CHAPTER IV-OTHER ELIGIBILITY REQUIREMENTS-ISSUANCE OF REGULATIONS In addition to the regulations summarized above, it was necessary to develop a substantial body of policies and procedures to implement the other provisions of the law and to reflect these in published regulations. These remaining regulations were published with notice of proposed rule making on March 4, 1971 (20 CFR Part 410). To the extent feasible, comparable regulatory provisions implementing Title II of the Social Security Act have been adapted for the "black lung" regulations. However, where otherwise indicated by the Coal Mine Health and Safety Act, or where adoption of social security regulations would be inappropriate, suitable regulations have been developed consistent with equitable an effective administration of the program. The statute includes a provision (Section 413 (c)) that no claim may be considered unless the claimant has also filed a claim under the applicable State workmen's compensation law prior to or at the same time his Federal black lung benefits claim was filed, except where such filing wuld clearly be futile. To expedite the handling of Federal claims, instructions were issued to permit processing these claims without awaiting final disposition of a State claim. Federal black lung benefits are not paid unless a State claim, if required, is filed. Once such a claim is filed, however, Federal benefits are payable effective with the original month of entitlement, subject to retroactive offset adjustment later if the State claim is paid. Every effort has been made to advise applicants about when such State filing would be unnecessary because it would be futile. The law provides no retroactivity in benefit payments. Specifically, it provides in Section 414 (c) that: "No benefits under this part shall be payable for any period prior to the date a claim there for is filed." Since payment periods are calendar months, a claim filed in a given month has been construed as having been filed for the entire payment period, i.e., such calendar month. Thus, an entitled claimant gets a full month's benefits regardless of the day of the month in which the claim is filed. In addition, the application form for a miner's benefit claim contains a "protective writing" which may serve to prevent the loss of benefits to the widow should she delay filing her claim. Without this special administrative provision, a widow would have to file in the same month of her husband's death or lose benefits. (10) CHAPTER V-BENEFIT ADJUSTMENTS AND OFFSETS Experience in the first year of program operations shows that substantial numbers of applicants for black lung benefits are also in receipt of social security cash benefits. Over 75 percent of all those awarded miners' black lung benefits are also receiving social security disability, retirement or survivors benefits. Generally speaking, this means the black lung beneficiary gets both types of benefits in full. However, both the Social Security Act and the Federal Coal Mine Health and Safety Act contain provisions which are designed to reduce the extent of overlapping and duplication of benefits. The Social Security Act has since 1965 contained what is commonly called a "workmen's compensation offset" provision. For people who become disabled after June 1, 1965, and are under age 62, section 224 of the Social Security Act limits the amount of combined income from social security disability insurance benefits and State or Federal workmen's compensation payments. The amount of the limitation is either 80 percent of the worker's average current earnings before he became disabled, or 100 percent of the amount of total family benefits under the social security disability insurance benefits program, whichever is higher. If the combined benefits would exceed this amount, the social security disability benefits are reduced by the amount of the excess. This is not a dollar-for-dollar offset. As a result of this provision, some current social security disability insurance beneficiaries have these benefits reduced when they become entitled to Federal black lung benefits. Most miner applicants are age 62 or older, however, and the offset therefore does not apply. Reduction of social security disability benefits has occurred in less than 5 percent of allowed miners' black lung claims and, in most instances, where reduction is necessary, only a partial reduction rather than total offset of the social security disability benefit is required. The Federal Coal Mine Health and Safety Act contains a somewhat similar provision with similar intent, but a different method of application. The amount of Federal black lung benefits payable is reduced if the miner or widow is receiving benefits under a State program based on the miner's disability. This is a dollar-for-dollar offset. For example, if a miner is receiving $120 a month under a State program, the Federal benefit is reduced by that amount. As of April 30, 1971, less than 5,000 recipients under the Federal program were receiving reduced benefits because of the receipt of such State benefits. The "maintenance of effort" provision of the law specifies that no benefits will be paid to the residents of any State which, after the date of enactment, reduces the benefits payable under its State laws to Part B beneficiaries. While not specified in the statute, the legislative history makes it clear that this provision does not apply where the State benefit is financed wholly from general revenues of the State, and the Administration has so interpreted it. In this connection, the State benefit program with the most extensive impact on the administration of Part B of Title IV has been the Occupational Disease Act of the Commonwealth of Pennsylvania. One part of that statute provides for supplemental payments of $100 monthly to miners in that State found to be totally disabled due to silicosis, anthraco-silicosis, miners' asthma, or coal worker's pneumoconiosis. These benefits become payable when the basic occupational disease benefits paid, if any, in an individual case are exhausted. As of December 31, 1970, over 20,000 claimants previously entitled to Pennsylvania Occupational Disease benefits had been awarded Federal black lung benefits. Before July 1970, this resulted in a dollarfor-dollar reduction of the Federal black lung payment in each case. However, in July 1970, the Commonwealth enacted a provision whereby the $100-a-month benefit payable under the State program is suspended if the beneficiary becomes entitled to Federal black lung benefits. As a result, since July 1970, the Federal black lung miner beneficiary who because of the new Pennsylvania provision does not receive the State $100 monthly