This study uses administrative data to evaluate the outcomes of the disability applications submitted to the Social Security Administration (SSA) through the Benefits Entitlement Services Team (B.E.S.T) Demonstration Project and to determine if the project successfully increased access to Supplemental Security Income (SSI) payments and/or Disability Insurance (DI) benefits for individuals experiencing homelessness. B.E.S.T—a unique partnership between the Los Angeles County Department of Health Services, SSA, and the California Disability Determination Services—was a collaborative effort to locate homeless adults and assist them in applying for SSI payments and/or DI benefits. B.E.S.T facilitated the completion of SSI and DI applications, including the compilation of all forms and medical evidence needed to submit the completed applications to SSA. The findings show that B.E.S.T contributed to increased access to disability benefits for applicants. Relative to other disability cases, the B.E.S.T cases had high allowance rates and short processing times.
Elizabeth Kennedy is a social insurance specialist and Laura King is a social science research analyst, both in the Office of Research, Demonstration, and Employment Support, Office of Retirement and Disability Policy, Social Security Administration.
Acknowledgments: The authors thank Leepi Shimkhada from the LA County Department of Health Services for providing background information on the B.E.S.T Demonstration Project. They also thank SSA's Office of Communications for creating and moderating the electronic bulletin board tool used to gather feedback from workers involved with the demonstration project. Lastly, the authors thank the numerous colleagues in SSA's Office of Retirement and Disability Policy who reviewed the countless drafts of this article.
The findings and conclusions presented in the Bulletin are those of the authors and do not necessarily represent the views of the Social Security Administration.
Introduction and Background
|B.E.S.T||Benefits Entitlement Services Team|
|DDS||Disability Determination Services|
|DHS||Department of Health Services|
|MBR||Master Beneficiary Record|
|MER||medical evidence of record|
|SSA||Social Security Administration|
|SSI||Supplemental Security Income|
|SSN||Social Security number|
|SSR||Supplemental Security Record|
The Benefits Entitlement Services Team (B.E.S.T) Demonstration Project was a new initiative of the Department of Health Services (DHS) of Los Angeles (LA) County to address barriers for persons with disabilities who were experiencing homelessness. In December 2009, the initiative began providing support through medical exams, mental health evaluations, and case management assistance to homeless adults applying for Supplemental Security Income (SSI) and/or Disability Insurance (DI).
The Social Security Administration (SSA) evaluated the outcomes of the applications submitted to the agency through the B.E.S.T Demonstration Project to determine if the project successfully increased access to SSI payments, DI benefits, or both for individuals experiencing homelessness. This article includes background information on the SSI and DI application process, general information on the B.E.S.T application process, and characteristics of B.E.S.T applicants. The scope of the evaluation addresses the following three key research questions:
- What were the allowance rates and processing times for B.E.S.T applications?
- What combination of internal and external methods supported the B.E.S.T application process?
- What characteristics of B.E.S.T applications increased the likelihood of an allowance?
Homelessness and Disability
LA has one of the largest homeless populations in the United States. According to the 2009 Greater Los Angeles Homeless Count Report, LA County had 48,053 homeless individuals1 on a given night (LAHSA 2009). About a quarter of those individuals experienced chronic homelessness, which means that they had a disabling condition and were experiencing long-term homelessness.2
The United States Interagency Council on Homelessness, which is composed of 19 departments and agencies including SSA, has set a goal to end chronic homelessness by 2015 (as of the publication date of this article). Increasing access to SSI/DI benefits and other mainstream resources not specifically targeted to persons experiencing homelessness is essential to meeting that goal. SSI/DI benefits can help reduce the number of disabled individuals experiencing homelessness by providing income for housing and access to health insurance through Medicaid or Medicare.
However, an inability to document a disability can be a major barrier to individuals experiencing homelessness receiving the SSI payments and/or DI benefits to which they otherwise would be entitled. Individuals experiencing homelessness often have difficulty providing the evidence required to document a disability because they do not have well-established physical or mental health records. Many of those individuals do not have access to consistent care because they have no health insurance or other health benefits. After application, it can be difficult for persons experiencing homelessness to receive mail or phone calls, and the lack of income creates difficulties in obtaining transportation to appointments.
Staff members of agencies that assist individuals experiencing homelessness sometimes assist those persons with the SSI and DI application process as part of their professional role. The B.E.S.T Demonstration Project—a collaborative effort to locate homeless adults and assist them in applying for SSI payments and DI benefits—was a unique partnership between the LA County DHS, SSA, and the California Disability Determination Services (DDS).
