survivors childhood disability claims where entitlement is precluded based on non-disability factors. | ||||
| 20:20:1.0.2.8.16.7.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.55 Purchase of consultative examinations at the reconsideration level. | SSA | (a) When a claimant requests a review of the Board's initial determination at the reconsideration level of review, consultative medical examinations will be obtained when needed, but not routinely. A consultative examination will not, if possible, be performed by the same physician or psychologist used in the initial claim. (b) Where the evidence tends to substantiate an affirmation of the initial denial but the claimant states that the treating physician or psychologist considers him or her to be disabled, the Board will assist the claimant in securing medical reports or records from the treating physician. | ||||
| 20:20:1.0.2.8.16.7.155.7 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.56 Securing medical evidence at the hearings officer hearing level. | SSA | (a) Where there is a conflict in the medical evidence at the hearing level of review before a hearings officer, the hearings officer will try to resolve it by comparing the persuasiveness and value of the conflicting evidence. The hearings officer's reasoning will be explained in the decision rationale. Where such resolution is not possible, the hearings officer will secure additional medical evidence (e.g., clinical findings, laboratory test, diagnosis, prognosis, etc.) to resolve the conflict. Even in the absence of a conflict, the hearings officer will also secure additional medical evidence when the file does not contain findings, laboratory tests, a diagnosis, or a prognosis necessary for a decision. (b) Before requesting a consultative examination, the hearings officer will ascertain whether the information is available as a result of a recent examination by any of the claimant's medical sources. If it is, the hearings officer will request the evidence from that medical practitioner. If contact with the medical source is not productive for any reason, or if there is no recent examination by a medical source, the hearings officer will obtain a consultative examination. | ||||
| 20:20:1.0.2.8.16.7.155.8 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.57 Types of purchased examinations and selection of sources. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 87 FR 27513, May 9, 2022] | (a) Additional evidence needed for disability determination. The types of examinations and tests the Board will purchase depends upon the additional evidence needed for the disability determination. The Board will purchase only the specific evidence needed. For example, if special tests (such as X-rays, blood studies, or EKG) will furnish the additional evidence needed for the disability determination, a more comprehensive medical examination will not be authorized. (b) The physician or psychologist selected to do the examination or test must be qualified. The physician's or psychologist's qualifications must indicate that the physician or psychologist is currently licensed in the State and has the training and experience to perform the type of examination or test requested. The physician or psychologist may use support staff to help perform the examination. Any such support staff must meet appropriate licensing or certification requirements of the State. See also § 220.64. (c) Use of video teleconferencing technology. Video teleconferencing technology (VTT) may be used for a psychological or a psychiatric consultative examination provided that the following requirements are met: (1) The examining physician or psychologist is currently state-licensed in the state in which the provider practices; (2) The examining physician or psychologist has the training and experience to perform the type of examination requested; (3) The examining physician or psychologist has access to video teleconferencing technology; (4) The examining physician or psychologist is permitted to perform the exam in accordance with state licensing laws and regulations; (5) The protocol for the examination does not require physical contact; (6) The claimant has the right to refuse a VTT examination without penalty; and (7) The VTT examination complies with all requirements in this subpart governing consultative examinations. | |||
| 20:20:1.0.2.8.16.7.155.9 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | G | Subpart G—Consultative Examinations | § 220.58 Objections to the designated physician or psychologist. | SSA | A claimant or his or her representative may object to his or her being examined by a designated physician or psychologist. If there is a good reason for the objection, the Board will schedule the examination with another physician or psychologist. A good reason may be where the consultative examination physician or psychologist had previously represented an interest adverse to the claimant. For example, the physician or psychologist may have represented the claimant's employer in a worker's compensation case or may have been involved in an insurance claim or legal action adverse to the claimant. Other things the Board will consider are: language barrier, office location of consultative examination physician or psychologist (2nd floor, no elevator, etc.), travel restrictions, and examination by the physician or psychologist in connection with a previous unfavorable determination. If the objection is because a physician or psychologist allegedly “lacks objectivity” (in general, but not in relation to the claimant personally) the Board will review the allegations. To avoid a delay in processing the claimant's claim, the consultative examination in such a case will be changed to another physician or psychologist while a review is being conducted. Any objection to use of the substitute physician or psychologist will be handled in the same manner. However, if the Board or the Social Security Administration had previously conducted such a review and found that the reports of the consultative physician or psychologist in question conform to the Board's guidelines, then the Board will not change the claimant's examination. | ||||
