20 CFR Part 416, Subpart A - Introduction, General Provisions and Definitions

We are revising our medical evidence rules. The revisions include redefining several key terms related to evidence, revising our rules about acceptable medical sources (AMS), revising how we consider and articulate our consideration of medical opinions and prior administrative medical findings, revising our rules about medical consultants (MC) and psychological consultants (PC), revising our rules about treating sources, and reorganizing our evidence regulations for ease of use. These revisions conform our rules to the requirements of the Bipartisan Budget Act of 2015 (BBA), reflect changes in the national healthcare workforce and in the manner that individuals receive medical care, and emphasize the need for objective medical evidence in disability and blindness claims. We expect that these changes will simplify our rules to make them easier to understand and apply, and allow us to continue to make accurate and consistent disability determinations and decisions.

We are revising our rules so that more of our procedures at the hearing and Appeals Council levels of our administrative review process are consistent nationwide. We anticipate that these nationally consistent procedures will enable us to administer our disability programs more efficiently and better serve the public.

We are extending, until December 28, 2018, the expiration date of our disability examiner authority (DEA) rule, which authorizes State agency disability examiners to make fully favorable determinations without the approval of a State agency medical or psychological consultant in claims that we consider under our quick disability determination (QDD) and compassionate allowance (CAL) processes. This is our last extension of this rule because we will phase out the use of DEA during the extension period under section 832 of the Bipartisan Budget Act of 2015 (BBA). This extension provides us the time necessary to take all of the administrative actions we need to take in order to reinstate uniform use of medical and psychological consultants. The current rule will expire on November 11, 2016. In this final rule, we are changing the November 11, 2016 expiration or “sunset” date to December 28, 2018, extending the authority for 2 years and 1 month. This is the final extension of our DEA rule. On December 28, 2018, at the conclusion of this extension, the authority for this test will terminate. We are making no other changes.

These rules finalize the rules we proposed in our notice of proposed rulemaking (NPRM), published on May 11, 2016. In these rules, we remove some of the requirements for evaluation of an unsuccessful work attempt (UWA) that lasts between 3 and 6 months, allow previously entitled beneficiaries to apply for expedited reinstatement (EXR) in the same month they stop performing substantial gainful activity (SGA), and provide that provisional benefits will begin the month after the request for EXR if the beneficiary stops performing SGA in the month of the EXR request. These changes will simplify our policies and make them easier for the public to understand.

We are revising the criteria in the Listing of Impairments (listings) that we use to evaluate claims involving mental disorders in adults and children under titles II and XVI of the Social Security Act (Act). The revisions reflect our program experience, advances in medical knowledge, recommendations from a commissioned report, and public comments we received in response to a Notice of Proposed Rulemaking (NPRM).

In accordance with section 812 of the Bipartisan Budget Act of 2015 (BBA section 812), these rules explain how we will address evidence furnished by medical sources that meet one of BBA section 812's exclusionary categories (excluded medical sources of evidence) as described below. Under these new rules, we will not consider evidence furnished by an excluded medical source of evidence unless we find good cause to do so. We identify five circumstances in which we may find good cause. In these rules, we also require excluded medical sources of evidence to notify us of their excluded status under section 223(d)(5)(C)(i) of the Social Security Act (Act), as amended, in writing each time they furnish evidence to us that relates to a claim for initial or continuing benefits under titles II or XVI of the Act. These rules will allow us to fulfill obligations that we have under BBA section 812.

We are proposing several revisions to our medical evidence rules. The proposals include redefining several key terms related to evidence, revising our list of acceptable medical sources (AMS), revising how we consider and articulate our consideration of medical opinions and prior administrative medical findings, revising who can be a medical consultant (MC) and psychological consultant (PC), revising our rules about treating sources, and reorganizing our evidence regulations for ease of use. These proposed revisions would conform our rules with the requirements of the Bipartisan Budget Act of 2015 (BBA), reflect changes in the national healthcare workforce and in the manner that individuals receive primary medical care, simplify and reorganize our rules to make them easier to understand and apply, allow us to continue to make accurate and consistent decisions, and emphasize the need for objective medical evidence in disability and blindness claims.