The project began on December 1, 2009, and ended on October 1, 2013. LA County had existing services that provided health care to individuals experiencing homelessness, but a main goal of B.E.S.T was to improve access to SSI/DI benefits by addressing barriers those individuals faced, especially the lack of medical documentation of their disability.
The LA County DHS funded B.E.S.T through a contract to a federally qualified health center, the John Wesley Community Health Institute, which had expertise in serving homeless clients. The collaboration between doctors, case managers, DHS administrative staff, and specific personnel at SSA and the DDS resulted in positive outcomes for the applicants. The LA County DHS worked with SSA, the DDS, and other LA County government offices throughout the demonstration to address issues of implementation, funding, and areas for improvement. The DHS had an administrative staff person dedicated solely to B.E.S.T, who provided policy oversight; day-to-day support, oversight, and assistance to the B.E.S.T team members; and who monitored weekly reports to ensure timely submission of cases by B.E.S.T staff.
SSI and DI Application Process
The SSI program makes payments to individuals with a qualifying disability and limited income and resources; the DI program provides benefits to eligible disabled workers and their eligible family members. Section 223 of the Social Security Act defines disability as, “the inability to engage in 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.” In addition to meeting that definition of disability, individuals must have worked long enough and paid Social Security taxes to be “insured” and qualify for DI benefits.
The disability determination process begins when the applicant completes forms and submits them to an SSA field office (FO), which verifies nonmedical eligibility requirements and sends the case to a state DDS office if the applicant meets nonmedical eligibility requirements. The SSI program is means tested and requires income and assets below certain levels; the DI program, on the other hand, requires a certain number of work credits based on yearly wages. The DDS makes a determination of disability based on medical evidence from the applicant's treating sources or from a consultative examination (CE)—that is, a physical or mental examination or test purchased by SSA. If the DDS determines that the applicant is not disabled, the applicant may request reconsideration, in which the DDS thoroughly reexamines all evidence used in the initial determination and any additional evidence or information submitted with the reconsideration appeal. If the applicant also receives a denial on a disability claim at the reconsideration level, he or she may request an appeal hearing before an administrative law judge. The applicant can also appeal to the following two higher levels: (1) the Appeals Council; and (2) by filing a civil suit in a federal district court, if the applicant does not agree with the Appeals Council's decision or the Council decides not to review the case.
B.E.S.T Application Process
The B.E.S.T process did not change SSA's SSI or DI claims process, but it was designed to expedite the application process and address some of the application challenges for persons experiencing homelessness. For purposes of this study, we spoke with the following three groups of staff participants to obtain background information and feedback about the process followed by B.E.S.T: LA County employees and contractors, DDS employees, and FO employees. This was necessary because the SSA staff who examined the outcomes of the B.E.S.T applications did not design the demonstration project. We asked general and targeted questions on the following topics: organizational involvement and goals, operational changes over time, roles and responsibilities, project challenges, impressions, and recommendations. We obtained feedback through an electronic bulletin board,3 which was a moderated online discussion; by e-mail; and through phone calls. (All references to the opinions and experiences of these groups later in the article refer to information obtained through these methods.)
The B.E.S.T Demonstration Project served street-based and shelter-based homeless individuals, in addition to homeless persons living in transitional housing settings or in permanent housing for less than a year. B.E.S.T identified clients through street-based outreach and referrals. B.E.S.T was composed of a multidisciplinary team that included a project director, general physician, psychiatrist, four case managers, and outreach staff. That team provided case management, physical and mental health evaluation and documentation, transportation resources, and coordination with SSA FOs. B.E.S.T shared information with various organizations (such as hospitals, medical clinics, mental health organizations, prisons, and homeless organizations) on how to refer clients to the demonstration project, and it accepted referrals from those organizations in LA County.
Based on the data collected through the homeless count, B.E.S.T established four site locations in different areas of LA County—El Monte, City of Bell, and two locations in LA. The goal was to establish sites to address areas of greatest need and to make B.E.S.T accessible countywide. The largest site was in Downtown LA in an area known as “Skid Row,” as part of a federally qualified health center (Center for Community Health) that was already located there. The other sites were in a recuperative care and shelter program (Bell Shelter), a substance abuse treatment shelter facility (MJB Transitional Recovery), and a federally qualified health center about 20 miles east of the downtown area (Cleaver Family Wellness Clinic). Because those sites were community based, B.E.S.T was able to identify applicants and maintain contact with them using scheduled check-ins. In addition to providing physical and mental health evaluations to support the disability application, the John Wesley Community Health Institute provided ongoing care to individuals experiencing homelessness and scheduled most of the check-ins to occur concurrently with health care appointments.
