TRICARE; constructive eligibility for TRICARE benefits of certain persons otherwise ineligible under retroactive determination of entitlement to Medicare Part A hospital insurance benefits. Final rule

The Department is publishing this final rule to implement section 706 of the National Defense Authorization Act (NDAA) for Fiscal Year 2010, Public Law 111-84. Specifically, section 706 exempts TRICARE beneficiaries under the age of 65 who become disabled from the requirement to enroll in Medicare Part B for the retroactive months of entitlement to Medicare Part A in order to maintain TRICARE coverage. This statutory amendment and final rule only impact eligibility for the period in which the beneficiary's disability determination is pending before the Social Security Administration. Eligible beneficiaries are still required to enroll in Medicare Part B in order to maintain their TRICARE coverage for future months, but are considered to have coverage under the TRICARE program for the retroactive months of their entitlement to Medicare Part A. This final rule also amends the eligibility section of the TRICARE regulation to more clearly address reinstatement of TRICARE eligibility following a gap in coverage due to lack of enrollment in Medicare Part B.     

Social Security benefits; disability insurance benefits; deductions, reductions, and nonpayments of benefits--SSA. Final rules with comment period

These regulations amend the existing regulations under which Social Security benefits payable to a disabled worker and his or her family may be reduced because of the worker's concurrent entitlement to workers' compensation benefits. They provide that entitlement to certain other public disability benefits may reduce the disability benefits paid by Social Security; that the reduction applies to the first month of concurrent entitlement regardless of the month in which we are notified of entitlement to the public disability benefit; and that the reduction applies to all months of concurrent entitlement until the disabled worker attains age 65. These regulations also provide that where a public disability law or plan provides for reduction of the public disability benefit on the basis of entitlement to Social Security disability insurance benefits that provision will preclude reduction of the Social Security benefits but only if it was in effect on February 18, 1981. These regulations implement section 2208 of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35).     

Federal old-age, survivors, and disability insurance; earnings test: Social Security Administration. Interim regulations

The Social Security Administration is issuing interim regulations to implement sections 1, 3, and 4 of Pub. L. 96-473 (enacted October 19, 1980) that make a number of changes in the application of the earnings test for retirement purposes. The provisions are designed to eliminate some unintended and harsh effects of the limitations on the use of the monthly earnings test imposed by the Social Security Amendments of 1977. Section 1 permits the use of the monthly earnings test by those beneficiaries entitled to child's benefits, young wife's and young husband's benefits (entitled only by reason of having an entitled child in their care) or mother's and father's benefits, in the year that entitlement terminates, if termination is for a reason other than death and the beneficiary is not entitled to another type of Social Security benefit for the month following the month of termination. Section 3 excludes from gross income, for purposes of the annual earnings test, self-employment income which is received in a year after the initial year of entitlement to insurance benefits under title II (other than disability benefits and childhood disability benefits) and is not attributable to services performed after the month of entitlement. Section 4 provides for all beneficiaries the use of the monthly earnings test in the first taxable year after 1977 in which a beneficiary has a non-service month in or after the month of entitlement to benefits.     

Exemption of work activity as a basis for a continuing disability review. Final rules

We are publishing these final rules to amend our regulations to carry out section 221(m) of the Social Security Act (the Act). Section 221(m) affects our rules for when we will conduct a continuing disability review if you work and receive benefits under title II of the Act based on disability. (We interpret this section to include you if you receive both title II disability benefits and title XVI (Supplemental Security Income (SSI)) payments based on disability.) It also affects our rules on how we evaluate work activity when we decide if you have engaged in substantial gainful activity for purposes of determining whether your disability has ended. In addition, section 221(m) of the Act affects certain other standards we use when we determine whether your disability continues or ends. We are also amending our regulations concerning how we determine whether your disability continues or ends. These revisions will codify our existing operating instructions for how we consider certain work at the last two steps of our continuing disability review process. We are also revising our disability regulations to incorporate some rules which are contained in another part of our regulations and which apply if you are using a ticket under the Ticket to Work and Self-Sufficiency program (the Ticket to Work program). In addition, we are amending our regulations to eliminate the secondary substantial gainful activity amount that we currently use to evaluate work you did as an employee before January 2001.     