We propose to revise our rules of conduct and standards of responsibility for representatives. We also propose to update and clarify procedures we use when we bring charges against a representative for violating our rules of conduct and standards of responsibilities for representatives. These changes are necessary to better protect the integrity of our administrative process and further clarify representatives' currently existing responsibilities in their conduct with us. The changes to our rules are not meant to suggest that any specific conduct is permissible under our existing rules; instead, we seek to ensure that our rules of conduct and standards of responsibility are clearer as a whole and directly address a broader range of inappropriate conduct.

We propose to revise our rules so that more of our procedures at the administrative law judge (ALJ) and Appeals Council levels of our administrative review process are consistent nationwide. We anticipate that these nationally consistent procedures will enable us to administer our disability programs more efficiently and better serve the public.

We are extending for one year our pilot program that authorizes the agency to set the time and place for a hearing before an administrative law judge (ALJ). Extending the pilot program continues our commitment to improve the efficiency of our hearing process and to maintain a hearing process that results in accurate, high-quality decisions for claimants. The current pilot program will expire on August 12, 2016. In this final rule, we are extending the effective date to August 11, 2017. We are making no other changes.

In accordance with section 812 of the Bipartisan Budget Act of 2015 (BBA section 812), we propose to revise our rules to explain how we would address evidence furnished by medical sources that meet one of BBA section 812's exclusionary categories (statutorily excluded medical sources). Under this proposed rule, we would not consider evidence furnished by a statutorily excluded medical source unless we find good cause to do so. We propose several circumstances in which we would find good cause, and we also propose to require statutorily excluded medical sources to notify us of their excluded status when they furnish evidence to us. These rules would allow us to fulfill obligations that we have under the Bipartisan Budget Act of 2015 (BBA).

We are revising the criteria in the Listing of Impairments (listings) that we use to evaluate claims involving respiratory disorders in adults and children under titles II and XVI of the Social Security Act (Act). The revisions reflect our program experience and advances in medical knowledge since we last comprehensively revised this body system in 1993, as well as comments we received from medical experts and the public.

We propose to remove some of the requirements for evaluation of an unsuccessful work attempt (UWA) that lasts between 3 and 6 months. We also propose to allow previously entitled beneficiaries to apply for expedited reinstatement (EXR) in the same month they stop performing substantial gainful activity (SGA). Provisional benefits will begin the month after the request for EXR if the beneficiary stops performing SGA in the month of the EXR request. These changes would simplify our policies and make them easier for the public to understand.

This final rule adopts the notice of proposed rulemaking (NPRM) that we published in the Federal Register on October 21, 2015. This final rule revises our rules regarding returning evidence at the Appeals Council (AC) level. Under this final rule, the AC will no longer return additional evidence it receives when the AC determines the additional evidence does not relate to the period on or before the date of the administrative law judge (ALJ) decision.

On September 14, 2015, we published in the Federal Register an advanced notice of proposed rulemaking (ANPRM) regarding Vocational Factors of Age, Education, and Work Experience in the Adult Disability Determination Process and solicited public comments. We provided a 60-day comment period ending on November 13, 2015. We are extending the comment period to December 14, 2015. Our extension of the comment date accommodates and facilitates public comments we expect in response to the National Disability Forum we are sponsoring on Friday, November 20, 2015. During the forum, we are hosting a moderator-led discussion entitled: The Realities of Work for Individuals with Disabilities: Impact of Age, Education, and Work Experience (for information on the forum see the SUPPLEMENTARY INFORMATION section).

We propose to amend our regulations by revising our rules regarding the return of evidence at the Appeals Council (AC) level. Our current rules state that the AC will return to the claimant additional evidence it receives when the AC finds the evidence does not relate to the period on or before the date of the administrative law judge's (ALJ) hearing decision. We are proposing these revisions to give the AC discretion in returning additional evidence that it receives when the AC determines the additional evidence does not relate to the period on or before the date of the ALJ decision.