B.E.S.T facilitated the completion of SSI and DI applications, including compilation of all forms and medical evidence needed for submission to SSA. The demonstration project assisted clients with applications at the initial and reconsideration level, and it referred them to public interest law firms if a hearing-level appeal was needed.4 B.E.S.T personnel submitted applications for SSI payments and DI benefits in person, by mail, and online, with completed forms and collected medical evidence. It assisted clients with the application process by completing the applications, obtaining medical evidence from other providers, providing physical and mental health evaluations and documentation, helping to find an appropriate representative payee, and coordinating with the FO.
In addition, B.E.S.T used an expedited process to obtain medical records requested from LA County DHS medical facilities.5 Medical records from the prison system and other medical facilities can take months to obtain. When B.E.S.T requested applicants' DHS records, a team of trained registered nurses familiar with LA County DHS medical records gathered the information. The project also assisted clients by helping them find a place to stay and access to transportation.
Downtown LA, Huntington Park, Watts, and El Monte were the participating FOs. LA North, LA West, and Roseville were the participating DDS branch offices. SSA and DDS staff provided extensive and recurring training to the B.E.S.T Demonstration Project manager, front-line workers, and medical staff on the application filing process, eligibility factors, and completion of forms. DHS staff provided ongoing technical assistance to B.E.S.T and served as a liaison to SSA and the DDS. Social Security staff had an on-site presence at the downtown location for 3 months.
The DDS medical staff provided the B.E.S.T medical staff with training on SSA's evidentiary requirements. Because of that training, B.E.S.T applications were submitted with extensive staff comments, including observations about the applicant's condition, which assisted the DDS branch offices in the evaluation process.
At the FO, designated SSA claims representatives processed B.E.S.T cases. B.E.S.T staff had direct phone extensions of FO management and claims representatives participating in the project. The FO staff applied a specific combination of flags, messages, and unit codes to help the DDS branch offices identify cases as part of the B.E.S.T Demonstration Project. The FOs tracked those cases and sent reports to SSA's area office.
Contact between SSA, DDS employees, and B.E.S.T staff occurred as needed and varied greatly, from daily to once a week to twice a month. At times, DDS and B.E.S.T staff used conference calls to discuss claims statuses and to engage in doctor-to-doctor communication. That type of close contact, with frequent calls between professionals, is not a typical part of the disability determination process. If the DDS needed additional information to adjudicate a claim, it contacted B.E.S.T staff, who provided additional records.
Characteristics of B.E.S.T Applicants
B.E.S.T applicants were not randomly selected from a larger group, and there was no comparison group for this evaluation. We recognize that B.E.S.T applicants are a particularly disadvantaged subpopulation of disability applicants, and the specific outcomes (that is, specific allowance rates) cannot be generalized to other populations. However, in some instances, this article compares B.E.S.T outcomes with published national averages to provide context about the typical disability application process and experience for a select group of applicants.
The characteristics of the B.E.S.T participants who applied for SSI, DI, or both from December 2009 through December 20126 are provided in Table 1. The participants were more likely to be male. Their mean age was 47, and almost 50 percent did not have a high school diploma. Less than 20 percent of the individuals who participated in B.E.S.T had any earnings history, and over 45 percent had previously applied for disability benefits. Eight percent had served in the military. Almost all of the participants applied for SSI, and about 90 percent had a mental condition as their primary impairment.7
|Younger than 25||50||4.4|
|60 or older||26||2.3|
|6th grade or less||39||3.4|
|7th through 11th grade||515||45.4|
|More than high school||133||11.7|
|Type of impairment|
|Field office of application|
|Earnings in a month between 1999 and 2008|
|Type of claim|
|SOURCE: SSA administrative records.|
|NOTES: B.E.S.T = Benefits Entitlement Services Team; DI = Disability Insurance; LA = Los Angeles; SSA = Social Security Administration; SSI = Supplemental Security Income.|
|a. The mean age was 47.|
First, we verified SSA's regional office list of the Social Security numbers (SSNs) of B.E.S.T participants. Then, we used multiple administrative data sources to gather demographic and application data on B.E.S.T participants. Our methods for accomplishing those objectives, in addition to detailing the other data sources employed in this study, are discussed in the following two subsections.
Identification and Verification of B.E.S.T Participants
SSA's regional office in San Francisco identified the names and SSNs of participants in the B.E.S.T Demonstration Project. We were able to verify that all names and SSNs matched SSA records. We extracted Master Beneficiary Record (MBR)8 and Supplemental Security Record (SSR)9 data for each of the SSNs provided and compared the names associated with each SSN in those records with participant names on the B.E.S.T list. If the name matched the SSN, we considered the SSN verified.