Continuation of benefit payments to certain individuals who are participating in a program of vocational rehabilitation services, employment services, or other support services. Final rule

We are publishing final rules that amend the rules for the continuation of disability benefit payments under titles II and XVI of the Social Security Act (the Act) to certain individuals who recover medically while participating in an appropriate vocational rehabilitation (VR) program with a State vocational rehabilitation agency. We are amending these rules to conform with statutory amendments that extend eligibility for these continued benefit payments to certain individuals who recover medically while participating in an appropriate program of services. These include individuals participating in the Ticket to Work and Self-Sufficiency Program or another program of vocational rehabilitation services, employment services, or other support services approved by the Commissioner of Social Security. We are also extending eligibility for these continued benefit payments to students age 18 through 21 who recover medically, or whose disability is determined to have ended as a result of an age-18 redetermination, while participating in an individualized education program developed under the Individuals with Disabilities Education Act with an appropriate provider of services. Providers of services we may approve include a public or private organization with expertise in the delivery or coordination of vocational rehabilitation services, employment services, or other support services; or a public, private or parochial school that provides or coordinates a program of vocational rehabilitation services, employment services, or other support services carried out under an individualized program or plan.     

Clarification of rules involving residual functional capacity assessments; clarification of use of vocational experts and other sources at step 4 of the sequential evaluation process; incorporation of "special profile" into regulations. Final rules

For purposes of this document, "we," "our," and "SSA" refer to the Social Security Administration and State agencies that make disability determinations for the Social Security Administration. "You" and "your" refer to individuals who claim benefits from the Social Security Administration based on "disability." In this final rule we clarify our rules about the responsibility that you have to provide evidence and the responsibility that we have to develop evidence in connection with your claim of disability. This includes our rules about when we assess your residual functional capacity (RFC) and how we use this RFC assessment when we decide whether you can do your past relevant work or other work. These clarifications address issues of responsibility raised by some courts in recent cases; clarify that we may use vocational experts (VEs), vocational specialists (VSs), or other resources to obtain evidence we need to help us determine whether your impairment(s) prevents you from doing your past relevant work; add a special provision to our rules stating that, if you are at least 55 years old, and specific other circumstances are present, we will find that you are disabled; and make a number of minor editorial changes to clarify and update the language of our rules, and to use simpler language in keeping with our goal of using plain language in our regulations.     

Rules for the issuance of work report receipts, payment of benefits for trial work period service months after a fraud conviction, changes to the student earned income exclusion, and expansion of the reentitlement period for childhood disability benefits. Final rules

We are revising our rules to reflect and implement sections 202, 208, 420A, and 432 of the Social Security Protection Act of 2004 (the SSPA). Section 202 of the SSPA requires us to issue a receipt each time you or your representative report a change in your work activity or give us documentation of a change in your earnings if you receive benefits based on disability under title II or title XVI of the Social Security Act (the Act). Section 208 changes the way we pay benefits during the trial work period if you are convicted by a Federal court of fraudulently concealing your work activity. Section 420A changed the law to allow you to become reentitled to childhood disability benefits under title II at any time if your previous entitlement to childhood disability benefits was terminated because of the performance of substantial gainful activity. Section 432 changes the way we decide if you are eligible for the student earned income exclusion. We will also apply the student earned income exclusion when determining the countable income of an ineligible spouse or ineligible parent. We are also changing the SSI student policy to include home schooling as a form of regular school attendance.     

Old-age, survivors, and disability insurance and Supplemental Security Income for the aged, blind, and disabled; substantial gainful activity amounts; "services" for trial work period purposes--monthly amounts; student child earned income exclusion. Social Security Administration. Final rules