We are extending the expiration date of our rule that authorizes State agency disability examiners to make fully favorable determinations without the approval of a State agency medical or psychological consultant in claims that we consider under our quick disability determination (QDD) and compassionate allowance (CAL) processes. The current rule will expire on November 13, 2015. In this final rule, we are changing the November 13, 2015 expiration or “sunset” date to November 11, 2016, extending the authority for 1 year. We are making no other substantive changes.

We are soliciting public input about how we should consider the vocational factors of age, education, and work experience in adult disability claims under titles II and XVI of the Social Security Act (Act). There have been significant changes in technology use and workforce demographics since we first adopted our vocational factor regulations in 1978. We are requesting public comments, along with any supporting data, to assist in our efforts to streamline, simplify, and ensure the ongoing relevance of our disability determination programs.

We are extending for one year our pilot program that authorizes the agency to set the time and place for a hearing before an administrative law judge (ALJ). Extending of the pilot program continues our commitment to improve the efficiency of our hearing process and to maintain a hearing process that results in accurate, high-quality decisions for claimants. The current pilot program will expire on August 10, 2015. In this final rule, we are extending the effective date to August 12, 2016. We are making no other substantive changes.

We are extending for 2 years our rule authorizing attorney advisors to conduct certain prehearing procedures and to issue fully favorable decisions. The current rule will expire on August 7, 2015. In this final rule, we are extending the sunset date to August 4, 2017. We are making no other substantive changes.

This rule adopts, with one change, the rule for evaluating growth disorders in children we proposed in a notice of proposed rulemaking (NPRM) published in the Federal Register on May 22, 2013. Several body systems in the Listing of Impairments (listings) contain listings for children based on impairment of linear growth or weight loss. We are replacing those listings with new listings for low birth weight (LBW) and failure to thrive; a new listing for genitourinary impairments; and revised listings for growth failure in combination with a respiratory, cardiovascular, digestive, or immune system disorder. These revisions reflect our program experience, advances in medical knowledge, and comments we received from medical experts and the public.

We are clarifying our regulations to require you to inform us about or submit all evidence known to you that relates to your disability claim, subject to two exceptions for certain privileged communications. This requirement includes the duty to submit all evidence that relates to your disability claim received from any source in its entirety, unless you previously submitted the same evidence to us or we instruct you otherwise. We are also requiring your representative to help you obtain the information or evidence that we require you to submit under our regulations. These modifications to our regulations will better describe your duty to submit all evidence that relates to your disability claim and enable us to have more complete case records on which to make more accurate disability determinations and decisions.

We are adopting, with two revisions, our interim final rules that implemented amendments to the Social Security Act (Act) made by the Social Security Disability Applicants' Access to Professional Representation Act of 2010 (PRA). The interim final rules made permanent the direct fee payment rules for eligible non-attorney representatives under titles II and XVI of the Act and for attorney representatives under title XVI of the Act. They also revised some of our eligibility policies for non-attorney representatives under titles II and XVI of the Act. Based on public comment and subsequent inquiries, we are revising our rules to clarify that an eligible non-attorney representative's liability insurance policy must include malpractice coverage. We are also reaffirming that a business entity legally permitted to provide the required insurance in the States in which the non-attorney representative conducts business must underwrite the policies.

We are extending the expiration date of our rule that authorizes State agency disability examiners to make fully favorable determinations without the approval of a State agency medical or psychological consultant in claims that we consider under our quick disability determination (QDD) and compassionate allowance (CAL) processes. The current rule will expire on November 14, 2014. In this final rule, we are changing the November 14, 2014 expiration or “sunset” date to November 13, 2015, extending the authority for 1 year. We are making no other substantive changes.

We are extending for one year our pilot program that authorizes the agency to set the time and place for a hearing before an administrative law judge (ALJ). Extending the pilot program continues our commitment to improve the efficiency of our hearing process and provide accurate, high-quality decisions for claimants. The current pilot program will expire on August 9, 2014. In this final rule, we are extending the expiration date to August 10, 2015. We are making no other substantive changes.