Of the 1,194 verified SSNs, we analyzed initial disability benefit applications filed from December 2009 through December 2012, totaling 1,175 cases. The other 19 SSNs provided by the regional office included duplicates (that is, individuals who were seen in more than one FO), individuals who applied for SSI or retirement benefits based on age (not disability benefits), and those who applied for SSI/DI at the initial level without the assistance of B.E.S.T and subsequently applied for a reconsideration with the assistance of B.E.S.T. Of the 1,175 individuals B.E.S.T assisted with submitting their SSI and/or DI applications, 41 cases lacked a medical decision at the time of the analysis. Some of those cases had no decision for reasons of unknown whereabouts of the applicant, the applicant died, or the applicant withdrew his or her claim. Others were pending decisions or had a technical (not medical) denial for not meeting eligibility requirements.
The goal of the B.E.S.T Demonstration Project was to assist homeless individuals applying for SSI payments and/or DI benefits; therefore, our analysis focuses on the medical decisions of the 1,134 applications for disability benefits submitted at the initial level through B.E.S.T from December 2009 through December 2012.
To describe the characteristics of B.E.S.T applicants and answer the three key research questions highlighted earlier in the article, we matched the list of 1,134 SSNs to the data available from SSA program records. Specifically, we matched SSNs to the following administrative records:
- Electronic Disability (eDib) claim file,
- Supplemental Security Record (for SSI applicants),
- Master Beneficiary Record (for DI applicants),
- Earnings Recording and Self-Employment Income System, and
- Veterans Benefits Administration database.
The eDib claim file maintains the information needed to make the determination of eligibility for benefits, including the name and SSN of the applicant, the application for benefits, supporting evidence and documentation, and correspondence between SSA and the applicant. The SSR and MBR provide historical accounts of the activity on an individual's payment record. The Earnings Recording and Self-Employment Income System contains summaries of every SSN holder's yearly earnings. The Veterans Benefits Administration database provides access to SSA staff for reviewing military discharge records pertinent to the disability application process for veterans.
In this section, we discuss the results obtained in this analysis pertaining to the three key research questions.
Research Question 1: What Were the Allowance Rates and Processing Times for B.E.S.T Applicants?
B.E.S.T applicants had relatively high allowance rates, with a 90 percent final overall allowance rate. B.E.S.T applicants also had shorter than average processing times for initial decisions. Of the allowances, 76.8 percent were SSI only, 22.7 percent were concurrent awards for SSI and DI, and 0.5 percent were DI only. To put these allowance rates in perspective, average allowance rates for all SSI and DI applications at all adjudicative levels in 2010 were 46.6 percent and 57.3 percent, respectively (SSA 2013b, Table 69 and 2013a, Table 59).10
The allowance rates for the B.E.S.T applicants at each adjudicative level of the determination process are provided in Table 2. The first two levels of the decision process take place at the DDS. The allowance rate for B.E.S.T participants at the initial level was 84.7 percent. To put this in perspective, average initial allowance rates for SSI and DI applications in 2010 were 31.3 percent and 36.7 percent, respectively (SSA 2013b, Table 70 and 2013a, Table 60). Among the B.E.S.T initial allowances, 77.6 percent were SSI only, 22.2 percent were concurrent, and 0.2 percent were DI only. Of applicants who were denied at the initial level, 61.5 percent appealed to the reconsideration level, and the allowance rate at the reconsideration level was 41.1 percent.11 Of those allowances, 65.9 percent were SSI only, 29.6 percent were concurrent, and 4.6 percent were DI only. The overall DDS allowance rate for B.E.S.T participants was 88.3 percent.
|Level of decision||Number of decisions||Allowance rate (%)|
|(2) Reconsideration a, b||107||41.1|
|SOURCE: SSA administrative records.|
|NOTES: B.E.S.T = Benefits Entitlement Services Team; DDS = Disability Determination Services; ODAR = Office Of Disability Adjudication and Review; SSA = Social Security Administration.|
|a. SSA electronically flagged 6 percent of B.E.S.T applications as falling under the Disability Redesign Prototype Model, in which an appeal for a hearing is the first step in the appeals process and there is no reconsideration step.|
|b. The 107 cases that went to the reconsideration step included 4 cases that received an allowance at the initial level, but chose to appeal some aspect of the initial decision.|
|c. The total number of decisions equals the number of initial and overall DDS decisions because every B.E.S.T applicant had an initial application.|
The third level of the decision process is a hearing with an administrative law judge. Of the claimants issued a denial from the DDS, only 22.6 percent requested a hearing, and 70 percent of the cases that went to the hearing level received a favorable decision. To put this in perspective, average hearing-level allowance rates for all SSI and DI applications in 2010 were 56.8 percent and 68.0 percent, respectively (SSA 2013b, Table 72 and 2013a, Table 62). Of B.E.S.T claimants with allowances at the hearing level, 52.4 percent were SSI only, 38.1 percent were concurrent, and 9.5 percent were DI only. This brought the final overall allowance rate to 90 percent.