We are revising the rules to automatically adjust each year, based on any increases in the national average wage index, the average monthly earnings guideline we use to determine whether work done by persons with impairments other than blindness is substantial gainful activity; provide that we will ordinarily find that an employee whose average monthly earnings are not greater than the "primary substantial gainful activity amount," has not engaged in substantial gainful activity without considering other information beyond the employee's earnings; increase the minimum amount of monthly earnings and the minimum number of self-employed work hours in month that we consider shows that a person receiving title II Social Security benefits based on disability is performing or has performed "services" during a trial work period, and automatically adjust the earnings amount each year thereafter; increase the maximum monthly and yearly Student Earned Income Exclusion amounts we use in determining Supplemental Security Income (SSI) Program eligibility and payment amounts for student children, and automatically adjust the monthly and yearly exclusion amounts each year thereafter. We are revising these rules as part of our efforts to encourage individuals with disabilities to test their ability to work and keep working. We expect that these changes will provide greater incentives for many beneficiaries to attempt to work or, if already working, to continue to work or increase their work effort.     

Old-age, survivors, and disability insurance and supplemental security income for the aged, blind, and disabled; substantial gainful activity amounts. Social Security Administration. Final rules

We are revising the rules for determining when earnings demonstrate the ability to engage in substantial gainful activity (SGA). This rule change applies to Social Security disability benefits provided under title II of the Social Security Act (the Act) and Supplemental Security Income (SSI) benefits based on disability under title XVI of the Act. (Eligibility for benefits under titles II and XVI also confers eligibility for related Medicare and Medicaid benefits under titles XVIII and XIX of the Act.) Specifically, we are raising from $500 to $700 the average monthly earning guidelines used to determine whether work done by persons with impairments other than blindness is SGA. We are raising this level as part of efforts to encourage individuals with disabilities to attempt to work, and to provide an updated indicator of when earnings demonstrate the ability to engage in SGA. This increase reflects our assessment of the amount that roughly corresponds to wage growth since the last increase in 1990.     

Social Security benefits and supplemental security income; disability termination hearings at the reconsideration level--SSA. Notice of proposed rulemaking

We are proposing regulatory changes to carry out a requirement of Pub. L. 97-455 (enacted on January 12, 1983). That legislation requires several changes in the procedures used by the Social Security Administration (SSA) to conduct periodic reviews of disability cases for continuing eligibility. The proposed regulations would implement Sections 4 and 5 of the new law, which require SSA to make a face-to-face evidentiary hearing available in connection with the reconsideration of any initial determination that an individual receiving disability benefits under title II of the Social Security Act (the Act) is not now disabled. We also propose to make the new reconsideration procedure available in blindness and disability termination cases in the Supplemental Security Income (SSI) program under title XVI of the Act, pursuant to the Secretary's broad rulemaking authority in the SSI program. Although Congress has not specifically required that we do so, it is customary to extend legislative improvements in the title II disability program to comparable SSI cases, since the medical eligibility requirements in both programs are quite similar. Moreover, the proposed inclusion of SSI blindness and disability termination cases would promote effective program administration by providing a uniform appeal procedure in the two programs. We believe that this new procedure will make the reconsideration level more meaningful in blindness and disability termination cases, that beneficiaries affected by these termination decisions will be better served and that the overall quality of the decisionmaking process will also be improved.     

Employee Retirement Income Security Act of 1974; rules and regulations for administration and enforcement; claims procedure--Department of Labor. Notice of proposed rulemaking

This document contains a proposed regulation revising the minimum requirements for benefit claims procedures of employee benefit plans covered by Title I of the Employee Retirement Income Security Act of 1974 (ERISA or the Act). This proposed regulation would establish new standards for the processing of group health disability, pension, and other employee benefit plan claims filed by participants and beneficiaries. In the case of group health plans, as well as certain plans providing disability benefits, the new standards are intended to ensure more timely benefit determinations, improved access to information on which a benefit determination is made, and greater assurance that participants and beneficiaries will be afforded a full and fair review of denied claims. If adopted as final, the proposed regulation would affect participants and beneficiaries of employee benefit plans, plan, fiduciaries, and others who assist in the provision of plan benefits, such as third-party benefits administrators and health service providers or health maintenance organizations that provide benefits to participants and beneficiaries of employee benefit plans.     

