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Unidad 3: Textos no literarios Lectura
There are many differences across the disability programs in terms of purpose, admin- istrative processes, eligibility, benefits, and size, all of which we discuss below. It is im- portant to be aware of these differences because they determine the potential applicability for VA of lessons from the other programs.
6.2.1 Application and appeals process
Each disability program has different administrative processes for filing claims and making appeals. This section summarizes the basic steps in applying for compensation in the various programs.
For VA disability compensation, the applicant begins by filing a claim with one of VA’s 57 Regional Offices (ROs). VA staff then ensure that all the necessary information is available for a Rating Veterans Service Representative (RVSR) to make a decision on the claim. If the applicant disagrees with the RVSR’s decision, then he or she can file a Notice of Disagreement with the RO and request a review of the decision by a Decision Review Officer in the RO. To pursue a claim further, the applicant files an appeal with VA’s Board of Veterans’ Appeals (BVA). Subsequent appeals go outside the VA (to the U.S. Court of Appeals for Veterans Claims, then the U.S. Court of Appeals for the Fed-
For SSDI and SSI, SSA is currently switching to a new claims system, which is called the Disability Service Improvement (DSI) process. It began gradually implementing DSI across the country by region in summer 2006. The system that DSI is replacing works as follows. An applicant first files a claim with one of the SSA field offices, which then verifies the applicant’s non-medical eligibility. Then the state’s Disability Determina- tion Service (DDS) makes a decision on disability. (DDSs are state agencies that are fully funded by the federal government.) If the applicant disagrees with the initial DDS decision, he or she can then request reconsideration at the DDS. A further appeal goes to SSA’s Office of Disability Adjudication and Review (ODAR), and that decision can then be reviewed by SSA’s Appeals Council. After that, there can be review by federal courts, starting with a lawsuit in a federal district court and potentially ending in the Supreme Court. The changes under DSI are that the first appeal is not reconsideration at the DDS but instead at the federal level by a Federal Reviewing Official. Under DSI, the next appeal still goes to ODAR, but SSA’s Appeals Council is being phased out. There is no change to federal-level appeals.
For FERS and CSRS, the disability compensation process begins when the federal agency where the applicant works forwards the disability application to OPM. The Dis- ability Division in OPM then issues a decision. The applicant can then request recon- sideration by OPM, and if the applicant wants to appeal that decision, he or she can go to the Merit Systems Protection Board, which is outside of OPM.
For FECA claims, the federal agency where the applicant works submits the claim to one of the 12 DOs throughout the country. If the applicant wants to appeal the DO decision, there are three options: the Branch of Hearings and Review (BHR), recon- sideration at the DO, and the Employees’ Compensation Appeals Board (ECAB). Technically, the applicant can pursue these three options in any order, but in practice it is easiest for the applicant to first go to BHR and then to DO reconsideration and then to ECAB.
For the DES, each service uses a slightly different process, but the basic approach is the following. An injured service member is referred to a Medical Treatment Facility (MTF) by a commanding officer or physician. At the MTF, a Medical Evaluation Board (MEB) determines whether the service member meets the medical standard for reten- tion in the military. If he or she does not, then the case goes to the service’s Informal Physical Evaluation Board (IPEB) for a decision about the level of disability. If the ser- vice member disagrees with the IPEB decision, he or she can then request a hearing and decision by the service’s Formal Physical Evaluation Board (FPEB). (The service member and/or representatives can attend the FPEB but not the IPEB.) Appeals be- yond the FPEB are allowed, but the exact appellate bodies differ by service.
6.2.2 Program eligibility and benefit determination
As already mentioned, the various disability compensation programs have different cri- teria for determining eligibility and benefit levels. This section describes those aspects of each of the disability programs, starting with a summary of the target population and purpose of each program in table 36. Recall that the discussion in this section is limited to monetary benefits for the disabled person only. It does not address benefits for dependents or survivors, nor does it address non-monetary benefits.
Table 36. Program coverage and purpose of compensation
Program Program coverage: Disabled people
within this population
Purpose of compensation
VA Veterans Full replacement of average earnings loss
SSDI Most workers (excludes federal employ-
ees and some state and local government employees)
Partial replacement of earnings
SSI People with low income and assets Income supplement
FERS/CSRS Federal employees Partial replacement of earnings
FECA Federal employees Partial replacement of earnings and/or short-
term compensation for permanent physical loss
DES Military service members Compensation for shortened military career
The VA disability compensation program has already been discussed extensively in this report, but descriptions of selected program elements are repeated here to help with the cross-program comparisons. The purpose of the VA program is of course to com- pensate disabled veterans for earnings lost due to their disability, although there is no mechanism for calculating individual-specific earnings losses. A disability is defined as either an injury or a disease that resulted from service or as a pre-existing injury or dis- ease that was aggravated by service. A veteran can have multiple disabilities, each of which is assigned a rating reflecting its severity. The combination of the disability rat- ings for all disabilities determines a veteran’s level of compensation.
to engage in “substantial gainful activity” (SGA) due to long-term physical or mental impairment, where SGA is defined as earnings above a certain amount. Both eligibility and compensation levels depend on an individual’s earnings history.