A high number of B.E.S.T claims were allowed at step 3 of the disability determination process, the first step that can result in an allowance. This indicates that many B.E.S.T applicants had some of the most highly disabling impairments.12
Wixon and Strand (2013) document how the steps of the determination process and the basis for medical eligibility decisions are identifiable in SSA administrative data. The agency uses a five-step sequential evaluation process to decide whether an individual is disabled.13 That process evaluates whether the individual is performing work (step 1), whether the individual's impairment is severe (step 2), whether the impairment meets or equals SSA's listing of impairments (step 3), whether the individual can perform his or her past work (step 4), or whether the individual can perform any work in the national economy (step 5). Applicants who are working and engaging in substantial gainful activity (SGA)14 are denied at step 1 without any consideration of medical criteria; those without severe impairments are denied at step 2; and those with the most highly disabling impairments are allowed at step 3, based on medical criteria. Step 4 can result in a denial only and involves an analysis of whether the applicant can do the work activities involved with his or her past work. Step 5 can result in an allowance or a denial and involves an analysis of whether the applicant can do any work in the national economy.
Table 3 presents the distribution of B.E.S.T claims, classified by the evaluation step at which SSA made the final disability decision (after any appeals).15 After all appeals, 65.6 percent of all B.E.S.T claims were allowed at step 3, accounting for 72.9 percent of all allowances. More than two-thirds of all claims (67.3 percent) were decided without the need for an evaluation of medical-vocational factors (steps 4 and 5), although, as expected, the majority of denials did require a medical-vocational evaluation. Generally, allowances for SSI applications at step 3 account for nearly a third of SSI cases (SSA 2013b).
|Disability determination step a||Allowance||Denial||Total|
|2||. . .||1.7||1.7|
|3||65.6||. . .||65.6|
|4||. . .||1.5||1.5|
|Other b||. . .||1.2||1.2|
|SOURCE: SSA administrative records.|
|NOTES: B.E.S.T = Benefits Entitlement Services Team; SSA = Social Security Administration; . . . = not applicable.|
|a. Omits step 1 (financial eligibility).|
|b. Includes insufficient evidence, failure to submit to a consultative examination, and drug abuse or alcoholism that was material to the determination of disability.|
Most of the B.E.S.T allowances were for SSI only or concurrent awards for SSI payments and DI benefits.16 The mean first regular monthly SSI payment amount for those recipients was $809.58, and both the median and mode of that payment amount was $856.40. That included the California state supplement, which is currently $156.40 per month. The mean federal payment amount (excluding the state supplement) that B.E.S.T participants received for their first payment was $623.97. Both the median and mode of that payment amount was $674.00.
For B.E.S.T participants in current-pay status as disabled-worker DI beneficiaries in October 2013,17 the average monthly payment amount was $809.34. The DI benefits received were lower than the average of $1,158.49 per month for disabled workers in California in 2012 (SSA 2013a, Table 16).18 Other family DI benefits associated with the SSNs of B.E.S.T participants included spouse benefits and child benefits. Spouses and children were not B.E.S.T participants, but received payments because of the B.E.S.T allowances. Three individuals received spousal benefits, in monthly amounts of $118.00; $1,000.00; and $1,338.00. Thirty-four individuals received child benefits, and the median monthly benefit amount for children was $174.50.
SSA assigns a representative payee for beneficiaries who are not capable of managing their SSI/DI benefits. Generally, a family member or friend of the beneficiary serves as the representative payee, but professional organizations can also serve as payees. Despite the high percentage of mental disabilities among allowed B.E.S.T applicants, only about 13 percent had representative payees, which is lower than expected.
For B.E.S.T participants, the average processing time for an initial decision was 45.5 days. For a medical determination, we calculated DDS processing time at the initial level as the time between the date the initial disability application was transmitted from the FO to the DDS and the decision date, not including reconsiderations at the DDS for participants who were appealing.19 Using that measure, the average initial processing time for all disability claims nationally from December 2009 through December 2012 was 90 days (refer to the chart below).
Average initial processing time for all disability claims nationally, December 2009–December 2012
Research Question 2: What Combination of Internal and External Methods Supported the B.E.S.T Application Process?
