Review of Continuing Eligibility

A member initially qualifies to receive a disability retirement benefit because medical evidence and employment information determined that they were unable to perform the essential functions of their employment position with reasonable accommodation and that incapacity could be expected to be permanent. After the incapacity has continued for two years, the standard for eligibility for continuation of the disability benefit is expanded to consider all available employment opportunities for which a recipient may qualify.

Standard on Review – eligibility for disability retirement benefits continues if the recipient is unable to engage in any substantially gainful activity due to functional limitations caused by one or more mental or physical condition.

Substantially Gainful Activity – Substantially Gainful Activity (SGA) is any combination of activities, tasks, or efforts, with any reasonable accommodations, for which a recipient is qualified by training, education or experience that would generate annual income in an amount in excess of the substantially gainful activity amount in the labor market for the member’s state of residence. A recipient’s SGA amount is equal to the minimum SGA, their average final compensation (AFC), or their Final Annual Compensation, adjusted annually by the Consumer Price Index for All Urban Consumers, whichever is greater.

Scheduling a Review of Continuing Eligibility – Review for continuing eligibility for disability retirement is scheduled two years after the date of determination that a member is eligible for disability retirement benefits.  Any subsequent review is scheduled only if earnings or other information about the recipient’s activities show that the recipient may have the capacity to engage in substantially gainful activity. At least one year must have passed since any previous review was completed prior to initiating a subsequent review.

Review Process

Complete a Report of Continuation – approximately 30 days before the review date, MainePERS sends a recipient a Report of Continuation form to complete. This form allows a recipient to provide an update on the status of any current medical conditions and to list current healthcare providers. Included with that form are a release form to allow MainePERS to receive updated medical evidence from current healthcare providers, a Transferable Skills Analysis and a Medical Certification form for a healthcare provider to complete. Forms are due to be received by MainePERS within 30 days of receipt.

Updated Medical Evidence – After a recipient submits the completed Report of Continuation and release forms, MainePERS requests updated medical evidence from current healthcare providers.

Review of Medical Evidence– Updated evidence received from a recipient’s healthcare providers is reviewed by MainePERS staff who may consult with the Medical Review Service Provider (MRSP) to determine whether the recipient is able to engage in any substantially gainful activity (not just their former employment position) due to functional limitations caused by one or more mental or physical condition.  If this standard is not met, the recipient will be offered the opportunity to undergo an independent medical examination.

Decision Issued – when a review is completed, recipients are notified in writing of the decision. At times, recipients may be contacted by phone prior to receiving the written notification.

Cooperation with Review – a recipient under review for continuing eligibility must cooperate by providing information to MainePERS, including providing medical evidence and releases that allow MainePERS to request medical evidence from healthcare providers. Timely filing of review materials is important in order to prevent the interruption of a recipient’s benefit.

Rebuttable Presumption – a recipient is presumed to no be longer eligible for disability retirement if the recipient has earned more than the substantially gainful activity amount in one or more years while receiving disability retirement benefits. This presumption may be rebutted by information that shows continued eligibility standards are met notwithstanding these earnings.