This final rule adopts, without change, the final rule with request for comments we published in the Federal Register (76 FR 41685) on July 15, 2011. We are revising our regulations to reflect our use of electronic case processing at the initial and reconsideration levels of our administrative review process. We are not changing the requirement that State agency medical and psychological consultants must affirm the accuracy and completeness of their findings of fact and discussion of the supporting evidence, only the manner in which they may provide the required findings and affirmation. This revision will improve our efficiency by increasing our use of electronic resources.

These final rules explain how a claimant may object to appearing at a hearing via video teleconferencing, or to the time and place of a hearing. These final rules adopt, with further clarification regarding our good cause exception, the notice of proposed rulemaking (NPRM) that we published in the Federal Register on June 27, 2013. We expect that these final rules will have a minimal impact on the public, help ensure the integrity of our programs, and allow us to administer our programs more efficiently.

We propose to clarify our regulations to require you to inform us about or submit all evidence known to you that relates to your disability claim, subject to two exceptions for certain privileged communications. This requirement would include the duty to submit all evidence obtained from any source in its entirety, unless subject to one of these exceptions. We also propose to require your representative to help you obtain the information or evidence that we would require you to submit under our regulations. These modifications to our regulations would better describe your duty to submit all evidence that relates to your disability claim and enable us to have a more complete case record on which to make more accurate disability determinations and decisions.

We reimburse States that provide interim assistance to Supplemental Security Income (SSI) claimants under our interim assistance reimbursement (IAR) program. We provide this reimbursement from the SSI recipient's initial retroactive SSI payment. On November 20, 2010, we began using an electronic Interim Assistance Reimbursement system (eIAR) to streamline the way we process reimbursements to the States. The eIAR process replaced our prior paper-based process with an electronic one, and greatly reduced our and the State's involvement in manually processing IAR cases. This electronic system did not change the amount of payments we make to States and SSI recipients. We propose to revise our rules about how we administer the IAR process to reflect the electronic process. We also made minor language changes and reorganized the sections for clarity.

We are extending the expiration date of our rules that authorizes State agency disability examiners to make fully favorable determinations without the approval of a State agency medical or psychological consultant in claims that we consider under our quick disability determination (QDD) and compassionate allowance (CAL) processes. The current rules will expire on November 12, 2013. In this final rule, we are changing the November 12, 2013 expiration or “sunset” date to November 14, 2014, extending the authority for 1 year. We are making no other substantive changes, although we are making minor, nonsubstantive editorial changes to the rule for clarity.

This final rule adopts, without change, the notice of proposed rulemaking (NPRM) we published in the Federal Register on January 28, 2013. We are replacing the term “mental retardation” with “intellectual disability” in our Listing of Impairments (listings) that we use to evaluate claims involving mental disorders in adults and children under titles II and XVI of the Social Security Act (Act) and in other appropriate sections of our rules. This change reflects the widespread adoption of the term “intellectual disability” by Congress, government agencies, and various public and private organizations.

We are requesting information from the public regarding whether and how we should change our rules of administrative finality. These rules govern when we can reopen and revise a determination or decision that has become final and is no longer subject to administrative or judicial review. We are requesting information about several possible ways to change various aspects of our administrative finality rules. We are interested in obtaining information about issues such as whether and how we should revise the rules that govern the timeframes in which we can reopen a determination or decision, and whether and how we should revise the rules that govern the diligent pursuit of an investigation. We are also interested in obtaining information about whether we should adopt rules that would address our ability to make prospective changes to the amount of an individual's benefits without making changes for months in which the individual has already received payment. We are requesting your comments on several questions that we address below.

We propose to revise our rules to protect the integrity of our programs and preserve limited resources. Prior to scheduling a hearing, we will notify the claimant that his or her hearing may be held by video teleconferencing. The claimant will have an opportunity to object to appearing by video teleconferencing within 30 days after the date he or she receives the notice. We also propose changes that allow us to determine that a claimant will appear via video teleconferencing if he or she changes residences while his or her request for hearing is pending, regardless of whether or not the claimant previously declined a hearing by video teleconferencing. Additionally, we propose changes that require a claimant to notify us, in writing, of an objection to the time and place of hearing at the earliest opportunity, but not later than 5 days before the date set for the hearing, or, if earlier, 30 days after receiving the notice of the hearing. We also propose to revise our rules so that an administrative law judge (ALJ) can direct a claimant and any other party to a hearing to appear by telephone in extraordinary circumstances. We anticipate that these proposed changes will have a minimal impact on the public, and will help ensure the integrity of our programs and allow us to administer our programs more efficiently.