| 20:20:1.0.2.8.16.8.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.100 Evaluation of disability for any regular employment. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63600, Dec. 4, 2009] | (a) General. The Board uses a set evaluation process, explained in paragraph (b) of this section, to determine whether a claimant is disabled for any regular employment. This evaluation process applies to employees, widow(er)s, and children who have applied for annuities under the Railroad Retirement Act based on disability for any regular employment. Regular employment means substantial gainful activity as that term is defined in § 220.141. (b) Steps in evaluating disability. A set order is followed to determine whether disability exists. The duration requirement, as described in § 220.28, must be met for a claimant to be found disabled. The Board reviews any current work activity, the severity of the claimant's impairment(s), the claimant's residual functional capacity, and the claimant's age, education, and work experience. If the Board finds that the claimant is disabled or is not disabled at any step in the process, the Board does not review further. (See § 220.105 if the claimant is not currently disabled but was previously disabled for a specified period of time in the past.) The steps are as follows: (1) Claimant is working. If the claimant is working, and the work is substantial gainful activity, the Board will find that he or she is not disabled regardless of his or her impairments, age, education, or work experience. If the claimant is not performing substantial gainful activity, the Board will follow paragraph (2) of this section. (2) Impairment(s) not severe. If the claimant does not have an impairment or combination of impairments which significantly limit his or her physical or mental ability to do basic work activities, the Board will find that the claimant is not disabled without consideration of age, education, or work experience. If the claimant has an impairment or combination of impairments which significantly limit his or her ability to do basic work activities, the Board will follow paragraph (3) of this section. (See § 220.102(b) for a definition of basic work activities.) (3) … | |||
| 20:20:1.0.2.8.16.8.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.101 Evaluation of mental impairments. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 74 FR 63600, Dec. 4, 2009] | (a) General. The steps outlined in § 220.100 apply to the evaluation of physical and mental impairments. In addition, in evaluating the severity of a mental impairment(s), the Board will follow a special procedure at each administrative level of review. Following this procedure will assist the Board in— (1) Identifying additional evidence necessary for the determination of impairment severity; (2) Considering and evaluating aspects of the mental impairment(s) relevant to the claimant's ability to work; and (3) Organizing and presenting the findings in a clear, concise, and consistent manner. (b) Use of the procedure to record pertinent findings and rate the degree of functional loss. (1) This procedure requires the Board to record the pertinent signs, symptoms, findings, functional limitations, and effects of treatment contained in the claimant's case record. This will assist the Board in determining if a mental impairment(s) exists. Whether or not a mental impairment(s) exists is decided in the same way the question of a physical impairment is decided, i.e., the evidence must be carefully reviewed and conclusions supported by it. The mental status examination and psychiatric history will ordinarily provide the needed information. (See § 220.27 for further information about what is needed to show an impairment.) (2) If the Board determines that a mental impairment(s) exists, this procedure then requires the Board to indicate whether certain medical findings which have been found especially relevant to the ability to work are present or absent. (3) The procedure then requires the Board to rate the degree of functional loss resulting from the impairment(s). Four areas of function considered by the Board as essential to work have been identified, and the degree of functional loss in those areas must be rated on a scale that ranges from no limitation to a level of severity which is incompatible with the ability to perform those work-related functions. For the first two areas (activities of daily living and… | |||
| 20:20:1.0.2.8.16.8.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.102 Non-severe impairment(s), defined. | SSA | (a) Non-severe impairment(s). An impairment or combination of impairments is not severe if it does not significantly limit the claimant's physical or mental ability to do basic work activities. (b) Basic work activities. Basic work activities means the ability and aptitudes necessary to do most jobs. Examples of these include— (1) Physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling; (2) Capacities for seeing, hearing, and speaking; (3) Understanding, carrying out, and remembering simple instructions; (4) Use of judgment; (5) Responding appropriately to supervision, co-workers and usual work situations; and (6) Dealing with changes in a routine work setting. | ||||
| 20:20:1.0.2.8.16.8.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.103 Two or more unrelated impairments—initial claims. | SSA | (a) Unrelated severe impairments. Two or more unrelated severe impairments cannot be combined to meet the 12-month duration test. If the claimant has a severe impairment(s) and then develops another unrelated severe impairment(s) but neither one is expected to last for 12 months, he or she cannot be found disabled even though the 2 impairments in combination last for 12 months. (b) Concurrent impairments. If the claimant has 2 or more concurrent impairments which, when considered in combination, are severe, the board must also determine whether the combined effect of the impairments can be expected to continue to be severe for 12 months. If 1 or more of the claimant's impairments improves or is expected to improve within 12 months, so that the combined effect of the claimant's impairments is no longer severe, he or she will be found to not meet the 12-month duration test. | ||||