payment, receives his monthly Federal black lung benefit in full, without offset reduction. The effect for the beneficiary, therefore, is no net change in the total amount of his combined monthly benefits from both sources. The Commonwealth could take its action without adverse effect on beneficiaries' rights under the "maintenance of effort" provision of the Federal law, because the $100-a-month benefit payable under the State's Occupational Disease law is presently funded entirely from general revenues and such payments are excluded from the "maintenance of effort" provisions. CHAPTER VI-ADMINISTRATIVE ARRANGEMENTS The Act states that in carrying out the provisions of Part B of Title IV, the Secretary shall to the maximum extent feasible (and consistent with the provisions of this part) utilize the personnel and procedures he uses in determining entitlement to disability insurance benefits under the Social Security Act. Under this provision, program administration authority was delegated by the Secretary to the Social Security Administration with the major responsibility within the Administration assigned to the Bureau of Disability Insurance, which carries primary responsibility for the administration of the regular social security disability insurance program. Other Social Security Administration components, such as the Bureau of District Office Operations (which is responsible for the management of the Administration's network of more than 860 district and branch offices), and the Bureau of Hearings and Appeals play important operating roles. Service and assistance to claimants The Social Security Administration has a well-established major organizational objective of treating every applicant as deserving of respect and entitled to prompt service of high quality provided in a courteous, friendly and helpful manner. In keeping with this objective, the Administration provides a full measure of assistance to all applicants as needed in pursuit of their rights under the law. In carrying out the black lung benefits program, it has been the policy and practice of the Administration to extend the same level and quality of service to black lung applicants as to regular social security applicants, to design policies and procedures which are as little burdensome on applicants as possible within the limits of the law, and to provide an extra measure of assistance and counsel to those who are in special need of help because of problems of age, impairment, or understanding. Processing of claims The processing of black lung claims is handled in largely the same manner as regular social security disability claims, with some modifications in the process necessary because of certain unique characteristics of the black lung claims workload, e.g., a very large one-time backlog of claims applications mainly limited to a small number of States. The major processing points and their role in the claims process are summarized below. Social security district offices The primary point of public contact and service in the administration of the black lung benefit program is the local social security district office. These offices provide information and assistance to claimants in the filing and processing of their claims. Trained staff in the offices answer inquiries about the program, explain the eligibility requirements, and give guidance and assistance to claimants on furnishing available medical and other evidence needed to document claims. Where necessary, the district office will request and obtain evidence from existing sources on behalf of a claimant. District offices advise each claimant on his or her rights and obligations under the law as a beneficiary. They furnish denied claimants with detailed explanations of the reason for the denial decision and the evidence on which it was based. On request also, the evidence on his claim is made available in the district office for inspection by the claimant or his representative. The claimant is informed of his rights of appeal and, if dissatisfied with the decision on his claim, is assisted in providing any additional evidence available that may be pertinent to the further review of his claim. He is also advised by the district office on obtaining reimbursement for reasonable medical expenses incurred in establishing his claim. Local social security offices carry out a wide range of informational activities to promote public knowledge and understanding of the provisions of the black lung benefit program. State agencies Many cases require medical evidence beyond that available from existing records, in order to assure proper consideration of the applicant's benefit rights. To obtain this evidence, as provided in Section 413 (b) of the Federal Coal Mine Health and Safety Act, the Social Security Administration enlisted the assistance of the State agencies which work with the Administration in the disability insurance benefits program. Under special agreements, these agencies are responsible for arranging for necessary medical examinations, in coal miners' claims, involving primarily X-rays and pulmonary function tests, as needed. These examinations are performed by qualified local physicians or medical facilities convenient to the applicant and at no cost to him. (All State agency costs, including medical examinations arranged by the agency, are financed by the Social Security Administration.) With the volume and geographical concentration of these claims and the limitations on medical resources in these areas, securing the necessary medical evidence posed a major operating challenge for some of these agencies. Bureau of Disability Insurance In addition to responsibility for overall program direction and policy formulation, the Bureau of Disability Insurance determines the adequacy of claims documentation, makes initial and reconsideration determinations as to entitlement and the amount of benefits in each claim under the Federal Coal Mine Health and Safety Act, notifies claimants of the decision, determines the amount of offsets and reductions where applicable, certifies payment to the Treasury Department Disbursing Office in allowed claims, and is responsible for continued maintenance of the beneficiary rolls. Bureau of Hearings and Appeals Under the law and regulations, claimants have certain appeal rights in the event of adverse decisions. Hearings provided as a part of such rights are conducted by hearing examiners in the Bureau of Hearings and Appeals and their decisions are subject to review by, or appeal to, the Appeals Council of the Bureau of Hearings and Appeals. Beyond this, judical review by the courts is available to claimants on issues as to total disability or death due to pneumoconiosis. |