Treasury, SSA, VA, RRB and OPM (Agencies) are adopting as final an interim rule to amend their regulation governing the garnishment of certain Federal benefit payments that are directly deposited to accounts at financial institutions. The rule establishes procedures that financial institutions must follow when they receive a garnishment order against an account holder who receives certain types of Federal benefit payments by direct deposit. The rule requires financial institutions that receive such a garnishment order to determine the sum of such Federal benefit payments deposited to the account during a two month period, and to ensure that the account holder has access to an amount equal to that sum or to the current balance of the account, whichever is lower.

Several body systems in our Listing of Impairments (listings) contain listings for children based on impairment of linear growth or weight loss. We propose to replace those listings with new listings, add a listing to the genitourinary body system for children, and provide new introductory text for each listing explaining how to apply the new criteria. The proposed revisions to our listings reflect our program experience, advances in medical knowledge, comments we received from medical experts and the public at an outreach policy conference, and comments we received in response to a notice of intent to issue regulations and request for comments (request for comments) and an advance notice of proposed rulemaking (ANPRM). We are also proposing conforming changes in our regulations for title XVI of the Social Security Act (Act).

This final rule is another step in our continual efforts to handle workloads more effectively and efficiently. We are publishing final rules for portions of the rules we proposed in October 2007 that relate to persons, other than the claimant or any other party to the hearing, appearing by telephone. We are also clarifying that the administrative law judge (ALJ) will allow the claimant or any other party to a hearing to appear by telephone under certain circumstances when the claimant or other party requests to make his or her appearance in that manner. We expect that these final rules will make the hearings process more efficient and help us continue to reduce the hearings backlog. In addition, we made some minor editorial changes to our regulations that do not have any effect on the rights of claimants or any other parties.

We propose to revise the criteria in the Listing of Impairments (listings) that we use to evaluate claims involving respiratory disorders in adults and children under titles II and XVI of the Social Security Act (Act). The proposed revisions reflect our program experience, advances in medical knowledge, and comments we received from medical experts and the public at an outreach policy conference and in response to an Advance Notice of Proposed Rulemaking (ANPRM).

We propose to replace the term “mental retardation” with “intellectual disability” in our Listing of Impairments (listings) that we use to evaluate claims involving mental disorders in adults and children under titles II and XVI of the Social Security Act (Act) and in other appropriate sections of our rules. This change would reflect the widespread adoption of the term “intellectual disability” by Congress, government agencies, and various public and private organizations.

We are revising our rules to give adjudicators the discretion to proceed to the fifth step of the sequential evaluation process for assessing disability when we have insufficient information about a claimant's past relevant work history to make the findings required for step 4. If an adjudicator finds at step 5 that a claimant may be unable to adjust to other work existing in the national economy, the adjudicator will return to the fourth step to develop the claimant's work history and make a finding about whether the claimant can perform his or her past relevant work. We expect that this new expedited process will not disadvantage any claimant or change the ultimate conclusion about whether a claimant is disabled, but it will promote administrative efficiency and help us make more timely disability determinations and decisions.

We are withdrawing the proposed rules we published in the Federal Register on December 5, 2005.

We are revising the Notification of implementation of requirement we published on January 31, 2012 (77 FR 4653). We are clarifying the requirement that appointed representatives file certain appeals using our electronic systems in matters for which the representatives request direct fee payment. Specifically, we are clarifying that the electronic filing requirement includes both the submission of the forms we require to file the appeal request and the Disability Report—Appeal. This is the first service required under the regulation we published on September 12, 2011 (76 FR 56107), Requiring Use of Electronic Services.