| 20:20:1.0.2.8.16.8.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.104 Multiple impairments. | SSA | To determine whether the claimant's physical or mental impairment or impairments are of a sufficient medical severity that such impairment or impairments could be the basis of eligiblity under the law, the combined effect of all of the claimant's impairments are considered regardless of whether any such impairment, if considered separately, would be of sufficient severity. If a medically severe combination of impairments is found, it will be considered throughout the disability evaluation process. If a medically severe combination of impairments is not found, the claimant will be determined to be not disabled. | ||||
| 20:20:1.0.2.8.16.8.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | H | Subpart H—Evaluation of Disability | § 220.105 Initial evaluation of a previous disability. | SSA | (a) In some cases, the Board may determine that a claimant is not currently disabled but was previously disabled for a specified period of time in the past. This can occur when— (1) The disability application was filed before the claimant's disability ended but the Board did not make the initial determination of disability until after the claimant's disability ended; or (2) The disability application was filed after the claimant's disability ended but no later than the 12th month after the month the disability ended. (b) When evaluating a claim for a previous disability, the Board follows the steps in § 220.100 to determine whether a disability existed, and follows the steps in § 220.180 to determine when the disability ended. The claimant, although fully recovered medically and regularly employed, filed an application on December 3, 1984 for a determination of disability for the period June 16, 1982 through January 31, 1984. The Board reviewed his claim in January 1985 and determined that he was disabled for the prior period which began June 16, 1982 and continued through January 31, 1984. A disability annuity is payable to the employee only for the period December 1, 1983 through January 31, 1984. An annuity may not begin any earlier than the 1st of the 12th month before the month in which the application was filed (See part 218 of this chapter for the rules on when an annuity may begin). | ||||
| 20:20:1.0.2.8.16.9.155.1 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.110 Medically disabled. | SSA | [74 FR 63601, Dec. 4, 2009] | (a) “ Medically disabled.” The term “medically disabled ”refers to disability based solely on impairment(s) which are considered to be so medically severe as to prevent a person from doing any substantial gainful activity. The Board will base its decision about whether the claimant's impairment(s) is medically disabling on medical evidence only, without consideration of the claimant's residual functional capacity, age, education or work experience. The Board will also consider the medical opinion given by one or more physicians employed or engaged by the Board or the Social Security Administration to make medical judgments. The medical evidence used to establish a diagnosis or confirm the existence of an impairment, and to establish the severity of the impairment includes medical findings consisting of signs, symptoms and laboratory findings. The medical findings must be based on medically acceptable clinical and laboratory diagnostic techniques. If the claimant has more than one impairment, but none of the impairments, by themselves, is medically disabling, the Board will review the signs, symptoms, and laboratory findings of all of the impairments to determine whether the combination of impairments is medically disabling. In general, impairments that the Board considers to be medically disabling are: (1) Permanent; (2) Expected to result in death; or (3) Have a specific length of duration. (b) Diagnosis of impairments. A diagnosis of a particular impairment is not sufficient for a finding of medical disability, unless the diagnosis is supported by medical findings that are based on medically acceptable clinical and laboratory techniques. (c) Addiction to alcohol or drugs. If a claimant has a condition diagnosed as addiction to alcohol or drugs, this condition will not, by itself, be a basis for determining whether the claimant is, or is not, disabled. As with any other medical condition, the Board will decide whether the claimant is disabled based on symptoms, signs, and laboratory findings. | |||
| 20:20:1.0.2.8.16.9.155.2 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.111 [Reserved] | SSA | |||||
| 20:20:1.0.2.8.16.9.155.3 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.112 Conclusions by physicians concerning the claimant's disability. | SSA | [56 FR 12980, Mar. 28, 1991, as amended at 68 FR 60291, Oct. 22, 2003; 74 FR 63601, Dec. 4, 2009] | (a) General. Under the statute, the Board is responsible for making the decision about whether a claimant meets the statutory definition of disability. A claimant can only be found disabled if he or she is unable to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. (See § 220.28). A claimant's impairment must result from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. (See § 220.27). The decision as to whether a claimant is disabled may involve more than medical considerations and the Board may have to consider such factors as age, education and past work experience. Such vocational factors are not within the expertise of medical sources. (b) Medical opinions that are conclusive. A medical opinion