Employee Retirement Income Security Act of 1974: rules and regulations for administration and enforcement; claims procedure. Pension and Welfare Benefits Administration, Labor. Final regulation

This document contains a final regulation revising the minimum requirements for benefit claims procedures of employee benefit plans covered by Title I of the Employee Retirement Income Security Act of 1974 (ERISA or the Act). The regulation establishes new standards for the processing of claims under group health plans and plans providing disability benefits and further clarifies existing standards for all other employee benefit plans. The new standards are intended to ensure more timely benefit determinations, to improve access to information on which a benefit determination is made, and to assure that participants and beneficiaries will be afforded a full and fair review of denied claims. When effective, the regulation will affect participants and beneficiaries of employee benefit plans, employers who sponsor employee benefit plans, plan fiduciaries, and others who assist in the provision of plan benefits, such as third-party benefits administrators and health service providers or health maintenance organizations that provide benefits to participants and beneficiaries of employee benefit plans.     

Medicare Program; establishment of the Medicare+Choice Program--HCFA. Interim final rule with comment period

The Balanced Budget Act of 1997 (BBA) establishes a new Medicare+Choice (M+C) program that significantly expands the health care options available to Medicare beneficiaries. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plan choices beyond the original Medicare program or the plans now available through managed care organizations under section 1876 of the Social Security Act. Among the alternatives that will be available to Medicare beneficiaries are M+C coordinated care plans (including plans offered by health maintenance organizations, preferred provider organizations, and provider-sponsored organizations), M+C "MSA" plans, that is, a combination of a high deductible M+C health insurance plan and a contribution to an M+C medical savings account (MSA), and M+C private fee-for-service plans. The introduction of the M+C program will have a profound effect on Medicare beneficiaries and on the health plans and providers that furnish care. The new provisions of the Medicare statute, set forth as Part C of title XVIII of the Social Security Act, address a wide range of areas, including eligibility and enrollment, benefits and beneficiary protections, quality assurance, participating providers, payments to M+C organizations, premiums, appeals and grievances, and contracting rules. This interim final rule explains and implements these provisions. In addition, we are soliciting letters of intent from organizations that intend to offer M+C MSA plans to Medicare beneficiaries and/or to serve as M+C MSA trustees.     

Health care continuation coverage. Final rules

This document contains final rules implementing the notice requirements of the health care continuation coverage (COBRA) provisions of part 6 of title I of the Employee Retirement Income Security Act of 1974 (ERISA or the Act). The continuation coverage provisions generally require group health plans to provide participants and beneficiaries who under certain circumstances would lose coverage (qualified beneficiaries) the opportunity to elect to continue coverage under the plan at group rates for a limited period of time. The final rules set minimum standards for the timing and content of the notices required under the continuation coverage provisions and establish standards for administering the notice process. These rules affect administrators of group health plans, participants and beneficiaries (including qualified beneficiaries) of group health plans, and the sponsors and fiduciaries of such plans. These rules also provide model notices for use by administrators of single-employer group health plans to satisfy their obligation to provide general notices and election notices.     

Medicare program; Medicare secondary payer for individuals entitled to Medicare and also covered under group health plans--HCFA. Final rule with comment period

These regulations establish limits on Medicare payment for services furnished to individuals who are entitled to Medicare on the basis of disability and who are covered under large group health plans (LGHPs) by virtue of their own or a family member's current employment status with an employer; and prohibit LGHPs from taking into account that those individuals are entitled to Medicare on the basis of disability. They also implement certain other provisions of section 1862(b) of the Social Security Act, as amended by the Omnibus Budget Reconciliation Acts of 1986, 1989, 1990, and 1993 and the Social Security Act Amendments of 1994. Those amendments affect the Medicare secondary payer rules for individuals who are entitled to Medicare on the basis of age or who are eligible or entitled on the basis of end stage renal disease and who are also covered under group health plans (GHPs). The provisions that apply to all three groups include-- The rules under which HCFA determines that a GHP or LGHP is not in conformance with the requirements and prohibitions of the statute; The appeals procedures respecting GHPs and LGHPs that HCFA finds to be nonconforming. The referral of nonconforming plans to the Internal Revenue Service; and The rules for recovery of conditional or mistaken Medicare payments made by HCFA. The intent of the MSP provisions is to ensure that Medicare does not pay primary benefits for services for which a GHP or LGHP is the proper primary payer and that beneficiaries covered under these plans are not disadvantaged vis-a-vis other individuals who are covered under the plan but are not entitled to Medicare.     