In examining the B.E.S.T cases, we found three practices that occurred at a high rate and correlated with the improved outcomes for B.E.S.T participants. First, B.E.S.T applicants' electronic disability folders were more likely to have one or more flags for expedited handling. Second, B.E.S.T applicants were very likely to have an authorized representative. Finally, B.E.S.T applicants were very likely to provide medical evidence at the time of application. All three of those practices were promoted by the B.E.S.T process and facilitated collaboration across organizations.
All of the B.E.S.T disability folders had at least one electronic flag, and the majority of folders had more than one. There are multiple types of flags, many of which identify the case for priority handling, and flags are not mutually exclusive. Each folder can only have one flag of each type. It is quite likely that the involvement of B.E.S.T alerted SSA staff to those special situations so that the agency could trigger any applicable special-case handling procedures.
About 78 percent of the B.E.S.T disability folders had a flag to indicate homelessness, 90 percent had a flag to indicate a representative's involvement, and 34 percent had a flag to indicate that special handling was required (Table 4). Three additional flags were common on B.E.S.T disability folders: Prototype,20 dire need, and presumptive disability.21
|Type of flag||Percent|
|SOURCE: SSA administrative records.|
|NOTES: Flags are not mutually exclusive.
B.E.S.T = Benefits Entitlement Services Team; SSA = Social Security Administration.
|a. Flag categories with "Other" as the flag type: acquired immunodeficiency syndrome, class action/court, Congressional inquiry, critical, homicidal/potential violent, institutionalized prerelease, special Title II disability workload, subsequent claim, suicide threat, terminal illness, military casualty, and unknown.|
In addition to the flagging procedures, the FOs identified B.E.S.T cases using special messages (for example, “B.E.S.T Project Claim”) and unit codes (for example, BEST) to help the DDS identify cases as part of the B.E.S.T Demonstration Project.
B.E.S.T provided authorized representative services to their clients free of charge. About 98 percent of applicants had an authorized representative on record at some point in the application process. SSI and/or DI applicants were able to choose to have an authorized representative act on their behalf. Those representatives were able to obtain information from SSA about the claim, give the agency evidence to support the claim, and represent the applicant at interviews and hearings. In interviews with FO and DDS employees, B.E.S.T's role as authorized representatives was found to be a very helpful aspect of the demonstration project.
Consideration of objective medical evidence is a key component of the disability evaluation process. Typically, SSA requests evidence from the applicant's own medical sources, which is called medical evidence of record (MER). The applicant or authorized representative can also provide medical evidence to SSA. When the evidence received is inadequate to determine disability, SSA will purchase a CE to obtain the necessary evidence.
According to SSA records, 85.5 percent of B.E.S.T claims had evidence supplied by the applicant or authorized representative. About 64 percent of all B.E.S.T applications had MER. Twenty percent had a CE report, compared with the national average of 48 percent for initial-level disability claims in 2010 (SSAB 2012). One possible explanation for the low rate of CEs is that only eight applicants neither supplied evidence nor provided MER.
About a third (34.4 percent) of the applications were decided based on the evidence supplied by the authorized representative or applicant (that is, there was no MER or CE). For those cases, SSA did not need to request any additional medical evidence. MER and CEs take time to obtain, so a reduction in the number of MER requests and CEs can result in a faster decision for the applicant. In addition, when supplied evidence negates the need for additional MER and CEs, it results in cost savings for SSA (that is, the fees paid to medical providers for evidence).
Table 5 shows the distributions of B.E.S.T applications across all possible combinations of types of medical evidence. B.E.S.T obtained medical evidence from other providers and had medical staff provide physical and mental health evaluations and documentation for the SSI/DI applications. The B.E.S.T process required submitting evidence along with the completed application forms to the FO, so those cases were more fully developed when the DDS received them than what would have been typical. The DDS did not have to spend as much time obtaining evidence for those cases, allowing for quicker decision making. The direct communication between B.E.S.T staff, SSA, and the DDS also decreased processing delays.
|Source of evidence||Evidence supplied||Medical evidence of record|
|Medical evidence of record|
|Yes||49.8||13.8||. . .||. . .|
|No||35.7||0.7||. . .||. . .|
|SOURCE: SSA administrative records.|
|NOTES: B.E.S.T = Benefits Entitlement Services Team; SSA = Social Security Administration; … = not applicable.|
Research Question 3: What Characteristics of B.E.S.T Applications Increased the Likelihood of an Allowance?