by a treating source will be conclusive as to the medical issues of the nature and severity of a claimant's impairment(s) where the Board finds that (1) it is fully supported by medically acceptable clinical and laboratory diagnostic techniques and (2) it is not inconsistent with the other substantial medical evidence of record. A medical opinion that is not fully supported will not be conclusive. (c) Medical opinions that are not fully supported. If an opinion by a treating source(s) is not fully supported, the Board will make every reasonable effort (i.e., an initial request and, after 20 days, one follow-up request) to obtain from the claimant's treating source(s) the relevant evidence that supports the medical opinion(s) before the Board makes a determination as to whether a claimant is disabled. (d) Inconsistent medical opinions. Where the Board finds that the opinion of a treating source regarding medical issues is inconsistent with the evidence of record, including opinions of other sources that are supporte… | |||
| 20:20:1.0.2.8.16.9.155.4 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.113 Symptoms, signs, and laboratory findings. | SSA | Medical findings consist of symptoms, signs, and laboratory findings: (a) Symptoms are the claimant's own description of his or her physical or mental impairment(s). The claimant's statements alone are not enough to establish that there is a physical or mental impairment(s). (b) Signs are anatomical, physiological, or psychological abnormalities which can be observed, apart from the claimant's own statements (symptoms). Signs must be shown by medically acceptable clinical diagnostic techniques. Psychiatric signs are medically demonstrable phenomena which indicate specific abnormalities of behavior, affect, thought, memory, orientation and contact with reality. They must also be shown by observable facts that can be medically described and evaluated. (c) Laboratory findings are anatomical, physiological, or psychological phenomena which can be shown by the use of medically acceptable laboratory diagnostic techniques. Some of these diagnostic techniques include chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.) x-rays, and psychological tests. | ||||
| 20:20:1.0.2.8.16.9.155.5 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.114 Evaluation of symptoms, including pain. | SSA | [68 FR 60291, Oct. 22, 2003, as amended at 74 FR 63601, Dec. 4, 2009] | (a) General. In determining whether the claimant is disabled, the Board considers all of the claimant's symptoms, including pain, and the extent to which the claimant's symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence. By objective medical evidence, the Board means medical signs and laboratory findings as defined in §§ 220.113(b) and (c) of this part. By other evidence, the Board means the kinds of evidence described in §§ 220.45 and 220.46 of this part. These include statements or reports from the claimant, the claimant's treating or examining physician or psychologist, and others about the claimant's medical history, diagnosis, prescribed treatment, daily activities, efforts to work, and any other evidence showing how the claimant's impairment(s) and any related symptoms affect the claimant's ability to work. The Board will consider all of the claimant's statements about his or her symptoms, such as pain, and any description by the claimant, the claimant's physician, or psychologist, or other persons about how the symptoms affect the claimant's activities of daily living and ability to work. However, statements alone about the claimant's pain or other symptoms will not establish that the claimant is disabled; there must be medical signs and laboratory findings which show that the claimant has a medical impairment(s) which could reasonably be expected to produce the pain or other symptoms alleged and which, when considered with all of the other evidence (including statements about the intensity and persistence of the claimant's pain or other symptoms which may reasonably be accepted as consistent with the medical signs and laboratory findings), would lead to a conclusion that the claimant is disabled. In evaluating the intensity and persistence of the claimant's symptoms, including pain, the Board will consider all of the available evidence, including the claimant's medical history, the medical signs and laboratory findings and statements about how the cl… | |||
| 20:20:1.0.2.8.16.9.155.6 | 20 | Employees' Benefits | II | B | 220 | PART 220—DETERMINING DISABILITY | I | Subpart I—Medical Considerations | § 220.115 Need to follow prescribed treatment. | SSA | (a) What treatment the claimant must follow. In order to get a disability annuity, the claimant must follow treatment prescribed by his or her physician if this treatment can restore the claimant's ability to work. (b) When the claimant does not follow prescribed treatment. If the claimant does not follow the prescribed treatment without a good reason, the Board will find him or her not disabled or, if the claimant is already receiving a disability annuity, the Board will stop paying the annuity. (c) Acceptable reasons for failure to follow prescribed treatment. The following are examples of a good reason for not following treatment: (1) The specific medical treatment is contrary to the established teaching and tenets of the claimant's religion. (2) The prescribed treatment would be cataract surgery for one eye, when there is an impairment of the other eye resulting in a severe loss of vision and is not subject to improvement through surgery. (3) Surgery was previously performed with unsuccessful results and the same surgery is again being recommended for the same impairment. (4) The treatment because of its magnitude (e.g., open heart surgery), unusual nature (e.g., organ transplant), or other reason is very risky for the claimant. (5) The treatment involves amputation of an extremity, or a major part of an extremity. |
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