Medicare program; continuation of Medicare entitlement when disability benefit entitlement ends because of substantial gainful activity. Final rule

This final rule will conform the existing Medicare eligibility regulations to reflect a change made by the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999. That statutory change that was implemented effective October 1, 2000, provides working disabled individuals with continued Medicare entitlement for an additional 54 months beyond the previous limit of 24 months, for a total of 78 months of Medicare coverage following the 15th month of the reentitlement period.     

Experiments and demonstration projects under the disability insurance and supplemental security income programs--Social Security Administration. Proposed rule

The Social Security Administration (SSA) is proposing to amend its regulations to implement section 505 of the Social Security Disability Amendments of 1980 (Pub. L. 96-265). That section requires the Secretary to conduct experiments and demonstration projects to test alternative conditions and limitations for stimulating the return to work of disabled title II beneficiaries and to otherwise improve the administration of the title II disability program. To the extent necessary to thoroughly evaluate these alternative methods, the Secretary may waive compliance with benefit requirements under titles II and XVIII of the Social Security Act. Section 505 also authorizes the Secretary to waive or add to the requirements, conditions, or limitations in title XVI of the Act to the extent necessary to conduct experimental, pilot, and demonstration projects which are likely to promote the objective or improve the administration of the SSI program.     

Supplemental Security Income: determining disability for a child under age 18. Social Security Administration. Final rules

On February 11, 1997, we published interim final rules with a request for comments to implement the Supplemental Security Income (SSI) childhood disability provisions of sections 211 and 212 of Public Law (Pub. L.) 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. We are now publishing revised final rules in response to public comments. We are also conforming our rules to amendments to Public Law 104-193 made by the Balanced Budget Act of 1997, Public Law 105-33. Finally, we are simplifying and clarifying some rules in keeping with the President's goal of using plain language in regulations.     

Work activity of persons working as members of advisory committees established under the Federal Advisory Committee Act (FACA). Final rule

We are revising our disability regulations under titles II and XVI of the Social Security Act to establish a new, special rule that affects individuals who are receiving payments or providing services as members or consultants of a committee, board, commission, council or similar group established under the Federal Advisory Committee Act (FACA). Under this special rule, we will not count any earnings an individual is receiving from serving as a member or consultant of a FACA advisory committee when we determine if the individual is engaging in substantial gainful activity under titles II and XVI of the Social Security Act (the Act). In addition, we will not evaluate any of the services the individual is providing as a member or consultant of the FACA advisory committee when determining if the individual has engaged in substantial gainful activity under titles II and XVI of the Act. Based on our experience with FACA advisory committees and the frequency and level of activity required by these committees, we believe that performance of activity on these committees does not demonstrate the ability to perform substantial gainful activity. We believe this to be consistent with Congress's view, as it has recognized in creating the Ticket to Work advisory committee, for example, that current disability beneficiaries should be considered for membership. This also will encourage individuals with disabilities to serve on FACA advisory committees, thereby providing the benefit of their unique perspective on policies and programs to the Federal Government.     

TRICARE; Continued Health Care Benefit Program expansion. Final rule

This final rule executes the expansion of section 1078a of title 10, United States Code (U.S.C). With the recent expansions of Military Health System (MHS) coverage, particularly with the Reserve Component (RC) members, some MHS beneficiaries would not be eligible to purchase Continued Health Care Benefit Program (CHCBP) coverage under certain circumstances that terminate their MHS coverage. This provision allows the Secretary to establish CHCBP eligibility for any category of MHS beneficiaries who otherwise would lose MHS coverage with no continued care eligibility. Although the proposed rule listed each authorized category of MHS beneficiary eligible to receive care, on further examination this format for the rule appeared cumbersome and perhaps confusing. Thus this final rule contains some organizational changes to simplify the rule to enhance understanding and make clear that any category including future categories of beneficiaries are entitled to purchase this CHCBP coverage. This final rule also includes administrative changes providing clarification on eligibility notifications and the CHCBP premium rate publication process. It updates the previous final rule published in the Federal Register on September 30, 1994.