Table 6 provides an overview of the application characteristics that were correlated with a higher likelihood of allowance. As discussed earlier, SSA staff adds electronic flags to the disability folder to identify special-case handling situations. For the B.E.S.T cases, the presence of more than one flag on an applicant's disability folder increased the likelihood of an individual receiving an allowance. The allowance rate for cases with a single flag was 71.7 percent, while the rate for cases with more than one flag was 88 percent or higher.
|Characteristic||Number of applicants||Allowance rate (%)|
|Number of flags on disability folder|
|Medical evidence on record|
|Any earnings on record|
|SOURCE: SSA administrative records.|
|NOTES: B.E.S.T = Benefits Entitlement Services Team; SSA = Social Security Administration.|
As previously discussed, almost all of the B.E.S.T applicants appointed an authorized representative who remained in contact with SSA on their behalf. Applicants with an authorized representative had a much higher allowance rate than those without one.
As stated earlier, a very high percentage of B.E.S.T claims had evidence supplied by the claimant or an authorized representative. B.E.S.T claims with supplied evidence had a very high allowance rate (91.3 percent), which was about 10 percent higher than that for claims without supplied evidence. Conversely, the allowance rate for claims with MER was about 10 percent lower than that for claims without MER (86.5 percent and 96.1 percent, respectively). The allowance rate for claims with CEs was about 25 percent lower than that for claims without CEs (70.5 percent and 94.9 percent, respectively).
Individuals with an earnings history were more likely to be allowed for benefits than those with no earnings history (93.2 percent compared with 89.3 percent).
In addition to the characteristics shown in Table 6, we evaluated two additional characteristics—recent earnings history and previous applications—for which we found no significant differences in allowance rates between applications with and without those characteristics. The allowance rate differential between persons with a recent earnings history (92.4 percent) and those without (89.7 percent) was not statistically significant.
B.E.S.T applicants with a previous application had a 91.0 percent allowance rate, while applicants without a previous application had an 89.2 percent allowance rate. However, these percentages are likely affected by the fact that SSA only has complete electronic data on initial cases beginning in 2006. That circumstance limited our ability to examine outcomes of any previous applications from B.E.S.T applicants. Although almost half of all B.E.S.T applicants had a previous application on record, we only had decision data on about half of those cases. Of the cases for which we had decision data, 32 percent of the original application's initial denials were due to either providing insufficient evidence (23.3 percent) or failure or refusal to submit to a CE (8.6 percent).
The goal of the B.E.S.T Demonstration Project was to address common barriers to receiving disability benefits for individuals experiencing homelessness, including the lack of medical evidence and difficulty navigating the disability application process. B.E.S.T staff addressed those barriers by serving as their clients' authorized representatives and providing medical evidence with completed applications. Over 1,000 individuals experiencing homelessness in LA County are now receiving benefits, which they may use for housing and other needs.
The project team successfully targeted the limited resources provided through its funding to identify individuals most likely to be eligible for benefits and to help them to access those benefits. B.E.S.T cases disproportionally met the listings, suggesting that many applicants had impairments that clearly met or exceeded the level of severity that defines disability in the Social Security Act. The vast majority of applicants had a mental impairment and no work history, and almost half of them had no high school diploma.
According to available data, a large portion of B.E.S.T applicants had applied for benefits previously and were denied because of either providing insufficient evidence or failing to submit to a CE. However, with the support provided by B.E.S.T, those individuals' claims were processed differently, resulting in very different outcomes. The allowance rate was much higher than what would have been typical, and the DDS processed the cases in about half the usual time taken for processing disability cases. Most of the B.E.S.T allowances were for SSI only or concurrent awards for SSI and DI benefits.
In addition to contributing to increased access to disability benefits for applicants, the project reduced the number of SSA resources required to process applications. Many of the applicants had been unsuccessful with their previous applications, and without the assistance of B.E.S.T, they may have also been unsuccessful with their recent applications and could have applied repeatedly for benefits for which they were eligible. It is to both the claimant's and SSA's advantage to eliminate the need to process additional initial applications. B.E.S.T also provided medical evidence early in the claims process—which often eliminated SSA's need to pay for costly MER and CEs—and saved SSA and/or the claimant the time required to obtain that additional medical evidence.
The feedback we received from FO and DDS employees who were actively involved with B.E.S.T suggests that they found the demonstration project worthwhile and beneficial. The participating employees found B.E.S.T to be helpful and cited providing physical and mental health evaluations as “extremely helpful.” They also found B.E.S.T's efforts in completing forms, obtaining medical evidence from available non-B.E.S.T sources, and serving as authorized representatives to be helpful. SSA and DDS employees' overall impression of the B.E.S.T initiative was that it was effective—citing the completeness of submitted applications, the quick decisions made on the claims, and the high allowance rates.