SSI is an income supplement for people who are elderly (at least 65 years old), blind, or disabled and who have low income and assets. The disability definition is the same as for SSDI. Benefit levels depend on the level of income and assets.
The purpose of the FERS and CSRS programs is to provide partial earnings replace- ment for federal employees who are unable to perform their jobs due to disease or in- jury. The benefit amounts are based on each individual’s earnings history.
Disability compensation under FECA provides partial replacement of earnings for fed- eral employees who are unable to work due to employment-related injuries and occu- pational diseases or due to employment-related aggravation of pre-existing conditions. It also provides short-term compensation for permanent loss, or loss of use of, certain parts and functions of the body. Compensation for inability to work is based on pre- injury earnings (if disability is total) or the difference between pre- and post-injury earnings (if disability is partial). The additional compensation for permanent physical loss is based on an individual’s degree of loss and on his or her earnings.
The DES provides compensation for service members who must separate from the military because they have become unfit to perform the duties of their office, grade, rank, or rating due to physical or mental impairment that occurred during service. As with the VA program, the disability is assigned a rating, although the criteria in DES can differ somewhat from VA’s. If a service member has at least 20 years of service, or a disability rating of at least 30 percent, then he or she is eligible for medical retirement, which includes an annuity based either on the disability rating and “retired base pay” (the average of the highest 36 months of basic pay) or on years of service and retired monthly base pay. Other service members receive a single severance payment, which is based on monthly base pay and years of service.
Table 37 summarizes some of the information that each program needs to ascertain to make decisions about eligibility and benefit levels. The amount and type of informa- tion needed for each program are important determinants of how difficult and time- consuming it is to process and resolve a claim. The VA, FECA, and DES programs all require that a disability be a consequence of an individual’s job in order to be eligible for compensation. The connection between employment and disability is straightfor- ward to demonstrate sometimes, but not always, especially for VA cases in which the in- jury or disability occurred many years previously. One factor that counterbalances this
complication for the VA program, though, is that it does not require a decision about how much the disability affects a particular veteran’s employment and earnings.
Table 37. Selected aspects of determining eligibility and benefits
Eligibility: Depends on whether disability is a result of em- ployment Eligibility: Depends on whether disability affects employment Compensation: Depends on indi- vidual work his-
tory Compensation: Depends on sever- ity of disability VA Yes Noa Noa Yes SSDI No Yes Yes No
SSI No Yes No No
FERS/CSRS No Yes Yes No
FECA Yes Yes Yes Nob
DES Yes Yes Yes Yes
a There are some minor exceptions (e.g., IU).
b The exception is short-term compensation for permanent physical loss.
6.2.3 Program statistics
Table 38 shows the relative sizes of the disability programs and the levels of benefits that they provide. The SSA programs (SSDI and SSI) are clearly the largest in terms of recipients. VA is next in size after the SSA programs, followed by FERS/CSRS, and then FECA and DES. Note that the information on average monthly disability pay- ments is a bit more difficult to use for comparison, because the DES figures are some- what outdated, the FERS/CSRS amount includes vocational rehabilitation, and there was no average available for FECA.
With respect to annual workload, SSA receives a larger number of claims than VA. SSA received 2.240 million SSDI claims and 2.180 million SSI claims in FY2004 [35], whereas VA received 788,000 in FY2005 [30]. As mentioned before, though, the time required to decide and resolve a claim depends on how complex the design of the program is. For example, although the VA program does not need to know a claim- ant’s earnings history, it does need to determine service-connection and severity for each disability, and each claim can have multiple disabilities.
Table 38. Program size and payments
Program Disability recipients Total annual disability
payments
Average monthly disability payment
VAa
2.6 million in FY2005 $23.4 billion in FY2005 $750 in FY2005
SSA b SSDI only SSDI & SSI SSI only 5.5 million in Dec. 2005 0.9 million in Dec. 2005 2.9 million in Dec. 2005 $67.0 billion in 2005 $8.4 billion in 2005 $20.7 billion in 2005 $1,015 in Dec. 2005 $678 in Dec. 2005 $558 in Dec. 2005 FERS/CSRSc
231,000 in FY2004 $3.6 billion in FY2004 (includes voc. rehab.)
$1,305 in FY2004 (includes voc. rehab.)
FECAd 85,000 for July 2005 to June 2006 $1.7 billion for July 2005 to June 2006 Not available DESe
92,000 in FY2004 $1.27 billion in FY2000 $1,088 in FY2000
a. From [30]. Average payment is a CNAC calculation (total annual payments divided by the number of recipi- ents).
b. From [31]. SSDI statistics refer only to workers. Total disability payments are a CNAC calculation (the pay- ments from December 2005 multiplied by 12).
c . From [32]. Total disability payments are a CNAC calculation (monthly average multiplied by 12 multiplied by the number of recipients).
d. From personal communication with OWCP staff.
e . Number of disability recipients comes from [33]. Disability payments come from [34]. Except for the number of recipients, these program statistics refer to medical retirement only (not lump sum disability severance). It is unclear whether the count of number of recipients includes lump sum recipients.