1 Individuals were considered homeless if they met the Department of Housing and Urban Development's definition of homelessness, which includes residing in places not meant for human habitation, emergency shelters, or transitional housing for homeless persons.
2 Under the federal definition, a chronically homeless individual has a disability and has experienced homelessness for at least a year, or has experienced at least four episodes of homelessness in the past 3 years.
3 SSA scheduled the electronic bulletin board for 3 days and extended it for an additional day, from February 26, 2013, through March 1, 2013.
4 Two of the DDS branches—LA North and LA West— are part of the Disability Redesign Prototype Model, which involves testing improvements to the disability determination process in 10 states. For initial determinations decided in those two DDS branch offices, an appeal for a hearing is the first step in the appeals process, and there is no reconsideration step.
5 LA County DHS medical facilities include three publicly funded acute care hospitals, a nationally recognized rehabilitation hospital, and a network of over 35 directly operated comprehensive health clinics and multiambulatory care centers.
6 We selected these dates based on data available when the research started.
7 SSA investigated the frequency of B.E.S.T decisions that involved a substance-use disorder. Among the B.E.S.T applicants, 17.5 percent had a substance-use disorder, but that was only material to the determination of disability for one applicant.
8 The MBR contains information about each DI claimant who has ever applied for benefits; it includes name, date of birth, date of filing, benefit amount and payment status, and information about the representative payee (if applicable).
9 The SSR contains information about each SSI claimant who has ever applied for payments; it provides a historical account of all activity on a particular record. The SSR includes name, date of birth, income and resources, data on eligibility, payment amounts, living arrangements, and information about the representative payee (if applicable).
10 These percentages are derived by dividing all medical allowances in a given year by all medical decisions in a given year.
11 For some parts of LA County, an appeal for a hearing is the first step in the appeals process, and there is no reconsideration step.
12 Applicants who are allowed later in the process at step 5 have impairments that, although severe, did not meet the criteria for disability purely on medical grounds.
13 The five-step sequential evaluation process is described in the Federal Register (20 CFR 404.1520 and 416.920).
14 For nonblind individuals, the monthly SGA amount for 2013 was $1,040.
15 Step 1 determinations were not included because those decisions are made in FOs, and this evaluation focused on DDS and hearing-level decisions.
16 Less than five individuals were dually entitled beneficiaries, and several of them were not receiving payments, so the sample was too small to provide a representative average payment amount.
17 October 2013 is when SSA's Office of Research, Demonstration, and Employment Support consulted the MBR for payment data.
18 The average monthly benefit in California is higher than the national average of $1,130.34.
19 Each fiscal year (FY), SSA publishes the average overall disability determination processing time in its Performance and Accountability Report. In that report, the processing time includes work performed by SSA at the FO and DDS levels; the combined average time frame was 111 days in FY2010, 109 days in FY2011, and 102 days in FY2012. See http://www.socialsecurity.gov/finance/.
20 Under the Disability Redesign Prototype Model initiative, there is no reconsideration step of the administrative review process, and cases may be decided by disability examiners with single decision-maker authority, without sign off from a medical or psychological consultant.
21 SSI applicants may receive up to 6 months of SSI payments prior to the final determination of disability if the FO or DDS makes a presumptive disability determination.
[LAHSA] Los Angeles Homeless Services Authority. 2009. 2009 Greater Los Angeles Homeless Count Report. http://documents.lahsa.org/planning/homelesscount/2009/HC09-fullreport.pdf.
[SSA] Social Security Administration. 2013a. Annual Statistical Report on the Social Security Disability Insurance Program, 2012. Washington, DC: Office of Retirement and Disability Policy, Office of Research, Evaluation, and Statistics. http://www.socialsecurity.gov/policy/docs/statcomps/di_asr/2012/index.html.
———. 2013b. SSI Annual Statistical Report, 2012. Washington, DC: Office of Retirement and Disability Policy, Office of Research, Evaluation, and Statistics. http://www.socialsecurity.gov/policy/docs/statcomps/ssi_asr/2012/index.html.
[SSAB] Social Security Advisory Board. 2012. Aspects of Disability Decision Making: Data and Materials. Washington, DC: Government Printing Office. http://www.ssab.gov/Publications/Disability/GPO_Chartbook_FINAL_06122012.pdf.
Wixon, Bernard, and Alexander Strand. 2013. “Identifying SSA's Sequential Disability Determination Steps Using Administrative Data.” Research and Statistics Note No. 2013-01. Social Security Administration, Office of Retirement and Disability Policy, Office of Research, Evaluation, and Statistics. http://www.socialsecurity.gov/policy/docs/rsnotes